Case Presentation

Monday, June 24th 2019

REHABILITATION MANAGEMENT OF PATIENT WITH SPINAL

CORD INJURY AIS D NL C6 DUE TO C5-C6 COMPRESSION
FRACTURE DUE TO SUSPECT OF METASTATIC BONE DISEASE

Author:
dr. M. Kamaluddin K

Examiners:
Dr. Indriati MS Tobing, SpKFR-K
Dr. Ronald Pakasi, SpKFR

PHYSICAL MEDICINE AND REHABILITATION

FACULTY OF MEDICINE DIPONEGORO UNIVERSITY
FATMAWATI HOSPITAL
JAKARTA 2019
 Table of Contents

CHAPTER I. CASE REPORT................................................................................ 2

1.1. Identity.......................................................................................................... 2
1.2. Anamnesis .................................................................................................... 2
1.3. Physical Examination ................................................................................... 3
1.4. Supportive Examination ............................................................................. 14
1.5. Diagnosis .................................................................................................... 16
1.6. Prognosis .................................................................................................... 17
1.7. Discharge Planning..................................................................................... 26
1.8. Goal ............................................................................................................ 27
1.9. Rehabilitation Programs .............................. Error! Bookmark not defined.
1.10. Follow Up .................................................. Error! Bookmark not defined.
CHAPTER II. CASE ANALYSIS ....................................................................... 28
REFERENCES...................................................................................................... 30
 CHAPTER I
CASE REPORT

1.1. Identity
Name : Mrs. D
Date of birth : July 25th, 1974 / 45 years old
Address : Jl. Jati Padang Utara no.9 Pasar Minggu, Jakarta
Occupation : Housemaide
Method of payment : BPJS
Education : Junior High School
Marital status : Married
Medical record : 01695685

1.2. Anamnesis
Taken on June 11th, 2019 by autoanamnesis and alloanamnesis (her daughter)

Chief Complaint:
Weakness of both her upper and lower extremeties since june 2nd 2019

History of Present Illness

Initially on june 2nd, patient complained of a little weakness of her lower extremities but still
could walk. When walking, she felt like there weren’t any energy on them. One day later, his
complaint was worse and she required someone to help her when walking to do acivity of
daily living like going to bathroom. At the same day, She also started feeling weakness on her
upper extrimities, could still lift a cup but couldn’t lift a pan. She also complained of pain on
her neck referring to her upper back. She’ve been getting it since may 20th. Initially, intensity
and frequency of the pain were mild but worsening from may 28th to june 4th. Therefore , On
june 4th, her family took her into Pasar Minggu Hospital because of worsening on her
Extremities and pain more severe. She was hospitalized and managed by a neurologist and
took gabapentin 300mg/day, mecobolamin 500mg/day orally and metilprednisolon 1000mg
injection in single dose. For hospitalized, her pain decresed but her weakness was still same.
Moreover, patient also couldn’t urinate so that the doctor gave her an indwelling
catheterization to overcome it. On june 9th, patient was referred to medical rehabilitation
department of Fatmawati hospital but patient went home firstly and come in on june 11th at
medical rehabilitation polyclinic of fatmawati hospital and then hospitalized in GPS 4 room.
This current time, patient still complains of weakness of her all extremities but no pain at
neck anymore . There is no history of trauma. She also feels numbness on both her palm of
hands and sole of feet. Patient still has a micturition problem. She feels sensation but not able
to urinate and until now, she still uses indwelling catheterization For defecation, patient feels
no sensation and without spontaneous defecation from june 4th to june 11th..

History of Past Illness

She had no history of hypertension, diabetes mellitus, cardiac event, respiratory illness, stroke
or tumor.

History of Functional Abilities

Patient was able to work independently by doing housework as a housewife assistant and
normal before her current illness.

Psychosocioeconomic Status
Before getting sick, patient worked as a housemaid and stayed in her boss’s house within all
her children. She got 2 million rupiahs a month. She has 4 daughters and her husband has
died since july 2006. Her first daughter works at beauty salon. She graduated from high
school. Whereas the second, the third and the fourth daughter are consecutive high school
class 2, junior high school class 3 and elementary school class 5. Currently, patient doesn’t
have adequate finance. She depend on her first daughter to fulfil her need. After hospitalized,
She and her daughters will stay live in her sister’s family consisting of her sister, her sister’s
husband and her sister’s sons. Patient has a good personality, because she has high motivation
and independent.

1.3. Physical Examination (june 11th 2019)

General status
Level of Consciousness: Compos mentis
Vital signs: BP: 100/70 mmHg HR: 86x/minute
RR: 20x/minute Temperature: 36.8oC
Nutritional status : body height 155 cm, body weight 49 kg
Body Mass Index : 20,4( normoweight)
General physical examination
Eyes : lower palpebral conjunctiva: normal /normal, sclera : no icteric
Neck : No enlarged lymph nodes
Lung :Symmetrical breathing, vesicular breath sound on both sides, ronchi -/-,
wheezing -/-
Heart : Normal heart sound I-II, no murmur, no gallop
Abdomen : supple, not palpated liver and spleen, no epigastric pain, tympanic percussion
sound, normal peristaltic movement
Skin : No decubitus

Musculoskeletal Status

International Spinal Cord Injury Musculoskeletal Basic Data

Set Form (Version 1.0)

Date performed: 2019/06/11

Neuro-Musculoskeletal history before spinal cord lesion (collected once):

Pre-existing congenital deformities of the spine and spinal cord : No
If yes, specify Diagnosis and Location If previous surgery due to this,
description Date of surgery YYYYMMDD
Unknown
Pre-existing degenerative spine disorders
If yes, specify Diagnosis and Location If previous surgery due to this,
description Date of surgery YYYYMMDD
 Unknown
Pre-existing systemic neuro-degenerative disorders : No
If yes, specify Diagnosis and Location If previous surgery due to
this, description Date of surgery YYYYMMDD
Unknown
Presence of spasticity / spasms
 No Yes
Treatment for spasticity / spasms within the last four weeks?
 No Yes
 Fractures, heterotopic ossifications, contractures, or degenerative
changes/overuse:
Fractures since spinal cord Heterotopic Contracture Degenerative
lesion (only those not ossification changes /
documented previously) Overuse
Right Left Date of Fragility Right Left Right Left Right Left
fracture fracture
YYYY/
MM/DD
Neck / Cervical - - - - - -
spine
Shoulder/ - - - - - - - - -
Humerus
Elbow - - - - - - - - -
Forearm - -

Wrist - - - - - - - - -
Hand - - - - - - - - -
Upper back /
Thoracic spine - -
- - - -

Lower back / - - - -
Lumbar spine
Pelvis - - - - -
Hip / Femur - - - - - - - - -
Knee - - - - - - - -
Tibia / fibula - - - - - -
Ankle - - - - - - - - -
Foot - - - - - - - - -
Method used to document heterotopic ossification, if present:
X-ray CT-scan Triple phase bone scan Other method, specify

Scoliosis
 No Yes
If scoliosis is present, method of assessment (check all that apply)
Observation in sitting Observation in standing
Plain radiographs in sitting Plain radiographs in standing
If scoliosis is present Surgically treated? If Yes: Date of
surgery YYYYMMDD Unknown
Other musculoskeletal problems; specify:

Do any of the above musculoskeletal challenges interfere with your activities of

daily living (transfers, walking, dressing, showers, etc.)?

 No – not at all Yes, a little Yes, a lot

Function In Sitting Test (FIST) Results
 FIST Test Item Date :
½ femur on surface; hips & knees flexed to 90° June 11th 2019
□ Used step/stool for positioning & foot support

Randomly Anterior Nudge: superior sternum 1(Max A)

Administered
Once Posterior Nudge: between scapular spines 1(Max A)
Lateral Nudge: to dominant side at 1(Max A)
acromion
Static sitting: 30 seconds 2

Sitting, shake ‘no’: left and right 2

Sitting, eyes closed: 30 seconds 2
Sitting, lift foot: dominant side, lift foot 1 inch twice 0
Pick up object from behind: object at midline, hands 1 (Max A)
breadth posterior
Forward reach: use dominant arm, must complete full 1 (Max A)
motion
Lateral reach: use dominant arm, clear opposite ischial 1 (Max A)
tuberosity
Pick up object from floor: from between feet 0
Posterior scooting: move backwards 2 inches 1 (Max A)
Anterior scooting: move forward 2 inches 1 (Max A)
Lateral scooting: move to dominant side 2 inches 1 (Max A)

TOTAL 16/56
Administered by:
dr.M.Kamaluddin
Notes/comments:
From scoring result, patient has an inadequate static sitting
balance that need upper extremity support and dynamic sitting
balance that needs maximal assistence
Scoring Key:
4 = Independent (completes task independently &
successfully)
3 = Verbal cues/increased time (completes task
independently & successfully and only needs more
time/cues)
2 = Upper extremity support (must use UE for support
or assistance to complete successfully)
1 = Needs assistance (unable to complete w/o physical
assist; document level: min, mod, max)
0 = Dependent (requires complete physical assist; unable
to complete successfully even w/physical assist)
.

2
Bed Mobility
 Rolling side to side : upper body rolling can be done by holding to handrail while
lower extremity is left behind and needs assistance from caregiver
 Side lying to sit : needs assistance for lifting upper body from side lying position to
upright position (75% assisted) and also moving lower body to sitting position (totally
assisted).

Upper Extremities Region:

Look : normotrophy, no deformity and no signs of inflammation
Feel : normotonus, no tenderness
Move : full ROM of upper extremities
Lower Extremities Region:
Look : normotrophy, no deformity and no signs of inflammation
Feel : normotonus, no tenderness, no edema
Move : full ROM of lower extremities

Neurological Status  See INSCI worksheet

3
4
Physiologic Reflex:
 Biceps Reflex : +3/+3
 Triceps Reflex : +2/+2
 Patellar Reflex : +2/+2
 Achilles Reflex : +2/+2
 ACR : positive

Pathologic Reflex of Babinsky : -/-

Functional Status
Functional Assessment:

The Spinal Cord Independence Measure, Version III (SCIM III)

Self Care:
1. Feeding (cutting, opening containers, pouring, bringing food to mouth, holding cup with
fluid):
0. Needs parenteral, gastronomy, or fully assisted oral feeding.
1. Needs partial assistance for eating and/or drinking, or for wearing adaptive devices.
2. Eats independently, needs adaptive devices or assistance only for cutting food and/or
pouring
and/or opening containers.
3. Eats and drinks independently, does not require assistance or adaptive devices.
ICF CODE Date: Exam

(dd/mm/yy) 11/6/2019

SCORE 3

2. Bathing (soaping, washing, drying body and head, manipulating water tap):
A. Upper Body:
0. Requires total assistance.
1. Requires partial assistance.

5
 2. Washes independently with adaptive devices or in a specific setting (adss), e.g. bars,
chair.
3. Washes independently, does not require adss. (not customary for healthy people)
ICF CODE Date: Exam

(dd/mm/yy) 11/6/2019

SCORE 2

B. Lower Body:
0. Requires total assistance.
1. Requires partial assistance.
2. Washes independently with adss (e.g. bars, chair).
3. Washes independently, does not require adss. (not customary for healthy people)
ICF CODE Date: Exam

(dd/mm/yy) 11/6/2019

SCORE 0

3. Dressing (clothes, shoes, permanent orthoses: dressing, wearing, undressing)

A. Upper Body:
0. Requires total assistance
1. Requires partial assistance with clothes without buttons, zippers, or laces (cwobzl).
2. Independent with cwobzl; requires adds.
3. Independent with cwobzl; does not require addss; needs assisstance or adds only for bzl.
4. Dresses (any cloth) independently; does not require adss.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 1

B Lower Body:
0. Requires total assistance
1. Requires partial assistance with clothes without buttons, zippers, or laces (cwobzl).
2. Independent with cwobzl; requires adds.
3. Independent with cwobzl; does not require addss; needs assisstance or adds only for bzl.

6
 4. Dresses (any cloth) independently; does not require adss.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

4. Grooming (washing hands and face, brushing teeth, combing hair, shaving, applying make
up).
0. Requires total assistance.
1. Requires partial assistance.
2. Grooms independently with adaptive devices.
3. Washes independently without adaptive devices.
ICF CODE Date: Exam

(dd/mm/yy) 11/6/2019

SCORE 3

Date: Exam

(dd/mm/yy) 11/6/2019

SUBTOTAL
6
0 - 20

Respiration and Sphincter Management

5. Respiration
0. Requires tracheal tube (TT) and permanent or intermittent a ssisted ventilation (IAV).
2. Breathes independently with TT; requires oxygen, much assistance in coughing or TT
management.
4. Breathes independently with TT; requires little assistance in coughing or TT
management.
6. Breathes independently without TT; re quires oxygen, much assistance in coughing, a
mask
(e.g. peep) or IAV (bipap).
8. Breathes independently without TT; requires little assistance or stimulation for
coughing.

7
 10. Breathes independently without assistance or device.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 10

6. Sphincter Management – Bladder

0. Indwelling catheter.
3. Residual urine volume (RUV) > 100cc; no regular catheterization or assisted
intermittent catheterization.
6. Residual urine volume (RUV) < 100cc or intermittent self - catheterization; needs
assistance for applying drainage instrument.
9. Intermittent self - catheterization; uses external drainage instrument; does not need
assistance for applying.
11. Intermittent self - catheterization; continent between catheterizations; do not use
external drainage instrument.
13. RUV <100cc; needs only external urine drainage; no assistance is required for drainage.
15. RUV <100cc; continent; does not use external drainage instrument.

ICF Date: Exam

CODE
(dd/mm/yy) 11/6/2019

SCORE 0

7. Sphincter Management - Bowel

0. Irregular timing or very low frequency (less than once in 3 days) of bowel movements.
5. Regular timing, but requires assistance (e.g., for applying suppository); rare accidents
(less than twice a month).
8. Regular bowel movements, without assistance; rare accidents (less than twice a month).
10. Regular bowel movement s, without assistance, no accidents.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

8
 SCORE 0

8. Use of Toilet (perineal hygiene, adjustment of clothes before/after, use of napkins/diapers)

0. Requires total assistance.
1. Requires partial assistance; does not clean self.
2. Requires partial assistance; cleans self independently.
4. Uses toilet independently in all tasks but needs adss (e.g. bars).
5. Uses toilet independently; does not require adds.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

Date: Exam

(dd/mm/yy) 11/6/2019

SUBTOTAL
10
0 - 40

Mobility
9. Mobility Room and Toilet
0. Needs assistance in all activities: turning upper body in bed, turning lower body in bed,
sitting up in bed, doing push - ups in wheelchair, with or without adaptive devices, but not
with electronic aids.
2. Performs one of the activities without assistance.
4. Performs two or three of the activities without assistance.
6. Performs all the bed mobility and pressure release activities independently.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

9
10.Transfers: bed – wheelchair (locking wheelchair, lifting footrests, removing and adjusting
arm rests, transferring, lifting feet).
0. Requires total assistance.
1. Needs partial assistance and/or supervision, and/or adaptive devices (e.g. sliding board).
2. Independent (or does not require wheelchair).
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

10. Transfers: wheelchair - toilet - tub (if uses toilet wheelchair: transfers to and from; if
uses regular wheelchair: locking wheelchair, lifting footrests, removing and adjusting
armrests, transferring, lifting feet).

0. Requires total assistance.

1. Needs partial assistance and/or supervision, and/or adaptive devices (e.g. grab - bars).
2. . Independent (or does not require wheelchair).
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

Mobility (indoors and outdoors, on even surface)

11. Mobility Indoor
0. Requires total assistance.
1. Needs electric wheelchair or partial assistance to operate manual wheelchair.
2. Moves independently in manual wheelchair.
3. Requires supervision while walking (with or without devices).
4. Walks with a walking frame or crutches (swing).
5. Walk s with a crutches or two canes (reciprocal walking).
6. Walks with one cane.
7. Needs leg orthosis only.
8. Walks without walking aids.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/19

10
 SCORE 0

12. Mobility for Moderate Distances (10 - 100 meters)

0. Requires total assistance.
1. Needs electric wheelchair or partial assistance to operate manual wheelchair.
2. Moves independently in manual wheelchair.
3. Requires supervision while walking (with or without devices).
4. Walks with a walking frame or crutches (swing).
5. Walk s with a crutches or two canes (reciprocal walking).
6. Walks with one cane.
7. Needs leg orthosis only.
8. Walks without walking aids.

ICF Date: Exam

CODE
(dd/mm/yy) 11/6/2019

SCORE 0

13. Mobility Outdoor (more than 100 meters)

0. Requires total assistance.
1. Needs electric wheelchair or partial assistance to operate manual wheelchair.
2. Moves independently in manual wheelchair.
3. Requires supervision while walking (with or without devices).
4. Walks with a walking frame or crutches (swing).
5. Walk s with a crutches or two canes (reciprocal walking).
6. Walks with one cane.
7. Needs leg orthosis only.
8. Walks without walking aids.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

11
14. Stair Management
0. Unable to ascend or descend stairs.
1. Ascends and descends at least 3 steps with support or supervision of another person.
2. Ascends and descends at least 3 steps with support of handrail and/or crutch or cane.
3. Ascends and descends at least 3 steps without any su pport or supervision.
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/19

SCORE 0

15. Transfers: Wheelchair - Car (approaching car, locking wheelchair, removing arm -
and footrests, transferring to and from car, bringing wheelchair into and out of car)
0. Requires total assistance.
1. Needs partial assistance and/or supervision and/or adaptive devices.
2. Transfers independent; does not require adaptive devices (or does not require
wheelchair).
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/2019

SCORE 0

16. Transfers: Ground – Wheelchair

0. Requires assistance.
1. Transfers independent with or without adaptive devices (or do es not require
wheelchair).
ICF Date: Exam
CODE
(dd/mm/yy) 11/6/19

SCORE 0

Date: Exam

(dd/mm/yy) 11/6/19

12
 SUBTOTAL
0
0 - 40

Date: Exam

(dd/mm/yy) 11/6/2019

TOTAL SCIM SCORE

18
0 – 100

 Spinal Cord Independence Measure (SCIM)

Self-care : 6/20
Respiration and sphincter management :10/40
Mobility : 0/40

Micturition and Defecation Function

Micturition function : sensation is absent, no spontaneous voiding / dribbling (retensio
urine)
Defecation Function : sensation is absent and no spontaneous defecation ( no incontinence)

13
1.4. Supportive Examination
Radiological Examinations

Thorax Radiograph ( june 3rd 2019)

Impression : Straight cervical

14
Thorax Radiograph withPA projection ( june 3rd 2019)

 Impression : Pulmo and cardiac are normal

Laboratory Examination
03/06/2019
Hemoglobin 14.6 g/dl
Hematokrit 41 %
Leukocyte 8400 /uL
Platelet 364000/ uL
Ureum 26 mg/dL
Creatinin 0.92 mg/dL
SGOT 17 U/L
SGPT 19 U/L
GDS 188 mg/dlL
LED 35 mm/jam
Natrium 143 mmol/mL

15
 Kalium 4.4 mmol/mL
Klorida 104 mmol/L

Supportive Examination Planning Program

1. Radiology : Cervical MRI with Contrast
2. Laboratory : Urine Analysis

1.5. Diagnosis
Medical Diagnosis
SCI AIS D NL C5 due to suspect of transverse myelitis

Rehabilitation Diagnosis
1. Self Care Problem
2. Mobility Problem
3. Neurogenic Bladder
4. Neurogenic Bowe
5. Risk of SCI Complicatio:
- Autonomic Dysreflexia
- Orthostatic hypotension
- ISK
- Fecal Impaction
- Overuse Tendinophaty

16
1.6. Rehabilitation Programs

No Problem Program
1 Self Care Problem Target: independent in upper and lower dressing
Obstacles: inadequate hand function and static sitting
balance
Potential: adequate cognition, high motivation
Program :
- Upper Extremities strengthening exercise
- Sitting balance training
- Education to patient and family for doing exercise
regularly
2 Mobility Problem Target:
1. independent bed mobility (rolling, supine to sit)
2. independent in wheeling
3. Transfer bed-wheelchair and wheelchair-bed by
cargiver
Obstacles: inadequate trunk control muscle and weakness
of upper extremities
Potential: adequate cognition, high motivation Program
- Upper Extremities strengthening exercise
- Trunk control muscle exercise
- Sitting exercise

3 Neurogenic bladder Target: caregiver and patient can do ICP with clean
technique, prevent episode of UTI
17
Obstacles: inadequate sitting balance
Potential: adequate cognition, functional upper extremity to
 insert catheter, supportive family
Program
- ICP 5x/day, if patient is like having sensation to
urine so paitient should do ICP for evaluating it
- Education for patient, caregiver, and family about
how the illness impact bowel habit, target, and
rehabilitation program for neurogenic bladder
- Education of patient and caregiver how to do clean
intermittent catheterization and regular
urinalysis/week during hospitalization
4 Neurogenic bowel Target: caregiver and patient can do digital stimulation
daily, regular defecation, no bowel incontinence in
between.
Obstacles: inadequate sitting balance
Potential: adequate cognition, functional upper extremity,
supportive family
Program :
- Train patient and caregiver to do correct digital
stimulation
- Digital stimulation / day on regular time and record
bowel habit regularly
- Education for patient, caregiver, and family about
how the illness impact bowel habit, target, and
rehabilitation program for neurogenic bowel

18
1.10. Follow Up

Follow Up : june 13th 2019

S: lower abdomen pain at midnight

O: BP 110/80 mmHg, HR: 98x/min

Pain description: VAS 4, pain is like burnt sensation at lower abdomen

Laboratory Report (taken at june 12th 2019)

-Urine Analysis: Nitrit (+), leucocyte (+2), leucocyte count 205,6/uL, bacteria
3.554,7/uL

A: UTI

P: - Cefixime 200mg twice a day for 7 days

- Urine culture

- Educate sterile ICP

- Check pain/day and evaluation of pain 3 days later (after taking cefixime 200 mg for 3
days)

S: No another complaint

O: BP 110/80 mmHg, HR: 98x/min

19
Mobility Assessment

Lying sidet to sitting position: assisted 75% with a caregiver

FIST Test Item Date :

½ femur on surface; hips & knees flexed to 90° June 13th 2019
□ Used step/stool for positioning & foot support

Randomly Anterior Nudge: superior sternum 2

Administered
Once Posterior Nudge: between scapular spines 2
Lateral Nudge: to dominant side at 2
acromion
Static sitting: 30 seconds 3

Sitting, shake ‘no’: left and right 3

Sitting, eyes closed: 30 seconds 3
Sitting, lift foot: dominant side, lift foot 1 inch twice 0
Pick up object from behind: object at midline, hands 1 (Min A)
breadth posterior
Forward reach: use dominant arm, must complete full 1 (Max A)
motion
Lateral reach: use dominant arm, clear opposite ischial 1 (Min A)
tuberosity
Pick up object from floor: from between feet 1 (Max A)
Posterior scooting: move backwards 2 inches 1 (Max A)
Anterior scooting: move forward 2 inches 1 (Max A)
Lateral scooting: move to dominant side 2 inches 1 (Max A)

TOTAL 22/56
Administered by:
dr.M.Kamaluddin
Notes/comments:
From scoring result, patient has better the improvement of
sitting balance rather than the examination at june 13th
Scoring Key:
4 = Independent (completes task independently &
successfully)
3 = Verbal cues/increased time (completes task
independently & successfully and only needs more
time/cues)
2 = Upper extremity support (must use UE for support

20
or assistance to complete successfully)
1 = Needs assistance (unable to complete w/o physical
assist; document level: min, mod, max)
0 = Dependent (requires complete physical assist; unable
to complete successfully even w/physical assist)

21
A : Inadequate sitting balance getting improvement

P : Continuing Sitting balance training

Follow Up : june 14th

S: No Complaint

O: BP 100/70 mmHg, HR: 88x/min

Cervical MRI with contrast Report (taken at june 13th 2019) : Compression fracture
and edema at C5-C6 vertebral corpus, straight cervical spine

INSCI worksheet

22
A : SCI AIS D NL C6 Due to Compression Fracture C5-C6 Due to Suspect of MBD
P : -Using Piladelphia Neck Collar when doing exercise and ADL
- Consulted to Orthopedist and Neurologist

Follow Up : june 15th 2019

S: No complaint

O: BP 100/60 mmHg, HR: 92x/min

Consultation result of Orthopedist : -Tumor Marker Examination

-ketorolac 30mg 3 times a day intravenous

-Gabapentin 300mg once a day orally

-Others treatment according to Physiatrist

Consultation result of Neurologist : -Mecobolamin 500mcg once a day intravenous

- Others treatment according to Physiatrist

A: SCI AIS D NL C6 Due to Suspect of MBD

P: - Continuing previous all programs

S : No complaint

Evaluation of midnight pain at lower abdomen by asking about the pain. Patient said that
no pain any more

O : BP 100/60 mmHg, HR: 92x/min, VAS : 1-2

A : UTI improvement

P : Continuing Cefixime 200mg twice a day

23
Follow Up : june 18th 2019

S : No complaint

O : BP 110/70 mmHg, HR: 86x/min

Mobility Assessment

Lying side position to sitting position: assisted 25% with a caregiver

FIST Test Item Date :

½ femur on surface; hips & knees flexed to 90° June 18th
□ Used step/stool for positioning & foot support 2019
Randomly Anterior Nudge: superior sternum 2
Administered Once
Posterior Nudge: between scapular spines 2
Lateral Nudge: to dominant side at acromion 2
Static sitting: 30 seconds 3

Sitting, shake ‘no’: left and right 3

Sitting, eyes closed: 30 seconds 3
Sitting, lift foot: dominant side, lift foot 1 inch twice 1
Pick up object from behind: object at midline, hands breadth 2
posterior
Forward reach: use dominant arm, must complete full motion 1 (Mod A)
Lateral reach: use dominant arm, clear opposite ischial tuberosity 1 (Min A)
Pick up object from floor: from between feet 1 (Mod A)
Posterior scooting: move backwards 2 inches 1(Mod A)
Anterior scooting: move forward 2 inches 1 (Mod A)
Lateral scooting: move to dominant side 2 inches 1 (Mod A)

TOTAL 24/56
Administered by:
dr.M.Kamaluddin
Notes/comments:
From scoring result, patient has better the improvement of sitting balance
rather than the examination at june 15th
Scoring Key:

24
 4 = Independent (completes task independently & successfully)
3 = Verbal cues/increased time (completes task independently &
successfully and only needs more time/cues)
2 = Upper extremity support (must use UE for support or
assistance to complete successfully)
1 = Needs assistance (unable to complete w/o physical assist;
document level: min, mod, max)
0 = Dependent (requires complete physical assist; unable to
complete successfully even w/physical assist)

Mobility for Moderate Distances (10 – 100 meters) examination

0. Requires total assistance.
1. Needs electric wheelchair or partial assistance to operate manual wheelchair.
2. Moves independently in manual wheelchair.
3. Requires supervision while walking (with or without devices).
4. Walks with a walking frame or crutches (swing).
5. Walk s with a crutches or two canes (reciprocal walking).
6. Walks with one cane.
7. Needs leg orthosis only.
8. Walks without walking aids.

ICF Date: Exam

CODE
(dd/mm/yy) 11/6/2019

SCORE 2

A : Sitting Balance improvement

P : -wheelchair mobility training

Follow Up : june 15th 2019

S: No complaint

O: BP 100/60 mmHg, HR: 92x/min

25
 Consultation result of Orthopedist : -Tumor Marker Examination

-ketorolac 30mg 3 times a day intravenous

-Gabapentin 300mg once a day orally

-Others treatment according to Physiatrist

Consultation result of Neurologist : -Mecobolamin 500mcg once a day intravenous

- Others treatment according to Physiatrist

A: SCI AIS D NL C6 Due to Suspect of MBD

P: - Continuing previous all programs

1.7. Prognosis
Ad vitam : Bonam
Ad sanationam : Bonam
Ad functionam : independent in self care and mobility

1.8. Discharge Planning: 1 weeks (july 1st 2019)

Micturition: Independent in ICP
Defecation: Independent in Digital stimulation
Transfer assisted by caregiver
independent in upper dressing
Lower dressing assisted by caregiver

26
Mobility by wheelchair for short distance

1.9. Goal
 Independent in wheeling for Moderate distance ambulation
 Independent in bed-wheelchair and wheelchair-bed transfering
 Independent in lower dressing
 No complication of SCI (Autonomic dyreflex, Orthostatic hypotension, ISK, Overuse
Tendinophaty)
 Back to leisure activity (cooking, tailoring) and role participation (socialization,
pengajian etc)

27
 CHAPTER II
CASE ANALYSIS

A 64-year old patient suffered from SCI AIS A NL T6 due to compression fracture in T8
from spondylitis TB. Regulation from Health Ministry in Indonesia (2015) defines geriatric
patient as patient older than 60 years old with multipathology, with impairment related to
functional declines in system organ, psychology, social, economic, and environment that
needed multidisciplinary approach. While spinal cord itself will affect multiple system organ
and become a severe stressor, the patient herself has already experience diminish physiologic
reserve from aging process and comorbidities. Possible geriatric giants that has been going on
in this patient could be infection and immunodeficiency that contribute to development of
lung tuberculosis and spondylitis TB. While patient was still active without any complaint in
doing activity and her role participation before her illness, normal aging process already
decrease her physiologic reserve especially in cardiorespiratory system and also after the
injury, she will be getting older and we should anticipate another geriatric problem to come.
All of this aspect will effect rehabilitation program and goal setting in this patient.
From the first back pain occurred, patient already experiencing radicular back pain in her
thoracic spine. Pain that induced by movement is also clue that her spine is already
compromised possibly by tuberculosis even though from spine radiograph only reveal lumbar
spondylosis. Patient was also suspected to have intraabdominal pathology because mimicking

28
pain pattern with working diagnosis of cholecystitis from abdominal USG in February even
though later abdominal USG in April reveal normal intraabdominal organ.
Compression fracture in this patient was caused by spondylitis TB that caused compression
fracture in T8. Tuberculosis infection of the spine comes from hematogenous spread which in
this patient may be caused primarily by lung tuberculosis. Symptoms in this patient comes
from pain progressing to spinal cord functional impairment like lower limb weakness, loss of
bladder and bowel control. This is in line with pathophysiology of spinal tuberculosis. Spinal
tuberculosis first infected intervertebral disc. Once infected, soft nucleus center and fibrous
annular wall may weaken, decays and collapse. This caused the disc to close and squeezing
down on nerve root causing pain. Then infection spread to vertebral bodies above and below
the disc causing bone weakness and collapse under the weight of human body. This deformed
anterior and medial pillar induce compression of spinal cord that manifest as functional
impairment. Once this happen, the spine will be unstable and prone to further compression if
stabilization is not achieved. In this patient further compression is happening manifesting by
worsen lower limb strength (MMT 2 0). This could happen from worsening edema or
improper mobilization.

Complete spinal cord injury with neurologic level T6 will effect multiorgan system. In this
patient, it paralyzes its lower extremity, abdominal muscle, and possibly intercostal muscle
up to T6 level. These muscle weakness compromise trunk control and respiratory function
while especially trunk control will be needed in most daily activities that needed upright
position. Motor recovery in this patient have a poor prognosis because of old age 1, and no
improvement in motor function after almost 1 month after stabilization of spine2, and long
time from neurological deficit until tuberculosis drug administration (>1 month)3. From
expected functional outcomes only by neurologic level, T6 paraplegia should be able to
achieve independent transfer, bed mobility, digital stimulation for bowel program, ICP, self-
care (eating, dressing, bathing), and manual wheel chair propulsion. However, considering
for this patient, different goal setting should be considered that is lowered than the ideal
expected functional outcomes. Rehabilitation exercise must also take into account a safe
measure with principle of exercise in geriatric “start low, go slow” especially for mobilization
training like frequent hemodynamic evaluation to within safe range (minimal subjective
complaint, <20% hemodynamic change from pre-exercise), comorbidities, and declining
physiologic reserve that continue to be expected on aging geriatric patient (cognitive,
cardiopulmonary, decrease muscle strength etc). Therefore, a standby caregiver considered

29
mandatory and continuing support from family. Rehabilitation itself should be intensive and
long-term in geriatric SCI as well as younger patient with purpose of improving physical
fitness, functional independence, and rehabilitation outcome.4
Being a geriatric patient with complete paraplegia, expected complication is pressure ulcer,
constipation from neurogenic bowel, urinary tract infection, decline kidney function,
autonomic dysreflexia, pneumonia, and cardiovascular disease. Geriatric patient with SCI are
more likely to develop pressure ulcer for following reason (1) arteriosclerotic risk factor and
small vessel circulation is decreased, (2) difficulty for them to take posture to reduce buttock
pressure, (3) malnutrition with extreme bony prominence, (4) anemia, (5) hypoalbuminemia
especially in the 1-year post injury. In this patient, correction of anemia, adequate nutrition,
hygiene, specialized cushion on wheelchair and most importantly long-term commitment by
patient and caregiver for pressure relief maneuver is mandatory for preventing ulcer. Pressure
relief could be achieved for this patient by leaning forward with chest towards the thigh or
sideways bending and should be routinely done for 15-20 second every 20-30 minutes or for
60-120 seconds every 60 minutes.5
Risk of fall during mobilization is also a concern for this patient. This patient has inadequate
trunk control, sitting balance, spasticity and involuntary movement that would impair
mobility, function and transfer issues. Spasticity and in LE would do harm in this patient
because it will be harder for this patient to use momentum effect for doing transfer therefore
upper extremity strength couldn’t be more important in this patient. Flexor spasm could be
beneficial for supine to sit in this patient to assist in LE lowering. In this patient, upper
extremity strengthening program may also be difficult from decrease muscle mass in aging.
This patient need long term rehabilitation with regular follow up of the SCI features like
neuropathic pain, spasticity and involuntary spasm and monitoring of complication
(pulmonary complication, pressure ulcer, malnutrition, anemia, kidney function, AD,
cardiopulmonary fitness) or consequence of the aging process (geriatric giant). The purpose
of rehabilitation is to optimize independency, prevent SCI complication, back to activity and
role participation, and increase quality of life. Interdisciplinary work with physiotherapist,
occupational therapist, nutritionist, nurse, social worker, psychologist is mandatory in this
patient.

References

30
1. Wilson JR, Davis AM, Kulkarni A V, Kiss A, Frankowski RF, Grossman RG, et al.
Defining age-related differences in outcome after traumatic spinal cord injury :
analysis of a combined , multicenter dataset. Spine J [Internet]. 2013; Available from:
http://dx.doi.org/10.1016/j.spinee.2013.08.005
2. Medicine SC. No Title.
3. Peng L, Hai N. The effect of time-to-surgery on outcome in patients with neurological
deficits caused by spinal tuberculosis. Turk Neurosurg. 2016;28(2):275–81.
4. Furusawa K, Tajima F. Geriatric Spinal Cord Injuries: Rehabilitation Perspective. In:
Chhabra H, editor. ISCoS Textbook on Comprehensive Management of Spinal Cord
Injuries. 1st ed. India: Wolters Kluwer; 2015. p. 960–5.
5. Chhabra HS. ISCoS Textbook on Comprehensive Management of Spinal Cord
Injuries. 1st ed. India: Wolters Kluwer; 2015.

31
APPENDIX 1

7
7
5
7
3
6

2
2

1
1
1

6
1
49

7
7

7
7
7
35
84