Jamie By: Missy Dappen, Stephanie Hayes, Anna Long, Trish Ruby and Kristen Thompson

P factors 23-year old female Complete C6; quadriplegia Complete trunk and LE paralysis; partial UE paralysis Sitting tolerance = 4 hr Good shoulder strength Minimal wrist strength No hand function Difficulty grasping utensils (eating and writing) Difficulty dressing lower extremity Difficulty transferring into and out of wheelchair Using facility’s wheelchair

E factors Lives independently in a one-bedroom apartment Drives a sports car Has supportive parents and a steady boyfriend

O factors Occupational roles: daughter and girlfriend Assistant to an accountant Recent graduate, hoping to continue her education Enjoys: dancing, playing softball, movies, theater and driving her sports car

Frame of Reference Biomechanical – Goal: To remediate loss of range of motion, strength and endurance – Purpose: If range of motion, strength, and endurance are regained the patient will use these skills to gain functional skills – Appropriate for Jamie: Remediate muscle strength in wrist extensors to help increase her grasp for ADL and leisure activities

Assessments Range of Motion (functionally and using goniometer) (P) Manual Muscle Testing (P) Endurance testing (P) Functional Tests – SAFER (E) – COPM (O) – Kitchen task assessment (E & O)

Strength in Shoulder Supraspinatus5 Teres Minor5 Deltoid5 Subscapularis5 Infraspinatus5 Rhomboids5 Levator Scapulae4

Strength in Forearm and Wrist Brachialis4 Brachioradialis3- Biceps3+ Extensor carpi radialis longus 2- Extensor carpi radialis brevis 2- Extensor carpi ulnaris 2- Extensor digitorum2- Extensor pollicus longus2- Extensor pollicus brevis2-

OP Limitations and Goals Limitation: Grasping utensils Solution: Strengthen wrist extensors to 3+ so she can use a tenodesis splint Goal: Jamie can increase wrist extensors to a 3+ for use of a tenodesis splint to facilitate grasp by 1 month

OP Limitations and Goals (cont.) Limitation: Difficulty with transfers Solution: Teach biomechanics principals of transfers to assist when transferring Goal: Jamie will be able to transfer from bed to wheelchair with contact guard assist by 6 weeks

OP Limitations and Goals (cont.) Limitation: Difficulty dressing especially lower extremity Solution: Strengthen biceps and provide and train on use of adaptive equipment Goal: Jamie will be able to dress using adaptive equipment and techniques by discharge

Role Play Begin with passive stretching of wrist and then fingers Kitchen stirring activity will strengthen Jamie’s wrist extensor in a horizontal plane remediating her extensors to at least a 3+ resulting in the ability for Jamie to independently return to cooking and have the strength to use a tenodesis splint for grasp Introduce and educate about splint

Efficacy article Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being Population: Men & Women: Age with SCI (C4 or below) Training Intervention: UE stretching; cardiovascular exercise, and resistance training for major muscle groups Exercise group had significant increases in strength, arm ergometry performance, as well as several components reflecting QOL & psychological well-being

Why Pertinent to Jamie Jamie needs to improve her strength in the muscles that were covered in the article By improving Jamie’s strength in affected muscles, her abilities could generalize to help with functional activities

Tenodesis Splint Purpose: To create functional grasp by facilitating joint movement and making use of passive tension properties of muscle Use: In therapy program when the wrist extensors are a 3+ or better Indications: C-5 (incomplete); C6 or C7 (complete) Position: Index and Middle Finger- MP: free, PIP: flexion o, DIP: flexion o ; Thumb- CMC: abduction 50 o, MP and IP: 0 o Precautions: Risk of Skin Breakdown

References Frames of Reference and Models of Intervention at Washington University in St. Louis School of Occupational Therapy on September 19, 2005, Dr. Patti LaVesser describing the Biomechanical Model. Coppared, B.M., & Lohman, H. (2001). Introduction to splinting: A critical-reasoning and problem solving approach (2 nd ed). St. Louis, MO: Mosby. Holm, M. (1986). Frames of reference: Guides for action. In, H. Schmidt Powell (Ed.) PILOT: Project for independent living in occupational therapy, pp Rockville, MD: AOTA. Hicks, A. L., Martin, K. A., Ditor, D. S., Latimer, A. E., Cravin, C., Bugaresti, J., & McCartney, N. (2003). Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord, 41, 34-43

References (cont.) Pedretti, L.W. & Early, M.B. (Eds.) (2001). Occupational Therapy: Practice Skills for Physical Dysfunction (5 th ed). St. Louis, MO: Mosby, Inc. Tenney, C. G. & Lisak, J. M. (1986). Atlas of hand splinting. Boston / Toronto: Little Brown & Co. Trombly, C.A. & Radomski, M.V. (2002). Occupational therapy for physical dysfunction (5 th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.