Page 20 - Mobility Management, June 2017

ATP Series
SCI: It’s Complicated
Bernstein said. “But if you see something that could poten- tially lead to a problem, then it’s your job to offer a potential intervention. If you’re going to correct someone’s posture, you’re going to limit their function most of the time. So it’s always trying to find that balance between what can you correct, what do you need to accommodate and how is that going to impact function?”
Strategy #1: Gather All the Info You Can
As the saying goes, forewarned is forearmed. Gathering facts and histories from SCI clients at the very beginning of the assessment process is critical to an informed outcome.
“Always look through their medical history as well as the report to find any secondary complications,” Bernstein said.
If a device improves a person’s mobility and [the client] has pain, a lot of times clients will not report it
— Curtis Merring
“You want to know anything they’ve been to the doctor for, anything they’ve had to have nursing care for, because it can really all be influential.”
Bernstein cited a colleague who “has a wonderful setup. The first day that they do their eval, all they’re talking about is their medical history and complications and goals. Then they come back and talk about the equipment. So she’s able to process and evaluate and determine over time what’s going to be the best given all those complications, or lack of complications. Not everyone is going to have these complications.”
Strategy #2: Try Positioning Options
Altered positioning can potentially affect a range of complica- tions, from pain to spasticity to, of course, pressure issues.
“Pain can be orthopaedic — my shoulder is hurting from pushing this wheelchair,” Bernstein said. “Or it can be neuro- pathic, which is this ominous burning, tingling, numbness, achy pain. It’s hard to put your finger on the cause of the pain. We rely not only on our cushions and backrests, but if you’re talking about power chairs, then we’re relying on repositioning and changing positions using power seat functions if someone can’t change their own position. Even providing relief by providing
a standing wheelchair. That can really help reduce some of the neuropathic pain that someone experiences.”
Strategy #3: Is Standing an Option?
Merring recently fit a client with a C3-4 SCI and a ventilator for a standing wheelchair.
“She wants to stand, she has really bad increased tone throughout the day, but it takes three hours and three people in order to get her into a stander for one hour,” Merring explained.
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“There’s something about the proprioceptive input from the joints compressing onto each other [when we stand]. When we walk, not only do we move forward, but each one of our bones goes into each other, and then pulls away. There’s a feedback loop mechanism in there that helps to inhibit some tone for people with paralysis.
“When someone comes into my clinic with SCI, I’m asking them: Can you stand, and if not, why not? Let’s get you onto a standing program. We have standing frames here, maybe we can get you a standing frame at home.”
Strategy #4 Keep Looking
Beyond seating and mobility are other options that can also help to relieve SCI complications.
Merring has seen some clients improve by using FES bikes. “That repetitive circular motion, and the electrical stimula- tion, has been proven to decrease spasticity and tone when it’s unwanted. Also, it helps with pain,” he said. “If I can put you on an FES bike and you can tolerate it for 45 minutes, we’ll see decreased tone just based off of fatigue immediately after the exercise.
“I also want to ask if there’s a stretching program that they and their caregivers can do. It’s not the end-all be-all, because shortened soft tissue is a lot different than spasticity. But spasticity causes shortened soft tissue, shortened soft tissue can then increase spasticity, then spasticity causes shortened soft tissue. So it’s a big negative cycle that needs to be managed and broken up.”
The bottom line is for clinicians and clients to keep looking for interventions — not just for the immediate relief they can offer, but also because SCI complications can be progressive if not addressed.
“The last thing is making sure they’re seeing their doctor, because there are medicines like Botox and Baclofen and Tizanidine that people can try,” Merring said. “That’s between them and their doctor, and sometimes I can help with
that discussion.
“Most times without an intervention, you’re going to get worse.
We weren’t meant to sit all day. We were meant to do varied amounts of sitting, laying and standing. There is a chance that even if I do put an intervention into place, [the complication] may get worse still, but at a much slower rate than if I didn’t address it. Then there’s a percentage of times where you do actu- ally stabilize the problem.”
“There’s potential to manage pain through repositioning, through nerve blocks, through different pain management interventions, medications, pain pumps,” Bernstein said. “Same with spasticity: You can manage that with medication, range
of motion, weight bearing, standing, Baclofen pumps. People’s bodies do change. Some people will have severe spasticity initially, and then it will kind of dissipate. Some people will develop spasticity afterward.
“When it’s not managed, it will continue to get worse.” m MobilityMgmt.com