virtual didactics today. My name is Sterling Herring. I'm a PGY3 at Vanderbilt. First, before we get started, we always want to recognize those that have been particularly affected by the pandemic. We recognize that it is unfortunately cast a broad net so there are a lot of people that are being that are affected professionally or even personally and we want to recognize and express our support for all of you that are that have been affected. Again, just to kind of outline the purpose of these didactics is to augment didactic curricula at your home institutions to offload overstretched faculty during logistically difficult times, provide additional learning opportunities for folks that have been either shuffled off of their scheduled rotations or otherwise affected in terms of learning opportunities, and then provide more digital learning resources and support the physiatric community in general. We are going to keep everybody video and audio muted per the norm just to kind of keep volume down and video distractions to a minimum. If you have any questions, please send them in a chat message to me. Again, my name is Sterling Herring. I should be near the top of the participant list and you can send me a message directly and then as opportunities allow, I will pose them to the presenter. If you have any general questions, suggestions, or concerns, please reach out via Twitter or via email to those on the screen. Without any further ado, let's move on. We're excited to hear from Dr. Margaret Jones today. She is a professor here at Vanderbilt specializing in spinal cord injury. Dr. Jones, thank you for joining us today. Sure. You can hear me okay? Yes. Perfect. Hi everyone. I'm gonna go ahead and share my screen and go here. So thanks everyone for joining. I, as Sterling said, am Margaret Jones. I, just for a little background of me and how I'm qualified to talk about this maybe, is I did my residency at UDAB, fellowship at Kessler, and moved here to Vanderbilt after being at Harborview Medical Center in Seattle for a few years, really managing a lot of spinal cord injury care both on the acute side and in chronic clinic. I wanted to touch on some of that today just to give you guys a little bit of help with regard to your board studying and your regular studying or maybe for those who don't see a lot of chronic spinal cord injury. Seeing it across the spectrum can be quite interesting. So some of our objectives today is to really talk about why this is important and why it's an important topic even in PNR and then raise some of the chronic medical issues as related to spinal cord injury. And there are many, so I will, I'm going to say it plenty of times today, but I cannot cover everything in an hour. That's that's pretty tough. But I also really want to make sure that you guys know that what you're learning on the acute side for new injuries is actually pretty important still in the chronic phase as well. So remember that. So again, this is going to be a brief overview of many of these topics and there's no way I could cover everything in just an hour. There's actually a full year fellowship to really cover a lot of this. But if we could do some highlights today and actually I wanted to even bring a little relevance to the pandemic too if possible. So a lot of this information of just talking about the general epidemiology. If you guys look up the facts and figures center at UAB for spinal cord injury, it can give you an idea of both the incidence, the prevalence, and I, you know, pretty simple, but make sure you know the difference between those two words. But in general, there's approximately 17,000 new cases every year and we used to sort of say there's a prevalence of about a quarter million, but I would say, you know, when you're estimating that now, it's more closer to 300,000 people living with spinal cord injury. Over time, the general percentage is about 80 percent of male injured and that has held true over time. The average age though has really increased with time. So it used to be back in the 70s, early 80s, that the average age was somewhere around 29. Now it's more 43 and anyone that's worked with me has heard me say that fall is a four-letter word and again that's true and we do see this bimodal, a lot of people falling older in age related to cervical myelopathy and so that's where we ultimately end up with a relatively large number of incomplete tetraplegia patients. But, you know, this is also important just in terms of thinking about the level of injuries that we're working with and their general classification because it does impact what we're talking about with regard to chronic medical complications. Again, it's important to talk about these issues to help somebody that already has an underlying chronic condition and a disability they're working with because despite the fact that people have spinal cord injuries, they're still going to age. They're still potentially going to have some of the issues that they would have if they didn't have that spinal cord injury. But the second that some primary care doctors really see, oh my gosh, spinal cord injury, they may say, no, I don't understand anything with spinal cord injury. But a lot of these conditions, while we do understand some of them, our patients still have other issues that they need to work through with their other doctors as well. But what we can do is really remember, not that safer at home is valid all the time, but for these patients, we're trying to keep them home. We're trying to keep them out of the hospital. We're trying to minimize the risk of re-hospitalization. As may be suspected, genitourinary issues, GU issues, are very common reasons for re-hospitalization across both folks with paraplegia and tetraplegia. But then within sort of each classification, those with tetraplegia often have a lot of issues with respiratory issues, which we're going to get into some today. And then with paraplegia, we're thinking a lot about GU issues as well as pressure injuries. So again, keeping folks home, safe, living the life they want to live, and not just in an institution or in a hospital. When we're looking at cause of death in the general population, number one is coronary artery disease, cancer, accidents. But for those with spinal cord injury, this really hasn't changed much over time. And pneumonia and respiratory issues are still number one. Heart disease is still important, but infection and septicemia is really a big reason for death in folks with spinal cord injury, which is not the case for our general population. So again, there's something we're doing in the chronic phase, or maybe not doing, that we need to think about. And I point that out even more here with, again, this is a table that gets updated every year by the facts and figures. I know it looks like there's a lot of information here, but the main things to point out is, one, that mortality in the first two years after injury really has improved, but in the chronic phase, things haven't. So if we look at someone who maybe was injured at the age of 40 and they didn't have a spinal cord injury, their expected age would be somewhere around 80. If they are surviving for at least a year after injury and have paraplegia, their life expectancy is actually 10 years less than someone who isn't injured. And for someone with tetraplegia, it's even less than that, or more than that. So again, there's something that happens with spinal cord injury that in the chronic phase, they have a lesser life expectancy. And, you know, it just makes me wonder what we can do in the chronic phase as we manage these patients chronically to help impart health and quality of life for them. So we're going to review a few medical systems today. This is not exhaustive at all. We'll review some of the things that we really miss. I just thought that these either were pertinent to what you might learn when you first start in residency, some issues that really we could sort of focus on that might be helpful for board studying as well. So without further ado, we'll start with neurogenic bowel dysfunction. And again, the real good staples of spinal cord management is bowel and bladder. And so I felt like I couldn't disregard this, even though it's something that is commonly touched upon in talking about spinal cord injury. So going back to that bowel program that we start folks on in the acute care state, or excuse me, in their acute rehab stay, the bowel program should be planned, predictable, and effective. You want to try to confer the most independence. It should be in a timely manner. And we want to avoid complications, whatever that might mean for one person versus the next. And we're trying to minimize the occurrence of unplanned bowel movements. That's true both when they're still on the inpatient rehab floor, but also when they get home or to the next setting after their injury. Part of why bowel function becomes impaired, again, acutely, there's spinal shock, there's loss of the balance of the autonomic system, loss of central control, people have narcotics, they might have an ileus, they aren't moving quite as much. But then some of this stuff is still impacted in the long term. So colonic transport time is almost double for folks with spinal cord injury as compared to those without injury. There's increased tone, and all of these things can get worse with time. So when we're thinking about aging with spinal cord injury in the GI system, even in uninjured adults, constipation is found more commonly in those older than 60 versus all adult ranges. So even if someone doesn't have a spinal cord injury, they may have issues with constipation with time. That becomes even more troublesome for someone with a spinal cord injury, just because the frequency and that severity of constipation may worsen. Sort of the benefit of that is incontinence may decrease with time, but their ability to have a timely bowel movement that they can really plan for gets a lot worse. And there's a lot of studies that have been done looking at how quality of life really can be worse after spinal cord injury, and part of that related to happiness or satisfaction with bowel care. So something that we really try to hone on even in the chronic setting. As you can see, even in the chronic stage, years after their injury, almost 100% of motor complete injuries and over half of incomplete injuries have some sort of GI complaints that they're still talking about. So in talking about if a program is effective, this in the chronic PM&R setting or in the primary care setting, talking to patients and really getting an idea of history is super important. So talking about positioning, talking about how long it might be taking somebody, figuring out their caregiver needs and burden, talking about the amount of time, and then some of those other complications that we really think about just with spinal cord injuries. So are they also having skin issues? Are they also having issues with AD? So as you're talking with patients, you still might be making changes similar to what you learned initially of like adding a suppository, subtracting one bowel med versus another. Whenever you're making changes, you want to give three to five programs to gauge the success of that change. You want to think about if diarrhea is related to something they ate. Is it mostly and probably related to constipation or is there something going on? And again, we need to be thinking about if they are overly constipated in that long term, could this cause issues with AD or could it lead to issues with impaction, which can be reasons for hospitalizations in these patients. So it is something to really consider in the long term for these patients as well. So that was a little bit on the bowels. Moving on to the bladder, and I know that's a lot of what we focus on early on, and it still is something that's super important in the long term. Like I said, it is a main reason for rehospitalization for folks with spinal cord injury. Going back to neurogenic bladder management, our goals are really working towards continence, sustainability, having their management style be compatible with their lifestyle. So figuring out if there's a caregiver involved or if they can do it themselves, doing everything we can to minimize secondary complications, I think is one of the most important parts of long-term management with these patients. So whether it's the vasiatrist or urologist or sort of working with the urologist, doing what we can to minimize these complications can be super important. So one thing that I want to make sure that we continue to think about is when to treat in a UTI in spinal cord injury. So most of our patients in the chronic term, if they're using an indwelling catheter or even if they intermittent cath, they're probably going to be colonized. So bacteria is often just present, and we don't just treat that. We want to treat bacteria in the context of pyuria with new onset signs and symptoms. And with time, you can ask people like, oh yeah, every time I have a urinary tract infection, my right leg starts to have increased spasms, it starts to have a specific smell, and I know I feel bad. And that for that person is their tell, so to speak, of yes, they have a UTI. But if it is just, oh, you know, maybe it smells a little different, but nothing else necessarily going on, you may not treat in that instance. But it's a super important thing to consider just for the risk of resistance to antibiotics in the long term and why it's a really important part either to educate your patients or to educate their PCPs of talking about not just treating, not just having people on prophylactic antibiotics, but really being mindful for antibiotic stewardship in the long term because it will help these folks in the long term. So long, long ago, again, the reason that people actually died from spinal cord injury was due to renal failure, and it's because we didn't really know how to well manage the neurogenic bladder. But I think that's really improved with time, and it's in part why we do the yearly surveillance that we do in folks in our chronic clinics. So often we think about looking at the upper tracts in some way, whether it's a renal ultrasound. For some folks, you want to look at the overall function and get a true renal scan. The creatinine can give you a little bit of an idea of renal function. For the most part with that, you're looking more of a trend. For those who, if you just get a snapshot, it may not be reflective. Again, in part because creatinine is going to be reflective of someone's muscle mass, and if they're relatively atrophic because of their spinal cord injury, it could be that a creatinine of 1.2 after it previously being 0.6 actually tells you there's trouble going on with the kidney function. And I say this too, is like these are things that we can order. We can work with our urologist to order. You know, we can empower ourselves to to take on some of these in management in the long term as well. But I do think it's really important to develop a good relationship with urology. They may be helping you with management planning. They may be getting urodynamics because things have changed and we don't necessarily understand why. They're often going to be helping with stone management. If a patient, I actually have a patient right now whose capacity is 30 mls, so he's probably going to need a bladder augmentation and that's totally urology. And hopefully we can get him back to controlling his AD. So you know, I think working with your urologist to figure out what to do in those situations is helpful. Bladder Botox is a big help these days and helps us to get them off some of these meds that are causing issues in the long term. But lots of reasons to have urology involved in the chronic phase for these patients. And finding a good neuro urologist is always helpful and exciting to have people interested in our patient population. So switching gears but still related, for those that have worked with me, bowel, bladder, and skin are like numbers one, two, and three of what we're constantly talking about with our patients. And this picture here really helps me think about what's going on in the chronic phase and what we're worried about where special injuries may happen. So the risk of pressure injuries starts acutely after injury. Actually even in the ambulance and in the ER bay, they should be thinking about log rolling patients, padding the mats, and padding the backboards to make sure that people aren't getting injuries acutely. And that continues through inpatient rehab and after discharge from rehab and whatnot. So the first year and actually in the really super chronic phase, so more than 25 years after spinal cord injury, are the biggest times that we see issues with pressure injury. So everything we can do to try to prevent it is super important for many reasons. One, it's a pain. Like people hate it. They get super worried about it. You know, it's estimated that in some way, shape, or form, most people with spinal cord injury are going to develop a pressure injury at some point. And it impacts quality of life if you're asking someone who's working full-time but they have a new wound on their bottom to stop working so that they can rest their skin. That just takes away from the life that they're trying to live. And outside of that cost of time and money and work, the financial cost is quite significant. And for some of our more severe pressure injuries, $100,000 is sort of the minimal because you're thinking about potentially getting flaps, having to have a surgery, having to be in a hospital or an institution for weeks at a time. So it's a pretty big deal. Locations of pressure injuries. There's sort of two phases and locations of where this may be. This is something that it's just good to know and good to think about and think about the function in the long term. But if from a test question standpoint, this can also be helpful. So in that acute phase, people are in bed more. They are sacral sitting more than I would like to admit. So those sacrums do see a lot more than they do in the longer term. Heels also often get ignored or else don't get enough padding. And then sometimes the ischium gets in wounds. In the chronic phase, hopefully, typically, folks are sitting more. So this ischia are seeing a lot more of the pressure and that's really why we try to harp on the timing of pressure reliefs and making sure that people do them. And then you can see those other sites. Again, the perineum and the greater trochanter is more often due to folks sitting for longer times and with the greater trochs, part of it's just positional. Part of it may be that they gain weight after they've had their chair initially fit and so there's just really squeezing there on the lateral supports of their chair. So important to keep in mind. I have a very good friend at my previous hospital who helped me with some of these pictures and presentations and we used to sit on a pressure injury committee together. For those that need a little bit more, this website here tells you everything you might need to know about definitions and pictures with regard to pressure injury. But we'll just go through these relatively briefly today and I'll give you a little bit of how I tend to think about things. So four stages of pressure injuries plus a couple other definitions that are often thought about. With this stage one injury, it's intact skin. So basically when I'm thinking about this, I'm kind of thinking about what it would look like if someone had a sunburn. But it's non-blanchable erythema. It may look a little different if someone has different skin color, but it doesn't go all the way through that dermis. Whereas stage two here, basically when I'm thinking about this, it's like a blister has been unearthed. So there's exposed dermis, but not fat. Basically if someone has a blister and they still have intact skin, the second that opens up it becomes a stage two injury. Pertinent to this patient actually, and I think it's pertinent to the current environment, is actually this was a, this is not a COVID patient, but this was a proned patient. And one of the main concerns when patients do get proned is the pressure that happens on the face. And if it's not appropriately offloaded, they can end up with a pressure injury. So that is what's going on with this gentleman's face there. Stage three wound, full thickness loss of skin. And you can see that adipose tissue there in the base. When you're looking at that, I think you do have to sort of determine whether this is adipose or if it might be fibrinous material, because that's going to change your classification a little bit. And around here on the edges is what's called the epibole, where sometimes there's just stalling at the outside of that wound. And you'll see that in some of these chronic wounds that are fairly deep. Our deepest pressure injury definition is full thickness skin and tissue loss, where you can see whatever you might see in the base is either muscle or bone. And that's again going to be a stage four injury. What's important when you're doing classification is basically whatever it is is its worst is what you call it. So a stage four wound is a stage four wound. And even if it starts to look more like a three or a two or a one, in those instances if you did see healing, you would say a healing stage four pressure injury. Unstageable wounds, you cannot see the full bottom of the base. So there's either going to be fibrinous material here or other eschar covering the base of the wound. So we aren't quite sure what might be underneath and so you can't necessarily stage it at that time. A deep tissue injury, I kind of think about it more like a bruise. So again skin might still be intact but what's going on underneath it tells you that there's been increased pressure somewhere. Like for this heel here, basically with time this skin's probably going to come off and underneath it may be relatively healing or you may get under there and end up at someone's heel. And then finally a couple other newer definitions. One is this medical device related pressure injury. So again this is an intubated patient with a pressure injury on their tongue. I do wonder if some of that's going to come with the pandemic right now. But you can also get those with catheters or even like EKG leads or something if they're left in the wrong place for a prolonged period of time and someone ends up with a wound that's going to be a medical device related pressure injury. And then finally not a pressure injury but still very important to the spinal cord population is incontinence associated dermatitis. So this is why it's super important to think about is someone leaking? Is someone having a lot of bowel incontinence? Because if they have impaired sensation they end up with like this diaper but basically the ability to heal that in the long term for our spinal cord patients is going to be super impaired. So still very important to think about that in the long term for these folks. The other things to consider with time and this happens both with uninjured but injured patients is that elasticity of the skin changes with time and aging. So what was done previously may change and worsen or just evolve with time. It should be said that those with a history of pressure injuries are at risk of future ones. Both what's going on at the area of the previous pressure injury is going to be different than fully intact skin but then you also have to wonder and I think there's a little bit of data showing like the physiology of someone who's developed a pressure injury may contribute to the potential risk of increased future pressure injuries. And in that long term as well you know I sort of mentioned like greater trochanters may see a lot in the long term because their chair doesn't fit them anymore. So we have to really consider making sure that equipment is appropriate for people. If they previously maybe didn't use an offloading mattress and developed a wound they might need one now. We need to make sure that the upkeep of their chairs or their equipment is appropriate. If they've got lateral supports but it's got this metal jutting out from it maybe you need to increase the padding so we don't break into the skin anymore. I think other things and I already mentioned a little bit with regard to bowel and bladder of just making sure that folks aren't leaking in the long term and aren't having comments because that does impact their skin in the long term. But I also think cognition becomes a big factor especially as folks get either are 70 and have a new spinal cord injury or if they develop cognitive changes with time we need to keep that in mind with regard to how we're managing their skin their bowel and bladder to keep them healthy as possible. There is more and more data coming out about cognitive changes and worsening with time after spinal cord injury so it's still that aspect of geriatric care applies to the spinal cord patient as well. Dr. Slinsky gave a great talk on autonomic dysreflexia and just a little bit on dysfunction the other day. He is much smarter than me but I will not go into AD at all. I do think orthostatic hypotension is another aspect of that autonomic dysfunction and it is something you would consider both in the acute and the chronic phase. But I'm not going to talk as much about that today. What I will talk about is sort of issues that we see with the metabolic syndrome which is a problem in with folks that don't have spinal cord injury but is also an issue both for patients with spinal cord injury. So while this little cartoon man is standing what I wanted to really point out here was that gut because often that gut seen in spinal cord patients is colloquially called the quad gut and similar aspects of issues going on in our uninjured populations are happening in our spinal cord populations. So there is has been found to be abnormalities in glucose and lipid metabolism. There is also found to have issues with insulin resistance so glucose load really is has an impaired metabolism and then to reduce lean muscle mass is a big issue in the long term with these patients. They have decreased activity. They have a hard time putting on muscle mass because of their neurologic impairment and then again that's going to impact their body composition. And so their weight versus someone who you know has more lean muscle mass is just going to impact their cardiovascular system a lot different. So these are all the things that we think about monitoring and this is sort of what people were doing in the long term. I know if chronically in the VA for a long time they've been watching all of these things as part of their yearly exam because they're important to cardiovascular risk whether you have a spinal cord injury or not. The newest consortium guidelines actually give us a little bit more specific information for people with spinal cord injury and providers you know even in the clinical setting. A lot of this is going to be done by a primary care provider but there are certain instances where if a primary care provider isn't able to see someone very often then we as a physiatrist can be helping to do hypertensive screening and thinking about dyslipidemia and looking at other aspects of cardiovascular impact. I think one of the main things that's really hard at least on my heart is basically someone that has a BMI of 22 is considered to be obese. So you know part of the question is like does someone get injured who has a BMI of 22 and they're immediately obese? Hopefully not but looking at sort of thinking about changing that cutoff for what is considered normal weight versus obesity. It's very hard for patients I think after they first get injured one of the things they can actually control is how much they eat but again their caloric needs because of their new functional changes might be less and so we do have to be counseling folks on their cardio metabolic risk just because of the other risks that come with that in the long term. So again mitigating that risk is really really tough. There is a really nice website out of UAB and I don't know why I'm mentioning UAB so much but they do have some really good resources as a one of the sites for the model systems but I will often either direct patients here or sort of review exercise options with my patients after reviewing this website so it's a nice one that can give you some good exercises and I'm sure some of the other bigger centers have some as well. That one's just been a really easy go-to for me because it does list links to other spots like the UW model systems but other ways you as a physiatrist even if like you just have someone who is has paraplegia and they're in your clinic for new shoulder injury you can talk to them about various ways of doing exercise even in the middle of a pandemic with a lot of things that are done or you can find at home or get brought to home. So going back to our very basic theraband various resistance that can be used you can also use other resistance bands the hand the table mounted hand cycle you know an easy way to get the heart rate up get cardiovascular system going. Remember that your can of soup or other can is about a pound so it's an easy way to get some you know light weights going. Your gallon of milk is about eight pounds so again that's another way that you can work, try to come up with some resistance training for somebody who, and again, we're trying to prevent overuse injuries in the shoulders, but considering that in the longterm. Some can use recumbent bikes. Some of these are from the student center at the University of Washington. This was a slider where the person can like slide their wheelchair in and then do a little bit of sled exercises that way. The new step actually outside of rehab gyms is pretty uncommon. So it is a good way for folks to get things going if they can sort of transfer in that way. And then this actually is a wheelchair treadmill that UW have, which I thought was pretty slick and I never really saw it used, but a nice way for someone to get their cardiovascular system going. So switching gears yet again, cardiovascular system often comes in with the pulmonary system quite frequently. And I think that's true here with spinal cord injury. I think especially in this day and age, as we think about our patients who are at risk with COVID and also in thinking about some of the ramifications from COVID, especially with ICU weakness, critical illness, myopathy, and polyneuropathy, some of the factors for the respiratory management and spinal cord injury may actually come up in looking at some of these COVID patients. And I'll comment on that in a little bit. I'm gonna open this one up with a little bit of a case. This was earlier in becoming an attending and a case that I will probably carry with me for a long time. But I had a middle-aged man, I guess, with complete C5 tetraplegia. At the time of his injury, he had been a really heavy pack smoker. He ended up requiring a trach and a prolonged progressive vent wean, but he did get decannulated. He was discharged from an adult family home, but also discharged without any respiratory equipment. So I actually met him, I think in November, or yeah, it was November of that year. So right during the respiratory viral illness season at the time. He said he felt a little short of breath. He was a little winded and talking, but his O2 stats were okay. His lungs didn't sound great. And so I asked him to go get an X-ray, but then he actually went home instead of coming back to the clinic. So I'll talk about what happened in a little bit. But for some of the changes that happen with spinal cord injury, why this is important is that diseases of the respiratory system are the leading cause of death following spinal cord injury. That's both in the first year, but also in the chronic phase. And other respiratory complications really can impact death. So if someone has respiratory issues, it may cause other arrhythmias. And so cardiac issues can be related to some of the respiratory complications. And pneumonia is just really, really risky in these patients, both viral and bacterial. The other reason that this is important, and I think especially in today's climate, is that the mean age of injury is increasing. So you may have older people who end up in an institution because they can't be cared for otherwise. They may end up in a skilled nursing facility where the risk of infection is super high. We're seeing that across the country. And the skilled care is just really challenging. The other side of it is just that if people do require hospitalization, they probably have to be there for longer than others. And the other side of it is trying to convince someone that maybe someone with C5 tetraplegia who just has a bronchitis may actually need to be hospitalized, whereas someone who doesn't have a spinal cord injury doesn't necessarily need that. But it's in part because of the amount of skilled care they need to manage their pulmonary system is just higher than a non-injured person. So going back to that step one, C3, 4, and 5 keeps the diaphragm alive. You can continue to remember that for the rest of your time. But the respiratory issues in chronic spinal cord injury come due to weakness of both inspiratory and expiratory musculature. Remember that your cough is forced expiration, but expiration's otherwise a passive process, but that cough is what's super important. So, but even folks with high paraplegia are gonna have issues. Their intercostal innervation may be impacted. The optimal length tension dynamic of their diaphragm may be impacted. And even as you sort of go down through paraplegia, you're gonna get increasing abdominal strength. But as you go higher up, you're gonna lose some of the abdominal strength is gonna impact someone's respiratory capabilities. So though what we're thinking about both with tetraplegia and for high paraplegia is restrictive dysfunction. So there's increased atelectasis, which happens in part just because these folks have a really hard time expanding their lungs. That weak inspiratory process comes both from the weakened diaphragm, but also some of those other weakened accessory muscles. There's also a component of an obstructive physiology. The way that the pressure gradients happen, the gas exchange doesn't happen maybe quite as sufficiently because people can't expand quite as well. So that's one thing to consider. There may be, especially in the acute phase, there's gonna be airway hyper reactivity. So there may be increased secretions, which is again, a lot harder to expel because cough is weakened. Poor airway clearance is a very major aspect of this. And then the other thing that's concerning or difficult is that if these folks are spending some time in their chair, but most of their time in the supine position, in the supine position, it actually helps optimize the length tension on the diaphragm. But when you go to sit up, a lot of those abdominal contents are coming down, the diaphragm loses the tension that it needs to be more effective. And we need to help manage that appropriately to help their respiratory mechanics in the longterm. This is an easy test question to remember or not. I think the best thing is that the residual volume is the only thing that goes up. So you have a decreased lung capacity, a decreased vital capacity, lots of decreases in some of these PFTs that get tested, and the residual volume just increases, and that's all a sign of restrictive lung disease. It should be said that the vital capacity can decrease almost to like 25% of normal for someone with high tetraplegia, but that can improve with time up to about 60 or 70% of normal. But again, it's that loss in the acute phase that can be super troublesome, and it still can be a hard aspect in the chronic phase as well. So pneumonia, like I've said, it's a big deal. In that acute phase, it may be more to dysphagia. That actually may also become an issue for someone who is aging and maybe losing some of their normal mechanics of swallow. If someone's in and out of an institutional lot, or if they live in an institution, they could have a healthcare-acquired pneumonia, which could be either viral or bacterial. Strep pneumo is the most common bacterial pneumonia, but pseudomonas is seen a lot as well, and those, again, that end up in a facility a lot of the time. So recommendations we make on the chronic phase are things like getting that yearly flu vaccine and considering pneumovax even in someone who's younger than 65, just because of their respiratory risk. Ways that we compensate and manage. This picture is ever so slight, but one of the main things and the way to help with that length tension of the diaphragm is to use that abdominal binder there to kind of help squeeze the abdominal contents in together, help get the diaphragm to an optimal position to help it to expand the lungs as best as possible. In addition to that, some of these folks may need regular hyperinflation techniques, or they really may need them if they were to get a cold or if they were to get some sort of virus. There are ways to help with that weakened cough. So one is that manual cough assist, where basically you're putting your thumbs up under where the diaphragm is and helping to expel the contents out. It's an assistive cough. A lot of people just call it a quad cough. I've had even some patients with paraplegia who were able to kind of like give themselves a hug and help with their cough in that way. For those that lack that upper extremity function, they may not be able to do that. The other device that can help is the mechanical insufflator exsufflator. I kind of call it the vacuum cleaner of the lungs. Another word for it is the coughulator or the cough assist. Again, that's a way to sort of help expand the lungs and then get the secretions out as may be needed. For many of these patients, because the respiratory status is so important in the longterm, I am thinking about PFTs and getting my neuromuscular pulmonary specialists involved to help us in directing management. There are other reasons, though, you might have pulmonary involved. So some folks in the longterm can have respiratory insufficiency that develops. They could have dyspnea. They could have detonated somnolence. If they're saying like, oh, I'm so tired and you sort of rule out that it's medication related, thinking about what's going on in the respiratory system can be helpful. So non-invasive ventilation may be needed. You may be thinking about other chronic management issues, too. One of the main issues we're thinking about if someone is having a lot of daytime somnolence is sleep disordered breathing. The prevalence is pretty high, could be over half. It can start even around two weeks post-injury. So if you have someone with high or relatively high tetraplegia in the acute care stage that just really can't stay awake for you, you may wanna think about whether this might be developing, having a little bit of CO2 retention, having difficulties just with gas exchange in the longterm. And there's other aspects that really impact this as well. Increased time supine, having obesity at baseline, having sleep apnea at baseline. Those can also contribute to the sleep disordered breathing that's seen. And again, the problem being excessive daytime sleepiness, poor participation in rehabilitation, causing some of those arrhythmias that may end up in death. So this is a big deal to make sure we're working on positioning, working on what's going on for our patients. But going back to that case of my gentleman who basically what happened is he had a ton of atelectasis. He probably had the start of pneumonia or at least had bronchitis at the time. He had a very weakened cough because he had C5 complete tetraplegia. And I got in touch with his PCP and tried to get him in both pulmonary as quick as I could. But basically he crumped pretty quickly. He ended up going to an outside facility. He had a new pneumonia. They couldn't get him off the vent. He actually needed a repeat trach and vent. And he did come off again, but I was quite wary making sure that we had him with a cough assist once he left. So both of these, this is kind of the older model of the mechanical insiplator, exsiplator. And this is the newer model, but just really helping pressure dynamics in the lungs there. So a little bit of a winding road for why does this matter for today's pandemic? So a lot of the respiratory mechanics and issues seen in spinal cord injury is actually quite true of those with neuromuscular dysfunction. And so as a lot has come out with COVID, I think it's been pretty interesting. So what I just talked about was spinal cord injury with regard to hyperinflation techniques and helping with secretions. For those that are able-bodied, they may not necessarily need that hyperinflation or they may not need that secretion management. And in the case of ARDS, you know, acute respiratory distress syndrome, which is what's presenting with these COVID patients, they may not need that hyperinflation and actually may be damaging to them. Sometimes if you're using too much hyperinflation, it can cause acute lung injury. And I think that's probably what a lot of these acute pulmonologists are trying to minimize. And so the recommendations for the most part is don't talk about hyperinflation or a special like secretion management for these patients because it could provoke things for other folks around them or worsen the patient's case. However, if you had someone with neuromuscular weakness, they are going to need some of these things. And it's important that, you know, if we can provide any input, just remembering that there could be co-infection, which I know is a little less right now, but there could be co-infection happening with their COVID. And that those with neuromuscular weakness may have a lot harder time, and that's why they're at so much risk. So the other side of it too, is I think that there is an ICU acquired weakness that's probably gonna come out of this. And thinking about those patients with critical illness polyneuropathy or critical illness myopathy, in the post-COVID state, they may still need some of these hyperinflation and other neuromuscular techniques that we talk about. I think there may be some relevance sort of to those that work with neuromuscular disease and pulmonary issues, as they may impact some of the patients recovering from COVID that don't have a spinal cord injury. All that being said, I still think that my patients have a very increased risk of respiratory issues related to COVID. Basically, the second that we sort of went to this being a pandemic, I stopped my in-person clinic. I've been doing a lot of telemedicine. I've been discussing vulnerability and why that's the case. I think the other things that we really consider are all of the supplies that our patients typically need have been scooped up by other people and really worried about PPE. So I think we're running into that issue right now. Personal care assistants, they're coming into the home. Have they been in someone else's home? Is there a risk of bringing exposure? I think it's vital, but it's also a very challenged aspect of what's going on. I think there's been a big question about ventilators in our patients and do patients with disabilities deserve the ventilators, which is asking us to value patients with disabilities in our population, which I think is a huge challenge because there's value to everyone's life. And there are plenty of people with disability who may require respiratory equipment that are very productive members of society. So I think all we can do is really make sure that we're talking to patients about their risks and ways to do what we're all trying to do anyways. There is a lot out there about folks with disabilities and as related to the COVID outbreak, even from the WHO. Some of our major spinal cord related programs have some information out there. So ASCIP has something, also the major spinal cord centers. The Christopher Reeve Foundation basically has a daily blog going on through this. And some of it's just people bored at home, but Craig Hospital has some information out there for folks and also the Shepherd Center. And I think if you looked at many of the major centers, they'd have things going on, which is good. And I think it's been super important to try to make sure our patients know that they're at risk and that we're thinking about them. Lots of musculoskeletal issues that I could talk about as we switch gears pretty immensely here. And while I could go and talk for hours about the risk of overuse injury and spinal cord injury for the shoulder, I'm actually just gonna focus a little bit more on some of the issues with bone health that we see. And I thought this would be a nice one to, again, sort of relay with the case. So I had a gentleman with motor complete paraplegia who came in with swelling, really big knee effusion there on the right. He'd been injured for about two years. He was transferring to his truck. He felt his knee twist and he heard a pop. And he's a pretty big football fan. So he came in wondering if he may have hurt his ACL, even though he wasn't out on the field. As we think about this, thinking about soft tissue issues certainly being a factor, main thing I want us to think about is bone health and spinal cord injury. So the second folks get injured, there's a loss of mechanical stimuli and weight bearing, which leads to demineralization. The timing is pretty rapid. These folks end up being hypercalciuric pretty early on and hypercalcemic in the long term. And then there's a peak of sort of worsened demineralization and then it continues in the long term. For some, it can be just osteopenia. For others, it could be full osteoporosis. And the general pathophys is just related to an imbalance. There's more absorption than there is formation due to altered mechanical, hormonal, neurogenic properties. So the most common area for fractures in spinal cord injury is the distal femur and then also the proximal tibia. It can increase with time. Part of it may be related to changing mechanics of a transfer. Part of it could be worsened bone health with time, could be dietary, like there's a lot of things that can impact this with time. And as we try to think about ways to prevent bone loss and what we can do in the chronic stage, we could think about various things. There is some contention that spasticity is helpful. There's some contention that standing frame can be helpful. Nothing is really definitely proven. There's risks that may come with the medications that are considered. So we can try to think about correcting endocrine abnormalities, or we could just sort of keep doing what we often do. Again, the overall benefit of the balance of any of these is really unknown. Bisphosphonates might be helpful. We all know there are some side effects that can come with it as well though. You would think bearing weight should be helpful. You would think that spasticity may be helpful, but again, it's just not been proven very well, unfortunately. What's tough in fracture management and spinal cord injury is that it's not always like noticed initially, or people may just think like, oh, I have increased spasticity. It may just be a UTI. And so thinking about those symptoms is super important because it may show up in various other ways. I think it's on, oops, no. Sorry. Sorry. So anyways, just thinking about that, it may show up in different ways. It may make you think about a DVT. It may show up because someone has increased AD. They may have a new fever. It's definitely hard to know. And then when you're doing the management, a lot of, some surgeons may say, this person is an ambulating. We probably shouldn't operate. But I don't know if that's always the case. And that's another topic for another time. So the other things that we have to think about is do you splint? Do you operate? Do you give DVT prophylaxis? Are we thinking about their skin? Just various physiatry concepts that we're considering. So again, back to our case. He thought he might have hurt his ACL, but what he really did was fracture that distal femur. It was pretty rough. And this actually was probably 10 years prior to when I met this gentleman, is when his fracture happened. But in the long term, this is what his CT looked like. So we had a ton of increased bone fragments in the actual joint space. I'm actually not quite sure what happened with his patella, but it does not look normal. Here on the left here being normal. And the other thing I really wanted to point out with this CT is just how thin his bones look. So you can see here on the left, really thick bones looking, I mean, shiny, so to speak, but just on the right, just lost a lot of muscle mass. And so those insertion points on the bones just are not as robust. And then the bones just aren't doing what they used to. And so they've thinned with time. One more big complication that we'll review, and I wanted to introduce it with the case. And this is on the neurologic side of things. So gentleman was C4 sensory, C5 motor. So five out of five strength at bilateral C5, complete tetraplegia. And he had called in because he had a really hard time placing his hand on his joystick. And he was not my patient, he was covering for a friend. I went to go see him. And so the only big symptom, there was no respiratory changes, no spasticity changes, no bowel or bladder changes, it was just that this arm wasn't doing what it usually should. So in thinking about this, we certainly consider unilateral RDIC, but also have to think about cystic myelopathy or syrinx. So this can happen at the site of an injury. There's an enlargement of that cystic cavity that happens at the injury. It can either go cephalad or caudad. Onset could be within months. It's usually within the first few years. There have been some chronic cases I've seen of syrinx in the long term. And the etiology is sort of unknown, but basically there's some sort of abnormality in the fluid flow of the cerebrospinal fluid impacting sort of the cyst to grow. And I've seen it go both down or up or both at the same time. The signs and symptoms can be sort of vague, but if you put it all together, it may sort of point you in thinking about a syrinx. So there could be loss of motor function, loss of sensory function. The hard thing about spasticity is there could be an increase in spasticity, or if someone had really increased tone and they totally lost it, it could be that they've totally lose their spasticity. There could be a change in the neurologic pain. Sometimes really vague AD episodes that are otherwise ruled out from the bladder can be related to a syrinx. And you can see the whole list here. So really, and how you're thinking about it just as we do with everyone, thinking about a really careful physical and history, looking at the neurologic level of injury and doing serial exams with time, you may end up needing to do electrodiagnosis. You may often end up needing to do an MRI when thinking about this. And then the treatment either may be monitoring or speaking with your surgeon to see if they might need an operation. So with this gentleman, here was sort of what his INSKEY exam was prior to me ever meeting him. So you can see here, there's a sensory level here at C4 bilaterally. C5 was five out of five strength documented bilaterally, and otherwise had a lot going on sort of impaired sensation, but present in a couple other dermatomes. When I did his exam here, it was a very distinct difference in four out of five strength there on the right as compared to the left. And then there was this very slight loss of sensory function there just on the right. The reason it gets important through here is we really do start to think a lot more about respiratory insufficiency. For someone who's already at risk, he, I think, had already been tricked prior to right after his injury. So it's certainly something that's considered and much more worrisome if we're thinking about loss of function. So I ended up sending him on to neurosurgery. I do think he ended up with a shunt, and I think he reported some improvement in his strength in time. This is actually someone on my service right now. So here on the left, she was a T4 AISA. This is her initial injury, so pre-stabilization, obviously. You can see, though, all this gray material, that's her cord. And this is T2, it just didn't show up very well, but this white is gonna be that flow of CSF around her cord. She had started to have increasing, especially right upper extremity weakness, and I think a little bit of truncal instability. And you can see that all through here is just fluid everywhere. Her syrinx was very diffuse. So her neurologic level of injury actually changed from T4 up to C5. That being said, she still had a lot of great movement through her right upper extremities. So it's not that she became a C5 complete, it's that she now just has a very large zone of partial preservation of motor function. And I think things have improved with time after she has had her shunt. She still has a lot of weakness through that right arm, but again, just sort of shows how diffuse and significant these sort of syrinxes can be in the long term. So I know a lot of that was a whirlwind. There's plenty that we did not discuss today, but I thought some of those were either relevant to the current time or give us a little bit of an overview of what we might see a lot of or see on your boards or just be able to help our other colleagues in thinking about, but there's plenty that can be talked about. Again, it takes up a whole fellowship, which was a lovely time of learning. But keep all of those things that you learned on the acute side and in your initial inpatient rehab rotations moving forward. So really remember your INSKEY exam, keep reviewing bowel water and skin management and keep doing your cognitive evaluations as you look at patients, especially across the age spectrum after spinal cord injury. Lots of thank yous out there. I think some of my trainees and folks that I've worked with are on here, so thank you. I actually, my rehab nurses have really been invaluable to learning about chronic spinal cord injury because they just really know it. And I just am really thankful for everyone I've had the chance to learn with and take care of. There's my email if you need me. I don't use Twitter too much, but I do have it. For those of you who are trying to counsel your patients, there are some hand hygiene basics for folks that are chair users that are out there. And I think I have the website somewhere in this talk, but it is helpful in thinking about, especially for our patients who are using their mouth and their hands a lot more than able-bodied patients. So thank you. Thank you very much. We do have a question or two, if you're okay with that. Absolutely. All right, so one is given that individuals with SCI are at higher risk of osteoporosis, at what point do we consider screening them with like bone scans and that sort of thing? I think that's tough. There's some people who, like there are certain centers where if they want to use an exoskeleton, that center will require a DEXA scan. And so in that instance, you might be doing it. The question is always, what are you going to do with that information? So figuring out, counseling patients, are they going to be standing for the first time in years? Are they going to be at risk of a fracture or an ear embolus or do they just want to know? In that instance, what are we, again, what are we doing with that information? There's nothing like set in stone of like at a year, we start DEXA scans once a year, like a renal ultrasound or whatnot. So I think you have to take it more on a case-by-case instance. Okay, and same thing with sleep apnea, no particularly, maybe a low threshold, but no set bounds? Not necessarily. I mean, again, I think it comes down to like your conversation with someone. So if, like I had a patient that like I met him and he just had this increased work of breathing, I randomly turned into him having bilateral phrenic neuropathies of unknown etiology. And when he had his PFTs done, it just showed all of the ways that he needed a BiPAP. But sometimes it's a lot more subtle with your sleep apnea patients. You know, if you're thinking about like, they've all of a sudden developed pretty significant hypertension that they didn't have before. And if it's not felt to be autonomic dysreflexia, it could be that OSA is their way of saying like, hey, let's start figuring out what's going on with the sleep. So just sort of screening in that way. Okay, and we've had a couple of people jumping in on the questions and fielding grounders, which I appreciate. But one of them was, does the MIE cough later also help with suctioning secretions or is it just insufflation and exsufflation? Somebody said that it helps in the sense that it helps your cough more effective, but it doesn't suction per se. Can you comment on that? Yeah, so it may help to kind of get it up. You may still have to use like a Yank-O or some other suction there. But actually I do think it gets some of the secretions out. I mean, I think it's gonna depend on the person, sort of what works for them, but it should be doing a little bit of helping the secretions at least get from deeper inside the pulmonary tree. All right, thank you so much for joining us. We appreciate it. Let's see, I'm gonna pull this up here. Again, thank you for teaching. Oh, screen just went away. There it is. And thank everybody for joining us today. Again, these lectures are every day at the same time. Feel free to reach out to any of us on Twitter if you have any questions, all the updated schedules, passwords, links, and all that sort of thing are at that website. Thank you again. And we look forward to having everybody back tomorrow.

spinal cord injury

respiratory complications

bone health

pressure injuries

bowel and bladder dysfunction

sleep-disordered breathing

autonomic dysreflexia

COVID-19 pandemic

patient outcomes