1. Rehabilitation after a Spinal Cord Injury Tom Kiser MD Assistant Professor UAMS Dept of PM&R Medical Director Arkansas Spinal Cord Commission

2. Objectives History of SCI Neurologic recovery after SCI Rehabilitation Process for SCI Advances in Rehabilitation for SCI

3. 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.”

4. 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.

5. Systems effected by SCI Cardiovascular Integumentary Gastrointestinal Metabolic Neurologic Musculoskeletal Urologic Psychosocial Sexuality Respiratory

6. Comprehensive Treatment Centers U.S. Munro in the 1930’s England Guttman in the 1940’s –Coordinated system of care –Decrease of secondary complications –Community reintegration –Provide life-long follow-up Yarkony GM RIC Procedure manual 1994

7. 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.

8. Causes of Death 1.Pneumonia 2.Non-ischemic heart disease 3.Septicemia 4.Ill-defined Conditions 5.Pulmonary embolus 6.Ischemic heart disease 7.Suicide

9. Neurologic recovery after SCI

10. 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.

11. 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. MSR’s need not be normal.

12. Ambulation Potential ASIA A3-6% ASIA B50% ASIA C75%* ASIA D95% * >50 yo 42%, <45 yo 90%. Burns et al Arch Phys Med Rehabil 1997 Dittuno Functional Outcomes. In Spinal Cord Injury. 1995

13. Neuroanatomy Zejdlik CP. Management of SCI 2nd ed. 1992

14. Recovery of 3/5 strength Wu etal. J Am paraplegia Soc 14:93; 1991. Mange et al. Arch Phys Med Rehabil 73:437; 1992.

15. Rehabilitation Process for SCI

16. Rehabilitation

18. Physical Therapy Acclimate to upright position Sitting balance - supported and unsupported Bed mobility Transfers Wheelchair mobility Upper Extremity ROM and strengthening Pressure Relief

19. Propped Sitting Nawoczenski et al. Physical Management. In SCI: Concepts and Management Approaches. 1987

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

21. Short Sitting Nawoczenski et al. Physical Management. In SCI: Concepts and Management Approaches. 1987

22. Sliding Board Nawoczenske et al. Physical Management. In SCI: Concepts and Management Approaches. 1987.

23. Sliding Board Transfer Nawoczenski et al. Physical Management. In SCI: Concepts and management Approaches. 1987.

24. Wheelchair Sitting

25. Pressure Relief Zejdlik CP. Management of SCI 2nd ed 1992.

26. Occupational Therapy Upper extremity activity Neuromuscular electrical stimulation Neurofacilitation techniques Feeding Grooming Dressing Bathing Toileting Driving evaluation and training

27. Assistive devices Nawoczenski et al. Physical Management. In SCI: Concepts and Management Approaches. 1987

28. Tenodesis Zejdlik CP. Management of SCI 2nd ed. 1992

29. Tenodesis Assist Zejdlik CP. Management of SCI 2nd ed. 1992.

30. Orthotic Devices Zejdlik CP. Management of SCI 2nd ed. 1992

31. Functional Triad Dittuno JF, Graziani V. Rehabilitation Report 5:1-4, 1989

32. Advances in Rehabilitation for SCI

33. Free Hand System

34. 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.

35. VoCare System

36. 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.

37. Parastep Constant tetanic stimulation to knee extensors during stance. Transient stimulation to the common peroneal nerve to obtain a flexion- withdrawl reflex that produces a swing phase of gait. Consists of walker, surface electrodes, control switch (activated by fingers)

39. 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

40. 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

41. 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

42. Questions? Zejdlik CP. Management of SCI 2nd ed. 1992.