The Physiatric Role in Spinal Cord Tumor Rehabilitation and ...

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The Physiatric Role in Spinal Cord Tumor Rehabilitation and ...

  1. 1. The Physiatric Role in SpinalThe Physiatric Role in Spinal Cord Tumor Rehabilitation andCord Tumor Rehabilitation and Pain ManagementPain Management Christine M. Villoch, MD
  2. 2. Physiatrist  Oh, a psychiatrist?  Oh, a podiatrist?  Oh, superman’s doctor!
  3. 3. Physiatric Approach  Holistic  Chronic Illnesses (traumatic brain injury, strokes, spinal cord injuries, etc.)  Function Physical Emotional  Pain Management
  4. 4. Spinal Cord Tumors
  5. 5. Frequency  Incidence: 1.1 case per 100,000 persons  15-20% of all CNS tumors occur in the spine  Intramedullary lesions comprise approx. 2- 4% of all CNS neoplasms
  6. 6. Anatomy of the Spinal Cord
  7. 7. Spinal cord tumor types  Extradural  Intradural intramedullary  Intradural extramedullary
  8. 8. Myelopathy  Any neurological deficit related to the spinal cord itself; frequently due to compression of the spinal cord by osteophyte or extruded disc material and infrequently by spinal cord tumors
  9. 9. Common symptoms  Pain, occurring at night when laying flat  Local or radiating pain  Progressive weakness & numbness in arm or legs  Impaired bowel or bladder function  Impotence
  10. 10. Key Findings of Pressure on Cord  Brisk muscle stretch reflexes, especially if greater in the legs  Tight leg muscles, worse as you test rapid passive ROM  Clonus (bouncing of the ankle involuntary after stimulus) Babinski (up-going or fanning toes after stimulus)  Hoffman’s (involuntary finger/thumb twitch after stimulus)  Poor balance (hard to walk a tandem gait, positive Rhomberg)  Electric sensation down neck or into both arms on neck extension or flexion
  11. 11. Surgical Options  Laminectomy  Resect Tumor  +/- Fusion
  12. 12. Side Effects of Resection  Numbness/Tingling  Weakness  Bladder and bowel dysfunction  Sexual dysfunction  Spine Instability  Chronic Pain
  13. 13. Pain  “An unpleasant sensation, occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder.” - Webster’s Dictionary  “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” – Int’l Assoc for the Study of Pain
  14. 14. What does that Mean?  Pain is Biopsychosocial  Biologic Factors - Actual Physical Diagnosis  Social Factors  Psychologic Factors
  15. 15. Types of Pain  Muscular  Overuse  Weakness  Spasticity  Neuropathic (central or peripheral)  Pain caused by nerve injury or disease, or involvement of nerves in other diseases processes such as tumor or inflammation: may occur in periphery or CNS  Central Pain  Pain originating in the CNS (spinothalamocortical pathway)
  16. 16. Characterization of Pain  Muscular Dull, achy, sore Cramp-like  Neuropathic Sharp, electric, pins and needles, burning
  17. 17. Central Sensitization  Amplification of excitability of neurons within the CNS  Release of signal molecules  Lowers activation threshold and opening of ion channels, increasing excitability of neurons.  Therefore, normally minimal inputs begin to activate the neurons causing allodynia or hyperalgesia  Hypersensitivity - Acute Phase  Late Phase – Transcriptional changes within the neurons
  18. 18. Central Sensitization
  19. 19. Neuropathic Pain  Allodynia Pain from nonpainful stimuli  Hyperalgesia Excessive pain from normally painful stimuli  Complex Regional Pain Syndrome
  20. 20. Myofascial Pain Syndromes  Spot tenderness  Taut band  Pain Recognition by the patient  Causes Overuse Poor body mechanics
  21. 21. Types of Pain  Mechanical/Structural  Post-surgical  Laminectomy  Instability  Lack of Muscle Attachments
  22. 22. Where does the role of physiatry fit in?  Coordinating Care (PT, OT, Social Work, Psych)  Patient Education  Pain Management
  23. 23. Fundamental Goals of Rehab  Restore structural integrity  Restore function  Quality of Life
  24. 24. Physiatric Treatment of Pain  PT/OT  Medications  Therapeutic Injections Trigger Point Injections Botox/Myobloc Joint Injections Spinal Injections
  25. 25. Treatment Options  Psychology  Relaxation techniques  Biofeedback  Alternative Medicine  Acupuncture
  26. 26. Physical Therapy  Posture  Desensitization  TENS unit  Range of Motion  Myofascial release  Strengthening
  27. 27. Medications  Non-Steroidal  Aleve, Ibuprofen, Diclofenac, Celebrex, etc  Neuropathic Meds  Lyrica, Cymbalta, Neurontin, Tricyclics  Muscle Relaxants  Valium, Baclofen, Flexeril, Skelaxin, Soma, Valium  Opioid-like  Ultram  Opioids  Lidoderm patches, Capsaicin  Sleep Aids
  28. 28. NSAIDS  Decrease Inflammation  Analgesic Effects
  29. 29. Anti-Depressants  Elavil, Nortripytline,  Cymbalta
  30. 30. Anti-Convulsants  Neurontin  Lyrica  Trileptal
  31. 31. Opioid Medications  Tolerance - same dose, less effective  Addiction - compulsive use of drug resulting in dysfunction  Pseudo-Addiction - Drug seeking behavior due to under-treatment  Drug dependence - withdrawal symptoms
  32. 32. Therapeutic Injections  Trigger point injections  Botox/Myobloc injections Loosens muscles  Spinal joint (facet) injections
  33. 33. Psychology  Subjective Component  Supportive Counseling  Cognitive/Behavioral Techniques Biofeedback Relaxation Techniques Improving Sleep Hygiene
  34. 34. Summary  Physiatry Holistic Approach Rehab Needs Pain Management  Spinal Pain Multifactorial Many different treament options
  35. 35. Useful Resources  www.spineuniverse.com  www.aapmr.org

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