Healthtouch - Spinal Cord Injury Treatment & Rehabilitation

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Hello everyone, I hope I am doing this right. This is FYI, just
something I found tonight.
My best to you all, Deborah

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This information is from the National Institute of Neurological Disorders and Stroke (NINDS).

Spinal Cord Injury Treatment & Rehabilitation


One mystery doctors would like to see solved quickly is why -- far from healing itself -- the spinal cord self-destructs following injury. Usually the spinal cord is not severed in an accident, but only crushed or bruised. However, in the next few hours (the acute stage) the injury gets worse. First the spinal cord swells. Then blood pressure drops off sharply in the damaged area, starving cells of their precious blood supply. Hemorrhaging begins in the center of the cord and spreads outwards. Nerve cells die, and their dying produces a gap in the cord with scar tissue forming on either side of the gap. Now the connections in the cord are well and truly broken and the result is paralysis and loss of sensation below the break.

Many investigators, including scientists at the Spinal Cord Injury Clinical Research Centers supported by the National Institute of Neurological Disorders and Stroke (NINDS) at Yale, New York and Ohio State Universities, and at the Universities of South Carolina and Texas are trying to solve this problem. One of the intriguing leads they are following involves drugs.

- Steroids. One family of drugs that may help prevent the cord's self-destruction is the steroids. These drugs have been used effectively to reduce the redness and swelling associated with a variety of illnesses or injuries. But their benefit in the case of spinal cord injury is not clear: Researchers at several NINDS-supported Spinal Cord Injury Clinical Research Centers have noted that small doses of steroids have little or no effect. On the other hand, larger doses may reduce the cord swelling but may retard healing. A collaborative study of the effectiveness of the steroid methylprednisolone is now under way at the five NINDS Spinal Cord Injury Clinical Research Centers and at the Universities of Miami and Puerto Rico.

- DMSO. NINDS-supported research scientists are also examining the properties of the controversial chemical, dimethyl sulfoxide (DMSO), a common industrial solvent thought to have healing and pain-relieving effects. DMSO is being tested on animals in experiments at five universities in the United States. As with all experimental drugs, the investigators are concerned with the safety and side effects of the drug as well as with determining its effectiveness.

- Endorphin blockers. A major discovery in the past decade concerns a class of brain chemicals called endorphins -- referred to as "the brain's own opiates" because they relieve pain. Now it appears that the endorphins are also involved in the production of shock. In shock, there is a sharp drop in blood pressure that can be life-threatening. During the acute stage of spinal cord injury, the cord also undergoes "spinal shock" -- when blood pressure drops off sharply. Some investigators now think that endorphins are released by the brain at the time of injury -- probably to relieve the victim's pain -- but unwittingly cause more damage by contributing to shock. Suppose you inject a drug that blocks the actions of endorphins, the investigators reasoned. Would that treatment prevent spinal shock in laboratory animals with induced spinal cord injuries? Simulating the course of events in a real-life accident, the scientists injected an endorphin-blocking drug about 45 minutes after the spinal cords had been severed in laboratory animals. Not only did most of the animals avoid shock, but they also recovered from the injury. Many were able to walk again -- some with no trace of injury. It is too soon to tell whether these results are applicable to human spinal cord patients, but the research is considered highly promising and is being followed closely.

Besides drugs, some specialists have tried cooling the injured cord to prevent secondary damage. If initiated soon after injury, the cooling should slow down metabolism and so might forestall tissue destruction.

Surgery during the acute stage may also be necessary to relieve pressure on the cord or reduce swelling. Damage to the bones of the spinal column -- the vertebrae -- might also need to be repaired, and the spinal column fixed in place around the cord.

Cool Head & Efficient Hands

Spinal cord injury represents a major medical emergency than demands knowledgeable handling at the scene of the accident and rapid specialized transport to medical facilities designed to treat trauma patients. The United States is considered the world leader in research on spinal cord injury, and the clinical research conducted at the five National Institute of Neurological Disorders and Stroke (NINDS) supported Spinal Cord Injury Clinical Research Centers reflects this expertise.

It is not unusual for a spinal injury victim to be taken first to a nearby hospital emergency room for immediate care of bleeding or other life-threatening conditions, and later be moved to an appropriate medical facility. Treatment might be at one of over 300 regional trauma centers, for example, special spinal cord injury units, or major medical centers equipped to treat spinal cord injury. In some cases, patients may qualify for participation in clinical research projects conducted at the NINDS-supported Spinal Cord Injury Clinical Research Centers. In any case, a multidisciplinary team at the center will be alerted to the arrival of a patient and prepared to make a rapid but meticulous diagnosis. First steps will include an evaluation of lung function -- especially important in the case of injuries in neck and chest regions. An anesthesiologist stands by ready to provide emergency respiratory aid.

An examination of the injury will determine what measures will be employed to relieve pressure on the cord, and how to stabilize the spinal column so that it does not move and is properly aligned around the cord. Traction and weights may be used, as well as special bed frames, to prevent movement.

A neurological examination will determine the extent of nervous system damage. All efforts will be made to preserve whatever movements the patient can make or sensations he or she can feel. Neurologists will test reflexes and question the patient, but also rely on a battery of electrical and other tests to determine the extent of damage to spinal cord nerves. At the Medical College of South Carolina, NINDS-supported specialists are refining electrophysiological tests to aid diagnosis and also to determine rapidly whether the cord has been partially or completely severed.

It is during this stage that drugs, cooling, surgery, or other techniques may be used to help prevent secondary damage to the cord. If, after 48 hours, the patient is unable to move or feel sensations below the level of injury, the resulting paraplegia or quadriplegia is considered "complete."

Man-Made Aids

Once the patient is out of danger, long-term treatment and rehabilitation can begin. Of growing importance in treatment are electronic aids that allow patients to regulate vital organs like the lungs or bladder, whose nerve supply may be impaired. Man-made devices that work by direct stimulation of nerves and muscles are one approach to the problem. The NINDS currently supports the development of a wide range of such devices, technically known as neural prostheses.

A Yale University research scientist has reported success with a new electronic device -- the Diaphragm Pacer -- designed to help paraplegics who have lost automatic control of their breathing muscles. Normally these patients have to be maintained on mechanical respirators. The system consists of an external radiotransmitter and antenna, a receiver implanted under the skin, and an electrode placed on the phrenic nerve. The phrenic nerve controls the diaphragm, the main breathing muscle. The transmitter's signals are picked up by the antenna, beamed to the receiver, and converted to electrical impulses which are sent to the phrenic nerve. The signals are beamed in an on-off pattern designed to match the normal breathing cycle. Electrophrenic electrodes have been implanted in over 200 patients so far. In clinical tests over a period of 8 years, the system has been found to be safe and effective.

Other neural prostheses designed to make life safer and more manageable for spinal cord injury patients are being developed:

- Bladder control. Urinary tract problems are a frequent complication of spinal cord injury, and serious infections are a major cause of death. At the University of California at San Francisco, a device designed to enable a patient to empty the bladder voluntarily is being tested on animals. This prosthesis involves electrical stimulation of the sacral nerve roots at the base of the spine. If the bladder device proves safe and effective, bladder infections could be reduced and perhaps eliminated.

- Hand control. At Case Western Reserve University in Cleveland, Ohio, investigators report that electrodes implanted in paralyzed finger and thumb muscles have enabled patients to grasp and hold pens, pencils, spoons, forks and other small objects. Plans call for further experiments aimed at the control of wrist and elbow muscles.

Paraplegic patients face other complications besides breathing difficulties and loss of bladder and bowel control. There may be painful muscle spasms, and bone and joint problems. Common illnesses present serious hazards. Flu or pneumonia, for example, can be fatal.

Pressure sores are a common problem. Sensations that ordinarily signal danger from heat, cold, or pressure may be lost below the level of injury. That loss, combined with reduced mobility, poor blood circulation, and inadequate nutrition, can give rise to troublesome skin ulcers. Careful daily inspection of the skin is necessary to prevent the sore and detect other problems.

The overall adjustment to a new life style is the overwhelming problem for the paraplegic, however. As one paralyzed veteran put it:

"The impact on the patient is traumatic, to say the least. There is the realization that a once whole and healthy body is no longer fully functional and is plagued with a myriad of secondary disabilities. The psychological/emotional problem of learning to accept this condition and learning how to cope with it is devastating in itself."

It is a tribute to human resourcefulness and strength that the great majority of paraplegics do adjust. They return to work, drive their own cars, and have fulfilling family and social lives.

Aiding and abetting them on their route to recovery are facilities designed to provide followup treatment once patients have passed the acute stage. Such treatment is available at regional spinal cord injury centers, rehabilitation institutes, veteran hospitals, departments of physical medicine or rehabilitation medicine in medical centers, and in clinics operated by nonprofit organizations such as the National Easter Seal Society.

The aim of a spinal cord injury rehabilitation program is to teach patients how to become independent. A variety of services and therapies are offered. Patients are often provided with self-care handbooks. An excellent example is one used at the New York University Institute for Rehabilitation Medicine, "Spinal Cord Injury -- A Guide For Care." No aspect of everyday living in a wheelchair is omitted. Here, for instance, are a few of the handbook's instructions on protecting skin and preventing pressure sores:

- Bathe daily and dry thoroughly, especially between toes and in the groin area. Make sure soiled skin is cleansed and dry thoroughly after bowel and bladder accidents.

- When sitting, buttock pressure should be relieved every 15 to 30 minutes by doing one-minute pushups or by shifting your weight from side to side. If you are unable to do this, ask for assistance.

- If you recline on a couch for long periods, use your air mattress or sheepskin under you.

The booklet tells patients what they need to know about nutrition, medication, foot care, and prevention of kidney and bladder complications. The assumption is that the patient will be independent. Tips range from how to negotiate a wheelchair to what to do about colds, asthma, allergies, or smoking.

Physical therapy is a major part of the treatment program in rehabilitation centers. If the patient is not yet permitted out of bed, a therapist will start bedside treatment. The degree of healing of fractured bones, the presence of pressure sores or infection, and the patient's general strength may limit the amount of exercise possible. But physical therapists will encourage patients to do as much as they can. A full physical therapy program often includes:

- Progressive regressive resistive exercises. These are exercises done with weights, pulleys and special exercise machines. They are part of a vigorous advanced program to strengthen muscles.

- Tilt table. A table that can be positioned at various angles to the horizontal helps the cardiovascular system readjust to upright position after a patient has been in bed for extended periods.

- Mat class. Working on a mat, the patient relearns and practices the skills needed for independent living: changing position in bed, getting dressed, moving from one place to another.

- Wheelchair class. The patient learns to handle a wheelchair, especially on curbs, ramps, stairs, and in a car. A patient's ability to negotiate these obstacles depends, of course, on the extend of impairment.

- Driver evaluation & training. Most patients ask "Will I ever be able to drive my own car?" The center says yes -- in the vast majority of cases.

At most rehabilitation centers, treatment is coordinated by a team that includes neurosurgeons, urologists, internists, physical therapists, and vocational rehabilitation specialists. Some patients may be ready to leave after a month's stay in a center. For others, rehabilitation takes longer, because a great deal more is involved than just physical problems.

There are days during rehabilitation when most spinal cord injury patients feel hopeless and helpless, unable to see much point in living. At the New York University Center, when a patient has these feelings, a volunteer, perhaps a successful advertising agency executive, is likely to wheel in for a visit. The executive tells the despondent patient that he, too, was once consumed with anger. In a rage, he demanded: "Why me? Why did this have to happen to me?" He talks about how he overcame his despair. He says, "I made it; you can, too." The executive himself was once a patient at the center.

A major factor in successful rehabilitation is motivation. It requires motivation, first, to accept irreversible facts. It takes still more motivation to make the most of what has not been injured -- talent, creative energies, intellectual resources. In addition, rehabilitation experts say that three factors always seem to be present: The patient has some definite activity -- a job, a career, plans for an education -- waiting to be undertaken as soon as he or she leaves the center.

Information provided by the National Institute of Neurological Disorders and Stroke. Prepared for Healthtouch, September 1997.

MSI-NINDS082

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