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 Clinical Timeline • Admitted after fall: • 6/5/2011: Admitted • Found at bottom of steps • 6/7/2011: Surgery • Only able to move his head • C3-4 discectomy • Arthrodesis • Social History: • Fixation • +ETOH - alcohol use • 6/14/2011: IVC filter placed • +COC - cocaine use • 6/15/2011: PICC placed • Lives with brother in 2 story home • 6/17/2011: Open tracheostomy and PEG tube placed • No insurance • 6/30/2011: Transferred to inpatient rehab
Chart Review: Pharmacology Medications: Possible Side Effects Include: • Baclofen - Antispasmodic • Dizziness and/or drowsiness • Tizanidine - Antispasmodic • Weakness • Gabapentin -Analgesic/Anti-Epileptic • Decrease bone mineral density • Naproxen - NSAID • Easy bruising • Warfarin - Anticoagulant • Docusate - Laxative
Chart Review: Major Imaging Findings • Cervical spine intact w/o evidence of • Grade-1 Anterolisthesis of L5 on S1 acute fracture • w/ chronic associated bilateral spondylolysis • Sclerotic interruption of the right posterior C1 arch • Multiple lesions in thyroid • Multilevel spondylosis, notably at C6-7 • Disc space loss, degenerative endplate changes, and mild to moderate canal stenosis
Chart Review: Major Clinical Barriers Lines and Leads: Precautions: • Right femoral arteriovenous • Autonomic dysreflexia (AD) fistula • Fall risk • PICC • Skin breakdown • NG tube • Foley catheter
Chart Review: Physical Therapy Evaluation Cognition: Pain: • Alert and oriented x4 • Present in LUE with P/AROM • Able to follow 1-step commands Tolerance to Activity: Sensation: • Poor • Grossly diminished in RLE • Reports tiredness after 45 minutes • Otherwise intact of activity
Chart Review: Physical Therapy Evaluation Strength Assessment Upper Extremities Lower Extremities • LUE: ⅕ grossly • LLE: ⅗ grossly • RUE: ⅖ grossly • RLE: 4-/5 grossly • Bilaterally • Horz Abduction: ⅘ • Clonus in bilateral ankles • Elbow extension > flexion • Intermittent extension spasticity of • Poor grip strength RLE
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
Chart Review: Medical Diagnosis 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: 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
Chart Review: Physical Therapy Evaluation Physical Therapy Prognosis: • Fair • Many factors affecting this: • Current functional status • If after 1 month, patient has ⅖ in the upper • Spinal shock extremity than there is a 100% chance that • Fatigue he will recover to ≥3/5 within one year • Co-morbidities (Waters, 1994) • Age • Central cord syndrome has been reported to have the best prognosis of the clinical spinal cord syndromes
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?
A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury Lam, T; Noonan, VK; JJ Eng, JJ Spinal Cord (2008) Study aimed to assess the reliability, validity and responsiveness of outcome measures currently used with SCI patients. Outcome Measures Examined: Timed: Categorical: • Timed Up-and-Go (TUG) • Functional Independence Measure (FIM) • 6 Minute Walk Test (6MWT) • Spinal Cord Independence Measure (SCIM (I-III)) • 10 Meter Walk Test (10MWT) • Walking Index for Spinal Cord Injury (WISCI (I&II)) • SCI-FAI* • 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) Timed Measures Reliability Validity Responsiveness High correlation coefficients 10MWT, 6MWT, TUG all ● Large effect sizes for ● 10MWT (r=0.98 &0.97) have very strong construct 10MWT & 6MWT ● 6MWT (r=0.98 & 0.97) validity from 0.88 to 0.95 ● Floor or ceiling effects ● TUG (r=0.98 & 0.97) 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 SCIM WISCI ● Reliability ● ● Reliability Reliability ○ Walk/wc = .44-.65 ○ ○ SCIM-III = 0.91 WISCI-II = 1.0 ○ Stair items = .32-.95 ● ● Construct validity Construct validity ● Validity ○ ○ Excellent Excellent ○ Poor - excellent ● ● Responsiveness (> FIM Responsiveness (eff ● Responsiveness (eff size for fxnl ∆ by 33-55%) size = 2.05, 1-3 mos & = 0.9 rehab adm-d/c) 0.73, 3-6 mos) *FIM & WISCI have ceiling effect; SCIM & WISCI have floor effect
A Systematic Review of Functional Ambulation Outcome Measures in Spinal Cord Injury Lam, T; Noonan, VK; JJ Eng, JJ Spinal Cord (2008) 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
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
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