So, you received your patient’s medical history form and there it is. Spinal Muscular Atrophy. If you did what I did, you searched and searched the internet and articles for best practices to treat and evaluate this patient. I found out more information on Spinal Muscular Atrophy and the different levels. I could not, for the life of me, find any examples of exercises or what even to expect of the patient coming in. I work in an outpatient orthopedic facility. There are no neuro outpatient facilities in this area that accept certain insurances. I received my first evaluation with a patient with SMA and he opened my eyes to a whole new way of thinking. I had to get out of my Orthopedic mindset and into my Neuro mind, which had cobwebs and needed some dusting off. Let the evaluation guide your treatment until you become a little more creative with your exercises. Below are some basic tips for your first patient with SMA.
Assess their level of independence. Complete your initial observation, asses their assisted devices, if any, and document. Asses their wheelchair to make sure it’s a proper fit, make sure their cushion is right for what they’re requiring. Is their mode of transportation too limiting for them or is it just right? These are all questions that can be detrimental to the patient if improperly fitted while in the wheelchair.
Assess their level of breathing. Do they require oxygen to breathe? Are they articulating clearly and with ease? Do they require multiple rest breaks in between words? These are all objective measurements that you can create goals for. Focus on goals that engage the diaphragm. Use tactile cueing such as thera-band around the abdominals to initiate diaphragmatic breathing.
Examples include quick, deep diaphragmatic breathing for time; and slow, deep diaphragmatic breathing for time.
Assess their posture. Many patients with SMA require some sort of positioning or postural support from their wheelchair. If, like my initial patient with SMA, they can sit upright independently but require the ability to weight shift to relieve pressure on their buttocks, you must assess every level of independence from the initial evaluation. Make sure they are able to relieve pressure points to avoid any sores. If they are unable to weight shift and relieve the pressure on their hips or legs, then you must make sure they’re in the proper wheelchair that allows them to tilt backwards.
Assess what their goals are for therapy. It’s likely this patient already knows what they want to achieve for physical therapy. Let their own goals guide your treatments. For example, my initial patient with SMA wanted to start working on his posture first. His main goal was to not require assistance while rolling down his ramp from his van. He initially had trouble controlling himself from falling forward. He required one hand assistance from a caregiver to prevent him from falling forward. Now, that we have been in therapy for some time now, he’s able to get down his ramp with ease and no assistance.
When you start strengthening, start proximal joints and muscles first. It’s always more important to focus on postural and stability muscles prior to mobility. It’s important to have the stability in the trunk first, before you focus on upper extremity movements and lower extremity movements. Think about a tree: the trunk has to be strong before the limbs can grow strong.
Example exercises include: isometric cervical forward bending, side bending, and backward bending. Isometric forward trunk flexion while sitting can help engage their core muscles to help support them upright. If your patient is willing and able you can to have them transfer on a table to work on sitting posture while unsupported. Trial and error can happen a lot, assess what they can and can’t do and modify their treatment from there.
Lastly, do not be afraid. You know more than you think you do. I’m sure your patient is wanting and determined to get as much out of rehab as possible. So make it enjoyable as well as constructive.
Laura graduated from the University of Houston, receiving her BS in Kinesiology. She then attended University of St. Augustine, located in St. Augustine, Florida, for Graduate level courses, graduating with dual Masters degrees in Occupational and Physical therapy in August 2011. She received her Doctorate in Physical Therapy in December of 2012. Since January of 2013, Laura has worked in an outpatient setting, and currently serves as a Director of an Outpatient Facility in Irving, Texas. She treats a range of patients, from orthopedic injuries to those with neurological disorders.