Rehabilitation after a Spinal Cord Injury
description
Transcript of Rehabilitation after a Spinal Cord Injury
![Page 1: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/1.jpg)
Rehabilitation after a Spinal Cord Injury
Tom Kiser MD
Assistant Professor
UAMS Dept of PM&R
Medical Director
Arkansas Spinal Cord Commission
![Page 2: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/2.jpg)
Objectives
• History of SCI
• Neurologic recovery after SCI
• Rehabilitation Process for SCI
• Advances in Rehabilitation for SCI
![Page 3: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/3.jpg)
Egyptian Physician circa 2500 BC in Edwin Smith Surgical Papyrus
“One having a dislocation in a vertebra of his neck while he is unconscious of his two legs and his two arms, and his urine dribbles.
An ailment not to be treated.”
![Page 4: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/4.jpg)
History• President Garfield died in 1881 after a gun
shot injury to the conus of his spinal cord went unrecognized. He died 79 days after his injury.
• WW I - a soldier with a SCI died within a few weeks, if they made it home they died within a year.
• General George Patton died in 1945, 2 weeks after a SCI in a MVA.
Yarkony GM. RIC Procedure Manual 1994.
![Page 5: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/5.jpg)
Systems effected by SCI
• Cardiovascular• Integumentary• Gastrointestinal• Metabolic• Neurologic• Musculoskeletal
• Urologic• Psychosocial• Sexuality• Respiratory
![Page 6: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/6.jpg)
Comprehensive Treatment Centers
• U.S. Munro in the 1930’s
• England Guttman in the 1940’s– Coordinated system of care– Decrease of secondary complications– Community reintegration– Provide life-long follow-up
Yarkony GM RIC Procedure manual 1994
![Page 7: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/7.jpg)
Life Expectancy
• Has Improved greatly, from certain death to approximately 10-11 years short of a normal lifespan.– 20 year old person with C5-8 complete
injury• 77% of total life expectancy• 69% of expected years after injury
Devivo MJ. SCI:Clinical Outcomes of Model System. 1995.
![Page 8: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/8.jpg)
Causes of Death
1. Pneumonia
2. Non-ischemic heart disease
3. Septicemia
4. Ill-defined Conditions
5. Pulmonary embolus
6. Ischemic heart disease
7. Suicide
![Page 9: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/9.jpg)
Neurologic recovery after SCI
![Page 10: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/10.jpg)
Monitor Neurologic status
• Incomplete - based on detection of sacral sparing, either motor or sensory.
• Complete - if no sacral sparing.
• Neurologic level of injury - needs to be monitored acutely to ensure a progressive neurologic loss is not missed.
![Page 11: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/11.jpg)
ASIA Impairment Classification
• A. Complete - No Sacral sensory or motor• B. Sensory but no motor below NLI• C. More than half of Key muscles below
NLI have muscle grade <3• D. At least half of key muscles below NLI
have muscle grade > or = to 3• E. Sensory and Motor normal. MSR’s
need not be normal.
![Page 12: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/12.jpg)
Ambulation Potential
• ASIA A 3-6%• ASIA B 50%• ASIA C 75%*• ASIA D 95%* >50 yo 42%, <45 yo 90%. Burns
et al Arch Phys Med Rehabil 1997
Dittuno Functional Outcomes. In Spinal Cord Injury. 1995
0%
20%
40%
60%
80%
100%
ASIA Impairment Classification
Ambulation Potential
ABCD
![Page 13: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/13.jpg)
Neuroanatomy
Zejdlik CP. Management of SCI 2nd ed. 1992
![Page 14: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/14.jpg)
Recovery of 3/5 strength
Wu etal. J Am paraplegia Soc 14:93; 1991. Mange et al. Arch Phys Med Rehabil 73:437; 1992.
![Page 15: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/15.jpg)
Rehabilitation Process for SCI
![Page 16: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/16.jpg)
Rehabilitation
![Page 17: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/17.jpg)
Rehabilitation
![Page 18: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/18.jpg)
Physical Therapy
• Acclimate to upright position• Sitting balance - supported and
unsupported• Bed mobility• Transfers• Wheelchair mobility• Upper Extremity ROM and strengthening• Pressure Relief
![Page 19: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/19.jpg)
Propped Sitting
Nawoczenski et al. Physical Management. In SCI: Concepts and ManagementApproaches. 1987
![Page 20: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/20.jpg)
Sitting Balance
Nawoczenske et al. Physical Management. In SCI: Concept and ManagementApproaches. 1987
![Page 21: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/21.jpg)
Short Sitting
Nawoczenski et al. Physical Management. In SCI: Concepts and ManagementApproaches. 1987
![Page 22: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/22.jpg)
Sliding Board
Nawoczenske et al. Physical Management. In SCI: Concepts and Management Approaches. 1987.
![Page 23: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/23.jpg)
Sliding Board Transfer
Nawoczenski et al. Physical Management. In SCI: Concepts and management Approaches. 1987.
![Page 24: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/24.jpg)
Wheelchair Sitting
![Page 25: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/25.jpg)
Pressure Relief
Zejdlik CP. Management of SCI 2nd ed 1992.
![Page 26: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/26.jpg)
Occupational Therapy
• Upper extremity activity
• Neuromuscular electrical stimulation
• Neurofacilitation techniques
• Feeding• Grooming
• Dressing• Bathing• Toileting• Driving evaluation
and training
![Page 27: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/27.jpg)
Assistive devices
Nawoczenski et al. Physical Management. In SCI: Concepts and ManagementApproaches. 1987
![Page 28: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/28.jpg)
Tenodesis
Zejdlik CP. Management of SCI 2nd ed. 1992
![Page 29: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/29.jpg)
Tenodesis Assist
Zejdlik CP. Management of SCI 2nd ed. 1992.
![Page 30: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/30.jpg)
Orthotic Devices
Zejdlik CP. Management of SCI 2nd ed. 1992
![Page 31: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/31.jpg)
Functional Triad
Dittuno JF, Graziani V. Rehabilitation Report 5:1-4, 1989
![Page 32: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/32.jpg)
Advances in Rehabilitation for SCI
![Page 33: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/33.jpg)
Free Hand System
![Page 34: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/34.jpg)
Hand System
• Combines surgical reconstruction with Implantable FES hand system.
• Seven epimysial electrodes sutured to muscles for grasp and release in forearm and one for sensory feedback near the clavicle.
• Opening and closing and locking controlled by movement of opposite shoulder.
![Page 35: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/35.jpg)
VoCare System
![Page 36: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/36.jpg)
Anterior Sacral Root Stimulator
– S2-S4 detrusor via pelvic nerves (PS) and EUS via pudendal(somatic) nerves.
– Simultaneous contraction of detrusor and EUS
– When interrupted EUS relaxes faster than detrusor.
– Repetitive bursts needed.– Dorsal Sacral Rhizotomy needed to
prevent DSD and AD.
![Page 37: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/37.jpg)
Parastep
• Constant tetanic stimulation to knee extensors during stance.
• Transient stimulation to the common peroneal nerve to obtain a flexion-withdrawl reflex that produces a swing phase of gait.
• Consists of walker, surface electrodes, control switch (activated by fingers)
![Page 38: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/38.jpg)
![Page 39: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/39.jpg)
Activity-based therapy
• Functional Electrical Stimulation bicycling– Enhanced muscle mass– Improved bone density– Improved cardiovascular endurance– Possible reduction of major medical complications– Possible recovery of function
Mcdonald JW Activity-based recovery: from mechanisms to clinical application. Presentation at American Paraplegia Society, Las Vegas 9/3/03
![Page 40: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/40.jpg)
Supported Treadmill Trainer
• Supported harness system• Treadmill with variable control• Benefit in incomplete SCI• Central pattern generator intact• Neuroplasticity felt to be due to weight
bearing and propioceptive input into the spinal cord.
Harkema
![Page 41: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/41.jpg)
Motorized bicycle training
• Passive lower extremity movement with a motorized bicycle in animal model.– Improved lower extremity muscle mass– Decreased spasticity– Improved neurologic function in neurologic
testing (H reflex) in nerve conduction studies.
Garcia-Rill
![Page 42: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/42.jpg)
Questions?
Zejdlik CP. Management of SCI 2nd ed. 1992.
![Page 43: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/43.jpg)
![Page 44: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/44.jpg)
![Page 45: Rehabilitation after a Spinal Cord Injury](https://reader033.fdocuments.net/reader033/viewer/2022061417/56814645550346895db350f6/html5/thumbnails/45.jpg)