Transcript 10 mos PTA
RB: A Case of Tetraparesis Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora. General Data RB 25/M From Camarines Norte Roman Catholic Married, with 1 child R handed Chief Complaint Inability to walk History of Present Illness 10 mos PTA (+) intermittent pain on R medial arm “Parang binabanat ang ugat” NPS 10/10 occurring 3x/wk Aggravated by exertion (e.g. reaching out or lifting an object) Relieved by an unrecalled analgesic (0/10) (-) numbness, (-) paresthesia, (-) skin lesions (-) hx of trauma History of Present Illness 10 mos PTA After 2 weeks, (+) similar pain on L arm and both scapular areas No consult was done History of Present Illness 9 mos PTA (+) weakness of R LE, (-) pain, (-) numbness (+) dyspnea Consulted at barangay health center: given vitamins and analgesic History of Present Illness 9 mos PTA A few days later, (+) weakness of R LE Admitted to LH: CXR, holoabdominal UTZ, cranial CT scan and labs done. Allegedly normal results Discharged and prescribed unrecalled medications Discontinued due to allergy to medications (rashes on both thighs) History of Present Illness 8 mos PTA assisted in ADLs (going to the bathroom, going around the house) (+) urinary incontinence 6 mos PTA bedbound developed bowel incontinence (+) bedsore (approximately 1 cm, sacral) History of Present Illness 5 mos PTA Consult was done at V. Luna A> t/c Decompression sickness P> recompression x 10 session Discontinued after 3rd session History of Present Illness 5 mos PTA (+) consult at PGH OPD Ortho A> Pott’s disease P> workup and follow-up x 2 mos History of Present Illness 3 mos PTA Admitted at Spine Unit Started on anti-TB meds Co-managed by Rehab 1 mo PTA s/p anterior decompression, debridement, fusion(C6-T2) with fibular strut graft (7/18/12) With relief of pain at upper extremities and scapular region Day of admission, admitted at Rehab Ward for further therapy Review of Systems (present) (-) Cough, colds, fever (-) headache, blurring of vision, dizziness (-) chest pain, difficulty of breathing (-) changes in appetite (-) heat or cold intolerance, irritability (-) muscle or joint pain (-) penile pain, discomfort, erectile dysfunction Past Medical History (-) HPN, DM, BA, CA, previous hosp (-) PTB/Primary Complex (?) drug allergy Family Medical History (+) HPN, father (+) BA, 5 siblings (+) DM, uncle (-) PTB Personal and Social History (-) smoking, alcohol intake, illicit drug use Breadwinner of the family Works as fisherman(diver) Married, with 1 daughter Finished 2nd yr HS Functional History Previously independent on ADL Previously works as a fisherman (diving, swimming) Environmental History Lives in a 1-storey concrete house with wife, daughter, and mother Bathroom is approximately 10 meters from the patient’s bedroom Main road is approximately 15 meters from the door of the house Current Physical Exam General: awake, NICRD, the patient is wearing a Minerva orthosis BP 110/60 HR 90 RR 18 T afebrile HEENT: AS, pink PC, (-) CLAD/NVE (+) surgical scar on L neck to anterior chest Chest/Lungs: DHS, (-) murmur/thrills/heaves ECE, clear BS (-) rales/wheeze/rhonchi Abdomen: Flat, normoactive BS, (-) masses/tenderness Skin/Extremities: FEP, pink NB, (-) edema/cyanosis/jaundice (+) sacral ulcer, healed, Current Physical Exam Motor: C5 5/5 C6 5/5 C7 5/5 C8 5/5 T1 5/5 Sensory: ASIA Sensory: (R) 5/5 5/5 5/5 5/5 5/5 (L) L2 L3 L4 L5 S1 pin prick (R) C5-L3 2/2 L3 1/2 L4 1/2 L5-S4 S5 2/2 5/5 5/5 4/5 4/5 3/5 (L) 2/2 1/2 2/2 2/2 (R) (L) 5/5 5/5 5/5 5/5 5/5 (Score 97) light touch (R) (L) 2/2 2/2 1/2 1/2 1/2 2/2 2/2 2/2 Current Physical Exam (-) sensory deficit (-) Babinski/clonus, (-) Hoffman’s sign (-) dysdiadochokinesia Poor proprioception, bilateral LE (+) weak sphincter tone (not lax), (+) perianal and anal sensation (+) bulbocavernosus reflex P.E. on Admission & Course Physical Examination on Admission General Survey: Awake, coherent, not in cardiorespiratory distress Vital signs: BP 100/70 HR 87 RR 20 T afebrile HEENT: Anicteric sclerae, pink palpebral conjunctivae, no cervical lymph nodes, no tonsillopharyngeal congestion Physical Examination on Admission Chest/Respiratory: Equal chest expansion, clear breath sounds, no thoracic spine deformity Cardiovascular: Adynamic precordium, normal rate regular rhythm, distinct S1 & S2, no murmurs Gastrointestinal: Flat abdomen, normoactive bowel sounds, no tenderness Genitourinary: (+) weak sphincteric tone, (+) BCR Physical Examination on Admission Extremities: Full and equal pulses, no edema, (+) multiple pressure ulcers - sacral area, grade 2 with undermining (+) well healing pressure ulcer on right posterior auricular area, right shoulder (+) grade 1 ulcer on heel, bilateral; medial knee, bilateral; lateral malleolus, bilateral Physical Examination on Admission ASIA Motor Right Left C5 5/5 5/5 C6 5/5 5/5 C7 4/5 4/5 C8 3/5 3/5 T1 3/5 3/5 L2 2/5 2/5 L3 2/5 2/5 L4 3/5 3/5 L5 3/5 3/5 S1 3/5 4/5 Physical Examination on Admission ASIA Sensory Pin Prick Light Touch Right Left C5-C7 2/2 2/2 C8 2/2 T1-L2 Right Left C5-C7 2/2 2/2 1/2 C8 2/2 1/2 2/2 2/2 T1-L2 2/2 2/2 L3-S3 1/2 1/2 L3-S3 1/2 1/2 S4-S5 1/2 1/2 S4-S5 1/2 1/2 Physical Examination on Admission Tone: (+) grade 1 – 1+ spasticity on both lower extremities DTRs: hyporeflexia on both lower extremities, (+) flexor spasm on both lower extremities (+) clonus (-) Babinski (-) Hoffman’s Course in the Wards Upon Ward admission: - noted (+) flexor spasm 1-3x/hr upon movement - able to tolerate sitting > 1 hr. during OT - fair sitting balance unsupported but cannot be totally challenged - still dependent in transition with sitting and transfer from bed - able to eat his dinner, can sit with brace on, independent with setup Course in the Wards Underwent PT exercises during the 1st month: Practiced transitions from supine to sitting sit to stand Table tilt at 30o increasing by 15o Standing with || bars with PKS on (B) knees, increasing in duration and number of reps || bars with one PKS || bars without PKS Ambulating using walker with PKSusing BAC with 4 pt gait3 pt gait(B) Axillary crutches Course in the Wards 8/27 – ASIA MMT: (R) (L) (R) (L) C5 5/5 5/5 L2 2/5 2/5 C6 5/5 5/5 L3 2/5 2/5 C7 4/5 4/5 L4 3/5 3/5 C8 3/5 3/5 L5 3/5 3/5 T1 3/5 3/5 S1 3/5 4/5 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 T1-L2 2/2 2/2 2/2 2/2 L3-S4 S5 1/2 1/2 1/2 1/2 DTR: hyporeflexia on (B) LE (+) flexor spasm (B) LE pathologic reflexes: (+) clonus (-) Babinski (-) Hoffman Course in the Wards (R) C5 5/5 C6 5/5 C7 4/5 C8 4/5 T1 4/5 (Score 8375) - ASIA Sensory: 9/18 – (L) 5/5 5/5 4/5 4/5 4/5 L2 L3 L4 L5 S1 (R) 4/5 4/5 4/5 3/5 4/5 (L) 4/5 4/5 4/5 4/5 4/5 maintained at Score of 97 Course in the Wards Underwent PT exercises during the 2nd month: Started Stepping Exercises Ambulating using BAC with 3 pt gait2 pt gaitBAC/3 pt. gait on level surface up/down stairs using BAC using quad cane Quad cane/3 pt. gait with ramp, stairs(B) axillary crutches Using Walker Course in the Wards 9/26 – Fall while ambulating in bathroom (+) pain (R) lateral aspect of foot - maintain MMT Score of 87 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 1/2 1/2 1/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-S4 S5 1/2 1/2 1/2 1/2 A> Quadparesis and SCC secondary to Pott’s disease ASIA D, NLC7 MLC7 SL C8 AL: C6-T1, T4 T5 T8 Sacral decubitus ulcer Gr 2 Cystitis Course in the Wards 10/2 – increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 5/5 C6 5/5 5/5 L3 4/5 4/5 C7 5/5 5/5 L4 5/5 5/5 C8 5/5 5/5 L5 4/5 4/5 T1 4/5 4/5 S1 3/5 5/5 (Score 9187) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-L5 1/2 1/2 1/2 1/2 S1-S4 S5 2/2 2/2 2/2 2/2 (Score 10797) Course in the Wards 10/8 – ambulate on level surface with ramp using quad cane. Not Stairs - increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 9791) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2 Course in the Wards 10/21 – ambulate using walker - able to do vocational training - (+) flexor and bladder spasm on CMG 10/24 – ambulate using walker - still with weakness of (R) plantar flexion 10/27 – still with poor proprioception of (B) feet Differential Diagnoses for Tetraparesis Trauma Tumors Infection Inflammatory Vascular Vertebral Others Disease Trauma Most common cause of tetraparesis Ruled out because the patient has no history of trauma Tumors Usual presentation is pain, often worse when in supine position, which can be axial (skeletal structures affected) or radicular (nerve roots affected) Usually presents with constitutional symptoms (night sweats, fever, unexplained weight loss, and anorexia) Radiographic examination is vital Can be metastatic (from lungs, breast, prostate and kidney) or primary (multiple myeloma, osteogenic sarcoma, vertebral hemangioma, chondrosarcoma, chordoma, ependymoma, astrocytoma, meningioma, schwannoma, neurofibroma) Infection Bacterial a osteomyelitis differential if the patient uses IV drugs, immunosuppressed, or undergoing dialysis usual etiology is Staphylococcus aureus Check via culture and inflammatory markers Spinal Usually epidural; commonly presents with fever HIV abscess infection Can present as primary HIV myelitis, vacuolar myelopathy, or as a result of opportunistic infection Inflammatory Transverse myelitis Myelopathic process of unknown cause from inflammation of spinal cord May start as pain or paresthesia in localized body parts and can progress to paresis and plegia Multiple sclerosis Immune-mediated demyelinating disorder which may also initially present as pain and progress to weakness of limbs Systemic lupus erythematosus Autoimmune illness which usually presents with other systemic symptoms such as pleuritis, hematologic, immunologic or neurologic alterations, and dermatologic signs Vascular Ischemia usually of spinal cord not very common; associated with anterior syndrome; often from: Anterior spinal artery occlusion Angioma AV malformation cord Vertebral Disease Vertebral disk prolapse Usually due to a tear in the outer fibrous ring (annulus fibrosus) May initially present as pain of extremities and progress to paresis depending on the level of herniation Spondylosis Degenerative odteoarthritis of the spine Presents as pain, paresthesia or muscle weakness Paget’s disease Due to excessive breakdown and formation of bone, followed by disorganized bone remodeling Causes bone pain but very rarely presents as quadriparesis Others Hereditary spastic paraparesis characterized by insidiously progressive bilateral lowerextremity weakness and spasticity, with family history of similarly affected individuals may be transmitted in an autosomal dominant, autosomal recessive, or X-linked recessive manner Degenerative motor neuron disease Usually presents in the 6th-7th decades of life heterogeneous group of neurologic diseases characterized by progressive degeneration of upper and lower motor neurons Usually presents with weakness, atrophy, fasciculations, and hypo/hyperreflexia Others Decompression syndrome caused by intravascular or extravascular bubbles that are formed as a result of reduction in environmental pressure can occur in divers, compressed air workers, aviators, and astronauts manifestations range from itching and minor pain to neurological symptoms, cardiac collapse, and death Presents acutely Impression Quadriplegia secondary to multiple compression deformity secondary to Pott’s disease (Asia D) NL: C6, AL: C6-T2, ML: C7, SL: C7 Neurogenic bowel and bladder Nephrolithiasis, right Problem List o Medical o s/p ADDT SCC sec to Pott’s Disease C7-T1 Neurogenic Bladder Altered Body Function Quadriparesis Sensory impairment below C8 Grade I spasticity of bilateral LE Poor proprioception Goals Short Term Goals Long Term Goals To improve strength of B LE To improve ambulating using walker in level surface and ramps To ambulate on stairs To ambulate using walker on level surface and ramps To attain improvement in all aspects of ADLs To acquire vocational training For Discharge if: With independent ambulation using walker on level surface and ramps Independent in all aspects of ADLs Ambulatory PT Supine Proper brace donning/doffing of brace Transitional technique from supine to sitting to standing Sitting Resistance exercises of bilateral UE/LE Transition technique from sitting to standing Ambulation/Standing Ambulate using walker on level surface and ramps Occupational Therapy Ambulatory OT vocational training energy conservation techniques Psych OT individual counselling Pott’s Disease Pott disease is usually secondary to an extraspinal source of infection. The basic lesion is a combination of osteomyelitis and arthritis. The area usually affected is the anterior aspect of the vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site. Pott’s Disease Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This leads to spinal cord compression and neurologic deficits. Kyphotic deformity occurs as a consequence of collapse in the anterior spine. Lesions in the thoracic spine have a greater tendency for kyphosis than those in the lumbar spine. Pott’s Disease The collapse is minimal in cervical spine because most of the body weight is borne through the articular processes. Healing takes place by gradual fibrosis and calcification of the granulmatous tuberculous tissue. Eventually the fibrous tissue is ossified, with resulting bony ankylosis of the collapsed vertebrae. Pott’s Disease Paravertebral abscess formation occurs in almost every case. With collapse of the vertebral body, tuberculous granulation tissue, caseous matter, and necrotic bone and bone marrow are extruded through the bony cortex and accumulate beneath the anterior longitudinal ligament. These cold abscesses gravitate along the fascial planes and present externally at some distance from the site of the original lesion. Pott’s Disease In the lumbar region the abscess gravitates along the psoas fascial sheath and usually points into the groin just below the inguinal ligament. In the thoracic region, the longitudinal ligaments limit the abscess, which is seen in the radiogram as a fusiform radiopaque shadow at or just below the level of the involved vertebra. Thoracic abscess may reach the anterior chest wall in the parasternal area by tracking via the intercostal vessels. Lesion The lesion could be: Recently, two distinct patterns of spinal TB Florid - invasive and can be identified, the destructive lesion classic form, called Non destructive - lesion spondylodiscitis (SPD) suspected clinically but identifiable by modern Atypical form investigations like CT characterized by scan or M.R.I. spondylitis without disk Encysted disease involvement (SPwD) Carries sicca Hypertrophied most common pattern Periosteal lesion of spinal TB SPwD seems to be the Regional Distribution 1 Cervical 12% 2 Cervicodorsal 5% 3 Dorsal 42% 4 Dorsolumbar 12% 5 Lumbar 26% 6 Lumbosacral 3% Anatomically the lesion could be 1. 2. 3. 4. 5. Paradiscal - destruction of adjacent end plates and diminution of disc space. Appendeceal (Posterior) involvement of pedicles, laminae, spinous process. Central - Cystic or lytic, concertina collapse. Anterior –longitudinal lig, Aneurysmal phenomenon Synovitis in posterior facet History Presentation depends on the following: Stage of disease Site Presence of complications such as neurologic deficits, abscesses, or sinus tracts The reported average duration of symptoms at the time of diagnosis is 3-4 months. Back pain is the earliest and most common symptom Patients have usually had back pain for weeks prior to presentation Pain can be spinal or radicular Constitutional loss symptoms include fever and weight History Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or cauda equina syndrome. Cervical spine tuberculosis is a less common presentation is characterized by pain and stiffness. Patients with lower cervical spine disease can present with dysphagia or stridor. Symptoms can also include torticollis, hoarseness, and neurologic deficits. The relative proportion of individuals with Pott’s who are HIV positive seems to be higher than HIV negative patients. Complications of tuberculosis 1. 2. 3. 4. 5. 6. Paraplegia Cold abscess Sinuses Secondary infection Amyloid disease Fatality Surgical indications 1. No sign of neurologic recovery after trial of 3-4 weeks therapy 2. Neurologic complication during treatment 3. Neurologic deficit becoming worse 4. Recurrence of neurologic complication 5. Prevertebral cervical abscesses, neurological signs, & difficulty in deglutition & respiration 6. Advanced cases: sphincter involvement, flaccid paralysis, severe flexor spasms Other indications Recurrent paraplegia Painful paraplegia– d/t root compression, etc Posterior spinal disease--involving the post elements of vertebrae Spinal tumor syndrome resulting in cord compression Rapid onset paraplegia due to thrombosis, trauma, etc. Severe paraplegia econdary to cervical disease and cauda equina paralysis 1 2 3 4 5 6 Decompression +/- fusion Debridement+/fusion Failed response,Too advanced Failed response after 3-6 months,Doubtful diagnosis,Instability Debridement +/-DECOMP+/fusion Debridement+/fusion Anterior transpostion Recrudescence of disease Laminectomy STS,secondary stenosis, posterior disease Prevent severe Kyphosis Severe Kyphosis +neural deficit Tuli’s recommended approach Cervical Dorsal spine –T1 Anterior approch spine –DL junction Antrolateral approch Lumbar spine &Lumboscral junction Extraperitoneal Transverse Vertebrotomy Problem List Medical Problems Spinal cord compression Neurogenic bowel Neurogenic bladder Pressure ulcers (Possible) Medical Problems Cardiovascular complications Hypertension Deep vein thrombosis and Pulmonary embolism Orthostatic hypotension Cardiac arrhythmia Pulmonary complications Musculoskeletal complications Osteoporosis Fractures Heterotrophic Ossification Altered Body Structure and Function Bilateral LE paresis Bilateral LE loss of sensation Neurogenic bladder Neurogenic bowel Pressure Sexual sores dysfunction and possible loss of sexual desire Possible MSK, cardiovascular and pulmonary complications Limitations in Activities of Daily Living Independence in feeding Dependence in self-care ADLs Bathing Grooming Dressing up Dependence in ambulation and transfers Poor sexual activity Limitations in Instrumental Activities Independence Communication Entertainment Difficulty Cannot (cellphones, etc.) (watching TV, etc.) in child-rearing anymore drive his motorcycle Limitations in Participation Inability to return to previous job Difficulty in finding another job Difficulty in community ambulation Short-term Goals To treat the underlying cause of the SCI Spinal To TB implement acceptable bowel and bladder management programs To address pressure ulcers and maintain skin integrity Long-term Goals To maintain socially acceptable bladder and fecal continence To prevent possible complications of neurogenic bladder and bowel To prevent and treat accordingly the complications that may arise from the thoracic-level SCI To minimize the functional limitations and allow the patient to complete ADLs independently or with assistive equipment Management of Spinal Cord Injury and Its Various Complications Neurogenic Bladder When pathologic CNS/PNS conditions cause disruption of the nerve control to the urinary bladder, causing urinary retention and/or urinary incontinence Bladder Innervation Pelvic Nerves Parasympathetic signals from S2-S3 segments to the detrusor muscles for bladder emptying/voiding Hypogastric Nerves Sympathetic signals from T11-L2 segments for bladder filling/storage Pudendal Nerves Somatic nerve fibers from S3-4 segments to voluntary skeletal muscles & external sphincter Management Goals To prevent urinary tract infections and other long-term urologic sequelae To maintain a socially acceptable bladder continence by developing and implementing a bladder management program that will allow patient to reintegrate back into the community Medical/Pharmacologic Management Targeting the autonomic receptors For urinary retention Cholinergics (for detrusor contraction) Alpha receptor antagonists (for sphincter relaxation) For urinary incontinence Anticholinergics ( for detrusor relaxation) Alpha receptor agonists (for sphincter contraction) Behavioral/Non-Pharmacologic Management Catheterization Independent programs intermittent catheterization every 4 to 6 hours, if the patient has preserved hand function and does not have UTI Limitation Timed voiding Schedule Use of fluid intake voiding of a voiding diary Behavioral/Non-Pharmacologic Management Bladder training programs Maneuvers Valsalva maneuver, suprapubic application of pressure Use of appliances Condom, foley, straight catheters Surgical Management When the mentioned medical and behavioral strategies fail… Augmentation Artificial cystoplasty sphincter Sphincterotomy Pudendal neurectomy Bladder outlet surgery Balloon dilatation Interruption of innervation Neurostimulation Neurogenic Bowel When pathologic CNS/PNS conditions cause disruption of the bowel innervation, causing stool incontinence (lax anal sphincter) and constipation (disrupted parasympathetic supply) Management Goals To achieve socially acceptable fecal incontinence Prevention of gastrointestinal complications Fecal impaction (most common) Medical/Pharmacologic Management Stool softeners (e.g. docusate sodium) Colonic stimulants (e.g. senna) Colonic irritants (e.g. glycerin, bisacodyl) Prokinetic Rectal Oral agents (e.g. metoclopramide) suppositories medications Behavioral/Non-Pharmacologic Management Timed/regular Taking bowel movement advantage of the gastrocolic reflex (about 30-60 minutes after meal) Dietary High modification fiber diet Increased Digital fluid intake stimulation Manual extraction Surgical Management Colostomy/ileostomy Decreases time required for bowel management Increases independence Pressure Sores Stages of pressure sores/ulcers (NPUAP) Stage I : Nonblanchable erythema not resolved within 30 minutes (epidermis intact) Stage II : Partial thickness skin loss; blisters with erythema, abrasion, shallow ulcer (possibly into dermis) Stage III: Full-thickness destruction of the skin; deep crater (into subcutaneous tissue) Stage IV: Full-thickness skin loss with deep-tissue destruction (up to fascia, muscle, bone, joint) Pressure Sores Management: Wound cleansing with plain NSS Debridement Wound dressing Topical antibiotics (e.g. Flammazine) Wound Care Modalities Whirlpool therapy, UV light, ultrasound Surgery skin grafts and skin flaps Pressure Sores Prevention: Egg mattress Proper turning frequency (at least every 2 hours) Adequate cushioning (e.g. surgical gloves with water) Osteoporosis Occurs below the level of injury Cause: reduction of bone mineral content Immobilization Lack Effect: of weight-loading activities Increased risk of lower extremity fracture Management: Ambulatory activities Medications (e.g. Vitamin D, calcitonin, biphosphonates) Functional electric stimulation Fractures Occurs in chronic SCI Common causes: Osteoporosis Falls Vigorous physical therapy Common in long bones of lower extremity Management: Patient and family education Training in proper transfer and ambulation techniques Fall prevention Avoidance of vigorous physical therapy Heterotopic Ossification (HO) Development of ectopic bone within soft tissues surrounding the joints Often seen in the first 6 months post-injury Incidence: 20-30% Common areas : Hip > Knee > Shoulder > Elbow Etiology is still unclear but may be due to metabolic, biochemical and circulatory factors Presentation: Heat and swelling over the joints Decrease in ROM Fever Heterotopic Ossification (HO) Complications: Peripheral nerve entrapment pressure sores Ankylosis increased risk of DVT Management: ROM Exercises Medications to limit ossification (e.g. disodium etidronate, indomethacin) Surgery for mature bone Pulmonary Complications Depend C4: on the level of the lesion highest level with spontaneous ventilation Above C8: loss of abdominal and intercostal muscles T1-T12: impairment of intercostal muscles, reduced cough, possible paradoxical retraction of chest wall during inspiration T8-T10: Below impairment of abdominal muscles T12: no impairment of respiratory function Pulmonary Complications Management: Position Deep Use changes/postural drainage breathing exercises of incentive spirometry Cough assist Glossopharyngeal breathing exercises. Pneumobelt Phrenic nerve pacing Non-invasive ventilatory support CV complications: Hypertension and Coronary Artery disease Inactivity causes: Increased cholesterol levels Increased risk of coronary artery disease Management: Exercise/ increased activity CV complications: Deep Vein Thrombosis 3 important factors (Virchow’s triad) Venous stasis Hypercoagulability Vessel wall damage Highest risk period: 1st 2 weeks Serious complication: Pulmonary embolism Risk of death decreases over time 210 19.1 8.9 times greater in the acute phase times 2-5 years post-injury times beyond 5 years post-injury CV complications: Deep Vein Thrombosis Management Pharmacologic Prophylactic (e.g. heparin, coumadin) measures compression stockings, external pneumatic compression, continuous rotation beds Avoid ROM and strengthening exercises on the affected limb Bed rest until medications are given CV Complications: Orthostatic Hypotension Common in higher levels of SCI Causes: Ineffective vasoconstriction Pooling of blood in the lower extremities Treatment: Progressive elevation Use of compression stocking and abdominal binders Liberal salt and fluid intake Elevated leg rests Medications (e.g. NaCl tablets, ephedrine) CV complications: Cardiac Arrhythmias Common during the acute period (14 days post injury) Usually in cervical and complete injuries Cause: autonomic imbalance sympathetic and parasympathetic activity Prevention: Use of atropine Induced hyperventilation Usually resolved within 6 weeks after injury Sexual Dysfunction Sexual desire is not necessarily affected but depression, poor body image and fears of inadequacy may alter sexual desire. Sexual function, however, may be affected. Erection (parasympathetic) Ejaculation (sympathetic) Lubrication (in women) Complete SCI (no sacral reflexes): more impairment Sexual Dysfunction Addressing concerns on body image, maintenance of intimate relationships, etcetera Management Oral options for erectile dysfunction: medications (e.g. sildenafil) Vaccum Penile devices injection programs (papaverine) Surgically implanted prosthesis Functional Rehabilitation Focuses on helping the patient to function at optimal levels Supervised PT and OT to improve strength in all active muscle groups and ROM in all joints Adaptive equipment Long-handled shoehorns Reachers Ambulation equipment Low-back wheelchairs are feasible because patients with lower-level SCIs have better truncal stability. Thank You!