They never taught me that in medical school:
Quick Approaches to Common
Conditions affecting Patients with
Mobility Issues
51st Annual Scientific Assembly
November 2013, Toronto
James Milligan BSc.P.T., MD, CCFP
Joseph Lee MD, CCFP, FCFP, MClSc(FM)
Faculty/Presenter Disclosure
Faculty: James Milligan
Relationships with commercial interests:
Research funding from the Ontario
Neurotrauma Foundation (ONF)
Disclosure of Commercial Support
•No commercial support
Mitigating Potential Bias
•Not applicable
Faculty/Presenter Disclosure
Faculty: Joseph Lee
Relationships with commercial interests:
Research funding from the Ontario
Neurotrauma Foundation (ONF)
Disclosure of Commercial Support
•No commercial support
Mitigating Potential Bias
•Not applicable
Challenge of Managing Physical
Disabilities
• Low prevalence (Lee et al, 2011)
• Little training (Lee et al, 2011)
• Office inaccessibility (McColl, 2008)
• Systemic (McColl, 2008)
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
Objective: To learn approaches to common
conditions in mobility challenged patients:
1.
2.
3.
4.
5.
6.
7.
Neurogenic bladder
Neurogenic bowel
Osteoporosis
Spasticity
Autonomic dysreflexia
Sexual health
General health
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?
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
What should be done?
• Urine dip?
• Urine R&M, C&S
• Treat with antibiotics?
• Review urinary routine
• Send to urologist?
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
Significant Bacteriuria
Method Urinary Drainage
Count
• Intermittent catheterization
• Condom catheter
• Indwelling/suprapubic
catheter
• Spontaneous urination
• ≥ 102 cfu/L
• ≥ 104 cfu/L
• Any detectable
concentration
• ≥ 105 cfu/mL
Look for lower counts!
Neurogenic Bladder: UTI
*treat same as complicated UTI
Anti-infective review panel, 2010; SCIRE, 2011
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)
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
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)
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?
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
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 2nd 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
Neurogenic Bowel
Bulking Agents
Metamucil
Bran
psyllium
prunes
-Too much fibre can precipitate
constipation, aim for 15-30g
-Bloating, gas
Stool Softeners
Docusate sodium
-not very effective
Hyperosmotic Agents
PEG
Lactulose
-PEG useful if more gentle options
fail
Stimulant
Bisacodyl 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)
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 2nd day
SCIRE, 2011; Stolzenhein, 2005; Consortium for spinal cord medicine, 1998
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?
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
What should be done?
• Encourage regular calcium and vitamin D
• Secondary workup:
–CBC, Cr, Ca2+, albumin, ALP, TSH, 25-OH vit D, PTH*
• Encourage physical activity when fracture heals
• Avoid excessive caffeine, ETOH, smoking
• Anti-resorptive therapy ?
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
Osteoporosis Issues
• BMD controversy
• Fracture pattern different (SLOP- Sublesional
Osteoporosis)
• Hypercalciuria common
Schrager, 2004; SCIRE 2011; Craven et al, 2009
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
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?
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
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?
Spasticity Etiology
• Infection (uti)
• Noxious stimuli (constipation, ulcer, fracture)
• Disease progression (MS exacerbation, syringomyelia)
• Medication or not taking
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)
Spasticity
Medication
Dosage (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
Diazepam
2-10mg tid-qid
Sedation
Withdrawal
Confusion
Consortium for Multiple Sclerosis Centers, 2005; SCIRE, 2011
* Possibility of elevated liver enzymes; hepatotoxicity
Note: some patients will need combination of medications
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)
Cannabinoids
• College regulation
• Conventional treatments
• Understand use in condition
• Not obliged to complete
• Informed consent documented
CMPA, 2013
Key Points
• Treat if interfering with function
• Investigate etiology
• Refer if spasticity refractory
• Medical marijuana -indications, motivations, risks,
benefits, informed consent
SCIRE, 2011
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?
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
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
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
Autonomic Dysreflexia
Monitor for hypotension if pharmacotherapy used
Milligan et al, 2012
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
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?
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
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?
Sexual Health
Medication
Dosage
Side Effects/Cautions
Phosphodiesterase type 5
Inhibitors (PDE5i)
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
Papaverine, phentolamine,
prostaglandin E1 alone or combo
(see urologist for dosing and
titration)
-pain,swelling injection site
-priapism
-fibrosis
Intraurethral Preparations
Intraurethral alprostadil
(PGE1)(MUSE)
250-500mcg 10-30 min before
-not been effective in SCI
-may consider in MS
Mechanical Methods
Vacuum device
Penile ring
-acceptable method
-loss of rigidity
-petechiae, edema
-don’t leave ring on > 30-45 min.
Penile prosthesis
May be effective when other
interventions fail
-infection
-may affect urinary techniques
(Level 1 in SCI)
Penile Intracavernosal
Injection
(Level 2 in SCI)
*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
Sexual Health
• Women-less & delayed orgasm, decreased lubrication
• Men-erectile dysfunction
• Fertility
• Different positions
• Appliances
SCIRE, 2011; Rutkowski, 2002
Pregnancy Issues
• Bladder, kidney infections
• Thrombosis
• Mobility
• Postural hypotension
• Autonomic dysreflexia
• Premature labour
Rutkowski, 2002
Key Points
• Important to patients
• Physicians don’t ask
• Unique issues
• Same medications as able-bodied
• Fertility and pregnancy concerns
• Referral
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?
Mobility
• Fitting Cane & Walker
• 20-30° flexion of elbow or to height of wrist crease
Lam, 2007
Mobility
Cane considerations:
• Usually used opposite side
• May need more support (quad cane)
Walker considerations:
• Consider brakes, weight, size
Mobility
• ADP pays up to ⃰ 75%
• Central Equipment Pool (CEP) - high technology
wheelchairs
• ADP does not cover repairs/maintenance (except CEP)
ADP, 2012
* ADP pays 100% for those on social assistance benefits (OW, ODSP,
ACSD)
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)
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
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)
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
Final Questions?
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
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)
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
THANK YOU!
References
• Steins SA, Luttrel W, Binard JE. Polyethylene glycol versus vegetable oil based bisacodyl
suppositories to initiate side-lying bowel care: A clinical trial in persons with spinal cord injury.
Spinal Cord 36: 777-781, 1998.
• Stolzenheim G. Management of the neuropathic bowel for adults with spinal cord injury. Targeting
health professionals. Rural Spinal Cord Injury Project. 2005.
• Consortium for Spinal Cord Medicine. Neurogenic bowel management in adults with spinal cord
injury. Paralyzed Veterans of America. 1998.
• SCIRE. Spinal Cord Injury Rehabilitation Evidence. www.scireproject.com. 2010.
• Frohman TC, et al. Symptomatic therapy in multiple sclerosis. Ther Adv Neurol Disord 4(2): 83-98.
2011.
• Gulick EE, Namey M. Bowel dysfunction in persons with multiple sclerosis. Constipation- Causes,
Diagnosis and Treatment. Dr. Anthony Catto-Smith (Ed), InTech. www.intechopen.com. 2012.
• Multidisciplinary Association of Spinal Cord Injured Professionals (MASCIP). Guidelines for
management of neurogenic bowel dysfunction in individuals with central neurological conditions.
2012.
• Schrager S. Osteoporosis in women with disabilities. Journal of Womens Health. July 13(4):431437. 2004.
• Dionyssiotis Y. Neurological osteoporosis in Disabilities, Osteoporosis (Ed). InTech.
www.intechopen.com. 2012.
References
• Marreiros H, Loff C, Calado E. Osteoporosis in paediatric patients with spina bifida. J Spinal Cord
Med. Jan; 35(1):9-21. 2012.
• Zikan V. Bone health in patients with multiple sclerosis. Journal of Osteoporosis. 2011.
• Craven C. Issues in osteoporosis management related to spinal cord injury. Osteoporosis Update.
Fall 2009. Vol 13 (3).
• Consortium of Multiple Sclerosis Centers. Spasticity management in multiple sclerosis: evidencebased management strategies for spasticity treatment in multiple sclerosis. Journal of Spinal Cord
Medicine. Vol 28(2):167-199. 2005.
• Health Canada. Information for Health Professionals: Cannabis (marihuana, marijuana) and the
cannabinoids. February, 2013.
• Canadian Medical Protection Agency. Medical marijuana: New regulations and transition period.
October 2013.
• Milligan J, Lee J, McMillan C, Klassen H. Recognizing a common serious condition in spinal cord
injured patient. Can Fam Physician 2012,; 58: 831-5.
• Bateman AM, Goldish GD. Autonomic dysreflexia in multiple sclerosis. J Spinal Cord Med. 2002,
25(1):40-2.
• Rutkowski S. Sexuality and fertility following spinal cord injury: targeting health professionals.
Rural Spinal Cord Injury Project. September 2002.
• Craven BC, Robertson LA, McGillivray CF, Adachi JD. Detection and treatment of sublesional
osteoporosis among patient with chronic spinal cord injury: proposed paradigms. Top Spinal Cord
Inj Rehabil. 2009; 14(4):1-22.
References
• Assistive Devices Program Ministry of Health and Long-Term Care. Mobility Devices Policy
and Administration Manual. September 2012.
• Lam R. Choosing the correct walking aid for patients. Can Fam Physician. 2007, 53 (12):
2115-2116.
• Kailes JI. Making Preventive Health Care Work for You – A Resource Guide for People with
Physical Disabilities, 2006.
• Dubey V, Mathew R, Katyal S, Iglar K. Preventative care checklist. www.cfpc.ca. 2011.
• Canadian Immunization Guide. Public Health Agency of Canada. www.publichealth.gc.ca.
2013.
• McColl MA, Aiken A, McColl A, Sakakibara B, Smith K. Primary care of people with spinal
cord injury: scoping review. Can Fam Physician 2012; 58:1207-16.
• Middleton JW, Leong G, Mann L. Management of spinal cord injury in general practicePart 2. Aus Fam Physician 2008, 37(5): 331-338.
• Middleton JW, Leon G, Mann L. Management of spinal cord injury in general practice- Part
1. Aus Fam Physician 2008, 37(4): 229-233.
• Nicolle LE. Complicated urinary tract infection in adults. Can J Infect Dis Med Micriobiol.
2005; 16(6): 349-60.
• Papaioannou MD et al. 2010 clinical practice guidelines for the diagnosis and management
of osteoporosis in Canada: summary. CMAJ, 2010.
• Anti-infective guideline for community acquired infections. Anti-infective Review Panel.
2010.