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WELCOME ADDRESS

Dear Colleagues and friends

We are very pleased to welcome you all to Chiang Mai and to the 16th Asian Spinal Cord Network (ASCoN) conference and workshop. This is the second time that we, the Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, host the ASCoN conference. The first time was back in 2003 when we firstly used the name of “ASCoN” for the 3rd ASCoN conference, together with the 4th Chiang Mai SCI workshop. Since then, we have agreed to meet each year and to share our experience in the management of spinal cord injury (SCI) in Asia, especially low and middle income countries, and also to learn from and with our good friends from Europe, Australia and America.

This year the theme is “sharing and learning for enhancing comprehensive rehabilitation management of SCI”, and there have been nearly 100 abstracts submitted for presentation, many more than expected. More than 200 participants from 11 ASCoN countries and 13 non-ASCoN countries, registered for the conference and workshop. This reflects that our ASCoN, which started from a small group of initiators meeting at CRP, Bangladesh in 2001, has been growing steadily. Thanks to all colleagues and friends from our Asian Spinal Cord Network who aim at better quality of life of our SCI patients and friends. This year we have about 20 SCI consumers/friends joining the conference and there are some sessions that we can learn from them to improve our rehab services. Besides knowledge, skills and research in SCI rehabilitation, you all will experience and enjoy our get together party where we can also share our cultures and tie our relationships closer.

Thanks to our supporters, ISCOS, SPIRIT, Livability, INUS, Rick Hansen Institute, the Faculty of Medicine Chiang Mai University and the Chiang Mai Foundation for the Well-being of the Disabled. Lastly, thanks to our team, without them this conference and workshop cannot become true.

Apichana Kovindha, M.D., FRCPhysiatrT Chairperson, the 16th Asian Spinal Cord Network (ASCoN) 7th-10th December 2017

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Chiang Mai, December 2017 Welcome

It is an honour and a pleasure for INUS, the International Neuro-Urological Society, to be invited to this 16th ASCoN Conference and Workshops and we would like to thank Prof.A.Kovindha for all her efforts on this behalf. INUS is the only medical and scientific society, which deals exclusively with Neuro-Urology. The aim of this young society is to offer the best possible care for neuro-urologic patients worldwide by enhancing its visibility through educational courses and research. Thus our activities, supporting a Workshop on Neuro-Urology and presenting lectures, during this important conference ideally fit into our mission. We invite all participants to share with us an up-date on several neuro-urological topics, moreover we are welcoming all involved in neuro-urological care and research to join our efforts. We wish you all a successful meeting and pleasant days in Chiang Mai.

Prof.Dr H.Madersbacher President of INUS

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Welcome to the 16th ASCoN Conference and Workshops

On behalf of the Rick Hansen Institute, I am very pleased to welcome delegates from the 18 member countries of ASCoN to Chiang Mai. The Rick Hansen Institute is very proud to be a sponsor of this event, which will provide valuable opportunities for researchers, healthcare professionals, service organizations, and individuals with spinal cord injuries to share a wealth of expertise and experience on a broad range of topics, all aimed at improving care and outcomes for individuals with spinal cord injuries.

The goals of ASCoN are fully consistent with the objectives of the Rick Hansen Institute, and we are very pleased to work with ASCoN and ISCoS to continue to build the Asian Spinal Cord Network, and promote ASCoN’s participation in SCI networks beyond Asia.

30 years ago, our founder, Rick Hansen, pushed his wheelchair through Asia and around the world, wheeling 40,000 km to raise awareness of the potential of people with disabilities and spinal cord injuries. Recognizing the almost limitless power of collaboration, he acknowledged that “no one – absolutely no one – gets anywhere on their own”. It is in this spirit of teamwork, collaboration, and shared success that we join together at the 16th ASCoN conference to advance spinal cord injury research, clinical care, and community services that will improve the quality of life for millions of people with spinal cord injuries.

I wish you a very productive and enjoyable conference.

Sincerely,

Bill Barrable CEO, Rick Hansen Institute

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ASCoN Executive Committee Chairperson Assoc. Prof. Apichana Kovindha (Thailand) Executive members Dr. Harvinder S Chhabra (India) Assoc. Prof. Nazirah Hasnan (Malaysia) Dr. Bum-Suk Lee (Korea) Prof. Khin Myo Hla (Myanmar) Dr. Luh Karunia Wahyuni (Indonesia) Mr. Sohrab Hossain (Bangladesh) Secretary Treasurer Ms. Maggie Muldoon Ms. Chindamai Muang-in

Scientific Committee Assoc. Prof. Apichana Kovindha (Thailand) Assoc. Prof. Siam Tongprasert (Thailand) Assist. Prof. Pratchayapon Kammuang-lue (Thailand) Dr. Sintip Pattanakuhar (Thailand) Ms. Nipapan Tipayajak (Thailand) Ms. Busara Buranapansri (Thailand)

Organizing Committee Assoc. Prof. Dr Somporn Sungkarat (Thailand) Ms. Sujitra Hundee (Thailand) Ms. Somprathana Rattanamanee (Thailand) Ms. Tuenchai Attawong (Thailand) Mr. Narongrat Sawattikanon (Thailand) Ms. Narumon Sumin (Thailand) Ms. Watchara Punyarat (Thailand) Ms. Wacharaporn Wittayanin (Thailand) Ms. Warangkana Sittikan (Thailand) Ms. Wilasinee Duangartit (Thailand) Dr. Thiti Thoowadaratrakool (Thailand) Ms. Arunothai Sukkraithai (Thailand) Dr. Luntarima Suttinoon (Thailand) Ms. Nawaporn Jitngarm (Thailand) Dr. Supattana Chatromyen (Thailand) Ms. Tarinee Prakobkhong (Thailand) Dr. Chatchai Tangvinit (Thailand) Ms. Kanticha Ruangdang (Thailand) Ms. Saithong Petsang(Thailand) Ms. Pataporn Bawornthip (Thailand)

Resource Persons International ASCoN Prof. Wagih El Masri (United Kingdom) Dr. Harvider S Chhabra (India) Prof. Helmut Madersbacher (Austria) Prof. Henry Prakash Magimairaj (India) Prof. Fin Biering-Sorensen (Denmark) Assoc. Prof. Apichana Kovindha (Thailand) Prof. Lisa Harvey (Austria) Assoc. Prof. Kanit Sananpanich (Thailand) Prof. James Middleton (Australia) Assoc. Prof. S Tongprasert (Thailand) Dr. Doug Brown (Australia) Assoc. Prof. Nazirah Hasna (Malaysia) Dr. Stanley Ducharme (USA) Assoc. Prof. Julia E Patrick (Malaysia) Dr. Dirk van Kuppevelt (the Netherland) Assist. Prof. P Kammuang-lue (Thailand) Dr. Yorck B Kalke (Germany) Dr. Bum-Suk Lee (Korea) Dr. Stefania Musco (Italy) Mr. Shivjeet S Raghav (India) Mr. Stephen Muldoon (Ireland) Ms. Kanyaluk Uttrachon (Thailand) Mr. Aaron Vamosh (Israel)

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Member Organisation CRP - Centre for the Rehabilitation of the Paralysed Bangladesh Square Hospital Bangladesh SCIDAB - Spinal Cord Injury Development Association Bangladesh All Party Parliamentary Group Bangladesh Dhaka Medical College Hospital Bangladesh Bangabondhu Sheikh Mujibar Medical University BSMMU Bangladesh Centre for Disability and Development Bangladesh Sher-e-bangla Medical Hospital Bangladesh Bangladesh Assoc of Physical Medicine and Rehabilitation Bangladesh Jigme Dorji Wangchuck National Referral Hospital Bhutan Rehab Centre for SCI Cambodia Peking University Third Hospital China University of Hong Kong Hong Kong Hong Kong Polytechnic Hong Kong Indian Spinal Injuries Centre India Hope Hospital India Ganga Hospital India Manipal University India Sree Balaji Medical College and Hospitals India King George Medical University India Nina Foundation India Manipal University India TSF India SIA Punjab India AIIMS - All India Institute of Medical Science India Christian Medical College, Vellore India Persahabatan Hospital Indonesia Siloam Hospital TB Simatupang Indonesia Fatmawati General Hospital Indonesia Dr Cipto Mangunkusumo National General Hospital Jakarta Indonesia Indonesian PMR Society Indonesia Universitas Padjadjaran Indonesia Hasan Sadikin General Hospital Indonesia National Rehabilitation Centre Korea SIA Korea University of Health Sciences Laos

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Member Organisation (con’t) UMMC Malaysia Queen Elizabeth Hospital Malaysia Spinal Injuries Association Malaysia Cheras Rehabilitation Hospital Malaysia Sosco Rehab Centre; Malaysia Assocation of Rehabilitation Physicians Malaysia Hospital Raja Permiasuri Bainun, Ipoh Malaysia Yangon General Hospital Myanmar Spinal Injury Rehabilitation Centre Nepal Nepal SCI Association Nepal Green Pastures Hospital Nepal Armed Forces Institute of Rehabilitation Medicine Pakistan Bahria University Medical College Pakistan Phillipine Orthopaedic Centre Phillipines Pacific Rehabilitation Singapore Tan Tock Seng Hospital Singapore SIA Sri Lanka National Hospital, Colombo Sri Lanka Sri Lanka Spinal Cord Network (SLSCoN) Sri Lanka MoH Sri Lanka Sri Lanka Dept of Rehab Medicine, University of Chiang Mai Thailand Mahidol University Thailand Prince of Songkla University Thailand Sirindhorn National Medical Rehabilitation Institute Thailand Siriraj Hospital Thailand

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SUPPORTERS

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MAP OF VENUE

Floor 1 Buathong Room Fai Kham Room Inthanin Room

Floor 2 Phuang Kram Room Fueng Fah Room Phuang Saet Room 10 16th ASCoN CONFERENCE AND WORKSHOP

TABLE OF CONTENTS

PRECONFERENCE WORKSHOPS WS 1 Neuro-urology, neurogenic bladder and bowel dysfunction: what rehab doctors, neurologists, urologist, nurses and therapists should know WS1.1 Neurophysiology and neuropathophysiology of bladder and sphincter; and discussion 20 Prof. Dr. Helmut Madersbacher WS1.2 The diagnostic work-up of patients with neurogenic bladder and sphincter: Are urodynamic tests 21 always necessary? and discussion Dr. Stefania Musco WS1.3 Management of urologic symptoms in patients with stroke, MS, Parkinson and dementia; and 24 discussion Prof. Dr. Helmut Madersbacher WS1.4 The spinal reflex bladder: which therapies can be offered nowadays? and discussion 25 Dr. Stefania Musco WS1.5 Neurogenic bowel dysfunction, pathophysiology and management, and discussion 27 Assoc. Prof. Apichana Kovindha WS 2 Enhancing mobility: how to? 28 Exercise training for wheelchair users and for ambulators Prof. Lisa Harvey WS 3 Building confidence after SCI 29 Ms. Nipapan Tipayajak WS 4 Building capacity of rehab professionals 32 Strengthening the Capacity of Health Systems to increase their inclusion and responsiveness to persons with SCI in Asia Mr. Stephen Muldoon WS 5 Tetraplegic hand 33 Assessment and therapy; and demonstration Assoc. Prof. Siam Tongprasert WS 6 Sexuality and disability 34 Counselling and management Dr. Bum-Suk Lee, Dr. Stanley Ducharme WS 7 Pressure ulcers 36 Wheelchair cushions selection, Pressure mapping and demonstration Assist. Prof. Pratchayapon Kammuang-lue, Ms. Kanyaluk Uttrachon

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PLENARY SESSIONS Plenary Session 1: Pressure Ulcer PS1.1 Development of an online toolkit for assessment and management of pressure ulcer injuries in 38 people with SCI Prof. James Middleton PS1.2 The reliability of measuring wound undermining in people with spinal cord injury 39 Dr. Mohit Arora PS1.3 Laser therapy for treating pressure ulcer in spinal cord injured patients: is it time to reconsider? 40 Dr. Sintip Pattanakuhar PS1.4 Educational programme using the health belief model as an educational programme for effective 41 pressure ulcer prevention in persons with SCI Assoc. Prof. Nazirah Hasnan Plenary Session 2: Improving Mobility PS2.1 Weakness is an important determinant of function yet we know little about the effectiveness of 42 different therapeutic interventions Prof. Lisa A Harvey PS2.2 Evidence-based on advanced therapy 43 Assoc. Prof. Julia E Patrick Plenary Session 3: Cardiovascular and Exercise Issues PS3.1 Heart and endurance activity for SCI persons 44 Prof. Henry Prakash Magimairaj PS3.2 Strength training for partially-paralysed muscles in people with recent spinal cord injury: a within- 45 participant randomized controlled trial Anjali Gambhir PS3.3 High sensitivity cardiac troponin-t in chronic spinal cord injury 46 Prof. Henry Prakash Magimairaj PS3.4 Bleeding complication from pharmacological treatment of DVT in Thai SCIs: is it time to reconsider 47 our guideline Dr. Sintip Pattanakuhar PS3.5 Deep vein thrombosis guideline 48 Dr. Sintip Pattanakuhar Plenary Session 4: Fact and Future of Recovery after SCI PS4.1 Neurological recovery 49 Prof. Wagih El Masri PS4.2 Surgery and stem cells 50 Dr. Harvider Chhabra PS4.3 The effect of N-Acetyl Cysteine (NAC) for improving neurological outcomes in animal model: a 51 systematic review Dr. Sintip Pattanakuhar

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Plenary Session 5: Urological Issues PS5.1 Urinary tract infection (UTI) 52 Prof. H Madersbacher PS5.2 Vesico-ureteric reflux (VUR) 53 Prof. H Madersbacher PS5.3 Incontinence 55 Assoc. Prof. Apichana Kovindha PS5.4 Urological checkup 56 Prof. F Biering-Sørensen Plenary session 6: Research in SCI and International Data Sets for SCI PS6.1 Developing an Active Spinal Cord Injury Collaborative International Research Culture 57 Prof. Doug Brown PS6.2 The use of the International SCI Standards and Data Sets in clinical practice and research – 58 current situation Prof. Fin Biering-Sørensen PS6.3 Is walking Index for Spinal Cord Injury II (WISCI II) proper for all SCI persons walking with 59 spasticity? Dr. Sintip Pattanakuhar Plenary session 7: How to Make Tetraplegic Hands Function? PS7.1 Surgery for tetraplegic hands 60 Assoc. Prof. Kanit Sananpanich PS7.2 Rehab therapy 61 Assoc. Prof. Siam Tongprasert

SYMPOSIUM SESSIONS Symposium session 1: After Care SS1.1 Multidisciplinary care programme 63 Dr. Dirk van Kuppevelt SS1.2 Results from ASCoN questionnaire 64 Dr. Yorck B Kalke SS1.3 Fact to be aware of in aftercare: experience in ASCoN countries 65 Stephen Muldoon SS1.4 Community-based care for reducing mortality and improving quality of life after spinal cord injury in 66 Bangladesh: a 3-year update on the CIVIC trial Sohrab Hossain SS1.5 Identification of wheelchair skills capacity, confidence and performance level of manual wheelchair 67 users with spinal cord injury in the selected community in Bangladesh Md Julker Nayan SS1.6 Access to proper urological care in persons with SCI in Thailand: a preliminary report 68 Dr. Donruedee Sripuppaphon 13 16th ASCoN CONFERENCE AND WORKSHOP

Symposium Session 2: SCI Rehab Services – Lessons Learned from ASCoN and European Countries SS2.1 Experience from Korea 69 Dr. Bum-Suk Lee SS2.2 Rehabilitation service in Malaysia 70 Dr. Yusniza Modh. Yusof SS2.3 BSM Medical University updates on SCI Rehab: looking for center of excellence 71 Prof. Taslim Uddin SS2.4 Thailand: Should we have a specialized rehab center/facility for SCI? 72 Assoc. Prof. Apichana Kovindha SS2.5 Treatment and Rehabilitation after SCI in Denmark 73 Prof. F Biering-Sørensen Symposium Session 3: Building and Maintaining Human Relationships SS3.1 Current status of traumatic tetraplegic married women in the community: a phone call survey 74 experienced at CRP Dr. Sayeed Uddin Helal SS3.2 Sexual well-being of patients with spinal cord injury: an approach from physiotherapist’s 75 perspective Ms. Azizatul Smrity SS3.3 Sexuality issues of persons with SCI, why & how to address 76 Mr. Shivjeet Singh Raghav SS3.4 Physician’s view on sexuality of persons with SCI 77 Dr. Bum Suk Lee SS3.5 A higher level of intimacy: caregiver for your own loved one 78 Ms Miriam Feinberg Vamosh SS3.6 An interdependent living with my caregiver 79 Ms. Busara Booranapansri SS3.7 33 years of my personal experience dealing with chiefs and colleagues 80 Ms. Nipapan Tipayajak SS3.8 Psychologist’s view on relationships 81 Dr. Steven Ducharme

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FREE PAPERS Free Paper 1: Pressure ulcer OP1.1 The paradox of pressure ulcers in spinal cord injury: comparison between tetraplegia and 83 paraplegia Shivani Rajasegaran OP1.2 Why-why analysis of pressure ulcer with ICF framework 84 Ms. Warangkana Sitthikan OP1.3 Integrative rehabilitation program in SCI patient with high risk pressure ulcer and depression can 85 prevent Pressure Ulcer: A Case Report Study Dr. Putri Khaerani OP1.4 How pressure sore prevented for person with spinal cord injury in Bangladesh 86 Shakhanwath Hossain OP1.5 A prototype of an automatic air mattress turning device for pressure ulcer prevention 87 Narongrat Sawattikanon OP1.6 Low level laser therapy in chronic pressure ulcer of cervical cord injury: is it beneficial? 88 A case report Dr. Anggie Putri Nayanti RESEARCH CONTEST Free Paper 2: Research Contest for ASCoN awards OP2.1 Effects of an endurance activity on cardiac and metabolic markers in person with and without 89 spinal cord injury Mr. Senthivelkumar Thangavelu OP2.2 Lower limb support ability and its correlation to walking in ambulatory patients with spinal cord 90 injury Mr. Teerawat Nithiatthawanon OP2.3 Effectiveness of harness gait training with body weight support gait system in patients with 91 incomplete spinal cord injury (SCI) at CRP in Bangladesh Mohammad Anwar Hossain OP2.4 The effect of modified Prasit Thai upper extremity exercises on unsupported sitting balance in 92 paraplegic patients: a randomized controlled trial with assessor-blind Dr. Anuwat Suwannakad OP2.5 The Association between the International Spinal Cord Injury Upper Extremity Basic data set and 93 Spinal Cord Independence Measure Dr. Kasan Sotthipoka OP2.6 Telephone-based management of pressure ulcers in people with spinal cord injury in low-and 94 middle-income countries: a randomized controlled trial Dr. Mohit Arora OP2.7 Anxiety, depression and exercise self-efficacy in paraplegic SCI in patients with pressure ulcer 95 Widya S Sari 15 16th ASCoN CONFERENCE AND WORKSHOP

OP2.8 Reliability of the international urodyanmic basic spinal cord injury data set 96 Dr. Kittamet Dejkriengkraikul Free paper 3: Work and Community life after SCI OP3.1 Early access to vocational rehabilitation: development, implementation and evaluation of a Novel 97 in-patient Service (the in-voc program) Prof. James Middleton OP3.2 Quality of life after SCI in Thai individuals living in an urban area: an in-depth interview 98 Mr. Aitthanatt Eitivipart OP3.3 Barriers to participate in activity of daily livings in the community among the persons with spinal 99 cord injury Shakhawath Hossain OP3.4 Facilitators and barriers of functional independence in spinal cord injury patients with motor useful 100 after discharge from rehabilitation ward Chutima Muangdan OP3.5 Factors influencing the success of home modification in paraplegic SCI individuals in Bangladesh 101 Mohammad Iqbal Hossain OP3.6 Perception of the women with spinal cord lesion about their vocational rehabilitation: an institutional 102 based study Ms. Shamima Islam Nipa OP3.7 Proposed sport rehabilitation protocol for friends with spinal cord injury (SCI) 103 Dr. Ratna Gaurang Vora OP3.8 What is your choice between health or success? A case series of Thai SCI athletes in the 9th 104 ASEAN Paragames Dr. Sintip Pattanakuhar Free paper 4: Secondary Conditions and Prevention OP4.1 A telephone-based version of the spinal cord injury-secondary conditions scale: a reliability and 105 validity study Dr. Mohit Arora OP4.2 Characteristics of shoulder pain among paraplegic wheelchair user 106 Rubel Ahmad Samir OP4.3 Therapeutic dose baclofen-induced delirium in elderly paraplegic patient: aware of risk factors to 107 avoid serious complication Dr. Pimthong Jitsakulchaidej OP4.4 The effects of task-oriented training on dressing lower part in paraplegic patient with pelvic 108 fracture: a case report Tarinee Prakobkhong OP4.5 One year follow up study on effectiveness of patient education in patients with SCI after discharge 109 Ms. Raveevan Jindamaneesirikul OP4.6 Health mechanics: a self management tool for spinal cord injured people: possibilities of 110 introducing through e-learning platform Mohammad Monjurul Karim 16 16th ASCoN CONFERENCE AND WORKSHOP

Free paper 5: Digestive and Metabolic Dysfunctions OP5.1 What’s wrong with digestive system after SCI? 111 Assoc. Prof. Apichana Kovindha OP5.2 Colonic obstruction from sigmoid volulus in tetraplegics: common symptom from uncommon cause 112 Dr. Sintip Pattanakuhar OP5.3 Dysphagia in Traumatic Cervical Spinal Cord Injury with A Large Anterior Bridging Osteophyte: A 113 Case Report Dr. Nita Theresia Reyne OP5.4 Severe Hyponatremia in SCI: Who Is at Risk and How to Treat? 114 Dr. Supattana Chatromyen OP5.5 Bowel care: why is it important? 115 Assoc. Prof. Julia E Patrick Free paper 6: Voice of Customer – What Rehab Team Should Know OP6.1 The hazards in aging with SCI 116 Mr. Aaron Vamosh OP6.2 Managing common problems of uncommon SCI’s 117 Ms. Rajshari Gunvantrao Patil OP6.3 Use of focus group for voices of SCI patients on leisure activities during post-acute rehab phase 118 Mrs. Arunothai Sukkraithai OP6.4 My career, my home 119 Mr. Manakit Taolorm Presented by Dr. Chatchai Tangvinit OP6.5 Inspiration of my life 120 Miss. Sudarat Thinnchak OP6.6 From a burden to a change agent 121 Mr. Atthapon Kantha-udom Presented by Dr. Supattana Chatromyen Free paper 7: Design and technology for mobility OP7.1 Challenges and potential solutions of effective assistive device technology service delivery system 122 Mr. Nekram Updhyay OP7.2 Safety adaptability, compliance and benefits of CYBO LIMB – robotic exoskeletal orthosis for 123 rehabilitating spinal cord injury patients with lower limb neurological deficit – a pilot study Asst. Prof. Karthikeyan Ramachandran OP7.3 The usability test of mechanical and robot assisted gait system in patient with spinal cord injury a 124 pilot study Wang Jae Lee OP7.4 New assistive technology for wheelchair: my personal experience 125 Mr. Aaron Vamosh OP7.5 Effectiveness of using Driving Simulator in Driving Rehabilitation Clinic 126 Mr. Auttapon Wongtakeaw

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STRUCTURED POSTERS Contest SP1.1 Comparison using two forms of bladder diaries for monitoring bladder functions of spinal cord injury 128 patients: a pilot study Leni Kopen SP1.2 The feasibility and effect of the mobile-game based respiratory rehabilitation exercise for people 129 with cervical cord injury Hyunju Park SP1.3 Maximal respiratory pressures in patients with spinal cord injury from SNMRI (pilot study) 130 Monticha Muangngoen SP1.4 The intervention for cervical cord injury patients using their smart phone according to neurological 131 disability level HongKyu Kim SP1.5 Increased lower limb loading ability during sit-to-stand associated with possibility of walking 132 progression in ambulatory patients with spinal cord injury Lalita Khuna SP1.6 Management of a case with two years traumatic tetraplegic spinal cord injury patient by three track 133 reasoning: a case report Farjana Taoheed SP1.7 Impacts of Sports on Psychological Status: Anxiety and Depression for the Spinal Cord Injury 134 Patients Sharmin Alam SP1.8 Association between duration of spinal cord injury and depression 135 Dr. Anada Marina SP1.9 Using the International Classification of Functioning Disability and Health Comprehensive Core Set 136 to measure environmental barriers and facilitators in persons with chronic spinal cord injury in Indonesia Dr. Sharon Loraine Samuel Non-contest SP1.10 Association between SCI profile with length of stay in rehab ward and SCIM III at discharge in 137 Fatmawait General Hospital, Indonesia Listyani Herman SP1.11 When delivery of standard care is not delivering enough: managing dual disabilities of clavicular 138 fracture in a complete thoracic spinal cord injury patient: a case report Dr. Judy Kwong Kee Ngu SP1.12 Non-traumatic spinal cord injury case profile in Fatmawati General Hospital 139 Dr. Ronald Pakasi SP1.13 A Rare Case Intra-Medullary Thoracic Tuberculoma and Tuberculous Myelitis Of The Spinal Cord 140 Presenting With Paraplegia: A Case Report Dr.Novaria Puspita 18 16th ASCoN CONFERENCE AND WORKSHOP

SP1.14 T2 spinal compression fracture due to tuberculosis spondylitis: can we mobilize patient without 141 stabilization? Dr.Neidya Karla SP1.15 Psychosocial-economic impact in management of traumatic spinal cord injury patient in Indonesia: 142 a case report Dr.Meinar Ferryani SP1.16 Unique cause of spinal cord injury in India 143 Dr. Ratna Gaurang Vora Poster only SP1.17 Dual disabilities in a spinal cord injury patient 144 Dr.Audrey Wong SP1.18 Rehabilitation Conservative Management in Spinal Cord Injury Patient due to Syringomyelia and 145 Multiple Congenital Anomaly: A Case Report Dr.Vanydia Aisyah SP1.19 Pelvic floor muscle exercise and biofeedback therapy following electrical stimulation in patient 146 spinal cord injury with neurogenic bladder dysfunction: a preliminary study Stephanie Therodora Yulinda SP1.20 Sports for recreation during admission for rehabilitation 147 Narongrat Sawattikanon SP1.21 Enabling Early Decompression Surgery for Spinal Cord Injury (SCI) using Malaysia Social Security 148 (SOCSO) Epulih Online Solution Dr.Ong Kuo Ghee SP1.22 Safety of UDS for SCI patients with Asymtomatic pyuria or Bacteuria: Asymtomatic Pyuria or 149 Bacteuria do not increase risk of UTI after UDS with prophylactic antibiotics Wonsan Seo, Kyungok Chung SP1.23 Comparison of Rehabilitation Outcomes between SCI and Non-SCI Specialized Rehabilitation 150 Facilities in Thailand: Results from the Thai Spinal Cord Injury Registry (TSCIR) Sintip Pattanakuha

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PRECONFERENCE WORKSHOPS

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The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand

WS1.1 Neurophysiology and neuropathophysiology of bladder and sphincter

Prof. Dr. Helmut Madersbacher

Part 1: Lectures (morning session) 1. An update on Neuro-Anatomy, Neuro-Physiology, and Neuro-Pathophysiology of the lower urinary tract; 2. The diagnostic work up in patients with already known (or suspected) neurogenic bladder; 3. Neurogenic detrusor overactivity – what can be offered to the patients nowadays; 4. Neurogenic detrusor underactivity – what can be offered to the patients nowadays; 5. Neurogenic bowel dysfunction – does one therapy fit all?

Part 2: Case study discussion (afternoon session) Participants are invited to present their cases and to discuss with lecturers 1. Diagnosis and problems related to neurogenic bladder dysfunction; 2. How to preform and interpret an urodynamic investigation 3. Management

It can be downloaded from the following link

https://goo.gl/uE5xhv

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The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand

WS1.2 The diagnostic work-up of patients with neurogenic bladder and sphincter: Are urodynamic tests always necessary?

Dr. Stefania Musco

Abstract The management of neurogenic lower urinary tract dysfunction (NLUTD) is an important issue in rehabilitation programs for patients with spinal cord injury (SCI)1. The impairment of bladder function results in a high risk of urinary tract deterioration, which increases morbidity2. The principal goals of managing NLUTD are preservation of upper urinary tract function and prevention of renal failure. Various approaches have been developed and different therapies have become available over the last 30 years to achieve these goals. The most appropriate therapeutic scheme should be carried out considering the functional classification for motor function based on clinical and urodynamic findings (fig 1). The initial clinical assessment of patients with NLUTD should include a detailed history, systematic physical examination (fig 2), urine analysis, urinary tract imaging (eg. ultrasound) and non invasive urodynamic testing such as voiding diary and post-void residual (PVR) (Tab 1). Besides all, the most of patients with SCI required a specialized assessment with invasive urodynamic studies, preferably videourodynamics when available (tab 2)10. Particular attention should be paid to possible warning signs and or symptoms such (eg. pain, infection, haematuria and fever) which may require further investigations. However, in patients with SCI it's often difficult to report accurately symptoms related to NLUTD complications3-5. Traditionally, neurological pathology of SCI has been divided in suprasacral and sacral spinal cord lesions (fig 1).

Suprasacral spinal cord lesions Traumatic suprasacral SCI results in an initial period of spinal shock, during which there is detrusor areflexia. After then, the interruption of nerve trasmission from the pontine (PMC) to the sacral micturition center (SMC) causes neurogenic detrusor overactivity (NDO) with detrusor sphincter dyssinergia (DSD). Clinically, patients with lesions above the cone usually suffer from incontinence secondary to NDO and urinary retention due to the functional bladder outlet obstruction (BOO). Furthermore, in patients with SCI above level Th 5–Th 6, a sudden severe hypertension can commonly occur as manifestation of autonomic dysreflexia (AD) and can lead to dramatic results if not properly treated6-8

Sacral spinal cord lesions Damage to the sacral cord may present several grade of upper and lower mononeuron lesions which results in different urodynamic diagnosis, as well as NDO like in suprasacral lesions, although the most common finding is detrusor areflexia (DA) with subsequently urinary retention. However, particularly in individuals with partial injuries, DA may be accompained by decreased bladder compliance9. The exact mechanism by which sacral parasympathetic decentralization of the bladder causes decreased compliance is still unknown. Furthermore, if the nuclei of the pudendal nerves are injured (eg. cauda equina), a paralysis of the urethra sphincter and pelvic floor muscles will occur often with loss of outflow resistance and stress incontinence.

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Figure 1. The pattern of LUT dysfunction following neurological disease is determined by the site and nature of the lesion10.

Figure 2. The neurological status of a patient with NLUTD: (a) dermatomes of spinal cord levels L2-S4; (b) urogenital and other reflexes in the lower spinal cord10.

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Tab 1. Recommendations – Initial assessment10 History taking Grade Take an extensive general history, concentrating on past and present symptoms. Strong ↑↑ Take a specific history for each of the four mentioned functions - urinary, bowel, sexual Strong ↑↑ and neurological. Pay special attention to the possible existence of alarm signs (e.g. pain, infection, Strong ↑↑ haematuria, fever) that warrant further specific diagnosis. Assess quality of life when evaluating and treating the neuro-urological patient. Strong ↑↑ Use available validated tools including the Qualiveen and I-QoL for urinary symptoms Strong ↑↑ and the QoL-BM for bowel dysfunction in multiple sclerosis and spinal cord injury patients. In addition, generic (SF-36 or KHQ) questionnaires can be used. Physical examination Acknowledge individual patient disabilities when planning further investigations. Strong ↑↑ Describe the neurological status as completely as possible, sensations and reflexes in the Strong ↑↑ urogenital area must all be tested. Test the anal sphincter and pelvic floor functions. Strong ↑↑ Perform urinalysis, blood chemistry, bladder diary, residual and free flowmetry, Strong ↑↑ incontinence quantification and urinary tract imaging.

Tab 1. Level of Evidence - urodynamic assessment 10 Summary of evidence LE Urodynamic investigation is the only method that can objectively assess the (dys-)function of the 2a LUT. Video-urodynamics is the optimum procedure for urodynamic investigation in neuro-urological 4 disorders.

1 Frankel HL, Coll JR, Charlifue SW, Whiteneck GG, Gardner BP, Jamous MA, et al. Long-term survival in spinal cord injury: a fifty year investigation. Spinal Cord 1998;36:266-74. 2 Stover SL, De Lisa JA, Whiteneck GG. Spinal cord injury: Clinical outcomes from the model systems. Gaithersburg, Maryland: Aspen Publishers;1995. p. 234. 3 Jayawardena V, Midha M. Significance of bacteriuria in neurogenic bladder. J Spinal Cord Med 2004; 27(2):102- 5 4 Massa LM, Hoffman JM, Cardenas DD. Validity , accuracy and predictive value of urinary tract infection signs and symptoms in individuals with spinal cord injury on intremittent catheterization. J Spinal Cord Med 2009;32(5):568-73 5 Linsenmeyer TA, Oakley A. Accuracy of individuals with spinal cord injury at predicting urinary tract infections based on their symptoms. J Spinal Cord Med 2003 Winter;26(4):352-7 6 Braddom RL, Rocco JF. Autonomic dysreflexia. A survey of current treatment. Am J Phys Med Rehabil 1991 Oct;70(5):234-41 7 Silver JR. Early autonomic dysreflexia. Spinal Cord 2000 Apr;38(4):229-33 8 Assadi F, Czech K, Palmisano JL. Autonomic dysreflexia manifested by severe hypertension. Med Sci Monit 2004 Dec;10(12):CS77-9 9 Herschorn S, Hewitt RJ. Patient perspective of longterm outcome of augmentation cystoplasty for neurogenic bladder. Urology 1998;52:672-8 10 B. Blok, J. Pannek, D. Castro-Diaz et al. EAU Guidelines 2017. http://www.uroweb.org/guideline/neurourology/ 24 16th ASCoN CONFERENCE AND WORKSHOP

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WS1.3 Management of urologic symptoms in patients with stroke, MS, Parkinson and dementia; and discussion

Prof. Dr. Helmut Madersbacher

It can be downloaded from the following link

https://goo.gl/8b2opf

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WS1.4 The spinal reflex bladder: which therapies can be offered nowadays?

Dr. Stefania Musco

INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) has a strong impact on Qol in SCI patients. Many aspects should be considered for the treatment of choice, which also cannot be disjoined from the entire rehabilitation program. Firstly, besides protecting upper urinary tract and improving continence, patients expectations, family and social conditions should be take in account in order to interfere as little as possible in their Qol. In patients with high detrusor pressure during the filling phase (neurogenic detrusor overactivity and/or low Detrusor compliance) or during the voiding phase (e.g. presence of detrusor sphincter dyssinergia and/or other causes of bladder outlet obstruction), the main goal is aimed primarily at ‘conversion of an active, aggressive high- pressure bladder into a passive low-pressure reservoir‘ despite post-voiding residual1. In SCI with low bladder pressures at urodynamics, continence with low bladder pressures can be achieved by intermittent catheterization (IC) and pharmacotherapy (eg. antimuscarinics). Whether IC is not feasible, assisted bladder emptying techniques and the use of external appliances can be proposed as solution. However, in this case patients needs to be strictly monitored. If a bladder outlet obstruction (BOO) is present, a drug therapy with alpha-blockers in male patients can be added as well (Tab 1) In NDO with severe detrusor sphincter dyssinergia (DSD) and high detrusor pressure, which are considered no safety for preserving kidney function, both solutions could be proposed: reducing detrusor pressure (eg. antimuscarinics and/or Botulinum toxin A injections) combined with IC regimen, or alternatively, decreasing the bladder-outlet resistance to permit assisted bladder emptying with safety bladder pressures (eg. sphyncterotomy). Furthermore, in case of incomplete spinal cord lesion, besides all treatments mentioned above, other strategies as neuromodulation techniques can be also indicated.

TREATMENT OPTIONS Triggered reflex voiding and bladder compression techniques like Valsalva or Credè manoeuvre are potentially risky for upper urinary tract and they should be recommended only for LUTD urodynamically safe and stable (eg. after sphynterotomy), whether an adequate follow-up can be guaranteed1. Catheters IC combined with antimuscarinics is the standard therapy for managing NDO. Frequency of catheterization depends on many factors as bladder volume, fluid intake, postvoid residual, urodynamic findings. Usually it is recommended to catheterized 4-6 times a day during the early stage after spinal cord lesions. Pharmacotherapy Antimuscarinics (eg. oxybutynin chloride, trospium chloride, solifenacin, darifenacin, tolterodine, fesoterodine and propiverine) have been documented to be effective for NDO treatment. The high incidence of side effects can limit their usage. Although the oral application is the usual way, intravesical instillation (oxybutynin) may be an alternative1. (Tab 1) Botulinum toxin A (BoNT-A) injections into the detrusor muscle was reported to improve incontinence and increase functional bladder capacity in spinal cord injured patients with NDO (Tab 1). Furthermore, chemical denervation using BoNT-A sphincter injections, it’s been considered a valid option to reduce the bladder-outlet resistance and protect the upper urinary tract, alternatively to sphincterothomy in SCI patients with DSD .

CONCLUSIONS The right early and multidisciplinary management in patients affected by SCI and more recently, specific therapeutic strategy, have showed excellent results in the rehabilitation of NLUTD with a significant reduction of mortality related to serious urological complications, as consequence. Furthermore, the individual clinical history, apart from neurological pathology, such as prostatic hyperplasia or previous surgeries should be weighed. necessarily, the best solution needs to be the most conservative and feasible treatment, according to the 26 16th ASCoN CONFERENCE AND WORKSHOP

functional limitations of SCI patients. With early instituted and optimal treatment, the large majority of patients can be adequately controlled without antireflux surgery or surgical bladder augmentation. Nowadays, augmentation cystoplasty is limited to a small group of patients in whom medical or minimally invasive treatment fails and persistent high filling pressure occured2.

Tab 1 Guidelines for non-invasive conservative treatment3

Summary of evidence LE

Long-term efficacy and safety of antimuscarinic therapy for neurogenic detrusor overactivity is well 1a documented.

Alternative routes of administration (i.e., transdermal or intravesical) of antimuscarinic agents may 2 be used.

Maximise outcomes for neurogenic detrusor overactivity by considering a combination of 3 antimuscarinic agents.

Botulinum toxin A has been proven effective in patients with neuro-urological disorders due to MS 1a or SCI in multiple RCTs and meta-analyses. Bladder augmentation is an effective option to decrease detrusor pressure and increase bladder 3 capacity, when all less-invasive treatment methods have failed.

1 Wyndaele JJ, Castro D, Madersbacher H, et al. Neurologic urinary and faecal incontinence: Abrams P, Cardozo L, Khoury S, Wein A editors. Incontinence, Vol 2, Plymouth, UK: Health publications; 2005 p. 1059-62 2 Chartier-Kastler EJ, Mongiat-Artus P, Bitker MO, Chancellor MB, Richard F, Denys P. Long-term results of augmentation cystoplasty in spinal cord injury patients. Spinal Cord 2000;38:490–4. 3 B. Blok, J. Pannek, D. Castro-Diaz et al. EAU Guidelines 2017. http://www.uroweb.org/guideline/neurourology/

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WS1.5 Neurogenic bowel dysfunction: pathophysiology and management

Apichana Kovindha, M.D., FRCPhysiatrT Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Neurogenic bowel dysfunction (NBoD) is generally referred to colonic or anorectal dysfunction causing impairments of defection and faecal continence functions. It is common after spinal cord injury (SCI) and often leads to poor quality of life.

Neural control of bowel consists of extrinsic nervous control (somatic and autonomic nervous system) and enteric nervous system control. During storage phase, the internal anal sphincter (IAS), a thick circular smooth muscle layer of the rectum, generates mechanical activity producing anal pressure to maintain continence whereas the external anal sphincter (EAS) reinforces during voluntary squeezing. When the rectum is stretched, urge to defecate comes and lead to recto-anal inhibitory reflex and falling in anal resting pressure, and defecation occurs with relaxation of the puborectalis and the EAS driven by peristalsis and increased intraabdominal pressure by Valsalva manoeuvre.

If spinal cord is injured at suprasacral level, defecation may be impaired due to anorectal dyssynergia, like detrusor-sphincter dyssynergia (DSD), and lower rectal compliance. Impaired sense of rectal fullness leads to excessive accumulation of stool, faecal impaction, difficulty defecation and incontinence. On contrary, sacral/subsacral lesion leads to weak anal sphincter and impaired sensation, faecal incontinence is more frequent. Therefore, aims of bowel management are regular bowel elimination and no incontinence. Bowel management consists of not only bowel care procedures but also nutritional management.

NBoD is classified as reflexic and areflexic bowel according to suprasacral and sacral lesions. In reflexic bowel with anorectal dyssynergia, soft and formed stool helps facilitate defecation with chemical and/or mechanical stimulants (e.g. suppositories or enema) whereas in areflexic bowel with loose sphincter tone, firm stool is appropriate for manual/digital evacuation. To achieve such stool consistency, at least 2 liters of fluid intake as well as 20-30 mg of dietary fibers are recommended. Mild stimulants, bulk-forming laxatives or stool softeners may be necessary. In addition, one should concern of patients’ functions and abilities to learn, to sit, to transfer, to dress/undress, to use arm and hand, to wash oneself as well as environmental factors such as toilet and necessary equipment. Regular bowel care at least 3 times/week should be stressed to avoid complications such as constipation, faecal impaction, incontinence, bowel obstruction etc. Those at risk of autonomic dysreflexia, xylocaine jelly should be applied before evacuation.

In conclusion, a successful bowel management needs right education, right faecal consistency, right (regular) time, right trigger (stimulant), right place and right equipment; and leads of better quality of life and free of complications.

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WS 2 Enhancing mobility: how to? Exercise training for wheelchair users and for ambulators

Prof. Lisa Harvey John Walsh Centre for Rehabilitation Centre, Sydney Medical School, University of Sydney, Sydney, Australia.

The focus of this workshop will be on mobility training for people with spinal cord injuries. The types of mobility skills that will be covered include moving about on a bed, different types of transfers, wheelchair skills and gait for people with different patterns of paralysis. The workshop will include a combination of lectures and practical sessions, and will involve analyzing videos of people who are recently injured and inexperienced at moving, and people who have been injured for a long time and have developed successful strategies to move. The workshop will be structured about a five step process for planning and implementing an appropriate mobility- training program. This includes assessing impairments, activity limitations and participation restrictions; setting goals; identifying key problems; administering treatments; and measuring outcomes. Time will also be devoted to learning about appropriate mobility goals for people with different levels of injuries and the implications of different patterns of paralysis on movement. Participants will encouraged to think about effective strategies for teaching patients motor skills and the importance of developing interesting, motivating and varied training programs. The importance of progression will also be emphasized. The last session will be devoted to gait and orthoses. In all, this workshop will provide participants with the necessary skills to train key mobility skills in people with spinal cord injuries while challenging participants to reflect upon their practices.

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WS 3 Building Confidence after SCI

Nipapan Tipayajak, Manakit Thaolorm, Atthapon Kantha-Udom, Sudarat Thianchak, Busara Booranapansri Consumer

Objectives 1. To share and exchange the individual experience in term of success, failure, challenge and change agent of what can lead a fully productive life. 2. To identify the specific strategies for building self-confidence. 3. To encourage and empower the participants to formulate self-help group or peer group in their community. Interesting issues Self-confidence is extremely important in almost every aspect of our lives especially people who become disabled as well as SCI consumer. When you become disabled, its affected to your physical function, emotional and social participation. SCI always ask some questions to peers for example; “what should I do when I hear negative words?” “How can I overcome shyness” “How to build my self-confidence to overcome embarrass while going out”. It makes they feel insecure or embarrassed. It means SCI consumer lack of confidence, but they can find it to become successful. SCI consumer . There are various ways to coping with disabilities, accept your disability, challenging, believe in yourself, respect, skill training. It may help you have more confidence and better independent life.

Conclusion Do not be afraid to push yourself beyond your physical limited. Remember that words are just words, they won't affect your health, your family and your job. Build up your self confidence, and you may soon be wondering why you were scared in it.

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WS 3.1 Building confidence after SCI- Till I believe in myself

Kanticha Reungdang, a practical nurse Rehabilitation Ward, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand

Abstract After an off-cliff car accident on 15th March 2003, my life was changed. My spinal cord (T10) was injured. I became paraplegic and unable to do daily activities by myself. As a single mon, I could not take care of my 9 years old son and became a burden. I felt depressed, hopeless and helpless. Pressure ulcer developed due to spending most of my time in bed. I was re-admitted at the rehab ward where I was surrounded by the rehab team and other SCI patients. They gave me encouragement. I then realized that I was not alone. I had to take care of my child. I became motivated and strictly followed the doctor and rehab team’s suggestions. Since then, my condition had improved. I could take care of myself and my son, have more confident and start to socialize with others. With a good health, being independent and the supports from my colleagues, I was offered to work as a practice nurse again but at the rehab ward. This work not only gives back my self-worth but also an opportunity to encourage other disabled persons to overcome their challenges. In addition, my past experience contributed greatly to my ability to advise and help others in need.

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WS 3.2 Building Confidence after SCI- Nothing impossible, believe in yourself

Busara Booranapansri

Objectives Confidence start up when you give it to the people around yourself. The more you give, the more you get.

Interesting issues  All in the stage of mind. If you think you can, you can. If you think you can’t, you can’t. If you like to do but you think you can’t, it absolutely you can’t at the moment you think. Most things are difficult…Before they are easy.  Attitude is everything. A person’s level of achievement depends on one’s positive thinking of oneself. Achievement person are ordinary people….with extraordinary determination!

Conclusion The success person are not the person who have 100% they need to USE, but they use 100% the HAVE!!!

See also abstracts on OP6.4, OP6.5, OP6.5 VOC

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WS 4 Strengthening the Capacity of Health Systems to increase their inclusion and responsiveness to persons with SCI in Asia

Workshop Facilitator: Stephen Muldoon

This workshop will emphasize the importance of adopting a structured Health Systems Strengthening approach in the design, establishment and delivery of sustainable and comprehensive SCI and Rehabilitation services.

The Health Systems Response to people with SCI remains inadequate in many countries. There is however hope for optimism and over the past 2 decades the coverage and quality of SCI services has increased and more people with SCI are receiving the healthcare and rehabilitation support they require to return to their communities as active participants.

This workshop will focus on practical steps that can be taken to develop sustainable and appropriate services for people with SCI. Appling the WHO advocated Health Systems Strengthening Approach the workshop will present the 6 pillars of this approach: • Leadership and Governance • Service Delivery • Human Resources • Assistive Technology • Information and Research • Finance

This will be a participatory workshop and those attending will have the opportunity to engage in group work, discuss the areas above and to make recommendations on how we continue to support the establishment of structured services to meet the needs of growing numbers of people with SCI in the countries where we work.

The findings from the workshop will feed into the ongoing process to determine the future strategies and priorities of ASCoN in the coming 5 years. This workshop will help determine the role that ASCoN may have in strengthening health systems in Asia that are inclusive of people with SCI.

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WS 5 Tetraplegic hand: Assessment and therapy; and demonstration Tongprasert S, Sumin N, Sukkraithai A

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

This workshop aims to increase knowledge in assessment of tetraplegic hand and management of this condition using occupational therapy approach. It will involve the audience in a lively debate stimulated by video presentation of patient case studies.

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WS 6.1 Sexuality and disability: Counseling and management Dr. Bum-Suk Lee1, Dr. Stanley Ducharme2 1National Rehabilitation Hospital, Seoul, Korea, 2Boston University Medical Center, Boston, USA

With longer life expectancies following SCI, the emphasis in rehabilitation over the past decade has gradually shifted to improved quality of life. Toward this goal, issues related to sexuality must be addressed by the rehabilitation team in the acute stages of SCI. Adaptation to an SCI is a gradual process that extends over a prolonged period of time. Successful sexual adjustment is influenced by many factors such as age at time of injury, quality of social supports, physical health, gender and severity of the injury. To achieve satisfying sexual adjustment, a person with an SCI will have to learn their new sexual abilities, as opposed to recapturing the past. Ultimately information on these issues will improve the individual’s return to the community and family.

Sexual adaptation after an SCI is a learning process that involves psychological and physical adjustments. This workshop will provide an overview of the physical, psychological and relationship issues of spinal cord injury as they relate to sexual functioning and fertility. The facilitators of the workshop will be a psychologist and a medical doctor with expertise in spinal cord injury. As such, the presenters will discuss information obtained in their clinical work as well as personal experience. Finally, specific information will be discussed as to who, when and what information should be provided to the individual and partner during the inpatient rehabilitation hospitalization. At the conclusion of this workshop, it is expected that individuals will have a broad understanding of how sexuality is influenced by spinal cord injury and methods to facilitate a good sexual adjustment.

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WS 6.2 Sexuality and disability: Counselling and management

Dr. Bum-Suk Lee1, Dr. Stanley Ducharme2 1National Rehabilitation Hospital, Seoul, Korea, 2Boston University Medical Center, Boston, USA

Objectives 1) To share our experiences of sexual rehabilitation in Korea National Rehabilitation Center(KNRC) 2) To share the practical experience in management of erectile dysfunction 3) To encourage starting a hospital based sexual rehabilitation programs

Contents 1) Sexual rehabilitation programs for 20 years in KNRC - Sexual rehabilitation counseling and evaluation - Educational program - Small-group Sexual Counseling - Sex practice room ('Shelter of Love’) - Erectile Dysfunction Clinic - Annual Seminar - 3 days’ Workshop for Couples with disability - Homepage -Researches and publications

2) How to treat the erectile dysfunction after SCI? - Prevalence of erectile dysfunction after SCI - Evaluation of erectile function with 100 erection scale - Oral medication (Viagra, Cialis) - Intracavernosal injection therapy (Carverject) and priapism - Vacuum pump, penile prosthesis

3) Introduction of the guide book for sexual issues - Questions and answers for the persons with spinal cord injury, stroke, traumatic brain injury, cerebral palsy, heart disease.

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WS7 Pressure ulcers: Wheelchair Cushions Selection, Pressure Mapping and Demonstration

Assist. Prof. Pratchayapon Kammuang-lue, Ms. Kanyaluk Uttrachon CMU, Chiang Mai, Thailand

Pressure ulcers are a medical problem for wheelchair users worldwide. In developing countries, this problem is more critical because of lack to specialized technologies and equipment. Seat cushions to relieve pressure represent one of the best ways to prevent pressure ulcer for people with spinal cord injury.

The objectives - to share the experience of wheelchair cushion selection for SCI wheelchair user in Thailand - to demonstrate how to use interface pressure mapping - to demonstrate how to make a cut-out cushion, which the pressure can be distributed better than the usual foam cushion.

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PLENARY SESSIONS 38 16th ASCoN CONFERENCE AND WORKSHOP

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PS1.1 Development of an Online Toolkit for Assessment and Management of Pressure Injuries in People with Spinal Cord Injury

James Middleton, Elizabeth Dallaway, Lyndall Katte and Frances Monypenny John Walsh Centre for Rehabilitation Research, The University of Sydney

Objectives To develop an online toolkit to support clinical decision-making and provide efficient access to best-practice pressure injury (PI) assessment and management information and resources for spinal cord injury (SCI).

Clinical/interesting issues The toolkit was developed using a process of co-design with input from a state-wide multidisciplinary group of ‘clinical champions’, including community and general hospital-based nurses, wound consultants, occupational therapists (OTs) and rehabilitation physician, and spinal plastics team clinical nurse consultants, OTs, dietitians, social worker and seating therapist. The Technology Acceptance Model was employed to determine the perceived usefulness (PU) and ease-of-use (PEU) of the online resource. Responses (n=16) rated PU high (i.e. >50% of respondents scored 5/5) for toolkit sections, including ongoing PI risk screening; comprehensive assessment; red flags; validated wound assessment tool; cause and contributing factors-psychosocial assessment; management-bed support surfaces. Respondents reported that the toolkit supported multidisciplinary assessment, facilitated clinical decision-making and was most useful to share with colleagues, new staff and students. PEU rated low or ease of navigation and flow of content. Following feedback, the content was revised, with an expanded multidisciplinary clinical pathway, as well as a new navigation strategy and a clinician’s checklist were added to improve ease-of-use.

Conclusion This online pressure injury toolkit has the potential to change the responsiveness, quality and involvement of the multidisciplinary team in PI management for people with SCI. The toolkit is a practical resource for clinicians who are new to working with people with SCI and pressure injuries, delivering the most important best practice information, tools and resources to its users.

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PS1.2 The reliability of measuring wound undermining in people with spinal cord injury

Arora M*, Harvey LA, Chhabra HS, Sharawat R, Glinsky JV and Cameron ID. *Postdoctoral Research Fellow, Sydney Medical School Northern, The University of Sydney.

Objectives The objective of this study was to determine the reliability of measuring wound undermining in people with spinal cord injury (SCI).

Methods A psychometric study was conducted at the Indian Spinal Injuries Centre, New Delhi, India. Thirty people with a complete or incomplete SCI and a pressure ulcer with wound undermining were recruited. Wound undermining was measured using the four cardinal points from a clock face (with 12o' clock defined as towards the head). Inter-rater reliability was tested by comparing the wound undermining scores from two different assessors. Intra- rater reliability was tested by comparing the wound undermining scores from the same assessor on two different days.

Results The intraclass correlation coefficients (95% confidence interval) for inter-rater and intra-rater reliability were 0.996 (0.992–0.999) and 0.998 (0.996–0.999), respectively. Repeat measurements by the same and different assessor were within 0.3 cm of each other, 80% and 83% of the time, respectively.

Conclusion Measurements of wound undermining have excellent reliability.

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The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand

PS1.3 Laser Therapy for Treating Pressure Ulcer in Spinal Cord Injured Patients: Is It Time to Reconsider?

Pattanakuhar S, Kammuang-lue P and Kovindha A Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objectives To determine the effects of laser therapy for treating pressure ulcers in in spinal cord injured (SCI) patients through a systematic review of randomized controlled trials (RCT).

Methods MEDLINE, SCOPUS and the Cochrane Library databases were searched, using the keywords of “spinal cord”, “pressure ulcer” and “laser”. The participants included both traumatic and non-traumatic SCI patients. The interventions were both single wavelength and probe cluster laser therapy. The controlled groups were using shame laser plus conventional wound care or conventional wound care alone. The outcomes measurements included reduction of ulcer size or ulcer grade, as well as percentage of the patients whose wound was 50% or completely healed.

Results Among the initial searched publications of 21, three publications met the inclusion criteria. 62 SCI patients with 94 ulcers were included. Since there was heterogeneity in the participants, the interventions and the outcome measurements, a meta-analysis was not conducted. All studies used probe cluster laser therapy with the energy of 4-6 J/cm2, 3-4 times per week for 4-5 weeks. One study significantly demonstrated more decrease in ulcer size and ulcer grade, as well as percentage of the patients whose wound was 50% healed, in the laser therapy group compared with the control group. The other studies cannot demonstrate any significant difference in ulcer size or ulcer grade reduction between two groups. Difference in baseline characteristics of the participants and the ulcers, as well as heterogeneity in outcome measurements might be responsible for this inconsistent finding.

Conclusion Evidence regarding the effect of laser therapy for treating pressure ulcer in SCI patients is inconclusive. Further well-designed, randomized controlled trials were needed to clarify this inconsistency.

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PS1.4 Educational programme using the health belief model as an educational programme for effective pressure ulcer prevention in persons with SCI

Nazirah Hasnan, Julia Patrick Engkasan, Natiara Hashim

Department of Rehabilitation Medicine, University of Malaya Medical Centre

Introduction: Education plays an important role in preventing the occurrence of pressure ulcers among persons with spinal cord injury (SCI). Many methods of preventive education have been described, however, they lack a theoretical framework of human behaviour. We have integrated the theory of Health Belief Model (HBM) in our pressure ulcer prevention education programme. The HBM proposed that adherence to a health regimen is motivated by beliefs about susceptibility and severity of the condition, the benefit of the behaviour to achieve the desired outcome and barriers to perform the behaviour. The main objective of this study is to examine the effectiveness of a structured HBM-based pressure ulcer prevention educational programme in the SCI population.

Methods: We created a multidisciplinary structured pressure ulcer prevention education programme based on the health belief model. The education programme was held in a group of 10 participants, consisting of didactic lectures, open discussion and a practical session. The sessions were conducted by an interdisciplinary team of doctor, physiotherapist, occupational therapist and a nurse. The skin care belief scale was administered pre, post and 8-week post intervention, measuring eight domains of the HBM. The skin care belief scale is an assessment tool that looks specifically into the behaviour related to belief barriers and belief benefits.

Results: 30 SCI participants from UMMC who fulfilled the inclusion and exclusion criteria completed this study. Our education programme had a statistically significant effect on the domains of belief in susceptibility, belief in barriers in skin checks, belief in benefits of wheelchair pressure relief, belief in barriers to turning and positioning and belief in self-efficacy.

Conclusion: The health belief model is an important element that could be integrated in pressure ulcer prevention education programme to improve compliance towards preventive behaviour.

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PS2.1 Weakness is an important determinant of function yet we know little about the effectiveness of different therapeutic interventions

Harvey LA

John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney School of Medicine, University of Sydney, Australia

Abstsract

Neurologically-induced weakness following spinal cord injury is an important determinant of function and potentially amenable to therapy. It limits mobility, upper limb function and independence. Numerous interventions are administered by therapists in an effort to reduce weakness and increase strength. These invariably involve progressive resistance training, electrical stimulation and/or repetitious practice of functional activities. Yet little is known about the effectiveness of any of these interventions. Our group has now conducted 5 randomised controlled trials involving 184 participants (246 limbs), all aimed at understanding the effectiveness of different interventions for increasing strength in people with spinal cord injury. Our first two trials provide some of the first evidence to support the use of progressive resistance training. Our third trial failed to demonstrate any benefit of electrical stimulation on strength, and our fourth trial suggests that very weak muscles are not as responsive to strength training as commonly assumed. Our fifth trial conclusively showed no effect from repetitious practice of functional hand activities. This work has led us to our current trial called The 200 Rep Trial. The aim of this trial (n = 120) is to determine whether 200 contractions per day for 8 weeks can increase the strength of very weak muscles (< grade 3). In this presentation I will discuss all these trials in the light of the work of others, and explain how our findings challenge some long held assumptions about the effectiveness of some interventions.

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PS2.2 EVIDENCE BASED ON ADVANCED THERAPY

JULIA PATRICK ENGKASAN Department of Rehab Med, UMMC, University of Malaya, KL, Malaysia

Objectives To review the available evidence on the effectiveness of advanced locomotor therapy in improving mobility in persons with SCI

Evidence based on advanced therapy Spinal cord can undergo activity-dependent plasticity and this is the basis for locomotor training in persons with SCI. There has been an intense development on advanced locomotor therapy and the use of robotics locomotion therapy is gaining popularity. Though they do have clear advantage over the more traditional locomotor therapy there has been mixed results with regards of their effectiveness. The Cochrane Rehabilitation Field, in their effort to facilitate the use of evidence for rehabilitation community performed a review of systematic reviews and presents it in this lecture.

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PS3.1 Heart and endurance activity for SCI persons

Prof. Henry Prakash Magimairaj

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PS3.2 Strength training for partially-paralysed muscles in people with recent spinal cord injury: a within-participant randomized controlled trial

Gambhir A, Bye EA, Harvey LA,Kataria C, Glinsky JV, Bowden JL, Tranter KE, Lam CP, White JS, Gollan EJ, Arora M, Gandevia SC

Objectives To determine the effects of a 12-week strength training program in partially paralysed muscles, as compared to usual care.

Methods A multi-centre, assessor-blinded randomised control trial with pre- and post- measurements was conducted. Thirty people with recent SCI undergoing inpatient rehabilitation participated. For each participant, one target muscle group (biceps/triceps/quadriceps/hamstrings) was randomly allocated to the strength training group. The same muscle group on the contralateral side of the body acted as the control. The primary outcome was strength. Secondary outcomes were spasticity and participants' perception of function and strength.

Results The mean (95% CI) between-group difference for strength was 4.3 Nm (1.9 to 6.8) with a pre-defined clinically meaningful treatment effect of 2.7 Nm. Participants perceived that both strength and function had improved (mean between-group difference (95%CI)of 2.2/10 points (1.3 to 3.0) and 2.1(1.2-3.0), respectively. The mean (95% CI) between-group difference for spasticity was 0.03/5 points (-0.25 to 0.32) indicating no adverse effects. There were no dropouts and participants received 98% of the training sessions.

Conclusion This is one of the first clinical trials to confirm the benefits of strength training for partially-paralysed muscles in people with recent SCI.

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PS3.3 High sensitivity cardiac troponin-t in chronic spinal cord injury

Henry Magimairaj, Anand V, SenthilT

Christian Medical College & Hospital Vellore, TN. India

Objectives To establish a reference range for high-sensitivity cardiac troponin-t (hs-cTnT) levels in persons with spinal cord injury (SCI) who do not have symptoms of acute coronary syndrome.

Methods Cross-sectional study among persons with chronic SCI, who did not have established ischemic heart disease. Venous Blood samples were collected to assess hs-cTnT and CPK levels. ECG to screen for ischemic changes. Urine was tested for urine protein-urine creatinine ratio.

Results 90% were male, 97% had traumatic etiology. Average age was 39.7 years (SD 10.5). None of them had abnormal ECG, CPK or urine protein-creatinine ratio. Based on currently accepted international cut-off values for general population, hs-cTnT was undetectable (<3 ng/L) in 9%, detectable but within normal range (<=14 ng/L) in 53%, and elevated (>14 ng/dL) in 38% individuals. Mean hs-cTnT was 15.91 ng/L (95% CI 12.81 to 19.01). 99th percentile of hs-cTnT in this study was 74.17 ng/L.

Conclusion A high proportion of apparently healthy persons with SCI (38%) without symptoms of coronary ischemia had elevated hs-cTnT. 99th percentile value of hs-cTnT in persons with SCI was found to be higher than in general population. Altered physiological factors that might contribute to this pattern need to be further evaluated to help determine clinically meaningful cut-off values to diagnose abnormal hs-cTnT in persons with spinal cord injury.

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PS3.4 Bleeding complication from pharmacological treatment of DVT in Thai SCIs: is it time to reconsider our guideline

S Pattanakuhar

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University

Abstract According to clinical practice guideline for prevention of venous thromboembolism (VTE) in individuals with spinal cord injury (SCI) from Consortium of Spinal Cord Medicine in 2016, all SCI patients must have pharmacological prophylaxis of VTE unless they are contraindicated. However, anticoagulants may increase risks of bleeding. We report three episodes of intramuscular bleeding, occurring in 2 SCI patients, following pharmacological prophylaxis of VTE, which prolonged the rehabilitation and length of stay of the patients. All of these bleeding complications resulted from anticoagulant therapy as a treatment of VTE. This addresses the significance of VTE prophylaxis, which using lower dosage of anticoagulant than VTE treatment. In addition, in a low risk factor of VTE patient from the low incidence of VTE countries, non-pharmacological prophylaxis may be considered first. Finally, patients who currently use anticoagulant should receive gentle stretching and range of motion exercises due to they are in risk of bleeding complications.

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PS3.5 Deep vein thrombosis guideline

S Pattanakuhar and Spinal Cord Injury Research Cluster

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University

Abstract According to clinical practice guideline for prevention of venous thromboembolism (VTE) in individuals with spinal cord injury (SCI) from Consortium of Spinal Cord Medicine in 2016, all SCI patients must have pharmacological prophylaxis of VTE unless they are contraindicated. However, anticoagulants may increase risks of bleeding. We analyzed in-depth details and reasons of this guideline, as well as summarized the incidence, risk factors, pathophysiology of DVT which related to this guideline. We proposed that, in a low risk factor of VTE patient from the low incidence of VTE countries, non-pharmacological prophylaxis may be considered first. Therefore, we organized our VTE prevention guideline in inpatient SCI individuals according to the duration of SCI, the risk factors of VTE and the clinical manifestation of VTE at the admission time. However, some components of this guideline are expert opinions. Further clinical study is needed to confirm the effectiveness of this guideline.

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PS4.1 Neurological recovery

Prof. Wagih El Masri

Please read

: "Active Physiological Conservative Management in Traumatic Spinal Cord Injuries: an evidence-based Approach

It can be downloaded from the following website address: http://journals.sagepub.com/eprint/V9qda2SDWRT7fEMYttqF/full

This manuscript was recently published in the Jounal "Trauma".

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PS4.2 Surgery and stem cells

Dr. Harvider Chhabra

Abstract Incidence of traumatic spinal cord injury (SCI) has been on a rise, especially in middle and low income countries. Limited resources and poor financial status play a crucial role in determining the management of traumatic SCI in these regions. Management of traumatic SCI has been evolving since many decades. However, many fields regarding the management of SCI are lacking sound evidence. One among them is the role of stem cell therapy in the management of SCI. The other of such kind, is management of vertebral fracture i.e. surgical versus conservative. Though reasonably good evidence solves the issue of conservative versus surgical management to certain extent, there is no evidence supporting the usage of stem cell transplantation for neurological improvement in SCI. The aim of the talk is to analyze the role of surgical management and stem cell therapy in neurological improvement following traumatic SCI in present day scenario.

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PS4.3 The effect of N-Acetyl Cysteine (NAC) for improving neurological outcomes in animal model: a systematic review

Dr. Sintip Pattanakuhar

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objective: To determine the effect of N-Acetyl Cysteine (NAC) for improving neurological outcome in animal models of spinal cord injury (SCI).

Methods: MEDLINE, SCOPUS and the Cochrane Library databases were searched, using the keywords of “spinal cord” and “N-Acetyl Cysteine”. The participants included both traumatic and non-traumatic SCI animal models. The intervention was N-Acetyl Cysteine. The controlled groups were using placebo or another intervention. The outcomes measurements included neurological outcomes with or without biological markers or histological measurements.

Results: Among the initial searched publications of 77, seven publications met the inclusion criteria. Three studies used contusion models, while the other three studies used ischemic-reperfusion model. Only one study used chronic compression model.NAC was administrated alone in 4 studies, while was combined with allopurinol, diltiazem and catalase, as well as was in NAC amide form in the other studies. Dosage of NAC was between 40-300 mg/kg. Focusing on neurological outcome, six studies demonstrated better outcome in the group treated by NAC compared with the control group. The difference in SCI models (chronic compression) and NAC dosage (less than 50 mg/kg)might be responsible for this inconsistent finding. Notice that the effect of NAC would be better when combined with methylprednisolone, iloprostor therapeutic hypothermia.

Conclusions: Evidence regarding the effect NAC for improving neurological outcome in animal models of SCI is inconclusive. However, evidence demonstrated that high dosage (> 50 mg/kg) of NAC may improve neurological outcomes in contusion and ischemic-reperfusion types of SCI. Further well-designed, randomized controlled clinical studies were needed to elucidate this inconsistency.

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PS5.1 Urinary tract infection (UTI)

Prof. H Madersbacher

It can be downloaded from the following link

https://goo.gl/HGEbWx

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PS5.2 Vesico-Ureteric Reflux (VUR)

Prof. H Madersbacher

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PS5.3 Urological issues: Incontinence

Apichana Kovindha, M.D., FRCPhysiatrT

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Abstract Urinary incontinence (UI) is a common consequence after SCI due to neurogenic lower urinary tract dysfunction. If UI is mild and occurs infrequent, it does not disturb quality of life and may be acceptable. However, many suffered from UI and would like it to be completely controlled.

To control UI, oral antimuscarinic is the first line management. It consists of oxybutynin, trospium chloride, tolterodine, propiverine, solifenacin, darifenacin etc. Due to side effects of antimuscarinics, botulinum toxin injection into the detrusor muscle is now accepted as the first line treatment for NDO. Recently a beta 3 agonist, “mirabegron” was approved by FDA for treatment of overactive bladder (OAB) and there was a retrospective study on treating NDO in patients with SCI with mirabegron.

For those with uncontrolled UI, some choose catheterization. Clean intermittent (self) catheterization (CIC/CISC) with control fluid intake is preferable. However, some cannot apply CIC/CISC and choose indwelling catheterization (IDC). Long-term transurethral IDC causes bladder neck and urethral erosion leading to UI; and suprapubic catheter (SPC) may be an alternative with less urethral complications.

If UI cannot be completely control, one needs continence products such as diapers, pads, sheaths (condom drainage system), bodyworn or handheld urinals. To select a proper product, questions should be asked, for examples: 1) Besides UI, is there also urinary retention or high post-void residue (PVR)? 2) Is there only UI or double incontinence (UI and faecal incontinence, FI)? 3) Are there problems with toilet access? If there is also urinary retention or high PVR, catheterization such as CIC/CISC is more appropriate. If there is also FI with difficulty in toilet access, diapers/pads are more appropriate. In addition, severity of SCI, physical characteristics, learning ability, mobility, dexterity, independence in self-care, eyesight, lifestyle, necessary facilities and personal preference should be assessed. To be noted, long-term use of continence products is costly and should be considered. If all conservative managements fail, a surgical intervention may be necessary such as continence stoma.

In conclusion, UI limits activities and restricts participation of SCI persons. Comprehensive assessments are necessary for an appropriate management of UI. The SCI persons and their caregivers should be educated and take part of decision-making.

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PS5.4 Urological check-up after spinal cord injury 1) How often shall we investigate the upper urinary tract after spinal cord injury. 2) Which urodynamic parametre may predict renal deterioration after spinal cord injury.

Fin Biering-Sørensen

Clinic for Spinal Cord Injuries, Rigshospitalet, University of Copenhagen, Denmark.

Abstract 1) Individuals with spinal cord injury (SCI) are recommended to attend follow-up-examinations of the urinary tract and renal function, but the need of lifelong examinations has not been investigated. Retrospective study-design: 116 individuals admitted to our clinic with a traumatic SCI sustained 1956-1975 were included. Results from routine renal and urinary tract examinations carried out from time of SCI until 2012, were obtained from medical records, i.e. Renography, Glomerular filtration rate (GFR) measured primarily with 51Cr- EDTA clearance, Urinary tract images (Ultrasound, CT scan, X-ray, intravenous pyelography), and Bladder emptying methods. Definitions: Moderate renal deterioration: Functional distribution outside 40-60 % on renography or relative GFR ≤ 75 % of expected according to age and gender. Severe renal deterioration: Functional distribution outside 30- 70 % on renography or relative GFR ≤ 51 % of expected according to age and gender. Conclusion: Renal deterioration occurs at any time after injury. Lifelong follow-up investigations of the renal function are important. A history of dilatation of upper urinary tract and/or renal/ureter stones requiring removal increases the risk of renal deterioration.

2) To investigate which urodynamic parameters are associated with renal deterioration over a median of 41 years follow-up after traumatic spinal cord injury. Medical records of patients with traumatic spinal cord injury sustained 1944–1975 were reviewed from time of injury until 2012. Patients who attended regular renography and/or renal clearance examinations and had minimum one cystometry and pressure-flow study were included. Detrusor function, presence of detrusor sphincter dyssynergia, maximum detrusor pressure, post-void residual volume and cystometric bladder capacity were obtained. In patients with detrusor overactivity a detrusor- overactivity/cystometry-ratio was calculated using duration of detrusor contraction(s) during filling cystometry divided by total duration of filling cystometry. 73 patients were included in the study, and the median follow-up time was 41 years after injury (range 24–56). 64 patients (88%) used reflex triggering or bladder expression as bladder emptying method for the longest period after injury. During follow-up 60% changed to clean intermittent catheterization. Conclusion: Duration of DO longer than one third of the total duration of cystometry (DO/cystometry-ratio >0.33) increases the risk of renal deterioration after SCI. In future studies, where curves are available electronically, we should evaluate the area under the curve during filling cystometry, in order to combine the time of increased detrusor pressure and the level of prolonged increased detrusor pressure in one parameter.

References: Elmelund M, Oturai PS, Toson B, Biering-Sørensen F. Forty-five-year follow-up on the renal function after spinal cord injury. Spinal Cord. 2016 Jun;54(6):445-51 Elmelund M, Klarskov N, Bagi P, Oturai PS, Biering-Sørensen F. Renal deterioration after spinal cord injury is associated with length of detrusor contractions during cystometry-A study with a median of 41 years follow-up. Neurourol Urodyn. 2017 Aug;36(6):1607-1615. McGuire EJ, Woodside JR, Borden TA, Weiss RM. Prognostic value of urodynamic testing in myelodysplastic patients. J Urol. 1981;126:205–209.

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PS6.1 Developing an Active Spinal Cord Injury Collaborative International Research Culture

Brown D, Peleg E.

Spinal Research Institute, Melbourne, Vic., Australia

Objectives Despite research over the last forty years, there have been few major advances that have brought fundamental improvement to the daily lives of those living with Spinal Cord Injury (SCI). Most trials have small numbers of participants, preventing statistically significant results. SCI research requires networks and partnerships to be more successful. Our aim is to develop international collaborations, build camaraderie and connections among established and early career clinical researchers.

Methods The development of an online web-based network dedicated to SCI researchers. Working with an Advisory Group of highly regarded SCI researchers and with experienced IT research developers we are building this functional tool.

Results Funding and prototype build of the platform has commenced with release due early 2018. The advisory group will determine features and governance that will promote collaborations between SCI researchers, clinicians and consumers.

Conclusion By developing a culture of collaborative SCI research it will be easier to move from a local to a global focus, leading to scientifically valid outcomes that can be translated to clinical practice.

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PS6.2 The use of the International SCI Standards and Data Sets in clinical practice and research – current situation

Fin Biering-Sørensen

Clinic for Spinal Cord Injuries, Rigshospitalet, University of Copenhagen, Denmark.

Abstract Increased survival after spinal cord injury (SCI) worldwide has enhanced the need for quality data that can be compared and shared between centers, countries, as well as across research studies, to better understand how best to prevent and treat SCI. Such data should be standardized and be able to be uniformly collected at any SCI center or within any SCI study. Standardization will make it possible to collect information from larger SCI populations for multi-center research studies. With this aim, the international SCI community has obtained consensus regarding the best available data and measures for use in SCI clinical practice and research. Data elements are continuously updated and developed using an open and transparent process. There are ongoing internal, as well as external review processes, where all interested parties are encouraged to participate. The first attempt to standardize reporting in the SCI community was the neurological/ functional classification of individuals with SCI, called the “Frankel classification”. The classification was further developed by the American Spinal Injury Association (ASIA), in collaboration with the International Spinal Cord Society (ISCoS), into the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) (http://asia- spinalinjury.org/learning), which paved the road for standardization including the International SCI Data Sets (http://www.iscos.org.uk/international-sci-data-sets). There are today the International SCI Core Data Set, 19 International SCI Basic Data Set, and 5 International SCI Extended Data Set. In the Danish Electronic Medical Record Epic are SmartForms Implemented for the International SCI Core Data Set and 14 Basic Data Sets. The remaining 5 Basic Data Sets are underway. However, some dataset data elements, e.g. history questions, are already tracked in Epic, so there exists a question of where and how to track this data. Worldwide experience and current distribution within the international SCI community is described. Translations for several of the International SCI Data Sets are available, and several new datasets are in development. The International SCI Data Sets are increasingly used in published work from all over the world. In epidemiological studies in particular the International SCI Core Data Set is used to be able to compare between studies. Standardization of reporting has been advised.

References: Biering-Sørensen F, Noonan VK. Standardization of data for clinical use and research in spinal cord injury. Brain Sci. 2016, 6, 29. Frankel, H.L.; Hancock, D.O.; Hyslop, G.; Melzak, J.; Michaelis, L.S.; Ungar, G.H.; Vernon, J.D.;Walsh, J.J. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969, 7, 179–192. Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey M, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (Revised 2011). J Spinal Cord Med. 2011;34(6):535-46. Walden K, Bélanger LM, Biering-Sørensen F, Burns SP, Echeverria E, Kirshblum S, Marino RJ, Noonan VK, Park SE, Reeves RK, Waring W, Dvorak MF. Development and validation of a computerized algorithm for International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Spinal Cord. 2016 Mar;54(3):197-203. Biering-Sørensen F, DeVivo MJ, Charlifue S, Chen Y, New PW, Noonan V, Post MWM, Vogel L. International Spinal Cord Injury Core Data Set (version 2.0)-including standardization of reporting. Spinal Cord. 2017 Aug;55(8):759- 764.

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PS6.3 Is walking Index for Spinal Cord Injury II (WISCI II) proper for all SCI persons walking with spasticity?

Amornrat Poowanaviroj, Sintip Pattanakuhar, Apichana Kovindha Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objectives The Walking Index for Spinal Cord Injury II (WISCI II) is recognized as a standard measurement of walking capacity in spinal cord injury (SCI) persons. However, it is difficult to assess WISCI II properly in paraplegic patients who walk using spasticity of the lower extremities.

Clinical/interesting issues A 26-year-old man was diagnosed with incomplete paraplegia T11C from gunshot injury 8 years ago. Modified Ashworth Scale showed static spasticity of 3 in extensor muscle group of both lower extremities despite baclofen was administrated 60 mg /day. Due to sever spasticity, it was difficult to manually test muscle power of the lower extremities. With suspicious combination of voluntary movement and involuntary muscle spasm, it was shown at least grade 2/2 (Rt/Lt) at hip adductors, grade 0/0 at hip flexors, grade 3/4 at knee extensors, grade 1/1 at ankle dorsiflexors, grade 0/0 at EHL and ankle plantar flexors. This patient could reciprocally walk in parallel bars without using any assistance, gait aids or orthoses, for therapeutic purpose only. He used hip hiking and circumduction during swing phase, and strong knee extensors and ankle plantar flexors spasticity during stance phase. This situation made difficult to give a correct walking level according to WISCI II

Conclusion According to the WISCI II guideline, there are two prerequisite conditions of using WISCI II. They are 1) Capable of standing and walking in parallel bars, and 2) capable to perform reciprocal gait. In this patient, both prerequisite conditions were achieved. However, his ambulation can still not be classified into any levels of WISCI II. This may address a practical point that, in a chronic SCI patient who has a specific style of ambulation (e.g. using spasticity as an enhancer), a modification of WISCI II in order to measure the ambulation is needed.

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PS7.1 Surgery for tetraplegic hands

Assoc. Prof. Kanit Sananpanich

Department of Orthopaedics, Chiang Mai University

Traumatic spinal cord injury (TSCI) is one of the most devastating injuries. The incidence of TSCI in Europe ranged from 5.5 to 195.4 cases per million populations. In China, Japan and Thailand, tetraplegia is more common than paraplegia. In cervical TSCI, the common level is at C6. Restoration of arm and hand movements in tetraplegia appears to be the highest priority, the critical factor to independence and quality of life. Traditional treatments to restore the function include tendon transfers and tenodesis. However, these tendon surgeries usually require prolonged period of splint and multi-stage operations. Single-stage tendon and joint operation was proposed by Fridén et al., offer improved treatment outcomes. The recent introduction and development of distal nerve transfers has opened new options for tetraplegia. Combination of several nerve transfers can restore function of different muscle groups in a single stage operation, which favors tetraplegic patients whose transportation may be difficult. Our patient received four pairs of nerve transfer in both upper extremities to restore multiple functions is a clear example. Also, the prolonged rigid immobilization after tendon transfers, is not required in nerve transfers by using only arm slings.

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PS7.2 Tetraplegic hand: Rehabilitation management

Tongprasert S

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Injury to the cervical spinal cord results in tetraplegia and associated impairment. Upper extremity usability is ranked to be the most desirable ability to regain which will increase their independence and quality of life. This lecture focuses on the assessment of tetraplegic hand, rehabilitation management using various modalities and how to preserve upper limb function in this group of patients.

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SYMPOSIUM SESSIONS

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SS1.1 Multidisciplinary care programme

Dr. Dirk van Kuppevelt

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SS1.2 Results from ASCoN questionnaire

Dr. Yorck B Kalke

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SS1.3 Fact to be aware of in aftercare: experience in ASCoN countries

Stephen Muldoon

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SS1.4 Community-based care for reducing mortality and improving quality of life after spinal cord injury in Bangladesh: a 3-year update on the CIVIC trial

Hossain MS, Islam MS, Rahman MA, Herbert RD, Muldoon S, HS Chhabra, Harvey LA

Centre for Rehabilitation of the Paralysed, Bangladesh The University of Sydney, Australia.

Objectives To provide an update on a 5-year clinical trial designed to determine the effectiveness of community based care to reduce mortality and improve quality of life in people with spinal cord injury (SCI) following discharge from hospital in Bangladesh.

Methods The CIVIC trial is a randomized controlled trial involving 410 people with recent SCI recruited from the Centre for the Rehabilitation of the Paralysed (CRP), Bangladesh. Participants are randomised to control and intervention groups at discharge. Participants in the intervention group receive regular phone calls and three home visits in the first two years after discharge. At this time participants are screened for complications and provided with ongoing support and advice. Participants in the control group receive usual care. The primary outcome is all-cause mortality and secondary outcomes are complications, quality of life and participation. The trial is being conducted according to ICF GCP standards and professionally managed by George Clinical India.

Results We commenced recruitment in July 2015. To date, we have randomised 360 participants and will finish recruitment in Feb 2018. The two year follow-up assessments for both groups commenced in August, 2017 and will finish in Feb 2020. Our team has successfully provided the intervention as per the protocol. That is, they have made 327 home visits and 3,189 phone calls to participants in the intervention group. The main problem experienced by participants in the intervention group is pressure ulcers with 53/167 participants experiencing at least one pressure ulcer. Many of these have been life threatening.

Conclusion The CIVIC trial will be the first large randomised controlled trial to determine the effectiveness and cost- effectiveness of a community-based model of care for reducing mortality and improving quality of life for people with SCI in a low and middle income country.

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SS1.5 Identification of wheelchair skills capacity, confidence and performance level of manual wheelchair users with spinal cord injury in the selected community of Bangladesh

Md. Julker Nayan, Md. Saddam Hossain and Shamima Akter

Centre for the Rehabilitation of the Paralysed (CRP)

Objectives The objective of this study is identify the level of wheelchair skills capacity, confidence and performance of persons with SCI, along with to find out the association between socio-demographic factors (age, sex, level of injury, wheelchair dependent life years) and correlation of wheelchair skills capacity with confidence and performance.

Methods A descriptive cross-sectional study design was used. Ninety manual wheelchair users were selected purposively from the rural community of Bangladesh based on inclusion criteria’s. Data was collected by using structures demographic questions and Wheelchair Skills Test Questionnaire (WST-Q) version 4.3 in Bangla. Data was analysed by using descriptive statistics and non-parametric test of SPSS (version 20.0).

Results This study found that the manual wheelchair user’s capacity, confidence and performance level is good in the context of Bangladesh. The mean age of the participants were 35 (SD ±12.89) years whereas male was 89%. Among the participants 70% were paraplegia and 30% were tetraplegia. Most of the participants were traumatic cases (93%), and 62% were married. Among the participant’s wheelchair dependent life mean 7.54 (SD±7.15) years. Results showed that SCI wheelchair user skills capacity, confidence and performance were significantly associated with gender and level of injury. It was also proved that SCI wheelchair user skills capacity was significantly correlated with their level of confidence (r=.95; P<.000) and performance (r=.88; P<.000).

Conclusion Many people with SCI are unable to perform some of the wheelchair skills that restrict them to participate in functional life. More intensive wheelchair skills training may improve the wheelchair skills capacity, confidence and performance that will enhance their community mobility, participation and improve quality of life.

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SS1.6 Access to proper urological care in persons with SCI in Thailand: a preliminary report

Donruedee Srisuppaphon1,2, Panarut Wisawatapnimit3, Parichart Suwanpon1, Kumaree Pachanee2

1Sirindhorn National Medical Rehabilitation Institute 2International Health Policy Program 3Boromrajonani College of Nursing Bangkok

Objectives Neurogenic bladder is a comorbidity which could cause profound kidney damage after spinal cord injury (SCI). In order to reduce morbidity, proper urological care and surveillance need to be employed. This study aims to explore availability of urological services and barriers to access from healthcare providers and persons with SCI’s perspectives.

Methods Availability, including healthcare personnel, medication, devices and urological interventions, was explored through questionnaire. In-depth interview of healthcare providers was performed to understand their perspectives toward persons with disability (PWD) and neurogenic bladder problem and the service system. Perspective of persons with SCI was also explored through in-depth interviewed. Available data was analysed by descriptive statistics. Qualitative data was thematically analysed.

Results From seven healthcare facilities in two provinces, Bangkok and one province in southern Thailand; there are two tertiary, one secondary and four primary care facilities. Urologists are available only at tertiary level, while there are rehabilitation specialists at two tertiary and one primary care facilities. Urodynamic study could be performed only at one teaching hospital. Neither anti-cholinergic medication nor silicone self-catheter is available at primary and secondary facilities. All primary care units in Bangkok do not have transurethral catheter available for dispensing at the facilities. In-depth interviews with healthcare providers reinforce the notion that neurogenic bladder problem is severely neglected at almost every facilities. Moreover, people with SCI face enormous barriers in accessing hospital-based care. Apart from the transportation problem, healthcare providers’ attitude of perceiving people in wheelchair as bedridden drives PWD away from seeking hospital care. Home healthcare nurses seem to be the only group of healthcare personnel that understand PWD’s need. Unfortunately they are not aware of morbidity of neurogenic bladder.

Conclusion It is obvious that neurogenic bladder problem is barely recognized by Thai healthcare providers. Their attitude and knowledge in neurogenic bladder as the cornerstone of a proper care has to be emphasized for further development.

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SS2.1 SCI Rehab Services ‘Experience from Korea’

Dr Bum-Suk Lee

President, Korea National Rehabilitation Center

Objectives 1. To share the epidemiology of SCI population in Korea 2. To share the successful medical rehabilitation service for Korean people with SCI 3. To share the successful social support system for Korean people with SCI

Contents - Epidemiology of SCI population in Korea - Medical rehabilitation service at national level - SCI rehabilitation program in Korean National Rehabilitation Center (KNRC) - Social support: financial support, caregiver support, back to job or school - Peer group support: Korea Spinal Cord Injury Association (KSCIA)

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SS2.2 SCI Rehab Services – Lessons learned from ASCoN and European Countries

Rehabilitation Services in Malaysia

Dr. Yusniza Mohd. Yusof

Rehabilitation Medicine Physician, Hospital Rehabilitasi Cheras, Malaysia

Abstract Rehabilitation Medicine services have grown steadily in Malaysia since 1930’s. It begins as vocational rehabilitation service in Sungai Buloh Leprosy Centre and at present there is a spectrum of rehabilitation care provided by multiple government agencies and a fast growing private sector.

In Ministry of Health (MOH), rehabilitation services are funded through tax revenue and are available at all tiers of healthcare delivery namely primary care services, acute care services and specialized rehabilitation hospitals/centre. Recently, MOH have introduced Cluster Hospital System to increase its efficiency and maximize facility usage. This move has allowed more specialized rehabilitation wards to be set up and provides specialized services nearer to home. Primary Care services have also introduced Domiciliary Care which provides care at home. Multidisciplinary approach is still the mainstay of patient management and it is practised in specialist rehabilitation care services and several primary care settings.

Rehabilitation Research and development initiatives in epidemiological study, clinical rehabilitation and rehabilitation medical devices have increased over the years. These efforts will further support the ever growing rehabilitation needs of Malaysian population.

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SS2.3 SCI Rehab services

BSM Medical University updates on SCI Rehab: looking for center of excellence

Taslim Uddin, AKM Salek

Professor and Faculty. Dept of PMR, BSil Medical University (BSMMU), Dhaka, Bangladesh

Introduction ln Bangladesh, SCI rehabilitation were doing mostly by the NGOs being the major share taken by CRP, government and other institutes in a rather self driven uncoordinated way. BSMMU is working as the country's largest Medical hub for treatments and post graduate medical education.- ln this 40 working departments in the 2100 bedded tertiary Hospital 18 plus bedded multidisciplinary rehabilitation unit was inaugurated 02yrs ago. Currently we are working with the objectives of developing this unit as the cenler of excellence in SCI Rehabilitation Services

Methods Patients admitted through OPDs after screening for the criteria of inpatient admissions in Rehab Unit for intensive rehabilitation. A retrospective analysis of the medical records of the admitted SCI patients were made during the period of 02 yrs from August 2015 to July 2017 to find out the demographic, clinical and functional status of the post traumatic SCI patients. Multidisciplinary rehabilitation protocol was followed for rehabilitating process. All the collected information was analyzed for demographic data and FIM motor scales. Administrative process of developing are noted from department records.

Results Of the 14 admitted cases of post traumatic SCI; 77.4yo af the patients were male, age ranging from 2.5rs to 55yrs, 64.2% were involving with paraplegia and 08 patients (56.8%) had fall from a height 01 (24%l are due to RTA. 65% of the patients were with ASIA A neurological extent of impairments with FIM ranging from 55- 100 at admission. Administrative steps are underway to develop a modernized University unit of excellence in the rehabilitation of SCI patients.

Conclusion This is a preliminary report of the challenges taken; this needs discussions and sharing among the national and international community.

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SS2.4 Thailand: Should we have a specialized rehab center/facility for SCI?

Assoc. Prof. Apichana Kovindha

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Comparing with stroke, spinal cord injury (SCI) has much lower incidence in Thailand. It was estimated about 23 per million populations. Therefore, the country’s health policy is aimed at stroke and elderly people, not SCI. The national health policy now stresses on shortening hospital LOS and providing home-based rehab services for those with disability including SCI individuals. To prove the necessity of specialized post-acute rehabilitation and long-term services for SCI patients/individuals, we conducted a Thai SCI registry (TSCIR) to gather data to support an importance of having specialized rehabilitation center for SCI. There are four advanced level hospitals/facilities joining the TSCIR. Among them, the rehabilitation ward at Maharaj Nakorn Chiang Mai Hospital is recognized as a role model of SCI comprehensive rehab in the country, and more than 2/3 of the new patients in the registry were treated here. When comparing rehab outcomes, those treated at the specialized facility had longer length of stay (LOS), higher functional gain and more rehab efficiency than those of the non-specialized SCI rehab facilities. According to the WHO’s international perspectives on SCI, appropriate post-acute medical care and rehabilitation as well as ongoing health care maintenance can assist the person towards a fulfilling and productive life; and all SCI patients should have the rights to equally access to medical care and rehabilitation services. The recent evidence from the TSCI does showing that new SCI patients need adequate LOS for post-acute medical care and comprehensive rehabilitation treated by a specialized team. To be able to change the national health policy, we should have more evidence to prove that not only a short-term but also long-term outcomes, and cost- effectiveness.

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SS2.5 Spinal Cord Injury Rehab Services – Lessons learned from ASCoN and European Countries

Treatment and rehabilitation after spinal cord injury in Denmark

Fin Biering-Sørensen

Clinic for Spinal Cord Injuries, Rigshospitalet, University of Copenhagen, Denmark

In Denmark with a population of 5.7 million inhabitants the National Board of Health have decided that individuals with spinal cord lesions (SCLs) are to be treated and rehabilitated in one of two centers and for very specialized treatments in one center only. Thus individuals with SCLs are to be treated in one of two centres only for: Acute spinal surgery, where there are neurological deficits Lifelong treatment and rehabilitation Urinary tract problems related to the SCL Gastrointestinal problems related to the SCL Plastic surgical treatment for pressure ulcers Obstetric challenges (pregnancy and birth) Respiratory support – including home ventilation Children with spinal cord lesions, including spina bifida Individuals with SCLs are to be treated in one centre only for: Implantation of phrenic pacers Upper extremity surgery for tetraplegics Treatment, rehabilitation and life-long follow-up for SC individuals are centralised to two centers in Denmark: Århus / Viborg for West-Denmark Copenhagen / Hornbæk for East-Denmark, the Faroe Island and Greenland

Briefly are treatment and rehabilitation examples related to respiration/ventilation, cardiovascular issues, bladder- and bowel management, sexual function, skin issues, spasticity and pain presented, as well a robot-, walking-, and exoskeletontraining.

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SS3.1 Current status of traumatic tetraplegic married women in the community: a phone call survey experienced at CRP

Jannathul Shapla, Sayeed Uddin Helal, Israt Jahan Urmee, Abdur Razzak

Centre for the Rehabilitation of the Paralysed (CRP)

Objectives To evaluate the current status of traumatic tetraplegic married women in the community at least one year after being discharged from CRP.

Methods It was a phone call survey on randomly selected tetraplegic married women who were discharged from CRP after completing full rehabilitation treatment and thereafter, stayed more than one year in the community. The period was from 2011 to 2016. Total respondents were 50. Data was collected by taking interview over phone. Data was analyzed in SPSS 20.

Results The age of the respondents was between 27 to 70 years. Most of the women (n=38) were involved inhousehold work while the rest of the 12 patients engaged themselves in job. None of them gave birth after injury and did not use any family planning method either. Most of them (n=45, 89%) were not satisfied in their conjugal lives. Few of them (n=5) got divorced after sustaining injury. Except few, most of them (n=37, 75%) faced some sort of problem during intercourse with their spouse. Almost all of them kept good relations with their family members and neighbors. Nearly everyone tried to follow the training and teaching learned at CRP. Only few (n=5) had pressure ulcers and were treated by local doctors. All the participants could manage jelly, nilaton catheters and spare parts of wheel chair from local market. The workers of CBR from CRP met with them at least once after reintegration into their community. None of them came to CRP for follow up after being discharged due to long distance (n=35) and unwillingness of their family members (n=15). The most common thing that we received from the interviews was that all of them cried and expressed their depression to the interviewer.

Conclusion Tetraplegic married women can get more emphasis in CBR program as they are the most dependable among all SCIs. More focus needs to be given upon Psycho-sexual aspect during visit.

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SS3.2 Sexual well-being of patients with spinal cord injury: an approach from physiotherapist’s perspective

Azizatul Zannat Smrity

Bangladesh Health Professions Institute, Centre for the Rehabilitation of the Paralyzed (CRP), Savar, Dhaka, Bangladesh

Objectives The purpose of the study was to explore the approach of physiotherapists to discuss about sexual wellbeing of patients with SCI. Try to find out the barriers and knowledge about sexual issue. Know about present service condition and training needs of physiotherapists to discuss about sexuality of patients with SCI.

Methods Qualitative study design with face to face interview with purposive sampling and thematic analysis was done. Open-ended question in BENGALI was used for this study.

Results In this study found five themes. That are, Theme 1- Sexual education to patients is yet to prioritize by health care professional including physiotherapists. Theme 2- Sexual rehabilitation should be included as an essential part in SCI rehabilitation to ensure better life for patients. Theme 3- Privacy and proper environment is needed to establish sexual rehabilitation. Theme 4- Sex and sexuality education for patients should be placed in formal university curriculum.. Theme 5-Update staff training on sexual education will ensure comprehensive rehabilitation that could improve service.

Conclusion Staff training and basic knowledge on sexual education for patients is needed for physiotherapists who deal with the patients with SCI to improve professional skill. Along with this, addition this topic to curriculum can prepare the upcoming professional more competent to provide comprehensive service.

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SS3.3 Sexuality issues of persons with SCI, why & how to address

Mr. Shivjeet Singh Raghav

Peer Counsellor, Indian Spinal Injuries Centre, India

Objectives: Share Consumer perspective on Sexual dysfunction in SCI with Rehab Team

Clinical/interesting issues: SCI happens mostly in the younger age group of 15 - 40 years, which happens to be the most productive time in anyone’s life. Most of the injured will either be married, about to marry, planning their family. Psycho-social and adjustment related issues due to Sexual dysfunction after SCI needs to be addressed keeping the consumer’s perspective in mind. It has to be through proper counseling, information, training and participation of rehabilitation team members. Psycho-social rehabilitation is not merely the responsibility of Psychologist, Social worker or Psychiatrist, rather each member of the rehab team has a share in it. More so Sexual rehabilitation is a very very important aspect of psycho- social rehab.

Conclusion: Team needs to have an idea of SCI perspective from Peer Counselor as to what they need to know about addressing the issue and also their role in successful sexual rehabilitation.

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SS3.4 Physician’s view on sexuality of persons with SCI

Dr. Bum Suk Lee

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SS3.5 A higher level of intimacy: caregiver for your own loved one

Ms Miriam Feinberg Vamosh

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SS3.6 An interdependent living with my caregiver

Ms. Busara Booranapansri

Objectives

To present an example of self-experience in being a tetraplegic person who could overcomes disability and has a successful career and a satisfy life. Getting trust, growing strong with CAREGIVER

Interesting issues  Experience on building and maintaining human relationship.  Humor is a weapon that makes us progress. Smile is a treasure.  Listeners better than speaker. Dare to step and Use the brain as much as the heart.  Giving someone all your love is never an assurance that they'll love you back! Don't expect love in return; Just wait for it to grow in their heart, but if it doesn't, be content it grew in yours.

Conclusion The happiest of people don't necessarily have the best of everything, they just make the most of everything that comes along their way.

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SS3.7 33 years of my personal experience dealing with chiefs and colleagues.

Nipapan Tipayajak

Consumer

Objectives To share/exchange my personal experience as a paraplegic who could get over the crisis and returned into a government officer.

Clinical/interesting issues A 59 years old complete paraplegic T-6 woman due to blood clot since Dec 1, 1984. It sudden happened after 5 months of being a new government officer. I perceived that my body might be paralyzed but need to return to my first government office approximately 500 Km. from hometown. Some colleague said that if you were paralyzed, you would resigned. I said “my body might be paralyze but my brain is not ”, so give me a chance. My lifestyle has been changed, I have to lead an active life with a foldable wheelchair and adapted hand-controlled car. Unfortunately, a new chief forced me to go upstair without elevator but I won’t so I was looking for another workplace. Dr.Apichana, the greatest person who always support and encourage me to work at Rehabilitation Center in Nonthaburi province next to Bangkok. A biggest challenge of my life to live fully independent for 12 years before moving back to ChiangMai. Incredible, how I have been worked as a government officer in 4 different workplaces with different role for 33 years. It’s not quite difficult to overcome those obstacles. In addition to show your knowledge and performance of what you do with getting a career development, I believe that positive thinking and a strong-willed person will help you have more self-confidence.

Conclusion Build up your self-confidence with positive thinking and push yourself beyond your physical limited. They will accept and respect you as human being.

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SS3.8 Psychologist’s view on relationships

Dr. Steven Ducharme

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FREE PAPERS

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OP1.1 The Paradox Of Pressure Ulcers in Spinal Cord Injury: Comparison Between Tetraplegia and Paraplegia.

Shivani Rajasegaran

Tertiary Referral Hospital, Hospital Raja Permaisuri Bainun Ipoh, Perak. Malaysia.

Objectives This study aims to determine the prevalence of Pressure Ulcers(PrU) among spinal cord injury (SCI) patients, including exploring the site and staging of PrU among paraplegic and tetraplegic patients.

Methods A retrospective analysis of all SCI patients referred to the Department of Rehabilitation Medicine within a duration of 7 months. Data was extracted from patients medical records and tabulated, after which, an in depth analysis was done to document the NPUAP stages and distribution of PrU. Patients with existing ulcers from Stage II-IV and unstageable were included in the study.

Results Incidence of PrU among SCI patients were alarmingly high at 56.9%. We reviewed notes of 58 SCI patients and included 33 who fulfilled the inclusion criteria. The results revealed a total of 55 PrU with an average of 3 ulcers per patient. 13 of them were tetraplegic and 20 paraplegic. Majority of tetraplegics had stage II ulcers (57.9%) as opposed to paraplegics with 33.3%. There was paradoxically higher incidence of stage IV PrU in paraplegics (30.5%) than tetraplegics (10.5%). This unprecedented outcome indicates that level of disability does not correspond to the severity of PrU. The sacrum is the dominant site for PrU in both tetraplegics and paraplegics (47.3% and 41.6% respectively). This study dispels the misconception that paraplegics are prone to develop ischial ulcers. The other susceptible sites for PrU in paraplegics include the heel (16.7%), gluteal area (16.7%), trochanter (13.9%) and ischium (11.1%). Other susceptible sites in tetraplegics are the heel (21.2%), trochanter (15.8%) and gluteal region (15.8%). In this study, none of the tetraplegic patients had PrU over the ischium.

Conclusion We advocate sound education on skin care, prescription of advanced dressings and pressure distribution equipment in both paraplegic and tetraplegic patients. The sacral region requires added attention during skin inspection. Paradoxically, paraplegics are developing more severe PrU than tetraplegics.

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OP1.2 Why – Why Analysis of Pressure ulcers with ICF Framework

Warangkana Sitthikan, Apichana Kovindha

Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand

Objectives To demonstrate how to apply ICF framework in rehab practice as a tool for root cause analysis (using why-why analysis)

Clinical/interesting issues An unmarried 40 years old man (personal factor) with C4 A tetraplegic (muscle power impairment) for 20 years started having multiple chronic unhealed pressure ulcers (disease, disorder) in 2014. Causes of pressure ulcers were inability to changing body position (activity limitation) and lack of body mass (body structure impairment). Originally, he did not suffer from pressure ulcers when he was cared by his mother (environmental factor, facilitator). After her death in 2005, we helped provide him a home visiting nurse service to assist in bowel and bladder care. However, once this help was ended, he was looked after by his sister only. She limited his foods (environmental, barrier) to prevent bowel movements and bowel accident (bowel continence function impairment) because she had limited time to assist bowel care, only once a week. Due to insufficient foods (environmental factor, barrier), he became extremely thin with bony prominences. And assist turning in bed only twice per day (environmental factor, barrier) leaded to pressure ulcers. Applying the ICF Framework to analyze causes and effects, chronic pressure ulcers in this patient were not caused solely by disabilities but there are other interconnecting psychosocial factors/issues that needed to be solved. Then we organized a rehab team meeting with his sister and a representative from a local hospital in his area in order to make problems clear, to enhance better family relationship and to clarify every stakeholder’s role.

Conclusion Secondary condition such as pressure ulcer is common in chronic SCI persons. Based on the ICF framework, such condition is not only due to body function and body structure impairments and limitation in activities but also influenced by environmental factors /psychosocial issues which are barriers that need a comprehensive and holistic approach of a dedicated rehab team and its network to solve.

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OP1.3 Integrative rehabilitation program in Spinal cord injury’s patient with high risk pressure ulcer and depression can prevent Pressure Ulcer: A Case Report Study

Putri Khaerani,MD1, Novitri, MD2, Sunaryo B. S, MD2,3, Deta Tanuwidjaja MD2

PM&R Department, Faculty of Medicine, University of Padjadjaran - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Objectives The core of rehabilitation program is to be active physically. Depression and anxiety disorders, negative self- concept, and frustration can interfere patient’s compliance. Patient with depression and anxiety disorders will be inactive, self-neglect, and have poor medical adherence. Thus, patient will likely have abandoned all rehabilitation programs that is prescribed. This article shows integrative program including in mental condition management will prevent pressure ulcer (PrU) in spinal cord injury’s (SCI) patient.

Clinical/interesting issues Individuals with SCI are at extreme risk for developing PrU due to their immobility, lack of sensation and moist condition, and other risk factors. Some cases were reported that develop-ment of a severe pressure ulcer was aggravated by an acute depressive episode during which self-care was neglected and significant time was spent in bed. Mrs. S, 55 years old, was consulted from neurology department with SCI AIS C NL TH X caused by Spondilytis TB. From the anamnesis and physical examination, it was found that SCI pressure ulcer scale (SCIPUS) was scored of 9 (high risk) and patient’s Depression and Anxiety Stress Scale (DASS) was at 19 (moderate depression), 17 (severe anxiety), 16 (mild stress). Considering patient’s DASS score, the rehabilitation programs were integrated with psychiatric program in order to prevent complication due to immobilization, such as pressure ulcer, and to address patient moderate depression and severe anxiety. After 3 times session of psychiatric counselling, the patient was more cooperative and had eager to do our rehabilitation program. The patient was discharged from hospital without pressure ulcer.

Conclusion DASS is one of mental condition risk assessment that should be considered in every rehabilitation assessment. By considering the level of mental condition risk in rehabilitation programs and integrating it with psychiatry program, early low level patient’s compliance to rehabilitation program can be prevented.

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OP1.4 How pressure sores prevented for persons with Spinal cord Injury in Bangladesh.

Shakhawath Hossain

Intern Occupational Therapist, CRP, Bangladesh

Objectives - Understand the role of Occupational Therapy in preventive pressure sores for persons with SCI. - Learn about the different techniques to preventive pressure sores. - Learn about the repositioning strategies used by people with spinal cord injury in the seated, supine and long sitting position.

Methods An integrative literature review was exploiting for the purposes of methodological analysis and concept review drawing on both the empirical and theoretical literature. There were some articles, all qualitative and quantitative which are included in this review. All studies were mixed methods in design. The literature search here, OT Seeker, Google search, Google Scholar, PubMed, and Hinari searched for literature related to the contribution to and involvement how can prevent pressure sores.

Results There were some articles all are mixed methods in design. All but one study was not conducted with participants. There are some statements for preventing pressure sores these are given below. These statements are described and demonstration when presenting my papers. - Use a pressure relief cushion: A pressure relief cushion will help to reduce pressure. - Sit upright: Sitting upright helps to distribute weight evenly. - Use pressure relief techniques: Regular pressure relief can be effective in preventing pressure sores. - Eat well and drink lots of water: A well balanced diet with fresh vegetables, fruits and meat can help to prevent pressure sores. - Avoid friction: Make sure the wheelchair fits correctly and has no rough edges. - Avoid moisture - Check skin every day - While lying or sitting, change positions regularly: Changing position regularly helps to relief pressure. For example, change position from sitting to lying.

Conclusion Occupational Therapists played a vital role in pressure care for persons with SCI. Occupational Therapist should inspect the skin and discuss the possible causes for pressure sore. Provide advice about positioning and bed mobility then Occupational Therapist should consider pressure relief cushion, seating, equipment, mattress, transfer and engage functional task.

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OP1.5 A prototype of an automatic air mattress turning device for pressure ulcer prevention

Sawattikanon N1, Uttrarachon K1, Kovindha A1, Pongvuthithum R2, Sucharitakul T2, Rangsri W2

1Faculty of Medicine, Chiang Mai University 2Faculty of Engineer, Chiang Mai Unviersity

Objectives To study a prototype of an automatic air mattress turning device to assist regular turning in bed in order to prevent pressure ulcer for bed-ridden patients.

Methods The prototype of automatic air mattress turning device consists of 4 chambers/air bags: 2 large air bags in middle and 2 small laterally. It was placed under a 4 inches foam mattress. There are microcontrollers, air pumps and solenoid valves controlling inflation and deflation of each the air bag so that the above foam mattress was curved to position the body in side-lying. These positions can be maintained from 0-120 minutes. To assess pressure at body prominences (occupit, spine of scapula, sacrum, greater trochanters), the pressure mapping was applied to record when a person was lying on the back, the right and the left sides.

Results When inflating the automatic air mattress turning device, it can turn an individual from supine lying to 30 degrees side-lying. The prototype had passed a 3 days continuous protocols testing with different positions and time programming. The pressure mapping in 3 able-bodied showed that the device may relief pressure at bony prominence in side-lying position nearly the same as regular turning with manner.

Conclusion The automatic air-mattress turning device can turn the body from supine to 30 degrees side-lying. With low pressure at the body prominences, it could prevent pressure injury for those who are bed-bound like tetraplegic persons.

Acknowledgement: Faculty of Medicine, Chiang Mai Unviersity for the supporting grant.

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OP1.6 Low level laser therapy in chronic pressure ulcer of cervical cord injury: is it beneficial? A case report

Anggia Putri Nayanti1, Farida Arisanti2, Dian Marta Sari2, Tertianto Prabowo2

Physical Medicine and Rehabilitation Department, Faculty of Medicine, University of Padjadjaran - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Objectives Pressure ulcer (PU) is an important and potentially life-threatening secondary complication of SCI and its incidence is as high as 25-66%, especially in higher level of SCI. Pressure ulcer and it’s treatment represent one of the most challenging clinical problems faced by chronic SCI patients. During the recent years several non- pharmaceutical treatments have been proposed as alternative or adjunctive treatment for chronic wounds including the low level laser therapy (LLLT). This study aim is to evaluate the effectiveness of LLLT on PU in a high level chronic SCI.

Clinical/interesting issues A 55 years old man, with ASIA Impairment Scale C at 3rd cervical level with chronic grade III PU at sacrum, received LLLT once daily, three times a week for 1 month with dose 8J/cm2. The outcomes are changes on pressure ulcer area (cm²) and Pressure Ulcer Score for Healing (PUSH). Those parameters were obtained at baseline, 2 weeks and after 4 weeks treatment. After 2 weeks of intervention there was 0,5 cm reduction of the PU length. The PUSH score was improving 1 point (10 at baseline and 9 at 2 weeks). After 4 weeks of intervention there was more reduction in PU length (1 cm) and width (0,2 cm) but there was no further improvement in PUSH score.

Conclusion Prior study suggested that LLLT enhances the healing process of PU in SCI by facilitates collagen synthesis, keratinocyte cell motility, and growth factor release and transforms fibroblasts to myofibroblasts. In this study LLLT is proven beneficial to reduce circumferential area and PUSH score at 3rd stage of chronic PU in SCI, yet larger studies were needed to substantiate the positive effect of laser in the treatment of PU.

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OP2.1 Effects of an endurance activity on cardiac and metabolic markers in person with and without spinal cord injury

Henry Prakash, Senthilvelkumar, Anand Viswananthan, Samuel Kamaleshkumar

Physiotherapist, Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, India

Objectives To evaluate whether cardiac and metabolic profiles of persons with paraplegia differ from those without SCI participating in a long distance physical activity.

Methods Fourteen persons with paraplegia and 15 non-SCI adults who had voluntarily registered to compete in the Chennai marathon 2014 consented to be part of this study. The persons with paraplegia used manually propelled tricycles to compete in races ranging from 10 kilometres (km) to 42.195 km. Their anthropometric parameters, body temperature (To), working heart rate, venous blood samples for serum sodium, potassium and cardiac troponin T were obtained before and after the event. All these values were compared with the non-SCI volunteers who were participated in the same marathon.

Results Persons with SCI had significantly higher baseline cardiac Troponin-T values (Mean 19 pg/L, SD 17.86) when compared to persons without SCI (5.62 pg/ L, SD 2.73), with a mean difference (MD) of 13.28 (95% CI 4.24, 22.52). Estimation of post-race blood samples showed that the magnitude of elevation in cardiac Troponin values with the endurance activity did not differ between persons with and without SCI, mean difference of change from baseline -23.85 (95%CI -49.03, 1.33). There was a significant difference in post-race To, Na, K levels between the groups. Average heart rate values did not differ significantly between the groups. No adverse events reported during the race.

Conclusion Persons with SCI have higher baseline cardiac Troponin-T levels than persons without SCI. The metabolic response of persons with SCI during long distance endurance activity varies significantly from those without SCI. Further studies should evaluate the clinical significance of these changes.

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OP2.2 LOWER LIMB SUPPORT ABILITY AND ITS CORRELATION TO WALKING IN AMBULATORY PATIENTS WITH SPINAL CORD INJURY

NITHIATTHAWANON T1, 4, AMATACHAYA S1, 4, AMATACHAYA P2, 4, MANIMMANAKORN N3, MATO L1, 4, THAWEEWANNAKIJ T1, 4

1School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand 2Department of Mechanical Engineering, Faculty of Engineering and Architecture, Rajamangala University of Technology Isan, Nakhon Ratchasima, Thailand 3Department of Rehabilitation Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 4Improvement of Physical Performance and Quality of Life (IPQ) research group, Khon Kaen University, Khon Kaen, Thailand

Objectives Lower limb support ability (LLSA) has been reported as an important ability for steady and efficient walking in many groups of participants. However, there is no clear data to support its importance in ambulatory patients with spinal cord injury (SCI) who suffer from various degrees of bilateral sensorimotor deteriorations. Thus, the study investigated the amount of LLSA on the less and more affected limbs during stepping and its correlation with spatiotemporal variables relating to walking ability in 35 ambulatory participants with SCI.

Methods The participants were assessed for their demographics and SCI characteristics. Then they were assessed for LLSA during stepping using a digital load cell, and spatiotemporal gait parameters while walking over a 10-meter walkway using a method of manual digitization. The data were analyzed using Pearson correlation coefficient with the level of statistical significance at p < 0.05.

Results The maximal LLSA on the more- and less-affected leg during stepping of the participants was 87.77 ± 19.96% and 90.53 ± 14.47% of their body-weight. This ability was significant and particularly correlated to temporal variables and walking speed of the participants, especially for the LLSA of the less affected limb (r = 0.53, p < 0.001).

Conclusion The LLSA of the participants was asymmetrical and clearly lower than that required in elderly who walked without a walking device (95% of the body-weight). The greater correlation of the less affected limb may suggest the higher contribution of the limb while walking that could further enhance risk of musculoskeletal injury due to asymmetrical use of the limbs while walking. Therefore, rehabilitation strategies to promote LLSA are important for walking ability of the patients.

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OP2.3 Effectiveness of harness gait training with body weight support gait system in patients with incomplete spinal cord injury (SCI) at CRP in Bangladesh

Mohammad Anwar Hossain1, Muzaffor Hossain2, Iffat Rahaman3, Farjana Taoheed4, Kazi Imdadul Hoque5

Centre for the Rehabilitation of the Paralysed(CRP)

Objectives To determine the effectiveness of harness gait training with body weight gait in walking ability and increases motor power ; to improve balance and mobility capacity of patients with incomplete SCI.

Methods Quasi-experimental study design was chosen to fulfill aims of the study. 15 samples were selected randomly from hospital patients for this study attending at CRP in between July-September, 2017 from Spinal Cord Injury unit. Motor function was measured by using ASIA scale, mobility capacity by using Spinal Cord Independence Measurement mobility section (SCIM), gait speed was measured by using 10m Walk Test (10MWT) and also Berg Balance Scale (BBS) was used for measuring the balance. Socio-demographic data were collected by a semi- structured questionnaire. Data was analyzed by using SPSS software version 20 which focused through column, pie chart and paired t-test.

Results A significant improvement was found in walking speed in both self-velocity and fast velocity measure (p < 0.05). Moderately significant change was found in balance. No improvement was found in mobility and motor function.

Conclusion The study found that harness gait training with body weight gait system is effective for the patients of incomplete SCI to improve their gait quality in perspective of walking speed and balance. It is also cost effective and easy to train. Further study need to be done in control group compared with harness gait training approach with large sample size to find out the effectiveness of this walking device.

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OP2.4 The effect of modified Prasit Thai upper extremity exercises on unsupported sitting balance in paraplegic patients: a randomized controlled trial with assessor-blind

Suwannakad A, Sawattikanon N, Kammuang-lue P, Kovindha A

Department of rehabilitation medicine, Chiang Mai university

Objectives To study the effect of modified Prasit Thai upper extremities exercises in unsupported sitting balance in paraplegic patients from spinal cord injury.

Methods All patients received 20 sessions of training (1-2 sessions/day, at least 3 days/week). Each session had total treatment time of 20 minutes including a 10-minute of static sitting balance training and a 10-minute of dynamic sitting balance training. For the latter, the invention group did modified Prasit Thai upper extremity exercises whereas the control group received a conventional training. An unsupported sitting balance was assessed with a modified Functional Reach Test (mFRT) and score of sitting with back unsupported from modified Berg balance scale (BBSsit) before and after completion of the training.

Results There were 7 patients in the intervention group and 5 in the control group. Before training, there were no significant differences in mFRT and score of BBSsit. After training, the mean distance of mFRT increased in both groups but the mean pre-post difference was different between the two groups (I: 1.18, C: 6.12; P 0.039). The mean score of BBSsit also increased significantly in the intervention group (1.57, 2.86; p 0.041) but not in the control groups (3.40, 3.80; 0.317); the mean pre-post difference was not significant different between the two group (1.29, 0.40; P 0.137).

Conclusion The modified Prasit Thai upper extremity exercises improve sitting balance but not forward reach distance for paraplegic patients.

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OP2.5 The Association between the International Spinal Cord Injury Upper Extremity Basic data set and Spinal Cord Independence Measure

Kasan Sotthipoka, Pratchayapon Kammuang-lue, Siam Tongprasert, M.D.

Department of rehabilitation medicine, Chiang Mai university

Objectives To assess the association between the International Spinal Cord Injury Upper Extremity Basic data set (ISCIUEBDS) and Spinal Cord Independence Measure (SCIM)

Methods Subacute and chronic cervical-level SCI/SCL patients who completed the rehabilitation program were recruited. The data of the ability to reach and grasp and shoulder function classification of the ISCIUEBDS and the three areas of function including self-care, respiration and sphincter management and mobility of the SCIM were collected on the same day. The relationship was analyzed by conducting Spearman Rank Correlation.

Results The total sample consisted of 108 individuals which 94 were male, 14 were female and mean age of the sample was 43.93+14.4 years. A Spearman’s Rank Order Correlation was run to determine the relationship between the better side of the ability to reach and grasp and shoulder function classification of the ISCIUEBDS with self-care subscale of the SCIM. There was a strong, positive correlation, which was statistically significant (r (hand) = 0.894, p<0.01, r (shoulder) = 0.808, p<0.01).

Conclusion The ISCIUEBDS has a strong, positive correlation with SCIM, especially self-care subscale. The ISCIUEBDS can accurately predict the upper limb function and daily functions of patients with SCI.

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OP2.6 Telephone-based management of pressure ulcers in people with spinal cord injury in low- and middle-income countries: a randomised controlled trial

Arora M*, Harvey LA, Glinsky JV, Chhabra HS, Hossain MS, Arumugam N, Bedi PK, Lavrencic L, Hayes AJ and Cameron ID.

*Postdoctoral Research Fellow, Sydney Medical School Northern, The University of Sydney.

Objectives The objective of the trial was to determine the effectiveness of telephone-based management of pressure ulcers in people with spinal cord injury (SCI) in low- and middle-income countries.

Methods A multicentre, prospective, assessor-blinded, parallel randomised controlled trial was undertaken. One hundred and twenty people with SCI living in the community were recruited through three hospitals in India and Bangladesh between November 2013 and March 2016. Participants had sustained an SCI 43 months prior and had a pressure ulcer. Participants were randomly allocated (1:1) to a control or intervention group. Participants in the control group received no intervention. Participants in the intervention group received weekly advice by telephone for 12 weeks about the management of their pressure ulcers from a trained health-care professional. Outcomes were measured by a blinded assessor at baseline and 12 weeks. There was one primary outcome, namely, the size of the pressure ulcer and 13 secondary outcomes.

Results The mean between-group difference for the size of the pressure ulcer at 12 weeks was 2.3 cm2 (95% confidence interval − 0.3 to 4.9; favouring the intervention group). Eight of the 13 secondary outcomes were statistically significant.

Conclusion The results of our primary outcome (that is, size of pressure ulcer) do not provide conclusive evidence that people with SCI can be supported at home to manage their pressure ulcers through regular telephone-based advice. However, the results from the secondary outcomes are sufficiently positive to provide hope that this simple intervention may provide some relief from this insidious problem in the future.

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OP2.7 “Anxiety, Depression, and Exercise Self Efficacy in Paraplegic SCI Inpatients with Pressure Ulcer”

Widya S. Sari

Clinical Psychologist at Instalasi Rehabilitasi Medik, RSUP Fatmawati Jakarta, Indonesia

Objectives Pressure ulcers remain a challenge in Spinal Cord Injury (SCI) rehabilitation and care setting. Despite the continuous counseling and education to raise patients’ awareness of warning signs and the need to regularly change position, prolonged immobility and sensory impairment are still the main SCI-related risk factors that increase patient’s chance of developing pressure ulcers. Patients with SCI and pressure ulcers experience burdening physical and psychological suffering. Depression, anxiety, and low self-efficacy often interfere with patients’ daily life during hospitalization and affect their exercise behavior. This study aimed to assess the level of depression, anxiety, and exercise self-efficacy in paraplegic patients with spinal cord injuries and pressure ulcers.

Methods This was a descriptive and analytical study, which included 12 adult paraplegic patients who were being treated as inpatients in the rehabilitation ward of RSUP Fatmawati (Jakarta, Indonesia). There were 6 patients with pressure ulcers and 6 patients without pressure ulcers. The data used in this study was collected between March and August 2017 using Hospital Anxiety and Depression Scale (HADS) and SCI Self-Efficacy Scale (ESES).

Results Multivariate analysis revealed significant differences in depression and exercise self-efficacy between paraplegic patients with pressure ulcers and without pressure ulcers. Paraplegic patients with pressure ulcer shows higher level of depression and lower exercise self-efficacy, valued with Z = -2.098 and Z = -2.929 respectively (p < 0.05). However, there was no difference in anxiety between the two groups.

Conclusion This findings confirmed associations of having pressure ulcers with depressive symptoms and lower self- confidence to perform exercises. Paraplegic patients should be assessed for these conditions to prevent further physical and psychological problems.

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OP2.8 Reliability of the international urodyanmic basic spinal cord injury data set

Kittamet Dejkriengkraikul, Tuankasfee Hama, Sintip Pattanakuhar, Siam Tongprasert, M.D.

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objectives To assess inter-rater reliability and intra-rater reliability of the International urodynamic basic spinal cord injury data set

Methods Two raters independently analyzed each patient’s urodynamic tracing and completed the International Urodynamic Basic SCI data set twice, one month apart. The interrater and intrarater reliability of this data set was computed using Kappa, Weighted Kappa and Intraclass correlation coefficient (ICC).

Results Of 50 SCI and SCL patients, 72% were male. Mean age was 48.24+16.62 years old. Median time (interquartile range) since injury was 27 months (148 months). Inter-rater reliability of International urodynamic basic spinal cord injury data set was fair to almost perfect. Intra-rater reliability of the first rater was fair to perfect. Intra- rater reliability of the second rater was moderate to perfect (Kappa, Weighted Kappa and ICC were 0.32-0.99, 0.37-1.00 and 0.51-1.00 respectively).

Conclusion The International urodynamic basic spinal cord injury data set has good inter-rater and intra-rater reliability. It is useful for evaluating urodynamic study in SCI/SCL patients.

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OP3.1 Early access to vocational rehabilitation: development, implementation and evaluation of a Novel in-patient Service (the in-voc program)

James Middleton, Deborah Johnston, Gregory Murphy, Kumaran Ramakrishnan and Ian Cameron.

John Walsh Centre for Rehabilitation Research, The University of Sydney

Objectives To investigate whether early access to vocational rehabilitation during inpatient care would increase employment rates and impact positively on health and well-being of persons with spinal cord injury (SCI).

Methods A novel program, called InVoc, was developed to provide inpatients in the SCI units in Sydney, Australia, with early access to vocational rehabilitation (VR). It was offered within 1-8 weeks of acute admission to all eligible patients over a two-year period by trained by Vocational Consultants (VCs) working within the in-hospital multidisciplinary rehabilitation team, being based on an individualised case management model using a strengths-based, coaching approach. Following informed consent, demographic, injury-related, psychosocial and employment data were collected at baseline (program inception), 12 and 24 months post-injury. In addition, semi-structured interviews and focus group discussions were conducted with participants with SCI, 4 VCs and health professionals, exploring perceptions about InVoc.

Results One-hundred inpatients (mean age 36 ±15 years, 82% male, 87% previously employed) were evaluated. Time to In-Voc inception was 61 days (median), with almost one-third commencing InVoc within the first month post- injury. The program lasted 11 weeks (median, range 3–39 weeks), delivering 9.1 hours (median, range 1–75.2hrs) of services per participant. The integration of early, patient-centred and paced vocational rehabilitation by expert VCs has contributed to positive RTW outcomes, with InVoc clients 1.5 times more likely to be employed than controls at 2 years post-injury (p = 0.039), and 61.6% of InVoc participants (in comparison to 39.1% of controls) being employed (p = 0.013). Most technician/trade, sales, machine operator and labourer type jobs were lost at 24 months post-injury, in contrast to professional and managerial occupations, with more people working in clerical/administrative jobs.

Conclusion The integration of early, patient-centred and paced vocational rehabilitation by VCs working within the in- hospital multidisciplinary rehabilitation team contributed to positive employment outcomes.

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OP3.2 Quality of life after SCI in Thai individuals living in an urban area: an in-depth interview

Aitthanatt Eitivipart, Anchalee Foongchomcheay

Objectives The aims of this study were to define the quality of life in individuals with spinal cord injuries living in Bangkok, Thailand, and to explain the mechanism in more depth.

Methods Semi-structured interviews were then used to elicit data from 11 volunteer subjects relating to their individual perspectives on HRQoL. Thematic analysis was used to make a systematic exploration of the transcribed data.

Results Qualitative data revealed that the most salient themes of HRQoL in SCI individuals were ‘supporting factors toward QoL’ and ‘driving force post injury’. The first theme, a moderating variable, had constituent subthemes of ‘having paid occupation’, ‘having personal assistant’, ‘enabling environment, ‘stigma’ and ‘self-advocacy’. The second theme, ‘driving force post injury’, consisted of ‘self-image’, ‘freedom mobility’ and ‘dignity and life’s goal’.

Conclusion The qualitative investigation of QoL themes of Thai individuals with SCI were similar to those of other research, but this study is unique in that it specifically represents the Thai socioenvironmental-cultural aspects.

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OP3.3 Barriers to participate in activity of daily livings in the community among the persons with spinal cord injury

Shakhawath Hossain1, Arpon Kumar Paul2, Sarmily Roy3

1Intern Occupational Therapist, CRP, Bangladesh 24th Year, Bachelor of Science in Physiotherapy, BHPI, CRP 3Clinical Occupational Therapist, CRP, Bangladesh

Objectives To assess the Socio-demographic information and understanding and communicating, mobility. Self-care, getting along with people, household activities, work or school activities and participation.

Methods It was a cross sectional study. 50 samples were conveniently selected from Savar and Dhamrai Upazilla of Dhaka district of Bangladesh for the study. Among them 78% (n=39) was male and 22% (n=11) was female. Interviewer administered Bengali version of The World Health Organization Disability Assessment Scale II (WHODAS II) 36 items was applied to people with spinal cord injury living in their own community who completed their rehabilitation from CRP.

Results In the study the total participants were 50.The minimum age was 20 years old. The maximum age was 80. Each item of WHODAS 2.0 questioner was rated on a 5-point scale, from 1 (no difficulty) to 5 (extreme difficulty/cannot do). The instrument produces a total score (disability level) and 6 domain scores, ranging from 0 (best) to 100 (worst).

Conclusion This study provides a common metric of the impact of spinal cord injury in terms of functioning. This study makes it possible to focus directly on functioning and disability and allows the assessment of functioning separately from the spinal cord injury.

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OP3.4 Facilitators and barriers of functional independence in spinal cord injury patients with motor useful after discharge from rehabilitation ward

Muangdan C1, Ratanapinunchai J2, Patanakuha S1, Sawattikanon N1

1Faculty of Medicine, Chiang Mai University 2Faculty of Associated Medical Science, Chiang Mai Unviersity

Objectives To find the factors that related with functional independence in patient with spinal cord injury after discharge from rehabilitation ward.

Methods Interviews by phone were conducted with 20 persons with traumatically acquired spinal cord injury (ASIS class D) living in the community. Patient’s information was collect from hospital data base. The interview content health status, environmental factors, economic status, coping strategies, anxiety and depression, all categories assumed to have an impact on functional independence.

Results This study will find the factors that related with functional independence in patient with spinal cord injury after discharge from rehabilitation ward more than 3 months, than the result are in the process of data collection

Conclusion The information can be used to develop and improve rehabilitation work before the patient returns home and improve the quality of life of people with SCI living in the community.

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OP3.5 FACTORS INFLUENCING THE SUCCESS OF HOME MODIFICATION IN PARAPLEGIC SPINAL CORD INJURED INDIVIDUALS IN BANGLADESH

Mohammad Iqbal Hossain, Luthfun Nahar

Occupational therapy department, Centre for the Rehabilitation of the Paralysed (CRP) Mirpur, Dhaka, Bangladesh.

Objectives 1. To identify the factors assisting participants to complete successful home modifications. 2. To identify the barriers experienced by participants to complete home modifications.

Methods A qualitative study design was selected to explore the individual experiences of people living in the community post rehabilitation.

Results Of the 30 participants, 15 were successful and fifteen were unsuccessful in the achievement of an accessible home environment. Factors presenting difficulties for the participants included: new and challenging environments, financial strains, insufficient space, poor understanding about modification, living in a rented home and inadequate support from family members and relatives. Those participants who had made sufficient modifications had: engaged themselves in productive occupation, a tendency to be independent in all activities, good family and relative support, understood the importance of modification, received regular follow-up and held promising future plans. Those who had insufficient home modifications were seen to: have little involvement in any form of productive occupation, be residing in rural areas or in a rental house, be facing financial insecurity, be lacking in confidence and receiving poor family support. These participants also held no specific plan regarding home modification and were fully dependent on their family.

Conclusion Following spinal cord injury successful home modification is affected by a number of factors such as challenging environment, financial strains and family support. Social awareness, community and local government support are essential to the process, and needs to be considered by any organization offering home modification services.

Key words: Spinal Cord Injury, paraplegia, home modification, rehabilitation, community.

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OP3.6 Perception of the women with spinal cord lesion about their vocational rehabilitation: an institutional based study

Shamima Islam Nipa1, Farjana Taoheed2, Mohammad Mustafa Kamal Rahat Khan3, Md. Akhlasur Rahman4 Md. Shofiqul Islam5

1 Lecturer- Rehabilitation Science, Department of M R S, BHPI, CRP, Dhaka, Bangladesh , 2Senior Clinical Physiotherapist, Department of Physiotherapy, CRP, Dhaka, Bangladesh, 3Senior Occupational Therapist, Department of Occupational therapy, CRP, Dhaka, Bangladesh, 4Senior Trial Site Manager, CIVIC Trial Project, CRP, Dhaka, Bangladesh, 5Assistant Professor, Department of Physiotherapy, BHPI, CRP, Dhaka, Bangladesh.

Objectives To find out the perception of the women with spinal cord lesion about their vocational training and to explore the in-depth and effective ways in decision making and coping with the utilization of the vocational training as well. Methods A qualitative study was conducted to explore the experience of women with spinal cord lesion about their vocational training. The convenience sampling method was chosen to select the samples and semi-structured face to face interviews were carried out to collect the data. Results Content analysis was used to analyze the data and several thematic factors were identified this leads that though none of their training was similar with their previous job, however, they were satisfied with their training. The study findings indicated that vocational counseling helped the participants to choose the best possible option for their training. However, different factors such as educational status, physical status, social context and interest about the training also influenced during decision making about the training. It had been also explored that all of them had proper planning about the implementation of the training which can enhance a good quality of life. Furthermore, several factors such as increase the duration of the training & development of scope of implementation of training can improve the quality of training.

Conclusion Spinal Cord Lesion is a devastating condition which reduces the quality of life. Therefore, to ensure the good quality of life for the women with spinal cord lesion,it is also necessary to reduce the economical dependency on their family. At there, vocational training can play a great role to involve in the different paid work or to earn money. However, not only the providing training is necessary but also, development of skilled manpower, increase the duration of training and scope of implementation of training need to develop as well.

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OP3.7 Proposed sport rehabilitation protocol for friends with spinal cord injury (SCI)

DR KETNA MEHTA, DR RATNA VORA

NINA FOUNDATION

Objectives -To motivate friends with SCI to enhance their fitness levels -To design a structured protocol for sports specific fitness for friends with SCI based on their level of injury

Clinical/interesting issues In India, though many SCI’s are capable of achieving trophies in sports; but lack of awareness, lack of motivation and sports specific trainers had led to only a handful of then achieving success. Hence, here we propose a sports rehabilitation protocol and help friends with SCI. POSTER COVERS – -EXERCISE BENEFITS ON OVERALL HEALTH OF SCI -VARIOUS COMPONENTS OF FITNESS (Flexibility, strength, endurance, plyometrics) WITH ‘FITT’ PRINIPLE DETAILS -VARIOUS MODES OF EXERCISE ( Eg CIRCUIT) -BARRIERS FACED BY SCI’s IN INDIA -NUTRITIONAL ASPECT FOR A SPORTS SCI

Conclusion Sports specific rehabilitation protocol will help trainers to take interest in motivating and training friends with SCI and help them in reliving them of the health issues and achieving success in various sports.

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OP3.8 What is Your Choice Between Health or Success?: A Case Series of Thai Spinal Cord Injury Athletes in the 9th ASEAN Paragames

Dr. Sintip Pattanakuhar

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Abstract Three Thai SCI persons participating in the 9th ASEAN Paragames experienced complications during the competitions. A 38-year-old C5A tetraplegic person reported a problem of fecal incontinence during competing chess resulting from fecal soiling. This may be from incomplete bowel management due to the intense practice. He told that his caregiver was very angry and he felt upset with this problem. He did not receive any medals from this competition. Another SCI athlete was a 30-year-old T4A paraplegic woman, who was a table tennis player. She has had two grade-3 chronic pressure ulcers at both buttocks for two years. She refused an operation because she wanted to go to the practice camp. At this tournament, she reported that she continued dressing the wounds every day and they did not disturbed her competition. She got one gold medal from the team woman event and one silver medal from single sitting class 1-3. The other athlete was a 31-year-old T6B paraplegic man, who played in a basketball team as a point guard. Because he was a starting and main player in both 3-on-3 and 5-player teams, he had no time to do urinary self- catheterization every 4-6 hour like normal situation. He got acute cystitis on the day before the final round of both events. He refused to take any medication due to fearing of the side-effect as well as it may decrease his confidence. Finally, he was able to win in both events and received two gold medals. Although having a positive effect on mental health, sports may cause physical health problems. When divided time in a day to three equal parts, namely biological time, work time and free time, SCI persons need more biological time to complete their self-care activity. However, SCI athletes need more work time to practice and compete, which may be more than 12 hours a day. These may cause complications from inadequate time to do self-care activity.

Conclusion To manage this problem, a rehabilitation team may use a medical ethics framework of decision making. This framework addresses considering four circumstances, which are medical indications, contexts, quality of life and patient preferences. Meeting half way between health-care providers and athletes may make the management of this situation more successful.

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OP4.1 A telephone-based version of the spinal cord injury - secondary conditions scale: a reliability and validity study

Arora M*, Harvey LA, Lavrencic L, Bowden JL, Nier L, Glinsky JV, Hayes AJ and Cameron ID.

*Postdoctoral Research Fellow, Sydney Medical School Northern, The University of Sydney.

Objectives The objective of this study was to determine the inter-rater reliability and validity of using a telephone-based version of the spinal cord injury–secondary conditions scale (SCI–SCS).

Methods A psychometric study was conducted. The study was conducted in Royal North Shore Hospital, Sydney, Australia. Forty people with a complete or an incomplete spinal cord injury. Inter-rater reliability was tested by comparing the telephone-based version of the SCI–SCS administered on two different days by two different telephone assessors. Validity was tested by comparing the telephone-based version of the SCI–SCS with the paper-based version of the SCI–SCS.

Results The median (interquartile range) age and time since injury were 54 (48–63) years and 28 (14–35) years, respectively. The intraclass correlation coefficient (95% confidence interval) reflecting the agreement between the telephone-based version of the SCI–SCS administered on two different days by two different assessors was 0.96 (0.93–0.98). The corresponding value reflecting agreement between the telephone-based assessment and the paper-based assessment was 0.90 (0.83–0.95).

Conclusion The telephone-based version of the SCI–SCS is a simple and a quick questionnaire to administer that has both inter-rater reliability and validity. It may be useful as a way to screen for secondary health conditions in low- and middle-income countries where it is not always feasible to provide routine face-to-face follow-ups and where literacy may be a problem.

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OP4.2 Characteristics of shoulder pain among paraplegic wheelchair user

RUBEL AHMAD SAMIR

Bangladesh Health Professions Institute, Centre for the Rehabilitation of the Paralyzed (CRP), Savar, Dhaka, Bangladesh.

Objectives To calculate number of all paraplegia patients with shoulder pain from 10th February 2016 to 15th October 2016 among all paraplegia patients and percentage of this proportion; to explore socio demographic characteristics (age, sex, residential area) of paraplegia patients with shoulder pain; to measure the severity of shoulder pain with find out aggravating and ease factors.

Methods A cross sectional design was carried out in this study. 30 paraplegia patients were convenience selected from SCI unit of CRP, Savar, Dhaka, Bangladesh. The tools used to collect data included direct interview, a body discomfort assessment tool that consists of Visual Analogue Scale (VAS) and a questionnaire. Data was collected by mixed type questionnaire and confidentiality of information and voluntarily participation were ensured by the researcher. Data were numerically coded and captured in Microsoft Excel 13, using an SPSS 19.0 version program.

Results The result of the study showed that, the severity of shoulder pain was (76.7% ) and (23.3%) was not suffered from shoulder pain among the paraplegia patients attended at CRP. The most affected age range is years of age 21-40years of age (33.3% ). The severity of pain among the cases includes moderate pain (30% ), mild pain (53.3% ), severe pain is (0% ) and (16.7%) have no symptomps of pain. Most of the participants (70% ) pain had increased during movement whenever only (30% ) patient’s pain had increased during rest.

Conclusion From this study it is concluded that shoulder pain is the common problem of paraplegia wheelchair user patients. Prevention of shoulder pain is beneficial for paraplegia patients. To prevent shoulder pain, we should focus on awareness about the caharacteristics of shoulder pain among paraplegia patients and greater attention to be given to other risk factors such as history of shoulder injury and perception of health status after spinal cord injury.

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OP4.3 Therapeutic dose baclofen-iniduced delirium in elderly paraplegic patient: aware of risk factors to avoid serious complication

Pimthong Jitsakulchaidej M.D., Sintip Pattanakuhar M.D., Assoc. Prof. Apichana Kovindha

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objectives Baclofen is the most commonly used to decrease generalized spasticity in spinal cord injury (SCI) patients. It can pass through blood-brain barrier and impairs mental functions especially in elderly persons.

Clinical/interesting issues An 83-year-old man, diagnosed with spastic paraplegia T11C from vertebral tuberculosis 2 years ago, was admitted for rehabilitation. He also had a history of stroke with complete recovery. Since the initial evaluation showed Modified Ashworth Scale of 3 in both lower extremities, 10 mg of baclofen three times per day was prescribed. After a second administration, he developed acute drowsiness and confusion with day-night fluctuation. Because laboratory and imaging results were normal, a hypoactive delirium from baclofen was provisionally diagnosed. After off baclofen, his consciousness recovered to normal conscious status within 6 hours. To control spasticity, tizanidine was prescribed at the starting dose of 2 mg twice a day and titrated to 8 mg twice a day. No side-effect of delirium was observed. The patient can continue the rehabilitation program and was discharged at one month.

Conclusion Baclofen is a gamma aminobutyric acid (GABA) B receptor antagonist. It can pass through blood-brain barrier and potentially cause CNS side-effects, such as alteration of consciousness or delirium. There has been no report of therapeutic dose baclofen-induced delirium. In this case, the potential risk factors of baclofen-induced delirium were very old age (≥ 80 years) and underlying disease of stroke. In those with these risk factors, tizanidine, which has no report about side-effect of delirium, might be a better drug of choice to treat spasticity than baclofen, but we should be aware of postural hypotension.

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OP4.4 The effects of task-oriented training on dressing lower part in paraplegic patient with pelvic fracture: a case report

Tarinee Prakobkhong, Tuenchai Attawong, Narumon Sumin, Siam Tongprasert

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objectives To presents a rationale of task-oriented approach to improve dressing lower part in patient with paraplegia and both hips ROM limitation.

Clinical/interesting issues In paraplegia with pelvic fracture, they may have difficulties with dressing and undressing on lower part from hips ROM limitation. When they have enough strength, balance and skill to do this task, training will begin. Paraplegic patients may practice the skills with Occupational Therapists at specific setting and may need to learn new techniques, use assistive devices to compensate for decreased muscle strength and range of motion or to compensate for decreased endurance. We reported a 30-year-old incomplete flaccid paraplegia T11C woman with fracture L1-L2 vertebral body and closed fracture right pelvic after traffic accident. External fixator (closed reduction and anterior fixator) and a Taylor Brace were applied to help stabilize the spine. This patient was transferred to a rehabilitation ward for intensive rehabilitation. At first presentation she has limited ROM of both hips and poor sitting balance. We followed a dressing training guideline and focused on task-oriented training intended specifically techniques to improve skill in dressing of lower part and prevent complication.

Conclusion Task-oriented training is also sometimes called task-specific training, goal-directed training, and functional task practice. In the present study, dressing training in the step-by-step and using assistive devices to compensate for decreased muscle strength and range of motion were tailored to the patient's ability, commencing with easy tasks and progressing to more difficult ones, according to the level of accomplishment.

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OP4.5 One year follow up study on effectiveness of patient education in patients with SCI after discharge

Raveevan Jindamaneesirikul1 and Apichana Kovindha2

1 Rehabilitation ward, Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University; 2 Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University

Objective: To report effectiveness of patient education on prevention of common complications in patients with new spinal cord injury (SCI) after post-acute rehabilitation.

Study design: A prospective and descriptive study

Setting: Rehabilitation ward, Maharaj Nakorn Chiang Mai Hospital

Subjects: Traumatic and non-traumatic SCI patients discharged from Rehab ward during October 2014-June 2015.

Materials and methods: During rehab admission, all patients received a handbook for patients with SCI and were educated one-by-one by a rehab nurse. Patient education was started with skin care, followed by bladder and bowel care. They were followed by telephone at 3 months, 6 months and one year after discharge; and asked about new pressure ulcer (PrU), symptomatic urinary tract infection (UTI) and fecal impaction that needed treatments.

Results: There were 190 patients completely followed up at one year. After discharge, none had PrU at 3 and 6 months, only one tetraplegic female (0.5%) reported new grade 2 PrU at coccyx which healed after one week. Two paraplegia females (1%) who needed clean intermittent catheterization UTI that needed treatment (one occurred at 3 month and the other at 6 month) but none at one year. There were12 patients (6.5%) at 3 month, 7 patients (3.8%) at six months and 6 patients (3.3%) at one year reporting fecal impaction. No one died in one year after discharge.

Conclusion: One year after discharge from post-acute rehabilitation, there are low incidences of pressure ulcer, urinary tract infection and fecal impaction among traumatic and non-traumatic spinal cord injury. The low incidence of such complications reflects effectiveness of patient education done by rehabilitation nurse. However patient education on bowel care and management needs to be focused more as fecal impaction is still prevalent.

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OP4.6 Health mechanics: a self management tool for spinal cord injured people: possibilities of introducing through e-learning platform

Mohammad Monjurul Karim1, Roksana Hoque2

1Deputy General Manager, CRP Mirpur, 2Senior Research Associate, BRAC University

Objectives To discuss possibilities of introducing the self management program to improve quality of life after a spinal injury on e-learning platform.

Clinical/interesting issues Living with limitations after a spinal cord injury is a reality. Rehabilitation program is essential to back to normal life, but often inability to adjust the limitations ruin up the positive outcomes. Michelle A. Meade, Ph.D. Department of Physical Medicine & Rehabilitation, University of Michigan created the Health Mechanics program in 2009 which is an interesting tool specific to SCI clients to cope with the limitations even after the complete rehabilitation. The program looks at the preventing secondary complications after SCI and focus on self management skills namely Attitude, Self-Monitoring, Problem-Solving, Communication, Organization, Stress Management in systematic way. Another part of the tool is created for rehabilitation professionals to realize how clients are going through the issue. I assume this could be an interesting tool to disseminate through e-learning platform on Asian Spinal Cord Network. Researching the outcome after applying on Asian context could be the next step though it’s already proven as effective tool to improve quality of life of the survivors. Conclusion This session is a food for thought for the practitioners in the field to know about self management program and assessing suitability to offer as an e-learning program by Asian Spinal Cord Network Governing Body.

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OP5.1 What’s wrong with digestive system after SCI?

Apichana Kovindha, M.D., FRCPhysiatrT

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Abstract Digestive system consists of digestive structures (salivary glands, oesophagus, stomach, small and large intestines, pancreas, liver, gall bladder and ducts) and functions (ingestion, digestive, defecation, and weight maintenance functions). Neural control of digestive system consists of extrinsic nervous control (somatic and autonomic nervous system) and enteric nervous system control.

After severe spinal cord injury, some digestive functions are impaired. Swollowing is usually intact but may be impaired due to cervical fracture and intubation. During acute spinal shock phase, digestive functions often impaired such as intestinal paralylsis, hyperacidity in stomach. Defecation functions (i.e. elimination of faeces, faecal consistency, frequency of defecation and faecal continence) are generally. After spinal shock phase, voluntary defecation is uncommon and leads to constipation and incontinence. To restore defecation functions, a proper bowel management aiming at regular evaculation of stool from rectum and sigmoid colon to prevent faecal incontinence, is necessary

Another function of digestive system is weight maintenance function. SCI patients usually lose weight during acute phase due to negative nitrogen and also less intake. If weight loss persists, it would disturb post-acute rehabilitation phase and lead to undernutrition that increases risk of pressure ulcer and infection.

These impairments of the digestive system should be concerned and proper management to restore such functions and prevent complications.

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OP5.2 Colonic obstruction from sigmoid volulus in tetraplegics: common symptom from uncommon cause

Dr. Sintip Pattanakuhar

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Objectives It is difficult to diagnose an acute abdomen condition in spinal cord injured persons due to abnormal sensation below the injured level and multiple co-morbidities. These will mislead the exact diagnosis and delay the proper treatment.

Clinical/interesting issues A 57-year-old tetraplegic C4C man developed symptoms of nausea and vomiting, abdominal distension and feeding intolerance. Physical examination showed positive bowel sounds and digital rectal examination revealed an empty rectum. Serum electrolyte was investigated and the results indicated severe hyponatremia. The provisional diagnosis of pseudo-gut obstruction was made. Plain abdominal X-ray demonstrated severe dilation of entire colon with absence of rectal gas shadow. After the failure of 48 hours of conservative treatment with nasogastric and rectal tube, abdominal CT was done, which compatible with sigmoid volvulus. Eventually, open sigmoid detortion with loop transverse colostomy was performed. The incidence of colonic (caecal and sigmoid) volvulus in spinal cord injured persons is 2.6%. The most important signs of SV are empty rectum during DRE and absent of fecal mass at left lower quadrant of abdomen. The classical coffee bean sign from plain X-ray is seen in less than 60% of cases. CT or MRI abdomen showing a whirled soft tissue mass has 100% accuracy.

Conclusion Because of the inconclusive clinical features from lack of supraspinal sensation control, early use of the objective investigation (e.g. radiologic investigation) is preferable in SCI person who is suspected with an emergency intra- abdominal condition.

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OP5.3 Dysphagia in Traumatic Cervical Spinal Cord Injury with A Large Anterior Bridging Osteophyte: A Case Report

Nita Theresia Reyne1, Farida Arisanti2, Vitriana Biben2, Irma Ruslina Defi2

Physical Medicine and Rehabilitation Department, Faculty of Medicine, Padjadjaran University - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Objectives To evaluate factors that may contribute to dysphagia in cervical SCI. Dysphagia is a secondary complication of cervical spinal cord injury (SCI) that associates with surgery and tracheostomy. Unusual anatomical abnormalities such as a large anterior cervical osteophyte can also cause abnormalities in deglutition. Combination of these situations can increase severity of dysphagia.

Clinical/interesting issues A 56-year-old male with C3 SCI ASIA C, complains multiple-swallowing, catching sensation, and has to clear his throat after swallowing. Sixteen months ago, he endured retrolisthesis C4-C5 and Hernia Nucleus Pulposus C4-5, C5-6. Anterior cervical discectomy and fusion (ACDF) was performed and tracheostomy tube was inserted due to pneumonia for 6 months. Decannulation site hasn’t closed yet until now. Fiberoptic endoscopic evaluation of swallowing showed posterior pharynx wall thickening, penetration and residue in the vallecula and pyriform sinuses. Cervical x-ray shows a large anterior bridging osteophyte at C3-4. Video fluoroscopic swallowing study has not performed yet due to unavailability. The patient refuses nasogastric tube and the dietary advice. The body weight decrease 11 kg in 16 months and BMI is 18.3. Osteophyte narrows the hypopharynx, incomplete epiglottis deflection and a local inflammatory. These are worsened by SCI lesion and retraction of midline structures after ACDF that reduce pharyngeal wall movement. Long-term tracheostomy may cause restriction in larynx elevation and the leakage contributes to inadequate subglottic pressure production. Follow up to evaluate for aspiration possibility and nutritional status is warranted.

Conclusion There are many possible contributing factors of dysphagia in cervical SCI and increased awareness is needed for proper rehabilitation program.

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OP5.4 Severe Hyponatremia in SCI: Who Is at Risk and How to Treat?

Supattana Chatromyen, M.D., Sinthip Pattanakuhar, M.D., Assoc. Prof. Apichana Kovindha, M.D.

Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Introduction Hyponatremia is not uncommon in acute spinal cord injury (SCI) patients. Symptoms of hyponatremia, such as alteration of consciousness or postural hypotension, are a barrier of the rehabilitation process.

Case presentation A 62-year-old man was diagnosed with C5-6 bilateral facet joint dislocation resulting in complete flaccid tetraplegia C5A. Ninth day after injury during in rehabilitation phase, he developed an alteration of consciousness. His serum sodium revealed severe hyponatremia, indicating by the serum sodium of 100 mEq/l. The diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH) was made by excluding all other causes. Hypertonic saline infusion, simultaneously with fluid restriction, was firstly administrated and followed by normotonic saline infusion. Twenty-four hours after treatment, the serum sodium was still 106 but the patients gained normal consciousness. The serum sodium was rising into 129 mEq/l and the rehabilitation program was restarted after 7 days of treatment.

Discussion The underlying mechanism was elusive, but may be related to increased sodium excretion via urine resulting from decreased in sympathetic control, as well as SIDH. Risk factors of hyponatremia in acute SCI were high neurological level and complete injury. There are two considering points in order to treat hyponatremia in SCI. First, it is difficult to observe the symptom of weakness from central pontine demyelinolysis, which is the complication from too much rapid increase in serum sodium. The other is that fluid restrict intending to treat SIADH may increase risk of urinary tract infection, especially in patients who are using indwelling urinary catheter.

Keywords: Tetraplegia; Alteration of consciousness; Hyponatremia; SIADH

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OP5.5 BOWEL CARE: WHY IS IT IMPORTANT?

JULIA PATRICK ENGKASAN

Department of Rehab Med, UMMC, University of Malaya, KL, Malaysia

Objectives To illustrate the importance of bowel care in persons with SCI

Clinical/Interesting issues Neurogenic bowel dysfunction is a major physical and psychological problem for persons with SCI, causing major restrictions on their social activities and quality of life. Persons with neurogenic bowel often suffered from prolonged evacuation, constipation, pain, haemorrhoids, fissures, and autonomic dysreflexia. Failure to achieve regular, timed voiding and continence prevent successful re-integration of the individual into her or his home life and community. Furthermore, bowel dysfunctions worsen with duration of SCI; the worsening functions accelerates when it is poorly managed. This lecture will convince the audience why aggressive and appropriate bowel management right from the start of SCI is an important component of SCI rehabilitation process.

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OP6.1 The hazards in aging with SCI

Mr. Aaron Vamosh

Disabled War Veterans Organization of Israel and Umbrella Organization of Persons with Disabilities

Objectives Sharing personal experience as an SCI consumer with therapists and other SCI consumers to raise awareness of what SCI consumers should be prepared to improve quality of life.

Clinical/interesting issues The purpose of this talk is to introduce SCI consumers and therapists to variety of topics that need to be addressed in preparation for a new way of life after injury. The subject will be presented by sharing anecdotes, incidents and mishaps in my own experience of 44 years as an SCI consumer. It will highlight lessons learned as a handicapped athlete and archery judge as well as traveling and organizing tours for persons with mobility impairments. The talk will also include a focus on special risks to SCI consumers such as joint damage, burns, pressure wounds and weight control. Aaron D. Vamosh was 23 years old when he became a paraplegic due to a war injury due to a shell explosion.

Conclusion Good preparation during rehab can and should enhance awareness of the hazards that SCI consumers may encounter and can help them avoid additional injuries and damage.

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OP6.2 Managing common problems of uncommon SCI’s

MS RAJSHRI GUNVANTRAO PATIL, DR KETNA MEHTA, DR RATNA VORA

NINA FOUNDATION (NF)

Objectives -To help rural SCI’s manage their health issues -To spread awareness about a new venture by Nina Foundation ‘ HOPE KIT’ -To educate rural/ignorant/illiterate SCI about the way of life through FAQ’s in local language

Clinical/interesting issues Due to lack of awareness of a condition SCI in rural India, many SCI’s lose hope and succumb to issues which are easily manageable with minimal resources. We at NF aim to solve these issues at grass root level. POSTER COVERS – -Common issues faced by a rural SCI (Bedsore issues, respiratory issues, suture site infection, UTI, psychological fear etc) -Detailed description of each of 12 items in the HOPE KIT that relieves a rural SCI of common difficulties in the most economical way. -Educating them to manage difficulties with available resources.

Conclusion HOPE KIT is a means of creating HOPE among friends with SCI in rural areas all over the world to make their lives easier.

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OP6.3 Use of focus group for voices of SCI patients on leisure activities during post-acute rehab phase

Arunothai Sukkraithai*, Tuenchai Attawong*, Apichana Kovindha**

*Occupational Therapist, **Associate professor, Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Thailand

Objectives All patients with spinal cord injury (SCI) hope that their impairments will be solved and their strength and capabilities will return to normal again with treatment and therapy provided by a skillful health professional/rehab team. However many cannot tolerate an intensive rehab therapy during a post-acute phase and lie in bed with stress and feeling of hopelessness and helplessness. Leisure activities are something that can help divert such feelings.

Methods To make the patients accept and actively participate in leisure activities as a part of therapy, we conducted a focus group interviewed and asked them four questions: 1) What are their leisure activities? 2) How do interesting leisure activities affect your mind and body? 3) Has your performance of leisure activities changed since injury? And 4) What leisure activities do you think you can perform now?

Results From the view of 6 SCI patients (2 tetraplegics and 4 paraplegics), the leisure activities are activities done after work or school to relax, enjoy and strengthen relationship such as watching TV, listening to music, cooking, looking after kids, doing house works, gardening, chatting with friends via Facebook/Line. These affect both body and mind. After SCI, their interest in leisure activities are changed due to mobility limitation and they feel regret that they cannot continue doing such. However, some with positive thinking say that our vision and hearing functions are good, therefore watching TV, reading books, listening to music are possible.

Conclusion The focus group interview is a good alternative approach to receive voice of customers. In this context, it not only provides occupational therapists the patients’ views of possible leisure activities but also enhance a positive view of such in SCI patients who previously have no idea and make them accept possible leisure activities as a part of rehab therapy during post-acute rehab therapy.

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OP6.4 My career, my home

Mr. Manakit Taolorm

Consumer

Objectives Voices of customer: In order to share/exchange the experiences as a tetraplegia patient who could get over his disabilities and success in his career as a graphic designer and supporting his family.

Clinical/interesting issues As a complete spastic tetraplegia C4A (ZPP C5) patient who got injured from car accident unexpectedly 21 years ago (onset 1996). Manakit Thaolorm would like to share/exchange his experiences in…

1. How he could get over from his disabilities (both mentally and physically). 2. How his family play an important role and made him as is today 3. How he made use of the limited resources and turn himself into a graphic designer

Conclusion For 10 years of self-studying and self-training, Manakit has successfully become a graphic designer and be able to support his family.

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OP6.5 Inspiration of my life

Miss. Sudarat Thinnchak

ฉันเคยได้รับบาดเจ็บที่กระดูกสันหลังบริเวณคอ ขณะหลับอยู่ภายในรถยนต์ที่ประสบอุบัติเหตุ เมื่อ ปี 2547ซึ่งเป็นผลให้ร่างกายของ ฉันไม่มีความรู้สึกและสั่งการไม่ได้ จึงได้เข้ารักษาที่โรงพยาบาลมหาราชนครเชียงใหม่ โดยมีทั้งการผ่าตัดจัดกระดูกสันหลังบริเวณคอ ระหว่างข้อที่ 6 ซึ่งเคลื่อนทับเส้นประสาทไขสันหลังและการอยู่พักฟื้นที่แผนกเวชศาสตร์ฟื้นฟูเพื่อท ากายภาพแ 7 กับละกิจกรรมบ าบัด ช่วงแรกของการเข้ารักษา ตัว ฉันเพิ่งจะอายุ ปี เป็นเด็กวัยรุ่น ก าลังเรียนรู้ชีวิตในช่วงต่อที่จะเติบโตเป็นผู้ใหญ่ ด้วยความที่ฉันไม่เคยรู้จักโรคบาดเจ็บไขสันหลังมาก่อน เลยได้ 13 แต่ฟังและเชื่อตามค าที่ทุกคนคอยให้ก าลังใจ บอกว่า “ไม่เป็นไร เดี๋ยวก็หาย” และอาการของฉันก็ค่อยๆดีขึ้นกว่าตอนที่เพิ่งประสบอุบัติเหตุท าให้ฉันยัง มีความหวังรอให้ร่างกายฟื้นตัวกลับไปเป็นปกติ แต่พออาการของฉันเริ่มทรงตัวอยู่เพียงในส่วนที่เส้นประสาทไขสันหลังไม่ได้รับบาดเจ็บ และร่างกาย ส่วนที่เหลือยังคงไม่มีความรู้สึก ไม่สามารถสั่งการให้ขยับได้เหมือนเดิมทั้งหมดอย่างที่คิด แล้วต้องใช้รถเข็นวีลแชร์ในการเคลื่อนที่พร้อมกับการท าบัตร ประจ าตัวผู้พิการ เช่นที่ได้เห็นและรับรู้เรื่องราวของผู้ป่วยที่แผนกเวชศาสตร์ฟื้นฟู นั่นก็เป็นค าตอบให้ฉันรู้ถึงความจริงของสิ่งที่ตัวเองเป็นและต้อง ยอมรับ ความรู้สึกแย่ๆจึงเกิดขึ้นมาท าให้ฉันตั้งค าถามมากมายกับตัวเองถึงอนาคตที่ต้องอยู่ในร่างกายที่มีข้อจ ากัด ยิ่งเมื่อการรักษาจบลงแล้วได้กลับ บ้าน กลับมาอยู่ในสังคมที่ต้องใช้ชีวิตกับคนทั่วไปความแตกต่างที่ชัดเจนขึ้นก็ยิ่งท าให้ฉันอยากรู้ว่า จะต้องใช้ชีวิตต่อไปอย่างไร ในระหว่างนั้น มีสิ่งที่ท าให้ฉันยังรู้สึกดีได้คือ ก าลังใจจากคนรอบตัว ทั้งพ่อแม่ ครอบครัวที่คอยช่วยเหลือดูแล เพื่อนๆ ญาติๆ ที่มาเยี่ยม , แพทย์ พยาบาล นักกายภาพและนักกิจกรรมรวมทั้งผู้ป่วย ผู้พิการ ที่ให้ค าแนะน า ชีวิตของฉันจึงยังอยู่ต่อมาได้ และเริ ,เยือนเสมอ่่มคิดถึงสิ่งที่ ตัวเองยังพอจะท าได้ ด้วยความคิดอยากท าอะไรที่มีค่าเพื่อน าไปตอบแทน นั่นเป็นพลังที่ท าให้ฉันเริ่มสู้กับข้อจ ากัดของตัวเอง ฉันเริ่มต้นด้วยการฝึกจับ ปากกา ด้วยนิ้วมือที่สั่งขยับไม่ได้ ท าให้ต้องเริ่มหัดเขียนใหม่ เพื่อจะกลับมาเขียนได้ และเรียนหนังสือต่อ หลังจากต้องพักการเรียน พอกลับมาเขียนได้ เป็นปกติ และได้เรียนต่อ ผ่านการศึกษานอกระบบ ท าให้ฉันมีความหวังที่จะลองท าสิ่งต่างๆตามความสนใจ แล้วฉันก็เริ่มมีความฝัน อยากเป็น ).กศน( นักเขียน เพื่อบอกเล่าสิ่งที่ฉันได้รับรู้ และเพื่อจะท าให้เกิดรายได้โดยเริ่มจากการเขียนบันทึกเรื่องราวในชีวิตประจ าวันพร้อมกับหาความรู้เกี่ยวกับงาน เขียนแล้วเริ่มแต่งเรื่องส่งให้ส านักพิมพ์พิจารณา ในช่วงแรกของการท าตามความฝันฉันก็ได้เจอกับความผิดหวังบ่อยครั้งจากงานเขียนที่ยัง ท าได้ไม่ดีพอและการถูกปฏิเสธจากทางส านักพิมพ์แต่นั่นก็เป็นบทเรียนให้ฉันได้กลับมาพัฒนาตัวเองเพื่อแก้ไขและมุ่งมั่นตั้งใจท าให้ดีขึ้น การมีสิ่งที่ยัง พอจะท าได้คือความหวังให้ฉันไม่อยากยอมแพ้ แล้วพยายามท าต่อมา พร้อมกับที่มีคนรอบตัวคอยสนับสนุนสิ่งที่ฉันท า และมีโอกาสต่างๆเข้ามา ฉันจึง ได้ลองท า แล้วก็ท าได้ และเมื่อฉันได้เห็นกิจกรรมการประกวดหนังสั้นเนื่องในวันมหิดลของคณะแพทย์ศาสตร์มหาวิทยาลัยเชียงใหม่งานสวนดอกร้อย ใจใส่ใจผู้พิการฉันจึงน างานเขียนที่ท ามาปรับเป็นหนังสั้นโดยท าการ์ตูนอนิเมชั่น ซึ่งฉันเป็นคนวาดรูปเขียนบทใส่เสียงประกอบและตัดต่อด้วยตัวเอง ทั้งหมดจากการศึกษาวิธีท าในอินเทอร์เน็ตมาฝึกใช้ หนังสั้นเรื่อง“พลังท่ซี ่อนอย่”ู เล่าถึงชีวิตหลังประสบอุบัติเหตุและการค้นหาค าตอบในชีวิตของฉันได้รับรางวัลรองชนะเลิศประเภท นักเรียน นิสิต นักศึกษา และ รางวัลชนะเลิศ Popular View หลังจากนั้นฉันได้ออกรายการต่างๆพร้อมกับที่งานเขียนบันทึกของฉันได้ตีพิมพ์เพื่อบอกเล่า เรื่องราวในชีวิตเป็นแรงบันดาลใจให้ผู้คนในหนังสือเล่มแรกที่มีชื่อเดียวกันกับหนังสั้นว่า“พลังที่ซ่อนอยู่” และหนังสือเล่มที่ 2 ชื่อHow deep is your dreamเล่าประสบการณ์การท าตามความฝันที่ฉันได้ไปด าน ้าลึก(Scuba) ซึ่งเป็นอีกความฝันที่ฉันได้ท าให้เป็นจริง และปัจจุบัน ฉันก็จะพยายามท าต่อ ทั้งการเป็นนักเขียนและนักเดินทาง ในวันที่ฉันสามารถท าความฝันเป็นจริงได้นั้นเป็นอีกจุดเปลี่ยนของชีวิต หลังอุบัติเหตุที่เปลี่ยนชีวิตฉันครั้งหนึ่ง เพราะฉันได้กลับมารู้สึกดีกับตัวเอง ด้วยสิ่งที่ฉันสามารถท าได้ ท าให้ฉันภูมิใจในตัวเอง อย่าง “ขอบคุณที่ยังมีชีวิตอยู่” การมีชีวิตอยู่เป็นค าตอบที่ส าคัญ ซึ่งฉันคอยบอกกับตัวเอง ในตอนที่ตัวเองรู้สึกแย่แล้วตั้งค าถามในชีวิตขึ้นอีก เมื่อฉันท าความฝันหนึ่งเป็น จริงแล้ว ฉันก็จะท าความฝันต่อไป เช่นการท างานหนึ่งส าเร็จและต้องเริ่มงานใหม่ โดยน าบทเรียนที่เคยได้รับจากความฝันหรืองานครั้งก่อน มาปรับใช้ ไม่ต่างกับชีวิตของฉัน หลังประสบอุบัติเหตุ ซึ่งต้องมีคนคอยดูแลในส่วนที่ฉันไม่สามารถช่วยเหลือตัวเองได้ และปรับเปลี่ยนที่อยู่อาศัยให้เหมาะกับการ ใช้รถเข็นวีลแชร์เพื่อให้ฉันสามารถกลับมาใช้ชีวิตอยู่ต่อไปได้เช่นเคย ฉันจึงสามารถกลับมาใช้ชีวิตเป็นปกติ แล้วท าสิ่งต่างๆและไปที่ไหนได้ไม่ต่างจาก คนทั่วไป เพราะข้อจ ากัดจากร่างกาย หรือจากโชคชะตาของแต่ละคนที่แตกต่างกัน ไม่ใช่ข้ออ้างในการใช้ชีวิตท าสิ่งต่างๆให้เป็นจริง

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OP6.6 From a burden to a change agent

Atthapon Kantha-udom (patient), Supattana Chatromyen, M.D. (First year resident/translator)

Objectives Voices of customer: In order to share/exchange the experiences as the tetraplegia patient who could get over his disabilities and turn crisis into the great opportunities.

Clinical/interesting issues As the Incomplete spastic tetraplegia C6B patient who got injured from the fall from height accident unexpectedly 6 years ago (onset 2011). Atthapon Kantha-udom would like to share/exchange his experiences in… 1. How he could get over from his disabilities (both mentally and physically). 2. How he made use of the limited resources and turn himself into a community leader. 3. How he has offered helping hands to those who are disadvantaged in his community, especially the disables.

Conclusion For years, Atthapon has offered helping hands to the disables in his community despite his Illness.

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OP7.1 Challenges and potential solutions of effective assistive device technology service delivery system

Nekram Upadhyay

Assistive Technology Engineer, Head, Department of Assistive Technology

Abstract Assistive Technologies provide opportunities to people with disabilities to lead a quality life within their living and working environment. Assistive Technology (AT) is not just a product; it is an approach which plays an even more significant role in the life of someone with a severe disability such as a spinal cord injury (SCI). Assistive Devices are designed to increase an individual's level of function and independence can be instrumental in providing a person with disability the highest possible level of function. Persons with disabilities in less resourced environment like India are not able to achieve maximum functional level of independence due to various factors. Lack of proper Assistive Technology provisions within the existing rehabilitation facilities and lack of trained professional in this area are the significant factors. Assistive Technology Service Provision for various disabilities and ailments should be established within their acute and chronic rehabilitation process to achieve their better quality of life with maximum independence. For example AT services could include proper Seating and Mobility systems, adaptive home/work environment, modified transportation, computer accessibility, environmental control systems and assistive devices for activities of daily living etc.

Conclusion AT services must be based on a client-centered approach in which the recommended device should be made available within the process of integrated service delivery while keeping in mind various factors such as affordability, usability, acceptance, and appropriateness to the environment.

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OP7.2 Safety adaptability, Compliance and Benefits of CYBO LIMB - Robotic Exoskeletal Orthosis – for rehabilitating spinal cord injury patients with lower limb neurological deficit – A Pilot Study.

Dr.Karthikeyan.R, Dr.Sivakumar, Mr. Veerabahu. STM.

Department of Physical Medicine and Rehabilitation, Sree Balaji Medical College and Hospital, Chromepet, Chennai. Tamilnadu, INDIA. Pin Code – 600 044

Objectives Among patients with SCI at different levels with neurological deficit of lower limbs, following were assessed. - Acceptance of CYBOLIMB among persons with SCI and no. of training sessions required for walking on CYBOLIMB without support. - Efficiency of CYBOLIMB and its impact on Patients walking through Sit to Stand ( Up and Go) – Time taken test, Ten meters - timed walk, Distance walked in 6 minutes - Physiological changes ( BP, Pulse Rate) on using CYBOLIMB

Methods 6 Participants with SCI at different levels with paraplegia were included. After the routine rehab for Upper limb strengthening and Trunk control, the participants underwent Gait Training with CYBOLIMB as per the framed protocol. No of training sessions required to walk independently was recorded. After training, Time taken for Sit to Stand (Up and Go) with CYBOLIMB, Distance on Ten meters timed walk and Distance walked in 6 minutes were recorded. Physiological changes – BP and Pulse rate variations were recorded.

Results Six participants were males with average age as 28.6 years and average age since injury was 3.9 years. Average no of training sessions to stand and walk 3 – 4 steps was 14.5 (each session - 2 hours), with T7 level with poor trunk balance taking 25 sessions and L1 taking 9 sessions. Average time for Sit to Stand (Up and Go time) is 83.6 minutes with 110 minutes with T7 level and 68 minutes with L2 level. Average time taken to cover 10 meters is 64.16 seconds, with 104 seconds with T7 level and 44 seconds with L2 level. Average distance covered with 6 minutes walk test is 55 meters with 31 meters with T7 level and 71 meters with L2 level. Average Pre Training BP was 121.2 / 79.2 mm Hg and on Post Training was 126.6 / 81.2 mm Hg. Average Heart rate on Pre training is 8.9 and Post training is 93.3. There was no adverse events like falls, skin and bony injuries during the study.

Conclusion CYBOLIMB is safe for gait training and rehabilitation of spinal cord injured with neurological deficit of lower limbs and complications due to immobilization can be prevented. Level of injury influences the number of training sessions, Sit to Stand,Ten meters timed walk and 6 minutes walk. Changes in BP and Pulse rate are within the physiological range without causing discomfort. Improvement with spasticity is noted with 2 participants and in bowel movements with 3 participants. Impact of CYBOLIMB on social and vocational re-integration and ADL requires further follow up, which is being done.

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OP7.3 The Usability test of mechanical and robot assisted gait system in patient with spinal cord injury: a pilot study

Bum-Suk Lee, Eun Joo Kim, Sung-Phil Yang, Tae-Young Kim, Jung Ah Lee, Wang jae Lee, Han Ram Pak, Hyun-Ki Kim, Hyun Choi, Ji Min Kim

Korea National Rehabilitation Center

Objectives The purpose of this study was to compare the usability during gait training with KAFO compared with Rewalk in patients with SCI

Methods A 32-year-old man with SCI (T5/T5 SCI, ASIA impairment) was recruited. The usability was tested using KAFO and Rewalk. The patient had 20 training sessions (60min/1 session) for each gait training system. The usability test was evaluated by a questionnaire constructed by the investigator which included 4 categories of safety(6), effectiveness(6), efficiency(4), and satisfaction(7). The 5-point Likert scale was used for each (1-very dissatisfied, 2-somewhat dissatisfied, 3-neither satisfied nor dissatisfied, 4-somewhat satisfied, 5-very satisfied).

Results For KAFO, mean safety score was 3.5, effectiveness 3.3, efficiency 3.3, and satisfaction 3.8, while for Rewalk, mean safety score was 3.5, effectiveness 3.3, efficiency 3.3, and satisfaction 3.9. The patient was satisfied with Rewalk more than KAFO system in overall satisfaction and did not report any adverse events when using the each gait training system.

Conclusion In this pilot study, the patient was satisfied with the safety, effectiveness, efficiency and satisfaction of the each gait training system. Through the usability test, we found that each gait training system had its own advantages.

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OP7.4 New assistive technology for wheelchair: my personal experience

Mr. Aaron Vamosh

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OP7.5 Effectiveness of using Driving Simulator in Driving Rehabilitation Clinic

Prajit A. B.Sc., Wongtakeaw A. B.Sc.

Occupational Therapy Department, Sirindhorn National Medical Rehabilitation Institute

Objectives: This study aimed to evaluate the effectiveness of using Driving Simulator in Driving Rehabilitation Clinic, Occupational Therapy Department, Sirindhorn National Medical Rehabilitation Institute.

Methods: 12 persons with spinal cord injury were participated in the study. Their age was between 18-56 years old with 30 years old average. All participants received 1 introduction course from occupational therapist in order to operate the simulator follow by 3 driving rehabilitation courses of simulator training. Outcome evaluations were driving ability score in 2 situations; the normal and the complicated / special situation. Times of evaluation were after the training course (1st evaluation) and after 3 driving rehabilitation courses (final evaluation).

Results: The results demonstrated that all participants had improvement of driving ability in both normal and the complicated/special situations after driving training course, especially in traffic sign, car position, speed control, steering, car following and lance changing.

Conclusion: Driving Simulator was benefit in driving rehabilitation for person with spinal cord injury.

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SP1.1 Comparison using two forms of bladder diaries for monitoring bladder functions of spinal cord injury patients: a pilot study

Kopen L1,Wirawan RP2

1Physical Medicine and Rehabilitation Department, Medical Faculty of University Indonesia / Cipto Mangunkusumo National Hospital, 2Physical Medicine and Rehabilitation Department, Fatmawati Hospital- Jakarta, Indonesia

Background: Bladder diary is a valuable non-invasive tool for monitoring bladder function of Spinal Cord Injury (SCI) patients objectively. Unfortunately, some patients had poor compliance to fill the diary completely. We used 2 design of bladder diary; one diary contains the timetable which is divided into hourly format; while the other diary was left blank and using picture.

Objective: This study is conducted to know, which format of bladder diary is user-friendly and had more compliance.

Material and Methods: Twenty five SCI patients were enrolled for this study. They were given the education about the importance of the bladder diary and instructed to complete one of the bladder diaries for 3 consecutive days and the other bladder diary form in the other week. The analysis was done for the completeness and their feel about both forms.

Results: The study demonstrated that completeness was good for blank format bladder diary (68% vs 28%). The duration since SCI didn’t influence patient’s compliance while using the blank form (p= 0.93), in contrast to while using the timetable bladder diary (p=0.001). The longer the duration since SCI, the more incomplete they filled the diary. They found that the blank bladder diary was easier and visually more convenience to fill. The participants highlighted that the timetable bladder diary was confusing.

Conclusion: This study reveals that patient’s compliance is still a crucial issue. The blank bladder diary is likely more user-friendly tool, which could increase patient’s compliance. Further study should be done with more participants.

Keyword: SCI, bladder diary

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SP1.2 The feasibility and effect of the mobile-game based respiratory rehabilitation exercise for people with cervical cord injury

Hyunju Park, Dongheon Kang, M.J. Lee, Jiyoung Park, Seon-deok Eun

National Rehabilitation Research Institute, Seoul, Republic of Korea

Objectives To determine the feasibility and effect of 8-weeks, mobile-game based respiratory rehabilitation exercise for people with cervical spinal cord injury.

Clinical/interesting issues Respiratory complications are the major cause of morbidity and mortality in people with spinal cord injury. Respiratory rehabilitation exercise is essential for people with spinal cord injury, especially those with high level cervical cord injury. However, patients face multiple barriers to exercise persistence including significant impairment of physical function, difficulty of moving, limited ongoing support. Therefore, it is very important to devise a device or a method that can enjoy a respiratory rehabilitation exercise at anytime and anywhere. The purpose of this study was to determine the feasibility and effect of a mobile-game based rehabilitation exercise for 1 hour per day, 2 times a week, 8 weeks for 6 people with high cervical cord injury (C3-4). The mobile game called “Spirits” is a game that the player uses only breathe to play the game. The target moves to the right if blowing and the target moves automatically to the left if not blowing, thereby avoiding obstacles. When subjects perform respiratory rehabilitation exercise using a mobile game, information such as connection time, game keeping time, breathing pattern, etc. is transmitted to the supervisor. Various pulmonary function tests using spirometry (Pony FX, Cosmed, Italy) were taken before and after the mobile-game based respiratory rehabilitation exercise. As a result, FVC, IC, VE, IRV, MEP and MIP were significantly improved after 8 weeks of mobile-game based respiratory rehabilitation exercise.

Conclusion The mobile-game based respiratory rehabilitation exercise is effective in improving the pulmonary functions in people with cervical cord injury.

Acknowledgements This study was supported by the Korean National Rehabilitation Research Institute (Grant No. #16-C-01).

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SP1.3 Maximal respiratory pressures in patients with spinal cord injury from SNMRI (pilot study)

Monticha Muangngoen, M.Sc., Chanapass Denduang, B.Sc. Sirindhorn National Medical Rehabilitation institute (SNMRI)

Objectives To assess the values of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) in patients with spinal cord injury from SNMRI. Methods This is an observational descriptive study. A total of 12 individuals with chronic spinal cord injury (C3–T11, American Spinal Injury Association (ASIA) Impairment Scale; AIS A-D) were admitted to the inpatient rehabilitation service. They were included to perform maximal inspiratory and expiratory pressure test.

Results There were 4 patients with paraplegia and 8 cases with tetraplegia. In tetraplegia patients the average MIP value was 38.63±14.83 cmH2O, the Min-Max was18-65 cmH2O and the MEP value was 29.00±11.45 cmH2O, the Min- Max was 10-43 cmH2O. In paraplegia patients the average MIP value was 69.25±21.97 cmH2O, the Min-Max was 39-86 cmH2O and the MEP value was 50.25±16.72 cmH2O, the Min-Max was 28-65 cmH2O.

Conclusion The average MIP and MEP value in both tetraplegia and paraplegia patients were found that less than the value reported in the previous study. Therefore, it is necessary that these patients, especially tetraplegics need to be trained in the strength of the respiratory muscles. However, the MIP and MEP value are considered according to the variables of age, gender, BMI and the level of injury. Consequently, we plan to continue record MIP and MEP value for establish normative data for spinal cord injury patients in Thailand.

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SP1.4 The intervention for cervical cord injury patients using their smartphone according to neurological disability level

Seung-Don Jang,Bum-Suk Lee, Hongkyu Kim, Yo-Ahn Park, Ju-Young Hwang

National Rehabilitation Center (NRC) in KOREA

Objectives Smartphone in people with Cervical cord injury becomes a significant tool. The purpose of study to investigate the necessary Methods This intervention of training program for using smartphone proceeded during the Occupational therapy about 30minutes every day. The program consists of Phone call, Messaging, Internet searching, Applications running. Patients use a assist device customized by individual.

Results After the intervention of using smartphone, the patient group of C4 level(33.3%), C5 level(48%) and C6 level(52.9%) presented with positive effect of its utilization ability(table1). And Around five among 39 people change the conventional mobile phone into the smartphone

Conclusion The training about the enhancing the smartphone utilization ability has potential as availability for people with cervical cord injury.

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SP1.5 INCREASED LOWER LIMB LOADING ABILITY DURING SIT-TO-STAND ASSOCIATED WITH POSSIBILITY OF WALKING PROGRESSION IN AMBULATORY PATIENTS WITH SPINAL CORD INJURY

KHUNA L1, 2, AMATACHAYA S1, 2, AMATACHAYA P2, 3,SOOKNUAN T2, 4,THAWEEWANNAKIJ T1, 2

1School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand 2Improvement of Physical Performance and Quality of Life (IPQ) Research Group, Khon Kaen University, Khon Kaen, Thailand 3School of Mechanical Engineering, Faculty of Engineering and Architecture, Rajamangala University of Technology Isan, Nakhon Ratchasima, Thailand 4School of Electrical Engineering, Faculty of Engineering and Architecture, Rajamangala University of Technology Isan, Nakhon Ratchasima, Thailand

Objectives A large proportion of ambulatory patients with spinal cord injury (SCI) require a walking device on daily basis. Improved walking ability is also associated with increased life satisfaction and physical function of the patients. This study explored factors associated with the possibility of walking progression as determined using the types of walking device among ambulatory patients with incomplete SCI.

Methods Thirty-five subjects were assessed for their demographics, SCI characteristics and functional ability relating to the requirement of a walking device. Then, subjects were assessed for the possibility of walking progression by gradually changes the type of walking device until the one with the least support that they could walk safely. The multiple logistic regression analysis was applied to determine factors associated with the possibility for their walking progression. The level of statistical significance was set at p < 0.05.

Results Twenty-three subjects (65%) could walk with a less support device than the customary one, and 14 subjects could even walk without a walking device. Among many significant factors relating to ability of walking progression, lower limb loading during sit-to-stand (LLL-STS) was the only significant factor in the final multivariate regression model (adjusted OR [95%CI]: 1.11 [1.01 to 1.22]; p < 0.05).

Conclusion The STS can be easily incorporated in rehabilitation practice. The findings suggest the use of LLL-STS to assess and promote walking ability of ambulatory patients with SCI in many clinical and community settings, particularly in the current era that the length of stay is dramatically decreased.

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SP1.6 Management of a case with two years traumatic tetraplegic spinal cord injury patient by three track reasoning: a case report

Farjana Taoheed1, Shamima Islam Nipa2, Md. Akhlasur Rahman3

1Senior Clinical Physiotherapist, Department of Physiotherapy, CRP, Dhaka, Bangladesh, 2Lecturer- Rehabilitation Science, Department of MRS, BHPI, CRP, Dhaka, Bangladesh, 3Senior Trial Site Manager, CIVIC Trial Project, CRP, Dhaka, Bangladesh

Objectives Clinical reasoning is internal thinking and decision making process in clinical practice. It helps the health care providers to solve the clinical problem in an effective and efficient way. Therefore, the purpose of this study was to explore the management strategies of a childhood spinal cord patient through three track reasoning. We have tried to show how the basic idea behind the reasoning process helped to solve this case. However it has performed through theory and observation.

Methods It was a single case based study through the three track reasoning process. Three track reasoning in one of the clinical reasoning process which includes the procedural, interactive and conditional reasoning to diagnose as well as ensure proper rehabilitation service according to patient and family members’ needs. The diagnosis and Intervention had been designed by the procedural reasoning. However interactive and procedural reasoning helped to ensure the patients participation and to meet the contextual needs as well.

Results After analyzing the reasoning process it was identified that, three track reasoning process was effective to solve the physical, psychological and social aspects of a childhood patient with spinal cord lesion. However, to be strict in a single reasoning process was very difficult. Clinical reasoning is the clinician’s ability through which they can consider the interpretation of different clinical findings. In addition, patient’s or patient’s family member’s knowledge, believes and reasoning was found an important part of clinical reasoning process in this study.

Conclusion Clinical reasoning has been practicing in our practice; however, we are not conscious about it. Therefore, three track clinical reasoning model has been selected for the case with traumatic tetraplegic spinal cord lesion to diagnose and treat accordingly.

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SP1.7 Impacts of Sports on Psychological Status: Anxiety and Depression for the Spinal Cord Injury Patients.

Mahmudul Hasan, Sharmin Alam, Kazi Imdadul Imran, Forhad Hossain Hoque

Centre for the Rehabilitation of the Paralysed(CRP)

Objectives 1) To identify and compare the anxiety and depression level of SCI patients before and after their participation in sports. 2) To explore the effectiveness of sports to reduce the anxiety and depression level of spinal cord injury patients.

Methods This study a Pre-test and post-test experimental quantitative research design. From CRP 31 patients were selected at randomly having spinal cord injury. Patients were allocated for sports and the subjects were participating in sports for 2 weeks. This is a quantitative same subject design study. Outcome was measured by State-Trait Anxiety Inventoty-X2, Depression scale developed by Md. Zahir uddin-National Institute of Mental health, Dhaka and Mohammad Mahmudur Rahman-Department of clinical psychology, University of Dhaka and Hospital Anxiety and Depression Scale.

Results We get a positive change in psychological status and reduce the anxiety and depression level of SCI patients after participating in sports. The ‘p’ value (by which we can measure the significance of the result) of the variable is (<0.05). According to state trait Anxiety Inventory and depression measurement the anxiety level reduces whose are tetraplegia patient rather than paraplegia but in case of depression, it reduces more whose are paraplegia patient. For incomplete patient, patients whose are enjoying sports and patient whose can play independently these factors are accelerate to reduce anxiety and depression.

Conclusion Anxiety and depression both are the prominent terminal psychiatric disorder after spinal cord injury. In SCI patients, sports activity can provide desirable psychological status showing a particularly strong association with general level of anxiety and depression. In this stud, it indicate that sports are effective in reducing the anxiety and depression level of spinal cord injury patients.

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SP1.8 Association between Duration of Spinal Cord Injury and Depression

Ananda Marina, Indriati MS Tobing

Department of Physical Medicine and Rehabilitation, Ciptomangunkusumo Hospital, Faculty of Medicine of Universitas Indonesia, Jakarta Department of Physical Medicine and Rehabilitation, Fatmawati General Hospital, Jakarta

Objectives To evaluate association between duration of spinal cord injury and depression in spinal cord injury patients.

Methods This cross sectional study includes 31 patients diagnosed with spinal cord injury, 14 from rehabilitation ward of Fatmawati general hospital and 17 were from nursing home. The data was collected between August to September 2017. Patients with cognitive impairment were excluded from this study. In these individuals, the level of depression was assessed using the Beck Depression Inventory (BDI), which has been tested for validity and reliability.

Results Among the patients, 23 (74.2%) were male, the mean age was 41.29 years and mean duration was 145.23 months postinjury. In the nursing home, patients had mean of 260.47 months postinjury, with mean BDI score of 9.41. On the other hand, mean duration of injury for inward patients was 5.29 months postinjury, and mean BDI of 15.93. This study found an association between the duration of spinal cord injury and BDI score (P=0.013). Similarly, an association is also found between BDI score in both instances of care (P=0.015).

Conclusion Duration of injury is associated with depression in spinal cord injury patients. Patients who were injured within the last 6 months, was shown to have higher score of BDI as compared to those with more than 6 months postinjury. It can then be concluded that depression occurs mostly on the acute phase of the injury. Therefore, early identification would assist in removing this obstacle towards a successful rehabilitation program in spinal cord injury patients.

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SP1.9 Using the International Classification of Functioning Disability and Health Comprehensive Core Set to measure environmental barriers and facilitators in persons with chronic spinal cord injury in Indonesia

Sharon Loraine Samuel, Rosiana Pradanasari Wirawan, Ira Mistivani

Perdosri

Objectives To measure environmental barriers and facilitators that influence participation of persons with chronic spinal cord injury (SCI) using International Classification of Functioning, Disability and Health (ICF) Comprehensive Core Set.

Methods Thirty SCI patients with chronic paraplegia were participated. Subjective experiences of environ-mental factors, captured by self-report, were collected through interview using 24 categories of component “environmental factors”, highlighting 4 domains (products and technology, support and relationships, attitudes, and services, system and policies) from ICF comprehensive core set for SCI in long-term context. The question and qualifier for each category was adapted in accordance with the linking rules.

Results Most of all domains of products and technology, also services, system and policies perceive as barriers due to economic problem and other barriers we could not assess. Domains of support and relationships, also attitudes perceive as facilitators. The instruments and approach used to assess the environment are a reflection of the complexity of assessing environmental factor. There were difficulties in assessing the qualifier of environmental factors. Some items did not applicable and hard to understand. Patients seem reluctant to share details about their rich lived experiences with their health condition.

Conclusion ICF were needed to evaluate environmental barriers and facilitators on participation within rehabilitation and community setting, and effecting system and policy changes to target barriers. Detailed and simpler measuring guideline and qualifiers' scale to assess environmental factors were recommended.

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SP1.10 Association between SCI profile with length of stay in rehab ward and SCIM III at discharge in Fatmawait General Hospital, Indonesia

Listyani Herman MD1, Indriati MS Tobing MD2

1Department of Physical Medicine and Rehabilitation, University of Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Indonesia 2Department of Physical Medicine and Rehabilitation, Fatmawati General Hospital, Indonesia

Objectives To evaluate the association between length of stay in rehabilitation ward (LOS) and Spinal Cord Independence Measure III (SCIM III) at discharge in SCI patients with different ASIA classification (AIS), neurological level (NL), and age.

Methods A preliminary cross-sectional study with consecutive sampling that included 32 SCI patients who underwent rehabilitation program at Fatmawati Hospital and were discharged from January until August 2017. The SCIM III was measured by using Indonesian version. The data was obtained from medical record and was analyzed by using SPSS v.20 with ANOVA and post hoc. Results were considered significant if p<0.05.

Results The LOS is significantly different within the AIS group (p=0.046) and age group (p=0.005), but not for NL group (p=0.226). As for discharged SCIM III, values were found to be significantly different within NL and AIS group, however the trend is not seen in age group (p=0.631). The lowest LOS was 19.17 days, while the highest discharged SCIM III was 73.83, both of which were in AIS D group, and was proven significant through post-hoc analyses.

Conclusion Length of stay in rehabilitation ward is associated with ASIA classification and age. Discharged SCIM III is associated with ASIA classification and neurological level.

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SP1.11 When delivery of standard care is not delivering enough: managing dual disabilities of clavicular fracture in a complete thoracic spinal cord injury patient: a case report

Judy KK Ngu, Syahiskandar Sybil Shah

Department of Rehabilitation Medicine, Hospital Queen Elizabeth, Kota Kinabalu, Malaysia.

Objectives We report a case of complete spinal cord transaction with retarded rehabilitation progress due to untreated left clavicular fracture which subsequent surgical correction made remarkable clinical improvement.

Methods Case Report

Results A 40 years old lady who was previously healthy sustained a motor vehicle accident resulting in complete spinal cord transaction at T8 level (ASIA A). Spine MRI revealed burst fracture of T8 vertebra with spinal canal compromise from retropulsed fragment. Emergency surgical decompression was performed followed by posterior instrumentation and fusion of T6-T10. Among the many other injuries, she also sustained a closed fracture of the left clavicle which was managed conservatively with arm sling support as per routine recommendation. The rehabilitation progress was discouraging as she faced great challenge mobilizing her left upper limb due to persistent pain from the unstable fracture which also failed to achieve union. Her SCIM score remained low from 10/100 to 16/100 after 6 weeks of active rehabilitation with extreme poor performance in self-care components. Joint decision was made after orthopaediac consult for left clavicle plating to aid rehabilitation process. Post procedure, patient steadily achieved assigned recovery milestones. In the next three months, she successfully regained independent bed mobility, ability for wheel chair transfer and propel, and excelled in personal living activity at sitting level (SCIM score: 64/100).

Conclusion Concept of individualized care is of utmost importance in rehabilitation care for patients with multiple disabilities. Rigid standardized care in routine clinical practice often leads underwhelming results. Timely and accurate identification of hindering factors helps patients overcome hurdles to recovery.

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SP1.12 Non-traumatic spinal cord injury case profile in Fatmawati General Hospital

Ronald Pakasi

Spinal Cord Injury Rehabilitation Division, Fatmawati General Hospital, Jakarta

Objectives Non-traumatic spinal cord injury (NTSCI) cases has an increasing number in Fatmawati Hospital. This study aimed to observe the case profiles and outcome of NTSCI in the spinal cord injury rehabilitation ward.

Methods All NTSCI cases from January to June 2017 are included in the study. Data collected from the medical record and round meeting record. The profile consists of gender, age, spinal cord injury American Spinal Injury Association Impairment Scale (AIS) classification, etiology, ability to walk, and independency.

Results Seventy NTSCI subjects of 35 males and 35 females. Most lesions were below T6 level (29 subjects, 41,43%), followed by high dorsal (n = 19; 27,14%); cervical (n = 13; 18,57%), and lumbosacral (n = 9; 12,86%). Most common etiologies were spondylitis tuberculosis (26 cases; 37.1%), followed by neoplasms (15 cases; 21,4%); canal stenosis (12 cases; 17,1%); degenerative (6 cases; 8,6%); and myelitis (4 cases; 5,7%). Most patients classified as AIS-D (n = 31; 44,29%), followed by AIS-C (n = 16; 22.86%); AIS-A (n = 16; 22.86%); AIS-B (n = 5; 7,14%); and AIS- E (n=1, 1,43%). After 6 - 8 weeks rehabilitation, 28 subjects (40,0%) regained the ability to walk. The Walking Index for Spinal Cord Injury II (WISCI II) mean scores before and after training were 6.10, and 15.69. Patients with AIS D classification showed the most achievement mean score of WISCI II (from 7 to 16.87). Functional independency was achieved in 37 subjects (52,86%).

Conclusion Spondylitis tuberculosis and neoplasms are the two most common causes of NTSCI in Fatmawati Hospital. Patient with AIS D and E level have better prognosis for walking and achieving independency.

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SP1.13 A Rare Case Intra-Medullary Thoracic Tuberculoma and Tuberculous Myelitis Of The Spinal Cord Presenting With Paraplegia : A Case Report

Novaria Puspita1, Farida Arisanti2, Marietta Shanti Prananta2, Irma Ruslina Defi2

PM&R Department, Faculty of Medicine, University of Padjadjaran - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Objectives To report a rare case of spinal cord injury (SCI) caused by intramedullary thoracic tuberculoma. It is a rare form of tuberculosis, as the incidence of only two in 100,000 patients. Intramedullary Tuberculoma (9.4%) has been reported as one of various complication associated with tuberculous meningitis.

Clinical/interesting issues A 35 year old woman is complaining about progressive weakness of the lower extremities, neurogenic bowel and bladder dysfunction since 4 months ago. She was diagnosed with Vth Thoracal SCI AIS (Asia Impairment Scale) B with Spinal cord independence measure (SCIM) score was 22. Previously, 5 months ago she was diagnosed with Meningitis Tuberculosis. The magnetic resonance imaging (MRI) showed excessive meningeal enhancement at meningen, particularly at posterior part and a ring-enhancing intramedullary lesion at the T9-12th intervertebral level. The patient was treated conservatively with anti-tuberculosis regimens for 5 months now, but no significant neurologic deficits improvement were obtained. The evidence showed that surgical resection must be conducted in intramedullary lesion with deteriorated neurological deficit or those who are irresponsive to anti-tuberculosis medication. The outcomes of combined surgery and medical treatment are excellent, and in the series reported by Mac Donnel et al, 65% of the patients had recovery after surgical resection. Surgical dissection and excision of the intramedullary lesion decompress the cord and furthermore, debulking of tuberculoma growing during and after anti-tuberculosis therapy may enhance the effectiveness of therapy by reducing the content of hypoxic, necrotic, or drug-resistant tissue. Rehabilitation programs consisted of paraplegic wheelchair training for independent mobilization, clean intermittent catheterization program (ICP) and digital stimulation for bowel evacuation. SCIM score is improving to 49 at 6th week.

Conclusion Although the outcome of Intramedullary Tuberculoma treatment is still unpredictable, combined therapy with anti-tuberculosis and surgical resection is preferable to obtain a better functional improvement.

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SP1.14 T2 spinal compression fracture due to tuberculosis spondylitis: can we mobilize patient without stabilization? (A Case Report)

Neidya Karla1, Vitriana2, Marina A. Moeliono2, Rachmat Z. Goesasi2

1Residen of Physical medicine and rehabilitation department, Faculty of Medicine, Padjadjaran University - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia 2Physical medicine and rehabilitation specialist of Physical medicine and rehabilitation department, Faculty of Medicine, Padjadjaran University - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Objectives Spinal column involvement is a common manifestation of musculoskeletal tuberculosis (TB). Neurologic deficit due to compression of adjacent neural structures may interfere with the functions to do activities of daily living. This condition needs an immediate medicamentous and surgical treatment to stabilize the spine to be able to mobilize the patient as early as possible

The aim of this study is to emphasize the importance of clinical assessment to arrange a rehabilitation program for spinal compression fracture due to infection

Clinical/interesting issues A 22 years old male, diagnosed with SCI AIS B NL T3 and unstable spine due to spondylitis TB. Radiological examination (MRI) showed destruction of the T2-vertebral body. Patient received pharmacological treatment and his AIS classification became AIS D. surgical stabilization is not done yet. Location of the lession at the T2 vertebra makes it difficult to apply a spinal orthosis, but on the other hand, it benefits the clinical improvement because the rib cage helps in distributing the spinal loading, stabilizing and minimizing movement of the T2. Management of tuberculous spondilitis Spinal TB with neurological complication includes anti-tuberculosis medications with or without surgical intervention. The purpose of a spinal orthosis is to stabilize the spine to promote bone healing, and makes it possible to perform exercises and activities. Spine compression fractures without surgery heal in two to three months, with immobilization and decreased weight bearing on the diseased vertebrae. The T2 vertebra is fairly immobile and stable by virtue of its location, thus it’s relatively save to mobilize this patient without any orthosis

Conclusion Comprehensive analysis including spine kinesiology analysis and clinical judgements in the evaluation of the structure of the fractured vertebra and of the deformity (the kyphosis angle) is most important in designing a mobilization program for this SCI-patient.

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SP1.15 Psychosocial-economic impact in management of traumatic spinal cord injury patient in Indonesia: a case report

Meinar Ferryani1, Farida Arisanti2, Ellyana Sungkar2 , Dian Marta Sari2

Physical medicine and rehabilitation department, Faculty of Medicine, University of Padjadjaran - Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Objectives To know the impact of psychosocial economic condition in management of traumatic SCI in Indonesia. Spinal cord injury (SCI) is a debilitating and devastating condition on a person’s physical, mental and familial as well as social life. The incidence of Spinal Cord Injury is increasing throughout the world with an annual incidence rate of 15- 40 per million with more prevalence in low socio-economic society. Limited numbers of SCI centers and medical staff with specialization in SCI care in Indonesia, causing higher expenses and more time consuming for patient and his caregiver.

Clinical/Interesting Issues A 52 years old male, with incomplete SCI AIS B C4 due to facet dislocation and lateral mass fracture of C5-C6 vertebra. Patient refused spinal surgery procedure due to psychosocial economic problems such as caregiver limitation, lacking of family support and long distance from home, since they live about 34 km from tertiary hospital that provide SCI rehabilitation care. Patient is decided to discharged from hospital and treated by primary care nearby his house. Mobilization is limited to log roll by using Philadelphia cervical orthosis for 6 weeks and followed by mobilization with Four poster brace. Pressure ulcers were developed at 3rd weeks, wound care was performed at primary health service. After 6 weeks of conservative treatment, there is increased in total motoric score based on ISCOS examination, but not a functional outcome. No improvement in SCIM (Spinal cord independence measurements) value. The Pressure ulcers at sacrum and calcaneal bilateral regions are improved 3-5 point on PUSH (Pressure Ulcer Scale for Healing).

Conclusion Early decompressive surgery is standard care in traumatic spinal cord injury that may lead to better improvement in neurological recovery. Psychosocial and economic factors may be a greatly burden in SCI management in Indonesia. SCI Rehabilitation needs multifactorial support from the government policy, insurance coverage and family their self.

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SP1.16 Unique cause of spinal cord injury in India

DR. RATNA VORA, DR. KETNA MEHTA

NINA FOUNDATION

Objectives - To spread awareness about ‘ GOVINDA’ – A festival as a major cause of SCI in India - Strict government laws that need to be implemented to make festival safer for Indians - Proposed rules and regulations for Govinda troop - Declaring Govinda as an “adventure sport” - Handy first aid services in case needed at the site

Conclusion GOVINDA is comparable to ‘ Running of the bulls’,LaTomaino in Spain and Onbashira festival in Japan where SCI is a probable injury. Similar rules and regulations need to be implemented so that these festivals are celebrated in a more safer way.

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SP1.17 Dual disabilities in a spinal cord injury patient

Wong Audrey YF, Syahiskandar S. Shah, Judy KK Ngu

Ministry Of Health, Malaysia

Objectives To explain the outcome of patient with dual disabilities

Methods Retrospective case report

Results A 60 year-old gentleman with left transfemoral amputation since 1980 ( Secondary to motor vehicle accident and prosthetically restored), was admitted for intensive spinal rehabilitation. He sustained central cord syndrome secondary to fall due to uneven and slippery road, and underwent left C3-C6 laminectomy. Premorbidly he is functionally independent and working as a gardener. Upon admission, he has poor bed mobility and totally dependant on caregiver. He also experienced neuropathic pain that affected his sleep and therapy sessions. Otherwise, he has no neurogenic bladder or bowel. At that time, he is unable to don and doff as he has weakness of bilateral upper limb with limited range of motion of left dexterity. For the first 2 weeks, patient was trained to improve both hand function especially in improving his finger opposition and grip strength. Though patient was moderately dependent in self care, he was able to transfer independently to wheelchair and self propel. Subsequently, he was trained to ambulate with his prosthesis and walking frame as his bilateral hand function has improved. This time he was minimally dependent in self care. Prior to discharge, patient was ambulating with single-pointed walking stick and independent in self care. His Spinal Cord Independence Measure (SCIM) improved from 49/100 to 90/100.

Conclusion At the end of 5 weeks of rehabilitation, patient is able to ambulate with prosthesis and single-pointed walking stick, and functionally independent. Functional outcome was good since he already prosthetically restored before he sustained spinal cord injury.

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SP1.18 Rehabilitation Conservative Management in Spinal Cord Injury Patient due to Syringomyelia and Multiple Congenital Anomaly: A Case Report

Vanydia Aisyah1, Damayanti Tinduh2

1Resident of Physical Medicine and Rehabilitation, 2Staff Lecturer at Physical Medicine and Rehabilitation Department, Faculty of Medicine of Universitas Airlangga, Surabaya, Indonesia

Objectives To report the rehabilitation conservative management of SCI patient due to syringomyelia and multiple congenital anomaly (hemivertebrae, severe congenital scoliosis and atresia ani)

Clinical/interesting issues Male, 32 years old with multiple congenital anomaly, hospitalized in ward with sudden paraplegia occurs while he was long-distance driving motorcycle. Previously, he felt radiating pain from buttocks to legs, incontinence bladder and colostomy. Physical examination revealed scoliosis and sensorimotor impairment on the level L1 down, with DAP and VAC could not be evaluated. Radiologic examinations result hemivertebra, kyphoscoliosis thoracolumbal and syringomyelia VTh12-L2. First assesment was Th12 paraplegia AIS C. The patient refused any surgery planning. Rehabilitation programme prescribed was consisting ROM, breathing and chest expansion, transfer, sitting tolerance and endurance exercises, modified thoracolumbal corset and CIC programme. Functional recovery priorities were identified including sensorimotor and autonomic function. After rehabilitation management, we can achieve improvement of muscle strength and sensory function in lower extremity. Combination of strategies have been lead to improvements in outcome and quality of life after SCI, measured by spinal cord independent measure (SCIM) and SF-36.

Conclusion Analysis of individual problem list provides better management in SCI patient in coping with impairment, disability and handicap occurs and improving his quality of life.

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SP1.19 Pelvic floor muscle exercise and biofeedback therapy following electrical stimulation in patient spinal cord injury with neurogenic bladder dysfunction: a preliminary study

Stephanie Theodora Yulinda, Martha Kurnia Kusumawardani

PMR Department, Faculty of Medicine, Airlangga University, Surabaya, Indonesia

Objectives To see the effect of transcutaneous parasacral electrical stimulation combined with pelvic floor muscle exercise and anorectal pressure biofeedback as a therapy tool in neurogenic bladder dysfunction of SCI patient.

Methods Inclusion criteria were age over 17 years, SCI lesion with neurogenic bladder dysfunction without decubitus ulcer at sacral area. 5 consecutive patients referred for initial pressure biofeedback would be performed transcutaneous parasacral electrical stimulation for 20 minutes afterward pelvic floor exercise would be taught then they would have BF measurement. The BF and ES treatment would be held 2 times/week.

Results A significant pressure difference between delta (Δ) maximum-minimum value comparison before and after exercise, BF, ES (p<0.05). There were no significant differences among the maximum and minimum value after exercise, BF, ES compared to before exercise, BF, ES (p>0.05).

Conclusion PFM exercise combined with BF and ES induced improvement of neurogenic bladder dysfunction of SCI patient.

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SP1.20 Sports for recreation during admission for rehabilitation

Sawattikanon N, Keratibumrungpong W, Suwanmanee T, Jernsawang N, Kovindha A

Faculty of Medicine, Chiang Mai University

Objectives To do group exercise by sport recreation and assess enjoy or decreasing stress.

Methods sport recreation every Thursday at 1.3o p.m. to 3 p.m in outdoor field including shooting basketballs, dart (plastic-tips), archery (vacuum-tips arrow), and pétanque. Before play the sports, PT will lead patient warm up by doing shoulder and arm active movement and upper limbs strengthening exercise with elastic bands and medicine ball. After that, PT will ask the level of stress before and after sport recreation by using 5 levels facial expressions assessment.

Results From September 2017, 4 times sport recreation. There were 14 patients including paraplegia 78%, tetraplegia 14%, and hemiplegia 8% participated in activities. The 5 levels facial expressions assessment were better, no change and worst facial expressions 21%, 71% and 8% respectively. The disadvantages from asking the patients to be suggestion are the weather was hot and the basketball board is too high for wheelchair player. Pétanque field is rough that is hard to ambulate and too sunny.

Conclusion Rehabilitation phase patients are able to b enjoy with group sport exercise. But the environment should be appropriate for wheelchair using patients and having the recreation in airy where is not hot or cold place.

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SP1.21 Enabling Early Decompression Surgery for Spinal Cord Injury (SCI) using Malaysia Social Security (SOCSO) Epulih Online Solution

Kuo Ghee Ong1, Hafez Hussain2, Mustapha Umar3, Nazatul Akma4

1 Rehabilitation Physician, SOCSO Tun Razak Rehabilitation Centre, Malaysia 2 Executive Director, SOCSO Tun Razak Rehabilitation Centre, Malaysia 3,4 Case Manager, SOCSO Tun Razak Rehabilitation Centre, Malaysia

Objectives Facilitate early decompression surgery for injured workers in Malaysia via online implant, assistive devices and rehabilitation therapy application for better neurological and return to work outcomes.

Clinical/interesting issues Spinal Cord Injury (SCI) affects approximately 750 million people worldwide with huge social and economic impact worldwide.1 Evidence shows that early and timely surgical decompression for SCI improves outcomes.2 Social Security Organization (SOCSO) of Malaysia provides social insurance coverage for 6.4 Million workers. In Malaysia, public healthcare are substantially subsidized, however implant costs are paid by patients. Typically patient pay for implants from one of the sources, such as government hospital allocated funds, welfare department assistance, private medical insurance, social security insurance and out of pocket payments. Most of these avenues will incur some application process that will hinder early decompression procedures. Since 2016, SOCSO has introduced an online E-Pulih System that operates round the clock. The treating doctors from public hospitals can key in patients details to check for SOCSO coverage eligibility; and if eligible, the doctor can proceed to apply for implant via the online system. The information required are patient’s identification card, implant quotation, medical details and planned procedures. Medical personnel team in SOCSO will be on standby to review and give instant approval for appropriate applications. Upon approval, a guarantee letter is automatically issued to the supplier and notification sent to the treating hospital. The system facilitates early decompression surgery in Malaysia by solving the implant funding delay. Moreover, post-operatively, the doctors can again use Epulih to apply for appropriate assistive devices and rehabilitation care for the injured workers.

Conclusion This online solution is essentially a communication tool that creates win-win situations for the doctors, workers and SOCSO. With timely and holistic care in continuum, hopefully, it will facilitate early returning to work and societal integration for injured workers.

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The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand

SP1.22 Safety of UDS for SCI patients with Asymtomatic pyuria or Bacteuria: Asymtomatic Pyuria or Bacteuria do not increase risk of UTI after UDS with prophylactic antibiotics

Seunghyun Kwon, Hyejin Lee, Eunyoung Kim, Bumsuk Lee, Wonsan Seo, Kyungok Chung

Korea National Rehabilitation Center

Purpose 1. finding the percentage of incidental pyuria and bacteriuria in spinal cord injury patients 2. assessing the impact of pyuria on urinary tract infection after urodynamic studies in spinal cord injury patients when prophylactic antibiotics are administered

Objectives & Methods Patients were recruited from August 2015 to December 2016. A total 227 consecutive patients with spinal cord injury underwent urodynamic study during period were included in this study. Definitions - Pyuria: ≥ 10 WBCs per HPF in urine microscopic examination - Bacteriuria: > 105 CFU per ml in urine culture - Symptomatic UTI : Pyuria + newly developed (fever or urethral pus discharge) Urinalysis and urine culture was done within 12 hours before urodynamic study. We use ciprofloxacin for First line Prophylatic antibiotics. Cefaclor was used for second line if previous urine culture showed resistance to ciprofloxacin or when patients have contraindication for using Ciprofloxacin. Prophylactic antibiotics was administered orally for 5 days after sampling urine. Twenty four hours after urodynamic study, urine microscopic examination and urine culture was done again. We designed the criteria to define symptomatic UTI based on urine microscopic examination. Symptomatic UTI was defined as presence of pyuria with newly developed fever or urethral pus discharge. Fisher’s exact test was used to compare the incidence of symptomatic UTI after urodynamic study. The level of statistical significance was defined as p<0.05

Results Of total 227 urine samples before urodynamic studies, pyuria was detected in 99 samples (44%), bacteriuria was detected in 159 samples (70%) . Symptomatic UTI was observed after urodynamic study in 5 patients. All 5 patients had a fever. 3(3.03%) of 99 patients had pyuria and 2 (1.56%) of 128 patients did not before urodynamic study present symptomatic UTI. There was no statistical difference (P=0.431) between two groups. 3(1.88%) of 159 patients had bacteriuria and 2(2.94%) of 68 patients did not before urodynamic study present symptomatic UTI. There was also no statistical difference (P=0.212) between two groups.

Conclusion Asymptomatic pyuria (44%) and bacteriuria (70%) was observed in many spinal cord injury patients. With oral prophylactic antibiotics, there was no significant difference of incidence of symptomatic UTI after urodynamic study between the patients who had pyuria or bacteriuria and patient did not. For SCI patients with asymptomatic pyuria and bacteuria, the UDS test may delay or cancel the test. However, these results suggest that Asymptomatic Pyuria and Bacteuria do not affect UTI after UDS test if prophylactic antibiotics are used.

150 16th ASCoN CONFERENCE AND WORKSHOP

The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand

SP1.23 Comparison of Rehabilitation Outcomes between SCI and Non-SCI Specialized Rehabilitation Facilities in Thailand: Results from the Thai Spinal Cord Injury Registry (TSCIR)

Pattanakuha S1, Komaratat N2, Mahachai R3, Chotiyarnwong C4, Kammuang-lue P1, Tongprasert S1, Kovindha A1

1Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University;2Sirindhorn National Medical Rehabilitation Institute; 3Department of Rehabilitation Medicine, Ratchaburi Hospital, Thailand; 4 Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University

Objective To compare inpatient rehabilitation outcomes of new spinal cord injury (SCI) patients between SCI and non-SCI specialized rehab facilities in Thailand.

Study design Prospective cohort study of the Thai SCI Registry (TSCIR) from February 2015 to October 2017. Setting: Rehabilitation facilities at tertiary hospitals in Thailand, one SCI specialized (Maharaj Nakorn Chiang Mai Hospital) and three non- SCI specialized facilities (Sirindhorn National Rehabilitation Institute, Ratchaburi and Siriraj Hospitals).

Methods Demographic data of SCI inpatients was collected according to the International Spinal Cord Injury Datasets. Rehabilitation outcomes were evaluated using Spinal Cord injury Independence Measure (SCIM) and rehabilitation efficiency index. Level of significant differences of categorical and continuous results between SCI and non-SCI specialized rehabilitation facilities were determined by chi-square and Mann-Whitney U tests, respectively.

Results There were 236 new traumatic and non-traumatic SCI inpatients admitted for rehabilitation; 72% were admitted at the SCI-specialized rehabilitation facilities. In the SCI-specialized rehab facilities had more proportion of tetraplegics whereas the non-SCI specialized ward had more proportion of paraplegics. No significant difference of SCIM score on admission was found between the SCI specialized and non-SCI specialized rehab facilities. Those of the SCI specialized facilities had significantly more SCIM score gaining and higher rehabilitation efficiency index than those of the non-SCI specialized facilities (median SCIM score gaining = 20 vs 13, p = 0.013; median rehab efficiency index = 0.64 vs 0.4, p = 0.030). Notice that patients’ length of stay (LOS) of the SCI specialized facilities was longer than those of the non SCI-specialized (median LOS = 46 vs 30 days, p < 0.001). In addition, multiple linear regression analysis demonstrated that admitted in the SCI specialized facilities was an independent predictor of SCIM score gaining (p = 0.003).

Conclusion SCI specialized rehabilitation facilities provide inpatient rehab services with better rehab outcomes than non-SCI specialized rehab facilities. This confirms an importance of having a dedicate inpatient rehab facilities for SCI patients to ensure better outcomes.

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