Rehabilitation medicine curriculum standards (adult)
Knowledge guides
Knowledge guide 4: Spinal cord dysfunction
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will describe the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the indications for and how to interpret the results of these investigations, procedures, and clinical assessments tools.
Advanced Trainees will know how to explain the investigation, procedure, or clinical assessment tool to patients, families, and carers.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management.
Presentations
The goal of rehabilitating spinal cord injuries (SCI) is to maintain as much mobility and activity as possible, and to prevent further injuries. Patients and caregivers need to be educated about safe ways to move and do exercises that will improve strength, balance, and endurance.
SCI rehabilitation is a long process that requires patience and motivation from the patient and caregivers. Early rehabilitation is important to prevent joint contractures and the loss of muscle strength, conservation of bone density, and to ensure normal functioning of the respiratory system, bladder, and bowel. The rehabilitation physician’s role is to maximise function and activity participation using an interdisciplinary approach.
Causes
Congenital and acquired traumatic
Non-traumatic
- Autoimmune/Inflammatory, e.g. systemic lupus erythematosus (SLE), transverse myelitis
- Iatrogenic, e.g. drugs
- Infectious:
- abscess/phlegmon
- discitis
- infectious disease, virus, bacteria, fungi, and parasites
- osteomyelitis
- Neoplastic (defined by structure affected):
- benign
- malignant:
- primary
- secondary/metastatic
- Neurodegenerative, e.g. multiple sclerosis (MS)
- Obstructive sleep apnoea (OSA)
- Vascular:
- haemorrhage
- ischaemia
Traumatic
- Accidental or iatrogenic
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Adult spina bifida
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Anatomy of the spinal column and spinal cord, including blood supply and topography of neural motor, sensory pathways, and autonomic pathways within the spinal cord
- Autonomic dysreflexia:
- pathophysiology:
- cause
- symptoms and signs
- pathophysiology:
- Common comorbid medical conditions and impact on SCI:
- obesity
- psychiatric and mental health issues
- TBI
- Epidemiology of traumatic and non-traumatic SCI in Australia and Aotearoa New Zealand, including:
- aetiology
- costs
- incidence and prevalence
- long-term outcomes
- mechanisms of traumatic SCI and fracture-dislocation types/classifications
- mortality and morbidity
- Factors influencing outcomes after SCI
- Level of injury, functional ability and expected level of independence
- Pathophysiology of SCI:
- associated injuries
- concussion, contusion, and laceration
- incomplete spinal cord syndromes
- new developments in the physiology of spinal cord regeneration
- secondary injuries
- spinal shock
- stem cell research
- Physiology of respiratory and cardiac systems:
- normal respiratory and cardiac function
- Physiology of the spinal cord, including:
- autonomic nervous system
- bowel function
- erection, seminal emission, and ejaculation
- micturition
- motor and sensory function including levels
- Prevention strategies
- Skin integrity and pressure injuries:
- assessment and diagnosis
- risk factors
- staging
Examinations
- Assessment of pre-injury personality, lifestyle, social support, and economic circumstances
- International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
- Neurogenic bladder:
- infrasacral, suprasacral, and mixed types of impairment
- Neurologic exam
- Physical examination, e.g. cardiac, respiratory, skin
Investigations
- CT myelogram
- CT scan
- MRI
- Neurophysiology studies
- Radiological and electrodiagnostic tests
- Urodynamic studies
- X-ray
Clinical assessment tools in SCI
- Activities, e.g. 10-metre walk test, spinal cord independence measure
- Impairments, e.g. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), hand-held myometer
- Participation, e.g. Craig Handicap Assessment and Reporting Technique (CHART), short form health survey
Activities of daily living (ADL)
- Fertility, reproduction, and pregnancy
- Health promotion and physical activity recommendations
- Immunisation and health screening recommendations
- Sexual function and sexuality
Acute management
- Acute pressure care
- Deep vein thrombosis (DVT)/Pulmonary embolism (PE) prophylaxis
- Differentiation of shock/types of shock, e.g. cardiogenic versus spinal
- First aid and retrieval principles of traumatic SCI patient
- Gastrointestinal dysfunction
- Hypotension
- Neuroprotection strategies
- Palliative care techniques
- Respiratory insufficiency, including indications for mechanical ventilation, and basic principles of non-invasive positive pressure ventilation and respiratory function in tetraplegia
- Surgical interventions and management
- Temperature control
Chronic/Long-term management issues - common complications
- Autonomic dysfunction, e.g. autonomic dysreflexia, orthostatic hypotension, temperature control
- Falls
- Heterotopic ossification
- Pain
- Respiratory insufficiency
- Skin integrity and pressure issues
- Sleep-disordered breathing
- Spasticity and contractures
- VTE
Common complications – types of dysfunctions
- Bladder and bowel:
- neurogenic bladder (upper or lower motor neurone)
- patient and carer education
- reflex voiding and bladder training
- suprapubic catheter/indwelling urethral catheter
- surgical interventions, e.g. colostomy
- the neurogenic bowel:
- bowel management programs
- dietary management
- pharmacological management
- physical interventions, electrical, e.g. nerve stimulators
- therapeutic interventions, such as:
- clean intermittent self-catheterisation
- pharmacological
- surgical interventions, e.g. external sphincterotomy, stenting
- types of bladder dysfunction
- Cognition and perception:
- impact of cognitive and perceptual changes
- Communication
- Mood and behaviour:
- impact on families and carers
- management strategies to promote independence
- other non-pharmacological therapies
- pharmacological management of issues
- psychiatric issues, including post-traumatic stress symptoms/disorder (PTSD)
- psychological reactions to disablement
- psychological therapies – components of therapy, indications
- theories of adjustment to disability
- Nutrition and swallowing:
- diet and exercise recommendations
- dysphagia
- energy imbalance and nutritional interventions
- parental feeding indications
- Physical deficits:
- aids and equipment
- dressings and wound care
- patient and carer education
- pharmacological and nutritional interventions
- physical interventions
- prevention strategies:
- extrinsic factors, including aids and equipment
- intrinsic
- respiratory
- return to sitting after a skin breakdown
- skin integrity and pressure injuries
- surgical management
- treatment strategies
Community reintegration
- Adaptive techniques and assistive devices for ADLs
- Carer training
- Community support services
- Computer support for recreation, vocation, and environmental control
- Disability income support options
- Driving assessment, modifications, and retraining
- Financial impacts of disablement
- Funding options for community reintegration
- Housing, home modifications, environmental controls, and equipment
- Leisure and sports activities
- Peer support organisations
- Principles of community care
- Seating and wheelchair prescription in community setting
- Vocational rehabilitation
Documentation
- Advanced care planning
- Medicolegal reporting
Rehabilitation interventions
- Assistive devices
- Cough and secretion removal
- Emerging experimental approaches
- Evidence-based rehabilitation strategies
- Hydrotherapy
- Inspiratory muscle training
- Pharmacological management
- Physical therapy techniques
- Role of functional electrical stimulation
- Surgical interventions to improve functional performance, including indications, complications, and outcomes:
- e.g. tendon and nerve transfers
- tenodesis and arthrodesis
- Technology-based interventions, e.g. functional electrical stimulation and neuromuscular electrical stimulation, neuroprosthesis, robotics
- Tracheostomy placement and decannulation
- Upper and lower limb resting splints, orthoses, and gait aids
- Upper limb adaptive and compensatory techniques
- Upper limb functional retraining and education
- Ventilation
- Wheelchair prescription, skills training, and education
Spina bifida and SCI
- Assessment and management of non-SCI issues
- Clinical manifestations
- Complications and chronic issues
- Principles of SCI management of chronic issues
- Principles of transition to adult services