1. They never taught me that in medical school: Quick Approaches to Common Conditions affecting Patients with Mobility Issues 51 st Annual Scientific Assembly November 2013, Toronto James Milligan BSc.P.T., MD, CCFP Joseph Lee MD, CCFP, FCFP, MClSc(FM)

2. Faculty/Presenter Disclosure Faculty: James Milligan Relationships with commercial interests: Research funding from the Ontario Neurotrauma Foundation (ONF)

3. Disclosure of Commercial Support No commercial support

4. Mitigating Potential Bias Not applicable

5. Faculty/Presenter Disclosure Faculty: Joseph Lee Relationships with commercial interests: Research funding from the Ontario Neurotrauma Foundation (ONF)

6. Disclosure of Commercial Support No commercial support

7. Mitigating Potential Bias Not applicable

8. Challenge of Managing Physical Disabilities Low prevalence (Lee et al, 2011) Little training (Lee et al, 2011) Office inaccessibility (McColl, 2008) Systemic (McColl, 2008)

9. Population Difficulty with ADLs Impairments in basic bodily functions (i.e. bladder, bowel) Locomotive difficulties Complex secondary conditions eg. Spinal cord injury, MS, MD, stroke

10. Objective: To learn approaches to common conditions in mobility challenged patients: 1.Neurogenic bladder 2.Neurogenic bowel 3.Osteoporosis 4.Spasticity 5.Autonomic dysreflexia 6.Sexual health 7.General health

11. Case 1 John is 30 years old and had a MVA 5 years ago in which he had a complete spinal cord injury at T5. He is concerned he has another UTI and wants antibiotics. His chart shows he has received antibiotics 4 times this year for UTI. What else would be important to know? What should be done?

12. What else would be important to know? What is his method of bladder management? – Clean intermittent self catheterization Fever – No Increased spasms – Yes Change in urine (cloudy, blood, sediment) – Yes, cloudy Incontinence – Yes Malaise, lethargy, unwell – Yes Abdominal discomfort – Yes Did he actually have symptomatic UTIs in past? – Scan of chart shows urine growing bacteria

13. What should be done? Urine dip? Urine R&M, C&S Treat with antibiotics? Review urinary routine Send to urologist?

14. Neurogenic Bladder: UTI Significant bacteriuria with some of: – Leukocytes in the urine – Discomfort/pain over kidneys, bladder or during urination – Onset of urinary incontinence – Fever – Increased spasticity – Cloudy urine with increased odour – Malaise, lethargy or sense of unease SCIRE, 2011

15. Significant Bacteriuria Method Urinary Drainage Intermittent catheterization Condom catheter Indwelling/suprapubic catheter Spontaneous urination Look for lower counts! Count ≥ 10 2 cfu/L ≥ 10 4 cfu/L Any detectable concentration ≥ 10 5 cfu/mL

16. Neurogenic Bladder: UTI *treat same as complicated UTI Anti-infective review panel, 2010; SCIRE, 2011

17. Key Points Symptoms may be different Asymptomatic bacteriuria common (catheterization) C&S gold standard May refrigerate urine for 24 hr Urology referral for > 3 UTIs; persistent hematuria Antibiotic prophylaxis by specialist (Consortium for Spinal Cord Medicine, 2006; Middleton, 2002; Nicolle, 2005)

18. Neurogenic Bladder: Long Term Goals: prevent high pressures to upper tract (kidneys, ureters) avoid bladder distension prevent urinary tract infections maintain continence New South Wales State Spinal Cord Injury Service, 2009

19. Primary Care Monitoring Annual creatinine, eGFR (Middleton, 2002) Consider ultrasound every 1-2 years (NICE, 2004) Consider urology referral & urodynamics Cystoscopy after 10-15 years if indwelling or suprapubic catheters (5X increased risk bladder cancer)(SCIRE, 2011)

20. Case 2 Mary is 50 yo who was diagnosed with primary progressive MS 10 years ago. She is able to walk short distances and uses a manual wheelchair for longer distances. She comes to the office reporting abdominal distension and bloating for 3 weeks. What else would be important to know? What should be done?

21. What else would be important to know? Worrisome S&S: – Bright red blood with bowel movements intermittently for months Bowel routine: – Taking 2 hrs every second day, not same time of day – Uses colace bid; bisacodyl suppository 30 min before – Digital stimulation – Drinks 1L fluid per day, not sure how much fibre Medications and dietary intake: – Increased oxybutynin 5mg tid from 2.5 mg bid for urinary management Changes in overall condition – No change in neurological status or function

22. What should be done? Physical exam: – Abdo: mild distension, no tenderness or rigidity – DRE: hard stool, prolapsed hemorrhoids with bleeding Consider Abdo Xray Bowel routine: – Encourage timing routine daily or every 2 nd day 30min after eating (gastrocolonic reflex) – Increase fluid to > 2L/day – Add 15-30g fibre per day – Continue colace – Make sure using “magic bullet” (bisacodyl-polyethylene glycol base vs bisacodyl-hyrdrogentaed vegetable oil base)(Steins et al, 1998) – Consider adding PEG 3350 – Handout on diet – Bowel diary

23. Neurogenic Bowel Bulking AgentsMetamucil Bran psyllium prunes -Too much fibre can precipitate constipation, aim for 15-30g -Bloating, gas Stool SoftenersDocusate sodium-not very effective Hyperosmotic AgentsPEG Lactulose -PEG useful if more gentle options fail StimulantBisacodyl suppository (PEG base) Senna Microlax enema Glycerin (gentler) -Rectal stimulants can cause liquid discharge with long time use due to chemical irritation of mucosa -cramping/abdo pain **Use magic bullet- bisacodyl-polyethylene glycol base instead of hydrogenated vegetable oil base (Steins et al, 1998)

24. Key Points Adequate fluid (> 2L/day) Fibre- at least 15g per day Physical activity Time routine around gastro-colonic reflex Same time each day or every 2 nd day SCIRE, 2011; Stolzenhein, 2005; Consortium for spinal cord medicine, 1998

25. Case 3 14 yo female with spina bifida and L hemiplegia presents to the office with her pharmacist mother. She is in a manual wheelchair and suffered a fracture above L knee 3 weeks ago with a fall out of her chair. This is her second fracture. Her mother says that friends say she should be on a bisphosphonate. What else would be important to know? What should/can be done?

26. What else would be important to know? Has she had a BMD? – 2011 (GRH pediatric BMD exam): Z-score -4.0 Is she followed by specialists? – Spina Bifida clinic (pediatrician, urology, orthopaedics) Spinal fusion for scoliosis and to help sitting and weight bearing 2012 Does she take calcium and vitamin D? – Not regularly Does she weight bear? – Not weight bearing much before fracture Other – No workup for secondary causes osteoporosis – No hx of kidney stones – Non smoker, no ETOH, no caffeine

27. What should be done? Encourage regular calcium and vitamin D Secondary workup: – CBC, Cr, Ca 2+, albumin, ALP, TSH, 25-OH vit D, PTH * Encourage physical activity when fracture heals Avoid excessive caffeine, ETOH, smoking Anti-resorptive therapy ?

28. Unique Issues in Physically Disabled Decreased or no ambulation Medications (anticonvulsants, steroids) Lifestyle factors (smoking, ETOH, caffeine) Typical guidelines don’t apply Schrager, 2004; SCIRE 2011; Craven et al, 2009

29. Osteoporosis Issues BMD controversy Fracture pattern different (SLOP- Sublesional Osteoporosis) Hypercalciuria common Schrager, 2004; SCIRE 2011; Craven et al, 2009

30. Key Points Fracture common- sublesional (SLOP) DXA every 1-2 years (most experts) Test for secondary causes of osteoporosis Treat lifestyle factors (smoking, ETOH, caffeine) Calcium and vitamin D beneficial (consider renal/bladder stones) Anti-resorptive therapy unclear, consult with specialist

31. Case 4 Bob is a 52 year old who suffered a stroke 3 years ago with spastic L hemiplegia. He is able to walk short distance with a quad cane but uses a wheelchair for longer distance. He is seeing you as his spasticity is bothersome and he was wondering if you would prescribe medical marijuana. What else would be important to know? What should be done?

32. What else do you want to know? Any acute change? – No When does it bother him? – At night if moves, sitting, transferring What medications is he currently on or been on before? – Nothing currently for spasticity – Was on baclofen a couple of years ago for a short time – Finds marijuana helps his muscles relax

33. What should be done? Physical Exam – Painful contractures shoulder, elbow, hand – Spasm noted with transfer Physiotherapy – ROM/stretching OT, seating assessment Medication – baclofen 5mg tid recommended Marijuana ?

34. Spasticity Etiology Infection (uti) Noxious stimuli (constipation, ulcer, fracture) Disease progression (MS exacerbation, syringomyelia) Medication or not taking

35. Spasticity Management Non-Pharmacological: Passive stretching Active exercise Seating assessment TNS (SCIRE, 2011; Consortium for Multiple Sclerosis Centers, 2005) Pharmacological: Oral medications Intrathecal baclofen Local injections (botulinum toxin, phenol)

36. Spasticity MedicationDosage (maximum)Side Effects Baclofen (oral) (Level 1a) 5mg tid, may increase by 15mg q 3d (40mg qid, not much further benefit at > 20mg qid) Lower seizure threshold Sedation weakness Tizanidine (Level 1b) 4mg daily, increase 2-4mg over 2-4 weeks Maintenance: 8mg tid-qid (36mg per day) Sedation Dizziness Dry Mouth COST NOT COVERED *monitor liver function Clonidine (Level 1b) 0.1mg bid (1.2mg bid) Sedation Dizziness Dry mout Constipation Dantrolene (Level 1b) 25mg daily for 7d, then 25mg tid for 7d, then 50mg tid for 7d, then 100mg tid Use lowest effective dose (100mg qid) Weakness Lightheadedness Nausea, diarrhea Constipation COVERED COST *monitor liver function Diazepam2-10mg tid-qidSedation Withdrawal Confusion * Possibility of elevated liver enzymes; hepatotoxicity Consortium for Multiple Sclerosis Centers, 2005; SCIRE, 2011 Note: some patients will need combination of medications

37. Cannabinoids Anecdotal reports but limited evidence for spasticity in MS, SCI (Health Canada, 2013)(SCIRE, 2011) Marijuana Medical Access Regulations (MMAR) – severe pain and persistent muscle spasm in SCI and MS who have not or would not benefit from conventional treatments (Health Canada, 2013)

38. Cannabinoids College regulation Conventional treatments Understand use in condition Not obliged to complete Informed consent documented CMPA, 2013

39. Key Points Treat if interfering with function Investigate etiology Refer if spasticity refractory Medical marijuana -indications, motivations, risks, benefits, informed consent SCIRE, 2011

40. Case 5 Alan (25) is a C7 tetraplegic patient from a MVA 1 year ago. He comes to you bothered by periodic headaches and sweatiness. What else would be important to know? What should be done?

41. What else would be important to know? Headache characteristics and associated symptoms – Pounding – Flushing of face – Nasocongestion – Sweating of head; cold, goosebumps abdomen, legs – Feels quite unwell when occurs – Often only lasts minutes When it has occurred – During bowel routine – During self catheterization – During sexual stimulation

42. What should be done? Baseline BP, HR – 100/60, 80bpm Education – Signs and symptoms of autonomic dysreflexia (AD) – Management of AD – Triggers of AD – Review bowel and bladder regimes – AD wallet card Home BP machine Refer to physiatrist? Medications – Consider medication to treat

43. Autonomic Dysreflexia *Serious, potential life threatening condition affecting those with lesions at T6 or above, characterized by Increased BP and risk of seizure, stroke, death* *SCI patients often have low resting BP of 90-100/60 mmHg Milligan et al, 2012

44. Autonomic Dysreflexia Monitor for hypotension if pharmacotherapy used Milligan et al, 2012

45. Key Points Potential life threatening condition Unopposed sympathetic activity triggered by noxious stimulus below level of injury Relieve noxious stimulus Refer if severe, frequent Prevention

46. Case 6 Jim 46 years old has relapsing remitting MS and has come to see you regarding troubles with erectile dysfunction. He wonders about trying Cialis after seeing commercials. What else would be important to know? What can be done?

47. What else would be important? Usual questions in regards to sexual dysfunction with special focus on: – Sensory and motor issues – Medications – Mood – Substances – Tried anything – Secondary issues (urinary, bowel, AD) Safety – STI, abuse General Health – cardiovascular Fertility – If desired or contraception

48. What can be done? Physical exam – BP, HR – Cardiovascular – Urogenital? Investigations – CBC, FBS, cholesterol, ECG, Cr, Education – About the issue and perhaps related to physical disability – Fertility, contraception, safety Medication – PDE5i Referral?

49. Sexual Health MedicationDosageSide Effects/Cautions Phosphodiesterase type 5 Inhibitors (PDE5i) (Level 1 in SCI) Sildenafil 50-100mg 30-45 min before Tadalafil 10-20mg 1-2 hr before - Caution if suffer from autonomic dysreflexia Monitor hypotension in tetraplegics for hours after -other side effects as general population Penile Intracavernosal Injection (Level 2 in SCI) Papaverine, phentolamine, prostaglandin E1 alone or combo (see urologist for dosing and titration) -pain,swelling injection site -priapism -fibrosis Intraurethral PreparationsIntraurethral alprostadil (PGE1)(MUSE) 250-500mcg 10-30 min before -not been effective in SCI -may consider in MS Mechanical MethodsVacuum device Penile ring -acceptable method -loss of rigidity -petechiae, edema -don’t leave ring on > 30-45 min. Penile prosthesisMay be effective when other interventions fail -infection -may affect urinary techniques *use of PDE5i in persons susceptible to autonomic dysreflexia carries a concern as nitrates cannot be used, washout after sildenafil is 24 hr and tadalafil 48 hr

50. Sexual Health Women-less & delayed orgasm, decreased lubrication Men-erectile dysfunction Fertility Different positions Appliances SCIRE, 2011; Rutkowski, 2002

51. Pregnancy Issues Bladder, kidney infections Thrombosis Mobility Postural hypotension Autonomic dysreflexia Premature labour Rutkowski, 2002

52. Key Points Important to patients Physicians don’t ask Unique issues Same medications as able-bodied Fertility and pregnancy concerns Referral

53. Case 7 Jane is a 40 year old female with myotonic dystrophy. She and her husband report gradually worse balance and some falls. She has found she does better using the shopping cart at the grocery store, so has borrowed her father’s wheeled walker. She has brought in the walker and finds that it helps but doesn’t think it’s the right size. What can you do?

54. Mobility Fitting Cane & Walker 20-30° flexion of elbow or to height of wrist crease Lam, 2007

55. Mobility Cane considerations: Usually used opposite side May need more support (quad cane) Walker considerations: Consider brakes, weight, size

56. Mobility ADP pays up to 75% Central Equipment Pool (CEP) - high technology wheelchairs ADP does not cover repairs/maintenance (except CEP) * ADP pays 100% for those on social assistance benefits (OW, ODSP, ACSD) ADP, 2012

57. Periodic Health Evaluation Agreement that an annual follow-up visit is compatible with addressing concerns and a plan for health maintenance and prevention of secondary complications (SCIRE, 2011; McColl et al, 2012)

58. Periodic Health Evaluation Health promotion/prevention (WHO, 2011)(Weigel et al, 2010) Secondary conditions- predictable and preventable (SCIRE, 2011) Physical disability -premature ageing (SCIRE, 2011) High health risk behaviours Social issues

59. Preventative Health Immunizations: Routine Pneumococcal < 65 at high risk (physical disability) -1 dose (Canadian Immunization Guide, 2013;Dubey et al, 2011) Psychosocial: – Health promotion/counselling needs (smoking) not met (SCIRE, 2011) – Depression rates higher and often not treated (SCIRE, 2011; Donnelly, 2007) – Community Functioning (Donnelly, 2007)

60. Health Prevention BP, weight (if able) Consider blood glucose, cholesterol earlier Osteoporosis (Middleton et al, 2008; Craven et al, 2008) Consider urinary tract imaging, labwork Routine cancer screening SCIRE, 2011

61. Final Questions?

62. Review of Key Points UTI Atypical symptoms Wait for culture Consider ciprofloxacin x 14 days Preserve upper tract/bladder Neurogenic Bowel 15 gm fibre “magic bullet”; Consider PEG

63. Review of Key Points Osteoporosis Fractures common & different BMD q1 to 2 years Screen for secondary causes Spasticity Investigate etiology Non-pharmacologic measures Consider meds (Baclofen, cannabinoids)

64. Review of Key Points Autonomic Dysreflexia Important to recognize! Look for and relieve noxious stimulus (eg. UTI, bowel) Sexual Health Ask! Use many of same agents General Consider early screening

65. THANK YOU!

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