Positioning: A power reclining WC, tilt-in-space positioning in chair to offload pressure points.

Mobility Intervention: Mat mobility rolling, head/neck stretches, PROM to UE and LE.

Patient will need proper seat cushioning to prevent pressure sores.

Tilt chair in variety of positions to offload pressure.

Check skin often for redness.

Seated repositioning (to help prevent pressure injuries)

• tricep dips (intervention) at w/c or in chair with arm rests

• May need MIN A to help relieve pressure at ischial tuberosities

• Shoulder shrugs (intervention) (to help with UE strength for repositioning)

Extension (to help alleviate/prevent contractures)

• Supine or prone (hip and knee ext, hip abduction with assistance)

W/C training

• ascending and descending curbs

• wheelies

  
  

Daily skin inspection (may require assistance and a mirror) on areas prone to pressure injuries (ie -- ischial tuberosities and scapular spine)

Custom w/c seat cushion may help

If using AD for hands/wrists -- check styloid processes, wrist, hand, forearm for irritation

General skin check for redness, dry skin, irritation

Repositioning/transfers (pt may need MIN A)

• Slide board

• Correct body mechanics for family/caregiver(s) (if pt needs help during repositioning)

• Repositioning done every 15-30 min for 60-90 sec

Special equipment

• W/C (safety/condition inspection; curbs; in/out of vehicle)

• Dressing aides

• Feeding utensils

Bladder/bowel program

• Catheters

• Adherence to routine and schedule

• Awareness of chance of UTIs with catheters

S/S of autonomic dysreflexia

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Shoulder flexion and abduction (Therabands; start with light handheld dumbbells as gain some hand function and strength)

Fine motor hand exercises (ie - flexor carpi ulnaris, extensor carpi ulnaris) -- help with feeding, writing, hair brushing, brushing teeth

• Digit flexion and abduction

Combined shoulder ER and abduction and shoulder horizontal ABD

GIF Credit (giphy.com)

Custom wheelchair

Repositioning/pressure release in w/c or chair to prevent pressure injuries on ischial tuberosities

w/c training and skills

• ascending/descending curbs

• wheelies

• chest press (pec major intervention) in w/c with dumbbells/resistance and rows (rhomboids intervention)

Therapeutic Ambulation (MOD to MAX A at clinic with parallel bars)

Extension (to help alleviate/prevent contractures)

• Supine or prone (hip and knee ext, hip abduction with assistance)

General/Daily Skin Checks (redness, irritation, dryness)

• Scapular spine

• Ischial tuberosities

• Palmar side of hands (check for possible irritation/blisters due to more use of w/c)

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Special equipment

• W/C (safety/condition inspection; curbs; in/out of vehicle)

  • Possible special w/c to aid with propulsion

• Dressing aides

• Gait belt (to help with standing at home)

• Specialty leg braces (some pts may walk with them) and bilateral crutches

Bladder/bowel program

• Catheters

• Adherence to routine and schedule

• Awareness of chance of UTIs with catheters

S/S of autonomic dysreflexia

Overuse/fatigue of UE

• Awareness of sore/fatigued UE muscles and helpful stretches

Deep breathing exercises (intercostal intervention)

Military press (anterior delt, triceps intervention)

Pec major stretch (both hands back of head with elbows out to the sides)

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Regular stretching of UE (deltoids, upper trapezius, pec major) - needed as UE may become overused/fatigued -- allows pt to continue to perform ADLs

Custom wheelchair

Educate how to assist with weight shifting activities

1 min of pressure relief for every 15-30 minutes of sitting

Frequent skin inspections,

Patient transfers, ADL tasks, WC mobility, ROM exercise application.

Educate about complications, precautions, safety factors, and probable outcomes.

Head and neck strengthening

Assisted cough techniques

Diaphragmatic strengthening

Spirometry techniques

Standing on tilt table

Stimulation to phrenic nerve to contract diaphragm

Adequate breath support: able to sip or blow to operate sip-and-puff mechanism

Neck range of motion: 30 degrees active cervical motion to use chin cup

Environmental control unit: enables patient to operate lights, appliances, phones, and instructions to caregivers from their wheelchair by computer.

Sliding board or sit pivot transfers

Forward raise with loops on back of WC

Patient will need proper seat cushioning to prevent pressure sores.

Can perform independent pressure relief with weight shifts

Educate caregiver or family member for setup of some activities that are non-independent.

Family/caregiver awareness of energy costs with activites

Educate on bed mobility techniques

Assistance with slide board transfers

Upright rows

seated shoulder ER with pulleys

Prone on elbows

Long sitting with extended arm support

Grooming with wrist splint

Environmental control unit: operate lights, appliances, phones, and instructions to caregivers from their wheelchair by computer.

Power wheelchair with hand control (preferred)

Manual wheelchair with rim projections

Splints

Built up ADL devices/orthosis

Slide board

Van with adaptive hand controls

Reposition in wheelchair (to avoid pressure sores)

Perform AROM of wrist extensions

Shoulder flexion and abduction to maintain ROM

Perform AROM of elbow flexion to maintain biceps and reduce atrophy.

Wearing clean clothes

Showering as often as possible without exacerbation of symptoms (shower chair)

Daily skin check for cracks or cuts on UE's and LE's

Check for pressure ulcers near the ischial tuberosities and lateral malleolus's

Reposition the patient every 15-30 minutes for 60-90 seconds to reduce the risk of pressure ulcers

Check for S/S of autonomic dysreflexia

Use of adaptive equipment to assist patient with daily activities like a bed cane or shoe horn.

Maintaining catheters and hygiene

Bicep curls w/ 5lb weighted cuffs to strengthen elbow flexors

Lateral raises w/ 3-5lb weighted cuffs proximal to humerus to strengthen shoulder flexors and abductors

Resisted wrist extension in sand to avoid atrophy in wrist extensors

Dressing the upper body

Using tenodesis grip for feeding

Writing with pen grip while using tenodesis grip

Power Wheelchair w/ hand controls

Manual wheelchair with modifications for easier handling

Recommendations for custom wheelchairs is NuMotion and ATP

Reposition in wheelchair to avoid pressure ulcers

AROM of wrist movements (flexion and extension)

Maintain ROM in shoulder (flexion, extension, ER, IR and Abduction)

AROM of elbow motions (flexion and extension)

Check skin daily for cracks, burns, pressure ulcers and infections.

Moisturize with lotion to avoid cracking in the skin.

Wear clean clothes and shower as much as possible

Reposition every 15-30 minutes for 60-90 seconds

The use of adaptive equipment like bed cane, shoehorn and grabber.

Check for pressure ulcers and monitor vitals

Check catheters for UTI's

Chair dips to strengthen elbow extensors and shoulder extensors.

Resisted wrist flexion and extension in putty.

Shoulder press in w/c w/ 5-10lbs to strengthen shoulder flexors.

Bicep curls w/ 5lb weighted cuffs

Brushing teeth using tenodesis grasp

Transfers w/ slide boards or lateral transfers from w/c to bed

Using manual wheelchair to enhance functional strength of UE's

Custom manual wheelchair

Slide boards

W/c accessible vehicle