Welcome to the TBI-HELP Live Chat

Today's topic is: "Muscle/Skeleton Problems Relating to Rehabilitation"

Our Guest is: Dr. Philip Harris, Chairman of Physical Medicine and Rehabilitation, Jamaica Hospital Medical Center

[19:00:51] Mod: Good evening to all our members. Tonight it is our pleasure to have with us Dr. Philip Harris, Chairman of Physical Medicine and Rehabilitation at Jamaica Hospital Medical Center. Welcome Dr. Harris.
[19:01:40] Dr.Harris: Thank you for inviting me here tonight. I am very excited about the work you are doing and I am glad to be involved.
[19:02:26] Mod: Thank You.
[19:03:05] Mod: Dr. Harris will be discussing musculosketal problems in traumatic brain injured population. Dr. Harris is there a high incidence of musculoskeletal problems in the traumatic brain injured population and what types of problems would you expect to find?
[19:04:20] Dr.Harris: Yes there is a high incidence of musculoskeletal injuries associated with TBI. THE FIRST SET ARE THOSE SUFFERED AT THE TIME OF THE INITIAL TRAUMA. These CAN BE MISSED SECONDARY TO THE EMPHASIS ON LIFE SAVING INTERVENTIONS.  As MANY AS 30% OF FRACTURES MAY BE MISSED ON INITIAL EVALUATION.
[19:07:10] Dr.Harris: There are another set of problems that evolve as a consequence of the neurologic deficits and brain injury.
[19:07:55] Mod: Rail: Since you don't often have a coherent patient-what longer term negative effects do these "oversights" contribute?
[19:08:03] Dr.Harris: The overlooked fractures can lead to severe pain which may not be localizable at first. This can also lead to increased spasticity, increased risk of complications from poor healing of the fracture and other comorbidities may develop such as reflex sympathetic dystrophy or heterotopic calcification.
[19:11:11] Mod: Harvey: What would be the effect of a missed disk fracture on treatment and complications of a patient?
[19:11:27] Dr.Harris: Harvey discs do not actually fracture. They are not bone. Discs can herniated and lead to neurological deficits such as weakness, numbness and pain. If the disc herniation is very large and in the neck it can cause quadriplegia like a spinal cord injury and there are some patients with TBI who also suffer spinal cord injuries. If the disc is huge and in the lumbar spine it can cause paraplegia. Less severe herniations can cause pain and may be hard tio identify clinically if the individual has impaired cognition or hemi paresis on the same side.
[19:14:24] Mod: Mark: You mentioned in passing RSD...I have a patient with this condition...what are some of the newer forms of treatment for this condition?
[19:16:21] Dr.Harris: Mark. The most popular treatment for RSD recently has been neurontin. Neurontin is a seizure medication which has become very popular in pain management.  RSD is also known as complex regional pain syndrome and you may find information under this heading. Another recent treatment involves infusions of anesthetic agent (pain numbing medicine) in the involved limb.
[19:18:38] Mod: Rail: Given that the patient is largely a blind, deaf, dumb, quad - aren't there more proactive diagnostic protocols that are invoked secondary to saving medical stability??
[19:19:30] Dr.Harris: Rail. The people working with the individual have to have a suspicion that something os wrong based on how the person responds to care. Based on this suspicion they can do testing to look for problems. The rehab team does this whenever they feel someone is not progressing properly or they do not understand the patients general presentation.
[19:21:07] Mod: Susan: What's the best way to advocate for splinting to avoid spasticity? First try the therapist or the rehab dr? Even in the ICU?
[19:21:41] Dr.Harris: Susan. The MD usually writes the orders so if you had to pick one I would pick the MD (spoken like an MD).
[19:25:46] Dr.Harris: In most hospitals the therapists let the MD know if they feel splinting is needed. If a patient has increased tone--spasticity they usually order splints.
[19:26:45] Dr.Harris: Rail. Trauma units have protocols to screen people who come in with TBI. It isn't left to chance.
[19:26:54] Mod: Susan: I've been reading up on botox injections for the legs I realize it works better on small muscles than large and in longer muscles many injections are needed. The baclofen pump is already in place. Would it make more sense to increase the pump as much as possible instead of trying botox?
[19:28:52] Dr.Harris: Susan. The pump is usually for lower extremity spasticity. If the spasticity bothering the individual is in the legs you would try to increase the pump as long as there are not problems with doing so. If the spasticity is in the arms you may want to try injections or different medication such as zanaflex. Phenol injections are another option for large muscle groups. The botox is not used in large doses and may not be able to control spasticity in muscles such as the hamstrings.
[19:30:02] Mod: Please remember to check with your own Dr. on treatment. These are the opinions of Dr.Harris

[19:30:55] Mod: Are there any musculoskeletal problems one has as a consequence of being brain injured or musculoskeletal problems that a brain injured person might have as opposed to just your average person?
[19:32:20] Dr.Harris: One of the unique aspects of musculoskeletal problems in TBI patients is the impact it can have on their function. For instance if you sprain the ankle of the leg you depend on to walk you can become non ambulatory. In addition if you sprain the side that has spasticity or weakness the treatment can be very difficult. The first thing you have to do is control the deforming forces. If the spasm is pulling the ankle you have to control it. This makes it more complicated and raises the stress involved for the individual. Another problem is the use of pain medications. Many of the stronger ones can make you dizzy, drowsy, slower to respond. TBI patients may not be able to tolerate this. It can inhibit their ability to maintain independance.
[19:37:18] Mod: Susan: How does heat help contracted limbs? I see heat and cold backs used before therapy sessions?
[19:37:27] Dr.Harris: Susan. Heat and cold modalities are used because they can decrease spasticity and pain.  This allows the therapists or family to more easily stretch the person out.
[19:40:13] Mod: Susan: Is there any creditability to magnet therapy?
[19:40:37] Dr.Harris: Susan. Magnets are very interesting but not well proven yet. I do not see any harm in them but it is unclear how to prescribe them.
[19:42:04] Mod: Ahmed: Do any of the holistic medications or approaches work in helping with the musclo-sketital problems faced by these patients?
[19:41:58] Dr.Harris: Ahmed I believe they can play a role. There have been some acupuncture studies which showed promise. The benefit is probably best obtained with early treatment. There are many obstacles to doing this in hospitals which make it very difficult. People who are far out from their injury may benefit less. One must realize that it also depends on what you are expecting. Holistic or complimentary health practitioners in general may feel they can benefit you by improving your overall health without improving your neorologic status.
[19:46:05] Dr.Harris: Also it is important to realize that herbs are not without side effects. You should check them out before taking them. They can cause bleeding, seizures etc... and can interact with medications.
[19:46:12] Mod: Ahmed: Just saw this question on magnets...what is the significance and how are they supposed to be helpful...I do not understand?
[19:47:20] Dr.Harris: Ahmed. I have not seen much in terms of magnets and TBI. I was discussing them more in terms of musculoskeletal problems (back pain,spasm).
[19:48:44] Mod: Carol: Have there been any new medications that help along with p.t. that assist with muscle spasms?
[19:49:45] Dr.Harris: Carol. Yes. Tizanidine or zanaflex is a relatively new medicine for spasticity. It has been shown to be as good as liorasil for some people and better for others. It may have less sedating effect. It is short acting and must be taken a few times a day. It can drop your blood pressure and most be started slowly.
[19:52:27] Mod: Susan: After discharge and the patient is home, what's the best way to keep up progress made if out patient therapy is not indicated? Sometimes that patients gets very lax without a formal therapy schedule?
[19:52:44] Dr.Harris: Susan. That's a great question. And like many great questions there is no simple answer. TBI patients need to exercise just like everybody else. Just like everybody else it is very hard for them to stay motivated. Furthermore they are sometimes pushed to exercise to hard. I believe you have to have an intelligent routine designed by the therapists before discharge. Depending on the patient you may have toi try different ways to motivate them just like you would with anybody else. You may have to alter the routine to keep it from being boring and come up with different incentives. It is important to realize that TBI patients need exercise like everybody else in order to be healthy. They need it more because one side may be doing the work of two. The side with neurologic deficits may need it just to prevent problerms and the good side needs it to withstand the wear and tear of doing double work.
[20:00:09] Mod: Well, it's that time of the night. We have to say good bye for this week. Thanks to Dr. Harris for a wonderful session and I hope that you will come back as a guest in the future.
[20:00:49] Dr.Harris: Thank you for having me here. It was very thought provoking and reminds me of how much more we need to do.
[20:01:17] Dr.Harris: I want to caution everybody that I was talking in very general terms. Each individual deserves to be assessed and the pros and cons of any decision weighed.
[20:02:04] Mod: Good Night and be safe!