Rehabilitation for acute spinal cord injury patients. Suttipong Tipchatyotin Nov 23, 2017

Transcription

1 Rehabilitation for acute spinal cord injury patients Suttipong Tipchatyotin Nov 23, 2017

2 Definition Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion. Resulting in temporary or permanent sensory and/or motor deficit.

3 Type of injuries Tetraplegia Impairment or loss of motor +/- sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Results in impairment of function in the arms as well as in the trunk, legs and pelvic organs.

4 Type of injuries Paraplegia Impairment or loss of motor +/- sensory function in the thoracic, lumbar or sacral (but not cervical) segments of the spinal cord, secondary to damage of neural elements within the spinal canal. Trunk, legs, pelvic organs may be involved Spared arm function

5 WHO statement 2013 Every year has SCI people. Major causes : road traffic, falls, violence SCI people 2-5 times more likely to die prematurely, esp. low to middle income countries. Social and economic loss

6 Cause of death: In years past: renal failure. National SCI Database since 1973: pneumonia pulmonary emboli septicemia. Netherland 2011: CVS, pulmonary Norway (50 yrs F/U) : pulmonary infection and dysfunctions, suicidal

7 Roles of rehabilitation in the acute care setting proper evaluation of functional disorders make prognosis and set goals Prevent comorbidities and manage patient safety Early ambulation and recover physical functions select a proper restorative rehabilitation facility and provide relevant information

8 Rehabilitation in post acute SCI Assess ASIA classification Prevent complications and early ambulation Set rehabilitation program and refer to proper facility

9 Why to do classification? There is a strong relationship between functional status and whether the injury is complete or not complete, as well as the level of the injury.

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11 Spinal shock Duration : Last from 24 hours to 3 months after injury,average 3 wks Spinal shock recovery : positive reflex activity return of BCR(S2-S4) & anal wink(s4-s5) Bulbocarvernosus reflex (S2-S4) Squeezing penis/clitoris/foley cath anal sphincter contraction 11

12 Neurological examination 2 components: Motor (myotome) Sensory (dermatome) Determine the sensory/motor and neurological levels Determine completeness of injury When the patient is not fully testable, record NT.

13 Sensory examination Test 28 dermatomes on the right and left sides of the body Test pinprick (PP) and light touch (LT) sensation. Don t forget to test also deep anal sensation by PR and grade as yes or no.

14 Sensory examination A three-point scale: 0 = absent 1 = impaired(diminished, hyperesthesia, allodynia) 2 = normal For pin-prick, use a safety pin For light-touch, use cotton / tissue paper *** Test at normal skin sensation before (e.g.face) Test from abnormal normal level***

15 Key sensory points C2 C3 C4 C5 C6 C7 C8 T1 occipital protuberance supraclavicular fossa superior AC joint lateral side of antecubital fossa thumb, dorsal PP middle finger, dorsal PP little finger, dorsal PP medial side of antecubital fossa

16 Key sensory points T2 apex of axilla T3 3 rd ICS T4 nipple line T5 5 th ICS T6 xiphoid T7 7 th ICS T8 8 th ICS T9 9 th ICS T10 umbilicus T11 11 th ICS T12 inguinal ligament at midpoint

17 Key sensory points L1 between T12-L2 L2 midanterior thigh L3 medial femoral condyle L4 medial malleolus L5 dorsum of 3 rd MTP S1 lateral heel S2 popliteal fossa S3 ischial tuberosity S4-5 perianal area

18 Motor examination 10 Key muscles a six-point scale: 0 = paralysis 1 = palpable contraction 2 = active movement, full ROM with gravity eliminated 3 = active movement full ROM against gravity 4 = 3+ against moderate resistance 5 = normal, 3+ against full resistance

19 10 key muscles Upper limbs C5 - elbow flexors (biceps, brachialis) C6 - Wrist extensors (ECRL and ECRB) C7 - Elbow extensor (triceps) C8 - Finger flexors (FDP to middle finger) T1 - Small finger abductor (ADM)

20 10 key muscles Lower limbs L2 - Hip flexors (Iliopsoas) L3 - Knee extensors (Quadriceps) L4 - Ankle dorsiflexors (Tib ant) L5 - Long toe extensors (EHL) S1 - Ankle plantarflexors (Gastrosoleus)

21 Complete or Incomplete Complete : loss of sacral sparing Perianal sensation Deep anal sensation Voluntary anal sphincter contraction

22 ASIA A ASIA-A Complete. There is no sensory or motor function preserved in the sacral segments of S4-S5

23 ASIA-B Sensory incomplete. Motor deficit without sensory loss below the neurological level, including the sacral segments of S4-S5 (light touch, pin sensation or deep anal sensation at S4-S5) There is no protected motor function from three levels below the motor level at each half of the body

24 ASIA-C Motor incomplete. Motor function is preserved below the neurological level and more than half of the muscles below this level have strength lower than 3/5 (0, 1 or 2)

25 ASIA-D Motor incomplete. Motor function is preserved below the neurological level and at least half of the muscles (half or more) below this level have strength higher than 3/5

26 ASIA-E Sensory and motor function in all segments are normal and in patients with pre-existing deficits there is "E degree of ASIA. Initially one without a spinal cord injury does not have an ASIA degree.

27 Prognosis Percentage change in ASIA grading after first year A to B 88.8 B to C 48.9 C to D 41.4 D to E 90.3

28 Prognosis of Motor Recovery motor recovery occur rapidly in first 1-2 week slow recovery slower pace during first 4 months (mostly plateau at 5 months) Recovery period : mo. Cauda equina lesion : 2-3 yrs.

29 Functional Goal For complete SCI Level of Injury ADLs Ambulation C4 Totally dependent Power wheel chiar C5 C6 Feeding, light hygiene care independent with orthosis +dressing upper part independent, sitting up with ladders Projection wheel chair [short distance] Manual wheel chair C7 Totally independent Manual wheel chair Same level transfer C8 Totally independent Manual wheel chair Same level transfer

30 Functional Goal For complete SCI Level of Injury ADL Ambulation and transfer T1-T10 Totally independent Manual wheel chair + same level transfer T11-T12 Totally independent +walk with KAFO for short distance L3-S3 Totally independent Community ambulation may be with AFO

31 Rehabilitation in post acute SCI Assess ASIA classification Prevent complications and early ambulation Set rehabilitation program and refer to proper facility

32 Acute care Prevent complication To deliver safe, effective, and efficient rehabilitative intervention There are several reasons for improper transfer process, such as the presence of severe comorbidity, concurrent mental disorder, or long-term artificial respiration management.

33 Continue rehab program in acute ward Acute medical management Rehabilitation unit or restorative hospital Long term care facility Or community hospital

34 Early as soon as possible? Sumida et al. compared the number of hospitalized days between the patients who were transferred to rehab hospital during the acute phase (early intervention group) to those who were transferred during the convalescent phase (delayed intervention group). The early intervention group showed a shorter length of hospitalization (185 days compared to 267 days) and higher Functional Independence Measure (FIM) efficiency (0.446 compared to 0.126)

35 Complete rehab in acute setting LOS restraint Limited resources Not all centers are equal.

36 Rehabilitation management Acute phase management Spine stability Prevent complications Provide maximal recovery Rehabilitation phase Functional outcomes Bladder Bowel management Pain management Nutritional supplement

37 Early rehabilitation plan Aggressive assessment and management of secondary complication lead to restore functions Recognition and early intervention : orthostatic hypotension, DVT/PE, early ventilatory failure Early assess neurogenic bladder prevent renal failure and uncontrolled incontinence

38 Contracture At least one joint contracture (43% shoulder,33% elbow, 41% forearm and wrist, 32% hip, 11% knee,40% foot and ankle) has been reported in about 66%of patients within 1 year. AFO to prevent contracture

39 Muscle changed after immobilized Cat soleus muscles Immobilized in shortened position Immobilized in lengthened position Length tension properties Decreased extensibility Not changed Total numbers of sarcomere Reversibility 40% decreased 20% increased Within 4 weeks

40 Stretching in neurological patient No study performed stretch for more than seven months. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions The short-term effects of stretch on quality of life and pain in people with neurological conditions,

41 Suggested interventions Strengthen weak antagonists local and general inhibition Passive lengthening

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43 Pressure ulcer

44 Pressure ulcer Proper position Avoid shearing, slipping when changing position Clean and moisture skin Nutritional management Bed or seating devices Risk assessment (Braden score)

45 Orthostatic hypotension Autonomic CVS control via spinal cord segment T1-T5, T1-L2 During spinal shock, generalize vasodilate profound hypotension (neurogenic shock)

46 Orthostatic hypotension Higher SCI level higher incidence Previous report 74% of SCI people, met diagnostic criteria 59% of SCI people, symtomatic hypotension Less incidence in elderly SCI

47 Orthostatic hypotension Mechanisms Sympathetic dysfunction Altered baroreceptor sensitivity Lack of skeletal muscle pumps Cardiovascular deconditioning Altered salt and water balance

48 Orthostatic hypotension Nonpharmacological management Avoid precipitating factors; diuretics, alcohol, caffeine Increased salt and water intake Abdominal compression Bandage and stocking Sleep with head raised by degree Minimized postprandial hypotension

49 Orthostatic hypotension Pharmacological management Fludrocortisone Midodrine (alpha-adrenergic agonist)

50 Autonomic dysreflexia Emergency and life threatening condition in SCI people Massive sympathetic outflow in response to noxious stimuli below the level of spinal cord injury (most common in above T6 level)

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54 Andrade LT. Rev esc enferm. 2013

55 Rehabilitation in post acute SCI Assess ASIA classification Prevent complications and early ambulation Set rehabilitation program and refer to proper facility

56 Rehabilitation team

57 Rehabilitation goals

58 Rehabilitation phase The most intensive rehabilitation program Inpatient setting At least 3 hours per day, 5-7 days per week Team/Family conference for program update and discharge plan

59 Intermediate care service plan เปล ยนภาระ เป นพล งของส งคม เป าหมายหล ก ระบบบร การฟ นฟ สมรรถภาพและการด แลต อเน อง Stroke traumatic brain injury spinal cord injury Flow chart: แนวทางการให บร การ ให บร การตามความพร อมและบร บทของพ นท โดยผ ป วยและญาต ม ส วนร วมในการต ดส นใจ เป าหมายรอง ลดความแออ ด รพศ. รพท. / เพ มอ ตราครองเต ยง รพช. ระบบส งต อผ ป วยกล มอ น เช น post-surgery, chronic wound, chemotherapy ผ ป วย (Stroke, Head injury, SCI) รพศ. รพท. ท พ นระยะ Acute และสภาวะทางการแพทย คงท ประเม น Barthel index Barthel > 15 No multiple impairment Barthel < 15 Barthel > 15 with multiple impairment จ าหน าย พร อมให home program ประสาน rehab team รพช. ต ดตาม ด แล IPD Intermediate ward อย างน อยแห ง ละ 10 เต ยง (ใน รพช. ท ม ความพร อม) intermediate bed รพช. ในพ นท อย าง น อยแห งละ 2 เต ยง OPD ให บร การฟ นฟ แบบผ ป วยนอก ประเม น Barthel index ท ก 1-2 เด อน จนครบ 6 เด อน ช มชน :ให บร การ ฟ นฟ ในช มชนโดย PCC, ท มเย ยมบ าน BI = 20 BI BI < 11 Discharge ต ดตามโดย ท มฟ นฟ ฯ LTC ประเม นความพ การ