Course:RSOT513/2009W2/spinal cord injury

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Spinal Cord Injury and Occupation

Laura Blackadar, Erin Brown, Emily Carley, Caitlyn DeBruyne, Naomi Dolgoy & Stephanie VanCitters

RSOT 513 University of British Columbia, April 16, 2010


Introduction

The spinal cord is a pathway for transmission of motor and sensory information between the brain and the body. (1) The four levels of the spinal cord, sacral, lumbar, thoracic, and cervical, carry motor and sensory information to different areas of the body. The cervical level, C1-C8, carries information to and from the head, neck, diaphragm, arms and hands. The thoracic level, T1-T12, carries information to and from the chest and upper trunk. The lumbar level, L1-L5, carries information to and from the legs and part of the feet. The sacral level, S1-S5, carries information to and from the remainder of the feet, bowel, the bladder, and sexual organs. (2)

Classification of Spinal Cord Injury

The Canadian Spinal Research Organization (CSRO) uses the International Standards for Neurological Classification of SCI (ISCSCI), to classify SCIs according to the number of limbs affected (tetraplegia vs. paraplegia) and the degree of injury (complete vs. incomplete).

  • Paraplegia involves loss of function below the C8 level, resulting in paralysis of the trunk, pelvis, bladder, bowels and legs.
  • Tetraplegia or quadriplegia involves loss of function above or at the C8 level, resulting in paralysis of part of all of the upper extremities and the lower extremities.
  • Complete SCI means that the injury has caused a complete cut through the spinal cord. The result of this injury is a loss of motor and sensory function to all parts of the body supplied by that level of the spinal cord and below it. This is because all incoming and outgoing pathways are severed at the injury site. (2)
  • Incomplete SCI means that the injury does not completely damage the spinal cord; sensation and some voluntary movement below the injury site are still possible. (2)

In both tetraplegia and paraplegia, function will vary depending on whether the injury is complete or incomplete. To illustrate the impact of a SCI on person's functional ability, we focus on an incomplete C7 level SCI. An individual with a C7 SCI will be able to:

  • Use neck and jaw
  • Breathe independently
  • Move shoulders and scapula
  • Flex elbows and turn arms downward and upward
  • Extend elbows
  • Flex and extend wrists
  • Weakly extend thumb and fingers
  • Have a trace amount of finger flexion (2)

C7 SCIs result in paralysis of lower extremities and trunk, and significantly reduce dexterity and grasp release by the hand. (2)

Etiology of Spinal Cord Injury

Within the spinal cord, the spinal tracts or white matter surrounds the central cord or gray matter. It contains sections of sensory and motor neurons. (3) The nerves that connect the brain and body via the spinal cord relay sensory and muscle information from the body to the brain, and send signals to cause movement from the brain back to the body. When spinal cord injury (SCI) occurs, the transmission of information from all of these neurons is affected; this impacts movement and sensation in the body. (4) By evaluating sensation and motor function, health care teams determine which segments of the spinal cord have been impacted by the injury. (5)

Because SCIs involve a trauma to the spinal cord itself, there is no cure. With careful precautions and early treatment, the severity of the injury may be reduced and improvement of functioning can be supported. (4) Occupational therapy plays a significant role in helping clients reach their rehabilitation goals through client-centred intervention plans, which may include engaging and participating in activities using adapted techniques, and grading activities.


Prevalence of Spinal Cord Injury

The Canadian Paraplegic Association estimates that 900 Canadians sustain a SCI each year, with a relatively equal split between paraplegia and tetraplegia. (6) Males aged 15-34 account for 80% of SCIs. (6) Motor vehicle crashes account for 35% of SCIs; other causes include sports or recreational activities, and falls. (6) Falls account for 63% of SCI in adults over 65 years, suggesting the importance of fall prevention plans for older adults. (7)

Signs and Symptoms of Spinal Cord Injury

At the time of injury individuals with SCI describe feeling a surge of something similar to electricity in their spines, and then cannot move affected body parts. (4) At the hospital, SCIs are diagnosed through computed tomography (CT), magnetic imaging resonance (MRI), and x-ray imaging. (4) The primary signs of SCI are paralysis of voluntary movement and loss of feeling at and below the level of injury, depending on the level of injury and whether the injury is complete or incomplete. (8) The impact of SCI, however, extends far beyond these primary signs to a number of secondary signs and symptoms that can greatly impact the individual. For an individual with an incomplete C7 SCI, secondary signs and symptoms include:

  • Difficulty breathing - paralysis of some muscles make clearing fluid from the lungs difficult. (8)
  • Pressure sores - wounds may develop because the individual lacks feeling and awareness of pain and pressure, and is not able to move their limbs in response. (8)
  • Bowel and bladder function - injury impacts the nerves that tell an individual to empty their bowel and bladder. Bladder infections are also a common problem. (2)
  • Sexual function - injury impacts the nerves that control sexual function, however individuals can still lead an active sex life. (8)
  • Pain - nerve pain can contribute to depression and greatly impact an individual's motivation to participate in life activities. (8)
  • Problems in muscle tone - the muscles can become either very tight, when in certain positions (spastic) or very soft and limp (flaccid). (8)
  • Fatigue - a number of factors, such as pain, medications, prolonged bed rest and emotional exhaustion can make individuals prone to fatigue. (8)
  • Depression - individuals may experience a period of sadness, grief, and depression; symptoms of depression are largely connected to an individual's changed ability to participate in everyday activities (8).
  • Autonomic dysreflexia - this drastic increase in blood pressure can be life threatening. It alerts individuals about a discomfort they cannot feel, such as bladder infections or pressure sores. (8)
  • Orthostatic hypotension - this is a drastic drop in blood pressure caused by blood pooling in the lower extremities; it can occur when an individual sits up quickly after a long period of lying down. (8)
  • Temperature regulation - decrease in skin sensation can put an individual at risk of hypothermia, frost bite and heat stroke. (8)


Spinal Cord Injury Implications in Occupation

The signs and symptoms of SCI significantly impact everyday activities. Occupational therapy plays an important role in the rehabilitation and management of SCI at all levels. An important therapeutic goal is to restore the client’s function, enabling them to participate in the activities and tasks that are important to them. The ability to participate in meaningful, everyday activities is essential to an individual’s health and well-being.

Occupational therapists (OTs) focus on three life areas, which include self-care, productivity, and leisure. (9) Self-care tasks include basic needs, such as bathing and eating. Productivity includes activities such as paid work, volunteering, caregiving, or parenting. Leisure includes fun and enjoyable activities.

Daily activities can be difficult to perform for an individual with an incomplete C7 SCI; however, the rehabilitation process may make it possible for a person with a C7 level injury to live independently in the community without full-time attendant care. (8)

OTs work collaboratively with their clients to identify challenges in the performance of daily tasks and activities (i.e. occupational performance issues or OPIs) related to self-care, productivity and leisure. (10) OTs use informal and formal assessments to gain information that helps them to understand these OPIs. Client with an incomplete C7 SCI experience OPIs relating to self-care, productivity and leisure.


Self-Care

Skin care, bathing, transportation and mobility, and sexual function. However, an individual can achieve relative independence in many self-care tasks including "positioning, bed mobility, hygiene, feeding, shaving, grooming, dressing, bathing, cooking and light housekeeping." (2) Good upper arm strength allows individuals to independently perform transfers and most self-care tasks. (11)

Taking care of skin is an important part of pressure sore prevention. (11) The ability to complete skin checks and shift one's weight reduces the development of pressure sores. Assistance with padding and positioning may be required to ensure correct positioning in bed or in a wheelchair. (11)

Independence in transferring in and out of the bath and shower is possible, however, because of reduced feeling there is an increased risk of burning the skin. Reduced grip strength leads to increased difficulty manipulating items while bathing. (11)

Transportation and mobility may pose many challenges. However, it is possible for an individual to mobilize independently using a manual wheelchair provided they have the strength and endurance. Indoor and outdoor environments present major barriers to community access because of doors, stairs, escalators, curbs, uneven terrain, and ramps. (2) Lack of accessible transportation can also pose challenges for getting around. (12) Driving a vehicle is possible with appropriate adaptations. (12)

The impact a SCI has on one’s sexuality depends largely on the extent and level of injury. (13) There may be a decrease in sexual desire and sexual activity and development of an altered sense of sexuality. (14) Both men and women may find sexual intercourse uncomfortable because of bowel and bladder incontinence. (14) Other factors that can impact participation in sexual activity include reduced muscle tone, changes in body temperature, and increased risk for skin breakdown. (14)

Productivity

Returning to work or volunteering can be overwhelming. A survey of 100 individuals with a C5 level injury or lower found only 33% of participants had returned to work. (15) Returning to the workforce can be a powerful builder of self confidence when and if the goal is reached. (15) According to Tasiemski et al. (15) the most common stated barriers to an individual returning to productivity tasks include: accessibility of the work place, reluctance of employers to consider an employee with a disability, and new hardships experienced in homemaking. Accessibility within a workplace goes beyond wheelchair ramps and accessible bathrooms. People who use wheelchairs are often at a height disadvantage when using office equipment, require extra time for travel within the building and wheelchair refuge space. (15) Public education is needed to remove stereotypes and discrimination by employers hiring individuals who use wheelchairs, false ideas about increased expenses to accommodate diverse needs, and myths about increased absentee rates. (15, 16)

Leisure

Participation in leisure activities such as sports and recreation can be a struggle. However, leisure can help individuals in their recovery by assisting them with acceptance of the injury, promotion of independence, and improvement in quality of life and self confidence. (15)

Self-care difficulties and social stereotypes can limit engagement in leisure activities. As previously discussed, bowel and bladder management can be challenging. An individual who does not feel proficient with their bowel and bladder routine may hesitate to participate in leisure activities in order to avoid embarrassment or unseen difficulties in public. (16)

Lack of adaptive equipment that meets one's needs is one of the most significant obstacles to returning to leisure activities. Examples of adaptive equipment include wheelchair accessible fitness equipment at fitness centers and adaptive devices that enable sport specific participation. (15) Limited financial resources may account for a lack of adaptive equipment available within the community. (16)

Social stereotypes can also make participation in leisure activities of interest formidable. (16) Society has identified certain leisure activities such as table tennis, archery and basketball as typical for those who use wheelchairs. Unfortunately, these leisure activities do not appeal to everyone. (15) Finally, lack of support from family and friends has been cited as the number one societal barrier when attempting to return to recreation activities. (16)


How Occupational Therapy Can Help Address Occupational Performance Issues

When an individual receives occupational therapy, they are referred to as a client. The role of occupational therapy in SCI rehabilitation is to assist clients in regaining abilities and roles that are important and meaningful. (17) After identifying the OPIs, the OT and client work together to prioritize and set goals. Together, they create plans that address the performance issues in order to encourage participation in everyday activities. An important feature of occupational therapy is the use of ‘therapeutic activities’ to achieve this goal. Finally, reassessment is done to measure the outcome of the effectiveness of the therapy plans. This contributes to the occupational therapy goal of using evidence-based practice.

Pallastrini et al (17) emphasize the importance of early occupational therapy, started immediately after stabilization of the client's functional state. The purpose of therapy in early treatment of SCI is to evaluate ability and level of functioning, provide individualized therapy to retrain performance of daily living skills using adaptive techniques. It is also to facilitate coping skills that could help a person overcome the effects of injury, to implement exercises and routines that strengthen muscles, and to determine the type of assistive devices that could help a person become more independent with daily living skills. (17)

When considering the role of OT in SCI, it is helpful to think about what interventions are commonplace during different phases of recovery, namely acute, acute rehabilitation and community phases. It is also worth noting that age and gender specific considerations are important.

Acute Recovery

During acute recovery, the focus is on support and prevention. The OT provides environmental controls to help the client gain a sense of control over a situation in which they likely feel little. (8) The OT may make splints to prevent deformities in the hands. Additionally, daily arm and hand exercises are performed to maintain normal function. Fitting and selecting the most appropriate temporary wheelchair to enable mobility is important in this stage. Finally, teaching the client and care providers appropriate positioning in bed and in the wheelchair is critical for the prevention of pressure sores. (8) Education regarding pressure sore prevention continues into the rehabilitation phase. See self-care skills.

Acute Rehabilitation

During acute rehabilitation, OT interventions focus on support, education for the client and family/caregivers, meaningful activities, choosing equipment and restoring the client’s self esteem and confidence. (8) It is particularly important to consider the client’s discharge environment (i.e. home, community and social setting) in order to prepare for community living. With the client, the OT creates an individual program to meet the client's needs. The following are key areas of intervention common to numerous rehabilitation settings (18):

Assessment and treatment of the upper limbs

Early in the rehabilitation phase, the OT evaluates the client’s strength and sensation in the upper extremity (UE); lower extremity (LE) evaluation falls under the responsibility of the physical therapist. The OT makes use of therapeutic activities to both strengthen muscles and develop improved hand function. Custom-made splints are commonly used to help position the hands in a functional position and assist in preventing deformity. (18) Because individuals with C7 level injury have their radial wrist extensor function, it is possible to teach the client how to use tenodesis grasp for picking up light objects. (8) Using meaningful activities to build strength, endurance, and coordination helps to differentiate the work of occupational therapists from physical therapists.

Self care retraining

Obtaining competency in self-care tasks contributes significantly to an individual's sense of self confidence and independence. The focus is on feeding, grooming, bathing, dressing and bowel/bladder management. (8) Assistive devices and specialized equipment are prescribed by the therapist to help the client achieve greater competency and independence in their activities of daily living. At the C7 level, the client can achieve independence in feeding, grooming, UE dressing and bathing. They may require adaptive equipment for dressing and bathing the LE. (2) Examples of commonly prescribed equipment include: dressing and bathing aids for the LE, a padded transfer tub bench, shower-commode chair, or hand-held shower. Adaptive devices may be required to assist with bowel and bladder management. A key role for the therapist is in educating the client and their caregiver(s) in the proper care and use of the adaptive aids/equipment. Practice sessions under the supervision and guidance of the OT are provided until the client feels competent using the adaptive aids.

Pressure sores are secondary complications of SCI. Educating clients about the risks that lead to pressure sore development and strategies for prevention is important to health and well-being. (18) For example, teaching the client about the importance of proper positioning and adherence to weight shift schedules form a part of the prevention strategy. In addition to education, the therapist assesses the client for the best pressure relieving surfaces (i.e. cushion and mattress) to aid in pressure sore prevention.

Transfer skills

Examples of different transfers include: moving from bed to wheelchair, from wheelchair to toilet or tub, and from wheelchair to driver’s seat. Transfers are a key area of education and skill development. (18) Strength in the upper extremities makes it possible to transfer independently from one surface to another either with the aid of a sliding transfer board or by utilizing grab bars. Frequent practice under the guidance of the OT assists clients with the necessary skill development.

Bed mobility

Occupational therapists teach their clients bed mobility skills required for many daily tasks, such as getting dressed, moving out of bed, and correct positioning in bed for skin protection and comfort. (18)

Mobility skills

Not being able to move around without help is the largest restriction to participating in activities of daily living. The wheelchair that a person uses can significantly affect their quality of participation. A key area of for the OT is to assist clients with the selection of the most suitable mobility aid in accordance with their needs, abilities, preferences and available technology. (19) A proper fitting wheelchair is critical for good posture and comfort. Creating an ideal match between the client's needs and the equipment available is challenging. The client's level of funding and the high cost of equipment adds further complexity. (19)

Clients can achieve independence with a manual wheelchair on all indoor surfaces and level outdoor surfaces. They require assistance with uneven outdoor surfaces. (8) For this reason, it is not uncommon to prescribe both a power and manual wheelchair for clients to allow for flexibility according to their needs. This involves fitting clients for both wheelchairs and selecting the best pressure relieving surfaces/cushions and backrests. In addition, power and manual wheelchair training assists clients in developing skills both indoors and outdoors.

Home assessment and modifications

Discussing the clients housing situation is an important part of the rehabilitation phase planning. Where possible, there will be a home visit to assess for required changes and adaptations. Examples of common adaptations include: widening doorways, adapting the bathroom and kitchen for wheelchair accessibility, placing switches at wheelchair level, and choosing wheelchair friendly flooring. Involving the client and family in determining solutions and making decisions is very important. Assessing the need for specialized equipment (i.e. hospital bed or pressure relieving mattress) also takes place during rehabilitation. The client will be encouraged to try different pieces of equipment in relation to self-care, communication, and other activities of daily living. With guidance from the OT, the client will decide on the most appropriate items of equipment to suit the clients needs.

Domestic retraining

During rehabilitation, opportunities are provided to practice a variety of domestic skills. For example, clients can practice cooking in a wheelchair accessible kitchen as well as trial different pieces of equipment that can enhance independence in this area. A variety of adaptive aids for the kitchen address limitations in grip strength. (17) OTs teach adaptive strategies for carrying out domestic chores (i.e. childcare, cleaning, laundry) that are adjusted to suit the client's needs and abilities. If necessary, hiring home care support from the community may bridge the gap in performance ability; light to total assistance with meal preparation and other household duties may be required for up to two hours per day. (8)

Assistance with return to driving/transportation

Clients with this level of injury can return to driving. This requires the client to be independent in transferring from their wheelchair to the driver’s seat using a sliding transfer board. Complete independence also requires the ability to load and unload one’s wheelchair from the vehicle. (8) A return to driving program is co-ordinated by the OT and the Driver Assessment and Rehabilitation Unit located within the hospital. The goal of the program is to provide education and retraining to help clients return to driving. Assistance with selecting an appropriate modified vehicle that will meet the client’s needs and budget are part of the program. For clients who do not wish to return to driving, alternate transportation options are also addressed (i.e. disabled parking, taxi subsidy vouchers, modified vehicle for passenger transit and public transportation).

Community living skills

Clients may be involved in a support group which addresses skills that prepare clients for returning home and to the community. As previously mentioned, driving and wheelchair mobility skills are important for accessing the community. Community outings are commonly organized to help to reintegrate the patient into the community. (18) (See community reintegration for more details.)

Leisure and recreation skills

Part of rehabilitation involves investigating options for returning to previous leisure/recreation interests as well as developing new pursuits. In addition, the therapist can assist the client in finding ways to cope with physical and social issues that may get in the way of leisure participation. (2)

Work/study skills

Addressing the client's career and educational goals is very important. If appropriate, a work site/school visit may be arranged to assess for accessibility. Otherwise, a referral to a community based work/school assessment service may be indicated. (2)

Sexual health

Exploring concerns related to sexual health and function should form an integral part of each client's treatment plan. The OT can assist their client by providing information and identifying alternate resources and adaptive devices as needed. (2)


Community reintegration

Following rehabilitation, the client begins the process of community reintegration. Community participation is an important aspect in maintaining quality of life. (20) During community reintegration, the focus of occupational therapy is on restoring client roles at home and in the community, and promoting social participation and life satisfaction. (20) Ongoing education of the client, family and caregivers continues throughout this stage. Referrals can be made to an outpatient clinic or community therapist to continue with treatment and progress made during rehabilitation. Outpatient programs teach clients how to use new movement and offer training for activities of daily living, as clients continue to gain strength during the first year after injury. In addition, OT and client work on goals and skills that encourage the client towards community integration (i.e. driving, vocational evaluation and training, participation in leisure interests). Additionally, the therapist identifies transitional services such as support groups and transitional living centres if required. Finally, if the client requires customized splints for support, the OT can design this equipment. (8)

Occupational therapists are also involved with advocacy on behalf of their clients. Advocacy can take many forms and apply in areas that impact upon the clients ability to fully participate within their community. This includes helping to address barriers to employment, and leisure at a policy level. Examples of large barriers involving physical structures are playground designs, city planning, and accessible buildings. An OT can address decision makers, argue in favour of their clients needs and bring important information and perspectives to others who may be causing a barrier for the client. OTs can promote awareness, and lobby on behalf of clients. Advocating for clients to address issues such as social stigma is also done by OTs and this can be done through challenging others to think differently, and become aware of marginalization, and loss of privileges that can occur through our society. (21)



References

1. Canada. Canadian Institute for Health Information. The Burden of Neurological Diseases, Disorders and Injuries in Canada. Ottawa: Canadian Institute for Health Information; 2007. p. 91-102.

2. Atchison BJ, Dirette, D.K. Conditions in Occupational Therapy. Effect on Occupational Performance. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2007.

3. Tortora GJ, Nielsen MT, editors. Principles of Human Anatomy. Hoboken, NJ: John Wiley & Sons, Inc; 2009.

4. Canada. Canadian Institute for Health Information. Life After Traumatic Spinal Cord Injury: From Inpatient Rehabilitation Back to the Community. Ottawa: Canadian Institute for Health Information; 2006. p. 1-8.

5. Canadian Spinal Research Organization. Spinal Injuries [Online]. 2009 [cited 2010 April 15]; Available from: http://www.csro.com/index.php?option=com_content&view=article&id=51&Itemid=145

6. Canadian Paraplegic Association. [Online]. 2009 [cited 2010 April 15]; Available from: http://www.canparaplegic.org/en/

7. Pickett GE, Campos-Benitez M, Keller JL, Duggal N. Epidemiology of traumatic spinal cord injury in Canada. Spine. 2006; 31(7):799-805.

8. Radomski MV, Trombly Latham CA. Occupational therapy for physical dysfunction: 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008.

9. Krupa T, Fossey E, Anthony WA, Brown C. Doing daily life: how occupational therapy can inform psychiatric rehabilitation practice. Psychiatr Rehabil J.2009; 32(3), 155-161.

10. Canadian Association of Occupational Therapists. Enabling occupation: an occupational therapy perspective (Rev. ed.). Ottawa, (ON): CAOT Publications ACE; 2002.

11. Ackerman PM, Broton S, Gillot A, Hartrich J, Hopkins P. Activities of Daily Living. In: Sisto S, Druin E, Macht Sliwinski, M, editors. Spinal Cord Injuries: Management and Rehabilitation. New York (NY): Mosby Elsevier; 2009. p. 210-236.

12. Hunter-Zaworski, Nead R. Transportation, Driving and Community Access. In: Sisto S, Druin E, Macht Sliwinski M, editors. Spinal Cord Injuries: Management and Rehabilitation. New York (NY): Mosby Elsevier; 2009. p. 495-517.

13. Alverzo JP, Rosenberg JH, Sorensen CA, Shultz DeLeon S. Nursing Care and Education for Patients with Spinal Cord Injury. In: Sisto S, Druin E, Macht Sliwinski M, editors. Spinal Cord Injuries: Management and Rehabilitation. New York (NY): Mosby Elsevier; 2009. p. 37-68.

14. Ricciardi R, Szabo CM, Poullos AY. Sexuality and Spinal Cord Injury. Nurs Clin North Am 2007;42:675-684.

15. Tasiemski T, Bergstrom E, Savic G, Gardner, B. Sports, recreation and employment following spinal cord injury – a pilot study. Spinal Cord 2000;38:173-184.

16. Vissers M, Berg-Emons R, Sliuis T, Bergen M, Stam H, Bussmann H. Barriers to and facilitators of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre. J Rehabil Med 2008;40:461-467.

17. Pillastrini P, Mugnai R, Bonfiglioli R, Curti S, Mattioli S, Maioli MG, et al. Evaluation of an occupational therapy program for patients with spinal cord injury. Spinal Cord 2008;46:78-81.

18. Ozelie R, Sipple S, Foy T, Cantoni K, Kellogg K, Lookingbill J, et al. Classification of SCI rehabilitation treatments #8: SCI Rehab Project Series: The Occupational Therapy Taxonomy. J Spinal Cord Med 2009;32:283–297.

19. Di Marco A, Russell M, Masters M. Standards for wheelchair prescription. Aust Occup Ther J 2003;50:30-39.

20. Cohen ME, Schemm RL. Client-centered occupational therapy for individuals with Spinal Cord Injury. Occup Ther in Health Care 2007;21(3):1-15.

21. Townsend EA, Polatajko H. Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa, Ontario: CAOT Publications; 2007.

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