Rehabilitation medicine curriculum standards (adult)

Knowledge guides

LG 14: Spinal cord dysfunction

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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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.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will describe the principles of the foundational sciences.

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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.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management.

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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
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