suzy kim, m.d. medical director, st. jude centers for rehabilitation & wellness spinal cord...
TRANSCRIPT
Handcycling InjuryParacycling
Suzy Kim, M.D.Medical Director, St. Jude Centers for Rehabilitation & WellnessSpinal Cord Injury & Neurologic RehabilitationRancho Los Amigos National Rehabilitation CenterUSC Keck School of MedicineTeam Physician, USOC Olympic and Paralympic Teams
AAPM&R Adaptive Sports Medicine Symposium, October 1, 2015
Disclosure
Suzy Kim, M.D. is on the Speakers Bureau
for Allergan Neurosciences
Acknowledgements
United States Olympic Committee, Sports Medicine (USOC)US ParalympicsUS Paralympic Paracycling Team
Union Cycliste Internationale (courtesy photos)
History
Chief Complaint: Right lower leg road rash following
handcycle crash on course during training ride at Nationals
History of Present Illness 26 y/o M handcyclist (H3
classification) with T8 motor complete paraplegia (T8 AIS B SCI)
During a sharp turn on the course, right leg came out of foot rest and twisted ankle under front wheel causing isolated rollover crash
Athlete reports a strong sudden right hip and knee flexion spasm pulled right leg out of foot rest
Anatomy of Competition Handcycle
Rear Wheels
Backrest
Headrest
Gear shiftersDraft bar
Fork
Fixed frame
Arm cranks
Footrests & strap
Hand pedals
Competition Handcycling (H1-H3)
Photo courtesy of UCI
History of Present Illness
From baseline, increased frequency of bilateral lower extremity spasms –primarily flexion based x 1 week prior to competition
Few episodes of urinary incontinence between scheduled intermittent catheterizations
Mild malaise, denies fever or chills
History…
Spasticity Baseline: episodic lower extremity
clonus and spasms. Not functionally limiting. Not taking any anti-spasmodic medications
Triggers: position changes. does not occur during wheelchair transfers, not painful. Changes with UTI or constipation
Alleviators: self ROM, WB with standing frame.
History…
Neurogenic bladder Scheduled clean intermittent
catheterization q4-6 hours depending on fluid intake
Receives botox injections q 6 months (last 3 months ago)
Ditropan XL 5mg daily
Past Medical & Surgical HistoryStable T8 AIS B SCISpinal ependymoma causing cord
compression at T10. Dx 2006 s/p tumor resection No surgical fusion or instrumentation
Neurogenic bladder Neurogenic bowelNo history of fractures since SCIMild neuropathic pain at NLI and below
No pain medications
Functional History
Mobility Primary manual wheelchair user Independent community mobility, transfers without
sliding board Activities of daily living
Independent at wheelchair level Independent driving adapted car with hand controls Independent bladder/bowel management
Community Lives with wife in single level wheelchair accessible
home Employed as a financial planner Travels independently-national/international
Physical Exam (on site)
Inspection No gross deformities, superficial road rash of right lower
proximal lateral leg, focal edema right ankle w/o ecchymosis. Generalized atrophy proximal and distal lower extremities
Palpation No bony deformities, knee joint laxity, crepitus, knee
effusions. 2+ edema over right lateral malleolus and dorsal foot
ROM Soft end range with PROM hip extension with 15 degrees
hip flexion tightness bilaterally. Full PROM knee flexion & extension. Ankle dorsiflexion subtalar neutral with PROM with knee extension and +15 with knee flexion
Physical exam (off site)
Neurologic Spastic paraplegia: L2-S1 myotomes 0/5 , T8
sensory level Clonus and spasms easily triggered by any
tactile stimuli or ROM Fair dynamic trunk control
Special Tests** Knee instability: (-) pivot shift, anterior &
posterior drawer, Lachman’s, McMurray’s, patellofemoral tests
Ankle instability: (-) talar tilt, anterior drawer
Differential Diagnoses
Photo courtesy of UCI
Differential Diagnosis
Cause of crash: Course conditions Athlete performance error Faulty competition equipment-handcycle Uncontrolled lower extremity spasms
Change in spasticity: Noxious stimuli: UTI, occult fracture, pressure
ulcers, constipation Fracture of femur, tibia, fibula Knee sprain Ankle sprain
Diagnostics: pelvis/hip x-ray
Diagnostics: Femur & tib/fib x-ray
Diagnostics: foot & ankle x-ray
Definitive Diagnoses
Photo courtesy of UCI
Diagnoses
1. Superficial soft tissue injuries – right lower lateral leg road rash
2. Mild right ankle inversion sprain3. New/acute UTI 4. Spasticity exacerbation: Increased
lower extremity spasms due to acute UTI
Initial Treatment
Local wound careUrinalysis and culturePain control
Phenazopyridine (pyridium) 200 mg tid RICE: NSAIDs, edema compression
Empirical cephalexin 500 mg bid for UTI
Handcycle adjustments Thigh and footstraps
Spasticity treatment options
PROM Focal NMES
(neuromuscular electrical stimulation) quadriceps and hamstrings to “fatigue” spastic muscles
Discussion
Injury Prevention
ILLNESS INJURYTreat underlying illness!Optimize daily managementUnique considerations for para-
athletes Impaired sensation Atypical pain responses (ie. spasticity,
AD) High risk low velocity fractures of
paralyzed limbs Pre-existing abnormalities**high index of suspicion
Photo courtesy of US Paralympics
Performance Implications
Symptom checklist UTI Change in spasticity/AD Skin check
Hydration w/ UTI & neurogenic bladder
Treatment limitations in competitionAthlete, coach, staff education to
seek early medical attention
Follow Up Treatment (when home) Continue local wound care Follow up UTI treatment Spasticity management Bone health:
Baseline DEXA scan/bone density
Vitamin D 25-hydroxy level
Consider FES leg ergometry Continue weight-bearing in
standing frame Calcium/Vit D supplements
✔
Photo courtesy of RTI
Photo courtesy of US Paralympics
Thank you.
Photo courtesy of US Paralympics