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Rehabilitation after a Spinal Cord Injury. Tom Kiser MD Assistant Professor UAMS Dept of PM&R Medical Director Arkansas Spinal Cord Commission. Objectives. History of SCI Neurologic recovery after SCI Rehabilitation Process for SCI Advances in Rehabilitation for SCI. - PowerPoint PPT Presentation
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Rehabilitation after a Spinal Cord Injury
Tom Kiser MD
Assistant Professor
UAMS Dept of PM&R
Medical Director
Arkansas Spinal Cord Commission
Objectives
• History of SCI
• Neurologic recovery after SCI
• Rehabilitation Process for SCI
• Advances in Rehabilitation for SCI
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.”
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.
Systems effected by SCI
• Cardiovascular• Integumentary• Gastrointestinal• Metabolic• Neurologic• Musculoskeletal
• Urologic• Psychosocial• Sexuality• Respiratory
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
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.
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
Neurologic recovery after SCI
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.
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.
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
Neuroanatomy
Zejdlik CP. Management of SCI 2nd ed. 1992
Recovery of 3/5 strength
Wu etal. J Am paraplegia Soc 14:93; 1991. Mange et al. Arch Phys Med Rehabil 73:437; 1992.
Rehabilitation Process for SCI
Rehabilitation
Rehabilitation
Physical Therapy
• Acclimate to upright position• Sitting balance - supported and
unsupported• Bed mobility• Transfers• Wheelchair mobility• Upper Extremity ROM and strengthening• Pressure Relief
Propped Sitting
Nawoczenski et al. Physical Management. In SCI: Concepts and ManagementApproaches. 1987
Sitting Balance
Nawoczenske et al. Physical Management. In SCI: Concept and ManagementApproaches. 1987
Short Sitting
Nawoczenski et al. Physical Management. In SCI: Concepts and ManagementApproaches. 1987
Sliding Board
Nawoczenske et al. Physical Management. In SCI: Concepts and Management Approaches. 1987.
Sliding Board Transfer
Nawoczenski et al. Physical Management. In SCI: Concepts and management Approaches. 1987.
Wheelchair Sitting
Pressure Relief
Zejdlik CP. Management of SCI 2nd ed 1992.
Occupational Therapy
• Upper extremity activity
• Neuromuscular electrical stimulation
• Neurofacilitation techniques
• Feeding• Grooming
• Dressing• Bathing• Toileting• Driving evaluation
and training
Assistive devices
Nawoczenski et al. Physical Management. In SCI: Concepts and ManagementApproaches. 1987
Tenodesis
Zejdlik CP. Management of SCI 2nd ed. 1992
Tenodesis Assist
Zejdlik CP. Management of SCI 2nd ed. 1992.
Orthotic Devices
Zejdlik CP. Management of SCI 2nd ed. 1992
Functional Triad
Dittuno JF, Graziani V. Rehabilitation Report 5:1-4, 1989
Advances in Rehabilitation for SCI
Free Hand System
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.
VoCare System
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.
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)
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
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
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
Questions?
Zejdlik CP. Management of SCI 2nd ed. 1992.