Spinal Cord Injury Community Follow-up

Role of the Physical Therapist

KATHLEEN A. CURTIS
and KARYL M. HALL

This study was conducted over a 14-month period to assess the physical therapy
intervention needs of 201 patients who attended monthly spinal cord injury (SCI)
outpatient clinics conducted in three outlying local communities of northern
California. Methods to identify and provide appropriate physical therapy services
for the patients were explored. An experienced physical therapist from a regional
SCI center and other clinic staff members screened the patients and identified
66 patients (33%) who needed physical therapy services, including evaluation
(82%), patient education (62%), and referrals to appropriate local health care
professionals or equipment vendors (52%). Losses of joint range of motion,
changes in sitting posture as a result of increased muscle tone or contracture,
and malaligned or misfitting lower extremity orthoses were identified as problem
areas not commonly recognized in routine follow-up examinations. Recommen-
dations based on our study findings included the use of a screening form for
physical therapy needs at each clinic, improved patient education about the role
of the physical therapist as a resource person during follow-up care, coverage
for each of the three clinics on a biannual basis, and continued study of the
mechanisms used by other SCI centers to fulfill the outpatient needs of their
patients. Physical therapy involvement in SCI follow-up services can maximize
efficient use of our health care resources and provide early identification and
management of specific postdischarge needs.
Key Words: Physical therapy, Spinal cord injury.

The goal of the spinal cord injury (SCI) rehabilitation
process is to prepare the individual for life after discharge with
a maximal level of functional independence and the necessary
resources and modifications to assist in returning to the
family, home, school, or work environment.1 Follow-up stud-
ies of SCI patients indicate that medical problems frequently
encountered postdischarge include noncompliance with self-
care routines or medication schedules, joint contractures, skin
breakdown, edema, bowel problems, spasticity, pain, bladder
management problems, diaphoresis, and insufficient home
health services.2 Social and environmental problems also are
reported, including architectural barriers, insufficient or mal-
functioning equipment, financial difficulties, and inappro-
priate dependence on others.2 The postdischarge functional
skills of SCI patients frequently improve.3-5 Few patients with
complete SCIs at T5 or below, however, continue lower
extremity orthotic use for functional purposes after discharge.6
The literature reveals little information on the postdischarge
use of physical therapy services by the SCI patient. Patient
education programs frequently address physical therapy con-
cerns such as prevention of joint contractures, prevention of
respiratory complications, and achievement of maximum
Ms. Curtis is Director and Educational Services Consultant, Health Direc-
tions, PO Box 491116, Los Angeles, CA 90049 (USA). She was Education
Coordinator and Supervisor, Spinal Cord Injury Service, Physical Therapy
Department, Santa Clara Valley Medical Center, at the time this article was
written.
Dr. Hall is with the Department of Rehabilitation Medicine, Veteran's
Administration Medical Center, Palo Alto, CA. She was Co-Director, Northern
California Regional Spinal Injury System, Santa Clara Valley Medical Center,
San Jose, CA, at the time this article was written.
This article was submitted April 2, 1985; was with the authors for revision 16
weeks; and was accepted January 9, 1986.
function in skills of daily living and vocational pursuits.1
Approaches to follow-up care commonly involve physical
therapy intervention only when problems are noted in one of
these areas. Fragmentation in the follow-up care of the SCI
patient frequently leads to management that is inappropriate
to the chronic nature of the disability and to frustration for
the patient and his family.7
SPINAL CORD INJURY OUTREACH
CLINIC SYSTEM
Our regional SCI center serves a geographical area that
includes north-central California, southern Oregon, and west-
ern Nevada, with an estimated population of 9 million indi-
viduals and an estimated SCI population of 1,800 individuals.
This region includes heavily populated urban and suburban
areas, as well as extensive, sparsely populated rural and agri-
cultural areas.
The regional SCI system sponsored and staffed monthly
SCI outreach clinics in one of three outlying community
hospitals for the six years before the study was initiated. These
clinics were instituted to provide comprehensive outpatient
SCI follow-up care for those individuals who were unable to
commute to the regional SCI center. Because the area served
is so large, many patients were limited by distance, lack of
transportation, or expense.
Staffing for each clinic routinely included a physician(s), an
occupational therapist, a local public health nurse(s), and an
SCI Project Outreach Coordinator. The SCI outreach clinic
team used automobile or air transportation to travel to the
clinics, which were located within a 120- to 300-mile radius
of the regional SCI center. For two of the clinics, travel also
involved overnight accommodations for the SCI outreach

1370 PHYSICAL THERAPY


clinic team. The SCI outreach clinic team saw an average of
200 patients a year before the study.
The SCI outreach clinic team initially lacked physical ther-
apy representation. When the SCI outreach clinic program
was implemented, the physical therapy department at the
center was understaffed, and experienced staff members were
needed for patient treatment and supervision of physical
therapy services at the SCI center. The physical therapy needs
of many of the SCI patients seen in follow-up remained unmet
and unknown because local physical therapists participated
in the clinics only sporadically. The substantial expense of
providing physical therapy coverage did not justify an SCI
center physical therapist attending the clinics. A local physical
therapist, therefore, could provide clinic services and ongoing
treatment locally, or the SCI center's physician could refer
the patients for physical therapy services locally.
This study was conducted 1) to document the types of
physical therapy services needed in the follow-up care of the
SCI patient and to determine the role of the physical therapist
in providing these services; 2) to document the actual number
of hours of physical therapy services needed at each monthly
SCI outreach clinic and to determine the optimal utilization
of the therapists' time; and 3) to assess the desired involve-
ment, capabilities, and availability of the SCI center's physical
therapists versus local physical therapists in each of the out-
reach clinic areas.
METHOD
We initially contacted the outreach clinic staff members
and participating local physical therapists to explain the ob-
jectives of the project and the potential functions at the clinic
of the physical therapists. An experienced physical therapist
from the SCI center collected data for 14 months at one of
the SCI outreach clinics.
Physical Therapy Services
The SCI center's physical therapist performed essential
services arid recorded information on a data collection form
(Appendix 1) regarding the frequency and time spent provid-
ing evaluative and therapeutic services, making local referrals,
ordering equipment, and providing patient education and
professional consultation. Additionally, the physical therapist
documented the types of physical therapy intervention
needed; the patterns of referral for these services (by patient,
family, other clinic staff member, or initial contact by physical
therapist); the age, sex, and degree of neurological involve-
ment of the patients needing physical therapy services; and
postdischarge problems.
Local Physical Therapy Survey
We contacted local physical therapy department directors
to explain the purposes of the study. The directors completed
a follow-up questionnaire regarding the availability of specific
patient services, potential staff coverage for the SCI clinic,
and capabilities of the local physical therapists to provide SCI
patient care. Written resource materials about SCI treatment
emphasizing appropriate functional goals and the role of the
physical therapist were distributed to all local physical therapy
departments. Local physical therapists were encouraged to
attend the quarterly clinic in their area.
Volume 66 / Number 9, September 1986
RESEARCH
Screening Procedure
The physical therapist briefly screened each patient attend-
ing the clinic to determine whether he required physical
therapy services. The therapist asked the patient to describe
any loss of joint range of motion, increased pain or discom
fort, change in motor or sensory function, malfunctioning
equipment or orthoses, and changes in functional abilities or
endurance.
Referrals to the Physical Therapist
The physical therapist encouraged all clinic staff members
and patients to request physical therapy intervention directly
for any of the above problem areas. The physical therapist
briefly assessed each referred patient and discussed with the
clinic team any active or potential problems of those patients
receiving physical therapy services. Appropriate team mem-
bers agreed on and carried out the plan. Individual physical
therapy records were filed with the patients' other medical
records.
Data Analysis
The data were analyzed by tabulating demographic infor-
mation, referral patterns, and postdischarge problems and by
calculating the total time spent in and frequency of perfor-
mance of physical therapy functions. In addition, we deter-
mined the mean number and percentage of patients seen and
the mean time for each type of physical therapy service
performed.
RESULTS
Of the 201 patients attending the follow-up clinics, 66 (33%)
received the services of the physical therapist. All subsequent
data are described for this group of 66 patients. The group
included 54 men and 12 women with a mean age of 29 years.
Eight patients (12%) were seen more than once during sub-
sequent clinic visits. Forty (61%) of the patients had cervical
lesions, and the remaining 26 patients (39%) had thoracic or
lumbar lesions. One patient had a brain stem lesion in addi-
tion to a cervical SCI; two patients were recovering from
Guillain-Barre syndrome and were functionally incomplete
paraplegics.
Types of Physical Therapy Functions
Evaluation, arranging for referrals, ordering equipment,
and patient education were the functions performed most
frequently by the physical therapist (Table). Fifty-four patients
(82%) were evaluated for at least one problem. Thirty-four
(52%) of the patients required follow-up services. Patient
education was provided for at least one problem for 41 (62%)
of the patients. Consultation was requested by another health
care professional regarding the appropriate plan of care for 19
(29%) of the patients. Actual treatment was initiated at the
clinic for only 12 (18%) of the patients.
The most frequently performed individual functions were
evaluation of ROM, gait analysis, patient education for ROM
or stretching exercises, and referral for physical therapy in the
local community.
Evaluation. Assessment of ROM, gait analysis, and manual
muscle testing were the most frequently performed evaluation
1371
TABLE efficacy of a single treatment required the therapist to refer
Physical Therapist Spinal Cord Injury Outreach Clinic Functions patients to a local physical therapist if ongoing treatment was
indicated.
Average Total
Patientsa Patients
Therapist Functions Time Time
(min) (%) (n) (%) Referral Sources

Evaluation 84 46 54 82
Equipment-referral follow-
up (paperwork-phone) 39 21 34 52
Patient education 32 18 41 62
Professional consultation 17 9 19 29
Treatment 12 6 12 18
TOTAL 184 100 160 —
a
N = 66 (32.8% of the 201 patients screened for physical therapy
needs in the SCI outreach clinic).
functions, involving 32 (49%), 23 (33%), and 12 (18%) of the
patients, respectively. Other procedures included evaluation
for standing equipment (10%), orthotic evaluation (10%),
scoliosis or posture evaluation (8%), endurance evaluation
(8%), and respiratory evaluation (8%). In addition, evalua-
tions of dysphagia, inhibition of muscle tone, back pain, and
edema each were conducted for one patient.
Referral and equipment follow-up. The referral and follow-
up activities primarily involved documentation or telephone
contact to arrange for desired services or equipment locally.
Most of the referrals were for local physical therapy services
and involved 13 (20%) of the patients. The most frequently
reported equipment needs were for the replacement or repair
of lower extremity or spinal orthoses and transcutaneous
electrical nerve stimulation devices. A total of 11 patients
(17%) received services for equipment repair or purchase.
Patient education. Therapist involvement in patient edu-
cation was most frequent in reviewing ROM and stretching
procedures (21%) and in encouraging compliance with the
standing program (14%). Patients routinely received individ-
ualized instruction with written materials and a detailed pa-
tient education manual before discharge from the clinic.
Many patients denied having been instructed previously in
these procedures.
Professional consultation. Local physical therapists were
encouraged to participate in the SCI outreach clinics. Even
though one area consistently scheduled local staff coverage of
its clinic, other priorities, such as inpatient hospital care,
frequently resulted in cancellation of the services of the phys-
ical therapists assigned to the clinic. Effective decision making
and planning, however, was possible because of the sharing
of specialized SCI expertise by the SCI center's physical ther-
apist and the coordination of local resources and appropriate
follow-up services by the local physical therapists. The SCI
center's physical therapist explained the role of the physical
therapist, provided evaluation skills, and recommended
equipment resources to other health care professionals for 19
(29%) of the patients seen.
Treatment Procedures
Of the limited actual treatment that was initiated at the
clinic, the most frequently performed procedures (12%) in-
volved techniques to increase ROM and to improve posture
or positioning. Time constraints, the rapid turnover of pa-
tients examined during the clinic hours, and the limited
The physical therapist made initial contact with 43 (65%)
of the 66 patients. Only 18 (27%) of the patients receiving
physical therapy services were referred initially by the SCI
center's physicians.
Postdischarge Problems
The most common physical therapy problem noted during
the postdischarge follow-up examinations was the patients'
failure to comply with the physical therapy home program (8
patients, 12%). The second most common problem was the
delay in receiving outpatient physical therapy services on the
local level (6 patients, 9%).
Time Requirements for Physical Therapy Services
An average of 184 minutes was spent in direct patient-care
services at each one-day clinic, although the time spent ranged
from as little as 75 minutes at one clinic to as much as 320
minutes at another clinic. Patient attendance varied markedly
with the extremes of weather and ranged from a low of 8
patients to a high of 32 patients. The physical therapist
devoted an average of 38 minutes to each patient.
Local Physical Therapy Survey
Only one of three directors of local physical therapy de-
partments reported that their staff members were trained
sufficiently to meet the physical therapy needs of the SCI
patient. No director could send a physical therapist full time
routinely on the day of the clinic because of staffing shortages.
The average number of SCI patients referred for outpatient
physical therapy at each facility was 7 a year. Many local
physical therapists expressed a need for training in both acute
care skills and community follow-up services. Although most
of them indicated a willingness to learn the needed skills, they
also emphasized the extreme limitations in their available
time.
DISCUSSION
In determining whether physical therapy services are
needed in the follow-up care of the SCI patient, we assume
that the patient's quality of life is improved by the delivery of
these services. Within the scope of this article, however, we
cannot probe the validity of this assumption.
Need for Physical Therapy Services
The results of our study indicate that physical therapy
intervention is needed in the areas of evaluation, referral, and
patient education. Actual evaluation and treatment services
can be provided by a physical therapist with some training in
SCI treatment techniques. The decision-making functions of
problem identification, goal setting, and treatment planning
can be accomplished more effectively by the SCI center's
experienced physical therapist. Inappropriate referrals for gait
training, orthoses fabrication, and maintenance functions can

1372 PHYSICAL THERAPY


be monitored effectively by a physical therapist in attendance
at the SCI outreach clinics. This prevention of inappropriate
treatment may save considerable time and money. The SCI
center's physical therapist can improve the continuity of care
in the rehabilitation process by identifying problems in reach-
ing functional goals after discharge (eg, orthosis malalignment
and inconsistencies in present status and projected goals).
The SCI outreach clinic physical therapist performs a val-
uable function in assessing the need for physical therapy
services as the patient's initial contact, rather than secondarily
to physician referral. Physical therapists are able to recognize
areas in which they have potential influence. Postdischarge
problems, such as orthosis fit or repair and progressive muscle
tone and postural changes often go unrecognized until they
cause major skin breakdown or loss of functional mobility.
This screening function also may be helpful in the early
identification of loss of ROM, chronic pain, or change of
neurological function. These complications often are not no-
ticed until function has been compromised severely.
A close working relationship among the physical therapist,
the physician, and the other team members is necessary to
coordinate and plan the delivery of services. Incorporating
the screening function of the physical therapist into the clinic
routine can improve the efficiency and productivity of the
entire outreach clinic team.
Occasionally, local public health nurses refer new patients
to the clinics. These patients have received their initial reha-
bilitation services at a center other than the regional SCI
center and require follow-up services. Previous medical infor-
mation on these patients frequently is unavailable. A medical
history and a summary of patients' current health status are
required for the SCI center to provide adequate services.
Patient needs often are too extensive to be met in the outreach
clinic situation. Additionally, financial and bureaucratic con-
straints often prevent us from meeting their needs in an
adequate fashion, such as admitting them to the SCI center.
The local public health nurse is instrumental in the delivery
of ongoing medical services to this patient group. Consulta-
tions between the local public health nurse and other members
of the outreach clinic team, therefore, are critical to successful
follow-up treatment in the weeks after the quarterly outreach
clinics.
Role of the Physical Therapist
To provide these services, the SCI outreach clinic's physical
therapist must be a resource person, a consultant, and an
educator. The model we have depicted may be useful in
defining the role of the physical therapist in the follow-up
care of many chronically disabled patient populations. Phys-
ical therapists know best what they have to offer the patient
and the health care community. Competence in physical
therapy evaluation and treatment techniques is not enough
to function effectively in this capacity. The physical therapist
also must be well-informed about SCI research, aware of
technological advances in equipment, assertive in presenting
new ideas to other health care team members, and receptive
to the questions and suggestions of both professionals and
patients. The patient education function may be implemented
est with careful attention to the health-related behavioral
sciences because patient compliance with education efforts
(eg, home programs and prophylactic care) at the SCI center
often was nonexistent.
Volume 66 / Number 9, September 1986
RESEARCH
Time Requirements to Provide Physical
Therapy Services
The actual hours of direct reimbursable patient-care serv-
ices provided by the physical therapists were insufficient to
support financially a full-time physical therapist's attendance
at the SCI outreach clinics. According to the SCI center's
physical therapy department standards, the center's loss of a
therapist for the day was equivalent to the loss of six treatment
hours. The average time spent in the delivery of direct services
was three hours, resulting in a productivity rate of 50%.
Important, nevertheless, are the intangible benefits of the
nonreimbursable services performed by the physical therapists
in the clinic, such as screening patients for potential problems,
educating and interacting with local health care professionals
and the outreach clinic staff, and acting as a liaison for the
transfer of information between the clinics and the SCI center.
Physical Therapy Staffing of Spinal Cord Injury
Outreach Clinic
Spinal cord iniury center physical therapist. Direct involve-
ment of the SCI center's physical therapy staff may lead to a
more realistic appraisal of patient compliance with assigned
therapeutic home-exercise programs and local physical ther-
apy follow-up care. The revision of plans to reflect this aware-
ness ultimately will improve the effectiveness of the SCI
center's patient-education efforts and may prevent ordering
unnecessary and under-used therapeutic equipment (eg,
standing frames, tilt tables, or orthoses).
Nonmedical community resources (community-college
programs, social agencies) are of critical importance to the
SCI patient's postdischarge reintegration. Knowledge of these
resources and a working relationship with liaison staff mem-
bers are helpful in facilitating referrals.
Local physical therapists. Inadequate staffing, rather than
a lack of interest, is the primary factor preventing more
frequent and consistent local physical therapist involvement.
When no physical therapist is available at the clinic and when
physician-initiated referral is the only means of physical ther-
apy involvement, the patient may not receive needed services
and may receive (and pay for) unneeded or inappropriate
services. Additionally, the SCI center's physicians often are
inaccessible to local physical therapists. The distance between
the SCI center and the outlying areas often limits communi-
cation and prohibits an atmosphere conducive to team partic-
ipation.
An optimal model arrangement is for a local physical
therapist and the SCI center's physical therapist to participate
in the clinic together, thereby providing consultation and
education while facilitating local follow-up physical therapy
care. At a minimum, the SCI center's physical therapist should
provide written materials and maintain periodic contact with
the local physical therapy staff.
Recommendations
To maximize the use of physical therapy services at the SCI
outreach clinics, we recommend the following:
1. Establish a check list-format screening tool for use at the
clinics to identify problems such as orthotic, postural, or
functional changes and loss of ROM or neurological func-
tion (Appendix 2).
1373
2. Schedule new patients for full evaluations at the regional
SCI center before a referral to a follow-up clinic.
3. Communicate with patients before the outreach clinics to
determine their potential needs for physical therapy. This
contact could maximize appointment scheduling, coordi-
nation, and the availability of necessary equipment at the
clinics for subsequent evaluations.
4. Provide more education to inpatients about the appropriate
use of outpatient physical therapy services, especially warn-
ing signs (changes in seating posture, gait instability or
change in speed, loss of ROM or neurological function), to
facilitate timely self-referral.
5. Continue to study methods to meet outpatient needs in the
context of our third-party payment system and growing
economic constraints and from the perspective of patients
and other health care professionals. Alternative models of
providing outpatient follow-up physical therapy services
should be developed for patient populations with chronic
disabilities. Physical therapy administrators must not con-
sider potential reimbursement for services as the only meas-
ure of the worth of a physical therapist as a team member
in the clinic situation. Further research also might focus on
the physical therapy needs of the aging SCI patient group.
CONCLUSIONS
Physical therapy involvement in SCI follow-up care serves
a previously unmet need in the SCI outpatient health care
system. Physical therapists skilled in SCI care should continue

APPENDIX 1
Data Collection Form Content

NCRSIS Outreach Clinic

Summary of Time Spent Providing Physical Therapy Services

1. Evaluation at clinic f. Other

a. Range-of-motion evaluation g. Other
b. Manual muscle testing h. Other
c. Standing evaluation 6. Professional consultation-education
d. Orthotic evaluation a. Explaining role of physical therapy
e. Gait analysis b. Attendant training
f. Endurance evaluation c. Evaluation skills
g. Scoliosis-posture evaluation 1. Describe
h. Respiratory evaluation 2. Describe
i. Other d. Treatment skills
j. Other 1. Describe
2. Treatment initiated at clinic 2. Describe
a. Range-of-motion-stretching exercises e. Equipment resources
b. Respiratory exercises 1. Describe
c. Endurance training 2. Describe
d. Strengthening exercises 7. Neurological level of each patient receiving physical therapy
e. Standing program services
f. Gait training 8. Contacts or referrals to outreach clinic physical therapist for
g. Posture-positioning patient care services initiated by:
h. Other a. SCVMC physical therapist (self)
i. Other b. Local physical therapist
3. Patient education (instruction of patient-family or attendant) c. SCVMC occupational therapist
a. Range-of-motion-stretching exercises d. Local occupational therapist
b. Respiratory exercises
e. SCVMC physician or nurse
c. Endurance training
f. Local physician or nurse
d. Strength training
e. Weight control g. NCRSIS staff
f. Standing program h. Patient
g. Transfer techniques i. Other
h. Posture-positioning 9. Observation of postdischarge follow-up problems
i. Other a. Delays in receiving outpatient physical therapy services (phys-
j. Other ical therapist- or patient-caused)
4. Local referrals made b. Poor follow-through with home program
a. Physical therapy c. Attendant not trained
b. Occupational therapy d. Inappropriate use of professional physical therapy services
c. Orthoses-prostheses e. Not aware of community resources
d. Community college program f. Other
e. Public health nurse follow-up g. Other
f. Other h. Other
g. Other 10. a. Total patients receiving your services at clinic:
h. Other Evaluation
5. Equipment ordered Treatment
a. Standing frame Patient education
b. Tilt table Referrals
c. Lower extremity orthosis b. Total patients seen at clinic
d. Spinal orthosis or corset c. Patient seen for physical therapy research purposes only
e. Transcutaneous electrical nerve stimulation 11. Other comments on utilization of physical therapy services

1374 PHYSICAL THERAPY

 RESEARCH

their interdisciplinary-team involvement to make the most REFERENCES

efficient use of our health care and patient-family resources.
Physical therapists are valuable resources to patients and to
other health care professionals in the outpatient SCI follow-
up system. A physical therapist trained in the care of the SCI
patient is able to minimize inappropriate referrals for equip-
ment and outpatient physical therapy services. Local physical
therapy departments often are staffed inadequately or lack
the resources to fulfill this function. Our recommendations
include a biannual staffing of clinics with preclinic screening
by telephone, improved patient education for self-referral,
and continued study of methods to meet the outpatient needs
of this patient population.
1. Pierce DS, Nickel VH (eds): The Total Care of Spinal Cord Injuries. Boston,
MA, Little, Brown & Co Inc, 1977
2. Better SR, Fine PR, Celes GW, et al: Complications among spinal cord
injury patients following discharge. Rehabilitation Nursing 4:8-10,1979
3. Bracken MB, Hildreth N, Freeman DH, et al: Relationship between neuro-
logical and functional status after spinal cord injury: An epidemiological
study. J Chronic Dis 33:115-125,1980
4. Forer SK, Miller LS: Rehabilitation outcome: Comparative analysis of
different patient types. Arch Phys Med Rehabil 61:359-365,1980
5. Rogers JC, Figone JJ: Traumatic quadriplegia: Follow-up study of self-care
skills. Arch Phys Med Rehabil 61:316-321,1980
6. Mikelberg R, Reid S: Spinal cord lesions and lower extremity bracing: An
overview and follow-up study. Paraplegia 19:370-385,1981
7. Jacobs BW, LaMantia JG: Lifetime follow-up care. Model Systems Spinal
Cord Injury Digest 4:51-55,1982

APPENDIX 2
Spinal Cord Injury Outreach Clinic Physical-Occupational
Therapy Screening Form

Spinal Cord Injury Clinic

Physical-Occupational Therapy Needs

Name Date

In the past year: Yes No Comments

1. Have you noticed increased difficulty in moving arms, legs,

neck?
2. Have you noticed a change in your sitting position or wheelchair
fit?
3. If you are on a standing program, have you noticed a change
or trouble in getting into the standing position?
4a. If you wear braces or splints, are there any red areas on your
skin?
4b. Are your braces or splints broken?
4c. Are you using your braces or splints at least once a day?
5. Can you not do something you could do when you were
discharged from rehabilitation? (Have you lost any functions
such as dressing-feeding yourself, self-care, transfers, hand
skills, standing, or walking?)
6a. Are there things you might be able to do independently with
more training?
6b. Have you noticed return of muscle strength or movement?
7. Is any of your equipment (wheelchair, braces, splints) in need
of repair or replacement?
8. Are you noticing shortness of breath or fatigue after light
activity?
9. Is there any problem that you would like to discuss with a
physical therapist or occupational therapist?
10. Is there any other area of concern we have left off this list?
11. For our future programs with spinal cord injured patients, are
there any areas that you feel should have been stressed
more or were left out of your physical or occupational therapy
program during your initial rehabilitation?

Physical-Occupational Therapy Action Taken:

OTR or RPT signature Date

Volume 66 / Number 9, September 1986 1375