Spinal Cord Injury Case Study

I was assigned a number of large projects this semester on the topic of spinal cord injuries. I am interested in working in the field, so I chose the topic hoping to learn more about it. We had to interview an individual with our specific disability and do a psychosocial case study presentation on him or her. Along with the presentation, we had to write a paper, which is the main topic of this post. The man I chose was an acquaintance of mine, who was injured in a body surfing accident 6 years ago. He had a strong pre-injury identity as an athlete, and misses that piece of his life quite a bit. The paper I wrote below shows just a small part of my presentation: one intervention that I chose to help improve this loss of identity. It's also a good way for my few readers to get an idea of what OT can do in the mental health setting.

Spinal Cord Injury Psychosocial Intervention Paper

Client Diagnosis: C4/C5 incomplete lesion spinal cord injury

Psychosocial Need: Loss of identity as an athlete after spinal cord injury

Sample Goal: Client will be able to participate in half of a wheelchair rugby game after 8 therapy sessions and extensive practice outside of therapy.

Occupational Intervention:

Therapist will provide client with practice of wheelchair rugby ball handling skills. Based on the results of range of motion and manual muscle testing, therapist will determine the client’s approximate wheelchair rugby classification and accompanying maneuvers (according to the International Wheelchair Rugby Federation, www.iwrf.com). The client being seen is most likely at level 0.5, and practice maneuvers will be as follows:

• Trapping direct passes on lap
• Batting close-range passes into lap
• One-handed under-hand “volleyball” pass
• Two-handed side “scoop” pass

(International Wheelchair Rugby Federation, 2010a)

As client masters the above skills, therapist will practice maneuvers with weighted balls of similar size. Supplies needed are as follows:

• One manual wheelchair (preferably of lighter, athletic style)
• One volleyball (beach ball if first time practicing)
• Medicine balls of light weights (2-4lbs, depending on the results of manual muscle tests)
• Ample space for physical activity

Theoretical Basis of Intervention:

The client’s previous identity as a collegiate athlete and his lifelong hobby of playing sports provide the rationale for this intervention. According to the Model of Human Occupation (MOHO), volition, habituation, and performance capacity are the three interacting components to an individual’s occupational well-being (Keilhofner, 2009). Volition is an individual’s motivation or desire to participate in a specific occupation (Keilhofner, 2009). Habituation, which consists of a person’s roles and habits, refers to the way in which an individual organizes actions (Keilhofner, 2009). The third component, performance capacity, is the individual’s actual ability to perform a task, physical or mental (Keilhofner, 2009). Due to his injury, the client at hand has extensive physical limitations, and no longer has the performance capacity necessary to play football. Before his accident, however, his role as an athlete was his main identity, and several other active sports filled his leisure time. This fact alone creates in the client a strong desire to be involved in competitive sports again, a void he wishes to fill with wheelchair rugby, a fast-paced, full contact sport for those who have impairments in all four limbs.

Objectives of Intervention:

By practicing ball-handling skills with the client, which are appropriate to the sport of wheelchair rugby, the therapist hopes to instill a new sense of self confidence in the client. The opportunity to fill the void left by football in the client’s life is motivating to the client, and once the new set of rugby skills are acquired, the client should feel empowered to get involved with the sport competitively. The therapist would like to see the client act on this confidence by becoming familiar with the sport, becoming part of a competitive team, and competing in officiated games.

Diagnostic Considerations:

The intervention itself is purely physical, using modified techniques to allow the client to catch and pass the ball. It addresses the following symptoms:

• Muscular weakness
• Muscular coordination
• Decrease/lack of muscular function

However physical, the intervention also addresses the psychological symptoms listed below, as it is a large contributor to the client’s perceived quality of life.

• Depression
• Loss of identity
• Anger
• Low self-esteem
• Loss of friends/social supports

Precautions:

Safety concerns include client’s limited ability to manage physiological responses to physical exercise, such as body temperature and respiratory functions. Client is unable to sweat below the level of injury, and may experience excessive sweating above (Atchison & Dirette, 2007). The client also may display respiratory impairments, such as shallow breathing (Atchison & Dirette, 2007). The therapist will watch for signs of overheating and provide ample water and rest breaks. Also, because of the level of injury, the client has limited to no trunk control (Atchison & Dirette, 2007). The therapist will make sure his manual chair fits appropriately and that he is properly strapped in. Also, practice of ball handling will begin with the wheelchair brakes locked and will not proceed until the client has practiced.

From a psychosocial standpoint, it will be important for the therapist to inform the client of the amount of time and effort it will take to gain the skill needed to play in a competitive rugby game. The client needs to be given the opportunity for small successes, building up his confidence over time. This will keep him from being discouraged and giving up on the sport all together.

Methods and Interpersonal Strategies:

Because this intervention and the ultimate goal are so important to the client, the therapist will employ Taylor’s (2008) collaborating mode during treatment. This will allow the client to feel as though he is a part of the therapy process, making him accountable for the results of his therapy (Taylor, 2008). It will also allow the therapist to receive feedback from the client, giving her the information she needs to keep therapy client-centered (Taylor, 2008). The therapist may also need to employ Taylor’s (2008) encouraging mode, in times when self-esteem is low and the client becomes discouraged.

Relationships:

The client would expect to experience a collaborative relationship with his therapist. He is a highly motivated individual who knows exactly what he wants to do. He is merely lacking the skills to do those things and therefore needs the assistance of the therapist. Although he would like to have control over his therapy plan, he is a respectful individual who will take the advise and expertise of the therapist seriously. Aside from personality, several other factors may affect the therapist-client relationship in this case. Among those factors are age and gender. The therapist and client are of similar age and opposite sex, which in some cases may entice inappropriate relationships to form. It will be important for the therapist to address the client as a peer, being sure to set boundaries where necessary, keeping the relationship professional.

Family and Significant Others:

The person closest to the client’s medical care is his mother. She lives in the same city and visits often. She has been involved in his medical care since the accident, however, unless the client gives permission, the therapist is legally obligated to keep all information about care confidential. If the client approves, then it will be important for the therapist to keep the client’s mother informed and collaborate with both of them on treatment options, goals, and progress.

The therapist will also need to keep in mind the client’s family history and other related issues when providing treatment. The client’s mother and father are divorced and his sister passed away from a car accident just a few months before his own accident. The family has experienced a lot of trauma and is most likely struggling to adjust, even five years later.

Cultural Factors:

The client is a Caucasian man, who values education, hard work, and leisure time. His whole life has revolved around on his athletic career, so this intervention and the possible results coincide with his values. His mother has always been supportive of his athletics, and made it a priority to make it to his games. The opportunity to compete again will provide the pair with new opportunities to bond and reminisce.

Environment:

This specific intervention requires a relatively large amount of open space, ideally with appropriate hard flooring to allow for wheelchair mobility. The client’s apartment is small, and it would be difficult for him to practice ball handling at home. The client currently lives in a community with ample resources for individuals who are interested in adapted sports. However, because he does not drive, he struggles to find transportation to facilities where he can access these resources. The therapist may be interested in researching and recommending driver rehabilitation for the client, which will be able to fit him for an adapted vehicle. In the meantime, the university he attends has an accessible recreation facility that is close enough to the client’s home for him to access without a car.

Expected Outcome:

Upon receiving this practice (ball handling), the client will experience an increase in strength and ability to perform the sport. However, this alone will not allow him to play in an actual wheelchair rugby game. The therapist will also work with him on maneuvering his manual wheelchair, and establishing a regular exercise routine which will help him improve and maintain upper body muscle strength. Along with these physical interventions, the therapist will provide other psychosocial interventions, which will help the client develop and improve the communication and interaction skills he needs to be part of a team or start up his own team. The ultimate goal of all of these interventions is to fill the void left by football in the client’s life. He will build the strength, endurance, and confidence necessary to compete as an athlete again.

Curious about wheelchair rugby? Watch the movie "Murderball." It is intense (as you can only imagine by the title). The film is a documentary featuring the USA Paralympic Quad Rugby Team. It is full of amazing input on society and disability and spills over with inspiration. I own it if you would like to borrow it. Pictured right is Mark Zupan, one of the main characters from the movie.