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.