In Part 3 of our webinar series on spinal cord injuries, the QLI team covers topics such as injury classifications, the cost of spinal cord injuries, the type of body functions available, environmental modifications, and more.
Speakers: Anna Calgaard, Brad Dexter, Tim Benak
Tim Benak – 00:00
All right. Good morning, everyone. Welcome to another Webinar Wednesday here in studio Q. We’ve got a part three of a series that our team has put together for you. We’re pretty excited about it.
So as always, we do want you to be engaged and participate, so don’t hesitate to ask any questions along the way. I’ve got Brad Dexter in the studio with me who is a frequent flyer, so he needs no introduction. And then Anna Calgaard is joining us today. So I’ll let Brad do her introduction. But Brad, tell me a little bit about yourself.
Brad Dexter – 00:34
Let’s see been at QLI for almost 10 years as a physical therapist. I’ve had a big role in our spinal cord injury program and in the last couple years, been working with our telerehab program as well. Three kids, wife.
Tim Benak – 00:52
Brad Dexter – 00:53
Avid outdoorsman. Enjoy the outdoors. Wish we had more mountains in Omaha.
Tim Benak – 00:57
Maybe you ran an Iron Man or like have I heard that?
Brad Dexter – 01:01
It’s was a half Iron Man. And it was like 10 years ago, before I had kids and lots of other activities
Tim Benak – 01:08
I ran around in my basement with my kids for 20 minutes the other night and I’m sore four days later.
Brad Dexter – 01:13
So pretty much the equivalent.
Tim Benak – 01:15
I mean, I’m also on par with you when it comes to athletic ability. So I want the audience to know that ahead of time.
But well, thank you for a quick introduction. As always, I do have to tell you guys, there will be a poll question. If you’re looking to get a CEU certificate, please stick around for that. That’ll be towards the end.
We’ve got 200 listeners on with us today. Right now. I’m sure that number will go up as we continue. So I won’t take a ton of time. You guys have a lot to cover. And so I’ll let you introduce and Welcome to Studio Q by the way.
Anna Calgaard – 01:46
Thank you happy to be here.
Brad Dexter – 01:48
I was glad to have Anna join us today recovering. Just managing the diverse needs of the individual with SCI.
So we’ve been going through this topic for the last five to six months or so with the series of webinars and we’re covering a lot today. We’re doing thoracic and lumbar spinal cord injury.
We’ll talk a little bit more about why we group those together in a bit but I’m glad that Anna could join me for this one too. She’s been a part of our spinal cord injury team here at QLI, been a PT for two and a half years. She is quite the adventurer enjoys the outdoors. Canada Goose apparel. Yes. And let’s see if I can click through this tab. There we go. There’s a little picture of of Anna. Little teaser because you have to stay on till the end to actually see the reveal. That’s the full face without the mask.
Tim Benak – 02:52
Brad asked me to put some action shots in the front of Anna.
Brad Dexter – 02:57
You can see the intensity in the eyes. Yeah, no, we’re thrilled and as a part of our team, and she’s made some incredible contributions to QLI already too. I will say that this presentation is approved by Anna.
Anna Calgaard – 03:12
Yes, two thumbs up.
Objectives for this Spinal Cord Injury Webinar
Brad Dexter – 03:14
Okay, so objectives today. We’re gonna go through some similar content as what we have done in the past. And just like I said in the last webinar that I did on this for lower cervical, the repetition is good. I think it’s nice to just kind of remind ourselves of where we’re at and understand some of the basics, always come back to those before we have a jumping off point to getting into the nitty gritty right.
We’re gonna focus on just understanding the basic terminology behind classifying a spinal cord injury,
Describing some expected prognosis due to injury levels. Today, we’re talking specifically about thoracic and lumbar level injuries, as well as trends and progress.
Recognize the impact of SCI on annual lifetime cost, return to work and marriage,
And then be able to identify and apply appropriate goals based on injury classification.
So, just starting at some of the basics, right? We’re talking about paraplegia and tetraplegia. In the last couple webinars, we’ve covered more tetraplegic types of injuries. Injuries that are up in the cervical level region are going to result in impairment in all four limbs, which is tetra or quadriplegia.
Today with a focus on more thoracic and lumbar level injuries, we’re going to be looking at injury classifications that are paraplegic and what that means is that they’re going to have full use of their upper extremities because the cervical spine with the exception of the level of T1 which gets grouped into cervical spine because of the way the the nerves travel out to the body.
We’ll be looking at T2 down to L5 types of injuries within paraplegia. They have full use of their arms and hands, but then varying degrees of use of their trunk, lower extremities, bowel and bladder function.
Injury Classification – ASIA Impairment Scale
So coming back to the ASIA impairment scale, this is a scale that we use to help define and describe the injury extent and severity. It helps us determine future rehab and recovery needs. And we’ll get into some of the classification levels here shortly.
Just in terms of defining and describing the injury, I can’t tell you the number of times that you may have someone that comes in and they say, yeah, I’m a T6 to T9, injury. Okay, like those are the vertebrae that have been affected. But my job as a PT, and I think as a rehab team in general, is to help educate and empower the individual so they understand their entry, and they’re able to help communicate their abilities, injury level, extent of injury to other healthcare providers, family, so on and so forth, right.
And so, slowing down a little bit and helping them kind of get a good map of their body, so to say, and to understand what’s working, what’s not working, what’s maybe changed a little bit, I think, is really, really helpful. And then it gives us a common ground, to kind of jump off of when we’re actually talking together about the injury and the prognosis and what all of that means.
I refer to that as demystifying the spinal cord injury a lot of the time because your average Joe isn’t really gonna understand what a spinal cord injury is. And that’s typically most of our patients.
And then, like I said, having that common jumping off point, you know, it helps us converse and make it more of a conversation as to what future rehab and recovery needs are going to look like.
So when we start having that conversation about a bowel or bladder program with the individual, we have that common ground to jump off of. Why can’t you just go to the bathroom on your own anymore, there’s a reason for that, let’s talk about it. Let’s talk about how we kind of get around that right now.
Or when we start to kind of visualize and map out a return to walking again for someone. If they have the ability to move their lower extremities, it gives us the opportunity to kind of map that out for them and help them understand, here’s where you are now based off of the ASIA impairment scale that we’ve done. We would expect that you can do X, Y, and Z. But given your so far out from your injury, here’s what we’d anticipate based off of the trends that you showed so far.
We can’t make crystal ball promises to anyone, but it at least helps give us a little bit of an understanding, right.
So let’s get into classification levels for this. So there’s five of them A, B, C, D and E, right? We’ll get into complete and incomplete, those are terms that you’re going to see in these definitions, and we’ll get into those in a moment.
But just so you know, an AIS A is a complete type of spinal cord injury. So complete means below your neurological level of injury, you’re not going to be getting any sensation or movement through that level. You come down to a B, we get into the incompleteness, so we’re actually starting to get some information passing through and in the case of an AIS B injury, that’s sensory information. So you start to get some sensory information below the neurological level of impairment.
C, you start to now add in some motor, though it’s weak and a D, you add in more motor, more movement. So you should see more strength and more sensation kind of flow through that level of injury as we move through the alphabet.
AIS E, we typically do not work with these but AIS E is someone that had a spinal cord injury and has a complete return of their neurologic function.
I think I’ve told the story several times has I’ve done this but just to repeat myself again, the only one that I’ve ever seen is actually a student PT student that I had a number of years ago that was a younger child. He had a spinal cord injury that left him in a wheelchair for 18 months or so before he started regaining the ability to walk again. And the only way I knew that he had a spinal cord injury was a scar on his neck, honestly, so very fascinating.
Dermatomes and Myotomes
And I wonder, would you want to tell us a little bit about dermatomes and myotomes and why those are important.
Anna Calgaard – 09:45
So when I have a resident come to QLI for the first time I really like to use these maps and that’s essentially what they are they’re maps to determine both sensory levels so that dermatomal map on the left is that color one. That’s really telling sensation levels, parts of your body that correlate with levels of your spine that are sending that information back up to your brain to interpret.
So someone might say, you know, I have sensation stops around my belly button. But it’s really nice to get an objective measure of where exactly is that correlated with your level of injury. So you’re looking down. So we know like a T4 level that’s going to be kind of around that like nipple area. T10, around that belly button area.
And so different areas correlated on the body that we can really determine specifically, where that level of injur is but also like where their amount of sensory is, and it’s a nice, objective measure to not only show the patient and give them some education on, hey, this is where you’re at right now, this is where you’re at previously, and it’s a nice determine of, we can kind of hopefully predict maybe where they’ll be in a few months down the road too and show where they’re trending.
Similarly, with the myotome. It’s a map showing where certain levels of the nerves are innervating muscle groups. So this is really important for people being more functional. So certain levels, we’re looking at like an L3 innervates our quad muscles, so that’s helping us extend our knee. L4 is helping pick up that foot.
So we can do certain tests, when I’m first meeting them to see where is their functional ability, where do they have some sparing of some motor control to determine level and then see kind of prognosis wise where we think they could get?
Brad Dexter – 11:41
Yeah, absolutely. I always kind of think about these, you know, we’re, again, kind of having that common ground in terms of education, where you start your conversations with people too, because you may have someone coming to you for that assessment for the first time. And if you just ask the question, What can you feel? Or can you feel your legs? Well, yeah, I can feel my legs.
Your next natural question, as a therapist should be, where can you feel? I need to kind of map this out a little bit more so I have a good understanding, and I can help progress you or, you know, I see you can move your legs, I would really love to get a closer look at that and have a good understanding of what muscles are being integrated right now. Because that’s going to help me kind of lay out my treatment plan a little bit more and help me kind of cast a vision for how we strengthen specific muscle groups to get you to a point where maybe you could stand again. Or maybe you could take some steps again. Or maybe it’s just even working on core strength for someone that doesn’t have any lower extremity movement, because that core strength is going to impact their ability to move themselves or even help with their bowel and bladder program in some cases, too.
Tim Benak – 12:54
When you guys are going over prognosis with a patient or a resident, are you showing these maps? Like, is this something where you’re like, okay, let’s take a look at this together? Because I know we’re talking about the education, right? It’s the unknown of like, if you can show them in front of them, you know. I’m just curious, how often does that happen in the hospital setting right after injury? Are you starting to educate them a little bit more about their injury early on? Or does it is it kind of, not until they get to our level of treatment when these are shared with with?
Brad Dexter – 13:23
I think there’s a lot of good done in terms of education. I think a lot of people are getting access to that. Some of it for me comes back to I don’t know how much of that is being held on to by the individual a lot of the time. And you know, in all reality, how well do you learn when you’re under stress? Or when there’s conflict of some kind? It’s really hard, right?
And so we’re talking about individuals that have had their lives turned upside down. And, hey, we are well meaning healthcare practitioners that want to empower and educate, but people are going to kind of come to some of those realizations and understandings and get to a certain educational level at different times throughout the recovery too. Certainly there’s plenty of factors, whether it’s education, previous experience with a spinal cord injury, socio economic factors that are going to come into play with some of that too. But you can speak to this too Anna, I think some of it just as I’m building relationship with someone, I also need to kind of figure out, how much do you want me to tell you? Where do I go with some of this?
Anna Calgaard – 14:39
But I do like to try to use some sort of visual information just to help with that education. I mean, they really need to be the most knowledgeable about their injury going forward when they leave us and be able to educate others. And so starting that groundwork, when they first come here and building upon that is going to be really important.
Injury Classification – ASIA Exam
Brad Dexter – 15:00
So this is the scoring sheet that we actually go through. We’re taking those maps into consideration. There are key points you can see kind of on the body in the middle of the ASIA exam here. Those are the key sensory points.
We check light touch and pinprick. And then we look at some of those key motor areas, which you see listed on the kind of outside columns on the right side and the left side of that sheet.
Now, the goal of this is to kind of establish a neurological level of injury. And that neurological level of injury is the lowest point where you still have normal movement and normal sensation. And then below that, we’re trying to determine is this a complete injury? Or is it incomplete? And that’s really defined through motor or sensory in some of the anal regions, right? So S3, S4, S5 from a sensation standpoint, and then the ability to sense pressure within the rectum, the ability to control the anal sphincter.
And so if they’re able to do any of those things, if if it’s a Yes, so to say, for any of those areas, then it becomes incomplete and we can look at is there sensation below the level of injury, or is there movement, ability to have level of injury and if there is movement, how much movement? You get upgraded from an AIS C to an AIS D, if there’s more than half of the muscles below the the neurological level of injury that have the ability to move against gravity at that point.
Injury Classification – Complete and Incomplete
Another way to kind of think about this complete and incompleteness of the the injury is kind of this styrofoam cup analogy.
If I have a styrofoam cup, and I put it under water coming out of a faucet, as is, there’s no water that’s going to get through that, right, that’s like a complete injury. There’s no information that would be getting through that level of injury.
But if I start poking some holes in that cup, we’re going to have a varying degree of water start to kind of get through the styrofoam. And that’s kind of what happens with the incompleteness of an injury. Based on the extent and the severity of the original injury, the inflammatory response of the body, you can get kind of larger areas that are impacted in the spinal cord, not letting information through or those areas can kind of recede a little bit, they can be smaller, allowing more information to still get through.
And so we’re emphasizing some of this, again, just to kind of hit on the point that, you know, one T6 level injury is not going to be the same as another T6 level injury.
Historically, you know, we may look at that T6 level injury and say, Yep, this is exactly what a T6 is going to need. That’s not quite the case. Or this is exactly what an L2 injury is going to need.
Now we can generalize in some way shape or form, but we really need to make sure that we’re personalizing care and education and responses based off of the individual and what their abilities are based off of some of this testing. Anything you would add to that?
Anna Calgaard – 18:29
I think you’re covered it well.
What do Spinal Cord Injuries Really Cost?
Brad Dexter – 18:33
Again, covered this slide in the past as well. But I think it’s helpful just to come back to to understand what injuries cost over time. Just so we have an understanding to, as I talk through some of the hospital stays, you might imagine that a more severe injury up in that cervical level of the spine may have a longer length of stay than an injury lower down in the spinal cord. And so the length of initial hospitalization following injury and acute units is around 11 days, average stays around 31 days.
First year expenses for paraplegics, you know, the folks that we’re talking about today around that $550,000 mark, are high quads, and our low quads are going to be higher in average expenses for that first year.
The average lifetime costs for a para, if their age of injury is around 25 is about $2.4 or $5 million. Again, we should expect that higher quads, lower quads are going to be slightly higher overall lifetime costs just because of the the extent of care that they may have and the complications that they may have, following their spinal cord injuries.
And then prevented percentage of individuals that are covered by private health insurance at time of their injuries close to 50%. And those that are unemployed 10 years after injury is around 77%.
We may hit a little briefly on this later, too. But that’s an area that we just need to get better at in the spinal cord injury world. We need to find ways to help advocate for and help people return to some form of meaningful work, reentering the workforce.
And as you may expect, an individual that maybe is categorized as that paraplegic, so there’s thoracic lumbar level injury, maybe there’s just a little bit more ability wise that they’re able to do. And they may have some more options. So those are some of the folks that we see being more able to re enter the workforce, as opposed to some of our quads, though, you know, it is feasible for that to happen.
Tim Benak – 20:52
Do you guys see, with the trend of working from home with COVID, does that open more doors for people to you know, have employment at home in their own space?
Brad Dexter – 21:01
I mean, that would be the assumption, right? I don’t know that that’s really been studied all that well at this point. Just, we’re not too far into that. But yeah, you would hope so. I mean, I think there’s more and more opportunities to be able to work remotely and that certainly may be a benefit to this population of people too. It’s a great question.
Body Function Available
And I do want to cover, in general, the body function that becomes available with the population that we’re talking about today.
Anna Calgaard – 21:33
Absolutely. So like Brad said before, this is going to be someone with a paraplegic injury. So they’re going to have full function of their upper extremity. So now we’re really looking at the effect of the trunk and the legs for how much return they’re going to get.
And so looking at that high thoracic level, that T2 to T6, they’re going to have those intercostals. So those are those muscles in between those ribs that really help expand the ribcage to get a deep breath. And so they may have varying levels of respiratory complications, because they may or may not have as much innervation to those intercostals. And they’re also helping a little bit with that trunk stability.
Then going down into that low thoracic. So now you’re looking at your intercostals, your abdominals and your partial paraspinals. And so, again, that respiratory, they should be able to take in a deep breath and be able to produce a larger cough. But then they’re also getting some of those abdominals and those postural paraspinal muscles. And so that’s really helping with their trunk stability, which gives them a lot of functional independence when they’re doing certain ADLs. And being able to dress, to perform transfers, things like that arereally kind of a game changer when it comes to getting some of those abdominal and paraspinal muscles.
And then when we’re getting down into the lumbar region, L1, we’re kind of looking at those iliopsoas those hip flexor muscles and rectus femoris muscles, or rectal muscles. And so again, that trunk stability being the ability, they might be able to flex their hip, which can really help with some bed mobility and in certain transfers, and then really, the L3 is a big one for them, because then they’re getting that rectus femoris, that muscle that’s helping extend their knee. And so now you’re looking at someone that could potentially perform standing transfers, or even walk with certain orthotic devices.
And then going down to that like L4 region that’s going to be able, that tibialis anterior, that’s a muscle that’s able to flex the foot up. And then the L5 is the ability to lift that toe. So someone could be an AIS A but be an L4, L5, and potentially be able to ambulate with certain orthotic devices. And so it’s pretty variable when we’re looking at a high thoracic versus a low lumbar potentially.
Brad Dexter – 24:09
So just in terms of you know, body function continues to become available, those are specific muscle groups that may be coming back. Just to kind of give you a visual then of what an AIS A or B is going to look like, you know, they’re gonna have full use of their arms, varying degrees of trunk stability, and lower extremity use based on how high in the thoracic region that injury is versus if it’s lower down in the lumbar region.
And then with C’s or D’s, C’s, we’re looking at some return of some weak muscle groups below the level of injury. You know, if that’s a T3 injury, maybe you’re starting to get some abdominals back, maybe have some wiggle of a toe, right? But if that’s say, a T12 injury, maybe you’re starting to get some weak muscle use back in the legs because you still have full abdominals at that point. And then D, you’re going to be getting potentially a stronger use of all of those muscle groups below a level of injury.
Again, we’re talking about a wide range from T2 down to L5. And so the level of ability is probably going to change a little bit based off of if that’s higher up versus lower down. So please keep that in mind as we roll through some of that too.
So we’ll cover a little bit of bowel and bladder, and some of the management tactics here aren’t going to end strategies aren’t going to change a lot from some of the other folks that we’ve talked about in the past. It’s still important to know what the person’s routines, especially for bowel management look like prior, diet, hydration, exercise, additional meds, timing of program, all those things are really important.
On the bladder management side of things, hydration is still key, we want to make sure that we have a sterile environment, we’re keeping things clean as we’re teaching people how to how to self cath. We may need to do some urodynamics to understand how the bladders functioning.
But one thing I want to hit on a little bit more closely this time around is flaccid versus spastic bowel or bladder. And the way that this is typically defined, you know, we’ve talked about the spinal cord, and the spinal cord itself actually ends around the vertebral level of T12 or L1. So that spinal cord doesn’t stretch throughout our full spine.
And what that means is around that T12, L1 level, if you have a vertebral fracture, that is impacting the spinal cord, it may not actually be hitting the spinal cord. It may be hitting nerves that have already exited the spinal cord and are still within the vertebral column and haven’t exited the vertebral column to go out to the body yet.
So the difference there is that you’re having a lower motor neuron injury, which is a nerve that goes out to the body versus an upper motor neuron injury, which is actually part of the spinal cord.
So the way that the bowel or the bladder manifests itself is going to be different between those. So managing a spastic bowel or bladder is going to look different than managing that flaccid, bowel, or bladder. So spastic we’re thinking above the level of T12. Flaccid, below.
So if I have someone that has an injury at the level of T8, if we’re going to start helping to train them in a bowel program, we may be looking at an every other day program or every day kind of based on a number of other factors that we would look at with them. If, however, we have someone that’s an L2 type of injury below that T12 level, we need to consider that as a lower motor neuron type of injury, in which case, anal sphincter is not going to be spastic or tight. And they may need to actually sit on the toilet multiple times throughout the day to kind of clear out. Timing wise, we may talk to them about after a meal, he may need to go sit on the toilet, and take care of your bowel management at that time.
That definitely impacts how we educate people in regards to how they may do their bowel management.
C’s and D’s, these levels of injuries, we may actually start to get some controls and voluntary control of bowel and bladder sphincters back at this point. And so these folks while they still may be on a program, or they may be intermittent cathing themselves, they may be able to get to a point where they’re able to voluntarily relax some of those sphincter muscles and control their own programs.
Things that we need to keep an eye on. And that’s part of the rehab process. It’s not just getting set in a certain way and that’s the way that you’re going to do it for the rest of your life necessarily. We need to kind of manage that and keep an eye on it and help them kind of progress through it.
So we’re really talking about a population of folks that maybe can be a little bit more active at this point, if they have full use of their arms, maybe we’re looking at them being in manual wheelchairs, maybe they’re able to get on adaptive exercise equipment a little more often. Maybe it’s even, like horseback riding.
There are lots of different opportunities that they may experience and they need to consider the seating surface, which Anna will talk about in a little bit, but they also need to kind of have a good understanding of how often they should be pressure relieving too. So this hasn’t changed much from cervical level injuries, we still need them pressure relieving every one to two minutes every 15 to 30 minutes, but instead of tilting back in a wheelchair, in a power wheelchair, these folks should have more of an ability to just lean forward or to push up through their arms using the armrests on a wheelchair to kind of get that pressure off of their bottom. So it should be a little bit easier for them to do that.
Same thing with relieving pressure in bed. We may be looking at them having more ability to kind of roll themselves turn themselves in bed. And so they should be able to actually pressure relieve.
As we move down into like a C or D type of injury, we’re looking at more sensation coming back. So then even though the sensation may diminished, they may be able to tell, I’ve been on this part of my body a little too long, I need to make a change. So we do have folks that maybe they don’t every 15 to 20 minutes, they don’t need to do that one or two minute pressure relief, because they’re just doing it more naturally like you were I would because they’re getting the sensory feedback at that point.
Again, things that we need to just keep an eye on and we need to be able to change and help them critically kind of think through what the best practice is for them in a long term.
Tim Benak – 31:10
We did have a question come in. And I’ve always wanted to do this. Kelly, I see that you just raised your hand. And I’ve always wanted to call somebody out who raised their hand. No, I’m just kidding.
If you have a question, just type it in. Linda, you also raised your hand. This is fantastic. I’ve never been able to call somebody out in zoom for raising their hand. There is a chat and a question and answer function. So if you have questions, please type those in there. I am monitoring them. We did have somebody ask, How soon after injury or when during rehab, can have bowel and bladder planning program begin? Like how far along do you kind of navigate through that? Is it kind of as they progress, it changes?
Brad Dexter – 31:49
Physical function in general, is going to change. I would say at QLI, we’re at a post hospital inpatient rehab facility and we’re getting folks anywhere from one month to three months, maybe even longer at times, post injury, and their bodies are changing.
Sometimes, and this isn’t necessarily right, but sometimes those bowel programs, you put on a schedule early on, more based off of convenience for hospital staff, rather than what needs to be done for the individual.
And so I think we just need to be proactive on that even when people get to us, we shouldn’t say oh, this is what you’ve been doing. We’re just gonna let you keep doing that. If it’s working great. If it’s not broke, don’t fix it. And we’ve had cases at times where it’s like, okay, we have someone that’s doing a bowel program every day. But they’re only having results every other day. So maybe we should shift to an every other day, focus and start to train in that. Because the body has kind of decided something at that point. It’s gotten onto a little bit of a rhythm.
At other times, if we have someone that is on a bowel program, but they’re having a lot of incontinence, we need to look at, what is your diet look like? What is the timing of this program look like? Is it consistently happening at nine o’clock in the morning, an hour after you’ve had breakfast? And do we need to make some considerations on your schedule? Or try to reset your body in a different way? So I just I don’t know that there’s a, this is a terrible answer for you, I’m sure. But I don’t know there’s a specific time I, obviously it needs to start out from the very beginning getting people on a program, but there needs to be just constant monitoring of that and reevaluation of it as time progresses.
Anna Calgaard – 33:39
And I would add to that just thinking always like about their life after QLI and what their life is going to look like. If this is someone that’s going back to work, we need to start planning now what that program looks like when they go home. So if it makes more sense for them to be doing it in the evening to allow them to get up and get to work early. We need to be factoring that in from the start.
Tim Benak – 34:01
Okay. Yeah, we had somebody chime in and say that they’re an OT and acute care facility and they initiate bowel and bladder right away, at very least initiate the conversation, which I think is what you guys were saying. So awesome. Thank you. Good.
Brad Dexter – 34:15
Great questions. All right. So seating and positioning.
Anna Calgaard – 34:19
So really, seating position wheelchair that is a massive tool for giving some of our residents independence and mobility to be able to access their community and their home. And so really looking at, again, this 2 to L level, we’re looking at the AIS A and B. So this is someone who more than likely is going to be in a manual chair versus a power chair because they’re going to have their upper extremities.
But there’s a lot of things to think about that, there’s a lot of factors as a therapist that I’m weighing when I’m looking at what I want to script for this person and so there’s definitely like power add on smart drives twion on wheels.
Thinking about someone’s shoulder integrity and accessing their environment and their community environment. That’s a lot of strain on the shoulders through propelling community distances. So we might be looking at some sort of power add ons, I like looking at power add ons for that, and just the king of long term health.
I’m also factoring in age, skin integrity, thinking about cushions. If this is someone who doesn’t have good sensation of the bottom and has maybe even previously had a wound, we might be looking at something that offloads a lot more. So thinking about like a roho cushion for someone like this, versus foam cushion.
But if someone is doing a lot of transfers and is able to pressure relieve, I might be looking at something more as a foam cushion so that they can really, that helps make those transfers easier when they’re popping on and off their wheelchair.
Even looking at the frame and wheels, we want something that is lightweight. If someone is doing car transfers and he’s able to independently pop into a car and be able to break down their chair and lift it into the passenger side seat, those are a lot of factors that we’re putting into when we’re scripting a manual chair.
And then going over into AIS C’s and D’s. So these people, like Brad said, are getting some amount of muscle return. AIS C’s are still likely going to be in more of that manual chair. But then looking at an AIS D, they may be able to emulate certain distances, either residential or even in the community. But they may be able to walk residentially fine, but once they’re in the community, they’re getting tired quickly. And so they may need a wheelchair for those community distances and thinking about foot play options for these people something that can fold up to make it easier to stand up from a chair.
And then the other thing I wanted to add was just thinking about level of injury. So someone who is a lower L4, L5, this person has potentially that quad activation, and so they may not need a manual wheelchair at all, they might just need some sort of orthotic to be able to walk and so there’s a lot of factors when looking at seating and positioning.
The other thing I say I would notice, it’s just so dependent and variable based off someone’s ability. I have a resident right now that is a T12 level injury, but we scripted a power wheelchair because he had a previous shoulder injury and he had wrist arthritis and hand arthritis from link flooring for many, many years. And so the power wheelchair gave him more independence than a manual chair.
So we’re always factoring in a lot of different things that are going to give them the most independence when they go home.
Brad Dexter – 38:13
Yeah, and one thing I would add on this too, you just bought your first house, like three to four months, right?
Anna Calgaard – 38:20
Yeah, it’s 100 years old.
Brad Dexter – 38:21
I just moved from my first house to my second house a couple years ago. And the things that I looked for in my second house were different based off of what I learned from my first house. And I think about that a little bit with our wheelchair prescription. One you hit on the fact that this is a person’s means to accessing life and accessing the community, accessing their passions in a lot of ways too.
And we try to do a really good job of getting that wheelchair fit right the first time. We have a lot of different eyes on it, we trial equipment before we ever actually script it for them. And so we we try to pressure map on different types of cushions and use different types of back rests and look at different types of wheels or ramps, things like that, that would impact that individual’s life.
But, you know, regardless, wheelchair one is usually going to get some kind of like upgrade or better fit on wheelchair two just because it’s that second go around. And even though we might have, you know, been pretty close to it that first time, there’s usually some kind of a tweak that happens on that second wheelchair.
Transfers & Bed Mobility
Anna Calgaard – 39:39
Moving into transfers and mobility. And so with these folks, again, they have those upper extremities and so we’re looking at more means of a slide board or pop over transfer with our AIS A’s and B’s. And they may need some amount of assist with that depending on how much trunk stability they have. If they’ve got that higher thoracic level injury, they may not have as much core stability.
And so those are all things factoring when being able to be independent with a slideboard, pop over transfer
Then moving into AIS C’s and D’s, they’re going to have some amount of of return. So they might be able to activate muscles to be able to perform certain transfers, or looking at even like more complex transfers. So can they get into a vehicle can they get on and off the ground, things like that.
And then AIS D. So they again have those muscles, 50% of their muscles that can move against gravity. And so they’re potentially being able to do standing transfers, or even independently standing and pivoting from surfaces. And so very variable again, but lots of different options for for these residents.
Tim Benak – 40:59
We had a question just about wheelchairs, what’s the typical lifespan of a wheelchair? For each type of wheelchair, I guess it’s probably depending on the type.
Brad Dexter – 41:08
I would say some of that depends on the part of the country that you’re in, how active you are too. I’ve seen people that are really, really active, go through a set of tires on their chair within a couple years.
You have people that really care about what their chairs look like, and making sure that they’re well kept up and others that will run it into a lot of things too, or maybe have a hard time controlling it at times. And so there are factors like that.
The frames are very, very durable on those. A lot of it is the the backrest, the cushions, the wheels, some of the additional parts that get added, the wheel locks, those additional parts are what tend to kind of start to cause problems. And certainly how you use that chair is going to have an impact.
Tim Benak – 41:58
When you have a wheelchair wizard like Todd, they tend to last a lot longer, right?
Brad Dexter – 42:03
Yeah, that’s true.
Tim Benak – 42:09
And then Linda, just appreciate your comment about the bowel program. You know, you guys touched on this, but she just wanted to reiterate the fact that long term goals are really what people need to focus on, especially in the rehab facility. It’s not just to your point about what’s happening in the moment. So we appreciate that, Linda.
Brad Dexter – 42:24
Yeah, that’s a great, great point.
Anna Calgaard – 42:29
Okay, and then moving into walking. And so for these AIS A’s and B’s, depending on their level of injury, we’re gonna likely need some amount of robotics or orthotics when we’re looking at walking. And so if they’re an AIS A, T6, they’re not going to have lower extremity muscle function. And potentially even some trunk stability. And so we’re looking at getting them up into an exoskeleton, some sort of robotic walking.
Brad Dexter – 43:02
So, T6 AIS A you’re probably looking at robotics, but if they’re like a T6, AIS D…
Anna Calgaard – 43:10
Yeah, then we’re looking at potentially walking with or without some amount of orthotic or assistive device, depending on how much muscle they have regained.
And then thinking again, like I mentioned before, like even an L4, L5 AIS A or B, these people have some amount of quad or muscle or ankle flexor. And so they may be able to walk with just an ankle orthosis or an ankle orthosis and some amount of assistive device like a cane or a walker.
AIS C’s kind of similar to the AIS A’s or B’s, they’re going to need some amount of robotic orthotic or even like a bodyweight gait training system to help strengthen the muscle function that they do have.
Like we kind of alluded to earlier, if we’re looking at someone who is regaining function pretty quickly, they likely could transition from an AIS C to an AIS D. But we’re increasing high repetitions and a lot of strengthening throughout their day to really maximize the amount of muscle return that they get. And then an AIS Dagain, I sound like a broken record. It all depends. So variable but these people likely do have more motor function in their legs, and are potentially residential or even community emulators with some amount of assistive device, orthotic device or completely independently walking,
Brad Dexter – 44:54
Grooming, hygiene and eating, you know, because we’re dealing with folks that have full of their upper extremities at this point, unless there’s some kind of outstanding factor where maybe there’s an amputation on one side or there’s a peripheral nerve injury or brachial plexus injury on one side, in general, folks should be able to manage their own grooming, hygiene, and eating just because of the level of fine motor control and upper extremity use that they have, regardless of age or impairment.
Tim Benak – 45:26
Just to backup. When it comes to walking, we had somebody asked what do you mean by robotics? Home verse inpatient? Like if you could clarify a little bit there?
Brad Dexter – 45:36
Good question. When we put robotics up there, we’re referring more on the rehab side of things, being able to use robotics within the rehabilitation setting. Personally, I don’t think robotics are at a point from development or at a price point where they should be utilized regularly within a home setting at this point.
Now, there are people that have purchased those, I know there are some funding sources that have also purchased those for individuals. But I think there’s just some continued growth that needs to happen in terms of safety and independence for the robotic systems that are utilized for walking. We’re referring to more from the rehabilitation tool, not as a measure of independent walking within the home.
Tim Benak – 46:26
I just had, my colleague Don Terry, call me out for misspelling hygiene on this slide as well. So just want to say.
Brad Dexter – 46:31
We’ll blame it on you, not me.
For our cervical level injuries, we have really hit on some of the assistive technology that can help improve independence for them, whether it’s for accessing the home or for accessing the community, front doors, things like that.
I think I tried to hit on this with the cervical level, injuries, but I’m going to harp on it again, here, too.
Technology has gotten to a point where it’s really at a consumer base level, it’s easy for any of us to go buy an Amazon Alexa or Google Home or Apple home products, and integrate all of those within our our houses. I mean, if you’re any amount of tech savvy or have a spouse or friend that tech savvy, you’ve seen that and we’ve experienced that.
And so I think those are things that we still need to consider with the individuals that we’re working with. Perhaps they are already tech savvy, and that’s not even an issue. But we may have folks that just have never thought about that or haven’t used it, but it could make their lives a little bit easier on a on a routine basis. And so we just put here that for any assistive technology really should, for these folks, T2 to L5, consider use of smart home technologies that are already readily available to consumers.
As far as environmental modifications, much of that is going to depend on the type of wheelchair that you end up putting an individual in. If you put someone in a power wheelchair, I think Anna gave an example earlier of an individual where just critical thinking wise and clinical reasoning, needed to end up going with a power wheelchair. Well, the width of that chair is going to be much greater than a manual wheelchair. The way that it performs on a ramp is going to be different than a manual wheelchair. There may be some other modifications that have to be made to the house because of the width of the chair, the turn radius of the chair.
Those are things that we have to also kind of consider when we’re choosing that seating and positioning system.
But overall, we’re probably looking at ramps into houses if it’s not a zero entry type of house, looking at those door thresholds to make the the entryway a little bit smoother to get over potentially widened doorways, like I said, based off of the the seating positioning system that you’re put in, open designs of living spaces, more universal design types of philosophies when it comes to either new builds or remodeling areas is always gonna be helpful.
So one thing that will often recommend is more of an open tiled bathroom. Most of the bathrooms that we may enter into for a house have kind of different compartments to the bathroom, maybe there’s a bathtub, but if we’re able to open that up and just have zero entry, not even put a pan in there, but just tile everything if it’s financially acceptable for the individual.
Those tend to work out really well where you just have like a sink over on the wall, open toilet shower on the other side. And it allows them to access all those things pretty easily.
So that’s that’s kind of that like opendesign, Universal Design type of layout.
Same thing with living spaces if you know if you’re able to do a new build or if you’re looking for a new place That’s what we’re gonna recommend is that , you try to find a space where you’re not having to cut all these corners or go through doorways a lot of the time.
And then you may expect, as we get into C’s and D’s, where maybe there’s a little bit more mobility, use of lower extremities, some of those environmental modifications may change.
You may be looking at individual that if they are an L3 AIS, D type of injury, or T10, AIS D type of injury, maybe they need to use a manual wheelchair over long distances. But perhaps they park their manual wheelchair, the front door in their home, and they tend to walk throughout their home, right. So those are also considerations that we need to think about in terms of those modifications to the house.
In terms of driving the transportation, this one is kind of across the board. There’s a lot of higher technology needs for cervical level injury due to lack of fine motor control, maybe even strengthen their arms, because arms can be affected up there.
But as we get into these thoracic and lumbar types of injuries, you may be looking at individuals that have a truck similar to this and they’re able to roll a chair on. Or maybe it’s a truck where the door opens up normally or an SUV where the driver’s door opens up normally, and you have a three way seat that kind of comes out and drops down and they transfer into that seat with an arm in the back of the truck or the SUV that picks up the chair. Or perhaps is just a sedan, and they’re able to transfer into the sedan, break down their manual wheelchair, and pull it across their bodies and put it in the driver’s seat or into the backseat.
So there’s a variety of options. What we need to do clinically, is kind of obviously look at what are your options as an individual? What’s going to be appropriate for you, and then start training based off of what financial resources may look like and what their ability level is going to be as well.
Anything you would add to that?
Anna Calgaard – 52:15
I think just looking at, again, they may need some amount of, some sort of hand pin, depending like you said, if they have some amount of like a brachial plexus injury, but most of the time, these people are going to have full function of their upper extremities and aren’t going to need something like that.
Brad Dexter – 52:32
For the most part, looking at hand controls, unless you perhaps get down into those AIS D level injuries where they have use of their lower extremities, in which case, they may be able to safely and appropriately use gas and brake without having those hand controls available to them.
Again, there’s some amount of it depends to this, right? We’re covering a large range of injuries here. But in general, in AIS A or AIS B, you may be looking at modified independent to four to six hours of care, modified independence to some amount of assistance with their ADLs.
May be independent with adaptive driving controls, all the way to dependent for transportation, someone else needing to drive them around. You get into some of those individuals that maybe there’s a weight issue or the size of a chair that maybe that actually affects their ability to access a vehicle and drive it on their own.
There are even considerations for like a C or D where maybe there’s no caregiver needed for these folks, maybe we need to consider a weekly cleaning time just to help with some household chores, things that they can’t do as well from a seated position a lot of the time and potentially they need some help with transportation again, just that depends on their situation, financially familial, so on and so forth.
Durable Medical Equipment
So, large range, again, most of the time we’re looking at some kind of a wheelchair for the individual. You see us we put on power wheelchair versus manual wheelchair there. But then we’re looking at slide boards. Like Anna mentioned earlier, sometimes you may even get to pop over transfers and not need that slide board.
I would say a larger majority of these folks are able to just get to a regular bed, a regular mattress, you know your typical queen, or full or maybe it’s a king with their spouse that they’re able to transfer into. But we may want to look at or trial different types of sleeping surfaces, whether that’s a spring base mattress with a pillow top to it. Do we need to put any additional overlays over it. Sleep Number beds, actually respond pretty well. I’ve taken a number of folks to a Sleep Number bed store in Omaha and actually pressure map them on it and try to with them before they decide to purchase.
And so those tend to map pretty well. It doesn’t negate the need to change positions overnight just like you or I would change positions because we get uncomfortable in our sleep at times, we move from side to side, from back to side, maybe your stomach sleeper, can’t believe it if you are.
So a lot of variety with that. If we have folks that are up walking, we need to determine what’s the most appropriate assistive device that’s going to allow you the most independence while also considering your ability to transition that assistive device in and out of a vehicle if you’re driving. Always balancing mobility with stability. Y
ou know, our typical thought processes as PT’s, we kind of start out giving people more stability. And then over time, as they get better with their balance, their walking speed, we start to pull away some stability, and often more for mobility, which is why you see transitions from standard walkers to rollator walkers to quad canes to a single point canes or forearm crutches to nothing at all. So those are kind of the decision making processes that we’re typically going through.
What does their bathroom look like? So some of this comes back to the environmental modifications or what a bathroom is going to look like in their home. And that will help us determine what they may need for durable medical equipment within their bathroom.
Tim Benak – 56:38
All right, questions. We did have one question pop up. Actually, I’m going to throw the poll question on the screen right now. So again, if you are looking to receive the certificate of completion, please make sure you answer this poll question. It is on the screen. Actually, Brad, if you could switch to the next slide with your guys’s contact information.
First, this is the reveal.
Brad Dexter – 56:52
So if you in your personal life have met someone new during the pandemic, and you have never seen it without a mask, and the first time it takes they take their mask off, you’re like, Oh, that’s what you look like. That’s amazing. Here’s Anna.
Tim Benak – 57:15
Alright, poll question is watch. So again, please answer that if you’re wanting to receive your certificate. I’m going to cover a few kind of housekeeping items real quick. And then I’ll throw it back to Brad and Anna for some questions.
I do ask for a little bit of grace, on the back end. We still have Taylor, who is a rock star, she is all over campus doing amazing things. And so I’m handling all the backend stuff for the follow up. So I may not be able to do it as quickly as she did.
I will try to get you your certificate in your evaluation email by the end of this week. So please, just a little bit of grace there.
Also next month, check us out it’s brain injury Awareness Month, March is. We have Dr. Snell joining us again in the studio. And he’ll be doing his presentation on anoxic hypoxic brain injuries. So more information to come with signups on that.
But if you have any questions for Brad or Anna, please ask them right now. We have them for a few more minutes. We did have somebody asked about their caregiver hours, was it four to six hours a day or a week?
Brad Dexter – 58:16
It depends. It all depends. If you’re looking at a lower level injury, you may be looking at just like one to two hours a day. So that’s more of like a four to six hours throughout the week type of need. If it’s someone that’s a little bit higher, T2, T3, T4, perhaps they end up needing a little bit more assistance. And so you could be looking at that four to six hour a day region there.
Tim Benak – 58:47
Okay. I’m going to launch the poll question one more time. We have a lot of people asking for a copy of the slides. Please answer the poll question. That’s what prompts me to send you your evaluation. And with evaluation, you’ll receive a certificate as well as the slides attached.
So I’m going to relaunch it. If you already answered, don’t worry about it. But just kidding. What I’ll have you do is if you didn’t answer the poll, and you are wanting to copy, reach out to me directly, just do QLIWebinars@QLIOmaha.com. And that’ll prompt me to add you to the list to get you the copy of the slide. So relaunching the slides gonna wipe out everyone else’s answers. So again, QLIWebinars@QLIOmaha.com.
We had someone asked about an isch dish cushion. Does that sound familiar?
Anna Calgaard – 59:42
isch dish. tuberosity.
Tim Benak – 59:45
Yeah, I was not going to come up with that word. You could have given me a long time and when they come up, but a cushion.
Brad Dexter – 59:53
I’ll have to look into that. Okay, I mean, just maybe terminology that I’m not familiar with either. There are cushions if it’s I’m assuming it’s hitting on the issue of tuberosities, which are your butt bones, right. And those tend to be areas that are susceptible to more pressure when you’re in a seated position. And so if you’re able to remove as much pressure or disperse that pressure off of the IT’s as possible, that’s what you’re aiming for a lot of the time.
I’ll look into that. And I’ll shoot you an answer to that.
Tim Benak – 1:00:23
And then we had a few folks, Becky, I’ll have Brad or Anna reach out to you directly. Thank you for your question. And then as always, if we can ever be helpful with anything, don’t ever hesitate to reach out to us here at QLI, you have Brad and Anna’s contact information there. But we hope you enjoy these these webinars.
If you have suggestions for other topics, we’re always looking for feedback, please share it with with your colleagues. We had 200 and I think 70 folks on today, so we appreciate y’all joining. But you know, we always love having more people join and if we can be helpful with anything. If you have any questions for spinal cord injury, brain injury, we do sit in the post acute rehab continuum. So reach out to us, we hope we can be helpful.
And with that, we do have a few other questions. Let’s see here. There are a few more that rolled in. I’ll have Brad and Anna reach out to you directly. So we look forward to having you join us next month. Again, Dr. Snell is joining us. So Brad, Anna, thank you for all the time and effort you put into this.
Brad Dexter – 1:01:31
Hopefully it was helpful today.
Tim Benak – 1:01:33
I think it was. We had some good feedback. So everyone, take care. Have a great rest of your day. And we’ll look forward to you joining us next month.
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