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SCI Traumatic Part 2 (Management and Treatment, Cutting edge concepts in practice, Gaps in evidence based knowledge)

  1. Disease/Disorder:
    Definition
  2. Essentials of Assessment
  3. Rehabilitation Management and Treatments
    Available or current treatment guidelines

    The Paralyzed Veterans of America (PVA) have sponsored the development of clinical practice guidelines of the Consortium for Spinal Cord Medicine for the management of those with spinal cord injury (SCI) based on literature reviews and expert panel consensus.1-6

    The Spinal Cord Injury Rehabilitation Evidence (SCIRE) project is a compilation of the research evidence underlying rehabilitation interventions for people with SCI.7

    At different disease stages
    • new onset/acute
      • Immobilization of the spine during transportation and in-hospital management, management of airway, blood pressure, heart rate, and temperature, and recognition and management of associated injuries are key components of early acute management.1
      • Surgical spinal stabilization and decompression may be indicated. Closed or open reduction should be done as soon as feasible with bilateral cervical facet dislocation in incomplete SCI.
      • Anticoagulation for deep venous thrombosis (DVT) prophylaxis should be initiated within 72 hours of injury unless contraindicated. In these cases, mechanical DVT prophylaxis should be initiated until it is safe to begin anticoagulation.
      • Oxygen saturation and arterial blood gas monitoring should occur in the initial days following injury, in order to monitor for declining oxygen saturation and carbon dioxide retention. This may herald the need for mechanical ventilation.
      • Positioning, range of motion, and skin, bladder, and bowel management should be addressed from the onset of hospitalization in order to minimize complications. Neurogenic bladder is initially managed with an indwelling catheter, while the patient is in spinal shock. Emergence from spinal shock is seen on physical exam with the presence of the bulbocavernosus reflex and/or the anal wink. The indwelling catheter may be discontinued, and timed prompted voiding may be initiated upon the emergence from spinal shock. Bladder scans are helpful in order to evaluate for incomplete bladder emptying and prompt intermittent catheterization.
    • subacute
      • The primary goals during the subacute period are to educate the person and family about SCI, prevent secondary complications, improve function, and prepare the person for integration into the community. Functional goals are established, taking into account the neurologic level and completeness of injury, individual factors, and coexisting conditions. Inpatient rehabilitation therapy includes increasing tolerance to the upright position, therapeutic exercises for strength, balance, and endurance, improving function in activities of daily living, bed mobility, transfers, wheelchair training, gait training, as appropriate, and bowel-bladder management training.
      • Indwelling bladder catheters should be discontinued, if still present, and timed prompted voiding trials with intermittent catheterization education and training should be intitiated. A urodynamic study may be necessary in order to evaluate the underlying bladder dysfunction and for planning long-term bladder management. The goal for the volume per void should be under 500 mL in order to prevent bladder overdistention and elevated intradetrussor pressure, placing the upper genitourinary tracks at risk.2
      • Goals of a bowel program are daily or every other day bowel movements with planned evacuations without accidental elimination. An upper motor neuron bowel responds well to nightly suppositories and digital rectal stimulation. Lower motor neuron bowel management usually requires manual dissempaction or enemas.3
      • Autonomic dysfunction can cause significant morbidity and mortality. Orthostatic hypotension can be managed with abdominal binders and elastic bandage wrapping of the lower extremities. Autonomic dysreflexia (AD) is a medical emergency occurring in patients with a level of injury T6 or higher.4 Signs of AD include blood pressure greater higher than 20 mm Hg above their baseline, often with bradycardia, headache, flushing, sweating, and piloerection above the level of injury. Bladder and bowel distention are the most common precipitating factors for AD. Management includes sitting the patient upright, loosening clothing, inspection of the body for noxious stimulants (pressure ulcer, ingrown toenails, etc), and immediate bladder catheterization. If symptoms persist, a rectal exam should be performed. An algorithm for the treatment of AD for both children and adults is available from the Dana and Christopher Reeve Foundation at no expense.
      • Pressure ulcer prevention includes turning in bed every 2 hours and teaching weight-shifting strategies.5
      • Spasticity management goals include preserving range of motion and treating functional impairments. In the subacute phase, spasticity may assist patients by providing trunk rigidity, assisting in breathing and sitting balance, and leg spasticity, which may assist in transfers and standing.
      • The higher the level of SCI, the greater the risk of pulmonary complications.6 Secretion management and maintaining lung tissue expansion are imperative to prevent atelectasis and pneumonia.
      • Pain in the SCI patient can be a multifactorial, both nociceptive and neuropathic, treatment, which is similar to other patient populations, and should be treated accordingly.
      • Weaning from the ventilator may be attempted using progressive ventilator-free breathing.
    • chronic/stable
      • Rehabilitation in the chronic stage is typically done in an outpatient setting in conjunction with a home exercise program.
      • For apneic patients, electrophrenic respiration may be possible if phrenic nerves are viable. SCI has been associated with obstructive sleep apnea, and a sleep study should be considered if symptomatic. Pneumococcal and influenza immunization and tobacco cessation counseling are important, as are ongoing measures to prevent cardiovascular disease.
      • DVT prophylaxis can be discontinued within 8-12 weeks after injury in uncomplicated cases.
      • Periodic genitourinary evaluation is done to ensure adequate voiding and minimizing complications. Changes in voiding warrants a urinalysis and culture to evaluate for a urinary tract infection. It must be stressed that patients with neurogenic bladder are often colonized and should only be treated if symptomatic.
      • Surgical management exists to increase bladder capacity and to allow improved catheterization access.
      • Bowel program should be optimized for decreasing total time spent on the program. A bowel movement at regular intervals is needed in order to prevent the risk of obstruction.
      • Spasticity may become a barrier to functional improvement and could cause contracture and skin breakdown. Oral antispasticity medications may be of benefit. Intrathecal pumps may be considered for some. For localized, distinct problems, chemodenervation is preferred, using botulinum toxins and/or phenol injections. These interventions are most efficacious in conjunction with a therapy plan utilizing physical therapy and occupational therapy for splinting, electric stimulation, and other modalities in order to help with improving range of motion and strengthening weakened muscles.
      • Endocrine function is affected in chronic SCI. Initial sites of osteoporosis in the SCI patient are not usually the hip and lumbar spine, as found in postmenopausal women. In SCI, the distal femur is often affected, whereas the lumbar spine is denser than normal because of osteoarthritic changes. In tetraplegia, the distal wrist is also evaluated. Treatment of osteoporosis in the setting of SCI is still evolving, and may include bisphosphonates and checking levels of 25-hydroxy vitamin D and calcium, with replacement as needed.
      • Musculoskeletal complications including heterotopic ossification, osteoporotic fractures, spinal deformities, and overuse syndromes should be identified and managed as appropriate. Measures for upper-extremity preservation should be monitored lifelong.
      • Sexual and reproductive health should be addressed in a supportive, respectful, and nonjudgemental manner.
      • Depression, suicide risk, and substance abuse are more common in SCI than in the general public, and should be managed appropriately.
      • Monitoring of bowel, bladder, skin, spasticity, and respiratory status should continue in the outpatient setting. Neurologic level should be stable. Worsening of any of these areas should prompt the patient for a physician appointment and may warrant a magnetic resonance imaging to rule out syringomyelia.
    • pre-terminal or end of life care
      • Unique clinical and ethical issues may need to be addressed with aging and end of life care.
    Coordination of care

    A team approach is necessary in the rehabilitation of SCI. Team meetings and communication are critical for coordination of care. Inclusion of the patient in goal-setting is essential.

    Patient & family education

    All organ systems involved are discussed in the acute rehabilitation setting in order to direct patient care in the community. Special emphasis should be placed on signs and symptoms of AD for those at risk. Literature focused on education and expected outcomes for SCI is available from the PVA in a series called Consumer Guidelines. There is also a financial guide for people with SCI called On the Move. Ongoing education and support are important to facilitate transition and prevent complications.

    Emerging/unique Interventions

    Measures of function include the Functional Independence Measure and the Spinal Cord Independence Measure, version III.8

    Physical outcome measurements include the Penn Spasm Frequency Scale, the Modified Ashworth Scale, and the International Standards for Neurological Classification of Spinal Cord Injury. Activity outcome measures exist for hand function (Jebsen Hand Function Test, Grasp and Release Test), sitting balance (Modified Functional Reach Test), standing balance (Berg Balance Scale), wheelchair propulsion (Functional Tests for Persons who Self-Propel a Manual Wheelchair), and ambulation (Walking Index for Spinal Cord Injury).

    The Craig Handicap Assessment and Reporting Technique (CHART) is a validated measure of participation.

    Translation into practice: practice "pearls"/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

    Physiatrists specializing in SCI often function as primary care physicians for this population. In addition to helping keep people with SCI in optimal health and function, their role includes advocacy and education within the health care system, because there is often a lack of knowledge about several aspects of SCI care and assessment amongst health care providers.

  4. Cutting edge/emerging and unique concepts and practice
    Cutting edge concepts and practice

    Functional electric stimulation (FES) is a cutting-edge concept and practice in the rehabilitation of SCI. Upper-extremity devices (NESS H200) and lower-extremity devices (NESS L300, WalkAide) exist for the treatment of functional deficits. FES ergometry provides electric stimulation to both the upper and lower extremities for maintenance of cardiovascular fitness and to fend off osteoporosis and metabolic syndrome.

    Diaphragmatic pacing systems provide electric stimulation to those with intact phrenic nerves and can help some candidates wean off mechanical ventilation.

    Direct epidural spinal cord stimulation of the L1-S1 cord segments used with training has been shown to allow standing with full weight bearing in a motor complete person with tetraplegia. Volitional leg movements with stimulation were observed 7 months after implantation.9

    Exoskeleton units have been developed to allow for ambulation with the use of assistive devices in those with limited leg strength.

    Intradetrussor botolinum toxin has allowed for increased capacity and improvement in patients with detrussor-sphincter dyssynergia.

  5. Gaps in the evidence-based knowledge
    Gaps in the evidence-based knowledge

    The use of steroids continues to be controversial despite 3 randomized, double-blind, multicenter trials (National Acute Spinal Cord Injury Study [NASCIS] I, II, and III). The NASCIS trials showed no statistical difference between steroids and placebo in terms of neurologic recovery (their primary endpoint) at 1 year, except in post hoc analyses of subgroups, and there has been considerable evidence of side effects in high-dose steriod therapy.

    There are no precise guidelines regarding the timing of surgical decompression following acute SCI except for cervical SCI. There is growing evidence that spinal decompression following cervical injury should be performed within 24 hours of injury.10

    Timing, dosage, and frequency of electric stimulation is controversial, because increasing activity at the site of injury acutely may lead to a larger penumbra. In the subacute period, there is insufficient evidence to quantify the amount of therapy required to obtain optimum results.

    There is controversy regarding outcomes in body-weight-supported treadmill systems versus overground ambulation training.

    References
    1. Consortium for Spinal Cord Medicine. Early Acute Management in Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2008.
    2. Consortium for Spinal Cord Medicine. Bladder Management for Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2006.
    3. Consortium for Spinal Cord Medicine. Neurogenic Bowel Management in Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 1998.
    4. Consortium for Spinal Cord Medicine. Acute Management of Autonomic Dysreflexia: Individuals With Spinal Cord Injury Presenting to Health-Care Facilities. Washington, DC: Paralyzed Veterans of America; 2001.
    5. Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2000.
    6. Consortium for Spinal Cord Medicine. Respiratory Management Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2005.
    7. Spinal Cord Injury Rehabilitation Evidence. Available at: http://www.scireproject.com/. Accessed August 3, 2012.
    8. Consortium for Spinal Cord Medicine. Outcomes Following Traumatic Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 1999.
    9. Harkema S, Gerasimenko Y, Hodes J, et al. Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case study. Lancet. 2011;377:1938-1947.‚Äč
    10. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7:e32037.