IPHREHAB: Spinal Cord Injury : Quadriplegic and Paraplegic Injuries

IPHREHAB

Spinal Cord Injury : Quadriplegic and Paraplegic Injuries

Paraplegic and quadriplegic (tetraplegic) are terms used to describe the medical condition, for a person who has been paralysed due to a spinal cord injury. This classification depends on the level and severity of a persons paralysis, and how it affects their limbs.

This  provides patient information about acute spinal cord injuries, as well as treatment, symptoms, information on long term rehabilitation issues and peer support, to help improve the quality of life of those affected by a spinal cord injury.

What is a Spinal Cord Injury ?

A spinal cord injury (SCI) is typically defined as damage or trauma to the spinal cord that in turn results in a loss or impaired function resulting in reduced mobility or feeling.

Typical common causes of damage to the spinal cord, are trauma (car/motorcycle accident, gunshot, falls, sports injuries, etc), or disease (Transverse Myelitis, Polio, Spina Bifida, Friedreich's Ataxia, etc.). The resulting damage to the spinal cord is known as a lesion, and the paralysis is known as quadriplegia or quadraplegia / tetraplegia if the injury is in the cervical (neck) region, or asparaplegia if the injury is in the thoracic, lumbar or sacral region.

The spinal cord injury level is usually refered to alpha numerically, relating to the affected segment in the spinal cord, ie, C4, T5, L5 etc.

It is possible for someone to suffer a broken neck,or a broken back without becoming paralysed. This occurs when there is a fracture or dislocation of the vertebrae, but the spinal cord has not been damaged.

What is a Complete and Incomplete Spinal Cord Injury

There are typically two types of lesions associated with a spinal cord injury, these are known as a complete spinal cord injury and an incomplete spinal cord injury. A complete type of injury means the person is completely paralysed below their lesion. Whereas an incomplete injury, means only part of the spinal cord is damaged. A person with an incomplete injury may have sensation below their lesion but no movement, or visa versa. There are many types in incomplete spinal cord injuries, and no two are the same.

Such injuries are known as Brown Sequard Syndrome, Central Cord Syndrome, Anterior Cord Syndrome and Posterior Cord Syndrome.

What is Spinal Cord Injury Rehabilitation

Someone with a spinal cord injury will have a long road of rehabilitation ahead of them, usually at a spinal cord injury rehabilitation centre or spinal injury unit, and it is important that they keep their sense of humor on their bad days to help them maintain a positive attitude.

Generally, paraplegics will be in hospital for around 5 months, where as quadriplegics can be in hospital for around 6 - 8 months, whilst they undergo rehabilitation. Both paraplegics and quadriplegics should have some kind of rehabilitation and physiotherapy before they are discharged from hospital, to help maximise their potential, or help them get used to life in a wheelchair, and to help teach techniques which make everyday life easier.

Disabled sports, and wheelchair based sports can be an excellent way to build stamina, and help in rehabilitation by giving confidence and better social skills. The ultimate reward for many disabled sportsmen and women, is to win at the paralympic games, which will be coming to London in 2012.

Spinal Cord Injury Cure and Treatment

A cure for long term paralysis is still some years in the future, but clinical trials are taking place with Olfactory Ensheathing Glial (OEG) cells and Embryonic Stem Cell based Therapy.

and conservative treatment via physiotherapy and rehabilitation approaches.

Paraplegic and Quadriplegic Discussion Forum

If you have any spinal cord injury related questions, please visit our discussion forums and join in on the many topics there. We will do our best to help you, or at the very least, put you in contact with someone who can if we can't. The discussion forum is intended to be a free flow of information between spinally injured people, carers, and their friends, and everyone is welcome.

Even if you don't have any questions, take a look at the forum anyway, as you may be able offer help and advice to others who have questions.

Quadriplegic, Tetraplegic, Paraplegic and it's Definition

Quadraplegic is derived from two separate words from two different languages, Latin and Greek. The word “Quadra”, meaning “four” which is derived from latin, relates to the number of limbs. “Plegic”, is derived from the Greek word “Plegia”, meaning paralysis.

Put the two together, and you have “Quadraplegia”.

“Tetra” is derived from the Greek word for “Four”. “Para” is derived from the Greek word for "two" Hence: Tetraplegic and Paraplegic.

In Europe, the term for 4 limb paralysis has always been tetraplegia. The Europeans would never dream of combining a Latin and Greek root in one word.

In 1991, when the American Spinal Cord Injury Classification system was being revised, the definition of names was discussed. The British are more aware of Greek versus Latin names. Since Plegia is a greek word and quadri is Latin, the term quadriplegia mixes language sources. Upon review of the literature, it was recommended that the term tetraplegia be used by the American Spinal Cord Association so that there are not two different words in English referring to the same thing.

IPHREHAB : Disabled people’s organization [DPO]

IPHREHAB

Disabled people’s organization [DPO]

—  Are membership organizations

—  Register as a legal entity

—  General body meetings are conducted every 1 or 3 yrs

—  By working with SHGs- meet the needs of disabled at local & wider level, & in short & long term.

 Initially- identify & understand the current situation & map services; then to identify what gaps exist & what is required 

CBR Personnel

1.     CBR workers are grass root workers-

a)      Act as local advocates on behalf of disabled

b)      Provide continuity of care & supervision

c)       Act as directors of community initiatives

d)      a positive role model

2.      Supervisors or medico social workers
3.      Professionals for referral

Working levels

     1.  National level- advocating  for policy change, CBR in curriculum of education, Fund raising, promoting CBR concept

     2.  District  level- training CBR Ws & committees, awareness activities, organizing referral system

     3.  Local level- work done by local committees – includes training of physically disabled, blind, deaf in their community 

CBR Resource Centre

•  Ex.- a school or a building provided by religious organizations or a separate house built for the purpose in slum areas
• Organize activities
•  Acts as an address for the community to receive communications & identity for the activities.

Evaluation

—  Means the activities which are done to see how a program is progressing

—  Monitoring & self assessment- two aspects

—  Benefits :

ü  Value of the program

ü  Making decisions to improve it

ü  Funding

Finding new knowledge about CBR

—  Too busy in implementing it- evaluation takes time

—  Skills to evaluate?

—  Means change in the routine to improve

—  Link it with discont. of the program

—  Promote the idea of evaluation in program before starting.

Transportation facilities

• —     Special  buses for the disabled- low platform & special seats are being implemented in  many places
• —              Even special parking facilities are made available 

IPHREHAB : COMMUNITY BASED REHABILITATION

IPHREHAB

Community based rehabilitation CBR]

1) Community based rehabilitation [CBR] is a strategy within community development for the rehabilitation, equalization of opportunities & social integration of all people with disabilities.

2) CBR is implemented through combined efforts of disabled people themselves, their family & communities, & the appropriate health, education, vocational & social services.

3)    At global level→ 7- 10 % of popln. Disabled & in India→ 5 % of popln.

4)   CBR concept was developed by WHO at late 1970s→ concentrating mainly on health, later ILO & UNESCO joined to make it a multi -sectoral approach- covering all aspects of life.

5)   To ensure that people with disabilities are able to maximise their physical & mental abilities, to access regular services & opportunities, & to become active contributors to the community & society at large.

6)    To activate communities to promote & protect the human rights of people with disabilities through changes within the community, for ex.- by removing barriers to participation.

7)  Health – state of complete physical, mental & social wellbeing & not merely an absence of disease or infirmity & includes the ability to lead a socially & economically productive life.

8)      First level of contact btw individual & health system & is closest to the people

9)  CBR is fully consonant with the concept of PHC- promotes awareness, self reliance & responsibility for rehab within community.  Encourages the use of simple methods & tech. that are acceptable, affordable, effective & appropriate for the local setting.

10)   The most rehab activities can be carried out in the pts own community.

CBR has 7 different components:

1.       Provision of rehab services

2.       Empowerment, Education & training opportunities

3.       Creation of income generation opportunities

4.       Long term care facilities

5.       Prevention of causes of disabilities

6.       Monitoring & evaluation

7.       Creation of positive attitude

Empowerment

—  Of disabled & their family

—  Of community by 5 approaches:

1)      Social mobilization

2)      Political participation

3)      Language & communication

4)      Self help groups

5)      Disabled people s organizations

Social mobilization

—  To bring people & resources together to achieve a particular task

—  Purpose- to get disability into social consciousness of community & integrate it into all development programs

—  Advocacy & negotiation skill is required to mobilize community

—  Advocacy- to ask & persuade, negotiation- what is required & what not.

Political participation

—  Political & economic approach is most powerful

—  Means- people using their power as citizens to take part in & shape the decisions that affect their lives 

a)     a common goal shared by all & originates from needs of the members

b)      a set of rules & regulations to work together

c)       shared responsibility among members

d)      democratic decision making

e)      leadership from within the group

Training of the Group on how to:

ü  Prepare an agenda

ü  Conduct meetings

ü  Resolve differences

ü  Learn from failure

ü  Delegate tasks

Effects of political participation

—  INCREASED awareness of political processes

—  INCREASED awareness of civic rights

—  INCREASED awareness of civic responsibilities

—  Ability to exercise civic rights & responsibilities

—  INCREASED knowledge of how to benefit from policies & programs

—  Ability to get grievances redressed through political processes

Communication & language

—  It’s an essential part of social, cognitive & emotional growth

—  It connects us to our family & community

—  CBR has a key role in working with people with disabilities, to improve their ability to express themselves & engage with others

     Self help group

—  Enable disabled to advocate for themselves & take responsibility for their own development

—  Characteristics of SHGs :

ü  Plan & review progress

ü  Speak in public with confidence

ü  Analyze- links btw. Disability, poverty & discrimination

ü  Create link with other existing programe of different issue

IPHREHAB: Spontaneous Subarachnoid Hemorrhage

IPHREHAB

Spontaneous Subarachnoid Hemorrhage

This is the fourth most frequent cerebrovascular disorder following atherothrombosis, embolism, and primary intracerebral hemorrhage. Saccular aneurysms are also called berry” aneurysms; actually they take the form of small, thin-walled blisters protruding from arteries of the circle of Willis or its major branches. Their rupture causes a flooding of the subarachnoid space with blood under high pressure.

Aneurysms are multiple in 20 percent of patients

In childhood , rupture of saccular aneurysms is rare, and they are seldom found at routine postmortem examination; beyond childhood, they gradually increase in frequency to reach their peak incidence between 35 and 65 years of age.

Approximately 90 to 95 percent of saccular aneurysms lie on the anterior part of the circle of Willis.

Clinical picture

• Prior to rupture, saccular aneurysms are usually asymptomatic. Exceptionally, if sufficiently large to compress pain-sensitive structures, they may cause localized cranial pain.
• The presence of a partial oculomotor palsy with dilated pupil may be indicative of an aneurysm of the posterior communicating-- internal carotid junction.
• With rupture of the aneurysm, blood under high pressure is forced into the subarachnoid space(where the circle of Willis lies).
• Rupture of the aneurysm usually occurs while the patient is active rather than during sleep , and in some instances sexual intercourse, straining at stool, lifting heavy objects, or other sustaining exertion precipitates the ictus. In patients who survive the initial rupture, the most feared complication is rerupture, an event that may occur at any time from minutes up to 2 or 3 weeks later.
• In less severe cases, consciousness, if lost , may be regained within a few minutes or hours, but a residual of drowsiness, confusion, and amnesia accompanied by  severe headache and stiff neck persists for several days.
• Since the hemorrhage is confined to the subarachnoid space, there are few or no focal neurologic signs.
• AVM is another most common cause for SAH
• Convulsive seizures, usually brief and generalized.

• Vasospasm  Delayed hemiplegia or other focal deficit usually appears 3 to 12 days after rupture and rarely before or after this period. These delayed accidents and the focal narrowing of a large artery or arteries, seen on angiography, are refered to as vasospasm.
• Hydrocephalus  If a large amount of blood ruptures into the ventricular system or floods the basal subarachnoid space, The patient then may become confused or unconscious as a result of acute hydrocephalus. A subacute hydrocephalus due to blockage of the CSF pathways by blood may appear after 2 to 4 weeks.

Laboratory Findings  

A CT scan will detect blood locally or diffusely in the subarachnoid spaces or within the brain or ventricular system in more than 90 percent of cases and in practically all cases in which the hemorrhage has been severe enough to cause momentary or persistent loss of consciousness.

In all other cases a lumbar puncture should be undertaken when the clinical features suggest a subarachnoid hemorrhage. Usually the CSF is grossly bloody within 30 min of the hemorrhage, with RBC counts up to 1 million per cubic millimeter or even higher.

Carotid and vertebral angiography is the only certain means of demonstrating an aneurysm and does so in some 85 percent of patients in whom the correct diagnosis of spontaneous subarachnoid hemorrhage is made on clinical grounds.

MRI and MRA detect most aneurysms of the basal vessels but are as yet of insufficient sensitivity to replace conventional angiography. Even when MRA or “ CT angiography  “ demonstrates the aneurysm, the surgeon usually requires the kind of anatomic definition that can only be obtained by conventional angiography. 

Establish the diagnosis

If there is a typical history, marked neck stiffness and no focal neurological deficit, lumbar puncture is still the best way to make the diagnosis, revealing uniformly blood-stained CSF. 

If the history is typical with marked neck stiffness, but the patient remains in coma or shows a marked focal neurological deficit, a CT scan is a safer way to establish the diagnosis (revealing blood in the subarachnoid space),since lumbar puncture may lead to worse condition in this group of patients (whose coma or focal neurological deficit may indicate the presence of an associated intracerebral blood clot).

Treatment 

• This is influenced by the neurologic and general medical state of the patient as well as by the location and morphology of the aneurysm.
• The general medical management in the acute stage includes the following , in all or part: 
• bed rest
• fluid administration to maintain above-normal circulating volume and central venous – pressure
• use of elastic stockings and stool softeners
• administration of beta-blockers
• calcium channel blockers

Treatment 

• intravenous nitroprusside
• or other medication to reduce greatly elevated blood  pressure and then maintain systolic blood pressure at 150 mmHg or less;
• and pain-relieving medication for headache ( this alone will often reduce the hypertension ).
• The prevention of systemic venous thrombosis is critical, usually accomplished by the use of cyclically inflated whole-leg compression boots.

Treatment 

• The use of anticonvulsants is controversial; many neurosurgeons administer them early, with a view of preventing a seizure-induced risk of rebleeding.
• Calcium channel blockers are being used extensively to reduce the incidence of stroke from vasospasm. Nimodipine 50 mg, administered intravenus, is currently favored.
• Notable advances in the techniques for the obliteration of aneurysms, particularly the operating microscope, and the management of circulatory volume have significantly improved the outcome of patients with ruptured aneurysms.
• Both the risk of rerupture of the aneurysm and some of the secondary problems that arise because of the massive amount of blood in the subarachnoid space can be obviated by early obliteration of the aneurysm.
• lumbar puncture is carried out for diagnostic purposes if the CT scan is inconclusive; thereafter this procedure is performed only for the relief of intractable headache, to detect recurrence of bleeding, or to measure the intracranial pressure prior to surgery. 
• Advice from specialist neurosurgical units should be sought. Patients who have withstood their first bleed well are submitted to carotid and vertebral angiography within a few days to establish whether or not an operable aneurysm is present. Patients who do not recover from their first bleed well, patients with inoperable aneurysms should be nursed in bed for a few weeks and then mobilized over a further few weeks, being encouraged to return to full normal activities at about 3-4 months.
• Prevent re-bleeding

Rehabilition

Since the incidence of significant damage to the brain is high  in patients surviving subarachnoid haemorrhage, many will not be able to return to normal activities.

They will need support from relatives,  nurses, physiotherapists, speech therapists, occupational therapists, social workers and specialist units in rehabilitation.

Course and prognosis

 Patients with the typical clinical picture of spontaneous subarachnoid hemorrhage in whom an aneurysm or arteriorvenous malformation cannot be demonstrated angiographically have a distinctly better prognosis than those in whom the  lesion is visualized.

 Vasospasm and rebleeding were the leasing causes of morbidity and mortality in addition to the initial bleed. In respect to rebleeding , Aoyagi and Hayakawa found that this occurred within 2 weeks in 20 percent of patients, with a peak incidence in the 24 h after the initial bleed.