The purpose of evaluation is to set the treatment goal, predict the prognosis, determine the training plan and determine the treatment effect. In order to achieve the above objectives, it is necessary to collect and analyze the information of the following aspects and projects. Because the patient has serious physical dysfunction, it is necessary not only to make a detailed evaluation through face-to-face examination and measurement, but also to closely observe and pay close attention to the patient during the evaluation process and the subsequent treatment process.
(2) Collect relevant information
1. Understand the general physical condition of the body. Whether there are any surgical complications (yes, the method of operation), neck movement or weight bearing, postural hypotension, sitting time, defecation, autonomic nerve disorder, respiratory disorder, ectopic ossification of bedsore, etc.
2. In terms of physical function, muscle strength (unarmed muscle strength examination), range of motion (ROM), sensory disturbance, pain or numbness, upper limb function, hand type (functional limb position), spasm and degree of spasm, and sitting balance.
3. Accept the psychological barriers, the tolerance of personality psychology, the desire or expectation for the relationship between family members, and the requirements for themselves and their families.
Completion of 4.4. ADL daily life movements, the completion method of each movement, the use of assistive devices and orthoses.
5. Social and professional background, educational background, economic situation, housing situation, family members, role in the family, hobbies, special skills, driver's license, social status and role, and medical system.
6. Professional ability includes intelligence level, social persistence, professional environment, housework ability, driving ability, etc. The starting time and duration of overtime, etc. , and choose the necessary items according to the specific situation of each patient.
(3) The contents of the evaluation Before the occupational therapy evaluation, we should fully understand the medical and nursing precautions in the daily activities of the ward (activitiesofdailyliving；; ADL) plays a very important role in determining the evaluation scheme.
The evaluation includes interview observation, physical function examination (ROM measurement, muscle strength examination, sensory examination, tendon reflex upper limb function examination), ADL and social activity information collection. The evaluation contents are summarized as follows (Table 7-4- 1):
Table 7-4- 1 Evaluation of Occupational Therapy for Spinal Cord Injury
The initial evaluation is generally carried out at the bedside when the patient is still in the acute stage, and attention should be paid to the contraindications and physical condition of the patient. In addition, in order not to increase the burden on patients, all professional departments should share information and avoid doing the same examination many times. It is best to have a detailed examination when the patient's physical condition is restored to the stage of allowing him to leave the hospital bed and go to the occupational therapy room for training, and then conduct it as appropriate according to the patient's physical condition. The following are matters needing attention in the evaluation.
1. To collect medical and other professional data of traumatic spinal cord injury, it is necessary to collect information such as the cause of the accident, the type of injury accompanying the accident (visible by ct or MIR), clinical medical treatment (whether there is surgery or neck fixation), and the accident process of extraspinal cord injury. Collect diagnostic information about current medical history and current treatment (drugs and surgery, etc.). ) and the purpose of this hospitalization. In the acute phase, priority should be given to sputum excretion, fever and blood pressure in the respiratory tract. In addition, before starting bedside training, due to the fixation of the neck, first determine whether there are bedsores and pain prevention methods in the range of motion and negative weight.
Table 7-4-2 Medical Related Information
ADL is almost completely assisted in the acute stage, and its auxiliary methods can be understood through nurses' records.
2. Interviews in the acute phase, the first interview is mostly conducted at the bedside. At this time, we should first consider the general situation and psychological adaptability of patients, such as consciousness and endurance. Secondly, we must know the general situation of patients before injury, and collect information such as family composition, hobbies and the status and role of patients in the family. We must also ask about the patient's injury and subsequent treatment. After the interview, it is necessary not only to ask questions, but also to introduce the role, work content and treatment methods of occupational therapy to patients and their families, so that patients and their families can know more about occupational therapy, which is also a good start to establish a trust relationship with patients. The interview may involve more professional knowledge, and the occupational therapist should explain it in plain language as much as possible. When patients and their families have questions, occupational therapists should repeatedly explain patiently, and at the same time listen patiently and respect patients' opinions. At this stage, patients are prone to fatigue and have limited time to continue to concentrate.
Information about the situation before the injury, the composition of family members, the patient's role in the family and society, education, professional experience, religious extracurricular activities, social attention and so on are all patients' privacy. Don't be too reluctant to ask questions, especially about the life before the injury, which may cause emotional changes of patients, so pay attention to it when talking (see Table 7-4-3 for interview contents).
Table 7-4-3 Interview Contents
The limited range of motion of joints will greatly affect the acquisition of ADL movements, and spasm and joint contracture caused by muscle strength imbalance will also affect the completion of ADL movements of patients.
(2) Muscle strength examination: Muscle strength examination is an important examination to predict prognosis and confirm training indexes. It is necessary to examine the cervical spinal cord which is mainly dominated by spinal cord segments in sequence. Even in the same spinal cord segment, different examination methods of up and down position have different effects on muscle strength recovery, which should be carried out in a stable posture of trunk. Although it is difficult to avoid compensation to a certain extent, we must pay attention to preventing compensation as much as possible.
Attention should be paid to even slight muscle strength recovery in acute stage, especially in the stage of 1 or 2. When the muscle strength stage is 1 or 2, to relax the antagonistic muscle, we can passively pull the antagonistic muscle to relieve muscle tension. Frequent body position changes should be avoided during muscle strength examination. After all the projects that can be inspected in the same post are completed, the post should be adjusted for other projects. The patient can't have a basic examination.
In the early stage when the stability of cervical spine has not been confirmed, the negative weight of neck and scapula should be confirmed to the doctor.
(3) Sensory examination: The therapist should examine the sense of touch and pain according to the segmental distribution of nerves, and determine the area where the sensation is dull or disappeared along the boundary line of medulla oblongata near the injury plane. For patients with incomplete injury, it is best to check the sense of temperature at the same time as the whole body touch and pain to confirm whether there is dissociative sensory disorder. Sensory examination needs enough psychological endurance, and fatigue is easy to occur during the examination, so pay attention to the patient's facial expression, especially in the acute stage. When sensory disturbance occurs due to emotional changes, it is necessary to make clear the position and degree of the disturbance, and give guidance to patients on how to prevent burns and injuries in daily life.
(4) Examination of tendon reflex and muscle tension: In the part with spasm or hyperreflexia, the diagnosis should be made by palpation of tendon reflex and traction reflex. Muscle atrophy is not common in limbs with increased muscle tension and parts with excessive exercise in spastic state, but joint contracture is easy to occur. Because of spasm, sometimes the adduction of both lower limbs suddenly occurs, resulting in the crossing of both lower limbs, thus losing the balance of sitting position, which should be paid attention to clinically.
(5) Upper limb function examination: Upper limb function includes grasping the object and other functions (judging the operating object by the distance to the object). Standardized examination methods include simple upper limb function examination (STEF). Patients with cervical spinal cord injury usually adopt various compensatory actions (using tendon sheath effect, etc.). ) to perform various operations. Pay attention to observation and make records during evaluation.
Simple upper limb function examination is the most basic examination content in the initial stage of occupational therapy. At the same time, it is necessary to carry out various tests related to intelligence level or housework ability. In addition, we should observe and understand the use of patients' sitting balance ability, push-ups, daily exercise, and other information of patients through PT and other related professionals, and sort out and summarize the relevant information.
5.ADL examination first needs to confirm the method, speed and safety of which daily life actions can be completed in patients' real life. These situations can be asked to the patient's family or nursing staff. When they are not sure or have questions, they need practical operations to confirm whether they can be completed and how to do it.
Secondly, it is necessary to confirm whether there are actions that can be done in evaluation but not in daily life. If this situation is found, it is necessary to find out the reasons for not doing it, such as time-consuming and security risks.
During the examination, we should pay attention to the patient's method of completing the action, and analyze the action at the same time, especially when the action cannot be completed.
There are many forms of assessment for ADL exam. When evaluating, we should not only judge "can" and "can't", but also clarify various conditions and record the time required to complete the action. Representative evaluation methods include Barthelindex (BI) and functionalindepencemeasure Assessment (FIM).
6. Evaluation of participation in social activities One of the ultimate goals of rehabilitation is to be able to return to society and participate in social activities.
Therefore, you should also evaluate your ability in this area before leaving the hospital. Most patients with cervical spinal cord injury rely on wheelchairs for mobility. Therefore, it is necessary to evaluate the housing structure of patients' activity places (home, work unit, school, etc.). ) After leaving the hospital, we should also know how patients can complete necessary activities in their work units or school life.
At present, CHART (CraigHandicapassessment Andreporting Technique) examination is widely used to evaluate patients' social activity ability. The adverse effects of Chart on society include six aspects, namely, policy determination, physical self-care, mobility, homework, social integration, economic independence and policy determination.
Except for one item, the other five items should be evaluated, and the patients' social participation ability should be judged according to the evaluation results.
Occupational treatment of cervical spinal cord injury is not limited to hospitals, but also includes outpatient treatment and guidance for family members' auxiliary methods.
The functional level and ADL of different segments of cervical spinal cord injury are as follows (see Table 7-4-4):
Table 7-4-4 Functional Level and ADL of Different Segments of Cervical Spinal Cord Injury