Transcription:
Regaining Independence for Patients with Spinal Cord Injury

Caitlin Whyte (Host): Life after a spinal cord injury is complex. So, today we are discussing regaining independence for patients with spinal cord injuries. We'll talk treatments, challenges, and rehabilitation options with Dr. Sandeep Singh, our Chief Medical Officer, Senior Vice President of Medical Affairs and the Program Director of Spinal Cord Injury at Good Shepherd.

This is Transforming Lives and Inspiring Hope, a Good Shepherd Rehabilitation Network podcast. I'm your host, Caitlin Whyte. Well, Doctor starting us off here, what made you choose to go into physiatry as a specialty?

Sandeep Singh, MD (Guest): That's a great question. It was a journey actually for me. Physical medicine rehabilitation was sort of one of those alienated specialties early on in medical school where you kind of don't know about what the field offers, just kind of heard of it through, you know, anecdotal exposures. What really got, or drew me to the attention of the field was I really got firsthand exposure working hand in hand with physiatrists in our anatomy lab and getting a scope of expertise and exposure to the scope of involvement with disabled individuals, specifically those that have had significant impairments or life-changing events and helping those folks kind of build a new function baseline and a new status for their quality of life to pursue going forward. So, it was kind of a eye-opening experience for me, which then kind of motivated me to then pursue the career for Physical Medicine.

Host: Wonderful. So as the Director of the Spinal Cord Injury Program, is there a common type of spinal cord injury that the Good Shepherd team typically see?

Dr. Singh: Yeah, we get a variety of spinal cord injury patients through our community system networks that are here in the Lehigh valley, but predominantly our main focus is on the traumatic spinal cord injury population. Predominantly those that are high-level spinal cord injuries that typically require more extensive rehabilitation. Specifically those that are vent dependent or have significant impairments from the neck or upper waist down. Those patients typically have more intense therapy needs, including, you know, the both physical and occupational therapy component, but also a speech and psychological component. But then also have extensive medical needs that kind of warn around stability of patients adjusting and adapting to their new homeostasis or baseline of their physiological set point with regards to their post spinal cord injury of care.

And then we are addressing these patients with their orthopedic and neurosurgical implications by, you know, basically keeping in close collaboration with those specialists to make sure that we're delivering the care at that high acuity and high complexity for them. We, we really cater well to the ventilator dependent patients that exist out there in the community that suffer from spinal cord injury, specifically those that are on the cusp of potentially weaning off of ventilators.

So, those patients are typically ones we do great work with. We've had many of those folks successfully wean. We've had some of those folks even trial on what we call diaphragmatic pacing, where we have worked with collaborating systems to implant a pacemaker that actually paces the diaphragm or the lung muscles and allows patients to be independent of ventilators, and really allows them to gain independence.

In our focus with spinal cord injury patients, we also do quite a bit of work around power mobility, resource planning for these patients, community reintegration. We have a comprehensive, both inpatient as well as outpatient program, and really look to support these patients lifelong with regards to, you know, resources that they'll need for them to sustain themselves in their home setting, as well as you know, support and infrastructure that they would need to continue to thrive in the community and access the community at a way that they can, given their impairments.

Host: Now, can you explain the differences between inpatient and outpatient spinal cord injury rehabilitation?

Dr. Singh: Absolutely. Yeah. So our inpatient population typically focuses around patients with acute spinal cord injury. When, I mean, acute, these are injuries that typically occur within a timeline of several days to several weeks post a traumatic event. Some of these patients experienced injuries secondary to motor vehicle accidents, falls, diving accidents. Or they may experience things that are non traumatic in nature, that are more progressive in nature. Like someone who has a metastatic oncological disease with compression of the spinal cord and needs surgical debulking and resection and reduction and decompression. Those individuals typically stay with us for a period of three to four weeks on average, sometimes longer, depending on need, but are having extensive adjustment in their acute spinal cord injury with their body kind of accommodating to their new set point of blood pressure balance, functional balance, pain level tolerance, anticipating all the complications that can occur in this acute setting, which include sequellae like blood clots and extra bone formation around joints, increased tone or increased limb movement through a term called spasticity as well as things that are related to just the internal infrastructure guts of the spinal cord, which include the autonomic nervous system and auto dysregulation. So, in that first few months is kind of a critical timeline to really project how patients do in their long-term recovery process. So, coming to an inpatient rehabilitation with specialization that focuses on spinal cord injury has a significant advantage in that, you know, you're really putting together the skills, the resources, the talent around, the expertise to ensure that patient progresses from that acute stable traumatic event to the point where they can reintegrate back into the community.

So that snapshot typically again, encompasses that first several weeks to months of their life. In the outpatient spinal cord program setting, we're typically taking them from that point forward. And following those patients for life. I've seen patients that have had spinal cord injuries less than several weeks to multiple decades.

In fact, I just took care of a patient that I was caring for out of Puerto Rico that was a patient with a spinal cord injury for almost 75 years, had experienced his injury back when he was 18. So he has lived with his injury over almost 93, almost a century as a spinal cord injury patient. And it's pretty fascinating in how he's navigated his life with a spinal cord injury, but we are always anticipating, you know, all the sequellae, all of the limitations that patients can endure because of their spinal cord injury.

And keep in mind, every spinal cord patient is different. Some have varying degrees of what we call weakness or paraplegia or tetraplegia. Others have a fair degree of pain. Others have a fair degree or variety of spasticity. So every patient's going to have their unique presentation to us. And it's upon us to make sure that we are incorporating their sort of expectation, their quality of life, their mitigation strategies to prevent them from rehospitalizations and really ensuring that they have as much of a good quality of life as possible. So, a lot of the things that we're doing on the front end, include you know, we're proactive about monitoring.

Every spinal cord injury patient gets an annual spinal cord injury assessment exam on a yearly basis. We usually try to link that up to their anniversary date of their accident so that we can kind of you know, monitor them on a yearly basis. We are routinely doing laboratory diagnostics on patients to assess for metabolic syndromes, bone health syndromes. And also endocrine syndromes that can occur after spinal cord injury. We also look at diagnostic imaging routinely. We are sometimes evaluating patients for their renal or kidney health, and we're using techniques like urodynamic studies and or kidney ultrasounds to make sure we're having adequate information provided to us to interpret and make educated decisions on.

And then we also get bone health imaging every couple of years to assure that their risk for what we call osteoporosis or bone thinning isn't occurring in that population. In addition to just imaging and laboratory studies, we're also plugging them in, in the outpatient setting into community resource integration.

So we've got a dedicated outpatient care manager, an outpatient nutritionist, we've got a wellness program that we integrate well with and we try to plug these patients into sort of a lifestyle approach of care so that they live successfully with their spinal cord injury for the remainder of their time.

Host: What would you say your treatment approach is for a spinal cord injury?

Dr. Singh: So our first approach is, is really, we try to understand the true neurologic level of injury when they're acutely injured. So we're establishing a baseline when they come from the acute care hospitals. Most, most times we're not getting an accurate reflection of what their actual spinal cord injury is. So, we try to establish that baseline pretty early on and communicate that to the team. Based on the assessment scale, so we use what we call an ISNCSCI exam, which is basically a neurologic assessment of the spinal cord injury to gauge a prognosis or projection of what the patient would likely look like in several weeks to several months. We're putting that together and then projecting that out with the team.

And then what we do is we build a care plan based on the expectation of prognosis and really do a couple of things right off the bat. We get the families engaged as well as the patients on their care plan. We educate them extensively on the impact of the spinal cord injury, the expectation of recovery and what their compensatory or recovery plan will look like over the next several weeks, as well as the next several months.

In addition to that, we start planning their care plan for them at home. Like we talk about what resources will they need to access their home now, if they're going to be wheelchair level? What is their, you know, basic bathroom and basic, you know, hygiene needs is going to look like in that setting. If these patients have those things started in the, on the front end, where we're already ahead of the gate, in terms of, you know, making sure we're planning for a safe discharge to home.

We then focus a lot of our care, medically, at least on their adjustment and their homeostasis, as they're accommodating to their spinal cord injury. After a spinal cord injury, the blood pressure system, the body's response to temperature regulation, the body's response to bowel and bladder function, all are severely effected by, by the actual injury itself. So, we're basically trying to implement a structured approach to, for the patient to understand their limitations with their blood pressure, the limitations with their temperature dysregulation, as well as an understanding of how to implement an appropriate and timed bowel and bladder program, which are basic necessities that we take for granted as able-bodied individuals. But it becomes such a chore for patients with spinal cord injury when they are heavily dependent on caregivers and support structures to help them defecate or urinate. And that's a big deal for patients to gain that control back. So we really try to create a process around them.

So there's more of a structure so they can participate in therapies. They can have some social well-being and not be embarrassed or worry about their hygiene management. And then we're also looking at pain management as the last component to making sure they're able to engage and, again, accommodate from the degree of central pain that has occurred from the initial spinal cord injury, as it pertains to allowing them to partake in therapies, allow them to engage socially allow them to do recreational therapies so that they can get a sense of wellbeing and participate.

Host: Working with some patients for decades, like you said, what are some of the most common challenges you see spinal cord injury patients facing, and how do you try to address those challenges?

Dr. Singh: The biggest issues we encounter right off the gate is the support structure around these patients and the resources that are limited for them. You know, these patients typically come in a lower socioeconomic class to begin with, tend to be a higher risk population or a risk-taker population. So hence the motorcycle, motor vehicle accident, unfortunate etiology to their condition. And so as a result, when they get back into the community. There's not much to anchor to or rely on support for.

So these folks are typically struggled with how do they get the care at home? How do they get from the home to their therapy appointments or to their doctor visits? Or how do they get access to the community? So that's, that's a large challenge that exists and it's been a prevailing challenge for the past several decades for many. I've been in multiple cities during my tenure as a spinal cord injury physician, and have not seen that change or that climate really cultivate or progress further from where it is. I think the second biggest issue that we experience too is, you know, there's, there's a lot of variability in spinal cord injury patients.

And so, there's I guess a perception that exists out there that you know, if you, you kinda do X, Y, and Z in your rehabilitation plan, or you go and do that, you're going to get to this level of equation of function. And that's not always the case. I think that's part of the challenge we have is, you know, we've got to provide a really thorough job of educating our patients, our populations, and our families about the variability of presentation and the expectation around.

You know, because for a patient not to walk again or not to use their hands and, and ask the first question, when can I walk? And to have that honest or truthful conversation with patients about that reality, that's never an easy discussion. That's one of the hardest discussions I had to do when I was a medical student. It's been one of the hardest discussions I have to do after being in practice for 18 years. It's just a, it's a very hard reality to digest for a patient that to say, we will not walk again, or you will not be able to feed again in the context of your injury. And so some of that stems back to obviously us painting the expectation to patients, providing that education and understanding, and that despite not being able to walk or do these self administered tasks, there is a quality of life and a function of life that can still be achieved and still be very impactful and influential to the community.

In fact, I actually worked with somebody who had suffered a high level of cervical spinal cord injury. He actually was a C4 level, which means he had very limited ability from the elbows down to use muscles to do and perform any type of work. And he actually became a world renowned gamer for adaptive, disabled individuals at Konami and later developed a whole influence on patients with that regard and also was a very effectuate mouth painter down in Baltimore. And, you know, he was a patient that I still talk to as an inspiration for many, because he'd done so much, given so little. And so I think that's part of the picture we have to learn how to paint is, you know, despite the glass looking half empty, there's also half of it that looks full, that we have to focus on and be optimistic towards and try to recreate a path forward that actually allows for people to embrace. And hopefully then deliver on.

Host: Can you speak to some of the technology that's used in rehabilitation for these types of injuries? Is it mostly traditional rehabilitation practices and equipment, or has newer technology impacted our treatment options?

Dr. Singh: Well, it's a combination of both. I mean, conventional therapies continue to be the main stable of how we habituate patients from their base of, of their acute spinal cord injury to the level of to participate. So really the fundamentals and the conventional methodologies of getting patients to tolerate just being out of bed or sitting upright. And then from that to learn how to do transfer training, all has not changed too much in the, in the last several decades.

Where, I think that the advantage of integrating technology and also incorporating innovation into the realm of spinal cord injury medicine is really talking through where we can advance pre-gait training, where we can get people upright, if they can tolerate and place them into an Ekso bionic robot where they can start to do machine-driven ambulation or machine assisted ambulation, allowing them to have a sense of both psychosocial wellbeing and also prevent osteoporosis.

And really focus on a principle called neuro-plasticity through central pattern generation, where we're looking to create feedback mechanisms within the spinal cord to allow for potential relearning and remapping that will allow them to potentially carry over and walk at a later point in time. This type of technology has been not only beneficial for all of the things I just outlined, but also what we've seen as a secondary outcome is that these patients are now having restorative bowel and bladder function, which again, equates to a huge success for patients and their wellbeing and their mental status adjustment to their spinal cord injury.

So we're seeing that piece. Other components of technology though may not be groundbreaking are certainly adopted and applied include a lot of functional stimulation therapies that we apply to patients both in their upper and lower extremities to help recover. We use this to preserve muscle mass, improve circulation, prevent osteoporosis, and also reduce what we call spasticity, which can be an inherent obstacle at times to patient's functional transfer or functional outcome. So we try to incorporate certain of these technologies into their day-to-day routine as part of our treatment plans in the inpatient, as well as in the outpatient setting. Once we translate these patients into the outpatient, though, the scope of technology grows even further with not only Ekso Bionics. But we start to incorporate like a zero G treadmill or a zero G lift that allows patients to offload their weight capacities and try to create a normalized pattern of walking. We can sometimes transition these patients into the pool setting and use like our underwater treadmills to help facilitate gait restoration.

And then we also incorporate other technologies like Bioness and other focal stimulation applications that can help really work on fine tuning their motor capacity and return as it pertains to the function that, you know, that they're experiencing with deficits.

Host: Well Doctor, if you had any advice for someone dealing with chronic or acute pain, but they were hesitant to try rehabilitation or weren't sure where to start, what would you tell them?

Dr. Singh: I'll start with the acute pain side because there's two different buckets in my perspective. And I think when you, when you look at patients that are in the acute setting, I think it's very important to understand the pain generator that's contributing to it. And nine times out of 10, if you can address acute pain quickly, especially less than several weeks to several months, you have a very good chance of not allowing it to develop into a chronic stage and causing long-term chronic disability. So reaching out to an appropriate provider, specifically a physiatrist who really understands not only function, pain and neurologic innervation, but really understands the whole encompassing wellbeing of a, of a individual can take a look at that pain generator and determine where the etiology is, how to go about correcting for it or, or mitigating it, and how to then also a path forward with the right treatment plan and collaborating with our colleagues, respectfully, the orthopedic surgeons, neurosurgeons, neurologists, and rheumatologists that exist in the community to work towards helping to mitigate and restore their quality of life.

In the other bucket of patients that are in the chronic setting. I certainly feel there's a strong role here for physiatry as well. These patients are probably the most challenging and consumptus with regards to resource and spend in the pain realm of benefit dollars being used by our, you know, our insurer payers and our Medicare beneficiaries.

So we definitely see that the chronic pain utilization is a challenge amongst how providers just are lost with what to offer these patients. Physiatrists come into play by really providing a scope of, again, stepping back and looking at the whole picture and understanding the nature, the psychogenic piece to it, the physiological piece to it, and addressing, you know, a multidimensional approach to the care plan.

And again, it doesn't go without coordinating. It doesn't go without saying that we rely on others to help work together on the treatment plan, but we tend to be the coordinators and really utilize not only imaging and medication optimization, but we're also considering other options that may be alternative in nature, like acupuncture or medical cannabis, or modalities that may be alternative in the physical therapy realm that help augment their experience with their chronic pain.

When we get patients with this type of population, we tend to think we got to get rid of their pain and that's literally impossible. What we try to do is really focus them away from their pain subjectivity and really to their quality of life and function objectivity so that they are gonna understand that they are doing well and they can do well.

To really take away the optics away from just the day-to-day perseverance of having that significant pain challenge. And a lot of times we have great success stories that come out of that. And again, it's without saying that we're not utilizing those high-end, you know, measures like surgery, but we're really taking advantage of some of the low hanging fruit that is available for resource like medications or just conventional therapies or even psychotherapy and psychology support that helps perpetuate these patients further into their recovery.

Host: Wonderful. Well Doctor, thank you so much for your time and for all your work here at Good Shepherd. To learn more, call 1-888-44REHAB or visit goodshepherdrehab.org. This is Transforming Lives and Inspiring Hope, a Good Shepherd Rehabilitation Network podcast. I'm your host Caitlin Whyte. Stay well.