Ageing with SCI:physical issues

Daniel Globokar, PRM specialist

University Rehabilitation Institute, Republic of Slovenia

Physical issues-challenges regarding ageing with SCI

• Ageing is inevitable process

• Specific geriatric problems in persons with SCI or secondary health conditions with SCI ?

Physical strain, capacity after SCI

Thomas Janssen-UN Amsterdam 1994 Physical strain and capacity in men with spinal cord injuries

Substantial need for more longitudinal research into physical capacity of persons with SCI in relation to physical strain during ADL activities and health problems.

Younger VS older patients after SCI

• Individual differences in physical capacity!

• Older patients-higher incidence of risk diseases (AH, DM, hyperlipidemia), reduced physical capacity, non-diagnosed hearth decompensation etc

• Adjacent degenerative process of cartilage joints, tendons, connective tissuse, muscles fascias etc.

Secondary health conditions after SCI

Jensen et al, Spinal Cord 2013, 51,

(Scope review of studies from 1986-2011, 92 articles included regarding prevalence, course and associations with age and duration)

Conditions and symptoms reported with 50% or more prevalence and

rated importance to patients

• Pain

• Bowel and bladder regulation problems

• Muscle spasms

• Fatigue

• Hearth burn

• Osteoporosis

Age and duration effect

• Bladder problems and spasms were not found to be associated with duration of SCI

• Cardiovascular disease, diabetes, respiratory complications and fatigue are more prevalent in older patients

• Bone mineral density loss higher in both older persons and with longer duration of SCI

Premature aging hypothesis ?

Preliminary support for the conclusion that older age and longer duration of patients with SCI tend to be associated with more frequent and severe health conditions

Secondary conditions are more frequent in patients after SCI relative to able bodied persons

Limitations of scope review

• Age at injury and year of injury were not included

• Level and severity of the lesions are also related to prevalence, severity and impact of secondary conditions after SCI

• Strong need for longitudinal studies of individual patients !

Preservation of the body

• Reassess the goals of rehabilitation?

Greater focus on ongoing maintenance of optimum health and fitness and maintenance of target systems bellow the level of injury (muculosceletal and cardiovascular system)

MP Galea, Spinal Cord 2012, 50

Muscle tissue after SCI

• Significant atrophy of denervated muscles

• Atrophy occurs in fibers type II before type I

• Increases in intramuscular-intermuscular fat tissue

• People after SCI have on average 5 kg more fat mass and 50% more total body fat than able-bodied controls

Bone system after SCI

• Mechanostat theory bone mass, strength and size of bone respond to increasing muscle forces through growth or loading

• Neurogenic osteoporosis reduced activity, hormon signalising and inflamatory proceses

Challenges

• Feasibility and effectiveness of very early training to prevent muscle atrophy?

• Effectiveness of whole body vibration on maintaning muscles and bones ?

• Assess bone integrity in patients after SCI ?

• Effects of lower limb FES cycling and mechanical loading on bone strenght ?

Challenges

• Properties of spinal bone, pediatric SCI population and prevention of scoliosis?

• Optimal training program to improve carbohydrate and lipid metabolism ?

• User friendly methods of delivering FES ?

• Affordable exercise programs and equipment for people with SCI in community ?

Younger VERSUS Older patients after SCI

• Need for longitudional studies of patients, ageing with SCI

• RCS?

Changing life expectancy for people with SCI

• Improvements in diagnostics and therapy leads to better survival for patients with SCI

• Increasing incidence of older patients with incomplete SCI lesions

• Improvements in long term medical care

Differences between different part of EU

• Differences in standards of medical care in acute and subacute period after SCI

• Differences of % BDP for health care

• Differences in accesibility-barriers or limitations of facilities and services

• Differences in socio-economic status of patients in EU…(south VS north EU)

Accessibility of FRM specialists in Slovenia

• 2 PRM spec. for SCI on hospital ward in URI Soča-population of 2 million

• 1 PRM spec.expert of urodynamics examin., 1 PRM spec. expert in nutritional assessment-BIA, 2 PRM spec. in th.of spasticity

• 1 spec. in neurology

• 120 active PRM specialistS in Slovenia-primary care, regional hospitals, spa-s

Other specialists

• 1-(2) specialist in urology in terciar University Clinic in Ljubljana

• Up to 10 specialist in traumatology, experts in spine operational techniques

Impact of self-management-I

• Socio-economic status of patients after SCI

• Home enviroment-barriers

• Accesibility of facilities and services

• Assistive technology

Impact of self management-II

• Personal believes-active life style

• Familiar support

• Social and employment status

• Active leisure time, occupation and inclusion

Medical approach to promote healthy ageing with SCI

• Education

• Promotion of active life style

• Prevention-screening for risk factors

Optimal medical approach?

• ICF model, SCI core sets for acute and chronic patients

Personal experience of ageing with SCI

• Father suffered C5 fracture-jump in the water in summer 1968

• Operation-extirpation of IV diskus C4-6 and parts of fractured body of vertebra C5, decompression of medulla, osteog.autolog.transplantat of tibia C4-6

• Imobilisation-Minerva and transport to Orthopedic clinic Ljubljana

Ageing with SCI-1968-2014

• Moderate fatigue

• Pain syndrome-cervical spine and radiating pain in right arm

• History of 3x pressure sore in gluteal region

• Moderate spasm in lower limbs

• Hip fracture in 2007-accidental fall, operation with osteosynthesis-no signs of profound osteoporosis

Ageing with SCI-1968-2014

• Stable kidney function-none hidronephrosis, reduced volume of u.bladder, with thickened wall; 3-times per day intermitent catheterisation, and use of urinal condom

• Stable bowel functions-use of bisacodil suppositoria

• Manual active light wheelchair and seldom electromechanic wheelchair

Ageing with SCI-1968-2014

• No regular medication

• Rare orthostatic hypotension

• Rare autonomic dysreflexia

General conclusions

• Better understanding of natural course and effects of secondary healthy conditions after SCI is necessary for better outcome and improvement of QOL

• Future development and testing of the interventions that would prevent the onset of these conditions, lower severity and minimize their impact

What can be done for healthy ageing

• Education of people after SCI

• Promotion of physical activity, sports and recreation for everybody

• Improvements in employment possibilities for younger and middle aged people

• Implementation of assistive technology to lessen the burden of DA, transfers, etc

Easiest and efficient approaches

NUTRITION balanced diet regarding calories, proteines, lipids and carbohydrate intake

PHYSICAL ACTIVITY

AVOIDANCE OF NICOTINE, ALCOHOL, DRUGS-younger patiens-canabis and other novel drugs

General conclusions

• Ensure best possible clinical practise for every patient after SCI everywhere

• Achieve total prevention of secondary health conditions after SCI in the near future for younger and older patients ?

General conclusions

Optimise multidisciplinary and interdisciplinary collaboration of specialists of …. neurosurgery, neurology, traumatology, physiology, nutrition, endocrine s, cardiology, pulmology, vascular s., PRM, rehab. PTs, OTs, etc

WITH SCI patients !

NOTHING ABOUT YOU WITHOUT YOU !!!