SPINAL CORD INJURY REHABILITATION

Abna A. Ogle M.D., FAAPM&R

Disclosure Statement

I have no relevant financial (or commercial interest) in relation to

this presentation.

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“The neurologic impairment is not nearly as important as is the quality of the rehabilitation,the social support system and the personality and mindset of the persons with spinal cord injurythemselves. (These latter) determine coping, and ultimately satisfaction with life after injury.”

Sam Stover

PARTNERSHIP FOR A CHANGED LIFE

Traumatic spinal cord injuries are unique in that they are :

• catastrophic• comprehensive

• cumulative

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PARTNERSHIP FOR A CHANGED LIFE

• Research has not yet lead to a cure, buthas yielded great insights into the

physiology of SCI.• Rehabilitation remains the only effective intervention for recovery of

function, and as such, should begin as soon as the person is medically and/or

surgically stable.

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PARTNERSHIP FOR A CHANGED LIFE

• Many complications of traumatic SCI occur PRIOR to admission to a Rehabilitation Hospital.

• Bladder and bowel management

• Pressure relieving surfaces

• Appropriate positioning to avoid contractures

• DVT prophylaxis• Pulmonary toilet

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PARTNERSHIP FOR A CHANGED LIFE

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Continues in STACH…• Identify primary caregiver/support• Explore resources that support discharge home

(insurance benefits, family available, accessible housing)

• Explanation of what Rehabilitation is (and isn’t)

PARTNERSHIP FOR A CHANGED LIFE

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In the Rehabilitation Hospital…• Rehab LOS have been steadily declining in the U.S. for

the past 40 years*• When inpatient stays from 1973-81 were compared

with those from 2002-2006, there was a reduction of 62.6 days.

• Shorter LOS does not appear to have affected rate of discharge home BUT, functional independence at the time of discharge has been adversely affected.

*DeVivo MJ. Sir Ludwig Guttman Lecture: trends in spinal cord rehabilitation outcomes from model systems in the United states: 1973-2006, Spinal Cord 2007;45(11):713-721

PARTNERSHIP FOR A CHANGED LIFE

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• American Spinal Injury Association (ASIA) Impairment scale comprises a detailed neurologic examination that establishes sensorimotor preservation and guides prediction of functional outcome.

• This neurologic assessment is the basis of the rehabilitation treatment prescription. All short term goals are addressed in order to maximize long term functional outcome.

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PARTNERSHIP FOR A CHANGED LIFE

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Early in Rehabilitation…• EDUCATION• Bladder and bowel management• Skin care/protection• DVT prophylaxis (up to 12 weeks for complete

injuries).• Autonomic dysfunction (Orthostatic hypotension)• Hypercalcemia• Pulmonary toilet/tracheostomy care• Transfers skills/gait training

PARTNERSHIP FOR A CHANGED LIFE

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Closer to discharge…• EDUCATION• Finalize equipment orders• Home visit for accessibility recommendations• Autonomic dysfunction( Autonomic dysreflexia)• Heterotopic ossification• Community reintegration• Recreational assessments• Spasticity management• Specialty referrals

PARTNERSHIP FOR A CHANGED LIFE…now that you’re home:

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*Vocational Rehabilitation*Return to school*Depression/Anxiety*Sexuality/Fertility*Revisiting bladder and bowel management(…maybe a colostomy is NOT such a terrible idea)*Communication with Primary Care physicians*Advocacy

PARTNERSHIP FOR A CHANGED LIFE

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PAIN MANAGEMENT• Multiple studies have consistently estimated

chronic pain in this population at 66-79%*• Delineate origin as clearly as is feasible

(musculoskeletal, neuropathic, radicular, visceral).

• Emphasize non narcotic therapies

*Wollaars MM, Post MW, Brand N. Spinal cord injury pain: the influence of psychologic factors and impact on quality of life. Clin JPain 2007;23(5):383-391

*Rintala DH, Holmes SA, Fiess RN, et al. Prevalence and characteristics of chronic pain in veterans with spinal cord injury. JRehabil Res Dev 2005;42(5):573-584

PARTNERSHIP FOR A CHANGED LIFE“But I still want to walk..”• Ambulation with

orthotics• Locomotor training with

body weight support systems +/- functional electrical stimulation

• Robotic training (alternative to manually assisted locomotor training).

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PARTNERSHIP FOR A CHANGED LIFE• Is there a cure out there?• “What about the mouse

serum injections in Guadalajara?”

• Provide resources and information for contacting internationally recognized clinical trials.

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THANK YOU