ACTIVE PHASE II

     During the second phase of rehabilitation, also known as the active, rehabilitative, or mobilization phase, the patient is able to sit in a wheelchair. Occupational therapy during this phase includes:

1. Beginning to develop upright tolerance

2. Initiating a method(s) of relieving sitting pressure to prevent pressure sores from developing, particularly on the ischial, trochanteric, and sacral bony prominences, such as:
   • Leaning forward over the feet to relieve pressure on the buttocks. if the patient has at least F+(3+) shoulder and elbow strength bilaterally
   • Securing loops to the back frame of the wheelchair to permit the patient with intact upper extremity musculature to perform a full depression weight shift off the arms or wheels of the wheelchair

   Until skin tolerance is determined, weight shifts should be preformed every 30 minutes.

3. Continuing active and passive ROM exercises to prevent contractures
   • Full elbow extension is essential to prevent elbow contractures and allow the elbows to be locked, a skill required to maintain balance during static sitting and assist in transfers. Static sitting is achieved by depressing, protracting, and externally rotating the shoulders, locking the elbows, and fully extending the wrist
   • Ranging the fingers produces the desirable contracture in the long finger flexors, used for the tenodesis grasp:
     • With the wrist fully extended, the fingers are passively flexed
     • With the wrist fully flexed, the fingers are passively extended

4. Splinting or casting the elbows to correct developing contractures

5. Strengthening via biomechanics, such as:
   • Biomechanics - the use of weights, pulley systems, skateboards, suspension slings, and mobile arm supports for progressive resistive exercises and resistive activities to innervated and partially innervated muscles. As muscle strength increases, the amount of resistance should be increased to help the patient gain upright tolerance and endurance
     • Shoulder exercises should emphasize the shoulder depressors (latissimus dorsi), the flexors, abductors, and extensors (deltoids), and the scapular musculature. The triceps, pectoralis, and latissimus dorsi are required for weight shifts in the wheelchair and for transfers
     • Wrist exercises should emphasize the extensors to maximize natural tenodesis function for functional grasp and release
   • EMG biofeedback
   • Functional electrical stimulation which increases muscle mass and circulation and favorably alters muscle fiber composition. Cycling improves fitness, lower-extremity circulation, and circulatory response to ischemia and reverses cardiac muscle atrophy in persons with tetraplegia. Ambulation improves upper-extremity endurance, lower-extremity circulation, and perception of body image. Arm and wheelchair ergometry increases arm endurance and decreases cardiovascular risks associated with hyperlipidemia. Resistance training of the upper extremities improves strength and endurance.

     These benefits can prevent complications of SCI, such as orthostatic hypotension (Jacobs & Nash, 2001). FES can also improve walking and grasping, and the FES system as a prosthetic device in ADL can be considered (Popovic, et al 2001).

6. Providing and training the patient in the use of assistive devices, when the patient cannot perform an activity independently
   • Universal cuffs are used to hold eating utensils, pencils and paintbrushes, and toothbrushes
   • Wrist cock-up splints attached to universal cuffs are used to stabilize the wrist in patients with little or no wrist extension
   • Plate guards, cup holders, extended straws with straw clips, and nonskid table mats can permit independent feeding
   • Wash mits and soap holders can facilitate bathing
   • Button hooks can permit independent dressing
   • Transfer boards can enable independent transfers
   • Mobile arm supports and wrist-hand orthoses
   • Mouthsticks and environmental control systems

7. Assessing, ordering, fitting, and instructing the patient in the use of durable medical equipment (DME), when goals and expectations for its use have been determined, and when all functional, positioning, environmental, psychological, and financial considerations have been evaluated. Due to the wide array of available equipment, the occupational or physical therapist should develop a close relationship with an experienced rehabilitation technology supplier (RTS). Wheelchair seating should:
   • Support the patient in an erect, well-aligned position, to stabilize the pelvis and enable proper trunk alignment
   • Enhance respiratory function
   • Maximize sitting tolerance, by providing comfort and distributing sitting pressure
   • Optimize upper extremity function, and prevent the development of pressure sores and deformities

8. Regaining independence in and expanding activities of daily living (ADL).
   • Independent feeding, oral hygiene, and upper body bathing and dressing, with or without devices
   • Communicating via writing, the telephone, tape recorder, stereo, and personal computer
   • Bowel and bladder care, such as independent stimulation and applying a urinary collection device, with or without facilitory equipment, using the best possible technique in the best possible position
   • Transfers using a sliding board

9. Providing psychological support to the patient
   • Allow and encourage the patient to express frustration, anger, fears, and concerns
   • Identify and address each patient's psychological problems, such as denial, apathy, depression, substance abuse, etc.
   • Assess the impact of psychological problems on the rehabilitative process and discharge
   • Identify and emphasize the patient's strengths and skills
   • Promote the development of support groups in the occupational therapy clinic

10. Educating the patient on a variety of subjects, such as accessibility rights, fire safety, environmental temperature management, home modification, travel, and sexuality, via group discussions, video programs, presentations by patients living successfully with their injury, etc.
    • Instruction modalities include demonstration followed by trial and error, observation of other patients with similar levels of injury, and step-by-step instruction by the therapist.
    • Instruction times include early morning and mealtimes, the best times to practice self-care activities in situations that resemble the home environment as much as possible
    • Instruction programs include combining several goals, such as strength training by practicing page turning

11. Family training includes education for:
    • Range of motion and upper extremity positioning
    • Pressure reliefs
    • Activities of daily living, including transfers and use of equipment
    • Selecting major equipment, such as the best wheelchair (based on mobility, positioning, transportation, home modifications, and attaching assistive devices) and bathroom equipment