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 1930s England Guttman in the 1940s
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. 2. 3. 4. 5. 6. 7. Pneumonia Non-ischemic heart disease Septicemia Ill-defined Conditions Pulmonary embolus Ischemic heart disease 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. MSRs need not be normal.

Ambulation Potential
Ambulation Potential

ASIA ASIA ASIA ASIA

A B C D

3-6% 50% 75%* 95%

100% 80% 60% 40% 20% 0% ASIA Impairment Classification A B C D

* >50 yo 42%, <45 yo 90%. Burns et al Arch Phys Med Rehabil 1997
Dittuno Functional Outcomes. In Spinal Cord Injury. 1995

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 Management Approaches. 1987

Sitting Balance

Nawoczenske et al. Physical Management. In SCI: Concept and Management Approaches. 1987

Short Sitting

Nawoczenski et al. Physical Management. In SCI: Concepts and Management Approaches. 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 Management Approaches. 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 flexionwithdrawl 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.