The Physiatric Role in Spinal Cord Tumor Rehabilitation and Pain Management

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The Physiatric Role in Spinal Cord Tumor
Rehabilitation and Pain Management

• Christine M. Villoch, MD

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Physiatrist

• Oh, a psychiatrist?
• Oh, a podiatrist?
• Oh, supermans doctor!

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Physiatric Approach

• Holistic
• Chronic Illnesses (traumatic brain injury,
  strokes, spinal cord injuries, etc.)
• Function
• Physical
• 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)
• Hoffmans (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. - Websters
  Dictionary
• An unpleasant sensory and emotional experience
  associated with actual or potential tissue
  damage, or described in terms of such damage
  Intl 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
• Neuropathic
• Sharp, 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
• Hyperalgesia
• Excessive 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
• Causes
• Overuse
• Poor body mechanics

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Types of Pain

• Mechanical/Structural
• Post-surgical
• Laminectomy
• Instability
• Lack 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 Injections
• Trigger 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 injections
• Loosens muscles
• Spinal joint (facet) injections

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Psychology

• Subjective Component
• Supportive Counseling
• Cognitive/Behavioral Techniques
• Biofeedback
• Relaxation Techniques
• Improving Sleep Hygiene

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Summary

• Physiatry
• Holistic Approach
• Rehab Needs
• Pain Management
• Spinal Pain
• Multifactorial
• Many different treament options

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Useful Resources

• www.spineuniverse.com
• www.aapmr.org