Spinal Cord Injury 3

What are the functional goals for the first 6 months after rehab in a 20 year old C4 ASIA A?
• C1-4: C4 may wean off vent, need rehab for caregiver training, equipment, and prevention of complications, intro to advanced technology
• C5: Prevention of elbow flexion and supination contractures, power wheelchair
• C6: Tenodesis, which may allow patient to do ICP
• C7-C8: C7 is key level for independence at transfers, weight shifts, light meal prep, may do bowel program
• T1-12: Household ambulation may be possible for lower levels of thoracic injury
• L1-2: Ambulation for short distances, but WC for functional ambulation
• L3-4: Usually lower motor neuron, so sacral reflexes are lost. Bowel management through contraction and manual disimpaction. Bladder through ICP. Ambulation with AFO.
• Community ambulation requires b/l hip flexors to be > 3/5, 1 knee extensor at least 3/5

How can you prevent and treat common medical complications in the first 6 months postinjury for a 20 year old man with C6 ASIA A injury?
• Autonomic dysreflexia: rise in BP of 20-40 mmHg above baseline, reflex bradycardia, HA. Can lead to stroke, hemorrhage, seizure, MI, death. Other signs are flushing, sweating, and nasal congestion above level of injury. Causes include: overdistended bladder, kidney or bladder stones, ingrown toenails, menstrual cramps, infection, bowel impaction, pressure ulcers, msk conditions, abdominal pathology. Treated by sitting patient upright and identifying underlying cause.
• Neurogenic bowel: Bowel program daily to q3days. Use of digital stimulation, adequate fluid, high fiber, oral meds, rectal evacuants. If changes in bowel meds, give at least three cycles to see effects. Colostomy if bowel program too difficult.
• Orthostatic hypotension: Compensation with gradual position changes, ace wraps, compression stockings, abdominal binders, midodrine (alpha agonist), fludrocortisones (mineralocorticoid). Usually resolves with spinal reflexes return.
• Immobilization hypercalcemia: N/V, decr appetite, lethargy, polyuria, usually presents 1-2 months postinjury. Treat with IV fluids or bisphosphonates.
• HO: Incidence between 16-53% in SCI. Presents in hips, followed by knees, elbows, shoulders. Swelling, decr ROM. Confirmed with bone scan, treat with etidronate at 20mg/kg orally for 3-6 months. Surgery if functional limitations, but wait until HO is mature.
• Spasticity: Treat with ROM, look for noxious stimuli (UTI), baclofen, benzo, dantrolene, alpha-2 agonists. Botox or phenol for localized spasticity.
• Depression 20-45%

What discharge planning is required for a 20 year old C4 ASIA A?
• Equipment: lift for transfers, padded commode or shower chair, power wheelchair with head, chin, or breath control (and independent pressure relief), manual WC for back-up, mouth stick, computer, van
• Housing evaluation and modifications

What advances are available for SCI?
• FES: improve hand grasp, lower extremity use, bladder control, respiration, and cardiovascular health
• Tendon transfers
• Wheelchairs: pushrum-activated power assist, iBOT 4000 Mobility System for climbing stairs
• Partial body weight support treadmill training
• Brain-based command signals