Final Draft Case Report
- 1. Neuroplasticity of Incomplete Spinal Cord Injuries: An Inpatient Physical Therapy Program Using a Variety of Activities. David Coyne
- 2. Introduction Traumatic spinal cord injuries (SCI) disable 12,000-20,000 Americans yearly, with males accounting for 80% of those affected. The average annual medical cost of SCIs is $15,000 to $30,000 per year, with estimated lifetime costs ranging from $500,000 to more than $3 million depending on the severity of the injury. An estimated 50- 70% of new SCIs occur in people between 15 and 35 years of age, and almost 25% of SCIs are a result of falls (1). In order to maximize their level of function, these individuals will likely require surgical procedures to stabilize the fracture and decompress nerve roots. A study published in 2008 by Kingwell et al. reports mixed results of surgical vs. non-surgical treatments to decompress and stabilize conus medullaris and cauda equine injuries with regards to neurological outcomes (2). However, with advances in equipment and nursing care, surgical intervention has led to shorted hospital stays and earlier rehabilitation and is the preferred treatment. There is no doubt that spinal cord injuries (SCI) are complex in nature and individualized outcomes dependent upon severity, level of injury, and therapeutic interventions. Activity-based restorative therapies have been established as an effective treatment promoting neuroplasticity and neuromuscular reeducation in SCI patients through restoration of synapses, re-myelination, cell regeneration, reorganization, and neural repair (3). The purpose of this case report is to describe the use of neuroplasticity in the neuromuscular reeducation physical therapy plan within an inpatient hospital setting for a patient with an incomplete L2 spinal cord injury. Case Description Patient The patient was a 13 year old male who took a 7 foot fall onto his back from a tree resulting in an incomplete spinal cord injury (SCI) as a result of a burst fracture of the second lumbar vertebra (L2). The patient also presented with a cauda equine syndrome and underwent a right hemi laminectomy of L2, ventral decompression, fracture reduction, and pedicle screw fixation of the first and third lumbar vertebrae (L1 and L3). The patient lived at home with his parents and participated in competitive swimming. The patient reported he was also independent in all activities of daily (ADLs), never had a major injury, broken bone or chronic sickness prior to his present injuries. The patient was initially restricted to bedrest upon admission until a lumbar corpectomy was performed on Day 4.
- 3. Examination The following examination was performed by the physical therapist on the date of injury and the date of admission (DOA) to the hospital. The patient had undergone a L2 right hemi laminectomy, ventral decompression, fracture reduction, pedicle screw fixation of L1 and L3 with posterolateral fusion earlier in the day. Posture DOA: Unable to test due to bed rest Sitting Balance DOA: Unable to test due to bed rest Standing Balance DOA: Unable to test due to bed rest Range of Motion DOA: Left ankle dorsiflexion limited to neutral Right ankle dorsiflexion limited to neutral Strength DOA: Left great toe: 5/5 Right great toe: 4/5 Gait DOA: Unable to test due to bedrest Activity Tolerance DOA: Unable to test due to bedrest Sensation DOA: Unable to test due to bed rest Pain Patient reports pain in back upon admission, but tolerable Cognition Alert and Oriented x4 Mobility Skills/Transfers Patient requires Maximum assistance (Max A) x2 for bed mobility/transfers Interventions The physical therapist, patients, and patient’s parents agreed to the following discharge goals within the patient’s acute inpatient hospital stay. 1) Patient will be modified independent in all bed mobility prior to discharge. 2) Patient will maintain static sitting balance for 5 min with stand by assistance (SBA) prior to discharge. 3) Patient will be independent with home exercise program (HEP) prior to discharge.
- 4. 4) Patient will be Moderate assistance (Mod A) with transfers prior to discharge. Was seen by inpatient physical therapy once daily for approximately 20 to 60 minutes depending on patient’s activity tolerance. Over the course of 10 days, the patient was seen 8 times including the initial evaluation for treatment to improve bed mobility, transfers, ambulation, balance, therapeutic exercise, and caregiver training. Transfer Training Mechanical assistance was initially used for transfer training using the hospital bed to acclimate the patient to an upright position due to orthostatic hypotension. This also increased the patient’s tolerance to activity, since he was restricted to a supine position in bed with limited physical activity. Treatments initially focused on forward trunk leaning and sitting balance and progressed using a front wheeled walker (FWW) and Mod A of 2 persons to perform sit to stand from edge of bed. As patient’s pain level decreased, logrolling was introduced utilizing verbal cues for sequencing, bedrails for upper extremity (UE) and trunk assist, and Mod A for lower extremity (LE) management. Therapeutic Exercises Exercises were introduced to the patient with the intent to increase range of motion, and to reeducate and strengthen musculature in order to increases functional mobility and independence. Therapists utilized verbal and tactile cues as well as demonstrative techniques. The following table highlights therapeutic exercises performed, including repetitions and frequency. Day 3 Supine PROM bilateral ankle dorsiflexion 1x10 PROM bilateral knee extension 1x10 PROM bilateral hip flexion 1x10 Day 5 Supine AROM bilateral ankle dorsiflexion 1x10 AAROM bilateral knee extension 1x10 AAROM bilateral hip flexion 1x10 Day 7 Supine Bilateral long arc squads (LAQs) 1x10 Bilateral quad sets 5x5 seconds (decreased activation R LE) Bilateral hip abduction/ adduction 1x10 Bilateral hamstring/ heel cord stretch 3x20 seconds Day 8 Supine Bilateral Quad sets 10x5 seconds Bilateral Hamstring sets 10x5 seconds Bilateral Hip Abduction/Adduction 1x10 Bilateral hamstring/ heel cord stretches 3x20 seconds
- 5. Gait Training Gait training was initiated once the patient’s pain and orthostatic hypotension and pain were managed within functional limits. Initial attempts were made at bedside utilizing a FWW and Mod A with repetitious forward and backward stepping 5 times. The patient was also instructed on sidesteps, but limited due to pain. With additional pain management, therapeutic exercises, and repeated transfer training, the patient progressed to gait training for 5 feet in the parallel bars utilizing cues for hip and knee flexion as well as ample positive reinforcement. Patient/Family Education Throughout the course of treatment, the patient required prompts to adhere to thoracic and lumbar spine precautions including no bending, lifting more than 10lbs, or twisting. The patient and his family were also educated on proper positioning to promote comfort and to prevent bedsores, as well as transfer safety and safety in the home environment. Outcomes The following table addresses the outcomes of physical therapy at the time of discharge. Due to the variability of pain and activity tolerance, range of motion and strength were not formally assessed, but the patient’s functional independence and ability to perform exercises were used in place. The patient was discharged to a children’s specialty hospital to continue his rehabilitation program in an effort to maximize this functional potential. The patient will likely be referred to outpatient physical therapy at that point. Posture No deficits noted Sitting Balance Patient able to control trunk to maintain static sitting balance for up to 1 minute, but limited due to back pain Standing Balance Static standing balance with Min A and FWW or 30 seconds before requesting to sit due to orthostatic hypotension Range of Motion Bilateral hip flexion 0°-120° Bilateral knee flexion 10°-110° Bilateral ankle dorsiflexion 0°-10° Strength Patient displays poor trunk strength Left lower extremity 5/5 MMT Right hip flexion 4/5 MMT Right hip extension 3/5 MMT
- 6. Right knee extension 4/5 MMT Right knee flexion 3/5 MMT Right ankle plantarflexion 3/5 Right ankle dorsiflexion 3/5 Right great toe: 4/5 Gait Patient can ambulate 5 feet in parallel bars with Min A Activity Tolerance Patient’s activity tolerance continues to vary due to orthostatic hypotension. Patient was able to tolerate up to 25 minutes of upright activity before BP dropped to 78/58. Sensation Patient tested normal sensation in all extremities. Pain Severe low back pain continues to limit function in static sitting, standing, and gait activities. Cognition Alert and Oriented x4 Mobility Skills/Transfers Patient required Min A for all mobility skills including bed mobility and sit to stand transfers in parallel bars. Patient does require Mod A when returning to bed for LE management. Discussion The goals of physical therapy during the immediate postoperative lumbar surgical fusion (LSF) typically fall into the category of one of the following goals: 1. Task-oriented practice 2. Development of problem-solving skills 3. Management of skin, bowel, and bladder care 4. Promoting locomotor training (4). With any lumbar spinal fusion, patients are cautioned to not partake in any bending, lifting (> 10lbs), or twisting activities during the early phases of recovery. These precautions were reinforced during physical therapy treatments as he was taught techniques to minimize unsafe movements during functional mobility training. Studies have revealed the central nervous system (CNS) has the ability to repair itself after traumatic spinal cord injuries, especially when patients engage in rehabilitation efforts using massed practiced exercise. A study by Lynskey (5) highlighted two rehabilitative strategies which activate the nervous system to promote plasticity and recovery through the use of motor neurons and sensory
- 7. afferent tracts: 1) use of passive exercise, 2) use of active modes of exercise. This case report utilized these techniques by guiding the patient through passive range of motion (PROM), active-assisted range of motion (AAROM), then active range of motion (AROM) exercises to provide sensory feedback to the CNS. The coordination of complex movement is controlled by reflex arcs located in the neural circuits of the spinal pathway. These reflex arcs are triggered by both efferent motor inputs and afferent sensory stimulus. Due to the injury of the spinal cord the efferent motor input is disrupted, leaving afferent sensory information as the sole provider of stimulus from peripheral tracts. Through repetitive exercise, passive exercise is able to “normalize” spinal reflexes and inhibit potential spasticity in the absence of functional efferent input (5). This patient supported these finding by progressing to active range of motion (AROM) exercises and further achieving increased muscle activation in the lower extremities. Recent research supports the use of trunk supported locomotor training to incorporate sensory feedback signals emphasizing limb loading during stance and hip extension at the end of the stance phase (4). These findings were used in the treatment of the patient in this case report during transfer training, standing tolerance, and gait training in parallel bars. Again, through the use of repetitive exercises the patient was able to improve initiation of movement and motor control, eventually taking five steps in parallel bars with minimum assistance prior to discharge. Conclusion With advances in our understanding of the neuroplasticity of the spinal cord, we are able to achieve greater outcomes in the rehabilitation of patient with traumatic spinal cord injuries. Through progressive PROM, AAROM, and AROM exercises physical therapist are able to work with the patient to ambulate and maximize their functional independence. Through surgical procedures for the spinal cord patient, a decrease in cost can also decrease the length of the patient’s hospital stay.
- 8. References 1. Spinal Cord Injury (SCI): Fact Sheet. (2010, November 4). Available at: http:// www.cdc.gov/TraumaticBrainInjury/scifacts.html. Accessed: November 7, 2014 2. Kingwell SP, Curt A, Dvorak MF. Factors affecting neurological outcome in traumatic conus medullaris and cauda equina injuries. Neurosurg Focus. 2008; 25(5):E7. 3. Sadowsky CL, Mcdonald JW. Activity-based restorative therapies: concepts and applications in spinal cord injury-related neurorehabilitation. Dev Disabil Res Rev. 2009; 15(2):112-6. 4. Dobkin, B., & Havton, L. Basic advances and new avenues in therapy of spinal cord injuries. Annual Review of Medicine. 2004; 55(1):255-285. 5. Lynskey, J. Activity-dependent plasticity in spinal cord injury. The Journal of Rehabilitation Research and Development. 2008; 45(2):229-240.