Spinal cord injuries - prevention the key

Total care, a fresh approach to rehabilitation of victims:

By Carol Aloysius

A surge in alcohol related violence, reckless driving and accidental falls from great heights have collectively led to a sharp increase in the number of patients with spinal cord injuries (SCI) in Sri Lanka. It is estimated that between 1,500 to 2,000 persons are paralysed from SCI per year. Spinal cord injuries are permanent with victims likely to die prematurely due to various complications they develop along the way.

Having a non communicable disease, lying in bed for a long time, long periods of immobility - all these can have their toll on the patient.

Apart from these physical scars, patients, who are mostly males aged 20 and upwards in the prime of their lives, also suffer psychological trauma from being isolated from their loved ones, deprived from their erstwhile positions of breadwinners and head of the family. Society further isolates them by making them social outcasts.

“Paralysed patients due to a spinal cord injury are a major challenge for their management, rehabilitation and survival as a whole. The resultant consequences to the patient, family, society and health care sector is enormous”, President of the Sri Lanka Spinal Cord Network and Consultant Orthopaedic Surgeon National Hospital Sri Lanka, Dr NARENDRA PINTO pointed out at discussion with other experts in the field, held at the Health Education Bureau last week.

Medical student Dinesh Palipana also gave us his personal experience on the subject.

Following are excerpts of the discussions...

The speakers first explained that the spinal cord was part of the central nervous system, and an extension of the brain stem usually 10 mm - 18” in length. The cord communicates between the brain and the rest of the body and thus functions primarily in the transmission of neutral signals between the brain and the rest of the body. It also contained neutral circuits that could independently control numerous reflexes and central pattern generators.

“When a spinal cord is damaged or there is a break in the cord, no message will be able to get through to the brain.” Dr Pinto said. Citing an example, he said that when we place our hands on a hot iron accidentally, the message immediately is conveyed to the brain warning us that it could burn our hands.

However, if a person with a spinal injury places his hand on a burning hot iron he will not realise he is touching something hot as no message is conveyed to the brain, and he could burn his hands without even feeling the heat.

“Spinal cord injuries are permanent. If there is a partial injury we may be able to minimise the injury to some extent. But if the full spine is broken, we can't repair it. So the important thing is to PREVENT these injuries occurring”, he stressed.

However, he added, even though spinal cord injury patients have to face many obstacles, all is not lost since their brain continues to work.

“If they use their brain well and intelligently, they can do many things that non patients can do with the help of their carers”, he noted.

Describing the levels of injury to the spine and the extent of paralysis, he said that the worst affected were paraplegic patients who suffered from paralysis in all four limbs.

“They need life long care which affects them, their family, society and country’, he noted.

Consultant Rhuemotology and rehabilitation, Negombo Hospital, Dr GUNENDRIKA KASTHURIATNE, in her discussion on ‘Long Term Rehabilitation of patients with SCI’, summarised the impacts of a spinal cord injury on the human body. She listed the following as the most common symptoms: Sudden paralysis of the legs and arms: Loss of sensation in the trunk and legs: Loss of bladder control: Loss of control in defecating: and problems with sexual functions.

“Patients with SCI also suffer from pressure ulcers (bed sores) due to their long period of immobility, from contractions and spasms and also respiratory (chest) infections leading to pneumonia.

They can also develop urinary tract infection, leg swelling, Deep Vein thrombosis (DVT), constipation and fractures,” she said.

Another important fall out of the injury, was depression which many patients suffered from due to their loss of jobs as breadwinners and inferior dependent role within their families and in society as well as their sense of social isolation. She said that the goal of the Rehabilitation Centre at the Ragama Hospital in Negombo was mainly aimed at reducing the impact of disability in patients and improving their quality of life and survival.

“It is essentially team work by many people: When a patient is brought out of the ICU or even when in the ICU, he will need the help of a multidisciplinary medical team: physiotherapists to improve his body movements and circulation, occupational therapists, medical doctors, neurologists, speech therapists to train them to use their vocal cords and help them breathe properly, plastic surgeons if his injuries have impaired his face or some other part of the body, opticians if their eyes are impaired.

Since all of them suffer from stress related disorders due to their injuries and are depressed, they will need psychologists, social workers to attend to the immediate needs of their families and sort out their insurance etc. We work with all of them including their care givers who need guidance on how to look after the patient", she said. She also stressed that they required custom made wheel chairs in order to prevent further injuries.” Any help from the public is welcome”, she said.

"We also have a workshop where we provide them with alternative occupations they can do in spite of their handicaps,” she said. Director YEDD, Ministry of Health Dr LAKSHMI KUMARATHILAKE stressed that Rehabilitation of a disabled person should not be mistaken for buildings and infrastructure rehabilitation.

It relates to the health of the person who has a disability and the health impacts that can occur as a result of that disability. Non communicable diseases such as diabetes which if uncontrolled in a disabled person could lead to amputation, further aggravating his disabilities. She noted that for the first time a national policy and guidelines for rehabilitation services in Sri Lanka had been drafted for 2014/15 and a Disability Steering committee had been set up with multi stakeholder membership.

National Professional Officer (NCD) WHO Dr LANKA JAYASOORIYA giving the International Perspective on Spinal Cord Injury said that those at risk of SCI were mainly young males between 20-29 and those over 70 years.

In females those most at risk were those between 15 -19 and above 60 years.

The causes are Road Traffic Accidents, Falls, Crashes and Violence.

Timely pre-hospital care, quick recognition of suspected SPI, rapid evaluation of injury and injury management including immobilisation were vital factors. She further emphasised the need for accessibility for disabled persons, in schools and public buildings, super markets and on the roads.

“We should provide a safe and friendly environment for them. We also need to tell people how to prevent SCI. If injured these patients must be taught how to survive and lead a quality life despite their handicaps.”

Facts on SCI

*Spinal cord injury is a devastating and preventable neurological injury

* It results in varying degrees of paralysis sensory loss and sphincter disturbancesloss of control of bladder and bowel) which are permanent and irreversible.

* Two ways of damaging the cord- Traumatic and non traumatic

Causes

*Domestic and industrial accidents Domestic ( falls from trees , ladders / stairs
*Accidents at work - falls from scaffolding, ladders , crash injuries
*Road accidents
*Self harm and criminal assault
*War casualties
*Diseases
* Neuro-degenrative diseases.

Effects

* spinal shock-sudden disability, changes in life pattern Loss of sensory and motor function below the level of the lesion Complete immobilityComplete dependence on others Stresses of hospitalization , pain and incapacity Uncertain future

Other effects

* Bowel , bladder sexual dysfunction

Male fertility affected

Very high injuries can result in loss of involuntary functions including ability to breathe necessitating breathing aids, such as mechanical ventilatoras or diaphragmatic pace makers

Complete SCI leads to…

Neurologic deficit below site of injury

-Quadruplegia ( tetraplegia)

-paraplegia

Permanent paralysis

Goals of Rehabilitation

* Educate patient and family about SCI
* Maximise proficiency with mobility and self care

* Teach appropriate bowel and bladder management

* Prevent co-morbidities (contractures, skin break downs) associated with SCI Assess psychological well being and initiate community and vocational re-intergration to society.

Calcium has surprising role in sensing pain

When you accidentally touch a hot oven, you rapidly pull your hand away. Although scientists know the basic neural circuits involved in sensing and responding to such painful stimuli, they are still sorting out the molecular players. Duke researchers have made a surprising discovery about the role of a key molecule involved in pain in worms, and have built a structural model of the molecule. These discoveries may help direct new strategies to treat pain in people.

In humans and other mammals, a family of molecules called TRP ion channels plays a crucial role in nerve cells that directly sense painful stimuli.

Researchers are now blocking these channels in clinical trials to evaluate this as a possible treatment for various types of pain.

The roundworm Caenorhabditis elegans also expresses TRP channels - one of which is called OSM-9 - in its single head pain-sensing neuron (which is similar to the pain-sensing nerve cells for the human face). OSM-9 is not only vital for detecting danger signals in the tiny worms, but is also a functional match to TRPV4, a mammalian TRP channel involved in sensing pain.

In the new study, researchers created a series of genetic mutant worms in which parts of the OSM-9 channel were disabled or replaced and then tested the engineered worms’ reactions to overly salty solution, which is normally aversive and painful.

Specifically, the mutant worms had alterations in the pore of the OSM-9 channels in their pain-sensing neuron, which gets fired up upon channel activation to allow calcium and sodium to flow into the neuron. That, in turn, was thought to switch on the neural circuit that encodes rapid withdrawal behaviour - like pulling the finger from the stove.

“People strongly believed that calcium entering the cell through the TRP channel is everything in terms of cellular activation,” said lead author Wolfgang Liedtke, an associate professor of neurology at Duke University School of Medicine. With then-graduate student Amanda Lindy, “we wanted to systemically mutagenise the OSM-9 pore and see what we could find in the live animal, in its pain behaviour,” Liedtke said.

To the group's surprise, changing various bits of OSM-9's pore did not change most of the mutant worms’ reactions to the salty solution. However, these mutations did affect the flow of calcium into the cell. The disconnect they saw suggested the calcium was not playing a direct role in the worms’ avoidance of danger signals.

Calcium has been thought to be indispensable for pain behaviour - not only in worms’ channels but in pain-related TRP channels in mammals.

So results from the engineered OSM-9 mutant worms will change a central concept for the understanding of pain, Liedtke said.

To see whether calcium might instead play a role in the worms’ ability to adapt to repeated painful stimuli, the group then repeatedly exposed pore-mutant worms to the aversive and pain stimuli.

After the tenth trial, a normal worm becomes less sensitive to high salt. But one mutant worm with a minimal change to one specific part of its OSM-9 pore - altered so that calcium no longer entered but sodium did - was just as sensitive on the tenth trial as on the first.

The results confirmed that calcium flow through the channel makes the worms more adaptable to painful stimuli; it helps them cope with the onslaught by desensitising them. This could well represent a survival advantage, Liedtke said.

To put the findings into a structural context, Liedtke collaborated with computational protein scientists Damian van Rossum and Andriy Anishkin from Penn State University, who built a structural model of OSM-9 that was based the recently resolved structure of TRPV1, the molecule that senses pain caused by heat and hot chilli peppers.

The team was then able to visualise the key parts of the OSM-9 pore in the context of the entire channel. They understood better how the pore holds its shape and allows sodium and calcium to pass.Liedtke said that understanding this structure could be a great help in designing compounds that will not completely block the channel but will just prevent calcium from entering the cell.

- MNT