By Lisa M. Ruppert, MD
Fall 2013 - The benefits of rehabilitation therapy in traumatic spinal cord injuries are well established. Recent studies examining its effects on individuals with neoplastic spinal cord injuries have shown similarly positive results(1) and indicate a complementary role to medical treatment for this patient population.
In fact, as treatments for neoplastic spinal cord injuries continue to improve and survival rates increase, the role of rehabilitation will undoubtedly expand and evolve. Ongoing research in this area will help establish and validate therapeutic care models that minimize disability and maximize quality of life. Physicians should pay attention to issues such as mobility, bowel and bladder dysfunction, and pain management.
Mobility and Activities of Daily Living
For individuals with neoplastic spinal cord injuries, their mobility and their ability to perform activities of daily living can be affected by weakness, loss of sensation (especially proprioception), ataxia, spasticity, and other factors.
Physical and occupational therapies can be initiated to address these impairments. Focus is placed on strength and endurance training, range of motion, sensory reintegration, transfer training, standing balance, gait training, wheelchair mobility (if needed), and assessment for an appropriate assistive device.
Heat, cold, ultrasound, and repetitive exercises are common modalities used in sensory reintegration. If appropriate, functional electrical stimulation and body-weight-support treadmill training can be incorporated into sessions.
If indicated, bracing of the extremity can be used to provide joint stability, compensate for weakness, and assist with functional joint positioning and proprioceptive feedback. Bracing can also be used to decrease spasticity. If a wheelchair is needed for mobility, one can be prescribed to fit the individual’s level of impairment and functional needs.
Bowel dysfunction is a common problem that can result in social inconvenience, embarrassment, and skin compromise. A thorough neurological assessment including reflexes can help establish an individual’s bowel pattern. A bowel program can then be initiated to allow for control of bowel movements over time and place with the desired frequency and without incontinence.
Medications such as stool softeners, oral stimulants, and contact irritants (suppositories) can be initiated for upper motor neuron (hyperreflexic) bowel patterns to promote timed and complete evacuation. Lower motor neuron (hyporeflexic) bowel patterns can be managed with oral bulk forming agents to promote continence. Distension from bulked stool will also promote peristalsis and possible emptying. If patient cannot empty spontaneously, manual removal of stool is recommended.
Bowel and Bladder Dysfunction, Skin Care, Spasticity
Bladder dysfunction can result in difficulty with urinary drainage and abnormalities in intra-vesicular pressure, placing an individual at risk for infections, renal disease, skin breakdown, and social embarrassment. Bladder symptoms can range from frequency and urgency to complete urinary retention.
A voiding diary, assessment of post-void residual volumes, and urodynamic studies can be used to further assess an individual’s bladder pattern and aid in establishment of a bladder program. Intermittent catheterization, indwelling catheterization, or suprapubic catheterization can be considered for both upper motor neuron bladder patterns (detrusor over activity with or without sphincter dyssynergia) and lower motor neuron bladder patterns (detrusor hypocontractility or acontractility).
Anticholinergic agents can be considered for individuals with upper motor neuron lesions, and manual techniques such as Credé and double voids considered for individuals with lower motor neuron lesions.
Loss of sensation and mobility, bowel and bladder dysfunction, and a catabolic state can place individuals at risk for skin breakdown. Education on pressure relief, skin checks, and nutritional support is provided during the course of rehabilitation. If a pressure ulcer develops, further evaluation and wound care is indicated.
Spasticity is a common component of neoplastic spinal cord injuries. It may prove to be beneficial for mobility and performance of activities of daily living (ADLs), but can present with negative symptoms such as pain and impaired function. Individuals are educated on the positive symptoms of spasticity, and the functional use of tone is promoted in therapies. Management of negative symptoms is warranted. Treatment options include continuous passive stretch in therapies or with stretching splints; systemic treatment with baclofen, tizanidine, benzodiazepines, or intrathecal baclofen; and localized treatments such as phenol and Botox.
Pain is common in individuals with neoplastic spinal cord injuries, especially in those with metastatic disease. Individuals may have localized tumor-related pain requiring oncologic treatment and/or treatment with pain medication, mechanical pain suggestive of instability that requires surgical intervention, or neuropathic pain.
Treatment options include transcutaneous electrical nerve stimulation (TENS), medications such as tricyclic antidepressants and anticonvulsants, behavioral techniques, compression garments, and desensitization techniques.
Cancer-specific medical complications such as pancytopenia, electrolyte abnormalities, deep venous thrombosis and spinal instability, overall life expectancy, and oncologic prognosis are taken into account when determining appropriate rehabilitation interventions and settings.