Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host) : Welcome to UAB MedCast. I'm Melanie Cole. And today, our discussion focuses on spinal cord injury rehabilitation. Joining me is Dr. Radhika Sharma. She's an Assistant Professor in the Department of Physical Medicine and Rehabilitation at UAB Medicine. Dr. Sharma, thank you so much for joining us today. Let's start by the prevalence. How many spinal cord injuries occur annually? Tell us a little bit about how and why and how many of these occur yearly.

Dr. Radhika Sharma: Sure. Thank you so much for having me. As far as spinal cord injuries, it's estimated that there's around 54 cases of traumatic spinal cord injury per every 1 million population within the United States. So, if you do the math, this translates to about 18,000 new spinal cord injury cases every year. And when you look at kind of individuals living with spinal cord injury, that's looking like somewhere between 252,000 to 273,000 per our last data collection of individuals currently living with a traumatic spinal cord injury in the U.S. There are non-traumatic spinal cord injuries, but the data for that is a little bit limited, because it's less reported. And so, that usually makes up, though, around 30-40% of all spinal cord injuries, so still a significant number coming from there.

Melanie Cole, MS: So then, I guess the question is how does this happen? And we're focusing more on the traumatic spinal cord injuries, and what are the most common causes that you see in your practice?

Dr. Radhika Sharma: Yeah, they definitely can happen for many reasons. Like you mentioned, there's two types of spinal cord injuries. So, there's traumatic. And then, there is also non-traumatic. The most common cause of traumatic spinal cord injuries would be from motor vehicle crashes. That's actually accounting for more than 37% of all spinal cord injuries, but it can also be caused by falls, acts of violence like gunshot wounds or knife stabs, sports-related injuries, diving, skiing. So, there are other causes of traumatic.

Extending into the non-traumatic, that most commonly we see actually occurring because of spinal stenosis, of narrowing of the bones around the spinal canal impinging on that cord. But it can extend to cancer infections like an abscess in the area, vascular ischemic strokes in the spinal cord, multiple sclerosis can cause it. There's a lot of other causes that can cause the non-traumatic side.

Melanie Cole, MS: Well, it's interesting to me you mentioned diving, because there are countries in the world that have banned it, because of spinal cord injury, just specifically because of that. And I think like their rate went down to almost nothing. And so, that's so interesting to me when you say that because there are so many sports that our youth do. So, that brings me to this question. Is this youth generally when we think of even sports like gymnastics or contact sports. Is this something we're seeing more in our younger and men generally?

Dr. Radhika Sharma: Yeah, definitely. Generally, men, in terms of spinal cord injury, the age can take on a bimodal distribution. So, you're definitely on the mark where we talk about maybe with sports-related or other sorts of injuries that it's a younger population. But when we extend into kind of maybe the falls or some of those non-traumatic injuries that can happen in the elderly as well. And so, we actually see a spike kind of in the younger populations and then an increase as individuals get older. The average age then kind of comes somewhere in the middle at around, you know, your 40s and 50s. And so, it evens out when you look at the average, but that's because we see those two spikes.

Melanie Cole, MS: And because of things like car accidents as well. Now, when there is spinal cord injury, there's complications that can occur. There's neurogenic bowel and bladder, spasticity, there's all kinds of things that go along. What do you see typically?

Dr. Radhika Sharma: So when you look at the disruption of signals, because that's what's happening when you have a spinal cord injury, the signals are disrupted from the brain and when they go to the body. The most visible symptom that we see is paralysis, right? Weakness of the muscles, causing difficulty in ambulation.

But there is, like you mentioned, the often less visible sequela of spinal cord injury. So to start off with, you were mentioning neurogenic bowel and bladder. So when you're talking about that interruption between the brain, there are these nerves that then also control the bowel and bladder. And so, that is what leads to us being continent with urine and continent with our bowels. And so, neurogenic bladder can either be like a difficulty of storing the urine or a difficulty of emptying, and that significantly can affect an individual's quality of life.

Most commonly, we work on managing neurogenic bladder with intermittent catheterization, which is short-term insertion of a catheter to drain the bladder four to six times a day. And the goal is to keep those catheterization volumes, somewhere between 300 and 500 cc's, and that is done usually lifelong in these individuals to help manage the difficulty storing or emptying that they may have. Other management options can be an indwelling Foley catheter or a suprapubic catheter, and decisions for those are usually made in conjunction with your spinal cord injury physician and maybe a urologist as well.

Neurogenic bowel similarly can present either as constipation or incontinence of stool. And we use a bowel program, which we define as kind of a scheduled, individualized plan that your spinal cord provider actually designs to retrain an individual's bowels to gain control of bowel function. And so, we use diet, medication, timing within the day, and either digital stimulation or digital removal of stool to help promote regular and complete bowel movements. To move on to other complications like you were mentioning, neuropathic pain, spasticity, and so muscles or nerves below that level that has been injured can also cause spasticity or neuropathic pain.

Spasticity usually manifests as twitching, jerking, or even a constant stiffness of the muscle. It can be bothersome, it can be painful, sometimes it's also beneficial. So, decisions to treat or not treat are an ongoing conversation of the spasticity. Neuropathic pain, on the other hand, is usually quite painful, and it is often described as this burning, pins and needles, icy hot sort of sensation that happens below that level of injury. So, we usually can use medications and even non-pharmacological treatments such as therapy to help with the pain and the spasticity.

We use pain and spasticity to also track symptoms in areas they may not otherwise feel pain. And so, we're able to use that to see if there might be a symptom of underlying problems that we may not be aware of. And so, being aware of what a baseline of their pain and spasticity is and seeing, "Oh, it's changed, it's new. Maybe there's something else going on."

And so, outside of medications, even addressing an underlying cause can help change the pain and the spasticity. But we do use medications very commonly, gabapentin, pregabalin to help manage neuropathic pain. We use baclofen to help manage spasticity. And there's even procedures like botulinum toxin injections or the placement of an intrathecal medication pump that can be used to manage these symptoms as well.

In terms of additional complications, an important one that I want to bring attention to is called autonomic dysreflexia. This one's actually a life-threatening medical emergency that can occur in individuals with spinal cord injury. It often develops in individuals with a neurologic level that's above that T6, or 6th thoracic vertebral level. And we define it as acute uncontrolled hypertension. And the reason this occurs is because of an imbalance of sympathetic discharge that occurs due to pain, a noxious stimuli, discomfort below the level of injury. And when you define this acute hypertension, we define it as 20 millimeters of mercury above their normal baseline of blood pressure.

And I think this is important to note, because individuals with spinal cord injury actually often have a baseline blood pressure that is often low. So, they usually sit in the 90 to 100s of systolic, maybe 60s of diastolic. And so when you're talking about 20 millimeters of mercury above that, they may be sitting in what might have been perceived as a normal range, 110s, 120s, but they might actually be experiencing this autonomic dysreflexia symptom.

And so, knowing a patient's baseline, asking them what their baseline is, is important to know because then you compare your measurements to that measurement. If the trigger of their autonomic dysreflexia is not identified and resolved, the blood pressure can continue to rise and lead to hypertensive emergencies, stroke, hemorrhage, and all of the side effects that can be caused from that.

Quite often, bowel, bladder, skin issues, sometimes as simple as a wrinkle in their bed sheet, their clothing is too tight, an ingrown toenail, these things can all be seen as a discomfort below the level of injury that can cause this trigger. So, identifying that cause, reversing it quite often helps, take care of this autonomic dysreflexia when it occurs.

And due to having this lower baseline of blood pressure that we talked about, individuals with spinal cord injuries are often at risk for orthostatic hypotension as well. And so, this is more severe when we see it in the acute phase. And this is one of the things we work on when patients are in rehab.

But individuals can be symptomatic with lightheadedness, dizziness, from this hypotension, from as simple as lying down to sitting up in their chair. And so, we manage this both non-pharmacologically by wrapping the legs, adding an abdominal binder to help support the pressure. But sometimes, we also use medications like midodrine to help with their orthostatic hypotension as well.

Melanie Cole, MS: That was such a comprehensive, informative answer, Dr. Sharma. So, speak about the goal of inpatient rehab for patients with newer spinal cord injuries and the UAB Medicine SCI model of care. I'd like you to speak about the multidisciplinary approach, who's in charge of guiding patients care. Speak about the program there and what you do.

Dr. Radhika Sharma: Yeah. So, the goal of inpatient rehab, I believe, is to maximize the functional independence of individuals with a new spinal cord injury. And so, you basically are taking this time in rehab to help transition them from the acute care hospital to ideally going back to their home and their community.

And in doing so, you help them learn or relearn their activities of daily living. And like you mentioned, a multidisciplinary approach is used to accomplish this. So, it is led by a physician, so someone like myself, a rehab spinal cord injury-trained physician, and also includes rehab nurses, therapists, physical therapy, occupational therapy, speech therapy, most commonly. We also have additional therapies like recreational therapy and music therapy to kind of help the process along as well. We engage rehab psychology with all of our patients too, as this is a big change and a big adjustment that they go through. So, it's been very helpful to have them on board. We work with case management that really helps coordinate that transition from hospital to home. And we work with pharmacy very closely for all the medication management we do as well.

And so, we educate and address the numerous issues that I've talked about in this podcast today from a medical perspective. But also, working on strength, range of motion and mobility, which can include wheelchair skills, or the use of new adaptive equipment.

And the ultimate goal, as I mentioned, is to have individuals return to their homes, return to their communities as independently as they possibly can, equipped with the knowledge and skills that we've taught them in rehab. It's definitely a long process of recovery and patient rehab is only a small part of the whole spectrum.

And so, there's a continuum of care that will continue even on the outpatient side. And so, we'll follow patients in clinic with ongoing therapies in the home, ongoing therapies in an outpatient clinic environment, and we build lifelong relationships with our patients that come through Spain Rehab.

Melanie Cole, MS: Dr. Sharma, such important work that you do. As we get ready to wrap up, I'd like you to summarize for us importance of this continuum of care for spinal cord injury and what you would like other providers to know about some of the cool equipment for neuro rehab, any research, because I've heard that recovery after spinal cord injury is one of the hot topics in neuro rehab research, and because of the younger age you and I were discussing earlier and severe impairment in many patients. So if there's any trials, research you're excited about, kind of just give us a whole wrap up of all the exciting things happening in your field.

Dr. Radhika Sharma: There is a lot of exciting research that's happening across the field of rehab, both here at Spain and at other institutions across the country. We have research individuals that come and speak with patients about ongoing trials during their time in rehab. They also come by in clinic and are able to recruit patients that are interested in candidates for trials from there. And it's definitely a really exciting time in the spinal cord injury world for medication therapies that are being tried, robotics and other equipments that we are currently working on from the research perspective of it.

And research is definitely a part of this entire continuum of care that we've touched on here today. Seeing where the next innovations, the next steps of the fields are to be able to continue to grow and be able to continue to care for the patients. And so, it's a really rewarding time to be a part of this field and to be able to help all of these patients.

Melanie Cole, MS: Thank you so much, Dr. Sharma, for sharing your incredible expertise and giving us a really great overview of spinal cord injury and the importance of rehabilitation for these patients. Thank you again for joining us. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.