“My back hurts right where they did the surgery”
The patient is a 25-year-old man admitted to the emergency department status post motor vehicle accident. His car rolled over and he was trapped inside. Emergency Medical Services (EMS) arrived at the scene within 15 minutes and extrication took approximately 30 minutes. In the field, the patient was placed on a long board with a cervical collar. He reported no feeling in his lower back, abdomen, or legs. He reported pain in mid-back and left chest (Glasgow Coma Scale [GCS] = 14). Transportation time from the scene to the emergency department was 10 minutes.
“My back hurts right where they did the surgery”
Will continue to see patient five to seven times a week to progress functional mobility. Will continue to progress balance, bed mobility, transfers, wheelchair mobility, and safety through strengthening and endurance interventions and education on respiratory mechanics, airway clearance, and positioning. Will coordinate functional plan with occupational therapy and rehabilitation plan with physician and discharge planner.
7. Describe at least two functional mobility interventions for the initial treatment sessions in acute care with physical therapist. Be specific as to the parameters and position of interventional techniques.
10. Did the patient’s vital signs respond appropriately to the physical therapy interventions performed on day 3? Why is it important to monitor vital signs before, during, and after physical therapy sessions with this patient?
1. The patient is a 25-year-old man who presented to the hospital status post motor vehicle accident. The patient was diagnosed with an incomplete SCI at the T7 level—American Spinal Injury Association (ASIA) classification B—and posterior rib fractures of ribs 5 and 6. The patient underwent T6–T8 spinal fusion and will follow post-op spinal fusion precautions of forward flexion, lifting, and spinal rotation. As a result of his spinal injury, the patient presents with lack of motor and sensory nerve function below T7 at this time. He is using 2 L O2 via NC to maintain proper oxygen saturations. All other lab findings are appropriate at this time. He would benefit from continued physical therapy to improve above deficits to maximize functional mobility and safety. Will continue to follow and progress as tolerated.
4. The physical therapist should discuss the findings regarding UE strength, lack of LE motor and sensory function, and mobility. The physical therapist and occupational therapist should develop a plan to optimize the patient’s skills for bed mobility, endurance, transfers, wheelchair mobility, wheelchair prescription, pulmonary education and interventions, and education regarding other ancillary complications (bowel and bladder, etc.). At a minimum, the physical therapist should take the lead on pulmonary interventions, wheelchair prescription, wheelchair mobility, endurance, and flexibility/maintaining ROM.
5. The patient is likely to have a decrease in inspiratory volumes. The thoracic cage muscles are involved although most are intact. This will lead to some decrease in inspiratory volumes, at least early on in the rehab process. All mobility will also take more effort for the patient placing even more demand on the pulmonary system. Therefore, it is important to monitor vital signs to make sure that the patient is still getting enough PaO2 volumes to sustain the body’s demand and that the lack of inspiration isn’t leading to decrease volumes, hence increase PaCO2, which could cause problems with the body’s pH.
6. An SCI can impact the patient’s sympathetic nervous system, which in turn can impact organ function, including production and regulation of fluid electrolyte levels. Since the electrolytes can impact the patient’s cardiovascular system, renal system, and liver, it is important for the medical team to monitor these lab values, and for the physical therapist to watch for any adverse signs and symptoms pre-, peri-, or postrehabilitation.
8. The patient should be educated on the need to maintain or improve inspiratory volumes. Interventions to promote this include deep breathing, diaphragmatic breathing, inspiratory hold, breath stacking, or other inspiratory breathing techniques. Again, anecdotally, these should be performed for at least 1 to 3 minutes each session and the patient should be educated to perform them at least once or twice a day.
For airway clearance, the patient should be educated on how to produce an effective and efficient cough and why maintaining an upright posture is important. For coughing, splinting technique or other self-assisted cough techniques may need to be implemented if the patient is unable to generate a strong enough cough independently. This should only need to be taught once and then have the patient demonstrate them once or twice over the first few physical therapy sessions to ensure they are being performed accurately and effectively.
9. In the short term, the physical therapist should elevate the patient’s LEs, but for a more long-term solution, an abdominal binder, and/or compression stockings may be added to assist with blood pressure regulation. Initially, generic off-the-shelf stockings can be used. However, if it is determined that the patient will need them long term to maintain venous return, then custom progressive resistance stockings should be prescribed and obtained for the patient.
10. The patient’s vital signs did respond appropriately to the physical therapy interventions performed on day 3. It is important to watch heart rate due to increased physical demand on the patient since he is unable to use his LEs. The physical therapist needs to ensure that motion and mobility aren’t placing too high of a demand on the patient’s cardiac system. Blood pressure is also important to monitor to assess for tolerance to physical demands. However, it is important to be mindful that the patient has lost muscle contractions to assist with venous return, and therefore he is at risk of developing postural hypotension. Respiratory rate and O2 saturations give the physical therapist the ability to monitor that physical activity isn’t placing too high of a pulmonary demand on the patient either.
11. The physical therapist will need to educate the patient on the spinal surgery precautions and evaluate that the patient understands them. During interventions, the physical therapist must make sure that the patient is not flexing or rotating the spine.
12. The patient is at risk of developing a pulmonary embolism, atelectasis, or pulmonary infection (most likely pneumonia). The patient is at a lower risk of developing a pneumothorax, pleural effusion, or pulmonary edema.
1. It is important for the physical therapist to evaluate motor and sensory nerve function regularly for this patient as there may be some improvement with time, to fully evaluate patient’s mobility, and to assess how other body systems are being impacted by the SCI and how those reactions may impact the patient’s rehab with physical therapy.
2. Primary goals for physical therapy management of this patient in the acute care setting are to stabilize his pulmonary system and prevent complications, encourage mobility and upright activities, and prepare the patient for the next phase of rehabilitation.
3. Program parameters should include mobility, functional movements, and pulmonary training as the main types of rehab. Duration should be about 15 to 20 minute in total with multiple rests for the patient. Intensity will be determined based on patient’s subjective complaints and vital sign responses. Frequency should be most days of the week to prepare for the next phase of rehab.