OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC C4 INCOMPLETE SPINAL CORD INJURY. A Doctoral Project A Comprehensive Case Analysis

Transcription

1 OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC C4 INCOMPLETE SPINAL CORD INJURY A Doctoral Project A Comprehensive Case Analysis Presented to the faculty of the Department of Physical Therapy California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHYSICAL THERAPY by David Lineback SUMMER 2017

2 2017 David Lineback ALL RIGHTS RESERVED ii

3 OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC C4 INCOMPLETE SPINAL CORD INJURY A Doctoral Project by David Lineback Approved by:, Committee Chair Bryan Coleman-Salgado, PT, DPT, MS, CWS, First Reader Katrin Mattern-Baxter, PT, DPT, PCS, Second Reader Michael McKeough, PT, EdD Date iii

4 Student: David Lineback I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project., Department Chair Michael McKeough, PT, EdD Date Department of Physical Therapy iv

5 Abstract of OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC C4 INCOMPLETE SPINAL CORD INJURY by David Lineback A patient with incomplete C4 spinal cord injury was seen for outpatient physical therapy treatment for 16 sessions over 8 weeks at a university outpatient pro bono clinic. All treatment sessions were administered by a student physical therapist under the direct supervision of a licensed physical therapist. Upon physical therapy evaluation, the patient s functional limitations were assessed with the 6 Minute Walk Test, 10 Meter Walk Test, the Walking Index for Spinal Cord Injury, Spinal Cord Injury Spasticity Evaluation Tool, and assistance required during transfers. Goals were established to evaluate improvement of the patient s gait speed and endurance, and decrease assistance required during gait and transfers. Treatments included over-ground gait training, balance training, transfer training, lower extremity and trunk strengthening, endurance training, and caregiver education. Improvement in these functional limitations was important for the patient to regain leisure activities within the community. v

6 The patient was discharged to home with his wife and caregiver, and was provided a home exercise program to promote further progress towards functional independence., Committee Chair Bryan Coleman-Salgado, PT, DPT, MS, CWS Date vi

7 ACKNOWLEDGEMENTS I acknowledge California State University, Sacramento and the Department of Physical Therapy for providing a medium for me to learn about individuals with neurological disorders, as well as the proper rehabilitation equipment, facility grounds, and supervision to treat patients with neurological disorders. vii

8 TABLE OF CONTENTS Page Acknowledgements... vii List of Tables... ix Chapter 1. GENERAL BACKGROUND CASE BACKGROUND DATA EXAMINATION TESTS AND MEASURES EVALUATION PLAN OF CARE GOALS AND INTERVENTIONS OUTCOMES DISCUSSION References viii

9 Tables LIST OF TABLES Page 1. Medication Table Examination Table Evaluation and Plan of Care Outcomes ix

10 1 Chapter 1 General Background Spinal cord injury (SCI) is a traumatic or non-traumatic event that can cause dysfunction to the motor, sensory, and autonomic systems at, and below, the level of lesion. 1 Damage to the spinal cord can have profound global effects on an individual, and can lead to reduced mobility, as well as impairment of vocational and self-care abilities, and a large increase in monetary burden. 2,3 It is estimated that 17,000 new cases of SCI occur each year in the United States, with average age at injury of 42 years old. 4 It is also estimated that, in 2016, approximately 282,000 persons in the United States are currently living with SCI. 4 Spinal cord injuries are commonly traumatic in nature, and traffic accidents are the most common cause of SCI, followed by falls, sports and recreation accidents, and acts of violence. 5 Given the accidental nature of most SCI, it is difficult to discern direct risk factors. However, epidemiological studies have shown that, in the United States, males account for approximately 80% of new SCI, Caucasians and African-Americans comprise the vast majority of patients with SCI, and SCI is mostly seen in those who lead an active lifestyle. 4,6,7 Spinal Cord Injury can occur at any level of the vertebral column, with the most common anatomical region being the cervical spine, ranging from 43.9% % of all cases. 5 Spinal cord injuries occur as a result of trauma to the vertebral column, in which the spinal cord sustains damage due to impingement by bony or soft tissue structures, penetration, ischemia, traction, or inflammation. 2 In traumatic SCI, primary

11 2 and secondary injury mechanisms are responsible for neuronal damage, affecting the functions at the level of lesion and extending caudally. 2,8 The American Spinal Injury Association (ASIA) established a method for classifying SCI based upon clinical presentation of symptoms, called the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). 9 Based on the ISNCSCI, patients are evaluated on the extent of motor and sensory deficits at each spinal segment. 9 Patients are then assigned a level on the ASIA Impairment Scale (AIS), rated A E, where AIS-A is a complete injury with no motor or sensory function preserved below the lesion, and AIS-E would indicate normal motor and sensory function. 9 Levels B, C, and D on the AIS scale refer to incomplete SCI, where motor and/or sensory function is preserved below the level of lesion. Neurologic recovery occurs most rapidly during the first three months and continues for the first year after injury; any recovery after one year is typically minimal. 2,10-12 Early physical therapy (PT) intervention is essential in maximizing the recovery following SCI. Physical therapy intervention varies depending on the AIS level of impairment; patients with AIS-A typically receive stretching, strengthening, and transfer training, while patients at AIS-D may focus on gait training, strengthening, and balance exercises. 13 Factors contributing to a positive prognosis of an individual following SCI include: an incomplete lesion, preservation of motor and pinprick sensory function below the level of lesion, younger age at time of injury, and early neurological return. 2,12

12 3 Chapter 2 Case Background Data Examination History The patient was a 58-year-old male retiree who was self-referred to PT following a C4 AIS-D SCI approximately one year prior to PT evaluation. The injury occurred while playing basketball when the patient struck his head on the post supporting the hoop. There was no traumatic brain injury or loss of consciousness, however, and the patient was immediately unable to stand up and recalled a loss of sensation. Following imaging procedures, the patient was diagnosed with C3/4 spinal contusion. He spent 11 days in the acute-care hospital, where he did not receive physical rehabilitation. The patient was transferred to a post-acute facility at which he received PT five times per week for three weeks. The patient was then moved to a different rehab facility where he stayed for two months, and reported receiving PT on only two occasions prior to being discharged to home. Multiple imaging modalities were used in this case. Contusion of the cervical spinal cord at C4 was confirmed by magnetic resonance image (MRI). Brain trauma was ruled out with computed tomography (CT). Osteoporosis was ruled out using a bone-density scan prior to approval of a standing-frame. Multiple radiographs were used to rule out bone fracture and confirm skeletal integrity at various levels. It is noteworthy and possibly contributory that the patient had a history of two cervical spinal fusion surgeries. The first in 1993 and the second in 2008 resulting in fusion of C4 through C6, due to the segments pressing against the spinal cord.

13 4 Prior to injury, the patient worked in an office and spent the majority of his day working at a computer. For exercise, he would intermittently walk in his neighborhood or play golf, but lived an otherwise sedentary lifestyle. Following the injury, the patient used a power-chair as his primary mode of locomotion and had various equipment and home modifications, including multiple wheelchair ramps, a platform 4-wheeled-walker (4WW), bilateral ankle-foot orthoses (AFO), hospital bed, ceiling lift, shower seat, handheld shower head, standing frame, Hoyer lift, and therapy table. His family, primarily his wife, was very involved in his rehabilitation and 24-hour care, and he also had a caregiver for 8 hours per day 5 days per week. The patient was unable to return to work due to the injury, and could not resume light exercise, such as playing golf and going for walks. During PT evaluation, the patient reported his chief complaints were the inability ambulate independently, dependence for bowel and bladder care, inability to balance independently, and the inability to perform fine motor movements with his bilateral upper extremities (UE). He had no signs of heterotopic ossification, and had no history of autonomic dysreflexia. The patient reportedly received BOTOX injections to bilateral UEs two weeks prior to evaluation to improve comfort. The patient s goal for PT was to ambulate independently. Systems Review The patient s cardiovascular system was unimpaired based upon patient report and measurement; resting blood pressure was 122/75 and resting pulse rate was 68 beats-per-minute. The musculoskeletal system was impaired, based upon deficits

14 5 found in strength measurements. The neuromuscular system was impaired, based on assessments of balance and gait. The integumentary system was unimpaired, based upon patient report and observation. A scar on the left forehead and on the posterior neck were noted, both well healed. The urogenital and gastrointestinal systems were impaired, based upon patient report. The patient s communication, cognition, language, and affect were all unimpaired, based upon observation and interactions. The patient s wife reported intermittent bouts of depression since injury, which was being treated with antidepressant medication. Examination Medications Table 1. Medications MEDICATION DOSAGE REASON SIDE EFFECTS Baclofen 20mg, 1 tablet QID Muscle relaxant; taken for spasms Lightheadedness, confusion, headache, nausea, constipation, skin rash, seizures, fatigue, Duloxetine HCL 60mg QD Serotonin and Norepinephrine reuptake inhibitor; taken for neuropathic pain Pregabalin 200mg BID GABA analog; taken for neuropathic pain Simvastatin 10mg QD Antihyperlipidemic; taken for high cholesterol Bupropion 75mg QD Antidepressant; taken for depressive moods weakness Dry mouth, constipation, nausea, decreased appetite, lightheadedness, confusions, weakness, restlessness, skin rash, itching Skin rash, itching, hives, double vision, fever, chills, muscle pain, weakness, dizziness, drowsiness, depression, constipation, dry mouth, confusion Dizziness, fainting, irregular heartbeat, fever, flushed skin, headache, fever, chills, loss of consciousness, nausea, vomiting, muscle cramps, spasms Anxiety, dry mouth, hyperventilation, irregular heartbeat, shortness of breath,

15 6 Melatonin 3mg QD, taken minutes before bed Abbreviations BID twice a day GABA Gamma-aminobutyric acid mg - milligrams QD once a day QID four times a day Hormone; taken for sleep regulation trouble sleeping, tinnitus, headache, skin rash, confusion, seizures Daytime drowsiness, depressed mood, irritability, stomach pain, headache, dizziness

16 7 Chapter 3 Examination Tests and Measures In order to categorize the patient s limitations, the International Classification of Functioning, Disability and Health (ICF) Model was applied to this case. 14 The ISNCSCI motor scale, Balance Master, Modified Ashworth Scale (MAS), and timed static standing were used to evaluate impairments at the body function/structure level. The 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), Walking Index for Spinal Cord Injury II (WISCI II), transfer assistance level, and Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) were used to assess limitations at the activity level. Patient report was used to evaluate restrictions at the participation level. The 10MWT is a commonly used outcome measure in patients with incomplete SCI that evaluates gait speed. 15 The subject is instructed to walk at his or her preferred pace for 10 meters while time is recorded. The patient was allowed two meters to reach his preferred pace prior to the start of timing, and two meters after timing had ceased to slow down. Gait speed is then calculated based upon the time it took the subject to complete the task. Normative data for patients with tetraplegia at AIS-D revealed an average time of 0.87 m/s. 16 The minimal detectable change at the 95% Confidence Interval (MDC 95 ) for the 10MWT in individuals with chronic SCI is 0.13 m/s, which indicates the minimum amount of change necessary in a subject s score to ensure that the change is not due to measurement error. 15,17 The minimally clinically important difference (MCID) for the 10MWT in individuals with chronic

17 8 SCI is 0.06 m/s, which specifies the change in scores necessary for the patient to truly feel a difference in his or her performance. To measure strength, the ISNCSCI motor scale was utilized for this patient. The ISNCSCI is a widely used evaluation tool for measuring the severity of SCI, and measuring its progression over time. 18 Strength is assessed in supine for myotomes C5-T1 and L2-S1 by testing key muscles for each respective level. Muscle strength is graded on a 0-5 scale, with 0 representing total paralysis, and 5 indicating active movement through full range of motion (ROM) against gravity and full resistance. The motor scale of the ISNCSCI yields an MDC 95 of 1 point for each myotome and has excellent interrater reliability (ICC = 0.99); this indicates that improvement by 1 point for a myotome ensures that measurement error is not responsible for the change, and that there is very little variation between raters with this measure The 6MWT is a submaximal gait test that assesses aerobic capacity and muscular endurance. The subject is instructed to walk as far as possible in six minutes, while timed and measured by the tester. Subjects are able to use assistive devices during testing, as long as the assistive device remains consistent between trials. In patients with chronic SCI at the AIS-D, the average distance covered during the test is meters, and the MDC 95 for patients with chronic SCI is meters. 15,20 The WISCI II is an outcome measure used to evaluate assistance needed during gait, including braces, assistive devices, and physical assistance. The scale ranges from 0 to 20, where 0 indicates the subject is unable to stand and/or participate in assisted walking, and 20 represents ambulation without assistance for at least 10

18 9 meters. 21 For patients with chronic SCI, the WISCI II has an MDC 95 of 0.785, indicating that a change of 1 level is significant. It also has excellent test-retest reliability (ICC = 0.994), and excellent interrater reliability (ICC = 0.98). 21,22 Spasticity is a velocity-dependent involuntary resistance to passive muscle stretching that is a common sequela to upper motor neuron lesions. 2,23 The MAS was used to diagnose and grade the presence of spasticity in this patient, as it is a commonly used diagnostic tool for spasticity in patients with upper motor neuron lesions. 2 The grades of the scale range from 0 to 4, with zero indicating no increase in muscle tone, and four signifying the affected limb is rigidly fixed in flexion or extension. 23 In patients with stroke, the MAS yielded a sensitivity of 0.5 and specificity of 0.92, indicating it has utility for ruling in the presence of spasticity. 24 From these values, a positive likelihood ratio (LR+) of 6.25 and negative likelihood ratio (LR-) of 0.54 were calculated. The +LR is representative of a moderate shift in the posttest probability of a patient having spasticity. Because spasticity is a phenomenon of upper motor neuron lesions, these psychometric values are valid for patients with SCI. Prognosis for recovery from chronic SCI at one year follows the typical pattern for neurological recovery; the majority of functional recovery occurs within the first year post-injury, and typically tapers off considerably around the one-year mark. 11 Common positive prognostic factors for acute SCI include age younger than 65 years old, presence of light touch or pinprick sensation, incomplete injury, AIS grades of C or D, and early neurological return. 2,10-12,25 While these factors are not specific to

19 10 chronic SCI, individuals with chronic SCI who possess these positive factors will have a better prognosis for regaining function. However, at one-year post-injury the course of neurological recovery is truly the main limiting factor. It is difficult for an individual to make large gains in function, regardless of the amount of positive factors present. Table 2. Examination Table Measurement Category Standing posture BODY FUNCTION OR STRUCTURE Test/Measure Used Test/Measure Results Therapist Observation Center of mass is translated posteriorly. To compensate for this posterior shift, the patient hyperextends at the knee joint and flexes at the hip joint. The pelvis is shifted anteriorly, which causes the lower thoracic and lumbar spine hyperextension in order to stay upright. Patient reported pain 2-4/10 in low back with standing, pain was relieved to 0/10 with sitting Weight distribution in static standing Static Standing Balance Balance Master Stopwatch Lateral (Right/left) Right = 60% Left = 40% Patient could maintain 60/40 distribution for ~30 seconds before deviating. Anterior/Posterior (w/ AFOs) Anterior = 40-45% Posterior = 55-60% Patient could maintain 40-45/55-60 for ~45 seconds before deviating. Anterior/Posterior (w/o AFOs) Anterior = 50% Posterior = 50% Patient could maintain A/P distribution more evenly w/o use of AFOs. Static Standing A total of 2 minutes of static standing was performed w/o assistance or AFOs prior to loss of balance. Time was stopped when patient required physical assistance to maintain balance.

20 11 Spasticity Modified Ashworth Scale Muscle Tested Right Left Biceps Brachii 1+ 0 Triceps Brachii Pectoralis Major 1+ 1 Iliopsoas 1 0 Quadriceps Femoris 3 3 Hamstrings 0 0 LE Adductors 2 3 Plantarflexors 3 3 Dorsiflexors 0 0 ASIA Impairment Scale Measurement Category ISNCSCI Key Muscles Right Left (Nerve root) Elbow Flexors (C5) 4 5 Wrist Extensors (C6) 4 4 Elbow Extensors (C7) 4 4 Finger Flexors (C8) 4 4 Finger Abductors (T1) 3 2 Hip Flexors (L2) 3 4 Knee Extensors (L3) 4 5 Ankle Dorsiflexors (L4) 3 3 Long Toe Extensors (L5) 1 4 Ankle Plantarflexors (S1) 4 4 Pin-prick sensation was preserved above the T8 dermatome, while light-touch was preserved above the T12 dermatome and was more affected on the right side. FUNCTIONAL ACTIVITY Test/Measure Used Test/Measure Results Gait speed 10 Meter Walk Test The 10MWT was modified for the patient s deficits in ambulation. The test was performed in an overhead harness track system, while wearing bilateral AFOs and using a reverse walker and minimum assistance from 1 PT and 1 SPT. The track was not straight and involved various turns; therefore, the patient was required to perform 2 right turns during the Trial 1, and 1 right turn during Trial 2. The patient was not un-weighted by the harness, and it was only utilized for safety purposes. Trial 1: 4 min 30 sec o Trial 2: 5 min 25 sec o Pre-activity RPE = 6/20, postactivity RPE = 14/20, post-activity RPD = 2/10 Pre-activity RPE = 6/20, postactivity RPE = 15/20, post-activity

21 12 RPD = 2/10 Average time: 4:57.50 (0.034 m/s) Gait endurance 6 Minute Walk Test The patient performed the 6MWT while using the overhead harness system, a reverse walker, bilateral AFOs, and minimum assistance from 1 PT and 1 SPT. The patient performed 3 right turns during this test. The patient was not un-weighted by the harness, and it was only utilized for safety purposes. Trial 1: meters o Pre-activity RPE = 6/20, postactivity RPE = 15/20, post-activity RPD = 2/10 Sit to stand transfers Assistance Level Moderate assistance required to complete transfer from wheelchair with use of bilateral armrests. Stand-pivot transfers Assistance Level Moderate assistance without AD required to assist with weight shifting, balance, and pivoting. Gait assistance WISCI II WISCI Level 2: ambulates in parallel bars, with bilateral AFOs and physical assistance of two persons for 10 meters. Parallel bars were 2 meters in length, patient performed four 180 turns in order to complete 10 meters. Impact of spasticity on daily life SCI-SET Negative score: -38 Positive score: 6 Total score: -32 Individual s average score: Bed mobility Assistance level Patient required maximum assistance for rolling and supine-to-sit. Patient s caregiver reported providing the same amount of assistance during bed mobility tasks at home. Patient reported right shoulder pain during right side-lying. PARTICIPATION RESTRICTIONS Test/Measure Used Test/Measure Results Measurement Category Community, leisure, Patient report and vocational involvement Abbreviations 6MWT 6 Minute Walk Test 10MWT 10 Meter Walk Test AD Assistive device ADL Activity of daily living AFO Ankle-foot orthosis ISNCSCI International Standards for Neurological Classification of Spinal Cord Injury PT Physical therapist RPD Rating of Perceived Dyspnea Unable to return to work, independently attend community outings, or perform recreational physical activities.

22 RPE Rating of Perceived Exertion SCI-SET Spinal Cord Injury Spasticity Evaluation Tool SPT Student Physical Therapist WISCI II Walking Index for Spinal Cord Injury 13

23 14 Chapter 4 Evaluation Evaluation Summary The patient was a 58-year-old male one-year post SCI at C4 and AIS-D. The injury affected all aspects of the patient s life, and he was dependent on 24-hour assistance for all activities of daily living (ADLs) and functional mobility. The patient was found to have deficits in UE and lower extremity (LE) strength, static standing balance, gait, functional mobility, and walking endurance. The patient was also found to have varying levels of bilateral UE and LE spasticity. Diagnostic Impression The medical diagnosis of C3/4 spinal contusion was consistent with an incomplete SCI involving all segments at and below the level of contusion. The patient was determined to be AIS-D at the level of C4 according to the ISNCSCI. The impairments at the body function/structure level were bilateral UE and LE weakness, impaired static standing balance, uneven weight distribution in standing, and spasticity in the knees and ankles, bilaterally. These impairments contributed to activity limitations of decreased gait speed, decreased walking endurance, the need for assistance during gait and transfers, and decreased independence for ADLs. The patient s activity limitations contributed to an inability to work in his previous occupation, attend community outings independently, and resume previous recreational physical activities.

24 15 Prognostic Statement The patient s positive prognostic factors included age younger than 65, SCI rated at AIS-D, strong family/social support, high motivation for rehab, and access to medical care and alternative rehabilitation services. The main negative prognostic factor was the chronicity of the injury. The patient s wife was highly involved in the patient s rehabilitation, and in addition to PT, he attended a gym twice a week that specialized in exercise for patients neurological disorders. During the 8-week treatment program, the patient was not expected to make large functional improvements due to neurological recovery having run much of its course. However, the patient s impairments and functional limitations were expected to improve enough to decrease caregiver burden and to increase community participation. G-Codes Current with modifier: G8978-CM Mobility: Walking and Moving Around; functional limitation. Current status. Based on the WISCI II. Goal with modifier: G8979-CK Mobility: Walking and Moving Around; functional limitation. Projected goal. Based on the WISCI II. Discharge Plan Patient was to be discharged to continue living at home with a home exercise program (HEP) and recommendation to continue seeking further PT and rehabilitation through any means possible. Wife and caregiver were to be instructed on assisting the

25 16 patient with performing the HEP, and strategies to decrease their burden while assisting the patient with ADLs.

26 17 Chapter 5 Plan of Care Goals and Interventions Table 3. Evaluation and Plan of Care PROBLEM Asymmetrical weight distribution during static standing PLAN OF CARE Long Term Planned Interventions Goals Interventions are Direct or Procedural unless (8 weeks) they are marked: (I) = Coordination of care intervention (E) = Educational intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS Patient will Interventions for weight distribution challenged improve weight the strength and motor control of trunk distribution musculature. Emphasis was placed on visual during standing feedback to augment weight distribution, by to a R/L use of a mirror and the Balance Master. distribution of 50/50%, as measured by Balance Master. Short Term Goals (4 weeks) Patient will improve weight distribution during standing to a R/L distribution of 55/45%, as measured by Balance Master. Interventions took place on flat ground with parallel bars for nearby support for safety, and on the Balance Master with a walker nearby for safety. When using the parallel bars, patient was instructed to use the mirror to find neutral postural alignment and weight distribution while using support, and then to let go of the parallel bars and hold that position. Verbal and tactile cues were used to promote gluteal activation and neutral posture. Once the patient showed ability to hold neutral alignment, the therapist provided light resistance in the anterior/posterior and lateral directions, for ~2 seconds in each direction. The amount of resistance and repetitions were adjusted based on patient response during treatment. The patient was also challenged with head and trunk rotation while maintaining neutral alignment and balance. The Balance Master was used to provide realtime feedback on weight distribution in standing. The patient was challenged to correct his weight distribution in the anterior/posterior and right/left directions to 50/50% and hold that position for as long as possible. Early in treatment, patient was instructed to keep his weight distribution between 60/40% in the right/left and anterior/posterior. As treatment

27 18 progressed, the window was narrowed as appropriate for the patient. Time was recorded to track his performance within the given distribution window, time was stopped when the patient deviated out of the window or contacted the assistive device. Trunk strengthening exercises also took place in supine and side-lying, with emphasis on improving core strength and stability, using manual resistance. The patient was placed in left side-lying, and instructed to hold that position while the therapist provided manual resistance into supine for 5 seconds x10. In side-lying, a 60 wedge was placed behind the patient, and he was instructed to roll slowly back onto the wedge, and then return to sidelying, with emphasis on eccentric control during lowering onto the wedge. The patient was later progressed to a 45 wedge. Due to right shoulder pain, the patient was unable to tolerate right side-lying, and these techniques were only performed in left side-lying. (E) The patient s caregiver was instructed to decrease assistance provided during bed mobility, specifically during rolling, in order to functionally challenge the patient s trunk control. The patient was instructed on using momentum to assist with rolling in bed. This was added to the patient s HEP. Impaired static standing balance Patient will improve static standing balance to 3 minutes prior to a loss of balance requiring assist to recover Patient will improve static standing balance to 4 minutes total, prior to a loss of balance requiring assist to recover Static standing interventions occurred concurrently with weight distribution, and utilized many of the same techniques geared towards improving balance through a means of strength and neuromuscular control. See above interventions for weight distribution for details on interventions for static standing balance. (E) The patient was provided bridging exercises as a part of his HEP. Given the lack of gluteal activation and excessive anterior tilt of the pelvis in standing, the patient was instructed on the importance of improving gluteal strength and control. Supine bridging 3 sets x 15 reps was added to the HEP. Decreased hip flexor strength No change in strength expected in Patient will increase strength of right Hip flexor strength was addressed through gait activities. The patient struggled with foot clearance in the swing phase of gait, and hip

28 19 right hip flexors, as measured by ISNCSCI. hip flexors to 4/5, as measured by ISNCSCI. flexor strength was challenged through functional activities. In order to facilitate hip flexion during gait, a high resistance blue Theraband was placed on the along the anterior surface of the patient s hip. Decreased knee extensor strength No change in strength expected in right knee extensors, as measured by ISNCSCI. Patient will increase strength of right knee extensors to 5/5, as measured by ISNCSCI. Knee extensor strength was addressed with functional activities, gait training, and resistance training. Sit to stand exercises from the patient s power wheelchair within parallel bars with emphasis on eccentric control was used to improve knee extensor strength. Patient was able to perform 1 set x 5 reps with ~1 minute of rest between reps. The emphasis on eccentric control included slow lowering, stopping mid-way between sitting and standing, and either sitting or returning to standing from that position. Verbal cues emphasized proper sequencing of transfer and gaining momentum prior to initiating the transfer. Treatment was progressed by lower the seat height and minimizing verbal cues for sequencing. The NuStep Recumbent Trainer was also be utilized to at higher resistance levels to promote a mix of strengthening and endurance. The NuStep was initially set at a workload level of 5 for 5 minutes, and was increased as appropriate in later treatment sessions up to level 7 for 5 minutes. Decreased gait speed Patient will increase gait speed, as measured by 10MWT, to 0.10 m/s using bilateral AFOs, a reverse walker, and overhead harness support system with standby assistance. ACTIVITY LIMITATIONS Patient will Over-ground walking training was the main increase gait intervention to improve gait speed. The patient speed, as initially began treatment using two stock measured by AFOs, a reverse walker, and bodyweight 10MWT, to supported harness system. While the patient 0.20 m/s using was wearing the support harness, the patient bilateral AFOs, was actually not unweighted at all, and the a reverse harness was simply for patient safety. The walker, and patient was instructed to walk for as long as overhead possible, while RPE was monitored by the harness support therapist, and walking was ceased with an RPE system with > 15 or by request of the patient. Over-ground standby walking training occurred indoors on a assistance. combination of smooth flooring and carpet, and outdoors on uneven surfaces. After 3 weeks of treatment, the patient received

29 20 custom-fit AFOs, as well as a new platform 4WW. There was a period of adjustment for the patient, as he reported the custom AFOs felt different than the stock AFOs, and there was a trial-and-error period for determining whether he preferred the reverse walker or platform 4WW. Treatment during this period followed the same pattern, and simply involved the patient walking as much as he could tolerate within one treatment session. In various treatment sessions, a heavyresistance blue Theraband was used on the patient s bilateral LEs to promote dorsiflexion, knee flexion, and hip flexion during gait. The Theraband was fastened around the distal metatarsals, and coursed anterior to the ankle, posterior to the knee, and anterior to the hip, and tied around the patient s waist. This technique was typically used during sessions where the patients struggled with foot clearance during the swing phase of gait. Approximately two weeks after receiving custom AFOs, the patient developed bilateral pressure injuries on the plantar surfaces of the 5 th metatarsals. (C) An on-site Certified Wound Specialist PT evaluated the pressure injuries and recommended a reduction in weight bearing activities for one week. (C)The patient was referred back to his orthotist in order to have the AFOs adjusted to address the areas of increased pressure. Decreased gait endurance Patient will increase walking endurance, as measured by the 6MWT, to 35 meters using two AFOs, a reverse walker, and overhead harness support system with standby assistance. Patient will increase walking endurance, as measured by the 6MWT, to 60 meters using two AFOs, a reverse walker, and overhead harness support system with standby assistance Interventions for gait endurance were addressed through over-ground walking and the NuStep recumbent trainer. To promote aerobic endurance on the NuStep, the patient will be set at a lower resistance and a longer duration than when it is used for strengthening. The NuStep was set at workload of 5 and lasted for 20 minutes during the first treatment session. Workload and duration was increased as appropriate throughout the course of treatment, finishing at a workload of 7 for 25 minutes. The patient was often provided goals to maintain his pace above a particular steps/min. Gait endurance training occurred concurrently with gait speed. See above for details on gait interventions.

30 21 Assistance required during gait Patient will decrease assistance needed during gait, as measured by WISCI II, to level 5 (ambulates in parallel bars, with braces and no physical assistance, 10 meters). Patient will decrease assistance needed during gait, as measured by WISCI II, to level 9 (ambulates with walker, with braces and no physical assistance, 10 meters). Gait assistance was addressed with overground gait training. See above for gait interventions. (E) The patient was instructed to walk at home as a part of his HEP. The caregiver was instructed on proper guarding during walking, and how to assess the patient s feet for pressure injuries following use of his AFOs. Assistance required for sit-to-stand transfers Patient will decrease assist level required for sit-to-stand transfers from wheelchair using armrests to min assist, as measured by SPT. Patient will decrease assist level required for sit-to-stand transfers from wheelchair using armrests to contact-guard assist, as measured by SPT. Interventions for sit to stand transfers included task-specific training with an emphasis on eccentric control and proper sequencing. Training also consisted of varying seat heights as a progression for the task. Training took place within parallel bars as well as with a 4WW. Sit to stand exercises from the patient s power wheelchair within parallel bars with emphasis on eccentric control was used to improve knee extensor strength. Patient was able to perform 1 set x 5 reps with ~1 minute of rest between reps. The emphasis on eccentric control included slow lowering, stopping mid-way between sitting and standing, and either sitting or returning to standing from that position. Treatment was progressed by lower the seat height and minimizing verbal cues for sequencing. (E) Sit-to-stand training was added to the patient s HEP, and the caregiver was instructed in properly facilitating transfers by cuing sequencing and adjusting the seat height. Assistance required for stand-pivot transfers Patient will decrease assist level required for standing pivot transfers without AD to min assist, as measured by SPT. Patient will decrease assist level required for standing pivot transfers without AD to contact-guard, as measured by SPT. Stand-pivot training was addressed with taskspecific training in conjunction with sit to stand training. Training mainly took place within the parallel bars, and the patient practiced 180 pivot turns without physical assistance, while maintaining adequate posture. Stand pivots were also practiced from wheelchair to mat and wheelchair to chair.

31 22 Limited community and leisurely outings No changes expected in participation restrictions, as measured by patient and wife report. PARTICIPATION RESTRICTIONS Patient will be able to participate in a light exercise program of walking in the community w/ platform 4WW, bilateral AFOs, and standby assist. Patient will improve in this category by a combination of all the above interventions. (E) The patient s HEP consisted of bed mobility, sit-to-stand transfers, bridging, and over-ground gait training. The patient s wife and caregiver were provided with strategies to lessen their burden on assistance with bed mobility, transfers, and basic ADLs. Abbreviations 4WW Four wheeled walker 6MWT 6 Minute Walk Test 10MWT 10 Meter Walk Test AD Assistive device ADL Activity of daily living AFO Ankle-foot orthosis HEP Home exercise program ISNCSCI International Standards for Neurological Classification of Spinal Cord Injury LE Lower extremity SPT Student Physical Therapist R/L Right/Left RPE Rating of Perceived Exertion WISCI II Walking Index for Spinal Cord Injury Plan of Care Interventions See Table 3. Overall Approach The theoretical model guiding this plan of care was an activity-dependent neural plasticity approach. The emphasis of this approach is to focus on recovery of a task with the objective to minimize compensation and activate the neuromuscular system below the level of lesion Task-specificity, high repetition, and high intensity training were all underlying principles tied into the approach to stimulate positive neural plastic changes. 26,27 The patient received a variety of interventions specific to the desired function, such as gait tasks, transfer training, and balance

32 23 exercises. The overload principle was also applied in order to determine the dosage of interventions within each session. The patient s capacity for gait speed, endurance, assistance, balance, strength, and transfers were challenged slightly beyond maximal capacity in order to promote physiologic adaptations. These techniques were utilized during treatment sessions and incorporated into the HEP. PICO question For patients with incomplete C4 SCI at AIS-D (P), is over-ground gait training (I) more effective than treadmill training (C) for improving gait speed and distance (O)? A single-blind randomized controlled trial (Sackett Level 1B) was assessed for this PICO. Field-Fote and Roach investigated the effects of four different types of gait training on gait speed and gait distance in individuals with chronic SCI: treadmillbased training with manual assistance (TM), treadmill-based training with electrical stimulation (TS), over-ground training with electrical stimulation (OG), and treadmillbased training with robotic assistance (LR). 29 Participants for the study included those with chronic SCI for 1 year, AIS-C or D, injury at or above T10, ability to take at least one step with one leg, and ability to rise to a standing position with, at most, moderate assistance from 1 other person. 29 There were 64 total participants that completed the trial, and each was stratified into their respective groups based upon Lower Extremity Motor Score (LEMS) results. The investigators hypothesized that the TS group would show the greatest improvements in both walking speed and walking distance. However, the results of the trial yielded moderate effect sizes only in the OG

33 24 group for gait speed (d = 0.43) and gait distance (d = 0.40), which was the largest effect size of any group in the trial. While electrical stimulation was used for subjects in the OG group to assist with ankle dorsiflexion during swing phase, it was also used in subjects in the TS group. Therefore, because electrical stimulation was controlled between the OS and TS groups, it was controlled for the improvement between treatment groups. The patient s presentation of chronic C4 incomplete SCI at AIS-D, ability to take a step with one leg, and moderate assistance needed for sit to stand transfers, fit well into the inclusion criteria for this study. Gait interventions for this patient were based upon the findings that over-ground walking produced the most substantial improvements in gait speed and gait distance. Subjects in this study were also allowed to use any orthotics or assistive devices necessary for ambulation, which was consistent with the patient, who preferred a platform four-wheeled walker (4WW) and AFOs for gait. For the patient s goal of regaining community ambulation, it was most appropriate to provide a task-specific intervention of over-ground gait training to work towards the goal of community ambulation. The OG treatment approach was likely more effective than TS simply due to the specificity of the task. The goal of gait training in this population is often to improve community ambulation, and over-ground gait training simulates this more closely than treadmill training. A limitation in this study was the lack of evidence to support the treatment dosage, frequency, and length of care. The interventions were planned as five days per week for 12 weeks, and patients were to aim for an RPE of

34 While this dosage lacks supporting research, it is likely an appropriate amount to stimulate improvement. Also, the OG group consisted of the largest proportion of participants who were less impaired and who met, or exceeded, the MCID for walking speed. Lastly, only a small percentage of subjects participated in the follow-up assessment of retention of ambulatory skills.

35 26 Chapter 6 Outcomes Table 4. Outcomes OUTCOMES BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Measure Initial Follow-up (DC) Change Goal Met? (Y/N) Weight distribution (Balance Master) Static standing balance (stopwatch) R/L: 60/40% R/L: 50/50% R/L: +10/-10% Yes 120 seconds 45 seconds -75 seconds No Right hip flexor strength (ISNCSCI) Right knee extensor strength (ISNCSCI) 3/5 3/5 No change MDC: 1/5 4/5 4/5 No change MDC: 1/5 No No ACTIVITY LIMITATIONS Outcome Measure Initial Follow-up (DC) Change Goal Met? (Y/N) 10MWT m/s m/s m/s No MDC: 0.13 m/s 6MWT meters meters meters No MDC: meters WISCI II Level 2: ambulates in parallel bars, with braces and physical assistance of two persons, 10 meters Level 9: ambulates with walker, with braces and no physical assistance, 10 meters + 7 levels MDC: 1 level Yes

36 27 Sit-to-stand transfers (assistance level) Moderate assistance Minimal assistance +1 assistance level No Stand-pivot transfers (assistance level) Moderate assistance Minimal assistance +1 assistance level No PARTICIPATION RESTRICTIONS Outcome Measure Initial Follow-up (DC) Change Goal Met? (Y/N) Patient report of community outings Discharge Statement: Patient is unable to participate in light walking program within the community Patient is unable to participate in light walking program within the community with standby assist No change Abbreviations: 6MWT 6 Minute Walk Test 10MWT 10 Meter Walk Test ISNCSCI International Standards for Neurological Classification of Spinal Cord Injury MDC Minimal detectable change R/L Right/Left WISCI II Walking Index for Spinal Cord Injury The patient attended outpatient PT for rehabilitation of chronic deficits due to C4 incomplete SCI for 16 total visits over the course of 8 weeks. Interventions provided included gait training geared towards improving speed, endurance, and assistance level, balance training, LE and trunk strengthening, patient education for proper use of assistive devices, caregiver training, and a home evaluation. Weight distribution was improved from a R/L distribution of 60/40% to 50/50%, and WISCI II increased from level 2 to level 9, indicating the patient was able to ambulate with a platform 4WW, bilateral AFOs, and no physical assistance for 10 meters. The patient s caregiver and wife noted reductions in burden of care throughout the course of treatment and at discharge. There was a brief one-week period where weight- No

37 28 bearing activities could not be performed due to bilateral pressure injuries on the patient s LEs. The patient was discharged to continue living at home with wife and caregiver, with a HEP to promote further progress towards more independence in gait, transfers, and functional ADLs. DC G-Code with modifier G8980-CK Mobility: Walking and Moving Around; functional limitation. Discharge status. (CK = At least 40% but less than 60% impaired, limited, or restricted). Based on WISCI II.

38 29 Chapter 7 Discussion The plan of care for this patient focused on improving gait speed, gait endurance, standing balance, functional transfers, and decreasing gait assistance. Interventions were based on a theoretical model of activity-dependent neural plasticity with emphasis on task-specificity, high repetition, high intensity, and the overload principle. Overall, the patient was unable to make significant improvements in functional independence despite exhibiting a high level of motivation for PT. The chronicity of the injury, age at onset of injury, presence of UE and LE spasticity, and lack of early rehabilitative interventions were likely the main factors limiting this patient s functional recovery. In my treatment of future patients with similar conditions, more consideration will be given to outcome predictors when setting treatment goals. Treatment was expected to yield greater improvements than those measured at discharge. The patient began gait treatment using a reverse walker and stock AFOs, but soon thereafter received custom AFOs and a platform 4WW. This custom equipment was predicted to improve the patient s performance in gait. However, the time is required to acclimate to the 4WW and AFOs, and the pressure injuries caused by the AFOS, both took away from treatment time. The patient also struggled to make improvements due to the presence of spasticity in his UEs and LEs. The patient had recently received BOTOX injections in his UEs, but did not have any injections in the

39 30 LEs. He would benefit from a referral to a physical medicine and rehabilitation (PM&R) specialist to explore further options for addressing LE spasticity. Interventions utilized in this plan of care were very appropriate based upon patient goals and his functional status. However, the long-term goals were set too high, and goals should be set with greater consideration of the patient s performance at evaluation. Given the patient s low gait speed and gait endurance at evaluation, the MDCs were not appropriate for goal setting. While evidence supports these values for goals, I believe it would have been more appropriate to establish goals that were based upon a percentage of the patient s initial performance. For example, it is unrealistic to expect a patient at this stage of SCI, who walks meters during a 6MWT, to improve his score by the MDC of meters. Instead, it may have been more appropriate to set a goal for him to walk 18 meters during a 6MWT, which would be approximately a 50% increase from his original score. In the study by Lam et al., the MDC of was a 22% change from the pre-test values. 15 Therefore, it may be more appropriate with people who are ambulating at such a low-level to accept a change greater than 22% as significant enough to detect real change. This patient was a unique case, because most individuals who survive to age 58 at C4 AIS-D SCI are more than one-year post injury. The patient also presented with a unique mechanism, extent, and type of injury. The tests, measures, and interventions in this plan of care were in best keeping for patients with SCI. However, these practice procedures were developed mostly for patients with acute SCI. The

40 31 management of patients with chronic SCI would benefit from further research focused on that patient population. With further research on chronic SCI, it would be possible to determine a more accurate prognosis and population-specific interventions.

41 32 References 1. Furlan JC, Noonan V, Singh A, Fehlings MG. Assessment of impairment in patients with acute traumatic spinal cord injury: a systematic review of the literature. J Neurotrauma. 2011;28(8): Somers MF. Spinal Cord Injury: Functional Rehabilitation. 3rd ed. Upper Saddle River, NJ 07458: Pearson Education Inc.; French DD, Campbell RR, Sabharwal S, Nelson AL, Palacios PA, Gavin- Dreschnack D. Health Care Costs for Patients with Chronic Spinal Cord Injury in the Veterans Health Administration. J Spinal Cord Med. 2007;30(5): National Spinal Cord Injury Statistical Center. Spinal Cord Injury (SCI) Facts and Figures at a Glance. 2016; pdf. Accessed August 29, 2016, Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global prevalence and incidence of traumatic spinal cord injury. Clin Epidemiol. 2014;6: Burke DA, Linden RD, Zhang YP, Maiste AC, Shields CB. Incidence rates and populations at risk for spinal cord injury: A regional study. Spinal Cord. 2001;39(5): Yang R, Lan G, Wang P, et al. Epidemiology of spinal cord injuries and risk factors for complete injuries in guangdong, china: A retrospective study. PLoS One. 2014;9(1):e84733.