Spinal cord injury rehabilitation

Spinal Cord Injury RehabilitationSpinal Cord Injury Rehabilitation in Vietnamin Vietnam

Cam Ba Thuc MDCam Ba Thuc MD

ContentsContents• Summary of Spinal Cord Injury (SCI)

• Epidemiology of Spinal Cord Injury

• Epidemiology of Spinal Cord Injury in Vietnam

• Set up care network of SCI in Vietnam

• Rehabilitation for Spinal Cord Injury patients in Central

Rehabilitation Hospital (Thanh Hoa province).

SummarySummary• Spinal cord injury (SCI) results in disruption of the nervous

transmission and has considerable physical and emotion consequences to an individual’s life

• Paralysis, altered sensation, or weaknesses in the parts of the body innervated by areas below the injured region almost always occur.

• In addition to a loss of sensation, muscle functioning and movement, individuals with SCI also experience many other changes which may affect bowel and bladder, presence of pain, sexual functioning, gastrointestinal function, swallowing ability, blood pressure, temperature regulation and breathing ability.

SummarySummary• Numerous secondary complications may arise from SCI

including deep vein thrombosis, heterotopic ossification, pressure ulcers and spasticity.

• The recovery can be long from the acute hospital admission to the return of full participation in the individual’s community.

• Even those individuals who make significant gains in rehabilitation may experience difficulty when returning to pre-injury activities.

• Thus, SCI has a serious effect on quality of life.

SummarySummary • Spinal cord Injury (SCI) occurrence is a worldwide recognized

health issue leading to serious medical and functional impairments, affecting mobility, activities and participation to society for the affected persons and his community.

• So far no cure of SCI is available, treatment of complications and management of mobility in order to increase independence of the affected person are the best options possible to ensure a better quality of life for the person affected.

• Although treatment techniques and psycho- social adjustment knowledge have improved significantly since the last decades, the access to the care is not evenly spread in the world. Economic considerations are given as the main reason.

SummarySummary• However, comprehensive training programs adapted to the

local context, health policy that allows decentralizing of

services and research and care promotion do increase the

awareness of SCI among the health professionals, health

financers and the general public.

• Prevention measures to avoid new SCI accidents should be

implemented in the long term and are the most cost effective

way to counter the serious social and financial consequences of

SCI on society

Epidemiology of Spinal Cord InjuryEpidemiology of Spinal Cord Injury

• Injuries to the spinal cord have been classified as either traumatic in cause (e.g., motor vehicle accidents, falls, violent incidences, diving) or non-traumatic (e.g., tumors, spinal stenosis, vascular).

• Traumatic SCI accounts for the larger proportion of SCI injuries, however, difficult to ascertain because reporting of non traumatic.

• The percent of traumatic SCI to overall SCI injury has been reported to range from 75% in Germany (Exner & Meinecke 1997), 61% in the United States (McKinley et al. 1999a) and 48% in the Netherlands (Schonherr et al. 1996).


• The global incidence of SCI estimated primarily from developed countries ranges from 10.4 to 83 per million populations per year when including only patients who survived before hospital admission (Wyndaele & Wyndaele 2006).

• If reports in international journals and papers suggest that SCI occurs on average between approximately 14 to 80 persons per

million habitants per year are exactly, at the moment We have between 250 to 861 persons per million habitants live with SCI

• Population of SCI on earth: estimate from 150 - 510 million SCI (world population is 6,77 billion people).


Proportion of spinal cord injury by gender in some countries in the world

Author Nation Report year Male/Female

Tricot A France 1981 4,6/1

Van Asbeck et al Netherland 1994 3,0/1

Maharaj JC Fiji 1996 4,0/1

Chen HY et al Taiwan 1997 3,0/1

Martins F et al Portugal 1998 3,0/1

Karacan L et al Turkey 2000 3,0/1

Wyndaele et al General features 2006 3,8/1


Proportion of spinal cord injury by genderin developing countries

Nation Male Female Male/Female

US 83,8% 16,2% 5,18/1

UK 85,8% 14,2% 6,04/1

Canada 78,9% 21,1% 3,73/1

General features 82,8% 17,2% 4,8/1


in Vietnamin Vietnam

SCI in war time of VNSCI in war time of VN

• The Vietnam War had caused the deaths of between 2 to 5 million Vietnamese (different depending on the source).

• Among the allies of the Republic of Vietnam, the Americans have the highest number of casualties with more than 58,000 dead and 305,000 wounded (of which 153,000 were injured or disabled). At about 4,400 to 5,000 soldiers from South Korea killed; Australia has about 500 dead and over 3,000 injured; New Zealand 38 dead and 187 injured; Thailand 351 dead and wounded; The Philippines also has no specific statistics.

• Source: https://vi.wikipedia.org/wiki

SCI in war time of VNSCI in war time of VN

• Against Japan: 1944 – 45 (2 years)

• French: 1946 - 54 (9 years)

• North – South war: 1954 – 75 (22 years)

• Border dispute with China, Cambodia: 1979-89 (10year)

• No national figures about spinal cord injury invalid are available (I don’t know how many SCI person);

• There are many SCI invalids lives in Center for Care Invalid people;

• Some doctors were trained abroad (Netherlands) to serve these invalid people;

SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN• After war ended, no have any more SCI patients, and SCI fall

into oblivion;

• Since 1986, due to the activities of industrialization, increased accidents, increased faster SCI, so SCI was interested back.

• No national figures are available in Vietnam

• In regard to this situation, it is assumed that averages in Vietnam fall within world’s values (ranges from 14 to 80 per million populations per year)

• It is estimated that at least 25.000 persons live with SCI in Vietnam today and each year at least 850 new persons get an SCI every year.

SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN

• From 2003 to 2008, Handicap International programs have been

developing SCI care and approached around 2400 SCI patients

and family members. 45 % of them were caused by Road

Traffic Accidents (RTA), more specifically motor bike

accidents.

• Data collections done between in 2008 – 2009 in Bach Mai

Rehabilitation Centre, suggest 268 patients who were

distributed by 10 age groups (0-4 years to 75years and above).


• Based on collected data, men were more likely than women to suffer SCI at all ages at a ratio of 85% to 15%. Moreover, age 35-54 years showed maximum number of patients suffering SCI (65% for male and 35% for female). The age range was between 5 years and 75 years with the age on average are 39 years.

• Etiology, 31% (n= 84) are due to transport, 44% (n= 119) due to falls, 2% (n= 6) due to assault, 1% (n= 2) due to sports activities, 9% (n= 24) due to other traumatic causes and 12% (n= 31) due to non-traumatic causes like tuberculosis in the spine, transverse myelitis.


• Systems of care that could address this condition were not widely available throughout the country before the end of the year 2000. With economic development taking shape (infrastructure building, road network expansion, and poverty reduction) in a very short time frame, mainstream population got access to transport means and use of improved roads, lacking proper prevention mechanisms for reducing the number of motorcycle accidents.

• Economic development activity brought more traffic, construction activity, informal enterprise exposing the active population to new occupational hazards causing an increase of falls, crushing and impacts leading to spinal injuries.


• Health care reform in Vietnam opened up possibilities for care innovation to address new needs for SCI patients admitted in Rehabilitation Hospitals. Post acute care and physical rehabilitation, care networks and their referral system were developed leading to better evacuation of victims, increased quality of emergency treatment, and increased survival rates after accidents.

• This lead to a more important number of SCI victims surviving their accident longer as well as needing comprehensive care to facilitate better social and economic integration.

Health care and physical rehabilitation of SCI Health care and physical rehabilitation of SCI in Vietnamin Vietnam

Thank to Handicap International Belgiumnow we have a SCI network

Set up care network of SCI in VietnamSet up care network of SCI in Vietnam

• In 2003, set up of a 50 bed pilot Spinal Unit in Ho Chi Minh

City - Southern Vietnam (answering to the rising needs in an

urban and highly industrialized setting).

• This pilot unit (supported by Handicap International Belgium)

was extended with “satellite units “in three Southern provinces

from 2006 to 2007 to ensure better proximity of care for the

mainstream SCI patients (mainly living in provincial areas after

their initial treatment phase).


• SCI care development was followed by setting up an SCI

training Unit at National Rehabilitation Centre of Bach Mai

hospital in 2008.

• This 20 bed unit aims to create a national care model from

which provincial Rehabilitation Centres can resource

themselves to implement SCI care in their specific setting,

answering to the needs of SCI patients locally for primary

rehabilitation services and, if necessary, referral for specialized

services to the National Rehabilitation unit.


• The decentralization policy from the Ministry of Health was still in process and aims by 2012 to have 11 Spinal Cord Units operating in throughout the country equipped with a total of 200 spinal beds;

• Then Duplication of this model in the remaining 34 rehabilitation centers can lead to very comprehensive system of care that can make SCI care services geographically available for its 90 million citizens.

• The Central rehabilitation hospital of Thanh Hoa has developed progressively since 2005 a Spinal Care Unit under cooperation between the Hospital and Handicap International Belgium.


• The construction of specialized units to treat SCI patients equally distributed in both Northern and Southern areas to ensure balance and meet the demand for treatment increased domestic.

• Although nearly 60% of the cost of treatment for patients covered by the state and support but I think that Vietnam also needs to ensure that patients with SCI in the provincial poor or remote areas can still access this treatment services;

• Guidelines and policies of the state to encourage the construction and development of specialized rehabilitation are important keys to create conditions for improving expertise and demonstrate the result of work as well as the effectiveness of the development these SCI Units.

Set up care network of SCI in VietnamSet up care network of SCI in VietnamOr Name of rehabilitation hospital

in which has SCI rehabilitation unitNumber

of SCI bed

1 Rehabilitation Hospital of HCM City 50

2 Bach Mai Rehabilitation Centre 20

3 Central Rehabilitation Hospital Thanh Hoa 20

4 Da Nang Rehabilitation Hospital 20

5 Khanh Hoa Rehabilitation Hospital 20

6 Phu Yen Rehabilitation Hospital 20

7 Ha Tinh Rehabilitation Hospital 10

8 Bac Giang Rehabilitation Hospital 10

9 Son La Rehabilitation Hospital 10

10 Thai Binh Rehabilitation Hospital 10

11 Phu Tho Rehabilitation Hospital 10

Distribution of SCI Unit in Vietnam

Training program of Handicap InternationalTraining program of Handicap International

• Classification of neurological deficit based on ASIA impairment scale (Ass-Prof. Apichana, Chiangmai)

• Prevent and cure pressure ulcer• Management of neurogenic bladder • Management of neurogenic bowel• Management of spasticity• Management of pain• Management of sexual dysfunction• Urodynamic• Intravescica pressure (water column measure)• Intra muscular nerve block (phenol 5%) (Dr. Arome from

Thailand).

Training program of Handicap InternationalTraining program of Handicap International

• Breathing exercise • Deep vein thrombosis• Hypotension (orthostatic hypotension)• Hypertension (autonomic reflex)• Heterotopic ossification• Physical therapy • Occupation therapy• Leisure activities (creative activities)• Peer counselor• Psychological therapy• Adaptation skill (independence living/ transit house)• Wheelchair training

Central Rehabilitation HospitalCentral Rehabilitation Hospital

Thanh Hoa provinceThanh Hoa province

Central Rehabilitation Hospital

(Ministry of Health)

Address: Nguyen Du road Sam Son – Thanh Hoa - VN

• Founded in 1972, a temporary hospital for invalid• Since 1999, change to Central Rehabilitation Hospital

(belonged to Ministry of Health).• 310 bed and 163 staffs• Main functions: + rehabilitation

+ primary health care for local people

+ emergency service

+ orthopedic surgery

+ prosthesis and orthotic service

+ co-operation: nationwide and worldwide

• 10 Departments and 1 Workshop:+ Outpatient and emergency service : 20 beds+ Rehabilitation Dept : 80 (20beds of SCI Unit)+ Internal Medicine Dept : 80 (Combine: Pediatric)+ Geriatric Dept : 80 beds+ Orthopedic Surgery Dept : 30 beds+ ENT – Dentistry – Eye. Dept : 20 beds+ Traditional Medicine. Dept : 40 beds+ Sub-clinic Dept: image, analysis, biology, parasite, function

diagnosis.+ Pharmacy Dept+ Infectious control Dept+ Prosthesis and Orthotic Workshop

Rehabilitation DeptRehabilitation Dept

• 36 staffs & 80 bed for inpatients

• 5 doctor, 12 nurses, 15 PT, 2 OT, 2 cleaner

• Inpatient area = 80 bed (20 bed for SCI)

• 03 Exercise room

• 01 Occupation therapy room

• 01 Speech therapy room

• Physical therapy rooms: such as electrical stimulation; short wave; micro wave, shock wave and magnetic field.

* Total patients of hospital:

- Outpatients: ♯ 38.000 per year

- Inpatients: ♯ 9.000 per year

* Inpatients of Rehabilitation dept.: ♯1.200

* Types of Patients in Rehabilitation dept: Stroke, Brain injury,

SCI, Cerebral Palsy, Neck Pain, Back Pain, Muscular Skeleton

diseases; Lymph Edema; CMD (Congenital Muscular

Diseases)…etc…; some time we have autism children;

SCI rehabilitation in my hospitalSCI rehabilitation in my hospital

• We received SCI patients for along time

• The protocol of care and rehabilitation not so good

• Since 2005, under sponsor of Handicap International Belgium, our service had changed.

• Handicap International help training a team work, consist of:

Rehabilitation doctor : 02

Rehabilitation nurses : 02

PT and OT on SCI : 03; OT and wheelchair = 01

Psychologist : 01 (doctors, give up now)

• Protocol of healthcare and rehabilitation based on standard of Handicap International Belgium.


• Classification of neurological deficit based on ASIA impairment scale;

• Temperature regulation: we have special room for patients with high level of injury to prevent suffering high temperature

• Prevent and cure pressure ulcer (PU):

+ Prevent PU when lie on bed or sitting on wheelchair

+ Education for patients and caregiver; use water mattress, alter pneumatic mattress, keep skin clean…

+ Turn regularly and check pressure region,

+ Necrosis debridement, wash and clean the wound, bandage

+ Nutrition supply; multi-mineral and vitamin supply


• Bladder care:

+ We do urodynamic or water colum measure to defined bladder function (active, capacity);

+ Training self clean intermittent catheterization, combine with intake enough water and management of urinary track infection

+ Use anticholinergic medication (ditropan);

+ If patients need do Intravesica Botox Injection, we will transfer patient to Bach Mai Rehabilitation Centre.

• Bowel care: training patients how to care bowel, use medication for softening or forming, combine with intake water of bladder care program.


• Circulation Care:

+ Prevent deep vein thrombosis: alter pneumatic massage, exercise, early detection by clinical exam and ultrasound scan

+ Hypertension: prevent autonomic reflex in patient with SCI upper T6 by education patient the symptom of hypertension, check blood pressure regularly; if there is a hypertension, check bowel or bladder and other triggers; use medication.

+ Hypotension: prevent orthostatic hypotension by education caregiver and patient, pay special notice when change position of these patients; use tight clothes, bandage and intake more salt.


• Management of spasticity:

+ Use medication such as oral take baclofen, mydocalm, decontractyl

+ Use phenol block: do ultrasound scan to find the location of the nerve, use TENS apparatus for electrical stimulation;

+ Botox injection (expensive, need sponsor): we use both ultrasound guide and electrical stimulation;

+ Use orthotic device

+ Obturatorius nerve denervation: this must do in orthopedic surgery department of my hospital;


• Management of pain:+ Evaluation of pain+ Use medication such as NSAIDs, neurotin, lyrica;+ Physical therapy such as massage, exercise, participate leisure time such as volley ball, ..etc…

• PT, OT and Self-care : + Exercise+ Wheelchair training+ Leisure time activities+ Self-care of bowel and bladder+ Peer counselor: some successful patient were advisors for new patients;

Cost of treatmentCost of treatment

• Most of disable person were provided health insurance (policy of government);

• Poor patients or patients live in remote area may provide meals during hospitalization;

• All the cost of healthcare and rehabilitation were paid by government through health insurance.

• Health insurance do not pay for prosthesis, wheelchair, botox medication. These often done by social wealthfair or benefactors

Thanks for your attention !

Date post:	14-Apr-2017
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