Non-Traumatic Spinal Cord injury

What are the various etiologies that can lead to NSCI

- ALS/PLS

- Structural

- Neoplasms

- Vascular

- Autoimmune

- Infection

What types of structural pathologies can lead to NSCI

- Stenosis

- Spondylosis

What types of neoplasms can lead to NSCI

- Intramedullary

- Extramedullary

- Metastatic

What types of vascular pathologies can lead to NSCI

- Hemorrhage

- Ischemia

What types of Autoimmune pathologies can lead to NSCI

- Transverse Myelitis

- MS

What types of infections can lead to NSCI

- Epidural Abscess

- Viral Infection

What the demographics associated with NSCI

- Gender - 1 male: 1 female

- Age - Higher average age

- Completeness - More incomplete injuries

- NLI - ↑ paraplegia

What the demographics associated with TSCI

- Gender - 4 male: 1 female

- Age - Lower average age

- Completeness - More complete injuries

- NLI - ↑ tetraplegia

What are the implications treatment approach for complete vs. incomplete NSCI

- Incomplete focus more on restoring remaining function and compensate for what can't be restored

- Complete focus more on compensation

What are the Survival Rates NSCI vs. TSCI

NSCI and TSCI survival rates are not significantly different UNLESS cancer etiology

What are the Most prevalent causes of death among NSCI and TSCI

- Tetraplegia = Respiratory

- Paraplegia = Infection/sepsis

How can PT prevent death caused by respiratory issues in tetraplegia patients

Respiratory training and breathing interventions

How can PT prevent death caused by infection/sepsis in paraplegia patients

For infections/sepsis work on pressure relief and positioning since main cause is from ulcers

What are key points about Disposition of TSCI vs. NSCI care

- 25-50% of SCI cases at specialized SCI Centers are of non-traumatic etiology

- High CA-related NSCI transfer rate from inpatient rehab back to acute care

- No difference in home discharge rate post inpatient rehabilitation

What are reasons why there is a prevalence of high transfer rate from inpatient rehab back to acute care among CA-related NSCI

- Respiratory decompensation

- Infection

- Debilitating fatigue

What goes into planning for home discharge post inpatient rehabilitation

Determined by personal factors

What which etiologies of NSCI, can Medical/Surgical Interventions be performed to Remove the Compressive Agent

- Stenosis

- Hemorrhage

- Tumor

What are the Medical/Surgical Interventions for NSCI due to stenosis of the spine

decompression and fusion

What are the Medical/Surgical Interventions for NSCI due to hemorrhage

- hematoma evacuation

- decompression

- fusion

What are the Medical/Surgical Interventions for NSCI due to tumors

- tumor resection

- radiation

- chemo

what is stenosis

narrowing of the spinal canal

What is Spondylosis

age-related degenerative changes of the vertebrae and intervertebral discs

What are common characteristics associated with Spondylosis

- Loss of disc height and elasticity

- Bone spur formation

- Common in adults 60+

What are key points about trauma and structural changes to the spine

Trauma > increased probability of pressure/compression to the spinal cord

What is the atraumatic cause behind structural changes to the spine that can lead to NSCI

Growth that can occur on lamina, narrowing intervertebral foramen, resulting in radiculopathy

What is Cervical Myelopathy

Congenital or degenerative narrowing of the cervical spinal canal results in cord compression

What are common characteristics/symptoms of Cervical Myelopathy

- Weakness in the hands

- Decreased fine motor skills

- Gait instability and falls

- Urinary incontinence (late stage)

- UMN signs

What are UMN signs that can indicate/be seen in patients with Cervical Myelopathy

- Spasticity

- Hyperreflexia

- +Babinski/Hoffman

What are key points about the prognosis for cervical myelopathy

- Significant decline over time without surgical intervention

- Prognosis for neuro recovery worsens the longer symptoms persist untreated

What vascular structures are we most concerned about for NSCI

- Posterior Spinal Artery

- Anterior Spinal Artery

What are the two primary etiology of Vascular NSCI

- Hemorrhage of spinal vessels

- Ischemia

What are causes of Hemorrhage of spinal vessels that can result in NSCI

- Anticoagulation

- Arteriovenous Malformation (AVM)

What are causes of Ischemia that can result in NSCI

- Aortic dissection

- Ischemia during surgery (aortic aneurysm repair)

- Vascular embolism (spinal cord stroke)

- Systemic hypotension

What is Transverse Myelitis

Rare condition involving inflammation of the spinal cord

TRUE or FALSE: Inflammation of the spinal cord spreads bilaterally in cases of Transverse Myelitis

True

What are the causes of Transverse Myelitis

- Idiopathic (most common)

- Viral infection

- Systemic inflammatory autoimmune disorders

What is the incidence/prevalence of Transverse Myelitis

- 70% of cases are thoracic

- Men and women equally affected

What does the medical management of Transverse Myelitis entail

- Compressive causes must be ruled out to diagnosis

- First line of treatment: IV glucocorticoids

what are key points about the prognosis for patients with Transverse Myelitis

- Most idiopathic cases have at least partial recovery

- ~40% have some level of permanent disability

What are Negative prognosticators associated with Transverse Myelitis

- Complete paraplegia

- Spinal shock

- No neurologic recovery in the first 3-6 months

what are the two main ways tumors invading the spinal cord can cause NSCI

- Intramedullary

- Extramedullary

What happens when Metastatic lesions invade the spinal cord

Bony collapse

What are the Goals of Rehab for Cancer-Related NSCI

- Improve patient comfort (i.e. manage transfers, reduce pain, achieve urinary continence)

- Facilitate comprehensive caregiver training

- Achieve functional and training milestones while minimizing LOS

Based on the Randomized Control Trial including 2 weeks of inpatient rehab for experimental group with NSCI and control group = no inpatient rehab, Is Inpatient Rehab Beneficial for NSCI?

- Rehab group averaged 26-week survival post rehab

- Non-rehab group averaged 6 weeks post discharge

What are the Clinically significant differences in rehab participant results following 2 weeks of Skin care, transfers, pulmonary exercises, bowel/bladder management, nutrition, transfer training, and caregiver training

- ↓ Pain

- ↑ Higher quality of life

- ↓ Incidence of depression

- ↓ Pain medication needs

- ↑ % independent transfers

- ↑ % home disposition

- 75% of rehab group returned home

- 20% of non-rehab group returned home

What types of PT training are beneficial for improving survival rates for patients with NSCI

- Skin care

- transfers

- pulmonary exercises

- bowel/bladder management

- nutrition

- transfer training

- caregiver training

What are Challenges in Oncologic Population with NSCI

- Rehab scheduling with other interventions (XRT/chemo)

- CA fatigue / medical complications

- CA Pain

- Systemic effects of CA (catabolic effects)

- Psychological Impact: Coping with both CA diagnosis AND SCI diagnosis

What are the factors to take into Consideration for engaging in/going to rehab for oncologic patients with NSCI based on their Neurologic status

- AIS grade

- Is deterioration expected?

What are the factors to take into Consideration for engaging in/going to rehab for oncologic patients with NSCI based on their Oncologic Status

- Oncologic prognosis provided by oncologist

- Is IPR or home discharge more appropriate?

- Bone metastasis and pathologic fracture risk

- Scheduling cancer-related treatment (chemo/radiation)

What are the factors to take into Consideration for engaging in/going to rehab for oncologic patients with NSCI based on their Medical Comorbidities

SCI-related medical complications and pre-existing conditions

What are the factors to take into Consideration for engaging in/going to rehab for oncologic patients with NSCI based on their Pain

Appropriate for transfer to IPR if 30-60 min OOB is tolerated

What are the factors to take into Consideration for engaging in/going to rehab for oncologic patients with NSCI based on their Rehabilitation Issues

- Reframe the mindset of the rehab team

- IPR LOS should be minimized

- Realistic goal-setting and preparing for home discharge

What are the factors to take into Consideration for engaging in/going to rehab for oncologic patients with NSCI based on their Support Status

- Review of social supports and environment

- The family meeting

What are possible discharge locations for patients with NSCI

- Comprehensive inpatient rehab with SCI focus

- Subacute rehab

- Skilled nursing facility

- Home

What are key points about being discharged to Comprehensive inpatient rehab with SCI focus for patients with NSCI

- Increased intensity, short duration

- Patient must tolerate 3 hours of therapy per day

- Vent weaning, seating evals, clinicians with expertise in SCI

- Comprehensive services including 24-hour physician, Rec Therapy, Rehab Psych, Vocational Rehab, and CM/SW for discharge planning

What are key points about being discharged to subacute rehab for patients with NSCI

- Decreased intensity with increased duration

- ~2 hours of therapy per day based on tolerance

- 1-2 disciplines per day i.e. OT and SLP, i.e. PT and OT

What are key points about being discharged to skilled nursing facilities for patients with NSCI

- Long care term care options

- Therapy not daily

What are key points about being discharged to home for patients with NSCI

- Home Care services

- Outpatient services

Betty is a 55-year-old female with loss of motor below T7 due to compression on cord by tumor. She has been able to tolerate OOB 2/6 acute PT sessions due to pain and fatigue. She has yet to undergo chemo and XRT. She reports that she has only intermittent assistance available from nearby family. Where should Betty be discharged to?

subacute rehab/skilled nursing facility

Amy is a 46-year-old female with newly diagnosed lung CA with mets to the spine. The patient is currently maxA for a lateral transfer with no motor/sensation below the umbilicus. She spends most of her day OOB and has even started propelling the wheelchair in the hallway. Her 26-year-old daughter is out of work and has committed to be her primary caregiver. Where should Amy be discharged to?

inpatient rehab

Carly is a 68-year-old female with primary diagnosis of acute myeloid leukemia (AML) with thoracic incomplete SCI. She also has mets to her liver, long bones, and is confused due to brain mets. She tolerates PROM of extremities with stable vital signs and no signs of distress, but she does not have adequate arousal for any active movement. Where should Carly be discharged to?

subacute skilled nursing

So, how do we evaluate and treat patients with NSCI?

The same as any other SCI

What is included in an assessment for patients with any type of SCI

- What is intact, what is impaired

- Skin integrity

- Tone

- ROM

- MMT

what is the Importance of Prognosis in planning care for patients with NSCI

- Establishing disposition

- Goal setting

- Devising treatment plan

- Patient education

What is important to include in patient education for NSCI

- Patient knowledge of diagnosis

- Medical prognosis

- Medical interventions

what are Considerations to take into account for goal setting with patients with NSCI

- Age

- Ambulation potential

- Duration of symptoms/Time since onset

- Initial recovery/Recovery within acute phase

- Pin prick

- Motor recovery, especially ASIA B

- Prior level of function

- Comorbidities, independence

- Cognition

- Direction of care

What types of factors will determine the direction of goal setting with NSCI patients

- Age

- Ambulation potential

- Duration of symptoms/Time since onset

- Initial recovery/Recovery within acute phase

- Pin prick

- Motor recovery, especially ASIA B

- Prior level of function

- Comorbidities, independence

- Cognition

- Direction of care

Upon admission to inpatient rehab a patients presents with:

•Max Ax2 bed mobility

•Max Ax2 lateral transfers via transfer board

•Max A for weight shifts

•Supervision UE ADLs

•Max A LE ADLs

•Dependent toileting

•Intact cognition

What are appropriate long-term goals?

- Go from max A to mod/min A

- Mod I for wheelchair propulsion