Compensatory Strategies for Patients with Spinal Cord Injuries
There are an estimated 282,000 people in the U.S. who currently have a spinal cord injury (National Spinal Cord Injury Statistical Center: Facts and Figures at a Glance, 2016).
If you’re a practitioner working with one of the many patients with a spinal cord injury (SCI), you know the diagnosis presents unique challenges. Depending on the type of injury, impairment may be permanent and severe.
This post outlines compensatory strategies you can incorporate to increase your patients’ self-care independence and quality of life.
When you begin working with a patient with spinal cord injury for the first time, there are 3 factors to consider:
The level of the injury in conjunction with complete/partial severance of the spinal cord determines the types of effects (sensory and motor impairments) and severity of deficits (partial or full paralysis). Furthermore, the level + complete/partial assessment helps the medical team make predictions about likely improvement and/or plateaus.
When plateaus in function occur, occupational therapists can introduce compensatory strategies rather than restoration of bodily functions.
Identifying the time of initial injury will shape the OT’s application and necessity for compensatory strategies. If a middle-aged man sustained a T2 level SCI 15 years ago, he may already know all of the tricks in the book to maintain participation in daily living tasks and just might roll his eyes if the therapist hands him one more reacher.
A patient who recently sustained an SCI may be at a complete loss with how to even generally approach life with limited mobility. In such cases, the occupational therapist can introduce all sorts of adaptations.
The following ADL/IADL compensatory strategies are commonly used with SCI patients. Compensation could either be introducing a piece of durable medical equipment, a piece of adaptive equipment, or a change in intact/voluntary movement.
“Dressing” can be applied to underwear, disposable underwear, jewelry, bras, skirts, pants, shirts (button-ups, pull-overs), sweaters, jackets, coats, hats, socks, and shoes. Depending on the injury level, adaptive equipment to consider using includes: sock aids, reachers, shoe horns, button hooks, pocket dressers, dressing loops, leg lifters, and dressing hook splints (Cisler et al., 2015).
For incomplete spinal cord injuries that result in hemiplegia, therapists can educate patients in carrying out hemiplegic dressing techniques. There are also ways for individuals to fully dress themselves while lying down in bed if core strength is an issue.
If the patient has severely limited movement and/or has to rely on the assistance from a caregiver, they may consider modifying or replacing dressing items and routines. Examples include switching out shoelaces for Velcro, trading out clasp jewelry for magnetic clasps, selecting button-ups instead of pull-over shirts, and switching out button-up pants for elastics.
Independent completion of self-feeding tasks are resolved by using the following equipment: plate guards, universal cuffs, built-up handled utensils, rocker knives, Camelback tubing, mugs or cups with open-hand slots, and mobile arm supports (Cisler et al., 2015).
The positioning of the body may have to be considered if the injury is high enough and if the patient has difficulty sitting upright. External supports like contour backs, lateral supports, tilt features, and safety harnesses on wheelchairs prop the patient up for safe ingestion.
The patient might also need modifications for food: pre-cut foods from the store, pureed or blended foods for efficient scooping, thickened liquids, or smoothies.
Adaptive equipment for bathing and showering tasks include tub benches, grab bars, long-handled sponges, reachers, open-handled shampoo bottles or press-down bottles, wheeled shower chairs with drop-arms, 3-in-1 commodes, and detachable shower heads. The goal is to complete bathing activities that involve fine motor movement and coordination without over-complicating.
If the individual has limited or no trunk control, they can use a shower chair with a back and/or safety harness. If the patient requires caregiver assist, compensatory strategies need to take into consideration body mechanics and amount of weight for the sake of the caregiver.
Toileting with an SCI is more complicated than typical toileting since it may include catheter and/or colostomy care. Additionally, colon and bladder care needs to be regulated in order to prevent autonomic dysreflexia. Adaptive equipment for toileting includes: toilet aides, raised toilet seats, grab bars, transfer/slide boards, 3-in-1 commodes, bedside commodes, universal cuffs, Betty hooks, bungee cords for catheter care, urinals (female and male), Cath Hand (Cisler et al., 2015), and suppository inserter with universal cuff.
You may also educate the patient and their caregivers on how to incorporate dressing equipment into toileting since the patient still needs to don and doff lower extremity clothing during this task.
Grooming and Hygiene
Grooming and hygiene care involves teeth, hair, nail, and skin care which requires the use of finer utensils. Adaptive equipment options include: automatic toothpaste dispensers, universal cuffs attached to toothbrushes, customized floss hook (Cisler et al., 2015), built-up handles, hair-brushes with hand-slots, and hand-slot loops to slide over hairspray bottles.
Functional Mobility and Transfers
OTs can recommend a wide array of options to improve overall functional mobility. This includes bed mobility, in-home and community mobility, toilet transfers, shower transfers, and car transfers. Basic transfer assistive devices include grab bars, transfer boards, and bedrails. (If you need a refresher on transfer training, be sure to check out our article on Transfer Training Tips for New Occupational Therapists, with detail on spinal cord injury transfers and safe body mechanics.)
OTs who are comfortable and have experience in doing so may also assist patients with SCI in customized wheelchair fittings. Whether or not the patient is fitted for a powered chair or a manual chair depends on the level of injury and what allows for modified independence in mobility.
There are some obvious restrictions when it comes to getting a patient with a spinal cord injury to drive independently again. For patients who are found safe to drive after an appropriate driving assessment, the following assistive devices or vehicular modifications are available: accessibility vans with ramps, hand-operated gas pedals/brakes, external wheelchair lifts, driving while seated in the wheelchair in a modified car, etc. (Anschultz, 2015). An interesting site to learn more about vehicle modifications is Automotive Mobility Solutions.
Be sure to remember that any kind of adaptation and compensatory strategy applied should be relevant to the patient’s needs and enhance their quality of life rather than complicating it with unnecessary changes or equipment. If you are still feeling unfamiliar with spinal cord injuries, don’t forget that there are continuing education options on SCI to help build your confidence.
References and Additional Resources