Clinical Integration: Acute Neuro Case Study Sean, Kelsey, Ryan, - - PowerPoint PPT Presentation

Clinical Integration:

Acute Neuro Case Study

Sean, Kelsey, Ryan, Kathy and Doug Department of Physical Therapy School of Allied Health Professions Virginia Commonwealth University

Chart Review: Patient Information

• 50-year-old male
• Admitted after fall:
• Found at bottom of steps
• Only able to move his head
• Social History:
• +ETOH - alcohol use
• +COC - cocaine use
• Lives with brother in 2 story home
• No insurance

Clinical Timeline

• 6/5/2011: Admitted
• 6/7/2011: Surgery
• C3-4 discectomy
• Arthrodesis
• Fixation
• 6/14/2011: IVC filter placed
• 6/15/2011: PICC placed
• 6/17/2011: Open tracheostomy and PEG

tube placed

• 6/30/2011: Transferred to inpatient rehab

Chart Review: Pharmacology

Medications:

• Baclofen - Antispasmodic
• Tizanidine - Antispasmodic
• Gabapentin -Analgesic/Anti-Epileptic
• Naproxen - NSAID
• Warfarin - Anticoagulant
• Docusate - Laxative

Possible Side Effects Include:

• Dizziness and/or drowsiness
• Weakness
• Decrease bone mineral density
• Easy bruising

Chart Review: Major Imaging Findings

• Cervical spine intact w/o evidence of

acute fracture

• Sclerotic interruption of the right

posterior C1 arch

• Multilevel spondylosis, notably at C6-7
• Disc space loss, degenerative

endplate changes, and mild to moderate canal stenosis

• Grade-1 Anterolisthesis of L5 on S1
• w/ chronic associated bilateral

spondylolysis

• Multiple lesions

in thyroid

Chart Review: Major Clinical Barriers

Lines and Leads:

• Right femoral arteriovenous

fistula

• PICC
• NG tube
• Foley catheter

Precautions:

• Autonomic dysreflexia (AD)
• Fall risk
• Skin breakdown

Chart Review: Physical Therapy Evaluation

Cognition:

• Alert and oriented x4
• Able to follow 1-step commands

Sensation:

• Grossly diminished in RLE
• Otherwise intact

Pain:

• Present in LUE with P/AROM

Tolerance to Activity:

• Poor
• Reports tiredness after 45 minutes
• f activity

Chart Review: Physical Therapy Evaluation

Upper Extremities

• LUE: ⅕ grossly
• RUE: ⅖ grossly
• Bilaterally
• Horz Abduction: ⅘
• Elbow extension > flexion
• Poor grip strength

Lower Extremities

• LLE: ⅗ grossly
• RLE: 4-/5 grossly
• Clonus in bilateral ankles
• Intermittent extension spasticity of

RLE

Strength Assessment

Chart Review: Physical Therapy Evaluation

Static sitting edge-of-bed: poor

• Min-mod assist x1
• Unable to use RUE to support
• Left, posterior lean
• With VC’s, patient is able to

use abdominals to correct posterior lean

Chart Review: Physical Therapy Evaluation

Activity Min A Mod A Max A D NT Roll Right X Roll Left x1 with cuing Supine to sit x2 with cuing Sit to stand x2 Bed to chair X

• Patient required VC to use arms in mobility
• Patient tolerated standing for 30 seconds with max assist x2

Central Cord Syndrome:

• A lesion involving the central gray

matter producing greater weakness in the UE than in the LE and sacral sensory sparing.

• Usually results from hyperextension

injuries.

Chart Review: Medical Diagnosis

Chart Review: Physical Therapy Diagnosis

Physical therapy diagnosis:

• Decreased strength, balance, endurance and tolerance to activity
• Decreased independence in functional mobility
• Decreased ability to perform ADL’s independently
• Decreased safety and awareness to external environment

Physical Therapy Prognosis:

• Fair
• If after 1 month, patient has ⅖ in the upper

extremity than there is a 100% chance that he will recover to ≥3/5 within one year (Waters, 1994)

• Central cord syndrome has been reported

to have the best prognosis of the clinical spinal cord syndromes

Chart Review: Physical Therapy Evaluation

• Many factors affecting this:
• Current functional status
• Spinal shock
• Fatigue
• Co-morbidities
• Age

Chart Review: Physical Therapy Evaluation

Patient Goals

• To get stronger and to get out of the hospital

Therapist Goals

• In one (1) week, pt will be able to:
• perform bed mobility with min A to decrease possibility of skin breakdown
• perform supine to sit transfers with min A to increase functional independence
• In two (2) weeks, pt will be able to:
• perform sit to stand transfer with mod A to facilitate functional independence
• increase static sitting balance to fair to increase ability to perform ADLs
• stand with mod A for 2 minutes to increase activity tolerance
• In three (3) weeks, pt will able to:
• perform bed mobility with independence
• perform all functional transfers with independence
• ambulate 10 ft with mod A to facilitate household ambulation
• tolerate 1.5 hours of PT to prepare for admission to inpatient rehabilitation

ICF Model

Clinical Question: Prognosis Is there a valid and reliable outcome measure to predict the one year post-injury functional independence of a 50-year-old male with traumatic central cord syndrome?

Study aimed to assess the reliability, validity and responsiveness of outcome measures currently used with SCI patients. Outcome Measures Examined: Timed:

• Timed Up-and-Go (TUG)
• 6 Minute Walk Test (6MWT)
• 10 Meter Walk Test (10MWT)
• SCI-FAI*

Categorical:

• Functional Independence Measure (FIM)
• Spinal Cord Independence Measure (SCIM (I-III))
• Walking Index for Spinal Cord Injury (WISCI (I&II))
• Spinal Cord Injury - Functional Ambulation Index (SCI-FAI)

A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury

Lam, T; Noonan, VK; JJ Eng, JJ Spinal Cord (2008)

A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury

Lam, T; Noonan, VK; JJ Eng, JJ Spinal Cord (2008)

Timed Measures Reliability Responsiveness Validity

High correlation coefficients

• 10MWT (r=0.98 &0.97)
• 6MWT (r=0.98 & 0.97)
• TUG (r=0.98 & 0.97)

10MWT, 6MWT, TUG all have very strong construct validity from 0.88 to 0.95

• Large effect sizes for

10MWT & 6MWT

• Floor or ceiling effects

not assessed

A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury

Lam, T; Noonan, VK; JJ Eng, JJ Spinal Cord (2008)

Categorical Measures FIM WISCI SCIM

• Reliability

○ Walk/wc = .44-.65 ○ Stair items = .32-.95

• Validity

○ Poor - excellent

• Responsiveness (eff size

= 0.9 rehab adm-d/c)

• Reliability

○ SCIM-III = 0.91

• Construct validity

○ Excellent

• Responsiveness (> FIM

for fxnl ∆ by 33-55%)

• Reliability

○ WISCI-II = 1.0

• Construct validity

○ Excellent

• Responsiveness (eff

size = 2.05, 1-3 mos & 0.73, 3-6 mos)

*FIM & WISCI have ceiling effect; SCIM & WISCI have floor effect

Conclusion

• SCIM-III - shows promise as future SCI gold standard
• WISCI-II - doesn’t factor in speed, endurance or energy consumption
• Could be paired with 10MWT or 6MWT for increased strength (improve floor and ceiling

effect)

• FIM - not the best tool for patients with SCI, but often used for reimbursement purposes

Interpretation

• There is no current gold standard. All tests have both strengths and weaknesses
• Use what will be most informative, based on your patient

Limitations:

• Focused on capacity rather than performance
• None directly measure balance

A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury

Lam, T; Noonan, VK; JJ Eng, JJ Spinal Cord (2008)

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Anderson, K et. al Journal of Spinal Cord Medicine (2008)

The aim of the study was:

• To identify and evaluate outcome measures that assess overall functional status

for patients with SCI 4 outcome measures under review:

• Modified Barthel Index (MBI)
• Quadriplegia Index of Function (QIF)
• Spinal Cord Independence Measure (SCIM)
• Functional Independence Measure (FIM)

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Anderson, K et. al Journal of Spinal Cord Medicine (2008)

MBI:

• Generic tool that does not measure the easiest/hardest tasks for patients

with SCI.

• Predictive studies available for other conditions, but none exists yet for SCI

QIF:

• Specific tool that is useful for detecting small but meaningful functional

changes in patients with quadriplegia

• Tasks are specific to patients with hand function and no LE function
• No predictive validity data have been established

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Anderson, K et. al Journal of Spinal Cord Medicine (2008)

SCIM:

• Most sensitive, valid, and reliable measure of global disability in

patients with SCI

• More sensitive to change for patients with SCI than FIM
• FIM missed 26% of the functional changes detected by SCIM
• There are no studies assessing the prediction of functional status

based upon initial SCIM scores.

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Anderson, K et. al Journal of Spinal Cord Medicine (2008)

FIM:

• Less sensitive measure for SCI compared to SCIM
• Predictive validity studies show that higher FIM scores at baseline

are associated with higher functional independence in 1 year

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Anderson, K et. al Journal of Spinal Cord Medicine (2008)

Conclusion: The FIM has the best known predictive validity of these 4 outcome measures.

• The patient’s initial score on the FIM would predict future functional

status Limitations of the literature:

• Further research would be ideal to determine the predictive validity of an
• utcome measure that is more sensitive to SCI, such as the SCIM

Neurological and functional capacity outcome measures: Essential to spinal cord injury clinical trials

John F. Ditunno, Jr., MD; Anthony S. Burns, MD; Ralph J. Marino, MD Journal of Rehabilitation Research & Development (2005)

• This paper examined the validity and reliability of the FIM, SCIM and The Walking

Index for Spinal Cord Injury (WISCI)

• The WISCI was found to be much more sensitive to change in patients with spinal cord

injuries than the locomotor subscale on the FIM

Conclusion:

“The WISCI is an instrument designed for measuring progress and improvement in a specific functional capacity, simple to handle, and usable without need for complex instruction.” Bottom line: The WISCI is a valid and reliable tool in assessing the ambulatory status of patients with incomplete SCI but it is not comprehensive and does not apply to our patient at this time

Clinical Question: Intervention What are effective interventions to increase functional independence for a 50-year-old male with traumatic central cord syndrome in an acute care setting?

Study aimed to: To determine the effect of massed practice with somatosensory stimulation on cortical plasticity in persons with incomplete SCI.

Methods:

• 10 subjects were randomly assigned either:

○ Massed practice with somatosensory stimulation (MP+SS) ○ Median nerve: 1 ms duration delivered at a frequency of 10 Hz ○ Duty cycle of 500 ms on / 500 ms off ○ Massed practice training alone (MP).

• Duration: 2 hrs a day, 5 days a week for 3 weeks
• Outcome measures used:

○ Maximal pinch grip force ○ Wolf Motor Function Test (WMFT) ○ Jebsen Hand Function Test ○ Motor Threshold via Transcranial Magnetic Stimulation

Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete tetraplegia

Beekhuizen KS, Field-Fote EC Neurorehabilitation and Neural Repair (2005)

Population:

• n = 10
• Required at least trace evidence of voluntary thumb movement
• Lesions at or above C7

Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete tetraplegia

Beekhuizen KS, Field-Fote EC Neurorehabilitation and Neural Repair (2005)

New Perspectives on Improving Upper Extremity Function after Spinal Cord Injury

Kristina S. Beekhuizen, PT, PhD Journal of Neurological Physical Therapy (2005)

Conclusion:

The results suggest that the underlying mechanisms that make massed practice and somatosensory stimulation effective after stroke may also apply to individuals with SCI. Massed practice and somatosensory stimulation are excellent tools for treating patients with SCI’s, in addition to CVA’s Limitations:

• small pilot study
• participants in this study were between 12 months to 3 years post-injury
• large time commitment of intervention
• patient dropout from TMS

Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete tetraplegia

Beekhuizen KS, Field-Fote EC Neurorehabilitation and Neural Repair (2005)

Use of Prolonged Standing for Individuals for Spinal Cord Injuries

Eng, JJ; Levins, SM; Townson, AF; Mah-Jones, D; Bremner, J; Huston, G Physical Therapy (2001)

• The purpose of this study was to document the patterns of use of prolonged

standing and their perceived effects in subjects with SCI

• 152 filtered to 126 adults with SCIs (mean age 34) - complete/incomplete
• Methods:
• 17 item self-report survey questionnaire
• Provincial spinal cord support organization
• Participated in standing program in standing frame (passive) or combination of braces

(active)

Use of Prolonged Standing for Individuals for Spinal Cord Injuries

Eng, JJ; Levins, SM; Townson, AF; Mah-Jones, D; Bremner, J; Huston, G Physical Therapy (2001)

Conclusion:

Prolonged standing for an average of 40 minutes per session, 3 to 4 times a week improved in perception of several health-related areas such as wellbeing, circulation, skin integrity, reflex activity, bowel and bladder function, digestion, sleep, pain, and fatigue. Our interpretation: Prolonged standing is a beneficial intervention at the acute level as well as

• subacute. Also, creating a plan of care focusing on LE strength and endurance is beneficial for

functional activities and allows to patient to progress to endurance standing activities. Limitations: Self-report, members of support organization, high nonresponse rate

Use of Prolonged Standing for Individuals for Spinal Cord Injuries

Eng, JJ; Levins, SM; Townson, AF; Mah-Jones, D; Bremner, J; Huston, G Physical Therapy (2001)

Relation to our patient:

• Male
• Mean age - 34, range 18-54
• Varied SCI but 50% incomplete
• Chronic injuries - more than 1 year
• Been in standing program an average of 54 months

How does this apply to the acute care PT?

• Future goal
• Aware of potential benefits of increased activity tolerance

Use of Prolonged Standing for Individuals for Spinal Cord Injuries

Eng, JJ; Levins, SM; Townson, AF; Mah-Jones, D; Bremner, J; Huston, G Physical Therapy (2001)

Plan of Care

Plan of Care - Week 1

In one (1) week, pt will be able to:

• perform bed mobility with min A to decrease possibility of skin breakdown
• perform supine to sit transfers with min A to increase functional independence

Interventions:

• PNF
• Chopping techniques for bed mobility
• Lower trunk rotations
• Initiate sitting balance exercises
• Rhythmic stabilization, reaching
• Pt education
• Skin checks, pressure relief
• Independence in directing care
• Orthostatic hypotension

Plan of Care - Week 2

In two (2) weeks, pt will be able to:

• perform sit to stand transfer with mod A to facilitate functional independence
• increase static sitting balance to fair to increase ability to perform ADLs
• stand with min A for 2 minutes with assistive device to increase activity tolerance

Interventions

• Supine strengthening exercises including bridges, short arc quads, glute sets, etc.
• Repetitive sit to stand transfers, from high surface (raised bed) → lower surfaces
• Progressing from tripod sitting → one hand in lap → two hands in lap → add dynamic
• Endurance standing activity → introduce weight shifts

Plan of Care - Week 3

In three (3) weeks, pt will able to:

• perform bed mobility with independence
• perform all functional transfers with CGA and assistive device
• ambulate 10 ft with min A and assistive device to facilitate household ambulation
• tolerate 1.5 hours of PT to prepare for inpatient rehabilitation

Interventions

• Standing weight shifts with assistance
• Standing marching exercises for foot clearance
• Reaching outside base of support, in both sitting and standing, to touch/grasp objects
• Decrease number of rest breaks during physical therapy session
• Patient education for assistive device training

Clinical Application

According to research:

• SCIM is a reliable and valid outcome measure for patients with SCI
• FIM, however, is currently the best prognostic measure for patients with SCI
• Used widely as a measure for insurance reimbursement including Medicare
• Massed practice with somatosensory stimulation and standing endurance activities

are effective interventions for increasing functional independence But above all else: The FIM and SCIM are both recommended outcome measures for initial evaluation of a patient with SCI. Although interventions are diverse, both massed practice with stimulation and standing programs could prove beneficial.

Questions?

Work Cited

1. Ditunno JF, Burns AS, Marino RJ. Neurological and functional capacity outcome measures: essential to spinal cord injury clinical trials. Journal of rehabilitation research and development. 42(3 Suppl 1):35-41. 2005. 2. Beekhuizen KS. New perspectives on improving upper extremity function after spinal cord injury. Journal of neurologic physical therapy : JNPT. 29(3):157-62. 2005. 3. Beekhuizen KS, Field-Fote EC. Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal cord injury. Neurorehabilitation and neural repair. 19(1): 33-45. 2005. 4. Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Physical therapy. 81(8):1392-9. 2001. 5. Lam T, VK Noonan, JJ Eng, and the SCIRE Research Team. A systematic review of functional ambulation outcome measures in spinal cord injury. Spinal Cord. 46:246-254. 2008. 6. Waters RL, Adkins RH, Yakura JS, Sie I. (1994) Motor and sensory recovery following incomplete paraplegia. Arch Phys Med Rehabil. 75:67-72. 7. Kim Anderson, Sergio Aito, Michal Atkins, Fin Biering-Sørensen, Susan Charlifue, Armin Curt, John Ditunno, Clive Glass, Ralph Marino, Ruth Marshall, Mary Jane Mulcahey, Marcel Post, Gordana Savic, Giorgio Scivoletto, Amiram Catz J Spinal Cord Med. 2008; 31(2): 133–144.