Hello, welcome back. Now we're talking about spinal cord injury again. This is the second part.
I may have a third part depending on how long this one goes. But now we're going to talk about medical management. So even before a patient gets to the hospital, there's the emergency management of a patient who has a possible spinal cord injury. So the first aid treatment at the scene of the accident is very crucial to the health and neurological integrity of the patient.
So stabilization of the injured spine is very important and this is why we need to make sure that the vertebral column, specifically the cervical spine, but all of the vertebral column is not allowed to move because that can cause the cord to sustain additional damage. In an emergency situation, if there's any indication of a possible injury of the spinal cord or spinal column, a person should be treated as though a spinal injury has occurred. In addition to stabilizing the spine, emergency medical personnel must ensure that ventilation and circulation are adequate, avoiding unnecessary motion of the spine while doing so. Discontinuation or ventilation may be necessary if either Associated injuries or cord damage above C5 significantly impairs breathing. Once the patient's spinal column has been stabilized and adequate ventilation and circulation have been assured, the injured person can then be taken by ambulance or helicopter to a trauma center.
Ideally, the patient is taken to a center that specializes in the care of spinal cord injuries, as these centers have better outcomes. But unfortunately not all cities have those options. When someone with a known or suspected spinal cord injury arrives at the hospital, the trauma team works to discover and treat any life-threatening conditions and to preserve neurological function. During all procedures care is taken to avoid motion in the spine.
The establishment of adequate ventilation, oxygenation, and circulation are of highest priority. Respiratory status is evaluated and arterial blood gases are monitored. Intubation and ventilation are performed if indicated. The trauma team will control hemorrhaging from any other associated injuries and monitors for and treats cardiac arrhythmias or any problems with hypotension.
Once the priority survival needs have been addressed, a neurological examination can be performed. This should include assessment of level of consciousness and cranial nerve function because the patient may have sustained a head injury as well during the accident. Sensation, voluntary motor function, and reflexes should also be evaluated thoroughly. This baseline data will influence decisions regarding fracture management and make it possible to detect any future improvement or deterioration in the neurological status of the patient.
Neurological examination results can also be used to determine the patient's neurological and functional prognosis. Imaging studies, of course, will be performed to detect damage in the spinal column and cord. CT of the entire spine in patients with signs and symptoms of spinal cord injury and plain radiographs when CT is not available are recommended.
A CT scan will often reveal injuries that are not evident on radiographs. MRIs are also recommended in areas that are known or suspected to have spinal cord damage. The MRI provides superior visualization of the spinal cord compression as well as morphologic changes in ligaments hematologic.
intervertebral disc and spinal cord tissue following trauma to the vertebral column fracture management is then considered when determining surgery versus no surgery they need to determine if the type of injury that the patient has. They need to know of any bone damage and also the degree of the spinal cord injury. Oftentimes patients are treated with some sort of traction to try and align the spine. In doing so, this decompresses the spinal cord and it may increase the patient's chances of neurological recovery. Indications for surgical intervention include an unstable fracture, a fracture that will not reduce without surgery, gross spinal malalignment, evidence of continued cord compression in the presence of an incomplete injury, deteriorating neurological status, and continued instability following conservative management.
We're going to talk a little bit more about the traction and different braces that can be used and different external fixators as well. So pharmacological management immediately after the spinal cord injury, we have to keep in mind that the neurological damage from the spinal cord injury may be a result of physical disruption of axons transversing the injury site or cellular events that follow the primary injury, as I described on the last PowerPoint video. As I said before, they believe that the secondary injuries to the surrounding tissues can be lessened by pharmacological agents, specifically methylprednisolone, and I ended up writing it on this slide, the GM1. To date, two major pharmacological clinical trials have been completed with these medications. So the use of high doses of methylprednisone in a study showed significant improvements in sensory and motor function six months after injury.
The methylprednisone enhanced the flow of blood to the injured spinal cord, preventing the typical decline in the white matter, the extracellular calcium levels, and the evoked potentials, thus preventing progressive post-traumatic ischemia. Therapists must be aware of the side effects that can occur with such high doses of steroids, including gastric ulcers, decreased wound healing time, hypertension, cardiac arrhythmias, and alteration in mental status. As stated on the last slide, fracture and spinal injury site management, the importance is to stabilize the spinal column. prevent any further damage to the cord.
Reduction and immobilization of the spinal cord or the spinal injuries can be achieved via conservative or through surgery. Closed reduction is indicated for patients with cervical subluxation or fracture dislocation injuries. It is achieved with the use of traction devices such as the Gardner-Wells tongs. Patients with thoracic or lumbar injuries that are managed conservatively without surgery require in- immobilization by positioning in a regular or rotating bed and the use of braces.
We'll talk about that further. Surgery can be performed within the first 24 hours after admission to the hospital or it actually can be following a period of days or weeks of skeletal traction or positioning in the bed. So that's a decision that the surgeons have to make is how stable is the patient, how important is it for them to need the surgery right away. So the traction can actually buy some time or the immobilization can buy some time to see what type of surgery would be best.
So when they do the surgery they can either go anteriorly or posteriorly and I'm not going to read the slide to you, you can actually read this yourself. Some patients actually end up having braces put on even before the surgery but if they do have some sort of surgery normally it is followed by a procedure. by some sort of a immobilization such as these type of collars.
Another way that some patients end up having immobilization is through a halo. We call this device a halo. It has four pins that are screwed into the skull, similar to the traction on the other one.
That one has two pins that are screwed into the skull. Normally they, I mean, the good thing about this the halo versus the garden wall tongs is that the patient can be mobile so they can actually start getting out of bed they can bathe they can they can't remove this at all but they can fasten it to be able to change shirts they just have to be very careful and because it's an external fixator they actually have an area that has to be cleaned every day and monitored for infection normally people are in this for about 6 to 12 weeks. Again, it allows for delayed decision making. So this person may end up needing surgery after a while, or they may be allowed to not have surgery because this allows for the healing that is required. Again, since they're mobile, you can actually start rehab with them.
If they have the garden walls tongs, they are only allowed to stay in the bed. They do have beds that actually can rotate. So a patient can be fixated in the bed and the bed starts to rotate from side to side.
So it allows for pressure redistribution. But when we're talking about halos, they don't have to stay in bed. But the halo itself is heavy and bulky. It is. can interfere with range of motion of the arms and it also can cause problems with swallowing and jaw pain.
If you can imagine, even though there's kind of like a sheepskin type material that's underneath the brace around the torso, it can cause a lot of pain. can cause some skin breakdown. The halo is actually one of the most effective devices in preventing cervical motion. It's very particularly effective in limiting rotation and lateral flexion of the entire cervical spine. It also limits flexion and extension in the higher cervical levels.
It provides maximal stabilization compared to all the other braces. There's also another brace that's called the Minerva Orthosis, which I think people have started using if they feel comfortable that the patient will be compliant because it's not screwed into the head. So you can actually google the Minerva, M-I-N-E-R-V-A orthosis and find out a little bit more about that. Complications that can occur In people wearing the Halo device include loss of reduction of the fracture, pin loosening, infections at the pin sites which can immediately turn into septicemia or osteomyelitis, pressure ulcers in the skin underlying the vest, skin rash from the heat under the vest, and injury of the supraorbital or the supratrochlear nerve.
You can also end up with dural penetration if the screws start moving at all, dysphagia, disfiguring scars, pin discomfort, and as I said before TMJ joint dysfunction. The majority of the complications actually are associated with the pins. So pin loosening is of concern for two reasons. It can result in loss of stability and it often precedes infection at the pin site. Infection at the pin site should be treated extremely early.
The other thing to think about is family members feel like they have something to hang on to when they're helping their patient their family member move so we need to make sure that everybody is educated not to grab on to those rods on the side to help them move because that would definitely cause issues with the pins internal fixation can occur a lot of different ways oftentimes harrington rods are used to go into each of the lamina and Rods are on either side of the spinous process. It helps to traction or distraction between the areas that are needed. You can see how this kind of takes place where the screws are screwed into the the vertebral bodies usually right where the transverse processes are at the body.
Then you've got the rods on either side and it can actually keep the space that is required. So this can be used for to reduce dislocations and to restore the height loss. These are some examples of thoracolumbar sacral brace or what we call a clamshell. The one in this area right here, the hard plastic one, we call it a clamshell because it literally is fit to the person.
and it's bifurcated so you can actually take off the front and then kind of squeeze it into the back and then use the velcro. The Jewett brace is also another one. Obviously it's a little less hot. The Jewett brace, it has three levels of stabilization. It's holding from basically moving laterally or it doesn't allow you to rotate and it definitely doesn't allow you to flex or extend.
So these could be used with or without surgery. If we have a patient that has had a spinal cord injury, we must know before we get them out of bed if they need any stabilization before getting them out of bed. If they do, we need to be the ones usually that start to train them in how to don and doff the braces. Oftentimes there's a lot of log rolling that's going on, and it's challenging for the patients to do.
If you end up with a brace that you are unfamiliar with, then you need to speak with your DME reps or your orthotist. So oftentimes they're the ones, if it's a custom fit, they can tell you, but even if it's not a custom fit, they're the ones that tend to be the suppliers. So getting to know a good orthotist is very beneficial to you.
Well, since I already went over this, I'm not sure that I'm going to talk about it a little bit more. I didn't realize that I had this slide as well. I apologize.
So next on the list is the spinal cord injury PT evaluation. So it's typical of any evaluation that we would do. Understanding what their previous level of ability is is very important. Knowing whether they were very sedentary or very athletic will make a difference. We definitely need to know their cardiopulmonary status.
and want to check their skin of course. Oftentimes, I mean, if we're working in the acute care hospital, we may be seeing seeing them shortly right after their admission. But if we're working in a rehab hospital, they may have been impatient for a week or two, depending on their complications.
And so we definitely want to know their integumentary status. Range of motion, reflexes, and sensation is important, as is strength of the muscles that they... have use of. If we have a patient that has a C3 injury, then we would want to know passive range of motion of all four extremities.
Communication is important because especially if they are going to need help after their injury, we want to know how well did they communicate because we want to teach them to be as independent as possible. Even if somebody's helping them move. They should be the ones that lead the movement once they've been taught how to do that. So they need to tell their provider how to assist, how much assistance they need, where they need to be, and so on.
So of course cognition is important. People who have a spot spinal cord injury, especially of the neck, we definitely want to be really kind of keeping an eye out for any cognitive impairments because they may have also had a traumatic brain injury that was not necessarily picked up because they were doing everything else and trying to protect everything else and fix everything else and their brain did not appear to be damaged, but they may have an injury to the brain as well. So language, of course, what language do they speak, learning style, that's all important. A complete neurological exam is going to be very important.
And we're going to talk about the sensory and motor and where that is normally tested when we do the lab on Thursday. And then, of course, a functional exam. How well do they move in bed?
Can they roll? Can they scoot? Can they go from supine to sit? Can they sit and hold themselves?
Can they do a sit to stand? You know, of course, all of this is going to depend on what what they have and what they don't, what the expectations are at the level of their injury. And remember, if we're working on them very early, we don't know the extent of their injury.
They may still be having the spinal cord shock and be very flaccid from their level of injury down, and so we don't know their complete functional ability at this point. But as we go on, we know pretty much where their injury was, and we can tell approximately approximately within three levels above or below that that's going to be about where they are functioning. So we'll talk about functional expectations in a bit. So this is where it's important to know your tracks.
So when we're talking about just sensation, we got to think about the posterior column, the lateral spinothalamic track, and the anterior spinothalamic track. So when we're testing the different types of sensation, you got to remember where you're actually testing. When we are testing for sensory, normally we are going to start with light touch and then we are going to go on to SharkDoll. We want to use the ASIA handout for the actual dermatomes. I have given you a copy in Blackboard and the next slide actually shows this.
We know that C2 is at least 1 cm lateral to the occipital protuberance at the base of the skull or you can find it 3 cm behind the ear. while C3 is supraclavicular fossa at the midclavicular line, C4 is over the acromioclavicular joint, and C5 is the lateral side of the antecubital fossa just proximal to the elbow, C6 is the dorsal surface of the proximal phalanx of the thumb, while C7 is the dorsal surface of the proximal phalanx of the middle finger, and C8 is of the little finger. T1 is the medial side of the antecubital fossa, just proximal to the medial epicondyle of the humerus.
T2 is at the apex of the axilla, and so on. Please review the international standards for the classification of spinal cord injury key sensory points that I have included in Blackboard. We will go over how to grade the ASIA in lab on Thursday. So also part of the neuro exam is looking at the myotomes. We are very specific with ASIA as to what is tested for each of these areas.
And again, we're going to go over this in class, but see the motor exam guide for specific grading, five to zero out of five. And in that paperwork, it also talks about common muscle substitutions that you need to be aware of and you need to be looking for. Because if you have a spinal cord injury and one of these areas is missing and you're asking them to perform, they're going to do everything they can to try and make that perform. So they may use other muscles to substitute.
So please be aware what is written in the motor exam guide. The second page are the ASIA work worksheet has the grading information and it also includes the non-key muscles. So when to test the non-key muscles. So this information, these are the different muscles that you can use to grade if there's some specific reason that you can't grade the what is expected. It tells exactly how to grade, exactly what you're putting down.
And we'll talk more about this, of course, when we get to the actual lab. The American Spinal Cord Injury Association has come up with the ASIA Motor and Sensory Exam. And through this ASIA Motor and Sensory Exam, we come up with the ASIA Impairment Scale. It helps us determine the specific diagnosis of the level and completeness of the spinal cord injury by looking at the motor and the sensation.
So you can find out... the varying degrees of sensory and voluntary motor function that can be seen coddle to the incomplete spinal cord lesions specifically. A person can be diagnosed as a complete injury or an incomplete injury as we spoke about in the last presentation. If they're a complete injury, they are considered to be an ASIA-A.
That means they have no sensory or motor function that is below the level of injury. They also have no motor sensory or motor function in the sacral segments of S4 through S5. B.
and C and D are considered incomplete injuries. So with an ASIA B, they have some sensory but no motor function in the sacral segments. While C and D is a little more difficult to differentiate, but a C is an incomplete with motor function preserved below the level and muscle strength of less than 3. Let me say that differently. The motor function is preserved at the most caudal sacral segments for voluntary anal contraction or the patient meets the criteria for sensory incomplete, meaning they feel S4 or S5 by light touch or pinprick. And they have some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body.
For Asia C, less than half of the key muscle functions below the single neurological level of injury have a muscle grade of greater than or equal to three. I know this seems confusing and hopefully it'll get cleared up on Thursday. A D. is a motor incomplete as well, meaning they have voluntary anal contraction or sensory incomplete status at the S4-S5, and they have at least half or more of the key muscle functions below the single neurological level of injury, having a muscle grade of greater than 3. Again, I think this will become much more clear when we do the lab on Thursday. E is normal, a person that has normal sensory and motor function, who had a spinal cord injury.
So someone that's never had a spinal cord injury would not receive an ASIA grade. So an ASIA-E is only for people who actually did have a spinal cord injury and had prior deficits and now has recovered. So the functional exam is going to include several activities. We want to look at Self-care, sphincter control, mobility, locomotion, communication, social cognition. These are really what we looked at with the FIM.
And of course, now we're using the care instead of the FIM. But I still wanted to keep this in your slide because these are the things that we are looking at. The SCI-EDGE, which is the Evidence Database to Guide Effectiveness, through the APTA Academy of Neurologic Physical Therapy. These that are listed, you should be familiar with all of them.
FEM again is listed, but it is changing that that will no longer be part of what we do. The ASIA we're learning, but all the rest of them you should already be very familiar with. Specifically, the EDGE Outcome Measure for Entry-Level Education has listed in the blue, students should learn to use.
So, again, you have learned to use all of them except for the ASIA impairment scale that we are going to be learning. Students should be exposed to all of the others. And I think we have spoke about most of them.
If you are not familiar with any of them, please do look them up in the Shirley Ryan web page and find out more information about them. If you have questions, please bring it to class. When we talk about complications of spinal cord injury, one of the most important things that you have to know about is autonomic dysreflexia. It is an emergent situation. It occurs in people who have a lesion above level T6.
However, it has been seen in individuals with a T7 or T8 injury. What happens is there's some sort of a noxious stimuli below the level of the lesion, but because of the injury, the information is not getting through. to the right place.
It usually first appears 6 or more months after the injury, but it can occur earlier. It can develop rapidly and is potentially life-threatening. An immediate response is necessary when it occurs.
The signs and symptoms of autonomic dysreflexia include systolic and diastolic blood pressure elevated 20 mmHg or more above the individual's normal. post-injury level, a pounding headache, heart rate slower than the individual's normal post-injury rate, profuse sweating or skin flushing above the level of the lesion, particularly in the neck and face, and shoulders, piloerection above the level of the lesion, meaning the hair is standing on its end, paresthesias in the head, neck, and upper chest, and the visual deficits, nasal congestion, anxiety, and cardiac arrhythmias. When a patient exhibits signs and symptoms of autonomic dysreflexia, their blood pressure should be assessed.
If an individual's blood pressure is above post-injury normal, they should immediately be placed in the sitting position, head and torso elevated and lower extremities lowered. This may lower the blood pressure and promote cerebral venous return. Then, you need to check clothing and other devices that may be constricting, and if they are, they should be loosened. During the episode, blood pressure and heart rate should be monitored frequently.
The underlying source of noxious sensation that is causing the dysreflexia should be investigated and eliminated as quickly as possible. It could be bladder distension. and that's a very common stimulus for an autonomic crisis so if they're catheterized using an indwelling catheter they you need to check to make sure it's not kinked they're not sitting on it there's no obstructions the other thing that could be happening is fecal impaction so those are some of the problems it could be a broken toe It could be, you know, there's a lot of things.
These people don't feel below the level of injury, so these are some of the things that could happen. The relevance for a high-level spinal cord injury being related to autonomic dysreflexia is based on the anatomy and the homeostasis between the parasympathetic and the sympathetic divisions of the autonomic system. In someone with a high-level spinal cord injury like T6 or above, when a strong sensation input, so say for example an overfilled bladder, from below the level of the injury tries to reach the cerebral cortex, it is blocked. But the ascending information is able to reach the thoracolumbar sympathetic nerves. specifically the major splenic sympathetic outflow at the T5-T6 level, which triggers a massive reflex sympathetic surge resulting in vasoconstriction of the splenic vascular This causes peripheral arterial hypertension.
The brain detects the hypertensive crisis through the intact baroreceptors in the neck delivered to the brain through cranial nerves, 9 and 10. Because of the level of the injury, the parasympathetic division can't counteract these effects. Because the impulses can't descend past the lesion and make it back to that major sympathetic outflow at T6 and below, the brainstem still tries to restore balance via the vagus nerve, which is still intact. But the result is bradycardia and vasodilation above the level of the injury. So another way to look at it is the sympathetic division prevails below the level of the injury and the parasympathetic nerves prevail above the level of the injury. Here's a list of some of the different things that could cause autonomic dysreflexia and here's a description of autonomic dysreflexia in a pictorial view.
So I already listed the symptoms that they have and interventions are immediately placed the patient in a sitting position. position to decrease the blood pressure. Check the Foley first, then check for anything else like tight clothing.
And you need to report this immediately to either the nurse or the physician. They may need Foley changed. They may need bowel checked for impaction, but they do need to know that they had an episode of autonomic dysreflexia. Patients should be getting educated. The Christopher and Dana Reeves Foundation has downloads for wallet cards for autonomic dysreflexia for DVT and sepsis for adults and children.
Other complications of spinal cord injury include orthostatic hypotension or postural hypotension. Patients with who haven't been upright need to be slowly progressed to upright and their vital signs need to be assessed while it's happening. To help reduce issues with orthostatic hypotension, besides medication that can be used, they can use compression stockings which help to keep the circulation from pooling. in the feet or in the gravity dependent position.
An abdominal binder helps to control that as well and of course edema control via the medication is very common. Oftentimes they will be prescribed vasopressors to help increase their blood pressure through peripheral vasoconstrictions. Normally temperature regulation is not happening below the level of the injury. Because of that they can no longer control the cutaneous blood flow or sweating. to increase or decrease temperature.
So if the patient is cold, they are unable to shiver. If they are hot, they don't sweat. So unfortunately, this is something that we need.
to be monitoring for them until they can start figuring it out, especially if they are a high level injury because then they don t have enough to really feel the difference. Anyone who has an injury above the level of C5, because remember 3,4,5 keeps the diaphragm alive, will have impairment to their respiration. These people are either going to be ventilated or they will need a phrenic nerve stimulator.
If you have never seen anything about a phrenic nerve stimulator, I am sure there are videos that show somebody using a phrenic nerve stimulator. It's pretty cool, but normally they have to have a vent back up just in case. So not only do higher lesions affect the diaphragm, but it also affects the external intercostals, and the internal intercostals. These people not only have a hard time breathing, but they also have a hard time coughing or clearing. You know, this is why pneumonia can be common in these individuals.
People with lumbar injuries would have an intact diaphragm and secondary respiratory muscles, but they may have the abdominal and the lower areas. So they may also have issues with breathing because of postural issues, but also clearing, if they accidentally swallow wrong, those type of things. Because a spinal cord injury is an upper motor neuron lesion, spasticity is a common problem after a spinal cord injury. Normally they start with flaccidity because of the spinal cord shock, and then usually they start having some increase in their hypertonicity, their reflexes increase. They have clonus.
But remember some of the individuals may have more than just a spinal cord injury. They may have also had some peripheral nerve damage depending on the injury. They may have had some avulsion of the nerve. So it's not always only an upper motor neuron that you see. But normally spasticity will increase over the next 6 months and usually plateaus about a year.
But they are normally treated with medication. to help reduce the spasticities. But this is where we have to be careful because some of the medications that decrease spasticity, like baclofen, Valium, Dantrium, all of them can make somebody very sleepy. And if they have severe spasticity, the amount of medication that they have to take can end up being dangerous to the other muscles that need to be working, like the diaphragm, the heart. So Treatment with medication is something that they can do, but they can also end up doing a baclofen pump.
We spoke about that last year when Dr. Sandberg came and spoke to you. So there are surgeries that can be performed, and here's a list of some of them. The three most common complications of spinal cord injury are pneumonia, pressure ulcers and DVTs. Because the diaphragm is involved, because postural muscles are involved, because abdominal muscles could be involved, any of those things are going to reduce ventilation.
Postural ulcers in any area that they have. have impaired sensation can be a problem but also if it's just in the lower extremities the buttocks that area if they have any issues with urinary incontinence they have wetness in that area that can lead to maceration of the tissues if they are not transferring well, they could have shearing across the skin as they are transferring, they could also have shearing when they go into a spasticity like an extensor spasm, they can also end up with pressure ulcers because they are not taking care of themselves in general. And DVTs of course can occur with any big trauma in any individual. So normally DVTs can occur in the first months following the injury. And they're normally on anticoagulants, they're normally wearing Ted Ho's, more doing passive range of motion and proper positioning, making sure that...
that they're not kinking behind their knees where oftentimes DVTs occur. Other complications can be contractures. Additionally, heterotrophic ossification can happen.
Heterotrophic ossification can happen anywhere below the level of a CNS injury. So in somebody who has a spinal cord injury, oftentimes it's the large joints that it happens in. It can happen in people who have spinal cord injury and TBI most commonly, but it can happen in people who have a spinal cord injury.
happen in any of the other CNS involvement. We don't know why people end up with it, but it does happen commonly. So here's an x-ray of the buildup of calcium in the hip.
And as you can imagine, this hip is not going to be moving much. Typically, we see it in the hips and the knees, sometimes in the shoulders, as I said, usually large joints. Symptoms that you see are a swelling in the area, decreased range of motion, ear attack, erythema of the area, local warmth. When they do tests, they have elevated serum alkaline phosphatase levels.
The x-rays are often negative at first, but we do need to figure out what's going on pretty rapidly. If all of a sudden you have a patient that their range of motion is much more limited, then we need to consider why this could be happening. And HO needs to be something that we are always in the back of our minds with these individuals that it could be a possibility. Treatment they can treat with some medications, non-aggressive range of motion if tolerated, and then possibly surgery if they have to. have extreme functional limitations because of it.
So another complication of spinal cord injury is pain. We can have traumatic pain from the actual injury or injury of other areas from the trauma they sustained. We can treat depending on what is causing the pain, but if it's soft tissue injuries, ligament injuries, fractures, of course we'd want to immobilize. If it's muscle spasms that's causing the pain, then there's medications.
Surgical interventions can help with, of course, any of those as well, except for the muscle spasms. They may be treated for the pain with analgesics, possibly TENS, and possibly mobilization. Normally the traumatic pain that they're having subsides in the first three months. The pains they have later on could be caused because of nerve root pain.
It could be caused for other reasons as well, but we'll talk about nerve root pain can happen because of the damage at the site of the injury or from the secondary spinal instability that's happening or possibly scarring or adhesions that's happening after or during the healing portion. If it's nerve root pain, normally this is really kind of nerve complaints. like sharp, stabbing, burning, shooting pain, oftentimes following the dermatomal pattern.
Treatment options are medication, usually gabapentin, Neurontin, those type of medications for nerve pain. Narcotics are not good medications for nerve pain. TENS units can be helpful, possibly a neurectomy, depending on how long and how pronounced the pain is. And they can actually do surgeries where they go in and do a rhizotomy. So spinal cord dysesthesias can be because of the injury itself in the spinal cord, and this can cause either nerve shooting type pains or in an area of the body that doesn't have sensation normally.
So it's kind of like what we call phantom pains. We don't know why that happens. There are some medications that can be helpful for these individuals listed on the slide.
And of course musculoskeletal pain. These are pain pain that is occurring above the level of the injury, like shoulder pain or neck pain, or normally this is from poor position. osteoporosis below the level of the lesion is very important to think about. With these individuals, they are not necessarily weight-bearing, specifically in their lower extremities.
Weight-bearing is a good activity for them to be doing, and if we can, we want to encourage that. The osteoclasts dissolve more bone than what the osteoblasts are able to replace. in these individuals. In the first six months, because of the decreased weight-bearing, it's very common. We need to treat with diet weight-bearing activities, and we also want to prevent UTIs and prevent urinary stasis, which actually I don't remember why, I don't know that I ever actually learned why, but that actually can play a role in osteoporosis in these individuals.
So just know that we want to prevent that. So rehab interventions. I think I have like two more slides and then we're calling it quits on this one and then I'll have a third slide show.
In the acute phase The biggest thing that we're trying to do is prevention of secondary complications like contractures, pain, osteoporosis. Those are going to be the most important things. We prepare the patient for the transition to the next level. The next level is usually going to be inpatient rehab. We are starting to do some family training specifically on expectations and discharge planning is important.
Like where are they going to go? If they can't tolerate three hours of therapy a day, then inpatient rehab is important. may not be the next phase of their treatment.
Inpatient rehab, like I said, they must tolerate the three hours of therapy per day. In inpatient rehab, they're going to begin their functional retraining. So getting out of bed, moving in bed, getting in a wheelchair.
moving in the wheelchair, taking care of the wheelchair, getting back to their ADLs or learning how to do their ADLs differently. So all of those are the things that we're going to be looking at. Family training continues.
We want to know what their goals are. Where are they going to go back to? Are they going to go to home?
Are they going to go back to work? Are they going to go to school? What's their plan? So vocational training may be important because if they can't go back to what they used to do, then I'm not going to be able to go back to work.
we may need to help get them involved in retraining. So home exercise programs are going to be very important because we're not going to get to see them in therapy for all that long, you know, maybe a couple months if we're lucky, and then they go home, and then they have to continue on with their outpatient rehab, but we want them to know the exercises we want them to do. Driving evaluations are usually done in occupational therapy, but unfortunately, Unfortunately, not all sites have the ability to do that. Driving evaluations are a great service that can be provided for them. And then of course discharge equipment and planning.
So we have to figure out what are the expectations of somebody with this level of injury. Do we expect them to walk? Do we expect them to use the wheelchair?
Do we expect them to be using an electric wheelchair or a motorized wheelchair? So hopefully in the end, Inpatient rehab, they have a room that the patient can spend a few nights in that's more like a home and they can see how safe they're going to be when they go home. Once they leave inpatient rehab then they have outpatient rehab and community reentry. Sometimes in the inpatient rehab they have some of the community reentry and we are going to be meeting with Jimmy Moody sometime this semester. and do some information about community reentry and the importance of it.
But this is where we're looking at, you know, transfers, not just to the commode or the bed or the wheelchair, but, or the car, because that's important as well, but getting off the floor, going up curbs, going up a step, you know, how, how do they get around? How do they get in and out of their chair? And then of course, how do they interact with their community? Do they need help? Do they have the equipment?
So that's the end of this slideshow.