Spinal cord injury rehabilitation model G. Zeilig, MD, Department of Neurological Rehabilitation, Sheba Medical Center, Tel Hashomer

Meeting the needs (the 3 “P’s”) Quality of care Cost containment Quality of life Patient Provider Payor

The patient

WHAT’S A SPINAL CORD INJURY ? Loss of motor and sensory function bellow the level of injury Spasticity Pain Sexual dysfunction Loss of bowel & bladder control

International Standards for Neurological Classification of Spinal Cord Injury ASIA (American Spinal Injury Association) Neurological level of injury (NLOI) Completeness of the injury (ASIA impairment classification) 72 hour exam - reliable prognostic time

American Spinal Injury Association (ASIA ) Classification

SCI = multi-systems failure RESPIRATORY NERVOUS ENDOCRINE IMMUNE GASTO-INTESTINAL GENITO-URINARY CARDIO-VASCULAR METABOLIC MUSCULO-SKELETAL PSYCHIATRIC SKIN REPRODUCTIVE

SCI – related medical conditions Spinal shock Spinal cord syndromes Autonomic dysreflexia Neuropathic pain Spasticity Heterotopic ossification Syrinx Gynecomastia

SCI = multi-functions failure B-ADL E-ADL Mobility Ambulation Socio – economic

International Classification of Functioning, Disability and Health (ICF)

Living with SCI

Living with SCI Acute restoration phase Maintenance phase Decline phase

Conflicting goals Quality of life Independence Preservation of function

Long-term survival Diminished life expectancy (?) Life expectancy has been improving

SPINAL CORD INJURY: Statistics

SPINAL CORD INJURY: Numbers > 10.000 SCI/year 30-50/1.000.000 new SCI/year 200.000 living SCI in USA Annual cost : $ 5 billion

Most frequent SCI 23.1 28.2 31.2 17.5 Paraplegia Incomplete (%) Tetraplegia 23.1 28.2 31.2 17.5

Average Yearly Expenses (in 2005 dollars) Severity of Injury First Year Each Subsequent Year High Tetraplegia (C1-C4) $710,275 $127,227 Low Tetraplegia (C5-C8) $458,666 $52,114 Paraplegia $259,531 $26,410 Incomplete motor at any level $209,324 $14,670

The provider

The Team Physician Rabbi Recreational therapist Engineer Secretary Social worker Speech therapist Cook Dietician Nurse Occupational therapist Orthotic technician Psychologist Physical therapist urologist, orthopedic, neurosurgeon, plastic surgeon, ID, ENT, medicine, pain, psychiatrist ………

Spinal cord injury rehabilitation unit ?

A Model Outpatient rehab Inpatient rehab Respiratory Clinics Day care Acute care Day care Clinics Amb. therapies SCI program CBRP

Living with SCI Lifetime follow-up Prevention: Secondary impairment Secondary disability Early intervention Education Health promotion/wellness education

The 2 “RE’s” Community re-entry program Re-rehabilitation program

New rehabilitation tools ד"ר גבי זייליג המחלקה לשיקום נוירולוגי neure@sheba.health.gov

Methods/techniques of training Medications Devices

Home adjustment Accessibility Accessories

Equipment

Sports & physical activity

The payor

Memento Main causes of morbidity & mortality: Equipment Accessories Infections Pressure sores Respiratory failure Cardio-vascular Suicide The annual cost of treating pressure sores alone is estimated at $1.2 billion (Byrne and Salzberg 1996). Hospital length of stay   Equipment Accessories Psych Housing Accessibility

Committee on Trauma. Resources for Optimal Care of the Injured Patient Committee on Trauma. Resources for Optimal Care of the Injured Patient. American College of Surgeons, 1990. “….It is illogical to develop sophisticated prehospital and hospital care to resuscitate and treat severely injured patients only to transfer them to custodial facilities after acute care without adequate rehabilitation…..The designation of rehabilitation facilities with the necessary staffing skills and programs to comprehensively serve people with spinal cord injury is as important as the need for specialized trauma services.