Activities of Daily Living Performed by People with Spinal Cord Injury

Original Editor - Wendy Oelofse

Top Contributors - Jess Bell, Ewa Jaraczewska and Kim Jackson  

Introduction

Activities of daily living (ADLs) can be classified into personal and instrumental activities of daily living. Personal activities of daily living include the skills needed to manage physical needs, such as grooming and personal hygiene, dressing, toileting and continence, transferring and ambulating, and eating. Instrumental activities of daily living (IADLs) include more complex tasks related to the ability to live independently in the community, such as domestic tasks, leisure, parenting, shopping, and managing finances and medications.

Understanding the ability of patients with spinal cord injury to perform daily activities is important when planning their rehabilitation and managing their long-term care. Functional impairments vary significantly among people with spinal cord injury, and they can have different impacts on quality of life. Some studies suggest that spinal cord injury is responsible for a significant decrease in quality of life and functional limitations. Other factors that influence quality of life are pain intensity, level of injury, and education status.

This article contains additional notes for Wendy Oelofse's Plus course on Activities of Daily Living, Self-Care, and Home Modifications for People With Spinal Cord Injury course.

Activities of Daily Living (ADL)

Level of Injury and Selected ADL

Hands-free hydration system

Eating and Drinking

C1-4:

• Full assistance in eating

• Independent in drinking with assistive technology
  • Example: Hands-free drinking system

C5:

• Set up assistive technology for eating
  • Example: Universal cuff (U-cuff) and wrist extension splint
• Independent with assistive technology in drinking
  • Examples: Add hooks to drinking bottles or cups, add a straw if the bottle or cup cannot be lifted high enough

C6 and C7:

• Independent with assistive technology in eating:
  • Examples: tenodesis grasp, using U-cuff, can also use ringed cutlery, and might be able to weave cutlery through the fingers

• Independent in drinking:
  • Examples: tenodesis grasp or can use hooks. Care must be taken to avoid burns when holding a hot beverage

C8-T1:

• Independent in eating and drinking
• Can manage with standard cutlery or might need built-up handles

Grooming

C1-4:

• Full assistance in grooming tasks

C5:

• Moderate assistance for some grooming tasks with universal cuff and wrist extension splint due to no active wrist extension

C6-7:

• Independent in most grooming tasks with U-cuff or intertwining utensils between fingers
• Use tenodesis grasp to hold small objects when wrist extension present; seldom use tenodesis grasp to hold heavier objects as it would be too weak

C8-T1:

• Independent in all tasks - may require built-up handles for some tasks

Dressing

C1-4:

• Assistance with all aspects of dressing, but they can DIRECT their caregiver independently about what clothes they would like to wear

C5:

• Can place arms into sleeves but generally need assistance for all other aspects of dressing

C6:

• Can become independent in all aspects of dressing but require extensive practice and modifications to some of their clothing

C7-C8:

• Independent with practice

Showering

C1-4:

• Assistance with all aspects of washing - can independently direct the washing

C5:

• Can wash parts of their body with assistive technology and can hold an adapted hand-held shower head to rinse their body, but generally need assistance for all other aspects of washing

C6:

• Can become independent in all aspects of washing with extensive practice, with appropriate assistive technology and an environment that facilitates independence

C7-C8:

• Independent with practice

Toileting

C1-C6/C7:

• Usually, a suprapubic catheter is used, but some males with an injury at C6/7 can learn to self-catheterise

Below T1:

• Normally intermittent self-catheterisation
  • Please note that for females to be able to self-catheterise, they also need good balance, and other factors such as spasticity and body shape can also influence their ability to be independent in self-catheterisation
• Skills to practise to ensure success at intermittent self-catheterisation include:
  • Dressing in the wheelchair
  • Washing hands/practising good hand hygiene

Bladder management:

The following problems need to be overcome:

1. Urinary retention -cannot control the bladder sphincter muscle, so cannot void on command - experiences leakage
2. Unable to feel when they want to void/when the bladder is full

Solution: Routinely empty the bladder using an appropriate and safe method.

Bowel management:

This article presents the guidelines for the management of neurogenic bowel dysfunction in spinal cord injury.

Watch this video to learn about adaptive tools to help patients with hand weakness successfully manage their bowel programme.

Pressure Care

Repositioning techniques: should be done every 15-30 minutes, and an appropriate technique should be used.

Forward lean is the position that is normally practised for pressure care, and it is the position that we encourage.

Side lean can be difficult, and the armrest can restrict movement, so this is usually used by people with low paraplegia.

The push-up technique is not encouraged because it can affect the individual's shoulders and is not always sufficient for pressure relief.

C1-C5:

• Require assistance to relieve pressure using the forward lean technique
• Can be independent in pressure relief by tilting their power wheelchair, but the wheelchair must be able to tilt at least 50 degrees
• Consider the tilt range when ordering a power wheelchair for a patient with high tetraplegia
• A caregiver can also manually tilt a wheelchair backwards to relieve pressure

Repositioning in bed is also important, even when air mattresses are used. Individuals with spinal cord injury should reposition every two hours.

Examples of pressure redistribution surfaces include:

• mattress
• wheelchair cushion
• padded surface for toilet

Communication

C1-4:

• Use preserved function in head, neck, mouth and voice and assistive technology:
  • Examples include mouth or head stick, speakerphone, headset, touch screen, mounting system on wheelchair and hospital bed

• Can sign documents holding a pen in mouth, turn pages if document or book is placed on an appropriate reading stand and use a mouth stick

C5-7:

• Uses functional skills with help from assistive technology:
  • Examples include using a U-cuff and writing splint (for a person with a C6/7 spinal cord injury), speakerphone, large buttons on the phone, touchscreen, headset, lanyard (to prevent the phone from being dropped); stylus or finger extension splint to use with touch screen, hook on a phone to help lift it to the ear (not as common now as technology has improved greatly)

C8:

• Can generally manage without aids, may require built-up writing device
• Able to use a computer; no adaptation to the computer is required, but may consider mouse and keyboard alternatives
• May use typing splints, mouth or headsticks
• May consider a voice dictation software

Instrumental Activities of Daily Living

Domestic Tasks

C6:

• May independently perform light housekeeping duties

C7:

• Able to perform household duties with fewer adaptive aids to manage independent living

Consider teaching persons with spinal cord injuries the following adaptations to assist with housekeeping tasks:

• When using a duster/sweeper/mop with limited hand function, use one with a hook eye on the handle. You can hook your thumb through to help grip
• Use your palm to press the spray bottle if you have limited hand function
• Use a scouring pad and stick to wash the bath
• Store cleaning supplies together in a basket that can be put on your lap

Parenting

To fulfil parenting duties, a person with a spinal cord injury may benefit from the following guidance.

Transporting and Carrying the Child

• Think about balance, posture, pressure changes on the wheelchair cushion, safety and transfers. When using carriers, watch for shoulder and back pain exacerbation

• When using carriers, wraps, and lap belts, make sure that you can open and close them
• Consider alternative methods of carrying
• When transferring the baby, ensure you are as close to the surface as possible to increase stability and safety and decrease the risk of injury
• Place the pillow on your lap to carry a child
• When lowering baby to the ground, use elbows on knees. When putting weight on your elbows and knees, it creates leverage and more proximal stability
• Use a velcro wheelchair seat belt to help secure the baby when transporting them

Car seats: use lightweight, swivel car seats and a buckle release tool

Strollers: Consider lightweight, adaptive wheelchair-compatible strollers

Feeding

Bottle feeding

• Adaptive bottle holders
• Nursing/bottle feeding specific pillows
• Bottle warmers
• Burping considerations
• Strap a bottle holder onto a wheelchair

Breastfeeding positioning

• Reclined, side-lying, sitting
• Use of positioning pillows

Feeding solids

• High chair considerations
  • Height, portability, straps/ways to secure, accessibility to put the child in a high chair
  • Strap a booster seat onto a barstool for feeding

Burping considerations

• There are three ways to burp a baby
  • Traditional burping over the shoulder
  • Baby sits on the caregiver's lap and leans over the hand of the carergiver
  • Place baby over your lap on their stomach and pat them on their back
  • Depending on the abilities of the parent/caregiver, the therapist can work with the caregiver/parent to see which position will work best
  • These positions are shown in the video below

Changing Diapers / Nappies

• Consider the changing surface and changing pad
• A dining table can be used for diaper changing

Dressing

• Install loops onto zippers, use velcro or magnetic closures
• A padded space on the lap can help with tasks that can be done from the wheelchair, such as dressing

Bathing

• Consider using the kitchen sink (if safe)

Sleeping

• Bedside bassinets and co-sleepers eliminate the need to transfer out of bed to feed/comfort the baby
• Consider a cot that opens sideways
• Adjustable/lower height crib

Play

• A bed can be a level play area
• Toys with loops, handles or hooks

Safety

• Provide physical boundaries
• Baby gates need to be wide enough for a wheelchair to pass through and should ideally not have a threshold
• Consider magnetic cabinet locks if limited hand function

Resources

• SCI Parenting- Spinal Cord Injury and Parenting
• Childcare Strategies for SCI – Detailed