Spinal Cord Injury Progress, Promise, and Priorities (2005) / Chapter Skim
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4 Current Therapeutic Interventions
4 Current Therapeutic Interventions
Pages 95-120
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From page 95... ...
Improvements in rehabilitative care and treatment options have also provided significant functional enhancement and improved daily function. Organized according to the stage of the injury and the targets for therapeutic intervention, this chapter describes the current standards of care and the treatment options for reducing the sequelae and secondary complications associated with spinal cord injuries, including improving sexual, bowel, and bladder functions; minimizing pulmonary embolisms, depression, and spasticity; alleviating pain; and enhancing function.
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From page 96... ...
A lack of clinical guidelines for a particular treatment does TABLE 4-1 Clinical Practice Guidelines for Treatment of Spinal Cord Injury Current Guidelines Acute Care · Acute management of autonomic dysreflexia: Individuals with spinal cord injury presenting to health care facilities (1997, 2001) a · Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals (2000)
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From page 97... ...
Immobilization at the Scene and Transport to Acute Care At the scene of the injury, the primary considerations related to the spinal cord injury are to stabilize the spine and to ensure rapid transport to the nearest acute-care facility. These goals are vital to preventing further injury, considering that it has been estimated that in the past between 3 and 25 percent of spinal cord injuries took place after the initial trauma, either during transport or early in the course of patient evaluation (Hachen, 1974)
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From page 98... ...
Studies of decompression in rodents after a spinal cord injury demonstrate that the longer compression of the spinal cord exists, the worse the prognosis for neurological recovery (Dimar et al., 1999)
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From page 99... ...
. The three clinical trials of methylprednisolone, a corticosteroid, were sponsored by the National Acute Spinal Cord Injury Study (NASCIS)
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From page 100... ...
. Experts in spinal cord injury-associated pain consider the development of pain therapies to be a major and feasible research priority, considering the body of research that has been amassed over the past 10 years about pain mechanisms in individuals with spinal cord injuries, as well as related research on other forms of neuropathic pain.
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From page 101... ...
. Few randomized controlled clinical trials of pain therapies for individuals with spinal cord injuries have been published in the medical literature, and none of the trials that have been conducted found commonly used pain therapies to be highly effective (Table 4-2)
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From page 102... ...
Relief of Spasticity Spasticity refers to the debilitating muscle spasms and other types of increased muscle tone that occur after a spinal cord injury. Spasticity is similar to pain in that both are highly common after spinal cord injuries and have multiple possible mechanisms that might account for their onset (see Chapter 2)
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From page 103... ...
Three types of bladder problems are common after a spinal cord injury. The first, flaccid bladder, results from injury to the sacral cord, which controls reflexive contraction of the bladder.
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From page 104... ...
The Consortium for Spinal Cord Medicine will soon be describing the strength of the evidence in a clinical practice guideline under development. Neurogenic Bowel Treatment Neurogenic bowel, the absence of voluntary control over stool elimination, affects the vast majority of individuals with spinal cord injuries.
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From page 105... ...
. Pressure Ulcers Pressure ulcers are a highly frequent and serious complication of a spinal cord injury that affect physical, psychological, and social functioning.
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From page 106... ...
Female Sexual Dysfunction and Fertility Sexual dysfunction in women with spinal cord injuries received scant attention until the 1990s. The problems include insufficient vaginal secre
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From page 107... ...
Depression Depression after a spinal cord injury is common and disabling. A key longitudinal study was conducted to track more than 100 individuals with spinal cord injuries for 2 years after discharge from the hospital (Kennedy and Rogers, 2000)
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From page 108... ...
Although this technique is promising, it is still unclear how effective body weight support treadmill training is at improving function in individuals with incomplete chronic spinal cord injuries. It is believed that body weight-supported training enhances the relearning of motor skills in the presence of spared pathways and facilitates the remaining pathways to
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From page 109... ...
To confirm these preliminary findings, an ongoing prospective large scale randomized clinical trial (The Spinal Cord Injury Locomotor Trial) has been designed to evaluate body weightsupported treadmill training and to compare that therapy with conventional physical therapy (Dobkin et al., 2003a,b)
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From page 110... ...
FDA has approved neuroprostheses for the restoration of hand function, bowel and bladder control, and breathing, and clinicians at many spinal cord injury centers are trained in their use. In addition, an FDA-approved walking system uses a nonimplanted FES and an FES cycle ergometric device that allow periodic exercise of paralyzed leg muscles.
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From page 111... ...
For respiratory control, electrical stimulation can be used to stimulate the phrenic nerve, which controls the contractions of the diaphragm muscles. This technique, known as phrenic nerve pacing, was introduced in the 1960s (Escher et al., 1966)
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From page 112... ...
FES devices have received a mixed reception from both clinicians and individuals with spinal cord injuries. Originally, the controllers and stimulating electrodes were large and cumbersome and did not provide very fine control; however, technological advances are leading to reductions in the sizes of these devices and reductions in the numbers of surgical procedures required for implementation.
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From page 113... ...
Department of Veterans Affairs reimburse individuals for associated costs. Ensuring that such benefits become available to individuals with spinal cord injuries in the future will require an effective delivery model, which requires collaboration between various clinical specialties (physical medicine and rehabilitation physicians, hand surgeons, and therapists)
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From page 114... ...
1994. Modeling of acute spinal cord injury in the rat: Neuroprotection and enhanced recovery with methylprednisolone, U-74006f and YM-14673.
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From page 115... ...
1997. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treat ment of acute spinal cord injury: Results of the third National Acute Spinal Cord Injury randomized controlled trial.
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From page 116... ...
2003b. Randomized trial of weight-supported treadmill training versus conventional training for walking during pa tient rehabilitation after incomplete traumatic spinal cord injury.
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From page 117... ...
2001. Combined use of body weight support, functional electric stimulation, and treadmill training to improve walking ability in individuals with chronic incomplete spinal cord injury.
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From page 118... ...
2000. Methylprednisolone for acute spinal cord injury: An inappropriate stan dard of care.
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From page 119... ...
2000. Consortium for Spinal Cord Medicine -- Pressure Ulcer Prevention and Treat ment Following Spinal Cord Injury: A Clinical Practice Guideline for Healthcare Profes sionals.
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From page 120... ...
1998. Clinical practice guidelines: Neurogenic bowel man agement in adults with spinal cord injury.
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