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

Pain ManagementPain Management

Christine M. Villoch, MD

Physiatrist Oh, a psychiatrist?

Oh, a podiatrist?

Oh, superman’s doctor!

Physiatric Approach Holistic

Chronic Illnesses (traumatic brain injury, strokes, spinal cord injuries, etc.)

FunctionPhysical

Emotional

Pain Management

Spinal Cord Tumors

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

Anatomy of the Spinal Cord

Spinal cord tumor types Extradural

Intradural intramedullary

Intradural extramedullary

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

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

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

Surgical Options Laminectomy

Resect Tumor

+/- Fusion

Side Effects of Resection Numbness/Tingling

Weakness

Bladder and bowel dysfunction

Sexual dysfunction

Spine Instability

Chronic Pain

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

What does that Mean?

Pain is Biopsychosocial

Biologic Factors - Actual Physical Diagnosis

Social Factors

Psychologic Factors

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)

Characterization of Pain Muscular

Dull, achy, sore

Cramp-like

NeuropathicSharp, electric, pins and needles, burning

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

Central Sensitization

Neuropathic Pain Allodynia

Pain from nonpainful stimuli

HyperalgesiaExcessive pain from normally painful stimuli

Complex Regional Pain Syndrome

Myofascial Pain Syndromes Spot tenderness

Taut band

Pain Recognition by the patient

CausesOveruse

Poor body mechanics

Types of Pain Mechanical/Structural

Post-surgical

LaminectomyInstabilityLack of Muscle Attachments

Where does the role of physiatry fit in?

Coordinating Care (PT, OT, Social Work, Psych)

Patient Education

Pain Management

Fundamental Goals of Rehab Restore structural integrity

Restore function

Quality of Life

Physiatric Treatment of Pain PT/OT

Medications

Therapeutic InjectionsTrigger Point Injections

Botox/Myobloc

Joint Injections

Spinal Injections

Treatment Options Psychology

Relaxation techniques

Biofeedback

Alternative Medicine Acupuncture

Physical Therapy Posture

Desensitization

TENS unit

Range of Motion

Myofascial release

Strengthening

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

NSAIDS Decrease Inflammation

Analgesic Effects

Anti-Depressants Elavil, Nortripytline,

Cymbalta

Anti-Convulsants Neurontin

Lyrica

Trileptal

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

Therapeutic Injections Trigger point injections

Botox/Myobloc injectionsLoosens muscles

Spinal joint (facet) injections

Psychology Subjective Component

Supportive Counseling

Cognitive/Behavioral TechniquesBiofeedback

Relaxation Techniques

Improving Sleep Hygiene

Summary Physiatry

Holistic Approach

Rehab Needs

Pain Management

Spinal PainMultifactorial

Many different treament options

Useful Resources www.spineuniverse.com

www.aapmr.org