PHTH 8133- Clin Man- Neuro rehab 2- Non-traumatic SCI (NSCI)

ALS/PLS, Structural (Spondylosis/Stenosis), Neoplasm (Intra-/Extramedullary, Metastatic), Vascular (Hemorrhage, Ischemia), Autoimmune (Transverse Myelitis, MS), Infection (Epidural Abscess, Viral infection)

Overarching types of NSCI (6)

Gender- 1 male: 1 female (no difference), TSCI--> 4 males: 1 female

Age- Higher average age than TSCI

Completeness- More complete injuries with TSCI than NSCI

NLI- NSCI--> paraplegia>tetraplegia TSCI--> tetraplegia > paraplegia

Demographics of NSCI compared to TSCI (Hint: Gender, Age, Completeness of injury, and Neurologic level of injury)

True

True or false: NSCI & TSCI survival rates are the same unless associated with a cancer etiology.

respiratory complications

Most common cause of death for pts with tetraplegia

infection/sepsis

Most common cause of death for pts with paraplegia

Respiratory decompensation, infection, debilitating fatigue

There is a high CA-related NSCI transfer rate from inpatient rehab back to acute care. What 3 things commonly makes them go back to acute care?

TSCI- 100% home dispo

NSCI- 61-64% home dispo (rest- LTACH, SNF, etc.)

Rate of home-disposition with TSCI vs NSCI

#1- Stenosis

#2- Tumor/Neoplasms/Cancer

Most common NSCI etiologies (2)

Stenosis and Spondylosis

2 common structural NSCIs

Stenosis

narrowing of the spinal canal due to overgrowth of bone

Spondylosis

age-related degenerative changes of the vertebrae and IV discs

- loss of disc height and elasticity

- bone spur formation

- common in adults 60+

A

A 70-year-old patient in acute care presents with chronic neck stiffness, loss of sensation, and MRI findings showing narrowing of the spinal canal.

Which structural change does this describe?

A. Stenosis

B. Spondylosis

C. Radiculopathy

D. Disc herniation

B

A 65-year-old patient reports gradual onset of neck pain and stiffness. Imaging reveals loss of disc height, decreased elasticity, and bone spur formation consistent with age-related degeneration.

Which structural change is most consistent with these findings?

A. Stenosis

B. Spondylosis

C. Radiculopathy

D. Spinal cord injury

Cervical myelopathy

pressure on the SC due to stenosis or spondylosis kills off nerve cells leading to an increase in edema and symptoms such as weakness in the hands, decreased fine motor skills, gait instability and falls, and UMN signs such as spasticity, hyperreflexia, and +Babinski/Hoffman

- significant decline in prognosis over time without surgical intervention

A

A 69-year-old patient in inpatient rehab presents with progressive hand weakness, difficulty with fine motor tasks such as buttoning shirts, and unsteady gait leading to several recent falls. On exam, you note hyperreflexia, spasticity, and a positive Babinski sign bilaterally. MRI reveals degenerative changes with narrowing of the cervical spinal canal.

A. Cervical myelopathy

B. Transverse myelitis

C. Amyotrophic lateral sclerosis (ALS)

D. Multiple sclerosis (MS)

Intradural-Intramedullary Tumor

Tumor inside the dura and within the spinal cord itself (e.g., ependymoma, astrocytoma).

Intradural-Extramedullary Tumor

Tumor inside the dura but outside the spinal cord (e.g., meningioma, schwannoma).

Extradural-Extramedullary Tumor

Tumor outside the dura, typically involving vertebrae or epidural space (e.g., metastatic lesion).

improve patient comfort and facilitate comprehensive caregiver training

Primary goals (2) of rehab for cancer-related NSCI

C

Based on research findings, inpatient rehab (IPR) for individuals with non-traumatic spinal cord injury (NSCI) has been shown to provide multiple benefits. All of the following statements about IPR for NSCI are true EXCEPT:

A. It is associated with decreased pain and reduced pain medication needs

B. It leads to higher quality of life and improved independence with transfers

C. It results in shorter survival rates compared to those who do not receive inpatient rehab

D. It decreases incidence of depression and increases the percentage of patients discharged home

D

A randomized controlled trial compared outcomes for patients with non-traumatic spinal cord injury (NSCI) who received two weeks of inpatient rehab (IPR) versus those who did not. All of the following findings were associated with the inpatient rehab group EXCEPT:

A. Increased survival time after discharge (average of 26 weeks vs. 6 weeks)

B. Higher percentage of home discharge (75% vs. 20%)

C. Decreased pain and depression

D. Greater dependence in transfers and self-care following rehab

A

You are a physical therapist working with a 27-year-old patient recently diagnosed with a non-traumatic spinal cord injury secondary to metastatic cancer. The patient becomes frustrated and says, “Why should I bother going to inpatient rehab when I know I’m dying soon?”

Which of the following responses best demonstrates compassion, honesty, and patient-centered care?

A. “I understand this feels discouraging, and it’s completely valid to feel that way. Even though your condition is serious, rehab can help you improve comfort, maintain independence, and return home safely for as long as possible.”

B. “I know this situation must feel incredibly unfair, and it’s understandable that you’re tired of hospitals. Some patients do choose to skip rehab, so we can explore comfort-based care instead.”

C. “It sounds like you’re feeling hopeless right now, and that’s not uncommon for patients with a terminal illness. While rehab won't change your overall diagnosis, it could give you structure and support, which might help you emotionally.”

D. “I hear that you’re questioning the purpose of rehab. It’s mainly recommended to help you regain some function and strength before discharge, but if you aren't interested in going, we don't see much of a difference in patients who do it anyway."

lower pain, incidence of depression, pain medication need

higher survival rates post-rehab, QOL, independent transfers, and home disposition

NSCI pts who do IPR see clinically significant differences and better outcomes compared to those that don't. List some differences seen in pts who chose rehab.

B

A 64-year-old man presents with unsteady gait and difficulty coordinating hand movements. He reports numbness in his feet but denies pain or temperature loss. On exam, he demonstrates loss of proprioception and vibration sense, but strength and pain sensation are intact.

Which of the following best describes the likely lesion?

A. Anterior spinal artery infarct affecting the corticospinal tracts

B. Posterior spinal artery infarct affecting the dorsal columns

C. Central cord syndrome from cervical hyperextension

D. Brown-Sequard syndrome from hemisection of the cord

A

A 58-year-old woman develops sudden bilateral lower extremity weakness and loss of pain and temperature sensation below the waist after an episode of severe hypotension. Light touch and proprioception are preserved.

Which vascular structure is most likely involved?

A. Anterior spinal artery

B. Posterior spinal artery

C. Vertebral artery

D. Artery of Adamkiewicz

Hemorrhage (Anticoagulation, Arteriovenous Malformation (AVM), and SAH) and Ischemia (Aortic dissection, ischemia during surgery, vascular embolism, and systemic hypotension)

Etiology of Vascular NSCI (2)

Anticoagulation, Arteriovenous Malformation (AVM), and SAH

Specific etiology of Vascular NSCI (3)- Hemorrhage

Aortic dissection, ischemia during surgery, vascular embolism, and systemic hypotension

Specific etiology of Vascular NSCI (4)- Ischemia

Transverse myelitis

- rare condition --> inflammation of the SC that spreads b/l

- common causes --> idiopathic, viral infection, systemic inflammatory autoimmune disorders

- Epidemiology --> 70% thoracic, men and women equally affected

- Medical management --> IV glucocorticoids

- Prognosis --> most idiopathic cases have partial recovery, 40% permanent disability, negative prognosticators- complete paraplegia, spinal shock, no neurological recovery in the first 3-6 months

idiopathic, viral infection, systemic inflammatory autoimmune disorders

3 common causes of transverse myelitis

idiopathic

most common cause of transverse myelitis

IV glucocorticoids

medical management of transverse myelitis

complete paraplegia, spinal shock, no neurological recovery in the first 3-6 months

negative prognosticators for transverse myelitis (3)

C

A 35-year-old woman presents with bilateral lower extremity weakness, sensory changes, and bladder dysfunction that developed over 48 hours. MRI reveals inflammation of the thoracic spinal cord. She is started on IV glucocorticoids.

Which of the following diagnoses best fits this presentation?

A. Multiple sclerosis

B. Guillain-Barré syndrome

C. Transverse myelitis

D. Spinal cord infarction

B

What is the most common region of the spinal cord affected in transverse myelitis?

A. Cervical

B. Thoracic

C. Lumbar

D. Sacral

C

Which of the following is the first-line medical treatment for transverse myelitis?

A. Oral prednisone

B. Plasma exchange

C. IV glucocorticoids

D. NSAIDs

C

Which of the following findings is associated with a poor prognosis in transverse myelitis?

A. Incomplete paraplegia at onset

B. Partial neurological recovery in the first 2 months

C. Complete paraplegia with no recovery in 3-6 months

D. Younger age at onset

C

A 42-year-old patient is diagnosed with transverse myelitis following sudden onset of bilateral leg weakness and sensory loss. MRI shows inflammation at the T6 level. The medical team initiates IV glucocorticoid therapy as first-line treatment.

Which of the following best explains why IV glucocorticoids are used in this condition?

A. They promote remyelination of damaged spinal cord neurons

B. They increase spinal cord perfusion by dilating blood vessels

C. They reduce inflammation and suppress the immune response to limit further spinal cord damage

D. They enhance neurotransmitter release to restore motor function

Remove compressive agent

1. Decompression/Fusion --> Stenosis

2. Radiation--> tumor shrinkage

3. Surgical tumor resection

4. Chemotherapy

Medical/Surgical Interventions for NSCI

Increased NSCI population

Cancer survivors are living longer due to advanced CA treatment. How does this affect the number of people with CA-related NSCI?

Inpatient rehab with SCI focus

Disposition here included the following for NSCI rehab:

• 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

Subacute rehab

Disposition here included the following for NSCI rehab:

• 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

Skilled nursing facility (SNF)

Disposition here included the following for NSCI rehab:

• Long care term care options

• Therapy not daily

Home

Disposition here included the following for NSCI rehab:

• Home Care services

• Outpatient services

C

Betty is a 55-year-old female with loss of motor below T7 due to compression on cord by tumor. She has only been able to tolerate OOB 1/6 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.

What is the most appropriate discharge recommendation?

A. Inpatient Rehabilitation

B. Subacute Rehabilitation

C. Skilled Nursing Facility (SNF)

D. Home (Outpatient/Home Health Care)

A

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.

What is the most appropriate discharge recommendation?

A. Inpatient Rehabilitation

B. Subacute Rehabilitation

C. Skilled Nursing Facility (SNF)

D. Home (Outpatient/Home Health Care)

C

Carly is a 68-year-old female with primary diagnosis of 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.

What is the most appropriate discharge recommendation?

A. Inpatient Rehabilitation

B. Subacute Rehabilitation

C. Skilled Nursing Facility (SNF)

D. Home (Outpatient/Home Health Care)

B

Tom is a 70-year-old male with a history of prostate cancer and new-onset thoracic NSCI. He is modA for bed mobility and minA for sit-to-stand transfers but fatigues easily and cannot tolerate more than 45 minutes of therapy at a time. He is motivated to participate and plans to return home with his spouse once stronger.

What is the most appropriate discharge recommendation?

A. Inpatient Rehabilitation

B. Subacute Rehabilitation

C. Skilled Nursing Facility (SNF)

D. Home (Outpatient/Home Health Care)

D

Rachel is a 52-year-old female with incomplete lumbar NSCI following viral infection. She ambulates short distances with a walker, is independent in transfers, and has strong family support. She demonstrates good safety awareness and motivation for continued progress.

What is the most appropriate discharge recommendation?

A. Inpatient Rehabilitation

B. Subacute Rehabilitation

C. Skilled Nursing Facility (SNF)

D. Home (Outpatient/Home Health Care)

A

A 52-year-old male with no prior medical history was admitted with back pain and lower extremity weakness. Imaging revealed metastatic lesions at T7-T9 from a primary colon cancer. He underwent T4-T10 surgical fusion. Exam shows deficits consistent with a T7 ASIA C spinal cord injury: ankles 0/5 and proximal lower extremity musculature 1/5 bilaterally. Considering his functional status and medical needs, which is the most appropriate discharge recommendation?

A. Inpatient Rehabilitation

B. Subacute Rehabilitation

C. Skilled Nursing Facility (SNF)

D. Home (Outpatient/Home Health Care)