Aging with a Spinal Cord Injury Michael A. Bush-Arnold, MD Kyle Weishaupt, PT, DPT, NCS

1. Aging with a Spinal Cord Injury Michael A. Bush-Arnold, MD Kyle Weishaupt, PT, DPT, NCS Rehabilitation Institute of Michigan

2. “This is my 18th year in a chair, and I’m starting to freak out about what my next 20 years will be like”

3. Spinal Cord Injury • Spinal accord injury- damage to any part of the spinal cord or nerves at the end of the spinal canal (cauda equina) and often causes permanent changes in strength, sensation and other body functions below the site of the injury

4. SCI Demographics • Incidence- 17,000 cases or 54 cases per million annually in the US • Prevalence- over 430,000 individuals or 1298 cases per million in the US • 80% of new SCI are men • In 1979, the average age of injury was 29 • Currently, the average age of injury is 42

5. SCI demographics • Top four causes of SCI • MVA- responsible for 40% in US • Falls- responsible for 30% in US • Violence • Sports

6. SCI Demographics • 45% of SCI individuals are incomplete tetraplegics • 21.3% of SCI individuals are incomplete paraplegics • 20% of SCI individuals are complete paraplegics • 13.3% of SCI individuals are complete tetraplegics

7. SCI Life Expectancy

8. Phases of Life • 1st phase of life-progressive increasing of functioning (from infancy to adolescence) • 2nd phase of life- plateau and maintenance during adult life • 3rd phase of life- a physiological reduction of functioning in aging.

9. Consequences of Aging and Disability • “Disability-related secondary conditions”- people with disability can have an increased likelihood of secondary conditions directly or indirectly • Usually occur about 20-25 years sooner • Usually associated with accelerated ageing

10. Consequences of Aging and Disability • “Age-related conditions”- these conditions are related to the aging and to the long-term effects exposure to environmental hazards • E.g: • Hypertension • high cholesterol • Diabetes • Osteoarthritis • heart disease • gait and mobility problems • Falls • respiratory infections/chronic obstructive pulmonary disease • urinary incontinence • Osteoporosis • skin disease • hearing and vision loss • dementia

11. Consequences of Aging and Disability • “Multiple Chronic Conditions,”- the risk to have two or more different chronic conditions together, • Dyads (hypertension and diabetes) • Triads (cholesterol, hypertension, and diabetes)

12. SCI Sequelae • Autonomics • GI • HO • Orthopedics • Pressure Ulcers • CVD • GU • Metabolic • Pain • Pulmonary

13. Aging in SCI • SCI individuals show signs of earlier aging • MSK • Endocrine • CV • Multiple factors affect aging in SCI • Level and severity of injury • Age at injury • Family health history • Lifestyle- (activity level, smoking or EtOH use, diet, access to community services, and social supports)

14. Aging in SCI • Immediately after SCI, the body accelerates its functional and metabolic decline • After initial insult, the aging process continues at a normal rate • SCI later in life is associated with poorer functional outcomes

15. Cardiovascular Diseases • SCI patients have higher risk for premature death • Cardiometabolic syndrome- combination of metabolic dysfunctions characterized by insulin resistance, impaired glucose tolerance, dyslipidemia, HTN, and central obesity. • Post SCI immobilization • Significant decrease in HDL lipoproteins • Poor diet and increase in caloric content • Obesity • Get regular checkups • Heart healthy diet • Stay active • Routine testing

16. Musculoskeletal changes • Muscle predisposed to increase fatigability • Increased atrophy • Increased fat mass • Increased BMI • Change of muscle fibers • Decreased strength • Decreased muscle mass • Avoid pain causing and repetitive movements • Avoid weight gain • Engage in Strengthening exercises • Improve muscle balance across joints • Lay flat to stretch • Maximize technology to reduce stress

17. Bone Health • Bone mineral density decreases 27% in first 4 months. • Significant demineralization • Increased osteoclast activity • Impaired Ca and Vit D metabolism • Distal femur and proximal tibia most affected areas • Functional electrical Stimulation cycle ergometry • *Bisphosphonates

18. Endocrine • Decreased testosterone secretion • Decreased human growth hormone

19. Neurogenic Bladder • High risk of complicated UTIs • Increased risk of bladder stones • Increased risk of kidney stone • Increased risk of bladder cancer • Increased renal decline 4-5 years post-injury • Drink plenty of water • Annual Urologic care and surveillance

20. Gastrointestinal • Constipation or incontinence • Hemorrhoids • Gallbladder disease • Longer GI transit time • Maintain health diet • Regular bowel program • Discuss other options with doctor

21. Pulmonary • Weaker lung muscles • Less physical activity • Increased risk of respiratory infections • Increased risk of pulmonary embolism • Get routine vaccinations • Don’t smoke • Maintain a health weight • Get PFTs routinely

22. Immune System • Increased chance of infection • Increased chance of resistance to antibiotics and other medications • Use clean, sterile, or aseptic bladder techniques • Get routine vaccinations • Eat a balanced diet • Get plenty pf sleep and exercise • Reduce stress

23. Skin • Increased risk of pressure injuries • Prolonged immobilization • Incontinence • Lack of sensation • Thinner skin • Daily skin checks • Pressure reliefs at least every 2 hours • Sunscreen • Hydration • Examine equipment for wear and tear

24. Pain • 25%-90% prevalence of pain • Development of neuropathic pain will likely continue • Acute increase in neuropathic pain warrants further investigation • Use correct techniques for transfers • Minimize undue stress on joints • Talk to physician about nerve entrapments • Monitor changes in sensation and strength at least every 5 years

25. What to Do • Maximize employment and personal independence • Normalize fears of aging • Adapt to new limitations • Participate in meaningful activities • Use adaptive equipment appropriately • Engage in regular physical activity • Learn something new • Volunteer

26. What to Do Daily • Self-skin assessment • Stay Active • Eat and Drink Responsibly

27. What to do every 1-2 years • Check weight • Annual doctor check ups • Annual flu shot • Annual bladder and urethra assessments for first three years

28. Things to do every 5 years • Full ASIA testing • Review changes in life situations • Pulmonary Function test

29. What to do every 3-5 years • Formal assessment of adaptive equipment and posture • Formal assessment of ROM, contractures, and function • Formal skin assessment • *Bladder and urethra examination

30. Aging Model • Acute restoration phase • Immediately following SCI; maximum amount of functional return during rehabilitation • Maintenance phase • This phase varies in length of time, however the level of function is relatively stable • Decline phase • Predictable functional decline from degenerative effects of overuse syndromes and the physiologic aging process as discussed by Dr. Bush-Arnold

31. Decline Phase • Can begin as early as 10-15 years post injury or as late as 20 years • Decline rate is not going to be the same for everyone • Depending factors; • Genetics, lifestyle, level of injury, age, weight, health history, level of supportive care, and comorbidities

32. Decline Phase • Isn’t just physical effects/changes on the body but, effects in major life areas for the SCI individual: • Recreation • Independent ADL function • Employment

33. Health Care Professional • Has to be aware of these effects of age-related changes. We must then implement services to limit our patient’s functional decline to the greatest extent possible or else must provide services or equipment to these individuals in a proactive way to replace lost function or to limit to effects of the functional decline

34. Musculoskeletal Changes • Secondary to peripheral nerve entrapment or overuse syndrome • Leads to DJD, rotator cuff tears, rotator cuff tendinitis, subacromial bursitis and capsulitis • These all Lead to PAIN!

35. Therapy and Aging • Therapy needs to address pain in the aging SCI patient by changing performance techniques or protecting the painful structure

36. Overuse Injury • Pain • 34-94% present overall • Tetraplegia • 55% Upper extremity pain • 46% Shoulder pain as primary pain • Paraplegia • 64% Upper extremity pain • Carpel tunnel syndrome primary complaint • Shoulder pain

37. Overuse Injury • Due to extra use of shoulders/upper extremities for mobility; • Wheelchair propulsion * • Transferring * • Propping • Pressure relief * • Ambulating with an assistive device

38. Therapy and Aging • Wheelchair propulsion: • Extreme humeral internal rotation and extension during wheelchair propulsion increases impingement of the RTC tendons under the acromion • This leads muscle imbalance: • Over strengthening/tightness of anterior shoulder muscles and overstretching/weakness of posterior shoulder muscles • A higher prevalence of rotator cuff disorders is also found in paraplegics with higher levels of injury, which are associated with decreased trunk control

39. Therapy and Aging • Wheelchair Propulsion: • Reviewing proper propulsion technique

40. Therapy and Aging • Wheelchair Propulsion • Assessing maintenance of the wheelchair • Low tire pressure or malaligned wheels • poor maintenance contribute to increased rolling resistance which thus increases the workload on the shoulders.

41. Therapy and Aging • Wheelchair propulsion • Consider Power Assist: • E-motion Wheels-Alber • Twion Wheels-Alber • Smart Drive-Max mobility

42. Therapy and Aging • Wheelchair Propulsion • Transitioning from Manual wheelchair to Powerchair? From walking with device to wheelchair? (power or manual)

43. Therapy and Aging • Wheelchair Propulsion • Looking at their seating in their wheelchair • Do they need more back support (upholstery to solid back) • Take out less dump or add more dump • Wider chair/more narrow chair • Postural Changes • More kyphotic • Scoliosis • prolonged periods of exaggerated cervical extension and rotation to look overhead while seated

44. Therapy and Aging • Transferring • Changing techniques • Sit pivot or modified sit pivot to Lateral scoot slide board transfer • Reduced strain on shoulder and risk of impingement • Those who suffered a fracture • Teaching how to transfer with a lower extremity locked in extension in a leg brace.

45. Therapy and Aging • Pressure Relief • Going from push-up style to weight shifting

46. Therapy and Aging • Exercises focused to strengthen and stretch • Shoulders • Strengthen external rotators, adductors, and scapular retractors • Rowing or backward propelling • Flexibility to the joints. • Stretch their internal rotators and the anterior capsule, pectoral, and biceps muscles • There was 40% improvement in Wheelchair User's Shoulder Pain Index scores after a 6-month selective strengthening program, even though there was a transient increase in shoulder pain during the first 2 months of exercise

47. Therapy and Aging • The Aging incomplete SCI Ambulator • Those who walked with an assistive device with gait deviations • Increase in Low back pain, hip pain, or knee pain • Contractures • Development of contractures from spasticity or HO in lower extremities can effect seating and positioning or ambulation functioning • Therapy • Strengthening • Increase flexibility • Encourage prone lying • Modify equipment • Cane->walker • Walker->wheelchair • -Updated bracing; AFO/KAFO

48. Therapy and Aging • Fractures • Surgery unlikely for this population (fractured limb likely mobilized in some form) • May need IPR for functional retraining, alternative wheelchair or wheelchair modification • Following healing (6-8 weeks) • Initiate passive range of motion • Begin static supported weight bearing when cleared (standing frame, tilt table)

49. Therapy and Aging • Fractures • No specific treatment to prevent osteoporosis and risk of • Education • Avoid risk factors (eg, smoking, caffeine, alcohol use) • Be aware of signs of a fracture (eg, localized swelling, hematoma, low grade fever, increase spasticity)

50. FES Cycling / Ergometry