Cooperation between a physiotherapist and an occupational therapist in the rehabilitation process after cervical spine injury: a case study

Introduction

Spinal cord injuries (SCI) are a current medical, economic and social problem [1-3]. Their incidence varies, but ranges from 15 to 40 cases per million in developed countries [4]. The most common causes of SCI are traffic accidents, falls from heights, sports injuries or violence [1,5,6]. Regardless of the mechanism of injury, it requires a complex treatment process and thus places a significant burden on the health care system [1,6]. SCI has negative consequences on motor, sensory and autonomic function [3]. Injuries at the level of the cervical spine due to loss of function of the upper limbs may lead to significant disability, independence and reduced quality of life [3,4].
An essential element of the treatment process for people after SCI is early rehabilitation. Its main goal is to re-educate functions and improve the quality of life [7]. By providing holistic care by a specialized medical team, it is intended to improve the functional condition of the patient, hasten their return to everyday activities and reduce the risk of complications. These goals are best achieved by involving the entire team when planning and conducting the improvement program. A specialized interdisciplinary team includes a rehabilitation specialist together with those from other areas, such as physiotherapists (PT), occupational therapists (OT), nursing team, or a psychologist.
Many patients with SCI demonstrate significant limitations in everyday functioning and may be unable to fulfil previous tasks, activities and social roles; as such, effective treatment should use a range of forms and methods of therapy. The most common approaches include hand therapy, adaptation of occupation and environment and social activation. The role of an occupational therapist is to help the client achieve the highest possible level of autonomy by enabling them to complete activities in all areas of occupation, i.e. the basic and instrumental activities of daily living, productivity, leisure, sleep and rest, leisure and participation in social life [8]. Interventions are aimed at improving and/or restoring lost functions and skills. If function cannot be improved, occupational therapists implement compensatory strategies to increase independence [9].
Specialists in PT and OT often work together to achieve goals. This is related not only to the holistic approach, but also to the overlapping scope of competences. Both PT and OT includes activities in the field of hand therapy, including fine motor exercises, manual therapy and the use of functional electrostimulation of the upper limbs; they can also teach positioning and performing everyday activities such as changing positions, sitting or walking on crutches. The scope of activities conducted by a specific professional group very often depends on the facility, the education of the therapists and the needs of the client. However, as the scope of activities and therapy methods may overlap between the two disciplines, it is possible that a conflict of competencies may occur. In contrast, proper communication and cooperation between PT and OT can allow for intensification and mutual complementation in conducting various types of interventions.
Although most research into the effectiveness of occupational therapy has been focused on large groups of patients, it is also desirable to describe the possibilities of cooperation from the perspective of an individual, particularly due to the subjective nature of the goals set and the complex functional condition of the client. As such, this case description is presented with the intention of demonstrating the possibilities for cooperation between members of interdisciplinary rehabilitation teams, while taking into account the division of the scope of interventions supporting the client's therapeutic successes.

Case report

A 39-year-old man was admitted to the Rehabilitation Clinic to improve his functioning. The interview revealed that he had been involved in a traffic accident three weeks earlier. The diagnosis was concussion of the cervical spinal cord and traumatic C4-C5 discopathy. The client was admitted for emergency surgery for tetraparesis; he underwent C4-C5 discectomy with Cage PEEK (one of the most frequently used cervical stabilization) implantation and anterior stabilization of C4/C5 using a plate was performed using an anterior approach. After the procedure, the neurological condition was found to improve, and trace voluntary movements appeared in the limbs. Magnetic resonance imaging (MRI) revealed a wide-base hernia of C4-C5 and edematous changes at this level of the spinal cord.
During admission to the clinic, the man was conscious and verbal-logical contact was preserved. The man could not stabilize his torso or head on his own. He was equipped with an orthopedic collar. Physical examination showed preserved passive movements in the upper and lower limbs, and the patient could move the shoulder joint and flex the elbow joint against gravity. Physical examination of the left upper limb confirmed that the patient could extend the wrist and elbow, but not against gravity. The client could also perform hip flexion and left knee extension, but not against gravity. However, in the right lower limb, muscle contraction was visible. Muscle tension increased in both limbs, rated at 1 on the Modified Ashworth scale [10]. Muscle strength was found to be higher in the legs and arms on the left side. The sensation of touch, rated on the ASIA scale, was normal in the upper limbs up to C5 level; however, it was impaired in the forearms and trunk from C6 to T12, and non-existent below T12. The patient scored 0 points on the Barthel scale.
An individually-tailored program was planned to meet the client's needs. Its design an implementation included cooperation with physiotherapists, an occupational therapist and a psychologist. One of the physiotherapists led the course of the therapy. All PTs had over eight years of experience in working with orthopaedic and neurological injuries, while the occupational therapist had two years of professional experience. Cooperation with the psychologist was ad hoc adjusted to the patient's needs. Although each specialist was assigned specific tasks in the improvement process, each intervention was aimed at achieving the main goal, which was defined in cooperation with the client. It assumed that by the end of the rehabilitation process, the client will be able to move independently using a wheelchair, including making transfers, and perform basic activities of daily living independently. On this basis, specific goals were developed and divided among the members of the interdisciplinary team.
The activities of the therapeutic team were carried out simultaneously and included various interventions to improve the functional status and quality of life. The activities of the physiotherapists primarily focused on introducing gradual verticalization and improving gross motor skills. Occupational therapy focused on transferring the acquired skills to everyday activities and improving fine motor skills, including the gripping function of the hand.
In the first weeks, physiotherapy included methods and techniques to prepare the client to adopt a sitting position and re-educate limb functions to engage in activity. The improvement program included the following: verticalization, passive and active-passive exercises, assisted exercises, relief exercises, breathing exercises, manual therapy of the upper and lower limbs and physical therapy, e.g. electrostimulation. This cooperative phase involved the use of the PNF method and NDT-Bobath elements. Due to the clinical condition of the client, the rehabilitation program was carried out at the bedside (three days) and then was moved to the rehabilitation room. After a week of rehabilitation, the client could tolerate taking a sitting position in an orthopaedic wheelchair well, but needed full assistance in changing positions.
The occupational therapy program was created based on the Canadian model and was based on the CPPF (Canadian Practice Process Framework) therapeutic scheme [11]. The cooperation was based on the Person-Centered Practice approach, which was based on taking the client's perspective, analysing his needs and resources, and providing support in various areas of occupations. After completing the assessment and determining the occupational profile, occupational therapy focused on the ability to perform activities that were meaningful to the client. Due to the current restrictions on visits to the clinic and internal motivation, the first specific goal to be set together with the client was to be able to make telephone calls independently. The interventions were carried out in two ways and included improving fine motor skills and adapting the occupation [12,13]. After analysing the components of the skills needed to complete the activity, the greatest difficulties were identified in unlocking the phone. An adaptation was used that involved temporarily resigning from blocking the phone's screen, and selecting an appropriate location that allowed the phone to be operated by movements in the wrist joint and the joints of the second finger. While the man could make calls in loudspeaker mode before he improved his whole hand grip, this approach allowed him to build a sense of independence and self-determination, and limited the help of third parties. After the adaptation, the man had the skills needed to answer the phone, and after two weeks of cooperation, the man could independently operate the phone in the appropriate position.
After three weeks of rehabilitation, the man could maintain a standing position on the ladders for about three to four minutes, assisted in his movement by therapists. The time required to assume an upright position on the verticalization table was extended to 30 minutes. When performing the exercises, the client began lifting the pelvis while lying on his back with stabilized feet and performed global movements in the facial area with his left upper limb. During this period, he acquired the skills needed to operate a remote control and touch his head.
Four weeks after the start of rehabilitation, the patient independently assumed and maintained an upright position with the knee hypertrophy mechanism for several minutes. An improvement in the grip of the left upper limb was also noticed. At this stage of the rehabilitation process, the patient developed the ability to use palmar and pincer grasps in the left upper limb (non-dominant). The range of motion of the right upper limb had improved, but it was still insufficient to allow an object to be held. The man noticed improvement in everyday activities that require gripping a light object. In this phase, he began to independently use the phone and change its location, as well as eating food that he could grasp with his whole hand.
During the process, all therapists constantly shared their observations and the client's perceived achievements. However, due to the significant improvement in functioning, it was decided to re-analyse the scope of the interventions. At this stage, occupational therapy focused on improving fine motor function, including passive exercises and manual therapy of the upper limbs. From that moment on, the process of improving the upper limbs was carried out exclusively within the scope of OT. As the length of time during which the client could tolerate a standing position lengthened and the muscles had partially strengthened, exoskeleton training was introduced into the physiotherapy program. After a week of training, the man walked 180 steps. In weeks 7 and 8, rehabilitation was limited due to a developing infection. Due to severe weakness, it was decided to carry out only selected physiotherapy activities (breathing exercises, passive and active exercises). After the end of isolation, the OT continued fine motor skills exercises, including performing everyday activities and, in cooperation with the PT, learning locomotion. During physiotherapy and occupational therapy, because of the weakness after the disease, the patient began to gradually introduce weight loads.
At week 8, the patient began performing activities requiring stabilization of the wrist joint and complex movements of the upper limb, such as eating a sandwich or drinking from a cup held with one hand (left hand). In this phase of improvement, after the team's consultations with the client, the scope of care activities in which he will be actively involved was established. PTs were responsible for providing information about the client's capabilities, OT was responsible for activity analysis and the possibility of introducing adaptations. The activity analysis focused on determining the skills needed to complete the activities and identifying factors supporting or hindering their implementation [14]. All information was shared with the nursing team. From this point on, the client actively participated in the care activities.
After 10 weeks of rehabilitation, the patient was able to independently drive the wheelchair and could cover the distance between his room and the rehabilitation room for the first time, including performing activities such as pressing the door handle and buttons in the elevator. After observing and analysing the activities by a PT and an OT, attention was paid to the components of movement that could improve the quality of movement using a wheelchair. On this basis, the following needs were identified: adapting the wheelchair to the man's needs by improving the sitting position, correcting the alignment of the spine, strengthening the right upper limb and improving the range of motion of abduction the left thumb.
At this point, the tasks were re-divided between the therapeutic team. The physiotherapists' activities focused on improving gross motor skills, including verticalization and learning to walk, providing passive exercises for the lower limbs, and strengthening the lower and upper limbs. Occupational therapy interventions included continuing to improve the quality of activity of daily living (ALD) performance, adapting difficult activities (e.g. writing), increasing strength and precision grips of the right upper limb and strengthening exercises for the left upper limb, and improving fine motor skills, including graphomotor skills. At this stage, the OTs analyzed activities much more frequently in order to incorporate the acquired skills into everyday activities.
As the rehabilitation progressed and the man achieved successes, a significant increase was noted in his motivation and willingness to continue rehabilitation in stationary conditions. At this stage, the patient showed willingness to participate in group occupational therapy classes while continuing individual therapy. Group classes were aimed at increasing the possibility of group participation, activation and social integration.
In week 11 of rehabilitation, the patient could independently perform some activities, such as eating dinner with a fork, but eating meals with a spoon remained difficult. Therefore, the OT increased the number of exercises aimed at precision and strengthening the grip strength of the left upper limb while continuing the existing occupational therapy interventions.
After another two weeks, the patient began to independently assume a sitting position on the bed with his feet resting on the ground. He noticed improvement in transferring with assistance, eating meals independently (including using a spoon) and moving around the building using a wheelchair. In week 15 of rehabilitation, the patient could independently transfer from bed to wheelchair and wheelchair to bed, which increased his participation in social life. The client completed rehabilitation after 15 weeks. The result on the Barthel scale was 65. At the end of the stay, the client was advised to continue exercises at home until the planned re-start of the rehabilitation period.
In the client's opinion, the provision of consistent recommendations by the entire interdisciplinary team played an important role both during and after the rehabilitation program. He indicated that he was now less afraid of returning home due to improved ability to perform everyday activities. The man declared that, thanks to the atmosphere and cooperation with various specialists, he still felt that he could achieve his goals during moments of difficulty or reduced motivation.
During the entire rehabilitation process, the team of PT and OT remained in constant contact. This type of procedure ensured the intensity of exercises was appropriate to the client's needs, despite the daily variation in functioning status and the use of complementary work methods and techniques. In the opinion of the trainers, good communication is need to cope with the complexity of the difficulties and the increased risk of complications. To achieve therapeutic success, it is extremely important to provide information about adding new exercises, changing the order of the program or adapting therapy hours when implementing an individual plan. Ensuring such an exchange of observations allows you to reduce the risk of overstimulation and overload due to excessive intensity and diversity of forms of rehabilitation.
Clinicians point out that ensuring cooperation facilitates much more effective rehabilitation because it allows for increasing the number of repetitions, extending the therapy time during the day and covering the process of improving all necessary motor functions. If rehabilitation were limited only to classes with a physiotherapist, it would be much more difficult to achieve various motor functions. This opinion is related to very common constraints on time and the ability of the personnel to work individually with the client. The clinicians did not notice any difficulties during cooperation or any conflict of competences, which may be related to their several years of cooperation, and knowledge of each other's abilities. In addition, occupational therapy is a profession whose main role is to ensure independence in performing ADLs. This allows for the possibility of performing activities before achieving improvement in function or transferring developed motor functions into skills needed to perform specific activities.
Due to some similarities between these professions, if necessary, OTs can help PTs, giving them time for other types of interventions, thanks to which the patient can extend the therapy time during the day. Moreover, each practitioner has different assumptions, experience, competences and knowledge of various methods, which translates into better adaptation of individual forms of therapy to the needs of the person. Additionally, we feel that any cooperation demonstrated by the team is noticed by clients, thus increasing the sense of care and reducing their anxiety.

Discussion

Including occupational therapy in the comprehensive rehabilitation of patients increases the chances of improving their functioning [15-17]. In the context of physical disorders, previous studies have noted the benefits of using occupational therapy in various conditions, such as improving the daily activities in people with multiple sclerosis [16] and after hip fractures [17], and to improve mobility skills in people with orthopaedic diagnoses [15]. Additionally, extending the rehabilitation program to include occupational therapy for people after SCI allows for increased independence when performing everyday activities [18]. The OT program increases the likelihood of clients returning to independent living and reduces the need for care.
People after SCI are exposed to significant limitations in their daily activities, reducing their independence and hindering self-fulfilment. Rehabilitation conducted by an interdisciplinary team may achieve the expected therapeutic effects due to its focus on functional disorders and, to a lesser extent, on the fact that diagnosis was set according to International Classification of Diseases (ICD) [19]. Providing holistic care based on positive interaction between PT and OT allows for the development of interventions suited to the functional status of the client. Moreover, the scope of the planned activities may be divided between individual professional groups. In this respect, physiotherapists and occupational therapists use similar methods and rehabilitation techniques; for example, both provide therapeutic activities associated with learning to move in bed, training in wheelchair mobility, equipment assessment, introducing range of motion exercises, strengthening exercises, balance training and stretching [20]. The use of this type of intervention is often distinguished only by the specific goals for a given discipline.
Currently, many studies indicate the need to provide multidisciplinary care for people after SCI [19,21,22]. However, while ensuring appropriate cooperation is a frequently-discussed topic, incorporating it into clinical practice may be difficult [21]. Perhaps because occupational therapy is a dynamically-developing field of health care, it is not widely understood among medical workers: practitioners in Poland most often associate OT with art therapy. In addition, those in other countries also appear to have an incomplete understanding of the scope of OT [23-25]. Respondents in the United States appear to have limited knowledge about the role of orthopedic surgery residents [23] and students of medicine and health sciences in Nigeria demonstrated poor or moderate knowledge about the profession, roles and working conditions of occupational therapists [24]. A study of professionally-active medical workers showed that physiotherapists had more knowledge about occupational therapy than doctors and nurses, but all three groups displayed limited knowledge in this regard [25]. Such an incomplete understanding of the roles and tasks performed by occupational therapists may limit cooperation and make it more difficult to refer potential clients [24].
However, special attention should be paid to the quality of the cooperation between the interdisciplinary team. It should take place throughout the entire patient improvement process and not only be limited to the division of tasks. With proper communication, many specialists can offer mutual support for achieving their goals, e.g. by introducing changes in the implemented interventions. Moreover, cooperation between physiotherapists and occupational therapists allows a greater number of repetitions to be performed, which is often lower than recommended by the literature [22]. By engaging in a constant exchange of observations and joint development of recommendations, it is possible to increase the sense of care and trust in professionally-qualified staff among our clients.
Future studies should endeavour to describe the cooperation between all interdisciplinary team members on a larger group of clients. Such works should include the responsibilities of doctors of various specialties, such as physiotherapists, occupational therapists, the nursing team, and psychologists. Research indicates that cooperation with other professional groups, e.g. neurologists, is often lacking [19]. It is beneficial to include representatives of other specialties, as this considerably increases the potential to provide a better level of care. It would also be advisable to conduct further research on the understanding of the profession of occupational therapist, and its roles and tasks, in countries with different cultural backgrounds.

Conclusions

The process of rehabilitation after cervical spinal cord injuries is a long-term and complex process. In order to achieve the intended effects, physiotherapists and occupational therapists often use similar methods and work practices. Proper communication and cooperation between PT and OT allows for more intense and complementary activity. Well-functioning cooperation is necessary to achieve the intended therapeutic effects.

Funding

This research received no external funding.

Conflicts of interest

The authors declare no conflict of interest.

References