Rebecca Martin, OTR/L, a senior occupational therapist at the International Center for Spinal Cord Injury at Kennedy Krieger Institute in Baltimore, is something of a miracle worker to her patients, many of whom come to the institute feeling beyond hopeless.

Unlike many centers, the center at Kennedy Krieger specializes in an innovative approach to spinal cord injuries known as activity-based restoration therapies. The program is structured around the principle that the use of repeated near-normal activity, facilitated manually and through functional electrical stimulation, can restore function lost after spinal cord injury.

And there has been success with the approach.

“We see great things every day in little kids up through adult patients with spinal cord injuries,” Martin says. “We work on pushing patients to the next neurological level. Regaining the use of just a couple of muscles can have a major functional impact.”

For example, in a patient with a high spinal cord injury (C1-C3), the team uses functional electrical stimulation to retrain the muscles of the shoulder, she notes, adding, “Recovery here allows a patient to move from a sip and puff wheelchair, like the one used by Christopher Reeve, to a wheelchair with hand controls. If you put someone in a wheelchair and never ask them to use their hands or arms, they may never regain those skills.”

According to Martin, this leads to the limited outcomes associated with traditional rehabilitation. What’s more, animal research shows that the spinal cord need not be fully intact to have near-normal function. “With appropriate therapy and intervention, we are able to facilitate recovery,” she says.

Setting Goals

Whether on an inpatient or outpatient basis, OTs such as Martin can and do play a vital role in helping patients with spinal cord injury regain their independence.

“The process starts with basic education and goal setting,” says Roger Kim, OT, an occupational therapist at Long Beach Memorial Medical Center in Long Beach, Calif. “Many patients come in with spinal cord injuries and do not know what to expect, so we educate them about their body and the changes they have experienced, and work together to come up with a list of goals that they want to achieve.”

Goals vary by patient, but the underlying theme is the desire for independence.

“It is very hard to have to depend on people, and people with spinal cord injuries want to return to work and be independent. They don’t want to be a burden,” he adds. “They want to be able to dress themselves, go on the computer, and engage in their hobbies.”

“Assistive technology can play a role in OT for patients with spinal cord injuries,” says Jennifer Yenser, OTR/L, an occupational therapist at the Good Shepherd Rehabilitation Hospital in Allentown, Penn. “It is a very scary experience for patients when they feel they have no control. Providing the person with the opportunity to use assistive technology can provide an individual with a sense of control.”

Certain assistive technology can help patients control their environment, such as managing the lights, turning the TV on or off, or opening and closing doors. These technologies can be activated by button, voice, or eye movement.

“I think that as OTs we can really offer patients a lot of hope and the opportunity to be independent and get back out into the community,” Yenser says. “We are able to show them different techniques and equipment that broadens their horizons and shows them that they can be independent again. Technology has opened the doors for so many people that otherwise would not have been possible.”

A Focused Approach

The resulting therapy program further depends on the nature of the injury.

“For paraplegics who have good use of their upper body, we can enroll them in a driving program where they can try driving using hand controls,” Yenser says.

If a patient has a C3-C4 level of injury, she focuses on family teaching and education. “The patients are dependent with all aspects of self-care,” she says. “Picking out the most appropriate equipment for what the client will need at home, such as shower/commode wheelchair or sponge bathing, positioning and weight shifting, powered mobility, and a lift system, is part of the OT’s job.” Home evaluations are part of the equation, she notes.

For C5-C6 spinal cord injuries, “I will address self-feeding with use of assistive devices,” Yenser says. “The use of a mobile arm support can be used, which can help support the arm and allow the patient to bring the hand to the mouth.”

She often uses electrical stimulation to engage the nerves and muscles. “I also look at positioning to prevent deformities with the use of splints at the hands [and] wrists, and monitor for any muscle tightness [or] tone that might develop,” she says. “Keeping the joints loose is important, so I do stretching with the upper extremities passively, or where the client is trying to help move the arm and I am providing some assistance.”

Many patients with spinal cord injuries develop pressure wounds, which can become infected. Preventing these wounds falls partly under the jurisdiction of the OT.

“The therapist needs to be involved to identify ulcers seen in the chronic phase or post-immediate phase that are related to sitting,” Martin says. “Wheelchair choice and cushion is critical. Making sure that the chair fits appropriately and that the patients are trained in pressure relief is part of it.”

Pressure relief can involve changing positions every hour, she says. “This depends on the level of function of the patient,” she explains. “Some lean forward and rest their chest on their knees or lean side to side, and patients who have triceps strength and can do wheelchair push-ups lift their bottom clear off the seat. We also train them to inspect their own skin.”