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General Rehabilitation of General Rehabilitation of Patient with Spinal TraumaPatient with Spinal Trauma

Vincent LauVincent LauPDPT, PDPT, Ass.Dip.HSMAss.Dip.HSM, , MMedScMMedSc, RPT, RPT

Physiotherapist IPhysiotherapist IDepartment of Integrated Rehabilitation ServicesDepartment of Integrated Rehabilitation Services

TseungTseung Kwan O HospitalKwan O Hospital

Asian Association for Dynamic Osteosynthesis

Workshop on Management of Spinal Trauma

22 April 2007 (Sunday)

Orthopaedic Learning Centre, PWH, Shatin, Hong Kong

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Spinal TraumaSpinal Trauma

Grossly categorized into Grossly categorized into ––

Acute injury Acute injury E.g. Sprain/strain, contusionE.g. Sprain/strain, contusion

Chronic injuryChronic injuryE.g. Cumulative traumatic disorderE.g. Cumulative traumatic disorder

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Important Anatomical Structures at Important Anatomical Structures at each Vertebral Leveleach Vertebral Level

VertebraVertebraSpinal cordSpinal cordSpinal nerve roots/spinal Spinal nerve roots/spinal nervesnervesBlood vesselsBlood vesselsIntervertebralIntervertebral disc (paindisc (pain--sensitive)sensitive)Facet joints (painFacet joints (pain--sensitive)sensitive)LigamentsLigamentsMusclesMuscles 44

Common Spinal InjuriesCommon Spinal InjuriesCervical regionCervical region

Sprain/strainSprain/strainDisc Disc herniationherniationFractureFractureSpinal Spinal stenosisstenosis/cord /cord compressioncompressionWryneckWryneckWhiplash injuryWhiplash injury

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Common Spinal InjuriesCommon Spinal Injuries

Thoracic regionThoracic regionSprain/strainSprain/strainCompression fractureCompression fractureDirect contusionDirect contusion

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Common Spinal InjuriesCommon Spinal Injuries

Lumbar regionLumbar regionSprain/strainSprain/strainBurst fractureBurst fractureProlapsed Prolapsed intervertebralintervertebral disc disc (PID)(PID)SpondylolisthesisSpondylolisthesisSpinal Spinal stenosisstenosis/cord /cord compressioncompression

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Common Spinal InjuriesCommon Spinal Injuries

Sacral and Sacral and CoccygealCoccygeal regionregionFractureFractureDirect contusionDirect contusionFall accidentFall accident

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General Principle of Rehabilitation General Principle of Rehabilitation for Spinal Trauma Patientsfor Spinal Trauma Patients

To prevent further damage.To prevent further damage.To decrease spinal related pain.To decrease spinal related pain.To improve strength, flexibility, lifting To improve strength, flexibility, lifting capacity and cardiopulmonary function.capacity and cardiopulmonary function.To minimize spinal related disability.To minimize spinal related disability.To normalize activities of daily living.To normalize activities of daily living.To assist in return to work and vocational To assist in return to work and vocational activities.activities.

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General Principles of General Principles of Physiotherapy Assessment on Physiotherapy Assessment on

Spinal Trauma PatientsSpinal Trauma PatientsTo take a complete history.To take a complete history.To perform a thorough physical To perform a thorough physical examination based on the history.examination based on the history.To establish a diagnosis.To establish a diagnosis.To rule out any To rule out any ““Red FlagsRed Flags”” (Factors that (Factors that may indicate serious underlying pathology may indicate serious underlying pathology -- fever, bladder and bowel dysfunction, fever, bladder and bowel dysfunction, unexplained weight loss, cancer history, unexplained weight loss, cancer history, fracture, significant trauma).fracture, significant trauma).

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History TakingHistory Taking

Chief complaint: Pain? Numbness? Weakness? Chief complaint: Pain? Numbness? Weakness? Deformity? Gait disturbance?Deformity? Gait disturbance?Symptom onset: Acute or insidious (nature of Symptom onset: Acute or insidious (nature of injury)?injury)?Symptom duration: Acute or chronic?Symptom duration: Acute or chronic?Pain location.Pain location.Pain quality and character: Sharp? Dull?, Pain quality and character: Sharp? Dull?, Radiating? Stabbing?Radiating? Stabbing?

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History TakingHistory TakingTemporal relationship of pain: Night pain? Temporal relationship of pain: Night pain? Rest pain? Constant/intermittent Rest pain? Constant/intermittent (irritability)?(irritability)?Aggravating and alleviating factors: Aggravating and alleviating factors: Mechanical or nonMechanical or non--mechanical in nature?mechanical in nature?Functional impairment.Functional impairment.Prior treatment.Prior treatment.WorkerWorker’’s compensation claim.s compensation claim.Past medical historyPast medical history

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Physical ExaminationPhysical Examination

Inspection: Posture, deformity, signs of Inspection: Posture, deformity, signs of inflammation, gait.inflammation, gait.Range of motion in different planes.Range of motion in different planes.NeurologicNeurologic examination examination –– sensation sensation (dermatome), muscle power ((dermatome), muscle power (myotomemyotome), reflexes.), reflexes.Nerve root tension signs (e.g. PNF, SLR, PNB Nerve root tension signs (e.g. PNF, SLR, PNB tests)tests)PalpationPalpation

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Physical ExaminationPhysical ExaminationSpecial tests Special tests ––

1.1. to delineate between upper motor neuron lesion to delineate between upper motor neuron lesion and lower motor neuron lesion (e.g. Hoffmann and lower motor neuron lesion (e.g. Hoffmann sign, sign, clonusclonus test, test, BabinskiBabinski sign)sign)

2.2. to rule out to rule out caudacauda equinaequina syndrome (e.g. bladder syndrome (e.g. bladder and bowel incontinence, saddle and bowel incontinence, saddle anaesthesiaanaesthesia))

3.3. to highlight the contribution of psychological to highlight the contribution of psychological and/or socioeconomic factors (e.g. Waddelland/or socioeconomic factors (e.g. Waddell’’s s signs)signs)To check one joint above and one joint below To check one joint above and one joint below (and any other associated injury).(and any other associated injury).Look for any abnormalities in XLook for any abnormalities in X--ray, CT, MRI ray, CT, MRI and laboratory test results.and laboratory test results.

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Role of Physiotherapy in the Role of Physiotherapy in the Rehabilitation of Patient with Spinal Rehabilitation of Patient with Spinal

TraumaTraumaPain control.Pain control.Instruction in proper exercise technique.Instruction in proper exercise technique.Advancement of the level of therapy based on Advancement of the level of therapy based on the patientthe patient’’s symptoms.s symptoms.Postural correction and gait rePostural correction and gait re--education.education.Providing supervision, motivation and goalProviding supervision, motivation and goal--setting during a therapy program.setting during a therapy program.Assisting the patient with creation of an Assisting the patient with creation of an individual home exercise program.individual home exercise program.

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Rehabilitation of Spinal TraumaRehabilitation of Spinal Trauma

OperativeOperative

Vs Vs

NonNon--operativeoperative

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OperativeOperative

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Common Spinal Operative Common Spinal Operative Procedures Encountered by Procedures Encountered by

PhysiotherapistsPhysiotherapists

Three Major Indications for Spinal Three Major Indications for Spinal OperationOperationDecompressionDecompressionStabilizationStabilizationRealignmentRealignment

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for Post OperativePost Operative Spinal Trauma PatientsSpinal Trauma Patients

Check vital signsCheck vital signsChest physiotherapy Chest physiotherapy –– chest complicationschest complicationsAnkle and toe exercise Ankle and toe exercise –– DVTDVTMaintenance to unaffected limbsMaintenance to unaffected limbsPain control if indicatedPain control if indicatedCheck neurologyCheck neurologyApplication of Application of orthoticorthotic device as indicated (e.g. device as indicated (e.g. Philadelphia brace, TLSO, Knight brace)Philadelphia brace, TLSO, Knight brace)Bed mobility and transfer training Bed mobility and transfer training –– e.g. log roll e.g. log roll turnturn

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for Post OperativePost Operative Spinal Trauma Spinal Trauma

Patients Patients –– ContCont’’ddIsometric postural muscle control upon Isometric postural muscle control upon pain subsided and wound stablepain subsided and wound stableMobilization/endurance training Mobilization/endurance training Walking exercise+/Walking exercise+/--walking aidswalking aidsPostural educationPostural educationHome adviceHome advice

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NonNon--operativeoperative

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for NonNon--operativeoperative Spinal Injury Spinal Injury

Patients Patients –– 1 1 Pain relief Pain relief ––

1.1. Heat and cold (e.g. hot pad, ice Heat and cold (e.g. hot pad, ice therapy) therapy)

2.2. Electrotherapy (e.g. TENS, IFT, Electrotherapy (e.g. TENS, IFT, infrared, shortwave diathermy, infrared, shortwave diathermy, ultrasound)ultrasound)

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for NonNon--operativeoperative Spinal Injury Spinal Injury

Patients Patients –– 2 2 Mobilization and Mobilization and strengthening strengthening ––

1.1. Intermittent traction Intermittent traction (INT/IPT)(INT/IPT)

2.2. Spinal Spinal mobilization/manipulation mobilization/manipulation (manual technique)(manual technique)

3.3. Spinal exercises (e.g. Spinal exercises (e.g. McKenzie exercise, McKenzie exercise, Williams exercise, spinal Williams exercise, spinal stabilization exercise)stabilization exercise)

4.4. HydrotherapyHydrotherapy

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for NonNon--operativeoperative Spinal Injury Spinal Injury

Patients Patients –– 33Home exercise Home exercise programprogramPostural rePostural re--educationeducationJoint protection Joint protection adviceadviceFunctional capacity Functional capacity evaluationevaluationWork rehabilitationWork rehabilitationErgonomics and Ergonomics and manual handling manual handling operation advice operation advice

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Functional Capacity Evaluation Functional Capacity Evaluation (FCE) (FCE)

Purpose of FCE Purpose of FCE ––Functional Capacity Evaluation Functional Capacity Evaluation (FCE) is commonly used to (FCE) is commonly used to determine the physical work determine the physical work abilities of individuals who have abilities of individuals who have sustained musculoskeletal injury.sustained musculoskeletal injury.An important purpose of workAn important purpose of work--related assessments is to ensure an related assessments is to ensure an appropriate match between the appropriate match between the injured workerinjured worker’’s abilities and work s abilities and work requirements.requirements.The test protocol is constructed with The test protocol is constructed with reference to various available FCE reference to various available FCE test systems, which have been test systems, which have been commonly used by the commonly used by the physiotherapists in different settings.physiotherapists in different settings.

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Work RehabilitationWork RehabilitationDefinition and Purpose Definition and Purpose ––

Work rehabilitation is interdisciplinary and uses Work rehabilitation is interdisciplinary and uses conditioning tasks that are graded for conditioning tasks that are graded for progressive improvement of the injured workerprogressive improvement of the injured worker’’s s biomechanical, neuromuscular, biomechanical, neuromuscular, cardiovascular, metabolic and psychological cardiovascular, metabolic and psychological functionfunction by using a series of real or simulated by using a series of real or simulated work activities.work activities.Work rehabilitation provides a transition between Work rehabilitation provides a transition between acute care and returnacute care and return--toto--work and addresses work and addresses the issues of productivity, safety, physical the issues of productivity, safety, physical tolerance and tolerance and behaviourbehaviour..Work rehabilitation is a highly structured, goal Work rehabilitation is a highly structured, goal oriented, individualized treatment program oriented, individualized treatment program designed to maximize ability to returndesigned to maximize ability to return--toto--work.work. 2626

Neck and Back ClassNeck and Back ClassA kind of intervention to handle individuals A kind of intervention to handle individuals presented with chronic or recurrent neck and presented with chronic or recurrent neck and back problems.back problems.Consists of a brief therapy that uses a health Consists of a brief therapy that uses a health education method to empower participants education method to empower participants through a procedure of assessment, education through a procedure of assessment, education and skill development.and skill development.Usually implemented in a class/group form in Usually implemented in a class/group form in order to enhance positive interactions among order to enhance positive interactions among participants. participants. Evaluation is usually made on the extent of Evaluation is usually made on the extent of improvement on the participantimprovement on the participant’’s quality of life s quality of life (e.g. SF(e.g. SF--36)36)

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Chronic Pain ProgramChronic Pain ProgramDefinition of Chronic Pain Definition of Chronic Pain ––

Chronic pain involves Chronic pain involves interelatedinterelated biologic, biologic, sensory, psychological, sensory, psychological, behaviouralbehavioural and and environmental factors.environmental factors.Chronic pain is persistent and does not Chronic pain is persistent and does not respond to conventional medical respond to conventional medical treatment.treatment.

Context of a Chronic Pain Program Context of a Chronic Pain Program ––Treatment of chronic pain requires a Treatment of chronic pain requires a biosocial model that helps the patient to biosocial model that helps the patient to improve function without necessarily improve function without necessarily diminishing or curing the pain.diminishing or curing the pain.

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Spinal Cord Injury (SCI)Spinal Cord Injury (SCI)

““The most devastating injury known to manThe most devastating injury known to man””

Common terminology Common terminology ––TetraplegiaTetraplegia refers to the impairment resulting refers to the impairment resulting from damage to neural elements within the from damage to neural elements within the cervical spinal canal.cervical spinal canal.ParaplegiaParaplegia refers to the impairment resulting refers to the impairment resulting from damage to neural elements within the from damage to neural elements within the thoracic, lumbar or sacral spinal canal.thoracic, lumbar or sacral spinal canal.

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for Spinal CordSpinal Cord InjuryInjury (SCI)(SCI) PatientsPatients

Key assessment for SCI patient Key assessment for SCI patient ––To identify the key muscles that are tested in To identify the key muscles that are tested in determining the motor level of the lesion (determining the motor level of the lesion (Motor Motor chartingcharting))To identify the key point for each sensory To identify the key point for each sensory dermatome that is tested in determining the dermatome that is tested in determining the sensory level of lesion (sensory level of lesion (Sensory chartingSensory charting))To identify level of functional independence and To identify level of functional independence and physical capabilities physical capabilities

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for Spinal CordSpinal Cord InjuryInjury (SCI)(SCI) PatientsPatients

Objectives of rehabilitation Objectives of rehabilitation ––To prevent movement of unstable spine causing To prevent movement of unstable spine causing further cord damage.further cord damage.To minimize To minimize spasticityspasticityTo prevent damage to skin and joints.To prevent damage to skin and joints.To maintain posture and circulation.To maintain posture and circulation.To train up safe and effective transfer technique To train up safe and effective transfer technique within the capacity of the patient.within the capacity of the patient.To maximize self care and locomotion capability.To maximize self care and locomotion capability.

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Physiotherapy Rehabilitation for Physiotherapy Rehabilitation for Spinal Cord Injury (SCI)Spinal Cord Injury (SCI) PatientsPatients

Means and Methods Means and Methods ––PositioningPositioningAssisted active/Passive mobilizationAssisted active/Passive mobilizationWeight bearing exercise (e.g. tiltWeight bearing exercise (e.g. tilt--table table standing, electric standing wheelchair)standing, electric standing wheelchair)Bed mobility/Transfer trainingBed mobility/Transfer trainingGait training with assistive devices as Gait training with assistive devices as indicated (for paraplegic only)indicated (for paraplegic only)Functional electrical stimulation (FES)Functional electrical stimulation (FES)Liaise with other disciplines to enhance self Liaise with other disciplines to enhance self care and prescription of appropriate means care and prescription of appropriate means of locomotion (e.g. wheelchair prescription)of locomotion (e.g. wheelchair prescription)

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ConclusionConclusion

Spinal trauma is a multiSpinal trauma is a multi--facet clinical facet clinical problem that demands sound knowledge problem that demands sound knowledge and skillful handling from health care and skillful handling from health care workers right from the acute phase to the workers right from the acute phase to the recovery phase in order to achieve the recovery phase in order to achieve the best possible outcome.best possible outcome.

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Thank YouThank You