T6 Complete Paraplegia Treatment Plan

T6 COMPLETE PARAPLEGIA TREATMENT PLAN

Lillie Zentmeyer

Western Carolina University

RTH 352-01

Debbie Logan

Definition

This patient’s diagnosis is T6 complete paraplegia, which means a permanent loss of sensory and motor function to the muscles and bodily functions that occur at or below the T6 level of the spinal column. Thoracic spinal cord injuries can affect areas of the body from the upper chest to the trunk. In this case, a T6 spinal cord injury mainly affects the trunk muscles in the abdominal and back region. This area of the spinal cord’s nerves and muscles are important for maintaining balance and posture. With this injury there is usually still normal upper-body movement and the ability to fairly control and balance the trunk while in a seated position. If the patient’s abdominal muscles are still intact he should still be able to cough productively. There will be little or no voluntary control of bile or bladder, but the patient should be able to manage on their own with special equipment (Shepard Center, 2017).

Patients found to have spinal cord injuries are not always obvious. Patients normally have injuries that involve the head, pelvic fractures, penetrating injuries of the spine, injuries sustained in motor vehicle crashes, severe blunt injuries, or injuries related to falling from heights or diving into water. Motor function and sensation testing is done in all extremities. Traditionally x-rays are taken of the possible injured area followed by a CT of the areas that appear abnormal on the x-ray to help determine if the patient does have a spinal cord injury (Wilberger & Dupre, 2015).

Demographic Information

According to the Merck Manual, approximately 11,000 spinal cord injuries occur in the United States over a period of one year. Motor vehicle crashes (48%) and Falls (23%) are found as the two most common causes of spinal cord injuries (Wilberger & Dupre, 2015). Other common spinal cord injuries are assault (14%), sports (9%), and lastly work-related accidents. About 80% of spinal cord injuries that occur are males. Falls, one of the most common causes normally happens to older adults. Osteoporotic bones and degenerative joint disease can increase the risk of spinal cord injury due to brittle bones, which allow for fractures to easily happen. “Patients with altered sensorium, localized spinal tenderness, painful distracting injuries or compatible neurologic deficits” should also be taken into consideration for spinal cord injuries (Wilberger & Dupre, 2015, para. 20).

Strengths of patient

This patient has a variety of strengths that will be able to help the RT when doing therapy with him. To start with he is 22 years old, his young age is a strength that should help him heal fast and effectively. He lives in an apartment with a friend and his father lives close by. This will help the patient to have friends and family close by to support him throughout the recovery process. The patient was fully ambulatory before the accident took place and has no records of past medical history. Fully ambulatory means that the patient has full functioning and control of their body. The patient is in good spirits, which means he should be motivated and eager to get better during therapy.

Needs of patient

This patient will need to be addressed with bilateral upper and lower extremities strengthening. This could be done during therapy to help the patient gain back strength. According to Hartigan et al., “Surveys of persons with SCI indicate that mobility concerns are among the most prevalent and that chief among mobility desires is the ability to stand and walk” (2015, p. 1). For patients with a T6 SCI, this is a typical need (Hartigan et al., 2015).
The patient will need to work on improving endurance, balance, and learning to walk without assistance. The patient will also need to acquire transfer skills and improving ambulation ability. This is found to be a typical need in most SCI patients. A particular study showed that a piece of equipment known as the exoskeleton can help provide weight-bearing posture, and support/coordinate upper and lower body movement for SCI patients (Hartigan et al. , 2015).
The patient will need to work on accessibility, balance, and mobility. The patient will need continuous therapy to learn how to walk again without assistance. This is a typical need of any patient with a SPI. In a study it was recorded that the most obvious barriers mentioned by the respondents were lack of accessibility, time constraints and health issues (Leisulfsrud, Ruoranen, Ostermann, & Reinhardt, 2016). In surveys of persons with SCI, it was indicated that mobility concerns are among the most prevalent and that chief among mobility desires is the ability to stand and walk (Hartigan et al. , 2015).
Time management will need to be worked on with the patient to balance their time with other areas of their life. This is a typical need for SCI patients. In a study that took place, the most obvious barriers mentioned by the respondents were lack of accessibility, time constraints and health issues (Leisulfsrud, Ruoranen, Ostermann, & Reinhardt, 2016).
The patient needs to learn to address self care skills such as getting dressed, and grooming. This is a typical need for most SCI patients, a study group reported poorer patient physical functioning than controls. “This may be attributed to physical limitations associated with the presence of pressure ulcers, which include difficulty dressing, moving, and exercising. However, the results suggest that SCI patients with pressure ulcers, although having impaired physical functioning, has adapted to these limitations over time” (Lourenco, Blanes, Salome, & Ferreira, 2014).
The patient will need help with management of comorbidity and how to address it. According to a recent study, the goal was to analyze the influence of previous comorbidities and common complications on the motor function outcome of patients with traumatic spinal cord injury if early surgery was performed (Kreinest et al., 2016). This study shows that comorbidity in SPI patients is a typical need.
The patient will need assistance with wound care. This is found to be a typical need for patients with any chronic injury, especially a post gunshot injury. According to Evans, “Patients with spinal cord injuries are particularly prone to developing trauma to their skin and underlying tissue because of pressure (2017). They are impaired in their ability to move themselves and often have impaired sensation and can’t feel when a wound might be developing” (Evans, 2017, para. 2).
The patient will need assistance with medication management. This is seen as a typical need for many patients that have any type of critical injury. There has been a resource guide developed to specifically integrate medication management within the medical home (Patient-Centered Primary Care Collaborative, 2012).
The patient will need help with bowel and bladder management. This is a typical need for patients with almost any SCI. It was observed in a study group that 91.7% of patients had uncontrolled urinary incontinence and 21.7% has uncontrolled anal incontinence (Lourenco, Blanes, Salome, & Ferreira, 2014).
The patient will need help with work accommodations. This is a typical need for SCI patients. It was found that employment was also perceived as a factor that enabled persons with SCI to structure their days, get errands accomplished or simply leave their house. “The time-structuring function of employment was also perceived as a distraction from impairment and pain” (Leisulfsrud, Ruoranen, Ostermann, & Reinhardt, 2016, p. 138). “Therefore, reducing work hours after their SCI was considered a step towards better social integration by many of the interviewees” (Leisulfsrud, Ruoranen, Ostermann, & Reinhardt, 2016, p. 140). Employment has also been considered as an important aspect for participation in society. Employment is important to fulfill people’s personal and collective identities in terms of being a member in society and having a good self-esteem (Leisulfsrud, Ruoranen, Ostermann, & Reinhardt, 2016).
Patient care will be needed to assist in preventing pressure ulcers while in the hospital. Pressure ulcers are typical in those with SCI. A current study showed that people with post gunshot SCI resulted in a significantly higher proportion of complications, with pressure ulcers being the most common, followed by pulmonary complications, deep-vein thrombosis and neuropathic pain (Joseph 2017). “It is therefore necessary to educate healthcare personnel and patients with gunshot SCIs and their families on the importance of remaining free from pressure ulcers and the positive effects of regular turning and pressure relief” (Joseph, 2017). “Pressure ulcers are considered the most common skin complication in patients with SCI and can lead to secondary complications, such as osteomyelitis, septicaemia, and even death. The presence of pressure ulcers is an important factor impacting the quality of life and self-esteem of the patient, because it aggravates and prevents the healing of other health problems, increasing suffering and morbidity” (Lourenco, Blanes, Salome, & Ferreira, 2014, p. 331).

Environmental Barriers

The patient may have trouble with climatic conditions and participation restrictions in their environment. This is a typical need for patients that have SCI. It was found in a study that more than half of the participants perceived that climatic conditions and insufficient accessibility of public infrastructure had a negative impact on their participation (Reinhardt, Ballert, Brinkhof, & Post, 2016).
The patient may struggle with inaccessibility of public and private infrastructures. This is typical for any type of patient that has a chronic injury that requires recovery time. It was shown in a study that just under half of participants perceived that their life was made a little harder due to difficulties in accessing the homes of friends or relatives (Reinhardt, Ballert, Brinkhof, & Post, 2016).
The patient will need assistance with transportation needs. This is typical for SCI patients, as they have to learn how to accommodate their needs without full functioning. It was found in a survey that transportation, as well as policies and services, were perceived as having a negative impact by approximately one-third of the participants (Reinhardt, Ballert, Brinkhof, & Post, 2016).
The patient may need assistance with financial situations due to all their medical needs. This is a typical need for most SCI patients that have a numerous amount of medical needs. It was found in a study that more than one-quarter of the study participants indicated a negative impact of their financial situation. (Reinhardt, Ballert, Brinkhof, & Post, 2016).

Cultural Information

The patient is a 22-year-old male. At a young adulthood age, it should be taken into consideration that the patient may still rely some on a parent figure in their life. A survey given to young adults came back with results that although they wanted more independence, autonomy, and respect as they moved through the transition to adulthood, they still expressed their desire to receive continued support from their family, friends, and medical providers (Hillard et al., 2014).
The patient’s race is African American, some things to take into consideration may be the patients’ cultural views and religious beliefs. “…Some African Americans equate good health with luck or success. An illness or disease, viewed as undesirable, may be equated with bad luck, chance, fate, poverty, domestic turmoil, or unemployment, and in such case, Black Americans will consult a physician only after attempts with home remedies have failed” (Giger, Davidhizar, & Turner, 1992, p. 1). Some Black Americans believe that the nurse should recognize cultural medical practices and the western medical remedies based on these beliefs (Giger, Davidhizar, & Turner, 1992). These things should be taken into consideration when working with this culture.
The patient is a male.
The patient lives in an apartment in New York.
The patient’s occupation is a manager at a fast food restaurant.

Efficacy Research

Lechner, H. E., Kakebeeke, T. H., Hegemann, D., & Baumberger, M. (2007). The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury.Archives of Physical Medicine & Rehabilitation,88(10), 1241-1248.Retrieved from

1 Summary

In this study 3 different interventions were tested on participants with spastic spinal cord injuries, to find out the effects of hippotherapy on spasticity and on the mental well-being of persons with spinal cord injuries. Hippotherapy consists of therapeutic strategies with the use of horse’s movements to help patients during therapy. In this study, the horse’s movements were being used to help patients’ muscle tightness and stiffness, known as spasticity. A sample group of 12 volunteers were tested twice weekly for 4 weeks. They all had been diagnosed with paraplegia or tetraplegia, for at least one year or more. The 3 interventions used by physiotherapists were hippotherapy compared to sitting astride a Bobath roll (a canvassed cylinder made of rubber foam) and sitting on a stool with a rocking seat. Long-term and short-term results were both tested on all participants. The Ashworth scale was used to measure movement-provoked muscle resistance, the visual analog scale (VAS) was used to measure self-rating of spasticity by participants, and lastly the Befindlichkeits-Skala of von Zerssen was used to measure mental well-being of participants. All these clinical measurements were done by a blinded examiner. After the results were combined it was found that hippotherapy was more efficient than sitting aside a Bobath roll or on a stool with a rocking seat, in reducing spasticity temporarily. Hippotherapy was also found to have the most effective short-term effect on participants mental well-being.

2 Subjects and Methods

The 12 participants that were recruited for this particular study were all diagnosed with motor-complete traumatic spinal cord injuries. Requirements were that all participants recruited had to have been diagnosed for more than one year after the onset SCI. Participants must have spasticity in the lower extremities and sufficient range of motion to sit on the horse or Bobath roll. No skin problems or wounds could be existent and they were not allowed to ride horseback at all during the 6 months before the study took place. A physiotherapist was present during each intervention with all 12 of the participants over the course of the study. Each intervention was approximately 25 minutes long to allow the same amount of time for each session held twice weekly for four weeks. All measurements taken after the interventions were given and rated by a blinded examiner. The hypothesis before the study began was that hippotherapy could be a potential intervention to help improve the mental well-being of people with spinal cord injuries.

During the study, the hippotherapy intervention was called intervention H. A mastered horse trainer led the Icelandic bred therapy horse and walked alongside the participant while riding at all times. The participant sat astride the horse without any type of saddle, but instead a sheepskin. The reason for this was so that the participant could feel all the movements of the horse on their body while riding. This intervention was held outdoors on a 270m dirt track, weather permitting or inside a riding hall. All sessions were held on Monday and Thursday or Tuesday and Friday to keep a consistent schedule.

The other two interventions were called Intervention R and Intervention S, Intervention R consisted of sitting on a Bobath roll made of rubber foam. Participants were seated upright with their feet on the ground and hands resting on their thighs. This intervention took place in a therapy room, beside the horse stables. Intervention S involved the participants sitting on a rocker seat powered by an electric motor. The rocking movements were similar to a horse’s walking pace to try and provide the same motions to the participants as if they were on a horse. This intervention was performed in the same therapy room as intervention R.

3 Finding and Implications

Spasticity and the well being of each participant was the main focus when taking measurements during each intervention. The Ashworth Scale (rated by clinician) and the visual analog scale (self-rated) were both used to measure spasticity after each intervention. The study says that it has been found in the past that self rating scores are important to measure to get the participants point of view as well when collecting data. The Bf-S of von Zerssen and Koeller was used to measure the well-being of participants after their intervention. It consisted of a self-evaluation assessment given to them by an examiner, rating their feelings from very happy to very unhappy. After all the interventions were performed as scheduled, it was found that hippotherapy was the most successful in immediate reduction of spasticity, demonstrated through both clinical and self-rating scores.

One participant did have to drop out of the study due to health problems, but the other 11 participants completed the study all the way through. Hippotherapy was found to be the most effective compared to intervention R and S. Hippotherapy effected mostly the patients’ short term results. According to clinical and self-rating scores an immediate reduction of spasticity was shown after hippotherapy. For long-term effects there was no reduction of spasticity shown that lasted longer than 4 days after treatment. After the hippotherapy, it was found that more than 20% of participants’ spasticity reduction lasted more than 36 hours and 33% of participants’ spasticity reduction lasted more than 24 hours. Mental well-being was improved slightly only immediately after hippotherapy, long-term results were not found. The hypothesis proposed was correct, hippotherapy does have a positive short-term effect on the participants with spinal cord injuries.