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The Physiatric Role in Spinal The Physiatric Role in Spinal Cord Tumor Rehabilitation and Cord Tumor Rehabilitation and
Pain ManagementPain Management
Christine M. Villoch, MD
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Physiatrist Oh, a psychiatrist?
Oh, a podiatrist?
Oh, superman’s doctor!
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Physiatric Approach Holistic
Chronic Illnesses (traumatic brain injury, strokes, spinal cord injuries, etc.)
FunctionPhysical
Emotional
Pain Management
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Spinal Cord Tumors
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Frequency Incidence: 1.1 case per 100,000 persons
15-20% of all CNS tumors occur in the spine
Intramedullary lesions comprise approx. 2-4% of all CNS neoplasms
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Anatomy of the Spinal Cord
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Spinal cord tumor types Extradural
Intradural intramedullary
Intradural extramedullary
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Myelopathy Any neurological deficit
related to the spinal cord itself; frequently due to compression of the spinal cord by osteophyte or extruded disc material and infrequently by spinal cord tumors
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Common symptoms Pain, occurring at night when laying flat
Local or radiating pain
Progressive weakness & numbness in arm or legs
Impaired bowel or bladder function
Impotence
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Key Findings of Pressure on Cord Brisk muscle stretch reflexes, especially if greater in the legs
Tight leg muscles, worse as you test rapid passive ROM
Clonus (bouncing of the ankle involuntary after stimulus) Babinski (up-going or fanning toes after stimulus)
Hoffman’s (involuntary finger/thumb twitch after stimulus)
Poor balance (hard to walk a tandem gait, positive Rhomberg)
Electric sensation down neck or into both arms on neck extension or flexion
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Surgical Options Laminectomy
Resect Tumor
+/- Fusion
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Side Effects of Resection Numbness/Tingling
Weakness
Bladder and bowel dysfunction
Sexual dysfunction
Spine Instability
Chronic Pain
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Pain “An unpleasant sensation, occurring in varying
degrees of severity as a consequence of injury, disease, or emotional disorder.” - Webster’s Dictionary
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” – Int’l Assoc for the Study of Pain
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What does that Mean?
Pain is Biopsychosocial
Biologic Factors - Actual Physical Diagnosis
Social Factors
Psychologic Factors
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Types of Pain Muscular
Overuse
Weakness
Spasticity
Neuropathic (central or peripheral) Pain caused by nerve injury or disease, or involvement of nerves
in other diseases processes such as tumor or inflammation: may occur in periphery or CNS
Central Pain Pain originating in the CNS (spinothalamocortical pathway)
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Characterization of Pain Muscular
Dull, achy, sore
Cramp-like
NeuropathicSharp, electric, pins and needles, burning
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Central Sensitization Amplification of excitability of neurons within the
CNS Release of signal molecules
Lowers activation threshold and opening of ion channels, increasing excitability of neurons.
Therefore, normally minimal inputs begin to activate the neurons causing allodynia or hyperalgesia
Hypersensitivity - Acute Phase
Late Phase – Transcriptional changes within the neurons
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Central Sensitization
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Neuropathic Pain Allodynia
Pain from nonpainful stimuli
HyperalgesiaExcessive pain from normally painful stimuli
Complex Regional Pain Syndrome
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Myofascial Pain Syndromes Spot tenderness
Taut band
Pain Recognition by the patient
CausesOveruse
Poor body mechanics
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Types of Pain Mechanical/Structural
Post-surgical
LaminectomyInstabilityLack of Muscle Attachments
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Where does the role of physiatry fit in?
Coordinating Care (PT, OT, Social Work, Psych)
Patient Education
Pain Management
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Fundamental Goals of Rehab Restore structural integrity
Restore function
Quality of Life
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Physiatric Treatment of Pain PT/OT
Medications
Therapeutic InjectionsTrigger Point Injections
Botox/Myobloc
Joint Injections
Spinal Injections
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Treatment Options Psychology
Relaxation techniques
Biofeedback
Alternative Medicine Acupuncture
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Physical Therapy Posture
Desensitization
TENS unit
Range of Motion
Myofascial release
Strengthening
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Medications Non-Steroidal
Aleve, Ibuprofen, Diclofenac, Celebrex, etc
Neuropathic Meds Lyrica, Cymbalta, Neurontin, Tricyclics
Muscle Relaxants Valium, Baclofen, Flexeril, Skelaxin, Soma, Valium
Opioid-like Ultram
Opioids
Lidoderm patches, Capsaicin
Sleep Aids
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NSAIDS Decrease Inflammation
Analgesic Effects
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Anti-Depressants Elavil, Nortripytline,
Cymbalta
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Anti-Convulsants Neurontin
Lyrica
Trileptal
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Opioid Medications Tolerance - same dose, less effective
Addiction - compulsive use of drug resulting in dysfunction
Pseudo-Addiction - Drug seeking behavior due to under-treatment
Drug dependence - withdrawal symptoms
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Therapeutic Injections Trigger point injections
Botox/Myobloc injectionsLoosens muscles
Spinal joint (facet) injections
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Psychology Subjective Component
Supportive Counseling
Cognitive/Behavioral TechniquesBiofeedback
Relaxation Techniques
Improving Sleep Hygiene
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Summary Physiatry
Holistic Approach
Rehab Needs
Pain Management
Spinal PainMultifactorial
Many different treament options
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Useful Resources www.spineuniverse.com
www.aapmr.org