Spinal cord injury rehabilitation in Vietnam

1. Spinal Cord Injury RehabilitationSpinal Cord Injury Rehabilitation
in Vietnamin Vietnam
Cam Ba Thuc MDCam Ba Thuc MD

2. ContentsContents
• Summary of Spinal Cord Injury (SCI)
• Epidemiology of Spinal Cord Injury
• Epidemiology of Spinal Cord Injury in Vietnam
• Set up care network of SCI in Vietnam
• Rehabilitation for Spinal Cord Injury patients in Central
Rehabilitation Hospital (Thanh Hoa province).

3. SummarySummary
• Spinal cord injury (SCI) results in disruption of the nervous
transmission and has considerable physical and emotion
consequences to an individual’s life
• Paralysis, altered sensation, or weaknesses in the parts of the
body innervated by areas below the injured region almost
always occur.
• In addition to a loss of sensation, muscle functioning and
movement, individuals with SCI also experience many other
changes which may affect bowel and bladder, presence of pain,
sexual functioning, gastrointestinal function, swallowing
ability, blood pressure, temperature regulation and breathing
ability.

4. SummarySummary
• Numerous secondary complications may arise from SCI
including deep vein thrombosis, heterotopic ossification,
pressure ulcers and spasticity.
• The recovery can be long from the acute hospital admission to
the return of full participation in the individual’s community.
• Even those individuals who make significant gains in
rehabilitation may experience difficulty when returning to pre-
injury activities.
• Thus, SCI has a serious effect on quality of life.

5. SummarySummary
• Spinal cord Injury (SCI) occurrence is a worldwide recognized
health issue leading to serious medical and functional
impairments, affecting mobility, activities and participation to
society for the affected persons and his community.
• So far no cure of SCI is available, treatment of complications and
management of mobility in order to increase independence of the
affected person are the best options possible to ensure a better
quality of life for the person affected.
• Although treatment techniques and psycho- social adjustment
knowledge have improved significantly since the last decades, the
access to the care is not evenly spread in the world. Economic
considerations are given as the main reason.

6. SummarySummary
• However, comprehensive training programs adapted to the local
context, health policy that allows decentralizing of services and
research and care promotion do increase the awareness of SCI
among the health professionals, health financers and the general
public.
• Prevention measures to avoid new SCI accidents should be
implemented in the long term and are the most cost effective
way to counter the serious social and financial consequences of
SCI on society

7. Epidemiology of Spinal Cord InjuryEpidemiology of Spinal Cord Injury
• Injuries to the spinal cord have been classified as either
traumatic in cause (e.g., motor vehicle accidents, falls, violent
incidences, diving) or non-traumatic (e.g., tumors, spinal
stenosis, vascular).
• Traumatic SCI accounts for the larger proportion of SCI injuries,
however, difficult to ascertain because reporting of non
traumatic.
• The percent of traumatic SCI to overall SCI injury has been
reported to range from 75% in Germany (Exner & Meinecke
1997), 61% in the United States (McKinley et al. 1999a) and
48% in the Netherlands (Schonherr et al. 1996).

8. Epidemiology of Spinal Cord InjuryEpidemiology of Spinal Cord Injury
• The global incidence of SCI estimated primarily from developed
countries ranges from 10.4 to 83 per million populations per
year when including only patients who survived before hospital
admission (Wyndaele & Wyndaele 2006).
• If reports in international journals and papers suggest that SCI
occurs on average between approximately 14 to 80 persons per
million habitants per year are exactly, at the moment We have
between 250 to 861 persons per million habitants live with SCI
• Population of SCI on earth: estimate from 150 - 510 million SCI
(world population is 6,77 billion people).

9. Epidemiology of Spinal Cord InjuryEpidemiology of Spinal Cord Injury
Proportion of spinal cord injury by gender in some countries in the world
Author Nation Report year Male/Female
Tricot A France 1981 4,6/1
Van Asbeck et al Netherland 1994 3,0/1
Maharaj JC Fiji 1996 4,0/1
Chen HY et al Taiwan 1997 3,0/1
Martins F et al Portugal 1998 3,0/1
Karacan L et al Turkey 2000 3,0/1
Wyndaele et al General features 2006 3,8/1

10. Epidemiology of Spinal Cord InjuryEpidemiology of Spinal Cord Injury
Proportion of spinal cord injury by gender
in developing countries
Nation Male Female Male/Female
US 83,8% 16,2% 5,18/1
UK 85,8% 14,2% 6,04/1
Canada 78,9% 21,1% 3,73/1
General features 82,8% 17,2% 4,8/1

11. Epidemiology of Spinal Cord InjuryEpidemiology of Spinal Cord Injury
in Vietnamin Vietnam

12. SCI in war time of VNSCI in war time of VN
• The Vietnam War had caused the deaths of between 2 to 5
million Vietnamese (different depending on the source).
• Among the allies of the Republic of Vietnam, the
Americans have the highest number of casualties with more
than 58,000 dead and 305,000 wounded (of which 153,000
were injured or disabled). At about 4,400 to 5,000 soldiers
from South Korea killed; Australia has about 500 dead and
over 3,000 injured; New Zealand 38 dead and 187 injured;
Thailand 351 dead and wounded; The Philippines also has
no specific statistics.
• Source: https://vi.wikipedia.org/wiki

13. SCI in war time of VNSCI in war time of VN
• Against Japan: 1944 – 45 (2 years)
• French: 1946 - 54 (9 years)
• North – South war: 1954 – 75 (22 years)
• Border dispute with China, Cambodia: 1979-89 (10year)
• No national figures about spinal cord injury invalid are
available (I don’t know how many SCI person);
• There are many SCI invalids lives in Center for Care
Invalid people;
• Some doctors were trained abroad (Netherlands) to serve
these invalid people;

14. SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN
• After war ended, no have any more SCI patients, and SCI fall
into oblivion;
• Since 1986, due to the activities of industrialization, increased
accidents, increased faster SCI, so SCI was interested back.
• No national figures are available in Vietnam
• In regard to this situation, it is assumed that averages in
Vietnam fall within world’s values (ranges from 14 to 80 per
million populations per year)
• It is estimated that at least 25.000 persons live with SCI in
Vietnam today and each year at least 850 new persons get an
SCI every year.

15. SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN
• From 2003 to 2008, Handicap International programs have
been developing SCI care and approached around 2400 SCI
patients and family members. 45 % of them were caused by
Road Traffic Accidents (RTA), more specifically motor
bike accidents.
• Data collections done between in 2008 – 2009 in Bach Mai
Rehabilitation Centre, suggest 268 patients who were
distributed by 10 age groups (0-4 years to 75years and
above).

16. SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN
• Based on collected data, men were more likely than women
to suffer SCI at all ages at a ratio of 85% to 15%. Moreover,
age 35-54 years showed maximum number of patients
suffering SCI (65% for male and 35% for female). The age
range was between 5 years and 75 years with the age on
average are 39 years.
• Etiology, 31% (n= 84) are due to transport, 44% (n= 119)
due to falls, 2% (n= 6) due to assault, 1% (n= 2) due to
sports activities, 9% (n= 24) due to other traumatic causes
and 12% (n= 31) due to non-traumatic causes like
tuberculosis in the spine, transverse myelitis.

17. SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN
• Systems of care that could address this condition were not
widely available throughout the country before the end of
the year 2000. With economic development taking shape
(infrastructure building, road network expansion, and
poverty reduction) in a very short time frame, mainstream
population got access to transport means and use of
improved roads, lacking proper prevention mechanisms for
reducing the number of motorcycle accidents.
• Economic development activity brought more traffic,
construction activity, informal enterprise exposing the
active population to new occupational hazards causing an
increase of falls, crushing and impacts leading to spinal
injuries.

18. SCI in Open door time (since 1986) of VNSCI in Open door time (since 1986) of VN
• Health care reform in Vietnam opened up possibilities for care
innovation to address new needs for SCI patients admitted in
Rehabilitation Hospitals. Post acute care and physical
rehabilitation, care networks and their referral system were
developed leading to better evacuation of victims, increased
quality of emergency treatment, and increased survival rates
after accidents.
• This lead to a more important number of SCI victims surviving
their accident longer as well as needing comprehensive care to
facilitate better social and economic integration.

19. Health care and physical rehabilitation of SCIHealth care and physical rehabilitation of SCI
in Vietnamin Vietnam
Thank to Handicap International Belgium
now we have a SCI network

20. Set up care network of SCI in VietnamSet up care network of SCI in Vietnam
• In 2003, set up of a 50 bed pilot Spinal Unit in Ho Chi Minh
City - Southern Vietnam (answering to the rising needs in an
urban and highly industrialized setting).
• This pilot unit (supported by Handicap International
Belgium) was extended with “satellite units “in three
Southern provinces from 2006 to 2007 to ensure better
proximity of care for the mainstream SCI patients (mainly
living in provincial areas after their initial treatment phase).

21. Set up care network of SCI in VietnamSet up care network of SCI in Vietnam
• SCI care development was followed by setting up an SCI
training Unit at National Rehabilitation Centre of Bach Mai
hospital in 2008.
• This 20 bed unit aims to create a national care model from
which provincial Rehabilitation Centres can resource
themselves to implement SCI care in their specific setting ,
answering to the needs of SCI patients locally for primary
rehabilitation services and, if necessary, referral for
specialized services to the National Rehabilitation unit.

22. Set up care network of SCI in VietnamSet up care network of SCI in Vietnam
• The decentralization policy from the Ministry of Health was still
in process and aims by 2012 to have 11 Spinal Cord Units
operating in throughout the country equipped with a total of 200
spinal beds;
• Then Duplication of this model in the remaining 34
rehabilitation centers can lead to very comprehensive system of
care that can make SCI care services geographically available
for its 90 million citizens.
• The Central rehabilitation hospital of Thanh Hoa has developed
progressively since 2005 a Spinal Care Unit under cooperation
between the Hospital and Handicap International Belgium.

23. Set up care network of SCI in VietnamSet up care network of SCI in Vietnam
• The construction of specialized units to treat SCI patients equally
distributed in both Northern and Southern areas to ensure
balance and meet the demand for treatment increased domestic.
• Although nearly 60% of the cost of treatment for patients
covered by the state and support but I think that Vietnam also
needs to ensure that patients with SCI in the provincial poor or
remote areas can still access this treatment services;
• Guidelines and policies of the state to encourage the construction
and development of specialized rehabilitation are important keys
to create conditions for improving expertise and demonstrate the
result of work as well as the effectiveness of the development
these SCI Units.

24. Set up care network of SCI in VietnamSet up care network of SCI in Vietnam
Or Name of rehabilitation hospital
in which has SCI rehabilitation unit
Number
of SCI bed
1 Rehabilitation Hospital of HCM City 50
2 Bach Mai Rehabilitation Centre 20
3 Central Rehabilitation Hospital Thanh Hoa 20
4 Da Nang Rehabilitation Hospital 20
5 Khanh Hoa Rehabilitation Hospital 20
6 Phu Yen Rehabilitation Hospital 20
7 Ha Tinh Rehabilitation Hospital 10
8 Bac Giang Rehabilitation Hospital 10
9 Son La Rehabilitation Hospital 10
10 Thai Binh Rehabilitation Hospital 10
11 Phu Tho Rehabilitation Hospital 10

25. Training program of Handicap InternationalTraining program of Handicap International
• Classification of neurological deficit based on ASIA
impairment scale (Ass-Prof. Apichana, Chiangmai)
• Prevent and cure pressure ulcer
• Management of neurogenic bladder
• Management of neurogenic bowel
• Management of spasticity
• Management of pain
• Management of sexual dysfunction
• Urodynamic
• Intravescica pressure (water column measure)
• Intra muscular nerve block (phenol 5%) (Dr. Arome from
Thailand).

26. Training program of Handicap InternationalTraining program of Handicap International
• Breathing exercise
• Deep vein thrombosis
• Hypotension (orthostatic hypotension)
• Hypertension (autonomic reflex)
• Heterotopic ossification
• Physical therapy
• Occupation therapy
• Leisure activities (creative activities)
• Peer counselor
• Psychological therapy
• Adaptation skill (independence living/ transit house)
• Wheelchair training

27. Central Rehabilitation HospitalCentral Rehabilitation Hospital
Thanh Hoa provinceThanh Hoa province

28. Central Rehabilitation Hospital
(Ministry of Health)
Address: Nguyen Du road
Sam Son – Thanh Hoa - VN

29. • Founded in 1972, a temporary hospital for invalid
• Since 1999, change to Central Rehabilitation Hospital
(belonged to Ministry of Health).
• 310 bed and 163 staffs
• Main functions:
+ rehabilitation
+ primary health care for local people
+ emergency service
+ orthopedic surgery
+ prosthesis and orthotic service
+ co-operation: nationwide and worldwide

30. • 10 Departments and 1 Workshop:
+ Outpatient and emergency service : 20 beds
+ Rehabilitation Dept : 80 (20beds of SCI Unit)
+ Internal Medicine Dept : 80 (Combine: Pediatric)
+ Geriatric Dept : 80 beds
+ Orthopedic Surgery Dept : 30 beds
+ ENT – Dentistry – Eye. Dept : 20 beds
+ Traditional Medicine. Dept : 40 beds
+ Sub-clinic Dept: image, analysis, biology, parasite, function
diagnosis.
+ Pharmacy Dept
+ Infectious control Dept
+ Prosthesis and Orthotic Workshop

31. Rehabilitation DeptRehabilitation Dept
• 36 staffs & 80 bed for inpatients
• 5 doctor, 12 nurses, 15 PT, 2 OT, 2 cleaner
• Inpatient area = 80 bed (20 bed for SCI)
• 03 Exercise room
• 01 Occupation therapy room
• 01 Speech therapy room
• Physical therapy rooms: such as electrical stimulation; short
wave; micro wave, shock wave and magnetic field.

32. * Total patients of hospital:
- Outpatients: ♯ 38.000 per year
- Inpatients: ♯ 9.000 per year
* Inpatients of Rehabilitation dept.: ♯1.200
* Types of Patients in Rehabilitation dept: Stroke, Brain injury,
SCI, Cerebral Palsy, Neck Pain, Back Pain, Muscular Skeleton
diseases; Lymph Edema; CMD (Congenital Muscular
Diseases)…etc…; some time we have autism children;

33. SCI rehabilitation in my hospitalSCI rehabilitation in my hospital
• We received SCI patients for along time
• The protocol of care and rehabilitation not so good
• Since 2005, under sponsor of Handicap International Belgium,
our service had changed.
• Handicap International help training a team work, consist of:
Rehabilitation doctor : 02
Rehabilitation nurses : 02
PT and OT on SCI : 03; OT and wheelchair = 01
Psychologist : 01 (doctors, give up now)
• Protocol of healthcare and rehabilitation based on standard of
Handicap International Belgium.

34. SCI rehabilitation in my hospitalSCI rehabilitation in my hospital
• Classification of neurological deficit based on ASIA
impairment scale;
• Temperature regulation: we have special room for patients
with high level of injury to prevent suffering high temperature
• Prevent and cure pressure ulcer (PU):
+ Prevent PU when lie on bed or sitting on wheelchair
+ Education for patients and caregiver; use water mattress, alter
pneumatic mattress, keep skin clean…
+ Turn regularly and check pressure region,
+ Necrosis debridement, wash and clean the wound, bandage
+ Nutrition supply; multi-mineral and vitamin supply

35. SCI rehabilitation in my hospitalSCI rehabilitation in my hospital
• Bladder care:
+ We do urodynamic or water colum measure to defined bladder
function (active, capacity);
+ Training self clean intermittent catheterization, combine with
intake enough water and management of urinary track infection
+ Use anticholinergic medication (ditropan);
+ If patients need do Intravesica Botox Injection, we will transfer
patient to Bach Mai Rehabilitation Centre.
• Bowel care: training patients how to care bowel, use medication
for softening or forming, combine with intake water of bladder
care program.

36. SCI rehabilitation in my hospitalSCI rehabilitation in my hospital
• Circulation Care:
+ Prevent deep vein thrombosis: pneumatic massage, exercise,
early detection by clinical exam and ultrasound scan
+ Hypertension: prevent autonomic reflex in patient with SCI
upper T6 by education patient the symptom of hypertension,
check blood pressure regularly; if there is a hypertension, check
bowel or bladder and other triggers; use medication.
+ Hypotension: prevent orthostatic hypotension by education
caregiver and patient, pay special notice when change position
of these patients; use tight clothes, bandage and intake more salt.

37. SCI rehabilitation in my hospitalSCI rehabilitation in my hospital
• Management of spasticity:
+ Use medication such as oral take baclofen, mydocalm,
decontractyl
+ Use phenol block: do ultrasound scan to find the location of
the nerve, use TENS apparatus for electrical stimulation;
+ Botox injection (expensive, need sponsor): we use both
ultrasound guide and electrical stimulation;
+ Use orthotic device
+ Obturatorius nerve denervation: this must do in orthopedic
surgery department of my hospital;

38. SCI rehabilitation in my hospitalSCI rehabilitation in my hospital
• Management of pain:
+ Evaluation of pain
+ Use medication such as NSAIDs, neurotin, lyrica;
+ Physical therapy such as massage, exercise, participate
leisure time such as volley ball, ..etc…
• PT, OT and Self-care :
+ Exercise
+ Wheelchair training
+ Leisure time activities
+ Self-care of bowel and bladder
+ Peer counselor: some successful patient were advisors for
new patients;

39. Cost of treatmentCost of treatment
• Most of disable person were provided health insurance
(policy of government);
• Poor patients or patients live in remote area may
provide meals during hospitalization;
• All the cost of healthcare and rehabilitation were paid
by government through health insurance.
• Health insurance do not pay for prosthesis, wheelchair,
botox medication. These often done by social
wealthfair or benefactors

40. Thanks for your attention !