Page 19 - Mobility Management, June 2017

Complication #2: Postural Changes
While SCI isn’t progressive, some complications can be. That includes postural changes.
“Postural changes can occur as a result of many different things,” Bernstein said. “It can be as a result of muscle spasticity, it could be a result of an incomplete spinal cord injury where you have one side of your body that’s stronger than the other, it could be due to surgical stabilization — that would be a non-flexible postural impairment. It could even be due to soft tissue damage. Or some people have heterotopic ossification, causing bone growth within the soft tissue that will push someone to one side or the other if it occurs in the hip joint.
“For people with SCI, [postural changes] definitely occur if someone has a muscular imbalance, where one side is stronger than the other, or more muscles are active on one side than the other. Weaker muscles lengthen and stronger muscles shorten. If you don’t have a balance around the joint, the stronger muscle is always going to win.”
Even supposed interventions can cause postural changes, Bernstein said: “I’ve seen postural changes from in-dwelling medical devices like diaphragm pacers or Baclofen pumps.”
Complication #3: Pain & Discomfort
Postural changes can also be a reaction to pain. While it might seem obvious that pain would be a priority for any client suffering through it, Merring said that’s not always so.
“If the [wheelchair] is not working and pain is involved, you’re definitely going to know,” he said. “It’s going to be one
of the first things that they’re going to tell you. But if a device improves a person’s mobility and [the client] has pain, it’s really important for clinicians and ATPs to know that a lot of times, clients will not report it. Or they won’t report the pain with the same severity. It’s like they’re thinking, ‘At least I have mobility, so I’m going to just deal with the pain.’ That has actually been supported with evidence and research, that they will choose mobility over pain and comfort.”
Adding to the puzzle are the different types of pain SCI clients can experience.
“People with spinal cord injury can have pain in different ways,” Bernstein said. “In an orthopaedic joint sense, where they have sensation. But also neuropathic pain, where they may not have full sensation or have absent sensation, but they still have pain. People will come in and say, ‘My butt hurts.’ You
say, ‘Where does it hurt? How does it hurt? When does it hurt?’ And they say, ‘I don’t know, I don’t really have sensation on my butt, but it just hurts.’ Is it aching, is it stabbing? ‘I have no idea.’ They’re getting these sensations they can’t really describe.”
Complication #4: Spasticity
Spasticity can be another fluctuating SCI complication. “Spasticity is a common complication,” Merring said. “My
mentor and neuro professor in college always called it ‘reflexes gone wild.’
“You know when you go to the doctor and they hit your knee and it kicks forward? Those reflexes are modulated by the brain. When you have a spinal cord injury, you no longer have that modulation. You no longer have the ability to stop those reflexes from going wild. And [spasticity] just depends on where they’re injured and how severely they’re injured. Anybody with an upper motor neuron injury, T10 and above, I think the statistic is 60 to 80 percent of people will have some sort of spasticity that affects their ADLs [activities of daily living]. So it’s a high incidence.”
A number of circumstances can exacerbate spasticity.
“If you had a stressful day, if it is cold outside, if you missed your meds, if you didn’t eat right — spasticity is a physiological reaction and representation of what’s going on internally and your body wanting to express that,” Merring said. “Not only is that going to change throughout the hours of the day, but it’s also going to change whether a storm is coming, or it’s colder or hotter, or if you had a stressful day at work. All these things have an effect on spasticity.”
Addressing the Problems
The good news: There are many ways to address the many complications of SCI. But SCI complications are, well compli- cated. Where should clinicians and ATPs begin?
“When [clients] come in,” Merring said, “we’re having a nice long discussion. What I’m getting from them is their perspective and their idea of what’s working and what’s not working.”
As mentioned earlier, clients won’t always disclose their pain, so Merring said clinicians need to dig deeper.
“It’s not that they want to hide it from me,” Merring said. “It’s because it’s not a priority. It’s that idea of ‘Maybe it’s neuro pain. Maybe it’s part of my paralysis. Maybe it’s because I sit all day, and that’s just how it is.’ But we’re the ones with the tools to help figure out if it is those things. If we want to do our jobs thor- oughly, we have to really drill down on those questions: ‘Are you sure there’s no pain? How are your shoulders, how is your back? After two hours, do you feel anything?’ Just ask a couple more questions, build a rapport.”
“Go through the body systems,” Bernstein advised, “and identify the limitations or impairments that someone has. Then decide what are your therapeutic goals to accommodate or correct or relieve those impairments? What are the patients’ goals in their equipment, and then what exact equipment do you need to achieve those goals?
“How am I going to address their skin impairment? How am
I going to address their trunk control? I want to correct for this convexity but accommodate for this obliquity, and I’m going to do that through a cushion and a backrest and trunk supports and power posi- tioning. You kind of have to break it down into the problem, the goal and the potential equipment solutions.”
Part of the intervention process, incidentally, is determining when to intervene and when not to.
“As the clinician, your job is not to correct everything,”
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