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Spinal Cord Injury - Suranjan Bhattacharji

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Spinal Cord Injury - Suranjan Bhattacharji

  1. 1. SCI - Rehabilitation Dr George Tharion Dr Suranjan Bhattacharji
  2. 2. Dr Mary Verghese and Dr Howard Rusk (1962)
  3. 3. Initial Evaluation • Determine Neurological level (ISNCSCI, ASIA scale) • Look for complications (DVT, HO, Pressure sores) • Evaluate residual strengths • Set appropriate short and long term goals with patient and relatives
  4. 4. FUNCTIONAL ABILITIES AT DIFFERENT (complete) SPINAL LEVELS IN TETRAPLEGIA Levels Indoor Mobility ADL Others C1-C4 (Powered w-chair) (Partial indep with UL FES) Mouth bar for page turning, writing (Ventilator / Phrenic Nerve Stimulation) C5 Powered w-chair with special controls / attendant propelled w-chair Some independence (with FES) / MAS & hand splints for eating, writing, computers / Tendon transfers (Standing Table / splints) Outdoor mobility in special vehicle, IDC for bladder C6 Self propelled w-chair +/- capstans / powered chair with joystick controls Can be independent with setup, +/- Splints / Deltoid to Triceps transfer (Standing Table) Car transfers with transfer board, males can do SICC C7,8,T1 Self propelled w-chair Independent with setup and home modifications BKAFOs /Standing Table (Drive an adapted car)
  5. 5. FUNCTIONAL ABILITIES AT DIFFERENT (complete) SPINAL LEVELS IN PARAPLEGIA Levels Indoor Mobility ADL Others T2-T7 Self propelled w-chair (RGO/HGO + Walker/ EC) Independent with home modifications BKAFOs + Walker Self-propelled Tricycle T8-T12 BKAFOs + ECs (Self propelled w- chair) Independent with home modifications Self-propelled Tricycle / Public transport L1,2 BKAFOs + ECs Independent with home modifications Public transport L3,4 BAFOs + ECs / canes Independent - L5,S1 +/- BAFOs +/- canes Independent -
  6. 6. Strengthening residual muscles • Can start as soon as patient is haemo- dynamically stable and can co-operate, but remember safety first • Leave equipment with patient to encourage self directed restoration (sandbags, weights: plastic water bottles, rubber tubing thera-bands, etc)
  7. 7. Mobilisation • Prone trolley, wheeled bed, wheelchair as appropriate • Cervical collars / halo-vest for Tetraplegics • Taylor-Knight brace (TLSO), Lumbar corset (LSO) for Paraplegics • Start Tilting when spine is stable
  8. 8. Orthostatic Hypotension • Graduated Tilting, slower for higher lesions • Abdominal binders, • Elastocrepe bandages for both lower limbs • Tab Ephedrine 15 - 30mg PO half hour before tilting • Tab Fludrocortisone 0.1mg PO
  9. 9. Skin care and pressure sore prevention • Crucial first step for patient, family and Rehab nurse • Use of hand mirror and ‘sensate’ limb • Pressure relief in lying down position: supine, prone, side lying (Sacrum, trochanters, heels, occciput) • Pressure relief in sitting position (ischium, elbows) • Pressure relief in standing position (heels, sole & toes)
  10. 10. Wheelchair training • Order wheelchair by seat height, seat length (depth), pelvic width, height of backrest, armrest, self propelled/powered • Order wheelchair cushion • Teach sitting balance, weight relief, transfers, speed and endurance, rough ground wheeling, curbs, wheelies
  11. 11. Ambulation • Determined by Neuro level, motivation, age, BMI, general health, spasticity, limb length discrepancy etc. • KAFO with custom moulded SA-AFO in 10 deg dorsiflexion • Reciprocal walker, EC with hinged forearm cuffs • Target walking speed of 20m/min and endurance of 500m for functional walkers
  12. 12. Neurogenic bladder • Check upper tracts with Ultrasound initially • Check lower tracts with Cystourethroscopy when needed • After urine culture and sensitivity, under appropriate antibiotic cover, start attendent ICC early to preserve the urinary tract and save money • Change to SICC as soon as feasible
  13. 13. Medications for Bladder voiding dysfunction • Evaluate using Urodynamics (Cystometrogram and UPP) after eliminating UTI • Evaluate using Transrectal ultrasound / voiding cystogram • Tricyclic antidepressants (Amitriptyline 25 mg PO) for closing the bladder neck • Alpha adrenergic antagonists (Prazocin 1mg PO) for opening the bladder neck
  14. 14. Antimuscarinic medications for Bladder storage dysfunction DRUG Initial Dose Half life (Hrs) Adverse effects COST per Dose Oxybutynin 5mg (ER) 12-16 Dry mouth 61%, constipation 13% ₹ 9 Tolterodine 2mg (ER) 3.7-9.6 Dry mouth 23%, constipation 6% ₹ 8.75 Solifenacin 5mg 40-68 Dry mouth 27%, constipation 13% ₹ 19 Darifenacin 7.5mg 13-19 Dry mouth 35%, constipation 21% ₹ 16 Trospium 20mg 20 Dry mouth 20%, constipation 9.6% ₹ 10 Fesoterodine 4mg (ER) 7 Dry mouth 34%, constipation 6% ($2.2)
  15. 15. Neurogenic Bowel • High fibre diet +/- Psyllium or Ispaghula • If sacral reflexes present, digital stimulation or Bisacodyl suppositories • If sacral reflexes absent, abdominal pressure in the sitting position or digital evacuation • Check digitally for complete evacuation • Complications: Constipation and Spurious diarrhoea
  16. 16. SPINAL CORD INJURY INDEPENDENCE MEASURE (SCIM VERSION III) ACTIVITIES OF DAILY LIVING SCORE SUB TOTAL SELF CARE (0-20) Feeding (0-3) Bathing Upper body (0-3) Lower body (0-3) Dressing Upper body (0-4) Lower body (0-4) Grooming (0-3) RESPIRATION AND SPHINCTER MANAGEMENT (0-40) Respiration (0-10) Sphincter management: Bladder (0-15) Sphincter management: Bowel (0-10) Use of Toilet (Perineal hygiene, adjust clothes, diapers etc) (0-5)
  17. 17. SPINAL CORD INJURY INDEPENDENCE MEASURE (SCIM VERSION III) ACTIVITIES OF DAILY LIVING SCORE SUB TOTAL MOBILITY (ROOM AND TOILET) (0-10) Mobility in bed and action to prevent pressure sores (0-6) Transfers: bed - wheelchair (0-2) Transfers: wheelchair - toilet (0-2) MOBILITY (INDOORS AND OUTDOORS, ON EVEN SURFACES) (0-30) Mobility indoors (0-8) Mobility for moderate distances (10-100m) (0-8) Mobility outdoors more than 100m (0-8) Stair management (0-3) Transfers: wheelchair - car (0-2) Transfers: wheelchair - floor (0-1) TOTAL (Admission / Re-assessment / Discharge) (100)
  18. 18. Sexuality and reproductive issues • Our duty to support re-integration into the family • Initially give permission for questions/concerns by individuals or discussion in groups and ensure they get limited but accurate information • Provide opportunity for counselling for patient and partner that promotes a positive body image and encourages a respect for one’s body after SCI • Then, when patient is ready, offer specific suggestions and intensive therapy and protect their confidentiality
  19. 19. Erectile dysfunction • Vacuum devices • Phosphodiesterase-5 inhibitors • Intracavernosal injections • Implantable penile prosthesis
  20. 20. Male Fertility • Semen quality and quantity affected by UTI, epididymo-orchitis, • Vibrector • Electroejaculation • Assisted Reproduction
  21. 21. Female fertility and reproduction • Advice regarding menstrual health • Advice regarding Birth control • Pregnancy and UTI • Labour and Autonomic dysreflexia
  22. 22. Reactive depression • Grief reactions and reactive depression are common • Remember denial, anger, bargaining, depression and acceptance of devastating disability are but stages • Use individual and group psychotherapy • Tricyclic and SSRI Antidepressants are useful
  23. 23. Spasticity • Can be useful • Treat complications like DVT, pressure sores, UTI, urinary calculi and heterotopic ossification first • Diazepam, Baclofen, Dantrolene and Tizanidine are useful • POP casts, Phenol or Botulinum injections and surgery have their place
  24. 24. Autonomic dysreflexia • Headache + sweating +/- chest pain in the presence of acute hypertension and bradycardia • In patients with lesions above D7, after spinal shock when reflex activity in the isolated cord returns • Remove the painful stimulus, elevated the head end of the patient • Sublingual Nifedipine 10mg
  25. 25. Neuropathic pain • Common problem and difficult to treat • Treat complications increasing nociceptive stimulus to the isolated spinal cord • Encourage exercises and activities like sports, games, standing, walking etc • Combinations of Antidepressants and Anticonvulsants work better than individual medications
  26. 26. Home modifications • Assess existing home by home visit, if possible • Encourage building a ramp for the front entrance, slope preferably 1:10 • Doors 90cm wide (at least 81.5cm for manual wheelchairs and 86.5 cm for powered chairs) • Electrical switches 91.5 cm from the floor
  27. 27. Vocational Rehab and reintegration into their community • Assess if patient can return to original vocation with adaptations • If not, assess patients residual strengths and interests and the job opportunities in their hometown or village and retrain for a new vocation • They may need startup assistance • Activities to encourage gradual reintegration into their own community are helpful
  28. 28. Life long follow-up • Life long follow-up to prevent complications of severe disability (altered Glucose tolerance, dyslipidemia, osteoporosis, CKD etc) • Get equipment like wheelchairs/KAFOs/crutches repaired or replaced • Encourage sports, games and avocational activities • Encourage restoration through participation in the lives of others and overcome shyness about large group activities
  29. 29. Grateful acknowledgement to Mary Verghese Institute of Rehabilitation, PMR department, CMC, Vellore
  30. 30. Thank you for your attention. 30
  31. 31. The view from my window
  32. 32. Can you see the ordinary people?
  33. 33. FES in SCI • FES for Upper Limb function: Implanted 1st Gen - FreeHand: stopped in 2001. Implanted 2nd Gen - Implanted Stimulator Telemeter (IST)-12. Surface NESS ( Compex http://case • FES for Lower Limb function: Implanted - for standing, transfers, walking (Trunk, GMax, Quads, Ankle PF/DF). Surface - Cycling for exercise. Hybrid Orthosis: FES + Exoskeletal bracing for walking and stair climbing
  34. 34. FES in SCI • Walk again project -Miguel Nicolelis, M.D., Ph.D., São Paulo, Brasil became well known when Pinto using VR and exoskeleton kick started the FIFA World Cup in 2014 • Worked with Duke Univ, in 8 patients, used a Virtual Reality (VR) environment to control an Avatar version of themselves and make it move around a soccer field, used a long sleeve T-shirt for haptic feedback to forearms simulating sensation of touching the ground, the arms being used as phantom limbs substituting the legs, fooling the brain into feeling that the patient was walking. Then used an Exoskeleton + FES + VR cap to pick up signals and relay them to the computer in the backpack. • Intraspinal Micro Stimulation for Gait Restoration uses smaller currents and stimulates pools of neutrons to restore Gait
  35. 35. FES in SCI • FES for Trunk control and Posture stimulation of the Quadratus Lumborum to straighten the spine and improve upper limb function by providing a stable base, allow returning from forward lean without using the arms. • FES for Diaphragmatic pacing for high Tetras • FES for Pressure sore prevention - Deep Tissue Injury (DTI) produces ‘inside out’ sores. Explores prevention by intermittent ES of Glutei (10 Sec every10min). GSTIM stimulates the Inferior Gluteal Nerve. Smart-e-pants uses surface electrodes to prevent sores.
  36. 36. FES in SCI • FES for Lower Urinary Tract (LUT) function to decrease Bladder pressure, prevent Vesico-Ureteric reflux and Autonomic dysreflexia and provide continence and also improve bowel evacuation. • Brindley SARS, started about 35 years ago, used the idea that intermittent stimulation will allow the skeletal muscle to relax, but the smooth muscle will continue to contract; implanted in thousands of patients but requires a dorsal Rhizotomy and a complex operation, so did not spread as widely as hoped • Pudendal Nerve Stimulation is being tried as well
  37. 37. FES and SCI • Ho, Chester H et al, “Functional Electrical Stimulation and Spinal cord Injury” Physical Medicine and Rehabilitation Clinics of North America 25.3 (2014) 631 • Oh, Sun Kyu, and Sang Ryong Jeon, “Current concept of Stem Cell Therapy for Spinal Cord Injury: A Review” Korean Journal of Neurotrauma 12.2 (2016): 40-46 • publications
  38. 38. Go out and change the world