Spinal Cord Injury PMR Refresher Course

1. SCI - Rehabilitation
Dr George Tharion
Dr Suranjan Bhattacharji

2. Dr Mary Verghese and Dr Howard Rusk
(1962)

3. Initial Evaluation
• Determine Neurological level (ISNCSCI, ASIA
scale)
• Look for complications (DVT, HO, Pressure
sores)
• Evaluate residual strengths
• Set appropriate short and long term goals with
patient and relatives

4. FUNCTIONAL ABILITIES AT DIFFERENT (complete) SPINAL LEVELS
IN TETRAPLEGIA
Levels Indoor Mobility ADL Others
C1-C4 (Powered w-chair)
(Partial indep with UL
FES) Mouth bar for page
turning, writing
(Ventilator / Phrenic
Nerve Stimulation)
C5
Powered w-chair with
special controls /
attendant propelled
w-chair
Some independence (with
FES) / MAS & hand
splints for eating, writing,
computers / Tendon
transfers
(Standing Table /
splints)
Outdoor mobility in
special vehicle,
IDC for bladder
C6
Self propelled w-chair
+/- capstans /
powered chair with
joystick controls
Can be independent with
setup, +/- Splints /
Deltoid to Triceps transfer
(Standing Table)
Car transfers with
transfer board, males
can do SICC
C7,8,T1 Self propelled w-chair
Independent with setup
and home modifications
BKAFOs /Standing
Table
(Drive an adapted car)

5. FUNCTIONAL ABILITIES AT DIFFERENT (complete) SPINAL LEVELS
IN PARAPLEGIA
Levels Indoor Mobility ADL Others
T2-T7
Self propelled w-chair
(RGO/HGO + Walker/
EC)
Independent with home
modifications
BKAFOs + Walker
Self-propelled Tricycle
T8-T12
BKAFOs + ECs
(Self propelled w-
chair)
Independent with home
modifications
Self-propelled Tricycle
/ Public transport
L1,2 BKAFOs + ECs
Independent with home
modifications
Public transport
L3,4 BAFOs + ECs / canes Independent -
L5,S1 +/- BAFOs +/- canes Independent -

6. Strengthening residual
muscles
• Can start as soon as patient is haemo-
dynamically stable and can co-operate, but
remember safety first
• Leave equipment with patient to encourage self
directed restoration (sandbags, weights: plastic
water bottles, rubber tubing thera-bands, etc)

7. Mobilisation
• Prone trolley, wheeled bed, wheelchair as
appropriate
• Cervical collars / halo-vest for Tetraplegics
• Taylor-Knight brace (TLSO), Lumbar corset
(LSO) for Paraplegics
• Start Tilting when spine is stable

8. Orthostatic Hypotension
• Graduated Tilting, slower for higher lesions
• Abdominal binders,
• Elastocrepe bandages for both lower limbs
• Tab Ephedrine 15 - 30mg PO half hour before
tilting
• Tab Fludrocortisone 0.1mg PO

9. Skin care and pressure sore
prevention
• Crucial first step for patient, family and Rehab nurse
• Use of hand mirror and ‘sensate’ limb
• Pressure relief in lying down position: supine, prone,
side lying (Sacrum, trochanters, heels, occciput)
• Pressure relief in sitting position (ischium, elbows)
• Pressure relief in standing position (heels, sole &
toes)

10. Wheelchair training
• Order wheelchair by seat height, seat length
(depth), pelvic width, height of backrest,
armrest, self propelled/powered
• Order wheelchair cushion
• Teach sitting balance, weight relief, transfers,
speed and endurance, rough ground wheeling,
curbs, wheelies

11. Ambulation
• Determined by Neuro level, motivation, age, BMI,
general health, spasticity, limb length discrepancy
etc.
• KAFO with custom moulded SA-AFO in 10 deg
dorsiflexion
• Reciprocal walker, EC with hinged forearm cuffs
• Target walking speed of 20m/min and endurance
of 500m for functional walkers

12. Neurogenic bladder
• Check upper tracts with Ultrasound initially
• Check lower tracts with Cystourethroscopy when
needed
• After urine culture and sensitivity, under
appropriate antibiotic cover, start attendent ICC
early to preserve the urinary tract and save money
• Change to SICC as soon as feasible

13. Medications for Bladder
voiding dysfunction
• Evaluate using Urodynamics (Cystometrogram
and UPP) after eliminating UTI
• Evaluate using Transrectal ultrasound / voiding
cystogram
• Tricyclic antidepressants (Amitriptyline 25 mg PO)
for closing the bladder neck
• Alpha adrenergic antagonists (Prazocin 1mg PO)
for opening the bladder neck

14. Antimuscarinic medications for
Bladder storage dysfunction
DRUG Initial Dose Half life (Hrs) Adverse effects
COST per
Dose
Oxybutynin 5mg (ER) 12-16
Dry mouth 61%,
constipation 13%
₹ 9
Tolterodine 2mg (ER) 3.7-9.6
Dry mouth 23%,
constipation 6%
₹ 8.75
Solifenacin 5mg 40-68
Dry mouth 27%,
constipation 13%
₹ 19
Darifenacin 7.5mg 13-19
Dry mouth 35%,
constipation 21%
₹ 16
Trospium 20mg 20
Dry mouth 20%,
constipation 9.6%
₹ 10
Fesoterodine 4mg (ER) 7
Dry mouth 34%,
constipation 6%
($2.2)

15. Neurogenic Bowel
• High fibre diet +/- Psyllium or Ispaghula
• If sacral reflexes present, digital stimulation or
Bisacodyl suppositories
• If sacral reflexes absent, abdominal pressure in
the sitting position or digital evacuation
• Check digitally for complete evacuation
• Complications: Constipation and Spurious
diarrhoea

16. SPINAL CORD INJURY INDEPENDENCE MEASURE (SCIM VERSION III)
ACTIVITIES OF DAILY LIVING SCORE
SUB
TOTAL
SELF CARE (0-20)
Feeding (0-3)
Bathing Upper body (0-3)
Lower body (0-3)
Dressing Upper body (0-4)
Lower body (0-4)
Grooming (0-3)
RESPIRATION AND SPHINCTER MANAGEMENT (0-40)
Respiration (0-10)
Sphincter management: Bladder (0-15)
Sphincter management: Bowel (0-10)
Use of Toilet (Perineal hygiene, adjust clothes, diapers etc) (0-5)

17. SPINAL CORD INJURY INDEPENDENCE MEASURE (SCIM VERSION III)
ACTIVITIES OF DAILY LIVING SCORE
SUB
TOTAL
MOBILITY (ROOM AND TOILET) (0-10)
Mobility in bed and action to prevent pressure sores (0-6)
Transfers: bed - wheelchair (0-2)
Transfers: wheelchair - toilet (0-2)
MOBILITY (INDOORS AND OUTDOORS, ON EVEN
SURFACES)
(0-30)
Mobility indoors (0-8)
Mobility for moderate distances (10-100m) (0-8)
Mobility outdoors more than 100m (0-8)
Stair management (0-3)
Transfers: wheelchair - car (0-2)
Transfers: wheelchair - floor (0-1)
TOTAL (Admission / Re-assessment / Discharge) (100)

18. Sexuality and reproductive
issues
• Our duty to support re-integration into the family
• Initially give permission for questions/concerns by
individuals or discussion in groups and ensure they
get limited but accurate information
• Provide opportunity for counselling for patient and
partner that promotes a positive body image and
encourages a respect for one’s body after SCI
• Then, when patient is ready, offer specific suggestions
and intensive therapy and protect their confidentiality

19. Erectile dysfunction
• Vacuum devices
• Phosphodiesterase-5 inhibitors
• Intracavernosal injections
• Implantable penile prosthesis

20. Male Fertility
• Semen quality and quantity affected
by UTI, epididymo-orchitis,
• Vibrector
• Electroejaculation
• Assisted Reproduction

21. Female fertility and
reproduction
• Advice regarding menstrual health
• Advice regarding Birth control
• Pregnancy and UTI
• Labour and Autonomic dysreflexia

22. Reactive depression
• Grief reactions and reactive depression are
common
• Remember denial, anger, bargaining, depression
and acceptance of devastating disability are but
stages
• Use individual and group psychotherapy
• Tricyclic and SSRI Antidepressants are useful

23. Spasticity
• Can be useful
• Treat complications like DVT, pressure sores, UTI,
urinary calculi and heterotopic ossification first
• Diazepam, Baclofen, Dantrolene and Tizanidine
are useful
• POP casts, Phenol or Botulinum injections and
surgery have their place

24. Autonomic dysreflexia
• Headache + sweating +/- chest pain in the
presence of acute hypertension and bradycardia
• In patients with lesions above D7, after spinal
shock when reflex activity in the isolated cord
returns
• Remove the painful stimulus, elevated the head
end of the patient
• Sublingual Nifedipine 10mg

25. Neuropathic pain
• Common problem and difficult to treat
• Treat complications increasing nociceptive
stimulus to the isolated spinal cord
• Encourage exercises and activities like sports,
games, standing, walking etc
• Combinations of Antidepressants and
Anticonvulsants work better than individual
medications

26. Home modifications
• Assess existing home by home visit, if possible
• Encourage building a ramp for the front
entrance, slope preferably 1:10
• Doors 90cm wide (at least 81.5cm for manual
wheelchairs and 86.5 cm for powered chairs)
• Electrical switches 91.5 cm from the floor

27. Vocational Rehab and
reintegration into their community
• Assess if patient can return to original vocation
with adaptations
• If not, assess patients residual strengths and
interests and the job opportunities in their
hometown or village and retrain for a new vocation
• They may need startup assistance
• Activities to encourage gradual reintegration into
their own community are helpful

28. Life long follow-up
• Life long follow-up to prevent complications of severe
disability (altered Glucose tolerance, dyslipidemia,
osteoporosis, CKD etc)
• Get equipment like wheelchairs/KAFOs/crutches
repaired or replaced
• Encourage sports, games and avocational activities
• Encourage restoration through participation in the
lives of others and overcome shyness about large
group activities

29. Grateful acknowledgement to
Mary Verghese Institute of Rehabilitation,
PMR department,
CMC, Vellore

30. Thank you for your
attention.
30

31. The view from my window

32. Can you see the ordinary people?

33. FES in SCI
• FES for Upper Limb function:
Implanted 1st Gen - FreeHand: stopped in 2001.
Implanted 2nd Gen - Implanted Stimulator Telemeter
(IST)-12.
Surface NESS (www.bioness.com).
Compex http://case med.care.edu/fir/
• FES for Lower Limb function:
Implanted - for standing, transfers, walking (Trunk,
GMax, Quads, Ankle PF/DF).
Surface - Cycling for exercise.
Hybrid Orthosis: FES + Exoskeletal bracing for
walking and stair climbing

34. FES in SCI
• Walk again project -Miguel Nicolelis, M.D., Ph.D., São Paulo, Brasil
became well known when Pinto using VR and exoskeleton kick
started the FIFA World Cup in 2014
• Worked with Duke Univ, in 8 patients, used a Virtual Reality (VR)
environment to control an Avatar version of themselves and make it
move around a soccer field, used a long sleeve T-shirt for haptic
feedback to forearms simulating sensation of touching the ground,
the arms being used as phantom limbs substituting the legs,
fooling the brain into feeling that the patient was walking. Then
used an Exoskeleton + FES + VR cap to pick up signals and relay
them to the computer in the backpack.
• Intraspinal Micro Stimulation for Gait Restoration uses smaller
currents and stimulates pools of neutrons to restore Gait

35. FES in SCI
• FES for Trunk control and Posture stimulation of the
Quadratus Lumborum to straighten the spine and
improve upper limb function by providing a stable base,
allow returning from forward lean without using the arms.
• FES for Diaphragmatic pacing for high Tetras
• FES for Pressure sore prevention - Deep Tissue Injury
(DTI) produces ‘inside out’ sores. Explores prevention by
intermittent ES of Glutei (10 Sec every10min). GSTIM
stimulates the Inferior Gluteal Nerve.
Smart-e-pants uses surface electrodes to prevent sores.

36. FES in SCI
• FES for Lower Urinary Tract (LUT) function to decrease
Bladder pressure, prevent Vesico-Ureteric reflux and
Autonomic dysreflexia and provide continence and also
improve bowel evacuation.
• Brindley SARS, started about 35 years ago, used the
idea that intermittent stimulation will allow the skeletal
muscle to relax, but the smooth muscle will continue to
contract; implanted in thousands of patients but requires a
dorsal Rhizotomy and a complex operation, so did not
spread as widely as hoped
• Pudendal Nerve Stimulation is being tried as well

37. FES and SCI
• Ho, Chester H et al, “Functional Electrical Stimulation
and Spinal cord Injury” Physical Medicine and
Rehabilitation Clinics of North America 25.3 (2014)
631
• Oh, Sun Kyu, and Sang Ryong Jeon, “Current concept
of Stem Cell Therapy for Spinal Cord Injury: A Review”
Korean Journal of Neurotrauma 12.2 (2016): 40-46
• https://sites.google.com/site/pmrcmcvellore/home/
publications

38. Go out and
change the world