Spinal Cord Injury at the Level of C7 Vertebra - Research Paper Example

? Neurology Case Report of the Occupational Therapy of the May 21, Neurological Case Report Case report Philip Spinal Cord Injury at the level of C7 Vertebra Philip sustained crush injury resulting in C7 spinal cord injury and complete quadriplegia. Quadriplegia is considered complete when sensory and motor function below the level of injury is completely absent (Lightbody, 1998). In this type of injury, there is damage to ascending sensory (spinothalamic) and descending motor (lateral and ventral corticospinal) tracts of the spinal cord resulting in motor and sensory dysfunction. A C7 injury leads to paralysis of the extensor of the elbow (triceps), while the flexor of the elbow (biceps) and extensor of the wrist (extensor carpi radialis) is spared (Kirschblum, 2007). Rest of the upper limb and lower limb muscles; and bowel and bladder are involved. Features of upper motor neurone lesion with spastic paralysis develop. Additionally, in cervical cord injury there is autonomic system disruption in which there is unregulated sympathetic activity below the level of injury due to loss of cerebral regulation and unregulated parasympathetic activity above the level of injury (Kirschblum, 2007). Impact on Occupational Performance A spinal cord injury at the level of C7 has favourable projected motor outcome one year after the injury (Kirshblum, 2007). Although, occupational performance in most areas of the activities of daily living, vocational and leisure activities will be affected, the effect is likely to be minimal and patient is expected to become independent in most of these areas, with or without the use of adaptive equipment and technical modifications (Kirschblum, 2007). However, the patient may need assistance in a few activities from friends and family members. So far as activities of daily living are concerned, feeding, grooming, preparation of a light meal and upper extremity dressing can be autonomously performed. However, bowel and bladder care, lower extremity dressing and bathing requires assistance (Kirshblum, 2007). Vocational performance may be affected in the sense that wheelchair propulsion across rough surfaces and curbs requires aid (Kirschblum). However, in Philip’s case, because of the managerial nature of his job, vocational rehabilitation is likely to be very successful. Also, leisure activities that the patient used to perform prior to injury, namely gardening and sports will need modification in technique and equipment as appropriate because mobility and transfers need assistance and a wheelchair. Assessment of Component Skills Philip’s biomechanical and sensori-motor component of occupational performance needs assessment in context of the tasks that his job requires (Chapparo & Ranka, 1997). As a part of biomechanical assessment, upper limb movements need to be comprehensively evaluated. Muscle power, range of motion, weight transfer etc. are assessed. Shoulder movements, arm wrist and forearm extension and flexion are tested. Gross and fine coordination; and ability to write, hold objects of daily use and perform activities like dressing and grooming are assessed (Hoffman, Hannetona, Roby-bramia, 2006). In addition to motor evaluation, assessment of upper limb sensation as a part of sensori-motor component is important for rehabilitation program as it has been found to correlate with the recovery of motor power in future (Lightbody, 1998). Also, dynamics of social and psychological aspects of his interpersonal relationships and interaction with the family members need evaluation (Chapparo & Ranka, 1997). Prior to sustaining injury, he was actively involved in activities of his son and wife. Post injury, although his wife is assisting him in his daily activities, he doesn’t like her to play the role of a care giver. Physical aspects of marital life are also likely to be affected as a result of the spinal cord injury. Also, he may no longer be able to coach his son in his football practice. On the contrary, he may require assistance of his family members for performing some tasks. All of these necessitate an assessment of the extent of cooperation and communication between the family members. Occupation Therapy Interventions Possible interventions within the scope of an occupational therapist in this case are evaluation of the job site and work related training as a part of vocational rehabilitation, those targeting activities of daily living and leisure, and functional skills that have been impaired as a result of the injury (Chapparo & Ranka, 1997). In a quadriplegic patient, the most important intervention is equipment related intervention, i.e. the use of a wheelchair for mobility enhancement. A lightweight manual wheelchair which is custom made, rigid or folding frame, is important to maintain independence, mobility, avoiding pressure sores and skin care(Kirschblum, 2007).. Also, he needs education regarding use of a sliding board for transfers, with or without assistance (Kirschblum, 2007).. Regarding activities of daily living such as bathing, grooming etc., some modification of equipment is required. For leisure activities, the patient may choose to indulge in same pre injury activities or may be advised to pursue different activities with same interests. As the patient has been an in-patient till now, apart from activities of daily living, he is likely to require more interventions that target his social and leisure tasks, once he is discharged home. As part of vocational rehabilitation, an occupational therapist evaluates the patient in terms of muscular function, mobility, coordination, sensory and cognitive deficit. Physical capacities of the patient are then matched to the physical demands of the job which the patient had prior to injury (Desiron, de Rijk, Hoof, & Donceel, 2011). After this comprehensive evaluation, a task focussed approach is used to enable the patient develop confidence and self esteem to accomplish a hierarchy of tasks (Desiron, de Rijk, Hoof, & Donceel, 2011). Case report 2: Lucy Traumatic brain injury Post traumatic brain injury, Lucy is having difficulty in articulating sentences, speech production and writing. These are the features of Expressive aphasia, also called Broca’s aphasia which is a language disorder characterized by a non fluent speech, short abbreviated and grammar-less phrases and problems in writing, whereas, comprehension and reading ability is mostly preserved (Fadiga, Craighero & D’Ausilioa, 2009). The affected structure in this type of aphasia is Broca’s area which lies in the inferior frontal gyrus of the left hemisphere of brain, represented as Brodmann’s area 44 and 45. This area is responsible for motor aspects of speech, that is, speech production. However, recent studies have found an involvement of Broca’s area in comprehension of syntactically complex material also (Fadiga, Craighero & D’Ausilioa, 2009). Associated features of right sided hemiparesis of upper limb suggest cortical dysfunction. Lesion in the left frontal gyrus affects motor function in the contralateral limbs, hence, the association of aphasia with right upper limb hemiparesis(Fadiga, Craighero & D’Ausilioa, 2009). Also, as Lucy finds it difficult to coordinate actions with right hand unless she is visually monitoring the activity, there is probably impairment of the joint position sense and stereognosis caused by cortical sensory loss. An additional tool for localisation of these symptoms in Lucy would be neuro-imaging studies. Impact on Occupational Performance As a consequence of the injuries, occupational performance areas that are likely to bear the brunt are self maintenance, productivity and leisure occupations (Chapparo & Ranka, 1997). Her work as a hairdresser requires precision and coordination in hand movements. Thus, the maximum impact of the head injury is going to be on her vocation. In her leisure time, Lucy enjoyed tennis and golf as her recreational activities. Again, both these activities necessitate hand coordination and strength. However, due to likely frontal motor cortex damage and cortical sensory loss, in-coordination and hand weakness in right upper limb has resulted. Thus, leisure associated tasks are also likely to be affected. Due to difficulty in articulating sentences, patient may have difficulty in expressing her feelings and emotions and may have communication problems. This can lead to social withdrawal, feelings of isolation, an uncaring attitude and depression (Peloquin, 2000). This can affect her occupational performance in the interpersonal area. Assessment of Component Skills Assessment of dimensions of sensory motor component, interpersonal component and cognitive component is performed (Chapparo & Ranka, 1997). From the patient’s perspective, a complete neuromuscular and sensori-motor evaluation is performed to evaluate coordination and limb weakness (Chapparo & Ranka, 1997). Muscle strength and reflexes in the right upper limb and rest of the limbs are graded and patient’s fine and gross coordination skills, laterality, postural alignment and visual-motor integration are tested in context of the tasks that need to be performed by the patient. Sensory system assessment includes that of proprioception, stereognosis, depth perception and other senses (Chapparo & Ranka, 1997). Cognitive and psychosocial assessment is required in view of the history of head injury, lack of self confidence and apathy towards her work. Cognitive assessment includes that of memory, learning, orientation, judgement, problem solving, decision making, initiation and termination of activity etc. in relation to her work (Desiron, de Rijk, Hoof, & Donceel, 2011). Psychosocial assessment is done regards apathy, neglect and awareness in the patient. Her psychological, social and self management components are assessed. The skills pertaining to these are her interests; perception of self and expression of self; social conduct and behaviour and interpersonal relationships compared to the pre-injury state (Chapparo & Ranka, 1997). Occupation Therapy Interventions The goal of occupational therapy interventions in this patient is to restore her participation in her career, her activities of daily living like cooking, cleaning and shopping; and her leisure activities which are golf and tennis. Possible interventions in an occupational therapy plan for this patient are neuromuscular, adaptive, musculoskeletal, cognitive and educational interventions (Radomsky & Latham, 2008). Neuromuscular interventions are required in her case in the form of postural awareness, balance training, muscle strengthening, one handed skills and improving the range of motion (Chapparo & Ranka, 1997). All these interventions aim to improve the upper extremity function. In Lucy’s case, educational intervention can be one of the most effective one to address occupational performance issues. These interventions target the patient as well as the family members. As she has plans to get married, her boyfriend is also involved in the education process. Education relating to home management, community integration, self grooming, activities of daily living and social skills is given (Chapparo & Ranka, 1997). Importance of speech therapy for treatment of aphasia is explained to the patient as well as care givers. References Case 1 Chapparo, C., & Ranka, J. (1997). Occupational Performance Model (Australia): Monograph 1(pp. 1-23). Sydney: Total Print Control. Retrieved from www.occupationalperformance.com/ Desiron, H. A. M., de Rijk, A., Hoof, E. V., & Donceel, P. (2011). Occupational therapy and return to work: a systematic literature review. BMC Public Health, 11, 615. Retrieved from http://www.biomedcentral.com/1471-2458/11/615 Hoffmann, G., Hannetona, L. & Roby-bramia, A. (2006). How to extend the elbow with a weak or paralyzed triceps: control of arm kinematics for aiming in C6–C7 quadriplegic patients. Neuroscience, 139, 749–765. Kirshblum, S. C., Priebe, M. M., Ho, C. H., Scelza, W. M., Chiodo, A. E., & Wuermser, L. A. (2007). Spinal cord injury medicine 3. Rehabilitation phase after acute spinal cord injury. Archives of Physical Medicine and Rehabilitation, 88, s62-s70. Lightbody, S. (1998). Assessment of upper limb sensation in patients with complete quadriplegia. Australian Occupational Therapy Journal, 45, 18-22. Case 2 Chapparo, C., & Ranka, J. (1997). Occupational Performance Model (Australia): Monograph 1(pp. 1-23). Sydney: Total Print Control. Retrieved from www.occupationalperformance.com/ Desiron, H. A. M., de Rijk, A., Hoof, E. V., & Donceel, P. (2011). Occupational therapy and return to work: a systematic literature review. BMC Public Health, 11, 615. Retrieved from http://www.biomedcentral.com/1471-2458/11/615 Fadiga, L., Craighero, L., & D’Ausilioa, A. (2009). Broca’s area in language, action, and music: The Neurosciences and Music III—Disorders and Plasticity. Annals of New York Academy of Sciences, 1169, 448–458. doi: 10.1111/j.1749-6632.2009.04582.x Peloquin, S. M. (2000). Occupation as therapy: activity as a therapeutic tool. In A. J. Punwar, & S. M. Peloquin (Eds.). Occupational Therapy: Principles and Practice (pp. 39-51). Philadelphia: Lippincott, Williams & Wilkins. Radomski, M. V. & Latham, C. A. T. (2008). Occupational therapy for physical dysfunction (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Read More