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SCI acute care and rehabilitation PT 2009

SCI acute care and rehabilitation PT 2009

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03/18/2014

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Spinal cord injury: medical, neurological & rehabilitation aspects

Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

. Zeilig, MD, Department of Neurological Rehabilitat Sheba Medical Center, Tel Hashomer

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

WATH’S A SPINAL CORD ?INJURY
•Loss of motor and sensory function bellow the level of injury

•Spasticity •Pain
•Sexual dysfunction

•Loss of bowel & bladder control
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

PATHOPHYSIOLOGY

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Three major classes of damage
• 1. Death of nerve cells • 2. Disruption of nerve pathways • 3. Demyelination (loss of axon isolation)

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

PRIMARY INJURY
SECONDARY INJURY:
 STROKE-LIKE ISCHEMIC INSULT
Disturbances in cellular calcium Free radical production Excitotoxcic amino acid release

progressive degeneration of white and grey matter
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Post-Traumatic SCI changes
• Primary cell loss • Secondary Cell loss
– central hemorrhage/ischemia – Wallerian degeneration

• Cystic degeneration
– Syringomyelia

• Muscle atrophy
– especially w/LMN loss

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Post-Traumatic Changes to the Spinal Cord
• “Primary” injury – Immediate nerve damage will lead to nerve degeneration • “Secondary” injury – Delayed nerve injury due to inflammatory response, ischemia, ca++, free radicals • Complete is NOT “complete”
– Transection is rare – 10% can support substantial function
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Prognosis following SCI
• Nerve regeneration - “currently” this does not occur within the CNS • Neurological recovery - can occur in incomplete injuries and w/I the ZOI • Functional improvements - occur in relation to LOI, comp/inc, motivation, staff training, decreased complications
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

?Why No SCI Regeneration
• 1. No stimulus for regeneration
– Nerve Growth Factors (NGF) • (Levi-Montalcini, Nobel Prize) – PNS has NGF, CNS does not • Produced naturally • Protects against cell damage • Stimulates regeneration

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

(Why

No SCI regeneration (cont

• 2. Inhibitory Factors
– Oligodendrocytes inhibit axon growth (Schwab1980’s) – Antibodies can block this inhibition

• 3. Impenetrable Regions
– Astrocyte scars can block regeneration

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SPINAL CORD INJURY: Statistics

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SPINAL CORD INJURY: Numbers
• > 10.000 SCI/year
• 30-50/1.000.000 new SCI/year

• 200.000 living SCI in USA • Annual cost : $ 5 billion
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Occipito-cervical dislocation: fusion C0-C3 by summit system: SCI

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

TBI: Hemiparesis; cognitive & behavioral disturbances

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

RT. Brachial plexus injury: Rt. UE. paralysis

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Bilateral avulsion fracture of occipital condyles and fracture of clivus

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Fracture of rt. distal femur:ORIF with .nailing

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Open comminuted fracture of Rt. Tibia and Fibula - ORIF with nailing

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Bilateral fracture of mandibular condyles

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

AK Amputation

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

ACUTE SPINAL CORD INJURY
Medical Care

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI-

Initial Evaluation - ER

! Be suspicious (25% missed spinal trauma)  SCI = Systemic organ failure (the ABC)  Neurological evaluation  Spine evaluation  Associated injuries  Team approach

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI- Neurological evaluation
• ASIA classification
 Motor score  Sensory score

• ASIA IMPAIRMENT scale • Neurological level of injury • Complete / Incomplete injury • Tetraplegia / Paraplegia
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

.(Spinal

Cord Anatomy (cont

• Spinal tracts: long fibers originating in the brain and running together through spinal canal in pairs

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

.(Spinal

Cord Anatomy (cont

• Corticospinal tracts of the anterior cord arranged in concentric circles

• Hands most central • Arms, shoulders intermediate • Lower extremities outer zone
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

International Standards for Neurological Classification of Spinal Cord Injury
• ASIA (American Spinal Injury Association(

• Neurological level of injury (NLOI( • Completeness of the injury (ASIA impairment classification( • 72 hour exam - reliable prognostic time
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

ASIA
American Spinal Injury Association ( ASIA ( Classification

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Case Study
M LT PP • • • • • • • • • • • C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 5 3 2 1 0 0 0 0 0 0 2 2 1 1 0 0 0 0 0 0 0 2 1 1 1 0 0 0 0 0 0 0

• • • • •

Motor Level ? Sensory Level ? NLI ? ASIA ? Neuro/Functional prognosis ?

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

(Neurological Level of Injury (NLOI
• Lowest level with normal sensory & motor
– can record as MLI & SLI and on each side:
• (ie: Right C5 sensory & C6 motor, Left C6 sensory & C7 motor( • motor level = sensory levels , 50% • If no key muscle for MLI, than NLI = SLI

– Zone of Injury (ZOI( - 2-3 levels below NLOI
• recovery may be better or worse in ZOI

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Sensory Exam
• 28 sensory “points” (within derm’s(
– Test light touch & pin/pain – **Importance of sacral pin testing

• 3 point scale (0,1,2(
– “optional”: proprioception & deep pressure to index and great toe (“present vs absent”( – deep anal sensation recorded “present vs absent”

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

(Sensory Exam (cont

• Sensory level (SLI( = most caudal segment with normal (2/2( LT & Pin sensation • Sensory index score (SIS( = addition of sensory points (total possible 112(
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Motor Exam
• 10 “key” muscles (5 upper & 5 lower ext(
• • • • • C5-Elbow flexion L2-hip flexion C6-wrist extension L3-knee extension C7-elbow extension L4-ankle dorsiflexion C8-finger flexion L5-toe extension T1-finger abduction S1-ankle plantarflexion

– Sacral exam: voluntary anal contraction (present/absent( – “optional m’s: diaphragm (VC(, abdominal (Beevors test( , hip adductors
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Motor Grading Scale
• 6 point scale (0-5( …..(avoid +/-’s(
– – – – – – 0 = no active movement 1 = muscle contraction 2 = movement thru ROM w/o gravity 3 = movement thru ROM against gravity 4 = movement against some resistance 5 = movement against full resistance
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

(Motor exam (cont
• Motor level (MLI( = lowest normal level with 3/5 (& level above 5/5(
– Each M has 2 root innervations, if 3/5 = full innervation by more rostral root level – (4/5 acceptable with pain, deconditioning( – Motor Index Score (MIS( = total 100 pts

Superiority of Motor level vs Sensory** •

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

:Case

• • • • • • • • • • • C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 M 5 3 2 0 0 0 0 0 0 0 LT PP 2 2 1 0 0 0 0 0 0 0 0 2 1 1 0 0 0 0 0 0 0 0

• Motor Level = C6 • Sensory Level = C5 • Neurological Level of Injury (NLOI( = C5 • Zone of Injury = C6-8 • Zone of Partial Preservation = C6-7

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Neurological Recovery
• Incomplete injuries have better prognosis
– sparing of motor/sensory WITHIN or BELOW the zone of injury (ZOI(.

• Key factors:
– incomplete > complete – **motor & PIN sparing are “key” – early recovery is better
‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

Neuro-testing & Neurological Prognosis
• MRI
– better than CT for cord & soft tissue visualization – Cord transection (rare( and hemorrhage correlate with poor prognosis – Edema (1-2 levels only( correlates with incomplete injury & better prognosis

• SSEP (may assist when assoc LOC(
– no more reliable than neuro exam
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

ASIA Impairment Scale
• A = Complete - no S/M sacral function

• B = Sensory incomplete -sacral sensory sparing • C = Motor incomplete -motor sparing below ZOI (strength < 3/5 in most m’s( • D = Motor incomplete -(>3/5( • E = Normal - Normal S/M exam

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

ASIA Classification & Outcome
Admit ASIA (at 72hr( A B-1 B-2 (sacral pin prick( C ASIA D (at 1 year( 0-5% 20-25% 40-50% 60-75%

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Neurological Outcomes in ZOI
• Most pts with complete injury recover one motor level • Recovery to 3/5 at one year:
– 25-50% of 0/5 m’s – 75-100% of 1-2/5 m’s

• Most occurs during first 6 months with greatest rate of change in first 3 months

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Community Ambulation and
Lower extremity motor strength (LEMS (at 1 month

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI – related medical conditions
• UMN vs. LMN

• Spinal cord syndromes

– CCS – BSS – ACS vs PCS – Cauda equina vs. Conus Medullaris syndromes

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Central Cord Syndrome
• Upper extremities weaker than LE’s • seen with older age (Spondylosis( also with hyperextension injuries • “favorable” prognostic factors:
– LE > UE (proximal > distal(, Bladder/bowel – age < 50yr (vs > 50 yr(: ambulation 90% (vs 35%(, bladder 80% (vs 30%(, dressing 80% (vs 15%(
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Characteristics
• Most common incomplete cord lesion • Bimodal distribution • Spondylosis and trauma major causative agents • Mechanism - hyperextension of the cervical cord
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Brown-Sequard Syndrome
Cord “hemi-section” incidence 2-4 %

• Motor: ipsilateral loss • Position: ipsilateral deficit • Pain & temperature: controlateral deficit
• “favorable” prognosis for ambulation (90%), ADL independence (70%), bladder (85%)
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Anterior/Posterior Cord Syndrome
ACS • Anterior spinal art. to ventral 2/3 of SC • loss of motor, pain (sparing of proprioception( • poor prognosis for neuro recovery PCS • Posterior spinal art.to posterior columns • loss of proprioception (sparing of motor & pain( • poor prognosis for ambulation

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Conus Medullaris/Cauda Equina Syndromes
• • • • • • Conus lies behind T10-12 vertebrae S1-5 spinal cord bladder, bowel & sexuality dysfunction more often complete poor prognosis • CES
• • • • • • • • L/S nerve root injury more often also with pain LMN lesion Bowel & bladder disturbances Wheelchair / walking capacity “ Trendelenburg gait” Orthotics better prognosis

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Spine evaluation
• Plain Films
Lateral X-ray Occipitocervical junction C7-T1 junction

• • • •

CT scan MRI CT Myelography SCIWORA

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI-

Associated injuries

• 2/3 of SCI population • Head - 10-50% • Thoracoabdominal • Extremities - 9.5 - 20% fractures
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

SCI- Acute
• • • • • • Neurological Immobilization Bladder & Bowel Lungs/Heart Extremities Skin

management

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

N= Neurological
• Fluctuation in neurological findings
(72h(

• Daily assessment • Spinal “shock” • Associated neurological deficits

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SPINAL SHOCK
• All phenomena surrounding physiologic or anatomic transection of the spinal cord that results in temporary loss or depression of all or most spinal reflex activity below the level of injury. • FLACCID PARALYSIS • AREFLEXIA • Hypotension - loss of sympathetic tone • Bradycardia - unopposed vagal stimulation
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Immobilization
• • • • • Stable - Unstable spine Surgical - Conservative care Skull traction Post injury mobilization Transfers
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

BB= Bladder & Bowel
• • • • • • • Fluids Foley catheter Urine U/A & culture - UTI !!! Stool softeners, suppositories Alimentation Gastric dilatation, Ileus, fecal impaction Narcotic analgesics

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Lower colon Rectu m

Descendin g colon

Upper GI

Sphincter s

-

Rectu m

+

Somatic

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Lungs/Heart
• Respiratory dysfunction (restrictive & obstructive)

• Associated chest injury • Previous lung disease, smoking
• Atelectasis, pneumonia (4/5 LLL), ARDS

• Aggressive pulmonary toilet, VC • Bronchodilators (?), breathing exercises • Bradycardia, Orthostatic hypotension
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Respiratory dysfunction
 Restrictive ventilatory failure
+ Oxygenation failure

 Previous medical history  Concomitant chest/lung injuries  Tracheostomy  Mechanical ventilation  Atelectasis (36%(, pneumonia (30%(, respiratory failure (22%(

Prevention of atelectasis, hypoxemia, aspiration
‫ד"ר ג. זייליג‬

 Adequate alveolar ventilation
Email: zgavriel@post.tau.ac.il  Aggressive pulmonary management

Cardiovascular dysfunction Spinal Shock  Hypotension (+ orthostatism + postprandial(  Bradycardia

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

E = Extremities
• • • • • DVT - PE Associated injuries PAO/HO Contractures / deformities Knee effusion
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

S= Skin
• • • • • High risk for pressure sores Pressure relief Beds, Mattresses Alimentation (Prot., Glu., Hb.( Braces, Halo vest, POP

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI-

Other medical complications

• Fever
• Hypercalcemia, Hypercalciuria, Urinary tract calculi

• • • • •

Pain Thermoregulation dysfunction Psychiatric conditions Spasticity Other GI conditions
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Early rehabilitation
((1
• • • • • • Initial care team member Neurological examination SCI protocols Surgical vs. Conservative Placement Family
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Early rehabilitation
((2
• • • • • • • Pulmonary care Thromboembolism prevention GU & GI management Communication, Swallowing Alimentation Skin, Musculoskeletal, Pain Neurological F/U
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Committee on Trauma. Resources for Optimal Care of the Injured Patient. .American College of Surgeons, 1990
• “….It is illogical to develop sophisticated prehospital and hospital care to resuscitate and treat severely injured patients only to transfer them to custodial facilities after acute care without adequate rehabilitation…..The designation of rehabilitation facilities with the necessary staffing skills and programs to comprehensively serve people with spinal cord injury is as important as the need for specialized trauma services. Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

:SPINAL CORD INJURY

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

RESPIRATORY NERVOUS ENDOCRINE IMMUNE GASTO-INTESTINAL GENITO-URINARY SKIN CARDIO-VASCULAR METABOLIC

SCI = multi-systems failure

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI REHABILITATION PROGRAM
across the continuum of care

G. Zeilig, MD

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Admission criteria
• Medically stable and expectation for improvement • Pre-morbid condition that indicates a potential for rehabilitation • Can withstand intensive inpatient rehabilitation
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

The
Cook • Dietician • Nurse • Occupational therapist • Orthotic technician • Psychologist • Physical therapist •

• • • • • • •

Physician Rabbi Recreational therapist Engineer Secretary Social worker Speech therapist

Family

Case manager
Email: zgavriel@post.tau.ac.il

Patient
‫ד"ר ג. זייליג‬

The intensive rehabilitation process
First phase

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

The rehabilitation process
Second phase – unstable patient
• Prevention and treatment of medical conditions
(impairment(

• Alimentation, communication, swallowing
(impairment(

• Skin care (imp( • Bowel and bladder training (imp. + disability( • Basic functional skills (disability(

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Medical conditions

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Cardiovascular dysfunction
• ANS failure; Spinal Shock  ORTHOSTATISM: a decrease in systolic

blood pressure of more than 20 mmHg, or a fall in diastolic blood pressure of more than 10 mmHg, while upright or during head-up tilt to 60o, for at least 3 min.  Dizziness, Blacking out, Loss of consciousness, Cognitive deficits, Muscle hypoperfusion, Weakness, lethargy, fatigue
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

To be avoided
• Sudden head-up postural change (especially on waking)  • Prolonged recumbency  • High environmental temperature (including hot baths)  • Drugs with vasodepressor properties

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

To be introduced
• Head-up tilt during sleep • High salt intake • Adopting different body positions

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

To be considered
• Elastic stockings  • Thigh cuffs  • Abdominal binders  • Water ingestion

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Drugs
1. Mineralocorticoids (fludrocortisone): (Reducing salt loss/plasma volume expansion) 2. Ephedrine, Midodrine, Noradrenaline, Clonidine: (vasoconstriction — sympathetic) 3. Dihydroergotamine: (On resistance vessels)
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

:Autonomic dysreflexia
 Sudden paroxysmal rise in both SYSTOLIC/DIASTOLIC blood pressure with compensatory slowing of the pulse rate  Above T5-6 level  Headache, sweating, redness face, convulsions  Painful stimuli: full bladder/ rectum, ileus, uterus, etc  Identification and elimination of triggering mechanism  Prevention

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Respiratory dysfunction
 Restrictive ventilatory failure
+ Oxygenation failure

 Previous medical history  Concomitant chest/lung injuries  Tracheostomy  Mechanical ventilation  Atelectasis (36%(, pneumonia (30%(, respiratory failure (22%(

Prevention of atelectasis, hypoxemia, aspiration
‫ד"ר ג. זייליג‬

 Adequate alveolar ventilation
Email: zgavriel@post.tau.ac.il  Aggressive pulmonary management

Thromboembolism - prevention & treatment

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

TSCI = high risk for thromboembolism
The highest among the hospitalized population 60% - 100% without prophylaxis
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Other risk factors for thromboembolism
• • • • Age Family history Limbs fractures Lower limbs surgery • • • • Cancer BMI Hormonal therapy Flaccid paralysis

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Thromboembolism prophylaxis
• LMWH • Warfarin • Unfractionated heparin
3-6 months

• Pneumatic compression • Functional electrical stimulation
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Thrombophilia associated with heparin failure in the prevention of venous thromboembolism in patients with acute traumatic spinal cord injury
G. Zeilig, MD
The Department of Neurological Rehabilitation The Chaim Sheba Medical Center, Tel-Hashomer Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬ Sackler School of Medicine, Tel Aviv University, ISRAEL

 This is the first study assessing thrombophilia as a risk for thromboprophylaxis failure after major trauma, specifically after ATSCI  We found genetic thrombophilia to be significantly more prevalent in the prophylaxis failure group and therefore a significant risk factor for prophylaxis failure.  The association found between a positive family history of VTE and prophylaxis failure further emphasizes the importance of genetic factors on prophylaxis failure.  The only thrombophilic mutation independently increasing the risk of VTE was the Prothrombin mutation.

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Infections - Fever
• • • • • • • Urinary tract infection Lung infections Thromboembolism Post-surgery abscess: abdomen, spine, lung Others: meningitis, PAO, osteomyelitis Central fever Unknown causes
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Other conditions
• • • • • Communication Swallowing Pain – musculoskeletal & neuropathic Nutrition (PEG; Calories; Fluids( Electrolytes disturbances

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Genito-urinal management:
• Neuropathic bladder

• Hyperreflexic vs. Hyporeflexic bladder; DSD • Permanent/Suprapubic catheter; ICC/ISC • Urinary tract infections; Lithiasis

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Gastro-intestinal management
• Neuropathic bowel: Upper vs. Lower motor bowel • Constipation; Post traumatic acalculous cholecystitis • Ileus; Gastric dilatation; Pancreatitis; • Superior Mesenteric Artery Syndrome

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

The rehabilitation process
Third phase – stable patient

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Third phase – stable patient
• CNS injury – related medical conditions • Functional skills: mobility, ADL, sphincters • Emotional adjustment • Social and financial concerns

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SCI – related medical conditions
• • • • (Autonomic dysreflexia( Neuropathic pain Spasticity Bone metabolism
– Hypercalcemia; Osteoporosis – Heterotopic ossification; Urinary tract calculi

• Psychiatric disorders

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SEX
• Psychogenic erection T11L2; S2-S4 • Reflex erection: S2-S4 • Erectile dysfunction
– – – – Penile implant Intracavernous injection Vacuum pump Sildenafil (Viagra(

Safe sex

• Body image • Orgasm ?
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Fertility
• Ejaculation disturbances • Retrograde ejaculation
– Vibratory stimulation – Electroejaculation – Sperm aspiration

• Poor semen quality
– Assisted reproductive technologies

Team work

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Psychiatric disorders
• Post traumatic stress disorder (PTSD(

• Depression
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Heterotopic ossification Periarticular ossification
 Ectopic bone within soft tissue surrounding peripheral joints • Hip, knee, shoulder, elbow • First weeks/months • Prevalence: 20%-30% • 10-20%: functional significance • Dd: fracture, DVT, bleeding • DX: Alkphos, X-ray, Bone scan • Treatment: biphosphonates, indomed, surgery ???????????????

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Enkephalins =Endomorphines are endogenous opioid produced by the pituitary gland and the hypothalamus producing analgesia and a sense of well-being
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Neuropathic pain
• Pain initiated or caused by a primary lesion or dysfunction in the nervous system.
– Peripheral neuropathic pain occurs when the lesion or dysfunction affects the peripheral nervous system – Central pain may be retained as the term when the lesion or dysfunction affects the central nervous system.

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Neuropathic pain
At level: Radicular pain (stabbing, shooting, electric shock-like) Segmental/end zone pain/border (tightness, burning) Bellow level: Central /deafferentation pain (burning/aching/pins and needles) Visceral pain
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

(Pathophysiology (1
• Peripheral Mechanisms
– Sensitization (an increased response to a given stimulus( – Ectopic neuronal pacemakers at various sites along the nerve ( abnormal or dysfunctional sodium channels ( -dorsal root ganglion – "Cross-talking" (abnormal electrical connections between adjacent demyelinated axons( – dorsal root ganglion – Neurogenic inflammation: Inflammatory neuropeptides (substance P and prostaglandins( from afferent nociceptors and sympathetic post-ganglionic neurons activate nearby receptors and triggering a process of spreading activation. – Nervi nervorum-related pain
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

(Pathophysiology (2

• Central Mechanisms:
– Increased spontaneous activity of the dorsal horn neurons – Increased responsivity to afferent input

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Pregabalin reduces influx of calcium into nerve terminals and decreases neurotransmitter release

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Visual Analog Scale

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

(Pain (cont’d
–Entrapment neuropathies –Chronic pain: bellow vs. above level of injury •3-95% •neurogenic vs musculoskeletal –Post-traumatic syringomyelia

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Pharmacotherapy
• Anticonvulsants: lancinating/shooting pain – Carbamezapine (Tegretol/Teril) – Gabapentin (Neurontin( – PREGABALIN (LYRICA( (reduces influx of calcium into nerve
terminals and decreases neurotransmitter releaseׁׁ

• Antidepressants:
– DULOXETINE (CYMBALTA(

• • • •

– Amitriptyline (Eltrol/Elavil) – Nortriptyline (Pamelor) – Desipramine (Norpramine) Capsaicin Opioids Lidocaine (IV); Mexillene NSAID’s
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Spasticity
• Definition: “Abnormal, velocitydependent increase in resistance to passive movement of peripheral joints due to increased muscle activity”

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Pathophysiology
• Intrinsic hyperexcitability of alpha motor neurons within the spinal cord secondary to damage to descending pathways
– cortico, vestibulo, reticulospinal

• CNS modification

– neuronal sprouting – denervation hypersensitivity
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Spasticity Scales
• Ashworth Scale
• 1= no increased tone • 2= slight “catch” in ROM • 3= moderate tone, easy ROM • 4= marked tone, difficult ROM • 5= Rigid in flexion or extension

• Spasm Frequency Scale
• • • • • 0= none 1= mild 2= infrequent 3=> 1 per hour 4= > 10 per hour

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

THERAPY/MANAGEMENT

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

:BEFORE TREATMENT
• Does the patient need the treatment ? • What are the aims of the treatment ? • Do the patient/caregivers have the time for the treatment ? • Will the treatment disrupt the life of the patient/caregiver ?
Tizard JP, 1980

 Financial cover ?

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

PHYSICAL Interventions
• Positioning (bed, wheelchair( • Functional training • Modalities
– heat (relaxation(; cold (inhibition( – electrical stimulation

• Therapeutic Exercise
– inhibitory to spastic muscles – facilatory to opposing muscles

• Orthotics • Other (Reflexology….(
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Colombo G, Joerg M, Schreier R, Dietz V. Treadmill training of paraplegic patients using a robotic orthosis. Journal of Rehabilitaion Research and Development 2000; 37(6):693-700.

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Computer generated, low-level electrical pulses transmitted through surface electrodes cause coordinated contractions of leg muscles. Sensors located in the ERGYS provide continuous feedback to a computer which controls the sequence of muscle contractions as well as the resistance to pedaling. The result is smooth and natural pedaling, with the ‫ד"ר ג. זייליג‬ leg muscles supplyingEmail: zgavriel@post.tau.ac.il the power.

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Siev-Ner I et al. Mult. Scler., 2003

“….was of benefit in alleviating motor, sensory and urinary symptoms in MS patients”
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

MEDICATIONS
• • • • • Baclofen (PO & ITB) Dantrium Diazepam Clonidine Tizanidine

• (limitations: non-selective, side effects(

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

(Baclofen (Lioresal
• GABA-B analogue; binds to receptors • inhibits release of excitatory neurotransmitters (spasticity control(
– Ca++ (pre-synaptic inhibition( – K+ (post-synaptic inhibition(

• may also decrease release of substance P (pain control(
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Dantrium
• • • • Inhibits Ca++ release at muscle level Preferred : TBI, CVA, CP SE’s - weakness, GI Hepatotoxicity (<1%(

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Clonidine
• • • • Alpha-2 receptor blockage Usage : SCI Max dose - .4mg/d (oral & patch( SE’s - hypotension, syncope, drowsiness

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

(Tizanidine (Zanaflex
• • • • 1996 - Approved for SCI, MS, CVA Alpha-2 agonist (pre-synaptic inhibition( 1/10 potency of Clonidine in lowering BP Dose: T1/2: 2-5hr, begin 4 mg qhs (max 36 mg( • SE’s - Sedation, nausea, LFT’s

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Diazepam
• VALIUM • GABA “potentiation” • SE’s - CNS depression, dependence,
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

CHEMICAL NEUROLYSIS
• PHENOL • ALCOHOL • BOTULINUM TOXIN
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

PHENOL
• • • • • Phenol 5-7%- Motor Point/Nerve block Non-selective destruction of axons/myelin Inds: Local (not general( spasticity Duration: 3-6 months SE’s - dysesthetic pain

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Botulinum Toxin
• 1989 FDA approved for strabismus & blepherospasm • Botox-A inhibits Ach Release at NMJ • Dose: 300-400u total (50-200/muscle( • Onset: 2-4 hours, Peak : 2-4 weeks • Duration: 3-6 months • ? Immunoresistance w/repeated inj’s
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

SURGICAL management
• ORTHOPEDIC procedures:
– – – – – Improve function, Increase mobility Correct severe deformities Tendons split/transfer Lengthening procedures Tenotomy, myotomy, osteotomy

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

`(SURGICAL management (cont
• NEUROSURGICAL approaches:
– Selective posterior rhizotomy (Salame et al, IMAJ, 2003(
– Percutaneous radiofrequency rhizotomy (Kasdon & Lathi, Neurosurgery, 1984( – DREZ lesions (Sindou et al., Neurosurgery, 1989( – Myelotomy & Cordotomy (side effects ?( – Spinal cord stimulation (Barolat et al., J. Neurosurgery, 1986(

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Pressure sores

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Syringomyelia
Post-traumatic syringomyelia

• Syrinx = fluid filled cavity (cyst( within the spinal cord • Syringomyelia = neurological symptoms due to syrinx
• incidence - 3-10% • etiology - trauma, tumor, congenital – area of tissue damage / inflammation – can expand, elongate, cause pressure
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Syringomyelia: symptoms
• • • • • • Pain (radicular( Sensory loss weakness Spasticity Hyperhydrosis Bladder / bowel
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Syringomyelia: Diagnosis &Treatment
Diagnosis: • clinical findings / suspicion, physical exam • MRI (CT/myelogram, U/S( Treatment • Surgical shunt / drainage to “low” pressure points: syrigopleural, syringoperitoneal • Cavity “repair” by surgery or implant • pain managementEmail: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Hyperhidrosis
• Both eccrine and apocrine sweat glands are innervated by postganglionic sympathetic fibers • Eccrine glands: acetylcholine • Apocrine glands: catecholamines • T2 to T4: to the skin of the face • T2 to T8: the skin of the upper limbs • T4 to T12 to the skin of the trunk • T10 to L2 to the skin of the lower limbs
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Activity & limitations
Participation & restrictions

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

FUNCTIONAL ASSESSMENT
A method for describing a person's“ ABILITIES and LIMITATIONS, in order to measure performances of ”activities necessary for living

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Daily living activities
• Personal care skills (B-ADL( Θ • Personal environment skills (I-ADL( • Leisure activities, vocational pursuits, social interactions

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Functional evaluation Activities of Daily Living assist, supervision, Total, max, moderate, minimal

modified independence, complete independence (1……..7( • Functional Measurement Scale (FIM( (18-126(
 Self care (6 items(: dressing, eating, grooming, bathing, toileting  Sphincter control (2(  Transfers (3(  Locomotion (2(  Communication (2(  Social cognition (3(
Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Functional evaluation Instrumental ADL (I(ADL

• Shopping, housekeeping, walking, public transportation, cooking
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

MOBILITY • Bed: positioning, transfers • Wheelchair: “push-ups”, transfers, propelling • GAIT ANALYSIS Θ • Walking assessment Θ
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Functional evaluation
(disability(

Ambulation
• Bed: positioning, transfers • Wheelchair: manual vs. powered; transfers…

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Functional evaluation (Ambulation (cont’d

• Standing

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Functional evaluation (Ambulation (cont’d
• Level of ambulation:
 Physiologic (training(

 Limited household  Independent household  Limited community  Independent community

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

• Orthosis: (RGO, KAFO, R-KAFO, AFO(

Functional evaluation (Ambulation (cont’d

• Aids (canes, walker, crutches( Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Physical activity
((Participation/handicap
Dis bility =re e a duc d phys a a tivity ic l c
q Immobility q Obesity q Pain q Musculoskeletal q Fatigue q Depression

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Employment
( (Participation/handicap
• Influencing factors:  age at injury  years of education  severity of injury  cause of injury  employment status at injury  gender  accessibility Email: zgavriel@post.tau.ac.il  employer/society attitude

‫ד"ר ג. זייליג‬

PARTICIPATION
• ENVIRONMENT-ACCESIBILITY • SOCIAL PARTICIPATION • FAMILY & COMMUNITY INTEGRATION

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Environment

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Home adjustment •Accessibility
• Accessories

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Equipment/accessories
• Transportation/Driving/Car • Assistive technology devices

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

TENS ? Electromagnetism ? ? Spinal cord stimulation

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Assistance – care givers
• Level of activity – severity of injury • Contributing factors:
– – – – – – Age Medical status Environment (house, office, school( Family Equipment Other
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

G. Zeilig, MD, Department of Neurological Rehabilitation,
Email: ‫זייליג‬ Sheba Medical zgavriel@post.tau.ac.il Hashomer .‫ד"ר ג‬ Center, Tel

Conflicting goals
• Independence

• Quality of life

• Preservation of function
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Body systems review(1(
• Respiratory system
– Diminished respiratory reserve • decreased compliance • decreased alveoli • skeletal deformities – Vulnerability to respiratory infections Flu vaccination Assisted cough Early management of URI Email: zgavriel@post.tau.ac.il Periodic pulmonary functions monitoring

‫ד"ר ג. זייליג‬

Body systems review (2(
• Ms u s e t l s se : o e/u d ru e u c lo k lea y t m v r n e s
– Ot o oo is (B D 6 %b 1 mnh p s juy se p r s M : 3 y 6 o t s o t-in r (
• P t o g a f a t r s(c ml > in o p -1 :1 ah lo ic l r cue o p c ml 0 (

– S o ld r e o a dwis p in f n t n l ima mn h u e, lb w n r t a : u cio a p ir e t – S in is u s p e se
• s o s &k p o is c lio is y h s • C ac ts in : p e d at o is, in t b y p r se l b n f r aio h r o p e s u o rh s sa ilit , ao t a o e omt n • d g n r t ed c e e eaiv is s

– L wre t e it s O c a g s Ms u rar p y o e xr mie : A h n e , u c la t o h – A b laio : in r a e e eg e p n it r , s o ld rp in b c mu t n c e s d n r y x e d ue h u e a , a k p in a
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Body systems review (3(
• Nervous system
– Neural loss – Decreased nerve conduction – Chronic pain: bellow vs. above level of injury • 3-95% • neurogenic vs musculoskeletal – Entrapment neuropathies – Post-traumatic syringomyelia – Spasticity
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Body systems review (4(
• Cardiovascular system : reduced maximum
aerobic capacity (VO2 max(: impaired autonomic control + paralysis – ASCVD

– HTN Risk factors
– – – – –

Obesity Abnormal lipids profile: reduced HDL Physical inactivity Stress depression

• Psychiatric conditions
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

CHD prevalence
17.3% (S.G) : 9.35% (C.G)

P < .05

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Body systems review (5(
• S in t in e e id rm + t ic e in o c lla e f es k : h n r p e is h k n g f o g n ib r
– P e s r u es r s ue lc r – Br s un – In r w t e a go n o n ils

• E d c in &Im u es se n o r e mn y t m
– – – – C a g sinGUmt b lis : G Uino r n e(?( hne L ea o m L t lea c C a g sinL idmt b lis : v r lo H L hne ip ea o m ey w D Ine t n f cio s Im u o u r s io (?( mn s pe s n
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Body systems review (6(
• Gastrointestinal system
– – – – – – – Alterations in gastric empting Alterations in acid secretion Increased cholelithiasis Increased colorectal diverticular disease Increased constipation Hemorrhoids (60%( Cancer screening
Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬

Body systems review (7(
• Genitourinary system
– – – – – – Increased UTI Prostatism Menopause Method of management Risk of bladder cancer Long - term follow - up

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Evidenced based rehabilitation ?

Department of Neurological Rehabilitation, Sheba Medical Center, Tel Hashomer, Israel
Gavriel.zeilig@sheba.health.gov

G. Zeilig, MD

Rehabilitation

Achievement of function that has been lost or diminished by disease or traumatic injury. The process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. A comprehensive program for patients to follow to reduce or overcome deficits following injury or illness…..to gain the optimal mental and physical ability.

“….is …. collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence” “…is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence….” "…. is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best".

Evidence based clinical practice

 Who

do I rehabilitate ?  How do I rehabilitate ?  How well do I rehabilitate ?

Who do I rehabilitate ?

The biopsychosocial model of functioning and disability
Health condition (disease, traum a)

Body function and body structure

Activity

Participation

Environmental factors

Personal factors

Contextual factors

ICF provides an international common language and universal conceptual framework for describing functioning, disability and health

The integrative model of functioning and disability
TBI

Paralysis, Agitation, Dysarthria, Memory deficit

Walking, Activity speaking, learning, climbing stairs

Carrying the baby, Participation doing housework, working as a teacher

- - 4. Floor without lift

+ + Physiotherapeutic treatment

Environment + + Wheelchair al factors

45 year old PersonalPHD Motivated,

factors

Contextual + + Cognitive treatment

factors

Optimal Functioning

?How do we evaluate
 Reliable

and valid scales:

The Glasgow Coma Scale (GCS(  American Spinal Injury Association ( ASIA ( Classification  NIH Stroke Scale (NIHSS(  Functional Independence Measure (FIM(  The spinal cord independence measure (SCIM(  The Community Integration Questionnaire (CIQ(  The Satisfaction With Life Scale (SWLS(

How do I ?rehabilitate

Neuroscience – based rehabilitation

Methods

Tools

Concepts

Brain plasticity
 

The ability of the brain to change with learning Cortical representation areas can be modified by:  Sensory input  Experience  Learning  In response to brain lesions The environment plays a key role in influencing plasticity

MOTOR LEARNING

N-methyl-D-aspartate receptormediated glutamate (NMDA receptors( in gray matter of spinal cord and respond to environmental cues by “learning” Long term potentiation (LTP(

Activity-dependent plasticity

Activity-dependent cortical plasticity has been found to accompany motor learning, and rehabilitation and training after injury have also been reported to influence the pattern of reorganization (H.I. Krebs et al, 2000( Greater intensity of task specific practice tends to improve motor (and cognitive) outcomes (Kwakkel et al, 2004; Karni et al, 1998) Activity Movement Therapy can prevent loss of the peri-infarct hand territory and can even force expansion into adjacent areas (RJ Nudo 1996(

Central pattern generators )(CPGs

 

Neuronal circuits in the spinal cord which generate rhythmic muscle activities Each limb is controlled by such a CPG Coordinated by neurons, which interconnect both sides and transmit information between the cervical and lumbar spine. Sensory feedback:
 

Loading and unloading of the limbs Hip position (extension at end stance)
Dietz V. et al, 2002

Bilateral movement therapy (BMT)

Symmetrical bilateral movements activate similar neural networks in both hemispheres when homologous muscle groups are simultaneously activated
Single central regulatory mechanism controlling both limbs in the bilateral situation ? (SMA, cingulate motor cortex, cerebellum etc)

Cauraugh JH & Summers JJ, 2005

Body weight-supported treadmill training )(BWSTT Allows the spinal cord & supraspinal locomotor areas to experience “ordinary steppinglike” sensory inputs
Allows massed practice at different walking speeds and level of limb loading

Low-level electrical pulses delivered by an implanted pacemaker type device that stimulate various tissues of the nervous system including the spinal cord, peripheral nerves, and brain.

FUNCTIONAL ELECTRICAL STIMULATION (FES)

Paralyzed or paretic muscles can be made to contract by applying electrical currents to the intact peripheral motor nerves innervating them. When electrically elicited muscle contractions are coordinated in a manner that provides function, the technique is termed functional electrical stimulation Neuroprostheses

Pecham H.P., 2005

ActiGait nerve stimulator

ActiGait® is based on an implanted stimulator, which activates the foot lift by stimulating a nerve (the common peroneal nerve) above the knee. The stimulation activates the lower leg muscles (dorsiflexors) which lift the foot. The stimulating electrode is located under the skin just above the knee while the stimulator is located under the skin on the thigh.

Phase II trial to evaluate the ActiGait implanted drop-foot stimulator in established hemiplegia- Journal of Rehabilitation Medicine, 39, (3), 212-218, 2007

Bladder Augmentation (augmentation cystoplasty(

is reconstructive surgery to increase the reservoir capacity of the bladder. may be recommended for patients with a reflex bladder in order to increase bladder capacity and keep urine from leaking involuntarily

Botulinum Toxin: An Effective Treatment for Overactive Bladder

The mean bladder compliance had increased significantly (p < 0.0001) by the first follow-up examination and non-significantly by the time of the second followup. No injection related complications or toxin related side effects were reported. The patients considerably reduced or even stopped taking anticholinergic drugs without recurrence of reflex incontinence J. Eur. Urology, 2004 and were satisfied with the treatment.

TOOLS

The BI MANU TRACK

 

Bilateral movement Active-passive Pronation/supinati on forearm Flexion-extension hand

Repetitive exercises to improve arm function
Reo Therapy Armeo

BWSTT

The NESS L300

The L300 has three main parts that use wireless communication to "talk" to one another. The leg cuff is a small, lightweight device that fits just below the knee and contains electrodes that can be put where a patient needs it most for stimulation. The gait sensor attaches to the shoe and lets the leg cuff know if the heel is on the ground or in the air. The handheld remote control allows personal adjustment of stimulation.

Effects of a new radio frequency-controlled neuroprosthesis on gait symmetry and rhythmicity in patients with chronic hemiparesis. Am J Phys Med Rehabil. 2008 Jan;87(1):4-13

Computer generated, low-level electrical pulses transmitted through surface electrodes cause coordinated contractions of leg muscles.

Erigo

Allows mobilization of neurological patients in the early phase of rehabilitation or of long bed rest patients

Virtual reality and rehabilitation

Virtual reality as a tool for assessing and training weight bearing and gait for individuals with incomplete spinal cord injuries. Patrice L.
(Tamar( Weiss and Gabi Zeilig

Virtual reality as a tool for assessing and training sitting and standing balance in individuals with spinal cord injuries. Patrice L.
(Tamar( Weiss and Gabi Zeilig  

 

HBM- Human Body Model
 Makes

it possible to view the generated muscle forces in the human body in real-time, in a way that makes clear the force transference in the human musculoskeletal system

Human brain mapping technologies

Diffusion tensor imaging )(DTI

It is a building block of the fiber-tracking images. The information is presented in colors that represent the predominant direction of movement, or diffusion, of hydrogen atoms within water molecules.

Functional magnetic resonance )imaging (fMRI

It measures the haemodynamic response related to neural activity in the brain or spinal cord
Blood-oxygen-level dependent or BOLD fMRI is a method of observing which areas of the brain are active at any given time.

Does acupuncture work for ?treating shoulder pain
  

9 research studies over 500 people who had shoulder pain People had either acupuncture, a placebo ultrasound, gentle movement or exercises usually for 20-30 minutes, two to three times a week for 3 to 6 weeks There is not enough evidence to say whether acupuncture works to treat shoulder pain or whether it is harmful

ERGYS II

In an exercise study patients who were paralyzed from the chest or waist down experienced an average increase in their oxygen uptake by 25% and in their heart pumping volume by fully 37% after eight weeks of training.

Gabapentin demonstrated efficacy and safety at doses between 2,700 and 3,600 mg/day as a therapy for the spasticity associated with the upper motor neuron syndrome.
(

Formica A., 2005 (

GABAB receptors do not mediate the inhibitory actions of gabapentin on the spinal reflex in rats Gabapentin reduces the spinal reflex in rats via mechanisms that do not involve gammaaminobutyric acid (GABA(A receptors.

(Shimizu S., 2004(

Robotic training improves upper limb motor control and muscle strength

Bilateral hand movement enhances activation of primary motor cortex compared with unilateral paretic hand movement in the early recovery stage (by f- MRI study) Better than FES (number of repetitions and the bilateral approach)

Hesse S. et al, 2005

RANDOMIZED CONTROLLED TRIALS

Dobkin, Apple and Barbeau et al., Weightsupported treadmill vs over-ground training for walking after acute incomplete SCI, Neurology 66 (2006), pp. 484–493. Dobkin, Barbeau and Deforge et al., The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial.Neurorehabil Neural Repair. 2007 Jan-Feb;21(1):25-35

Robots vs human beings

Enhanced Gait-Related Improvements After Therapist- Versus Robotic-Assisted Locomotor Training in Subjects With Chronic Stroke A Randomized Controlled Study ׂ Stroke. ( 2008;39:1786-1792.(:  “Therapist-assisted LT facilitates greater improvements in walking ability in ambulatory stroke survivors as compared to a similar dosage of robotic-assisted LT”.

Transcranial Galvanic Stimulation )After Stroke (the TRAGAT study

Transcranial galvanic stimulation (tDCS) seems to promote motor recovery after stroke by stimulating (anodal) or inhibiting (cathodal) neural circuits in the brain Combination of tDCS + robotassisted arm training

The Re-Walker
• This is a light, wearable brace support suit which comprises DC motors at the joints, rechargeable batteries, an array of sensors and a computer-based control system. • Designed to enable people with lower limb disabilities to carry out routine ambulatory functions (standing, walking, climbing stairs etc.( • Israeli development

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

A Study Testing Safety and Tolerance of the ReWalk Exoskeleton Suit

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

NeuroRecovery Network Center Opens the • The X State University Medical Center celebrates

opening of the Christopher and Dana Reeve Foundation NeuroRecovery Network Center. The mission of the center is to deliver …, evidence-based rehabilitation therapies to promote function and improve the health and quality of life of people living with paralysis. • The center offers therapy called locomotor training whereby a patient is suspended in a harness over a treadmill while trained therapists move their legs to simulate walking. Locomotor training can improve cardiovascular and pulmonary function, promote strength and healingpotential of the skin, increase blood flow to the arms and legs, increase bone density, and even improve bowel and bladder functioning among some patients. It can also lead to demonstrable improvements in the emotional and psychological well being of patients and facilitate Email: zgavriel@post.tau.ac.il ‫ד"ר ג. זייליג‬ their integration into the community.

Life expectancy
:Contributing factors
• Age at injury • Severity of injury; mobility • Years of injury • Re-hospitalizations • Social set-up; social integration
• • • • • Multiple pressure sores “No giving up” Self-esteem Family support Quality of life

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Causes of death
• Respiratory system • Cardio-vascular system • Infections • Suicide

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

Autologous Activated AutologousActivated Macrophage Therapy
A novel therapeutic approach for Complete Spinal Cord Injury
G. Zeilig, N. Knoller, M. Hadani, H.Z. Rappaport, J. Attias, G. Auerbachand V. Fulga
Email: zgavriel@post.tau.ac.il

PRONEURON ‫ד"ר‬ ‫ג. זייליג‬ BIOTECHNOLOGIES

Email: zgavriel@post.tau.ac.il

‫ד"ר ג. זייליג‬

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