OVERVIEW: EVALUATION AND GOALS

INITIAL EVALUATION

     The initial occupational therapy evaluation, used to chart progress during the rehabilitation stay and justify continued therapy, is the most important. Because the newly injured patient is scared and confused, requiring the therapist to be confident, empathetic, and positive, it is also the most difficult. Components of the initial evaluation, done on the day of admission, include:

  1. A brief social, vocational, and leisure history, including the patient's job, hobbies, family, and past and expected living situations.  The Occupational Performance History Interview (OPHI) is sensitive to changes in occupational performance following SCI and can be used with confidence for diagnostic and therapeutic decision making (Lynch and Bridle, 1993).  Studies show that there is relatively little change in a person's interests following SCI, although there appear to be an increased interest in the physical world and science, and a decreased interest in activities that require persuading, leading, and dominating others, and other more sophisticated social interactions (Rohe and Krause, 1998)

  2. Passive range of motion evaluation, including measurements of all upper extremity joints and all digits, to determine available pain-free movement and identify the presence of or the potential for joint contractures. Shoulder pain is common in C4-7 injuries, may result from immobilization, and should be thoroughly assessed to ensure rapid and effective treatment

  3. Manual muscle test, including muscles of the scapula, shoulder, elbow, wrist, and digits, as well as grip and strength measurements, to determine the degree to which the patient can manipulate objects. All muscles should be tested, despite the diagnosis, due to the possibility of partial preservation and/or an incomplete injury. After spinal shock resolves, muscle tone should be tested in response to stimuli to detect spasticity

  4. Sensory evaluation of all dermatomes of the upper body, including evaluation for light touch, pin prick, joint proprioception, stereognosis, and kinesthesia, to determine areas of absent, impaired, and intact sensation

    ASIA sensory chart

  5. Clinical observation to assess endurance, oral motor control, head and trunk control, LE functional muscle strength, and total body function

  6. Cognitive and perceptual evaluation if head injury is also suspected, including assessing the patient's ability to initiate tasks, follow directions, carry over learning day to day, and do problem solving, and understanding the patient's learning style, coping skills, and communication style

     After completing their initial evaluations, occupational therapists, physical therapists, and physicians confer to identify the level of injury, determine if the injury is complete or incomplete, recommend specific equipment, such as positioning splints or universal cuffs, and identify long- and short-term goals for the patient. The Assistive Technology Device Predisposition Assessment Quality of Life subset can be useful in identifying predispositions to assistive devices use early in rehabilitation (Scherer & Cushman, 2001). Short-term goals are derived from the therapist's ability to perform an activity analysis, such as increasing a patient's sitting tolerance to 90 degrees to permit independent use of a computer mouthstick. It is critical for the patient to play an active role in the development, prioritization, and achievement of goals, particularly long-term goals.

FOLLOW-UP AND OTHER EVALUATIONS

     Follow-up evaluations are usually done monthly for tetraplegics and consist of a manual muscle test and a sensory test. Other types of evaluations are ongoing, such as:

  1. Functional evaluation includes performing light activities of daily living (ADLs), such as feeding, light hygiene, and object manipulation, to determine present and potential levels of functional ability, and should begin as soon as the patient is cleared of bedrest precautions, depending on the level of injury

  2. Psychosocial evaluation includes
    • Observing the patient's interaction with family and friends and the nature of the activities the patient participates in
    • Using instruments to assess the patient's level of motivation, determination, acceptance of the disability, ability to adapt or discover new roles, socioeconomic and educational background, and financial resources

  3. Other evaluations assess performance in areas such as:
    • Vocation
    • Access to home and community
    • Leisure time activities
    • Driving
    • Appropriateness of treatment and equipment.

GOALS

     Although patient-specific goals should be formulated with active participation of the patient, the following are general treatment objectives for SCI patients that contribute to feelings of self-worth:

  1. Maintain or increase joint ROM and prevent deformities by active and passive ROM, splinting, and positioning

  2. Increase strength of all fully and partially innervated muscles via enabling and purposeful activities

  3. Increase physical endurance through functional activities

  4. Develop maximal independence in all aspects of self-care, mobility, homemaking, and parenting skills

  5. Explore leisure interests and realistic productivity potential, including vocation, education, volunteering, hobbies, etc.

  6. Assist with the psychosocial adjustment to the disability

  7. Evaluate, recommend, and train in the use and care of medical and adaptive equipment

  8. Ensure safe and independent home accessibility by recommending home modifications

  9. Teach communication skills to enable the patient to train caregivers

The PoinTIS Spinal Cord Occupational Therapy site of the SCI Manuals for Providers is based on information in Trombly CA. Occupational Therapy for Physical Dysfunction, 4th ed. Baltimore: Williams & Wilkins, 1995, and Pedretti LW, ed. Occupational Therapy; Practice Skills for Physical Dysfunction, 4th ed. St. Louis: Mosby, 1996, except for information where other papers are cited.