Rehabilitation after a Spinal Cord
Injury
Tom Kiser MD
Assistant Professor
UAMS Dept of PM&R
Medical Director
Arkansas Spinal Cord
Commission
Objectives
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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
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Cardiovascular
Integumentary
Gastrointestinal
Metabolic
Neurologic
Musculoskeletal
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Urologic
Psychosocial
Sexuality
Respiratory
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
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. MSR’s
need not be normal.
Ambulation Potential
Ambulation Potential
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ASIA
ASIA
ASIA
ASIA
A
B
C
D
3-6%
50%
75%*
95%
* >50 yo 42%, <45 yo 90%. Burns
et al Arch Phys Med Rehabil
1997
Dittuno Functional Outcomes. In Spinal Cord
Injury. 1995
100%
80%
60%
A
B
C
D
40%
20%
0%
ASIA Impairment
Classification
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
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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
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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
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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.