3. OT Evaluation
• Start as soon as medically cleared by MD
• Assess basics first
• Include precautions/medical conditions/medical
history in report
• Coordinate with the rest of the team when planning
for treatment and patient/caregiver education
4. OT Evaluation
• ADLs
• Pinch and grip
strength
• Bowel and Bladder
programs (in
conjunction with
nursing)
• Dressing
• Eating/Feeding
• Sensation testing
5. Assessment Tools
• Measures ADL performance, respiration, sphincter
management, and mobility
• Can be used for goal determination and outcomes assessment
• A simple one-step scoring sheet (posted on Bb)
• Can be scored while client engages in routine activities
• Designed for adults
Spinal Cord Independence Measure (SCIM-III)
American Spinal Injury Association (ASIA) Impairment Scale
• Designed to classify neurological impairment level after SCI
• Assesses motor and sensory impairment level
• Uses a rating system of A to E
• For all ages
7. Assessment Tools
• Used for ADL assessment
• Designed for individuals 18 or older
• Useful in documentation of small but clinically significant gains
in function after SCI
Quadriplegic Index of Function (QIF)
Canadian Occupational Performance Measure (COPM)
• Designed to measure a client’s perception of his or her
occupational performance over time
• Assesses performance in self-care, productivity, and leisure
activities
• For ages 7+
8. John sustained a T10 compression fracture two weeks ago. His motor and sensory
function have not changed since admission:
• Strength – normal (5/5) in B UE’s
-- absent (0/5) in B LE’s
• On the right side of his body, his sensation is intact in the C1 – T11 key sensory
points, impaired at T12, and absent below T12.
• On the left, his sensation is intact in the C1 – T12 key sensory
points, impaired at L1-L2, and absent below L2.
• Sensation in anal area is absent, and voluntary contraction is absent.
How is John’s level of SCI classified according to the ASIA? Complete vs. incomplete?
John asks what the chances are that he will regain the use of his legs. How do you respond?
9. Spasticity
• Spasticity after SCI can be painful or irritating, and limit one’s ability
to perform tasks in a functional manner.
• Spasticity is not always harmful and does not always need to be
treated.
• Problems that can result from spasticity:
• Loss of ROM
• Difficulty with driving, transferring, staying seated in a wheelchair
• Spasticity in the chest muscles
• Increased risk for falls
• Sleep disturbances
• Can make volitional movement harder to control
10. Treatment for Spasticity
Physical treatments
• Regular stretching (ROM)
• Weight-bearing
• Splints, braces, or progressive casting into desired position
• Use of cold or hot packs
Oral medications
• Baclofen
• Muscle relaxants
Nerve or motor-point blocks – when spasticity affects only part of the
body (ex. Botox injections)
• Surgical options
• Delivery of medication via a pump
• Severing nerves/nerve roots
• Lengthening a tendon
11. Treatment for Spasticity
Positioning
• Limit contact points
• Maintain posture, including
pelvic positioning as close to
neutral as possible
• Facilitate arm function
whenever possible, providing
trunk support if needed
• Allow for change in position,
either by not limiting or by
providing assistance
• 90 – 90 – 90 for
hips/knees/ankles
12. Self-Feeding
• A person with a high-level SCI can be independent in drinking using
a secured drink container and a straw at a stationary location
• Cup-to-mouth movements can be independent for someone with
adequate shoulder and elbow strength to allow hand-to-mouth
pattern movements from a table surface
13. One example of an adaptive method is to mount a fork with the
tines angled downward to gain better leverage for spearing a food
item. Cutting food and opening packages tends to involve the
highest level of strength or control, but a number of devices are
available to open soda cans or bottles, and adaptive knives for
cutting up food are also available.
Self-Feeding
14. Dressing
Devices - Reachers, dressing sticks, sewn-in adaptations such as leg loops
and thumb loops can be added to the waist band of pants or cuff of socks,
and Velcro closures can be used in place of a zipper.
15. Hygiene and Grooming
• Sink countertop space/height and frontal approach to sink
• Limited walking or standing skills- countertop may need to be
raised to help support the individual to maintain the most stable
upright position.
• To compensate for a lack of grasp- brush the teeth by maneuvering
the toothbrush by rotating the arm
• Electric toothbrush
• Electric razor
22. Common Reactions to SCI
• Anxiety and Fear
• Confusion
• Guilt or shame
• Blaming/second-
guessing
• Depression
• Anger
• Hopelessness
• Negative body image
• PTSD
• Apathy
• Stress and conflict in
relationships
Retrieved from http://www.msktc.org/sci/slideshows
23.
24. The Role of OT in Addressing
Psychosocial Implications of SCI
• Addressing physical, psychosocial, cognitive and
other skills
• Analysis of interaction between person,
environment, and task
• Quality of life can be improved with psychosocial
support, through education and facilitation of
problem-solving, by providing autonomy in
making decisions, and through supporting
participation in meaningful occupations
30. Spinal Cord Injury and Sexual Function
“Sexuality has a particularly predictive correlation with how clients
come to terms with their disability” ) Hattjar, 2012, p. 87).
“Sexuality appears to play an important role in individuals’ ability
to cope with their disability” (Novak & Mitchell, 1988, p. 105).
The client’s sexual persona – how the person sees himself of herself
as a sexual being – is part of his or her identify. Thus the body and
mind must both be considered in the rehabilitation process.
31. • Four categories of sexual activity:
• Sexual activity and preferences
• Sexual abilities
• Sexual desire, arousal, and satisfaction
• Sexual adjustment
Spinal Cord Injury and Sexual Activity
32. Sexuality and the Role of O.T.
Sexuality can symbolize how a person is dealing with the world.
If a person feels inadequate as a sexual, sensual, and lovable human
being, the motivation to pursue other avenues of life can be affected.
Sexual activity – an ADL?
33. Therapeutic Communication
• Clients often feel safe asking the OT about sexual
matters related to their disabilities, because the therapist
deals with other intimate activities such as bathing,
dressing, and toileting.
• It is also important to discuss sexual hygiene as an ADL.
34. Vascular System Nervous System Endocrine System
Settings/stages of recovery in which the topic is often addressed
Acute
phase
Months
following
d/c
35.
36. Why might an OT not address this topic
in working with a person with an SCI?
37. Sexuality - aspects of a person’s life related to sex and sexual orientation,
including thoughts and actions, whether related to the sex organs or not
Sexual Activity – the engagement in activities that result in sexual satisfaction
Intimacy – Closeness with another individual
Sensuality – tenderness as it is linked to information processed through the senses
related to mood
Multidimensional Sexuality Questionnaire (MSQ)
http://www4.semo.edu/snell/scales/MSQ.htm
Trueblood Sexual Attitudes Questionnaire (TSAQ)
38. How do we, as OT’s, broach the subject?
Positioning Aides
ADL Routines
Adaptive Devices
Emotional Well-being
Therapeutic Relationship
39. Stage Description Example
P - Permission Give permission for the
person to talk about feelings
and ask questions.
Many women diagnosed with
SCI have concerns about
intimacy. Is it ok if we talk
about that topic?
L - Limited
I – Information
Offer limited or basic
information and resources
to dispel myths and provide
facts.
You mentioned that you are
concerned about your fertility.
Do you have specific
questions?
S – Specific
S - Suggestions
Give specific suggestions to
help the person proceed
with sexual relations.
There are many ways couples
can adapt their sex lives to
adjust to SCI. How would you
feel about focusing on some
other types of sexual activity?
I- Intensive
T - Therapy
Identify further support and
make appropriate referrals.
Some people find it helpful to
get more support for the
issues we’ve discussed. Is that
something you’d like to do?
The Ex-PLISSIT Model
-The American Association of Sexuality Educators, Counselors, and Therapists (AASECT)
43. When bladder drainage requires catheterization,
different types of catheters and various procedures
may be used:
• Indwelling catheter
• Condom sheath catheter + leg bag (males)
• Intermittent catheterization (q 4-6 hours)
Pharmacological intervention is often also
necessary in bowel and bladder programs after SCI.
44. Neurogenic bowel problems:
• Lower-motor neuron syndrome – areflexic
• Upper-motor neuron syndrome - reflexive
• Use of suppository
• Stimulation to evoke reflexive defecation
• Mirrors and other equipment
45. Sexuality and the Role of OT
References/resources:
Sex is an activity of daily living. It’s an occupation that OT addresses as part of
holistic intervention with a variety of clients, including those with SCI and other
neurologically-based conditions.
.
• Article about SCI and sexual function -
http://www.cnn.com/2014/07/31/health/paralysis-sexual-
function/index.html
• AOTA Fact Sheet - http://www.aota.org/About-Occupational-
Therapy/Professionals/RDP/Sexuality.aspx
• AOTA Press book – Sexuality and Occupational Therapy: Strategies for
Persons With Disabilities (available through www.aota.org)
Finger food items
Mobile-arm support (MAS)
Positioning a utensil in the hand - an orthotic, a palmar cuff, or weaving the utensil through the fingers
Utensils can be elongated, angled, mounted on a swivel, or have the handle built up to adapt for a lack of wrist or hand movements.
Fit often changes after SCI
Garments with high-profile seams sometimes cause skin breakdown over the sacrum or coccyx
Elastic waistbands more easily accommodate abdom protuberance; oversized shirts are easier to pull on overhead
Many people prefer to use a poncho-style coat for easier donning and doffing as well as the added protection against inclement weather to the exposed surface of the legs
To independently dress the upper body, the person must have at least limited to normal arm placement, tenodesis hand function, and limited trunk stability using adaptations such as loops, Velcro closures, and a buttoner or zipper-pull device. Braces for cervical-level injuries (halo brace) sometimes prohibit pulling an upper body garment over the head; adaptations can be made to accommodate this lack of neck flexion by enlarging the shirt collar.
Dressing the lower body tends to be performed in bed to allow the person a variety of positions from which to leverage clothing onto the lower body. Having skills to roll side-to-side in bed is important for advancing the garment over the hips when the individual is dressing in bed.
The person without full hand function can use adaptive closures or fastener devices. Often, it is possible to pull pants on by trapping material between the palmer surfaces of both hands or using wrist extension inside the waist band. Devices used for lower body dressing include reachers, dressing sticks, and leg loops. Sewn-in adaptations such as thumb loops can be added to the waist band of pants or cuff of socks, and Velcro closures can be used in place of a zipper.
The Jordan Hand Challenge
Meg’s Movie Minutes – on YouTube – or go to http://megjohnsonspeaks.com/
Prioritize - Determine what tasks (or which parts of a task) can be delegated, skipped, or delayed. Use prepared foods when possible and look for “short-cuts” when available.
Plan – Gather supplies needed for a task before starting. Prepare foods in large batches and freeze/store for later. Scheduling plenty of time for an activity and for breaks. Replace household materials with easier-to-use items as much as possible.
Pace – Incorporate rest breaks throughout the day. Do less work-intensive tasks earlier in the day.
Position – Store things near where they’re used. Sit instead of standing when possible. Wear an apron/tool belt to keep things handy. Bed should be located on first floor when possible.
https://vimeo.com/214019291
Adjustment to the injury is a process that proceeds gradually over an extended period of time. It is not linear and is unique for each individual. For most people, the psychosocial adjustment is an overwhelming process that involves many complex emotions and coping mechanisms. It typically begins at the time of the injury and extends t/o the person’s life, demanding new adjustments as the individual progresses and faces new/different challenges.
In the beginning, adjustment may involve –
Learning about SCI and what it means to be an individual with a SCI
Loss of independence
Doubting that you will be a productive person
Wondering if you are worthy/loved
Changes in roles and relationships with others
Worries about money
Learning to care for yourself in the context of physical changes
Fluctuating emotions
Questioning if life is worth living
After the initial adjustment, the person may be –
Incorporating skills learned in rehab into daily life
Living day-to-day with a different level of indep
Re-establishing self in family, at work, at in the community
Changing or adapting activities like performing job, parenting, and leisure
Developing new interests as well as new routines and roles
Lifelong adjustment may involve discovering what it means to live life to the fullest in a different way that previously thought. Sense of purpose and accomplishment may be different.
Over time, the person with SCI begins to perceive the injury as less of a threat and more of a challenge to overcome.
Rehab – both physical and psychological growth
Sometimes depression and other emotions don’t fully emerge until after d/c to the home/community.
Role of OT – education to client and family, problem-solving, coping skills, methods to manage anxiety. Support and resources. Equipment.
OTs are trained in the therapeutic use of self, and a big part of the therapeutic relationship between an OT and a client after SCI involves active listening on the part of the OT as the client shares about his/her experiences, emotions, and thoughts. Open-ended questions, being present
No right or wrong feelings
Referral to other mental health providers – in cases when a client is expressing suicidal or homicidal thoughts, significant PTSD or anxiety, psychotic symptoms such as paranoia, hallucinations, or delusional thinking, substance abuse, or continual refusal to participate in therapy and/or in a therapeutic exchange
http://www.handihelp.net/index.html - Handihelp.net is a website that contains simple ideas and tools that are either inexpensive to purchase or cost little to make.
http://www.instructables.com/howto/assistive+technology/
Great resource on SCI: http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.4453181/k.7884/Assistive_Technology.htm
http://www.spinalistips.se – tips and tricks from people with SCI, grouped by category or level of injury
http://sci.washington.edu/info/forums/reports/Arm%20and%20hand%20function%20slides.pdf
In the above article by CNN, Kent Stephenson, who was paralyzed after a motorcross crash, said, “I told them that not walking isn't such a big deal; wheelchairs are so advanced these days. But not being able to have sex is a big deal.” Stephenson participated in an experiment that used electrical stimulators implanted in the spine and despite the fact that he wasn’t able to walk after the experiment, he was happy to regain sexual function.
VIDEO LINK: https://www.youtube.com/watch?v=iDdYSrA6fWY
Sensuality and sexuality are important aspects of everyone's activities of daily living (ADLs) and directly relate to the quality of each person's life. As an ADL, sexual activity is in the domain of occupational therapy (OT). Occupational therapists work with clients in all areas related to sensuality and sexuality.
Research has shown a positive correlation b/w patients’ avoiding a realistic consideration of their sexuality and avoiding a realistic acceptance of their disability. The SCI presents a strong external picture of disability and probably an even stronger internal script of the personal and private ramifications of disability.
Sexuality can symbolize how a person is dealing with the world.
If a person feels inadequate as a sexual, sensual, and lovable human being, the motivation to pursue other avenues of life can be affected.
OT intervention should include goals that facilitate an increase in self-esteem and enable the client to feel lovable.
Part of the role of OT is to foster feelings of self-worth and help the client engage in occupation and to help minimize feelings of worthlessness and hopelessness.
Modification – changing the environment or routine to allow for practices of safe, healthy intimacy. Examples of the use of this approach are –
Using energy conservation techniques to address fatigue
Placing pillows under stiff or painful joints
Adjusting “body mechanics” during intimacy to compensate for paralysis/weakness
Using adaptive equipment to promote safe, healthy sexual practices
The OT is the most appropriate professional to solve some problems, such as motor performance needed for sexual activity.
For example, discussing positioning to reduce pain or hypertonicity or to enable the client to more comfortably engage in sexual relations will help the client deal with problems before they occur.
A discussion of feelings will also help the client explore her or his new body or adapt to ongoing degeneration of the body if there is a progressive disability.
These conversations may take place while other therapeutic activities are in progress, so that billing insurers for time is not a barrier.
With longer life expectancies following SCI, the emphasis in spinal cord injury rehabilitation over the past decade has gradually shifted to improved quality of life and community integration. Toward this goal, issues related to sexuality are important to address in both the acute and post acute stages spinal cord injury.
Adaptation to an SCI is a gradual process that extends over a prolonged period of time. Successful sexual adjustment is influenced by many factors such as age at time of injury, quality of social supports, physical health, gender and severity of the injury. Losses need to be mourned so that the remaining strengths can be nurtured and developed. To achieve satisfying sexual adjustment, a person with an SCI will have to learn their new sexual abilities, as opposed to recapturing the past.
Possible reasons why a person in the acute stage of SCI wouldn’t bring up the subject of sex?
-reduced sexual drive: Although libido is not affected by SCI, it may be diminished by depression, trauma of the injury, medications or lower testosterone levels.
-focused on ambulation and recovery of functioning
-cultural or personal reasons
Some individuals may go through a period of sexual "acting out" (i.e., unacceptable sexually explicit language, inappropriate unwanted physical contact with staff, etc.) while on the rehabilitation unit. Such behavior is not uncommon as an individual grapples with the changes and implications associated with a spinal cord injury.
During the acute rehabilitation phase, a sensitive discussion regarding sexuality is appropriate. The person with SCI may inquire about issues such as dating, attractiveness, relationships, parenthood and physical appearance. Other topics of interest may include erections, lubrications, positioning, sensation, orgasm, ejaculation and fertility. Many individuals will inquire about sexuality as it related to bladder and bowel function. Even if the individual does not initiate discussions about these topics during rehabilitation, it is important for members of the rehabilitation team to provide basic information.
In the months following discharge, most patients begin to experiment with the changes in their sexual functioning. Most people with injuries are sexually active within the first year following discharge from the rehabilitation hospital. However, the process of mastering the sexual changes is a gradual process that can extend over a prolonged period of time. It is during these months following discharge that most people with a spinal cord injury are most ready to receive information and counseling regarding sexuality. Unfortunately, at this time they may be isolated from their previous rehabilitation staff members and lack the community resources to obtain accurate and useful information.
http://cirrie.buffalo.edu/encyclopedia/en/article/5/
Although the OTPF defines sexual activity as an ADL, it is not routinely addressed by OT’s and other health care professionals. Might not be addressed b/c –
OT is uncomfortable with the subject; lacks educational preparedness, assumes someone else is addressing it, and lack of adequate time during intervention.
Another factor may be the view of a client as being in a “sick role,” in which the traditional medical model of care is used with the injury being the primary focus of care.
http://ajot.aota.org/ on 07/06/2015 Terms of Use: http://AOTA.org/terms
Health promotion – support groups, educational programs, and stress-relieving activities (can include in-services for facility staff members in some cases)
Remediation – restoring skills (such as ROM, strength, and endurance) as part of meeting sexual needs
Modification – changing the environment or routine to allow for practices of safe, healthy intimacy.
If we practice under the idea that the client is the only true expert on his personal situation and if we adopt a client centered approach to evaluation and treatment, we must incorporate sexuality and sexual activity into our intervention – which includes intimacy, closeness with another individual, and sensuality.
OTPF defines sexual activity – engaging in activities that result in sexual satisfaction
Sexuality – the constitution and life of an individual as related to sex; all the dispositions related to intimacy, whether associated with the sex organs or not
Intimacy – closeness with another individual
Designed for use with “able-bodied” individuals
Occupational therapy is a safe place for addressing sexuality, allowing the client to express fears and concerns, and offering assistance with problem solving. Empathy, sensitivity, and openness are necessary aspects of the therapeutic relationship, the foundation of occupational therapy, and are used in addressing sexuality. Partners are often included in occupational therapy interventions to achieve goals of mutual concern, such as sexual expression and satisfaction.
Sexuality can be addressed by practitioners in any setting. Intervention can occur in homes, group homes, nursing homes, rehabilitation centers, community mental health centers, pain centers, senior centers, hospitals, retirement communities, and other venues.
The vast majority of men with all levels of spinal cord injury experience difficulties in the attempt to have a child through the impregnation of an egg during sexual intercourse. These problems are often called male related factors are typically associated with erectile dysfunction, ejaculatory dysfunction, poor semen quality or a combination of these factors. Naturally, lack of sexual desire may also be a significant factor that can affect arousal, sexual performance and frequency of sexual contact. Some disturbance or interruption in any of these aspects can lead to reproductive problems.
For men with spinal cord injuries, successful pregnancy rates range from 10 percent to 35 percent. In general, men with incomplete lesions (both upper and lower motor neuron) are more likely to become fathers than those with complete lesions. Conditions that may contribute to infertility include retrograde ejaculation and especially repeated urinary tract infections. Issues such as elevated testicular temperatures from sitting in the wheelchair, tight underwear or other lifestyle factors are generally not considered significant issues in sperm quality.
As a result of ejaculatory difficulties, men with SCI must often utilize techniques, other than intercourse, to achieve impregnation of the female's egg. These include manual stimulation, the use of penile vibratory stimulation or the use of a rectal probe, called electroejaculation. Although electroejaculation is the least preferred, it is the most effective with up to an 83% success rate. In general however, any of these techniques can be used to obtain the semen sample. Both of these techniques may precipitate autonomic dysreflexia so that couples need to be aware of the symptoms associated with this sudden increase in blood pressure.
After obtaining the sample and determining the quality of the semen, the couple can attempt pregnancy with various fertility procedures. These currently available fertility procedures include intra-vaginal insemination, intra-uterine insemination (IUI), in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT) and intracytoplasmic sperm injection (ICSI).
While men with spinal cord injuries have a variety of options in obtaining sperm and in fertilizing the egg of their partner, they still face challenges as a result of the effect of the SCI on the quality of the sperm. Research has demonstrated that although men with spinal cord injuries have normal numbers of sperm, the percentage of motile sperm tends to be lower than men without injury. In general, men with SCI have been shown to have approximately 20% of motile sperm as compared to 70% in men who are able bodied.
Immediately after injury, 44 percent to 58 percent of women suffer from temporary amennorhea. Menstruation usually returns within 6 months post injury. Neither the level nor the completeness of the injury appears to be associated with the interruption of menstrual cycles. In a small percentage of women with SCI, there are also changes in cycle length, duration of flow, amount of flow and amount of menstrual pain. Most women with SCI are fertile and should use appropriate birth control techniques unless the couple desires to have a child.
Pregnant women with SCI have an increased risk of urinary tract infections, leg edema, autonomic dysreflexia, constipation, thromboembolism and pre-mature birth. Since uterine innervation arises from the T10 to T12 levels, patients with lesions above T10 may not be able to perceive uterine contractions or fetal movements. It may be difficult to differentiate between pregnancy induced hypertension (pre-eclampsia) and autonomic dysreflexia. Autonomic dysreflexia may be the only clinical manifestation of labor. During the second and third trimester, pregnant women may have difficulty in performing functional tasks that were previously completed independently. Transfers may require the assistance of a caregiver and a power wheelchair may be necessary for mobility. Locating an obstetrician and anesthesiologist with a supportive attitude, an accessible office and experience in SCI can be difficult in many areas.
Source: http://cirrie.buffalo.edu/encyclopedia/en/pdf/sexuality_and_spinal_cord_injury.pdf
Bowel and bladder control comes from the S2-S5 spinal segment, and so any SCI at this level or higher will involve the loss of B & B control. Voiding becomes reflexive and is not consciously controllable, and so catheterization and a B & B program is imperative.
Indwelling catheters- stay in urethra and are periodically changed – often used in acute phase of SCI
Condom sheath catheters
Females who reflex void after SCI wear a diaper because of leakage due to shorter urethra. Skin irritation and breakdown is common due to leakage.
LMN – characterized by slow stool propulsion and dry, round stool constipation and a risk of incontinence
UMN – increased colon wall and anal muscle tone, stool pulpulsion occurs and incontinence is common
The unexpected benefit of the spinal implant underlies a brewing debate in the spinal cord injury community: While it's often assumed that walking again is the ultimate goal for people using wheelchairs, many of the people in those wheelchairs argue that what doctors call "secondary conditions" such as sexual function and bowel and bladder control are just as important, if not more so, and should be given a higher research priority. A 2004 survey of more than 300 people paralyzed from the chest down -- mostly men -- found that regaining sexual function was their highest priority. Bowel and bladder control was No. 2 on their list. Regaining the ability to walk was No. 5.
