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Movement and strict bed rest for threatening spinal cord lesion


Medical editor Nina Aass MD
Oncologist
Oslo University Hospital
Norway

General

Approximately 5% of the patients with advanced malignancies develop symptoms of threatening spinal cord lesion. The condition is most frequently in patients with cancer originating from lungs, prostate or breast, but is also seen in other types of cancer where bone metastases may occur.

Symptoms

  • Pain in the back, possibly in the neck
  • Changes in existing pain (increased intensity, changed character, radiance of pain)
  • Pain that worsens with exertion (for example cough, sneeze or going to the toilet)
  • Walking difficulties and inability to control the extremities
  • Paralysis of the legs and-/or arms
  • Loss of sensation
  • Urinary problems and/or defecation problems

The stability in columna

  • Ambulatory patients without neurological deficits do not need strict bed rest.
  • For other patients, it may be appropriate to have strict bed rest until the stability of columna is assessed. The need of strict bed rest is assessed by a physician based on the risk of increased neurological deficits and the degree of pain. When columna is considered stable enough (usually clarified 2 to 4 days after the initiation of radiotherapy), gradually mobilization until pain threshold should quickly get started. Increasing pain or neurological deficits should be observed during mobilization.
  • For strict bed rest, the head end of the bed can be elevated up to 30 ° C.
  • If flat bed rest causes increased pain, the head end of the bed should be raised until pain reduction.

Indication

  • Threatening spinal cord lesion caused by tumor/metastases.

Goal

  • Limit spinal cord damage so that  functions may be maintained.

Preparation

The patient and their family should receive proper information and guidance regarding to disease, treatment and restrictions. For advanced disease, small chance of getting better and short life expectancy, quality of life rather than strict restrictions should be emphasized.

The patient should, if he/she wishes, be involved in decisions regarding to treatment and further training.


Implementation

Use of cervical collar and corset

  • Lack of documentation of the effect of using cervical collar and corset, require the patient's wishes to be taken into account in assessing whether this should be used.
  • Cervical collar may be relevant for spinal cord lesions in the cervical level of the spinal cord. Some patients find this pain relieving. A neurologist/neurosurgeon will decide whether there is a need for cervical collar.
  • A corset are generally not used preoperatively, but if prescribed by a surgeon, it may be used postoperatively.
  • The corset must be adjusted by a prosthetist or physiotherapist.
  • The corset is put on in either supine position, sitting position or in standing position, initially by competent personnel. The patient is instructed to put on the corset unassisted.

Bed rest and positioning

  • The patient should be referred for physical therapy at an early stage. To avoid accumulation of mucus in the lungs, the physiotherapist should give instructions in appropriate breathing exercises, consider use of mini-pep and need for chest physiotherapy.
  • Patients who need strict bed rest must have electrically controlled bed with a pressure relieving mattress.

Movement in bed

  • The patients must be instructed in how to move to lateral position in bed using logrolling. Logrolling involves moving to lateral position without rotation or flexion/extension in columna. The healthcare staff are performing the movement to lateral position by rolling the patient while their hands are securely placed over the patient's hips and back/shoulder.
  • If the patient has mobility in the legs, he/she may, using bent knees and hips and feet down in the mattress as well as arms straight up in the air as levers, roll over to lateral position.
  • When the patient needs to be moved higher up in bed, the bed should be tilted a bit backward, the patient is lifted calmly with the sheet close to the body by means of the draw sheet and two persons.
  • Slingbar is not recommended for cervical or thoracic lesions.

Activity during bed rest

  • By instructions from a physiotherapist, nurses can assist the patient to do appropriate activity and exercises. Passive exercises when paresis or paralysis is present, otherwise active exercises.
  • Activity that causes pain must be interrupted.
  • Individually customized movements of upper and lower extremities, passive or active, are carried out in a supine position with a low strain on columna.
  • A footboard made of compact foam at the end of the bed is an aid to prevent the patient from sliding down in the bed and provides a resistant surface against which the patient can push for a good venous-/muscle pump.
  • Strength training of arms by static resistance to the mattress and without movement of the columna, is recommended. Light hand weights for arm exercises are only considered when the affection is in the lumbar level.
  • The need for contracture prophylaxis is considered, and if there is a drop foot a footboard should be customized.
  • Instructions in self-training will be given, preferably also as a written program as well.

Thrombosis prophylaxis

  • Bedridden patients should have compression stockings in thigh/- possibly knee length, unless contraindicated.
  • Patients at high risk of venous thrombosis should also have subcutaneous thrombosis prophylaxis with low molecular weight heparin.
  • The duration of thrombosis prophylactic treatment is considered individually based on current risk factors, general health condition and mobilization of the patient.

Pressure relief and prevention of pressure ulcers

  • Patients who must have strict bed rest is particularly prone to pressure ulcers.
  • Prevention of pressure ulcers must be followed in relation to risk assessment, assessment of the patient's skin, skin care, nutrition, pressure relieving underlay, change of position in bed/chair and mobilization.
  • For patients with/having strict bed rest, change of positions in bed must be in accordance with the restrictions.

Bladder function

  • An assessment of  the bladder function is done at arrival. An accuracate anamnesis is obtained: Last urination, episodes of incontinence, frequency, painful urination and abdominal pain.
  • Evaluate the  bladder function at least once a day for any changes.
  • If incontinence, insert a permanent catheter.
  • If it turns out to be permanent muscle tone, evaluate eventually intermittent catheterization or insertion of suprapubis catheter.
  • Bedpan/urinal bottle should be easily accessible at strict bed rest. When using bed pan, loggrolling is required.

Gastrointestinal function

  • An assessment of  the gastrointestinal function is done at arrival.
  • An accuracate anamnesis is obtained: Last bowel movements, frequency, consistency, nausea/vomiting, abdominal pain and previous ailments.
  • Evaluate the gastrointestinal function evaluated at least once a day.

Pain relief

  • Spinal cord compression can cause severe pain that may be difficult to treat. If so, contact the pain -/palliative team.

Mobilization

  • The patient and the healthcare staff collaborate to find the right level of activity.
  • Go gradually from an increased angle on the bed`s back rest to sitting position, to sitting position on the bedside and then to standing position. The back rest is gradually raised to about 45 ° and the bed´s leg-rest is angled and the patient can try this sitting position, further to 60 °. By worsening of pain and/or neurological outcomes, the patient is returned to the previous position for reconsideration. If the increase of the back-rest is unproblematic, the patient can further be mobilized to the bedside.
  • The first time the patient is moved to sitting position on the bedside, this is preferably done by a physiotherapist together with a nurse by rolling over to lateral position (logrolling). The patient sits up assisted by two persons, one at the upper body and one supporting the legs over the edge of the bed.
  • When affection in the cervical region only, the patient can be mobilized up to a sitting position by raising the head of the bed and bring the legs over the bedside. The patient is allowed to sit for a little while, blood pressure and pain are evaluated.
  • Exercises to increase circulation and good breathing exercises are recommended. Balance in a sitting position is considered.
  • When the patient is moved to standing position, custom walking aids must be used (pulpit walker or forearm walker). To ensure safe mobilization the first time, assistance of two persons are recommanded.
  • For lasting paresis, a high-back reclining wheelchair with leg rests should be customized.
  • The need of other aids, like transfer slide board, drop foot brace, grasping forceps and similar equipment, should be considered.
  • Instruction in self-training should be given, preferably after a written program in standing exercise and walking exercice with support.
  • Gradually, the patient can sit  for short periods of time, using a good armchair with a high seat and good backrest.

Follow-up Care

  • Patients with a long life expectancy should be considered for further training at a suitable institution.
  • Patients with a short expected life expectancy are usually not recommended for stay at rehabilitation institutions.

The website www.physiotherapyexercises.com is recommended for obtaining exercises.


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