Neurophysioplus Ltd | Registered Office | 22 George Road, Edgbaston, Birmingham, West Midlands, B15 1PJ
Registered in England & Wales Reg No. 5988036. © Copyright Neurophysioplus Ltd 2007
Registered in England & Wales Reg No. 5988036. © Copyright Neurophysioplus Ltd 2007
Example Case History:
This case history is an overview of the progress a young gentleman has made over the past 18 months following an incomplete spinal cord injury and illustrates the advantages of a Multi-disciplinary team (MDT) approach.
Mr X was involved in a road traffic accident at the end of 2007. He sustained numerous injuries including a burst fracture of C5 (neck at the level of the fifth vertebra), an un-displaced vertical fracture of the body of the vertebra of C5 and spinal cord damage at this level. He fractured his left 9th and 11th ribs and sustained a pneuomothorax (collapsed lung). Furthermore he suffered a small mid brain haemorrhagic brain contusion.
Mr X spent a very short time in a General Hospital to ensure that he was medically stable before being transferred to a specialist spinal cord injuries unit. Following a period of approximately 12 weeks bed rest Mr X was able to commence his rehabilitation. He had no lasting affects from his head injury and his memory and cognitive abilities (problem solving) were reported as normal. His lungs and ribs had healed well. Mr X continued as an inpatient at the spinal injuries unit for seven months. Mr X was on antispasmodic medication which included 25 mgs Baclofen three times a day and 5 mgs of Diazepam once daily. Despite what was described as intensive Physiotherapy and hydrotherapy he returned to his home dependent on all cares.
Mr X returned home living with his parents who were in their mid fifties. He was engaged and his aspiration was to be able to stand to marry. Prior to his injury he was finishing a course at college and had secured employment.
Mr X presented with an incomplete spinal cord injury at the level of the 5th cervical vertebra. Incomplete spinal cord injury means that all the spinal nerves above the lesion (injury) are normal. For Mr X this meant that he was able to move his head, shrug and elevate his shoulders and was able to bend his elbows. Mr X had an incomplete spinal injury which meant that some of the spinal cord was damaged below the level of the 5th vertebra in his neck. The damage meant he had very weak elbow extension, poor ability to move his wrist and fingers. There was underlying muscle activity in the trunk and Mr X did have some volitional (active movement) in his legs. There was marked weakness in the legs and the activity was masked by spasticity. The nerves that supplied the skin were relatively well preserved so he was able to feel light touch, hot and cold. This reduced his risk of developing pressure areas.
Mr X's spasticity was poorly controlled despite being on oral antispasmodics. The spasms in his legs made it difficult for him to bend his legs whilst lying in bed and often spasmed when in his wheelchair. Any attempt to stand Mr X would result in strong flexor spasm (knees bending without warning). He required hoist transferring for all transfers. He had been provided with a commode which he was unable to use because of the muscle spasms. His father would lift him into to the bath as he was dependent on all cares. His package of care included three visits a day to assist with washing, dressing and toileting. He was unable to sit unsupported and was unable to stand. He had reduced hand function.
His initial NPP therapy was aimed at controlling his muscle spasms through physiotherapy and normal movement and ensuring that his antispasmodic medication was optimised. Mr X was assessed by our Neuro-Consultant and was started on Gabapentin which had an immediate affect in reducing the flexor spasms and tone sufficiently so that he could access the underlying motor activity (muscle contraction). Over the course of a few weeks this medication was adjusted to an optimal level allowing the Physiotherapists to work on sitting balance and standing.
His ability to sit unsupported reduced the risks of falling when sitting over the side of the bed and allowed the Occupational Therapist to work on washing and dressing. Within a month Mr X was able to able to wash his upper body and face and put a "T" shirt on. Mr X had some underlying active movement in all major muscle groups within the legs and the trunk allowing the Physiotherapist to concentrate on standing and transfers. At this point it was extremely difficult to assess how much progress could be made due to the extent of the damage to the spinal cord. Mr X always expressed a desire to stand and walk and trying to reconcile the client's aspirations whilst setting realistic goals was always going to be difficult. We were however fortunate to have the assistance of a very skilled Neuropsychologist who was able to discuss the issues with the client and also assist the therapist when these challenging questions were posed.
Within a few months Mr X was able to stand with the assistance of the Physiotherapist. With the provision of a stand turner his partner and relatives were able to assist with standing transfers which allowed the family to place him on the commode. The Case Manager then recruited skilled rehabilitation care assistants that could assist with his personal care, Physiotherapy and Occupational Therapy programme. Soon Mr X was able to stand and transfer with a disc turner which allowed him to be transferred into the front seat of a car, negating the need for costly Taxis.
So that Mr X could stand for periods at home with support from his Rehab Assistants, he was provided with bespoke custom made Knee Ankle Orthoses (KAFOs); supplied by our in-house Orthotist. The provision of the KAFO meant that Mr X could stand and strengthen his trunk muscles which in turn would improve his ability to stand and balance. Mr X was also encouraged to play on the Wii fit™ on such games as the Wii™ boxing. Physiotherapy concentrated on sitting to standing, standing balance, activating and strengthening specific muscle groups and assessing his ability to step.
Following several months of intensive Physiotherapy Mr X had the ability to step however, he required considerable support of three therapists so we hired the Biodex system at a local NHS hospital. The Biodex™ system is a de-weighting system that can reduce an individual's loading on the legs by up to 40%. This facility enabled him to step and also demonstrated that he had reasonably well preserved movement of the legs. Over a number of weeks, the Physiotherapist then reduced the de-weighting and he is now able to "walk" approx 30 metres within the Biodex™ system without need to reduce the loading on the legs. At present we have begun to move out the system and started stepping with the assistance of two. Even at this stage it is difficult to say whether Mr X will be able to walk without considerable assistance; we are still on that journey.
Whilst working on Mr X's Physiotherapy, the Occupational Therapist has been concentrating on working on activities of everyday living. To assist with hand function Mr X was provided with Lycra Gloves again provided by our Orthotist. These give increased awareness of the hands to the brain and assist in supporting weaker muscles. The pictures nicely illustrate Mr X undertaking normal functional activities such as dusting and preparing a meal.
A further consequence of spinal cord injury can be bladder or bowel problems and even incontinence. Following careful questioning it was clear that Mr X had awareness of when he needed to void his bowels and bladder. A bowel regime was established meaning that he could be toileted as part of his morning routine. Although Mr X was aware of when he wanted to urinate he preferred to use a convene in-order to avoid accidents and negate the need for assistance with toileting during the day. With improved manual dexterity and a programme of bladder training Mr X is now able to use a urinary bottle with relative ease. Mr X is now able to go through the night without the convene and continues to use a bottle whenever possible whether at home or out. During the bladder training regime we were able to ensure that the bladder was draining effectively by performing ultra-sound bladder scans. This was done on one of Mr X's routine medical follow-ups with our Consultant Physician.
During the management of Mr X we have been fortunate to work closely with his Case Manager who has ensured that his needs are met in a timely and coordinated manner. This was facilitated through regular case conferences with the Multi-Disciplinary team.
On a lighter note Mr X has found a suitable property with help from his Case Manager and Occupational Therapist within close proximity to their respective families that is large enough to accommodate them and the rehab/care team. The Occupational Therapist has worked in close collaboration with the Architect to ensure that any alterations encompass all their needs for a home as well as facilitate his rehabilitation goals.
Any Neurological damage can be devastating on the individual and the family, even more so when you're in your twenties with a fiancé and a newly born baby. His fiancé has found coping with a baby and the needs of her partner extremely difficult and stressful. The situation was further exacerbated by moving into a small ground floor flat and having two rehab/care assistants present for most of the day. The Psychologist has been pivotal in maintaining lines of communication and suggesting solutions which has gone some way in reducing the tensions and ensuring that Mr X and his family, in its wider context, have moved forward together. It has been important that Mr X, his fiancé and their child spend proper family times together. This was difficult for them as they only met a few months before his injury and learning to make time for each other was something that they had to work on with some guidance from the Psychologist.
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