C5 – ASIA A
♂ pt. arrived to facility in a Halo 3/1/08 s/p spinal fusion 1 wk. ago. Pt. states that he underwent immediate medical intervention after sustaining a C4 flexion teardrop fracture. There was severe ligamentous disruption and posterior dislocation. Pt states that injury was caused by falling from his motorcycle. Pt. is a 19 y.o. Landscaper, from New Jersey. Parents state that Pt. suffers from depression and substance abuse. Hx. of a previous fibula/tibia fx. due to motorcycle accident in 2004. Current Medications: Seroxat 30 mg for depression, anti-embolytics for edema. Parents state that the Pt.’s overall health is good.
MMT: 3/5 deltoids (per Halo precautions, will be re-evaluated with Halo removal for full strength), 5/5 R elbow flexors, 5/5 L elbow flexors, 1/5 R wrist extensors, 1/5 L wrist extensors , absent bilat. elbow extensors, absent bilat. finger flexors, absent bilat. finger abductors, absent bilat. hip flexors, absent bilat. knee extensors, absent bilat. ankle dorsiflexors, absent bilat. long toe extensors, absent bilat. ankle plantar flexors. Pt. is w/o sacral sparing.
Neurological evaluation: Pt. is sensitive to both pinprick and light touch in all key sensory points up to and including C5. Below this sensation is absent. Patient’s position sense from C5 and above could not be tested due to Halo restrictions and precautions. Below C5, position sense was absent. Pt. presented with areflexia below C5.
Range of Motion: Bilat. ROM included: hip flexion 0-75°, elbow flexion 0-120°, UE horizontal adduction 0-5°; R long finger flexion 0-85°, L long finger flexion 0-80°; bilat: long finger extension not tested (to preserve tenodesis), knee flexion 0-130°, df 0-20°. No contractures noted.
Functional Abilities: To be assessed in re-eval: bed and mat skills, transfers, w/c skills, instruction of others.
Skin Integrity: Skin inspected each time the patient is turned. Redness over bony prominences disappears within 30 minutes. No evidence of skin breakdown. Edema noted bilat. LE. (+) TEDS. Pt. and family educated on how to reposition patient q 2 hours. Pt. and family re-educated on proper hygiene at the Halo pin sites and of the skin underlying the vest.
Cognitive: A + O x 3
Respiratory: Vital Capacity 30% of normal. Impaired forceful exhalation. Some capacity for cough. Decreased chest expansion, normal epigastric rise. BP 90/60. HR 60.
Equipment: Pt. lacks needed equipment. Arrangement for equipment purchase will be made. Talk to family about ordering options for:
- Feeding – sling, universal cuff, plate guard.
- Self care – bath mat, non slip surface in the bath, soap and shampoo dispensers, long handled comb, toilet transfer aids, bath transfer aids (commode), catheter and catheter aids (loops and straps for leg bag), and suppository.
- Dressing – trapeze, loose clothing (1-2 sizes bigger), no buttons, extensions to zippers.
- Beasy™ board/notched transfer board, bed mobility aids.
- See Home Modifications.
Pt. is not expected to be functionally ambulatory. Due to the fact that this patient has diaphragmatic innervation, his vital capacity will improve with stabilization, breathing exercises, chest expansion, and accessory muscle breathing. Pt. demonstrates adequate deltoid and bicep strength, as well as ROM in shoulders and elbow to prepare for rolling and transfers. Diagnosis: Practice Pattern 5H: Impaired Motor Function, Peripheral Nerve Integrity, and Sensory Integrity Associated With Nonprogressive Disorders of the Spinal Cord.
Will see Pt. BID @ B/S. Will train Pt. and family in respiratory hygiene, ROM, bed mobility, skin integrity and strengthening. Educate Pt. on avoiding trunk motion, hip flexion > 90° and shoulder flexion> 90°.
Short Term Goals
- Pt. will be able to achieve a VC of 40-60%. Improve VC with positioning, trunk supports, abdominal binder. Improve chest expansion for posture and strengthen accessory respiratory muscles.
- Pt. will be able to phonate 6-8 syllables per breath.
- Pt. and family will be educated on how to assist with bronchial hygiene/assisted cough 3-4 times per day.
- Pt. will learn facilatory breathing techniques with accessory respiratory musculature.
- Pt. will maintain full ROM in all UE joints for proper self-care, posture, and eating.
- Improve shoulder extension by 5° to prepare Pt. to hook arms behind push handles.
- Pt. will maintain at least neutral extension at hip to prepare for prone lying and prone mat activities.
- Hamstrings ROM 90° to prepare for mat mobility, sitting ability, and transfers.
- DF to neutral to prevent skin breakdown at metatarsal heads and toes.
- Improve strength by 1 Grade in MMT for periscapular muscles, horizontal shoulder adductors, and elbow flexors to prepare for transfers, bed mobility, and ADL.
- Build strength of scapular adductors, shoulder flexors and elbow flexors for future w/c mobility.
- Pt. will tolerate upright sitting without skin compromise in tilt in space wheelchair for 10 minutes.
- Pt on Roto-rest to avoid skin breakdown.
- Family will demonstrate padding/ positioning.
- Pt. will inspect skin BID.