Application of Wheelchair Skills
Training Program for a Patient
with T4 Level Spinal Cord Injury:
A Case Report
Richard J Fernandez, SPT
UIC Department of Physical Therapy
Background
• Meningioma and Tumor Resection
• Wheelchair statistics
• Wheelchair Skills Training Program (WSTP)
• Wheelchair Skills Test (WST)
Spinal Meningioma
•
•
•
•
25% of spinal lesions, almost always benign
45yo avg age
Women 4-10x men
Meninges (posterolateral)
• Dura
• Arachnoid (most common)
• Pia
• Treatment:
• Surgery (resection) – 1st choice
• Radiation therapy
• Stereotactic radiotherapy
Spinal Meningioma. Columbia Department of Neurosurgery. [ColumbiaNeuroSurgery.org] Accessed: 1-15-2015
SCI and Wheelchair Use
• 276,000 people with SCI
• 1.6 million wheelchair users
• AIS C first year expenses: $510,883
• 57.3% patients with SCI use w/c or scooter within year
• Good w/c mobility indicator of longer-term survival
• #1 reason PTs don’t teach advanced w/c skills: lack of confidence
teaching skills
Facts and Figures at a Glance. 2014, National Spinal Cord Injury Statistical Center: University of Alabama at Birmingham.
Kaye, H.S.K., T.; LaPlante, M.P., Mobility device use in the United States, Disability Statistics Report 14, D.o. Education, Editor. 2000, National Institute on Disability and
Rehabilitation Research Washington DC.
2013 Annual Report Complete Public Version 2013, National Spinal Cord Injury Statistical Center: University of Alabama at Birmingham.
Parsch, D., R. Mikut, and R. Abel, Postacute management of patients with spinal cord injury due to metastatic tumour disease: survival and efficacy of rehabilitation. Spinal
Cord, 2003. 41(4): p. 205-10.
Wheelchair Skills Program
• For wheelchair, power chair, and scooter users, trainers, and family
• Wheelchair Skills Training Program (WSTP)
• Manual of suggested progressions for skills training
• Describes indoor, community, and advanced skills
• Wheelchair Skills Test 4.1 (WST)
•
•
•
•
Diagnositic reassessment tool
WST-Questionnaire also proven to have similar reliability
Excellent test-retest reliability ICC = 0.904
Interrator reliability: ICC = 0.855 performance ICC = 0.061 safety*
• Training Available
Kirby, R.L., et al., The wheelchair skills test (version 2.4): measurement properties. Arch Phys Med Rehabil, 2004. 85(5): p. 794-804.
Bonaparte, J.P., R.L. Kirby, and D.A. Macleod, Learning to perform wheelchair wheelies: comparison of 2 training strategies. Arch Phys Med Rehabil, 2004. 85(5): p. 785-93.
WSTP and WST
• See examples
Why Advanced W/C Skills?
• Enhance independence and access to environment
• Increase patient efficiency, confidence and safety
• Wheelie for:
•
•
•
•
Navigate soft ground surface
Forward curb descent to watch traffic
Pressure relief
Stair navigation: ⬇caregiver strain
• Increased mobility:
• ⬆job opportunity
• ⬆activity
Purpose
To demonstrate the application of the Wheelchair Skills Training
Program (WSTP) to the traditional physical therapy intervention for a
patient with spinal cord injury (SCI)
Secondary clinical question: Is this training program practical in the
rehab setting?
Clinical Case
• 54 year old male, post-spinal tumor resection admitted to inpatient
rehab
• T3-T4 meningioma, C7-T4 syrinx
• POD 1 following tumor resection with dorsal laminectomy
• Tumor resection with no complications
• Motor and sensation loss
• No h/o of SCI, motor or sensation loss
• PMH: HTN, cholersterolemia
Examination: Subjective
• Retired woodworker, builder
• Married, wife full-time accountant, no children, rural 1 story home
with “tight quarters”
• PLOF: Constructing 2-story home
• Pt reports: “one day I was up there laying down the roof, then the
next morning I couldn’t walk”
• Can’t move R leg, loss of sensation BLE (L worse than R), feels tight
band around torso
• Nausea with continuous upright sitting in bed (10+ minutes)
Examination: Subjective
Examination: Physical
• 2 -1hr sessions
• AROM (session 1)
• MMT (session 1)
• Sensation (session 1)
• ISNCSCI ASIA (session 2)
• ISNCSCI ASIA Scale
• T4 AIS C
• Motor: 47
• Light touch sensory:
56
• Pin-prick: 57
Examination: Measures
• FIM (initial):
•
•
•
•
•
Bed Chair Wheelchair: 1
Walk: 0
Wheelchair: 5
Stairs: 0
Locomotion: by wheelchair
• Week three: WST
• 34/60
• 57%
Findings (Initial and Week 3)
• MMT
L
R
L
R
Hip F
2+/5
1/5
Sh F
5/5
5/5
Knee E
3+/5
1/5
Sh Ab
5/5 p+
5/5
DF
3+/5
0/5
Elbow F
5/5 p+
5/5
PF
3+/5
0/5
Elbow E
5/5 p+
5/5
Week 3: no change in RLE MMT scores
• FIM:
Eval
Wk 3
BedChair-WC
1
4
Walk
0
0
w/c
5
6
stairs
0
0
Evaluation
Following meningioma tumor resection
• Decreased BLE strength decreasing overall function
• 2 weeks, continued poor recovery of RLE strength/active mm cxn
• Patient prognosis sufficient for short or long term w/c use
Goals
• Independent with bed mobility (3weeks)
• Mod I with community mobility over 500ft (6 weeks)
• Mod I slideboard transfers bed<> w/c (6 weeks)
• Mod I with slideboard car transfer (6 weeks)
• *Added goals for 30sec wheelie with supervision and independent
curb navigation (ascend, descend 15cm curb)
Interventions:
• PT and OT total 3hrs/day
• PT 1-2hrs/day
• Weeks 1 and 2 limited by nausea and L shoulder pain (overuse)
• Bed mobility, transfer training, ROM exercise, basic wheelchair
mobility
• Week 3+: W/c inclines, outdoor mobility, AAROM, car transfers,
stander training, family training (3 sessions, wife very involved)
• Increased activity: trained rehab aid to assist patient with HEP
eventually including EasyStander and MotoMed ergometer
Interventions:
Advanced W/C
Skills
Intervention: Lesson Plan/Progression
Advanced w/c Skills
• Spotter strap w/o antitippers
• Safe and effective
• WSTP progression
Kirby, RL, Lugar JA. Spotter strap for prevention of wheelchair tipping. Arch Phys Med Rehabil. 1999 Oct: 80(10):1354-6
Wheelchairs
• LT-800T - Lightweight (34lb)
• TiLite AeroR – Ultralightweight (13.3lb)
Outcomes
Outcomes
• WST
• Initial: 34/60, 57%
• Week 4 Training: 48/60, 80%
Discharge
• Week 7: Patient discharged home with OP PT, fitted with own
Ultralight W/C
• Mod I with sideboard transfers between all even surfaces and
moderate inclines (up to 10cm)
• CGA/close supervision squat pivot bed<>chair
• Tolerated 18 minutes in EasyStand
Pay out of Pocket?
• Rehab wheelchair training: $30/unit
• 2units/session x 16 = 32 units
• $30/unit x 32 units
• $960 total
• Alternatives?
• Outpatient wheelchair training
• Group training
• Self training with spotter
Patient Satisfied?
• Patient reports increased confidence
with wheelchair use
• Increased preparedness for home and
community mobility
• Wife confident in ability to assist
• In the end, the patient just wanted to
GO HOME
What Did I Learn?
• Incorporating organized teaching manual within POC
• Making time for therapy
• Working with wheelchair vendors
• Community reintegration to challenge motor learning
• Justifying intervention with outcome measure
Discussion
• Possible follow-up:
• QOL (Hosseini et al., curb
navigation not wheelies)
• Wheelchair confidence
• Home f/u
• Trainer (student) w/c skill
• More measures:
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•
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Reintigration to normal living
Satisfaction with life scale
SF-36
Spinal cord injury functional
independence measure III
• Any other suggestions?
• Is the time spent worth the
skill acquisition?
Hosseini, S.M., et al., Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury. Arch Phys Med Rehabil, 2012. 93(12): p. 2237-43
SCI EDGE 2013 “SCI EDGE outcome measures for motor incomplete (AIS C, D) SCI. [http://www.neuropt.org/docs/sci-edge-/sci-edge-motor-incomplete.pdf?sfvrsn=2].