Discogenic Lumbar Pain
[…] late degenerative disk disease (DDD) and internal disc disruption.1 DLP symptoms are distinct from those occurring as a result of spinal deformity or radiculopathies. Etiology Strong familial predisposition to DLP2 DDD is associated with advanced age, male sex, and smoking3 […]
Sleep Disorders in Diseases of the Central Nervous System
[…] to the central nervous system (CNS) and in neuro-degenerative disorders. Sleep disorders have been studied in traumatic brain injury (TBI), spinal cord injury (SCI), stroke, Parkinson’s disease, epilepsy, dementia, and other neurologic conditions. A multitude of sleep disorders have been described including […]
Fall Prevention in the Elderly
[…] and a multifactorial intervention initiated as appropriate.9 Specific secondary or associated conditions and complications Complications from falls include lacerations, fractures, spinal cord/head injuries, hypothermia, pneumonia, pressure ulcers, rhabdomyolysis, venous thromboembolism, and dehydration. Falls can also lead to hospitalization, greater dependence, loss of autonomy, and depression as well as nursing home residency. Persons hospitalized for falls are more likely discharged to nursing homes and to need more in-home services; they are less likely to regain pre-injury mobility status. Fear of falling alone can result in functional decline.1 Essentials of Assessment History All older persons should be asked at least annually if they have fallen.9,14 A positive response to falls screening questions (>2 falls in past 12 months, medical evaluation for an acute fall, difficulty with walking or balance) should prompt a […]
Obesity
[…] 2, hypertension, and coronary artery disease in people with visceral adiposity. This pattern frequently exists in certain disability populations (e.g., spinal cord injury, spina bifida, cerebral palsy). Therefore, insulin resistant diabetes should be recognized in these populations. Epidemiology including risk factors and primary prevention Obesity is a chronic disease with an increasing prevalence in the United States as well as worldwide. More than one-third (34.9% or 78.6 million) of the adults in the United States are obese.13 The estimated annual medical cost of obesity in the US was $147 billion in 2008 US dollars; the medical cost for people who are obese was $ 1.429 higher than those of normal weight.13 People with disability have a higher prevalence of obesity than people without disability.14 There are several challenges that people with disability face in trying to prevent obesity. These include difficulty accessing healthy foods, side effects of certain medications, poorly monitored enteral feeding,15 pain, reduced ability to exercise, decreased energy, lack of accessible environments and resources.14 Low socioeconomic status plays a large role in the development of obesity for a variety of reasons. Obesity prevalence among preschoolers was the highest for families in which the household income was at or below the poverty threshold.16 Prevention: Obesity is a complex health issue and there is not a simple strategy to help prevent it. There are state and local programs available as well as community efforts that try to prevent obesity by promoting healthy living behaviors.17 Patho-anatomy/physiology Obesity is a complex, multifactorial condition influenced by social, behavioral, physiologic, metabolic, cellular, and molecular interactions. Risk factors in adults: Genetic predisposition Diabetes mellitus Seasonal affective disorder Childhood physical abuse Shorter sleep duration ( 35 kg/ m2and a serious obesity-related comorbidity (i.e., DM, CAD, sleep apnea) One of the above AND both of the following: Have failed less invasive weight loss methods Are highly motivated to improve their quality of life Separate guidelines exist for bariatric surgery in adolescents and children42but very few directly address people with disabilities. The pediatric guidelines of the American Society for Metabolic and Bariatric Surgery include one sentence recommending against denying treatment to adolescents with cognitive disabilities.43 Types of bariatric surgical procedures: Gastric banding Roux-en-Y gastric bypass Sleeve gastrectomy Biliary pancreatic diversion Long-term Effects Potential nutrient deficiencies including vitamin B12, folate, vitamin D, and iron Greater weight loss (20-35% of initial weight at 2-3 years post-op) than conservative measures25-27 Longer duration of maintaining healthier weight in adults25-27 Favorable effect on obesity-related comorbidities: Reductions in fasting glucose and insulin levels Decreased incidence of type 2 diabetes Greater likelihood of remission of diabetes Improvement in most measures of health-related quality of life at 2 and 10 years post-op25-27 At different stages Childhood onset Childhood and adolescent obesity should be addressed as soon as possible. A combined approach including decreased caloric intake and increased caloric expenditure is optimal. Children should always be in a medically supervised intervention program. Adult identification Lifestyle modification in combination with a weight-loss program should be initiated. Unless one is in a medically supervised intervention program, the lowest daily caloric intake recommended is 1,200 calories for women and 1,500 for men. Medical comorbidities should be discussed and reviewed. Identification with disability and prevention The risk of developing obesity is also an important health concern in individuals with disability. A significant predisposing factor is impaired mobility, as it can be a barrier to accessing healthy food options,44 as well as limit opportunities for physical activity.45,46 There can also be additional condition-specific mechanisms that increase risk of developing obesity, eg. In spinal cord injuries.47. There must be anticipatory guidance to monitor nutritional intake early on and to implement an adapted exercise regimen. Coordination of care Most dedicated weight loss programs involve multidisciplinary teams, including exercise physiologists, athletic trainers, dieticians/nutritionists, and psychologists, with involvement of physicians, especially when participants have chronic conditions and/or disability. People with disability can engage in and benefit from weight management strategies, but may require cognitive, motor, or environmental modifications and different supports from those typically offered. Self-management programs, while individually driven, require frequent clinical assessment and outside monitoring. Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills Obesity is a prevalent health problem. Physiatrists care for a large variety of patients with obesity as a cause for disability, or in association with disability. Typical office practices can be organized to include routine measures of healthy weight status (e.g., on-site weight/height measurement, determination of BMI, waist circumference measurement, or other accepted measurement), discussion of and guidance for physical activity, guidance for caloric intake or referral for individual discussion, and sources for dedicated weight loss programs, health clubs and gyms (especially those offering modified programs), or self-management strategies. Please note that there is a poorly utilized CPT-code for physical activity counseling (ICD-9: V49.89 and ICD-10: Z78.9). Observing trends of mobility associated with weight changes in individual patients or patients grouped by disability type can offer insights into rehabilitation interventions. Documentation of even some of the above can demonstrate participation in quality measures and can support appropriate ICD and CPT coding. Counseling rates for obesity and weight management are low among healthcare professionals.33 The low rates are attributed to limited physician education in undergraduate and graduate medical education about the topic, time restraints in clinical practice, and difficulties broaching the subject.22,48 As the prevalence of obesity continues to rise in the population at large, as well as in those with disability, it is imperative that this issue not be overlooked. Population medicine and public health have been promoted in undergraduate medical education and include information about obesity and strategies to engage patients. Graduate medical education must also include obesity prevention and management within each specialty area. Understanding the theories and constructs of behavior change is a key element of health promotion strategies (Table 2). As health/medical homes and quality measures become more mainstream, documentation of obesity and interventions may be required. Training physicians in motivational interviewing would make it easier to start conversations with obese patients about their weight and the importance of noting this health issue. A life-style events vs. body weight graph (that tracks life events with associated weight gain) may allow physicians to begin conversations about the path to weight management.22Patients must be aware that behavior modification is significant in long-term success for losing weight and subsequent weight management. Table 2. Theories of behavior change and health promotion Theory Description Transtheoretical Model49 Stages of or readiness to change behaviors: – Pre-contemplative (no thought about change) – Contemplative (thoughts about change) – Preparation (taking steps to change) – Action (initiating changes or activities) – Maintenance (sustaining activities of change) Processes or strategies used to change: consciousness raising, goal setting, social support, role modeling, self-efficacy, decisional balance, self-rewards Social Cognitive Theory50 Interrelationships of social environment, personal cognitive capabilities, present behaviors that may affect future behaviors, with a focus on education Behavior influences and is influenced by the person and the environment Behavior changes explanations: self-efficacy, self-regulation, outcome expectancy values, observational learning, reinforcement Ecological Models of Health Behavior51 Influence of behaviors by intra- and interpersonal factors, sociocultural groups, policy and physical-environmental factors Comprehensive approaches (multi-factorial program) more effective than a single approach Cutting Edge/ Emerging and Unique Concepts and Practice Recognition and management of unhealthy weight for people with disability Although this document presents recognition and management of obesity in people with and without disability, it is not common for practitioners in general to consider weight management for people with disability. Routinely following weights or assessing %BF is an important component of follow-up for the health and function of people with disability, because both over- and underweight conditions can develop. Anticipatory guidance and preventing significant obesity in people with disability may be up to the physiatrist, who has the knowledge and skills to develop an exercise program with needed modifications. Measurement of obesity: BMI has been shown to not effectively measure obesity for people with disability in general, because disability and disease can affect the measurement of accurate height/weight and correct practices are not often done; %BF is actually the value of interest. There have been a number of studies about a variety of disability types showing this inaccuracy, and a few of interest are people with SCI should be considered obese with BMI >22 kg/m2;52 amputation and limb loss limit use of BMI, and a “BMI calculator” has been developed to accommodate for this weight discrepancy;53 people with intellectual disability more closely follow the general public on BMI usage.54 Heath Promotion programs: Weight management has been successfully achieved for people with disability through organized health promotion programs providing guidance about physical activity, nutrition, stress management, health responsibility and self-management, and behavior change.55-57 Curricula have been based on existing programs, with physical and cognitive modifications plus routine personal support and feedback. Many of the same adherence issues are seen for people with as without disability. Telemedicine: Littman et al tried a telephone-delivered physical activity and weight management intervention for individuals with lower extremity amputation. The intervention arm received self-monitoring tools (e.g., pedometer, scale) and written materials, a single exercise counseling home visit by a physical therapist, and up to 11 telephone calls from a health coach over 20 weeks that involved motivational interviewing to set specific, attainable, and measurable goals, with better response when being followed up by phone calls.58 Bariatric surgery: There are increasing numbers of case reports and series documenting success with bariatric surgery managing obesity for people with disability, primarily those with spinal cord dysfunction and intellectual and developmental disabilities. Subjects were determined to be obese with BMI typically >40kg/m2 with comorbidities (e.g., DM, sleep apnea) and failed conservative measures. Most subjects noted weight loss and decreased obesity-related comorbidities.59-61 […]
Therapeutic Modalities
[…] Erhan B, Gunduz B, Lakse E. The effect of low-frequency TENS in the treatment of neuropathic pain in patients with spinal cord injury. Spinal cord. 2013;51(4):334-337. Forst T, Nguyen M, Forst S, Disselhoff B, Pohlmann T, Pfutzner A. Impact of low frequency […]
Acute Flaccid Myelitis
[…] ventilation or neurological complication leading to death.18 Physical examination Examination of these patients reveal findings similarly seen in patients with spinal cord injury; this includes spinal shock.19 Weakness is evaluated as asymmetric paralysis in arms or legs. Often, patients are weaker proximally […]
Myelomeningocele (Spina Bifida)
Disease/ Disorder Definition Myelomeningocele (MM) is a developmental birth defect of the neural tube (NT), resulting in an open spinal cord lesion. The following are types of NT defects: Anencephaly occurs when the cephalic end of the NT fails to […]
Pulmonary rehabilitation after ventilatory failure
[…] RF. Epidemiology including risk factors and primary prevention Listed below are some common disease processes as epidemiology varies with each. Spinal Cord Injury: Respiratory complications are the most common cause of morbidity and mortality in acute SCI, with an incidence of 36% to 83%. Risk factors include level of injury, aspiration, chronicity of disease, prior lung disease amongst many others.1 Multiple Sclerosis: Advanced respiratory support in MS is highly unusual. A study by Pittock et al. found a total of 22 patients requiring mechanical ventilation over a period of 33 years. The median time to death after the start of ventilation was 22 months.2 Amyotrophic Lateral Sclerosis: Respiratory complications are the most common cause of mortality in ALS and the average survival time for diagnosis is 2-5 years. Older individuals >65 and those with severe bulbar involvement have a much poorer respiratory prognosis. The use of invasive ventilation is rarely […]
Somatic Abdominal and Pelvic Pain
[…] blocks, as well as sympathetic ganglion blocks (celiac/hypogastric plexus, Ganglion of Impar) may be considered in the treatment of CPP.16 Spinal injections have success when a referred or radiculopathic pain is suspected. Caudal ESI (epidural steroid injection) plays a particularly relevant role in CPP. Temporary yet consistent response to nerve blocks may guide the interventionalist to consider more permanent procedures, such as chemical neurolysis, pulsed frequency neuromodulation, or radiofrequency ablation. Considered as a permanent measure, neuromodulation with spinal cord stimulators or peripheral nerve stimulators can be considered if all other prior measures have been trialed, or if patient is found to be an exceptional candidate with a permanent disease/illness. Other surgical techniques may include pre-sacral neurectomy, laparoscopy and hysterectomy.12 Pre-Terminal or End-of-Life Care Cancer-related abdominal wall pain may require opiates or interventional procedures including nerve blocks. Palliative radiation may be considered with bony metastases. Spectrum of treatment approaches Treatment availability may vary greatly depending on regional resources. Physical therapists trained in pelvic floor rehab are often sparse, as may be physiatrists with knowledge in this area. Accordingly, these patients may be cared for by gynecologists and internists. It is important to advocate for the patient to utilize all resources available, and to proceed in a step-wise, risk-averse pattern. Benzon et al (2017) described an algorithm for a step-wise, interventional approach to CPP:12 physical therapy>trigger point injection>lumbosacral epidural steroid injection>peripheral nerve block>sympathetic block>spinal cord stimulator>surgery>intrathecal pump Patient & family education Both the patient and family members should be kept informed of diagnosis and disease […]
Administrative Rehabilitation Medicine: Systems-based Practice
[…] during the cost reporting period must match one or more of thirteen CMS designated medical conditions. These conditions are: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of the hip, brain injury, burns, active polyarthritis, systemic vasculitis with joint involvement, specified neurologic conditions, severe or advanced osteoarthritis (involving 2 or more joints), knee or hip replacement (bilateral, or unilateral with body mass index >50, or age 85).10,29 Payments under a PPS are made on a per discharge basis, and payment rates are based […]