Well, thank you for having me, doctor style and everybody else. It's quite an honor to be here and nice to do it in person with the post covid world. Hopefully and, uh, see everybody in person rather than to zoom. Um, and regarding my background. So for us as a team and our service were a consult service at CMC, and we handle a lot of different things. My specific background is in the neuro side of things, uh, brain injury, stroke, spinal cord injury. And we've been explaining that consult service. And so we really enjoyed it. And I had a chance to a lot of different patients and a lot of different, um uh, teams to work with. And there's been a lot of fun to start that consulate service and get it going. And there's obviously a need for it. Spinal cord injury. It's a very complicated injury, and it takes into account a lot of different pieces of the health system. And it's also a challenge as a result of that. So happy to get into it. And thanks for having me. All right. No conflict sent to get into all right content, So I'm gonna start with a background in epidemiology. How much fine? According to do we have, um how do we assess them in physical exam? Um, rehabilitation and the medical side of rotation. What I'll do with this campaign is going to do the rehabilitation side of it from the therapy side of it, and then we'll summarize it. My goal today is really more presented. A practical clinical approach for patients, spinal cord injury. Given the audience, I'm going to do a little less about the research studies and the, um, and the current ongoing stuff that's going on simply because for our needs, that seems to be what we need for our patients. I wanted to focus on a clinical approach that we can use on a practical basis. So epidemiology there is about 12 12.5 1000 new injuries every year in the country, and they may not seem like a lot compared to diabetes and hypertension, but realize these are very dramatic injuries that changes life not only for the patient but the entire family. And the prevalence is about a quarter million, meaning the existing total injuries is about a quarter million in the year, quarter million the US The other part of this, though, is that this is the most one of the most complex injuries, one of the most expensive anywhere from 500 to 2,500,000 to $2 million of cost of care. Direct costs of care during someone's lifetime. And it's the most expensive injury, uh, and disability that's out there. And that's not even calling. Calling out the indirect costs like loss of work, et cetera, uh, that affect patients. And then, in terms of causes, envious follows violence. You name it, it's It's sort of what we see. It seems she is. What is what The cause of injuries. Vascular injury is a component of all of you. Don't just say that because it's a vascular conference, but it's less of the impact of the vascular side as much as the level of injury. And that's what we're going to focus on for for the talk and really, for the care of the patient, the anatomy of this and apology. It's hard for me to get up there, but I'll do it up here. So this is, uh, sorry. You think I can handle I t. But this is a cross section of the spinal cord. So if you imagine the spinal cord going down your spine and just take a cross section of it just to see a piece of it, this really defines a lot of our care along with the level of injury. So these are different nerve bundles within the spinal cord, and we think of the spinal cord is one set of nerve bundles that goes down. But really, it's different. Different tracks in there. They do different things. I'm not gonna go through all these. But, for example, if we look at the chrysalis tracks, the physical is tracks in the back there really response for appropriate section and to help us stabilize in space and know where we are. Balance and coordination. Um, if you look at the, uh, spinal climate track, these are for pain and temperature. So things when we feel some with our hand and the nerves that go through it, go through this tract and allow us to feel pain, allow us to feel temperature and their related right. When something feels hot and it hurts at the same time, it's because it's in the same tract. And so that's why we can feel in same nerve fibers. And so that's why pain and temperature go together. And a lot of these go together in that sense, and they're organized in different parts of the cord. And so and then the motor tracks, meaning the parts that help us move our cerebral spinal cerebral tracks here on both sides. And so those are some of the main areas for pain, temperature, motor and then appropriate reception that we see. But that cross section defines where the injuries or other injuries and what the effects of that injury are as we go forward. And then this part on the top right is where they cross. So those nerve fibers cross or dick, you state at different parts of the, uh, of the spinal cord and brain. So somewhere higher up at the brain stem and ponds level, some are lower. Some are a little bit lower down, and so it depends where they are and what the effects are. And when we do the exam, I'm sorry for the basket parts and put this in there for I get to the exam, but is the vascular supply for the spinal cord. Sorry is, uh it's really divided to answer. Two thirds in the front, two front two thirds and the back one third. And the answers Spinal artery, Right. Very uh, very ingenious name. And your spinal artery covers the anterior part, the front part. And then the poster covers the poster part, Um, the, uh the artery Adam covets in the U. S. Where Adam Kravitz in different parts of the world is the primary justifies the lower part of the spinal cord, the lumbar sacral region. And then the other part I want to point out is that the T 46 area? So a lot of times, we'll see patients coming out of surgery with spinal cord injury because that area is very, uh, uh predisposed to having an in fart. And this is where we see a lot of infarct injuries because when you clamp the aorta and clamp uh, parts of the body with arteries for surgical reasons, you can actually get decreased supply and that hypoxia ischemia can cause damage to the spinal cord as well, because that's an area that we see often and then in terms of the exam. This is where we find out in talking about the different parts. Um, there's anterior poster that which tracks are affected. The exam really helps us do that in much more depth. And so the motor exam is testing the strength and the upper extremities lower extremities. Um, there's five million items in each and then, uh, the century exam going from the paratroopers all the way down to the sacral area in terms of looking at where the sensory level is for the patients, uh, and then rectal exam, often for also for sensory motor as well, because that helps us identify the level of injury to, you know, there's connections all the way down to the bottom of the cord. Uh, and so through all that process, putting together a century level motor level, we get what's the neurological level, which is a composite of all of that. And oftentimes what you'll see in our notes is that the radiological level does not match the neurological level. And this happens often because you'll see something on CT or MRI. That may be a say, a T six or T 78 injury. How are the patient's behavior may be more of a T five t four meaning higher up, and that happens very often. And it's not that the radiologist got it wrong or that the person taking the patient got wrong. But what happens is what you see on film doesn't match function because there's a demo. There's an information. There's other things. And so the functional part of the spinal cord that may be affected may be different than what you see on film. And so there's often a mismatch. However, the neurological level is the most important in terms of determining the care needs of the patient, because that's what causing the effect on the spinal cord itself and then the extent of injury. So the level of injury and then the thickness of the inter meaning is all the way from tobacco is a complete or incomplete, and there's levels for a D. D. For that. And I'm not gonna go into the depth of how you do the analysis. But just for awareness of what these numbers mean when you see them and then this is a chart of how we market and code it. And then once you, uh when I said could I mean for the purpose of analyzing the injury and you go down through this and once you do it, it makes it a lot easier visually to see where the level of injury is and result. Put that as a neurological level. And so this is a standard Asia American spinal cord injury Association form for for doing so and then comorbidities. And this is one of the main areas. Having the spinal cord injury itself is devastating. But then all the other things that go with it are really important. So I'll go through ventilation, status, food and nutritional status. Energetic bowel know that there's an energetic bladder. I'm going to focus more on the bowel because a lot of times, for practical reasons, you end up using fully. And so I wanna clinical perspective, talked with the Baltimore and then quit your apathy. So respiration. Right? Um, I want to do one with the mask just for the 2000 2021 sort of experience. But, um, so pulmonary physiology on the left shows what is what a normal on normal function and for all of us, you know, when we breathe If we don't have an injury to a frantic nerve, which is the nervous supplies, the diaphragm, then what happens is as we breathe, our diaphragm goes down, are down almost to stretch out, and they help create suction and that suction automatically the air will go in because there's negative pressure. So we don't actually actively breathe, even though it feels like it. We actually just actively create suction within our body, and then the lungs pull the air in from that negative pressure. And so, for all of us, when we're normal chest while moves out, the diaphragm moves down and the abdominal wall moves out. So that's what normal physiology is, however, um, in spinal cord injury. It's actually the exact opposite of diet from actually moves up, the chest moves out, which is the same, however, abdominal wall moves in and actually creates more pressure on the on the lungs. It's harder to breathe in, and so if you notice patients on his spinal cord injury, it's harder to get them off the vent. One of the reasons is because there's added pressure in that pulmonary chamber that creates it makes it harder for the air to come into the the lungs, and so they become air hungry, and then we have to account for that. So when it comes to ventilation management, we really wanted The goal is to focus on diaphragmatic function, meaning, trying to get that diaphragm to expand and trying to push those lungs open. And this is actually very different than normal. Uh, ventilation management for patient would say it with pulmonary injury or a R. D s. Uh, it s great distress syndrome where you do, you wouldn't worry about so much pressure. You worry about not damaged than lung. Here you're more about. You really want to push that lung out. You don't cause more damage by shrinking the lung, and so the levels typically are C3 to C5 are affected, and then your title volume's meaning. How much air you're blowing in on a normal breath is about 10 to 12 ccs of air per kilogram of body weight, which is a lot higher in, um, normal ventilation management. For medical issues, it's about 4 to 8 cc's per kilogram, so this is much, much higher, 40 to 50% higher, and the recipe rate is a lot lower. In RDS, you typically have respirator of 16 to 20 to 24 have less volume per breath. This is the exact opposite. More breaths. I'm sorry, a few breaths, but more volume to manage that patient, and that will actually help them a lot better. And so the adverse events. If you don't do it this way, you'll get effusions in the lung fluid around the lungs. And the reason that happens is the lung shrinks their space created. And if that space is not filled with something, meaning the long expanding, then the body will fill with something else, which is effusions and fluid into that area, which creates additional pressure on the lungs. It makes it harder to breathe, and so expanding the lungs out from the beginning accounts for that and gets rid of some of those issues. The other part is air hunger, meaning you're not getting enough air if you're just feeling like you're really short of breath. If you imagine, if you're on a treadmill and you run and can't breathe in fast enough, that would make you feel anxious, and that would make you feel very air hungry And that's the same feeling that a lot of patients with spinal cord injury have. Is that air hunger, which then creates anxiety? Because when you can't breathe, you're scared, right? And that's the That's the feelings they have. A lot of times will treat them with accessories and other things, but often if we just give them more air, that actually solves a lot of that issue. Alright, going on the fluids. So food physiology. This is a complex, uh, diagram. Here I'll go through a little bit, but normal setting for a kidney is, um, when you have, uh, kidneys. Depending on level of profusion, it will secrete rent in and go through the system angiotensin and Tencent in two. And you've heard of the blood pressure medication, the ACE inhibitors, And that's what inhibits this enzyme from converting it. And the idea is to increase the blood blood pressure so that you get more and increase the sodium water retention to get more profusion at the kidney. The kidney really controls a lot of blood pressure with the profusion level, so that the kidney sees more fluids and things that there's higher blood pressure and acts accordingly. If it doesn't seem a fluid, then it'll act accordingly and try to increase the blood pressure and also try to commit more fluid. What happens with for most of us is that we're up and upright. We're walking around, and so we require higher levels of fluid by about 23 leaders, at least when we're upright and have the force of gravity. Because fluid is pulled into our legs into all parts of our body, and as a result, you require higher level of fluid to be upright, walk around and be around. When your spinal cord injury patient you're not. You're supine, meaning lying flat in bed most of the time, and as a result, you require less fluid. Because it's not going, it doesn't have the pull of gravity into the legs. As a result, you also have, uh, an increase of fluid. Initially in the acute phase coming to the kidneys and the kidneys feel that it's hyper for perfumes, meaning there's too much volume because all the food that used to be in the legs is not your soup on it. Lying down is coming to the kidneys and the kidney. See it as a lot of volume. So what does a kidney do, which is to maintain balance? Homeostasis, So it decreases a lot of that fluid, and so as a result, you get over profusion and the decrease in writing secretion and leads the diaries of fluid meaning leads to dehydration, and patients become very dehydrated very quickly. And when I go on the chart, I'll see it all the time. Patients. Spinal cord injury minus 23 liters day one minus 23 Thursday, too, And by about day three or 4, it's about -89 L of fluid. And now, when therapy is trying to get at them and try to set them up in bed, they get dizzy and they get dizzy because they're dehydrated. And so if you don't catch the fluid part of it, that's the effect of it, and then oftentimes you're not aware of this. Then you end up going through additional work up and other things that may delay the patient care. But the recommendation to mitigate this is to really just give them maintenance or maintenance or treatment does fluids up front, and it scares people because it's 7525 cc's of normal saline continuously, Um, and the patient was so diaries. But at least it keeps them from diabetes so fast that they can't do the other things that they need and mitigate some of the dizziness. Unsinkable symptoms. Um, but it's different management than we're typically used to. As a result, people become very cautious. Uh, and so it's something that we have a lot of effort to work to do in terms of educating everyone around the spinal cord injury. Alright, energetic bowel. And I know this is a topic we talked to the nurses about and talk to everybody about, and she was like, Let's say you've got a million things going on. Why are we worried about their bowel? Well, it's, I know it seems like a small thing, but bowel management actually is. Um, it happens because lack of central nervous control, but it's also life altering, and it caused a lot of other issues. If you don't manage, the bowel can get over full, and then you get a lot of leaking and accidents because the ball is so full that it keeps leaking out of just a little bit of time. well. That makes it really difficult, Difficult for nursing care, right? For having an accident every two hours. You have to change the sheets and everything, and the patient has spinal cord, and you got to get him out of bed. Change all she's gonna back in bed. That's a lot of time and effort and a lot of staff. Time and effort. Um, furthermore, if they end up sitting in the bed because somebody can't get to them right away and someone doesn't realize it, then they get skin issues, infection issues, White count goes up, and there's a lot of things that happen. And so the bowel management is actually really important and for spinal cord into that higher level up, say, in the cervical region. The other part that can happen is automatic. This reflects CIA. I didn't get into it here, but it's a area where you can really get high levels of high blood pressure into the one eighties and nineties, and actually patient can stroke out. And so it's really important to manage the bowel because it avoids a lot of complications down the line. If you do it up front, so about physiology uh, there's three main controls for the for the bowel and bladder both and very analogous. I'm gonna focus on the bow, uh, a little bit easier for what we do for clinical care and the time we have to appear sympathetic. Um, we typically think is rest and Digest. And so digestion means that things are moving more, uh, in a normal patient, cones moving more. There's more digestion happening, and and and And this is the right way to do when you're when you're at the that point of time. And so the pelvic nerve, but then sympathetic, which is the opposite. When you think of flight in flight, this is actually when, um inhibits colony contraction, uh, relaxes the anal sphincter on the internal side. That's a hippo, gastric nerve and then somatic, somatic nervous. The potential nerve meaning when we have that urge to go and we actually go and we push out, that's the voluntary contraction that we have. And that's the final step of the whole whole process. Actually get through the movement and then to the to the to the anus for, um, for removal. And so to put a visual onto that This is the large colon, right? Ascending, transverse descending. And these are the different parts of the act of different areas. And so, uh, this combine is the helper gastric, and then the, uh sorry. Um, and then the Vegas parasympathetic nerve comes in more on the spending side. Uh, and then the, uh, anal region is where the, uh, the somatic control is for the most part of it. And then the main thing with energetic bowel control is, as I said, increased accidents. Right. If we control the accidents, you control skin issues, you control nursing care, uh, challenges you control better care for the patient and therapies and other things, and so they can get the care that they need. The other part is what a lot of times gets called diarrhea for a patient is when the when the ball gets fall, it has to empty somewhere. And if you don't have control and you're not emptying properly, then it's gonna just empty at random, and it's gonna leak out just enough so it doesn't get keep getting over full. And so that's where having the proper bowel program is really key. Um, and then I don't know, just reflects that talked about. And then this is also the barriers for therapies and patient improvement. And the other thing is from patient perspective, really quality of life Because they get very embarrassed. If you're in bed and your soil, it's embarrassing. People come visit you and you can imagine there's about 30 different people that might see a patient on a given day from physicians. Two nurses to Emma is to whoever else right family members visiting. And it's a really huge quality of life, not only in the hospital, but certainly when you go out and then when you're out. If you don't feel comfortable, your, um, bowel and bladder situation, you're not going to be going out and having the quality of life that you want. So treatment, though, is actually quite straightforward, and it really makes it a lot easier for people. And the other part of this is 6% of patients have a dynamic Elliott's meaning in the 1st 48 72 hours. They're not moving much, and so that's a great chance when they get really over full, Uh, and the final. When you start the program, they're really really full. And so usually we recommend a KB around this time just to monitor that, Uh, and then the ball program is to minimize accidents. And then medical management is really a combination of bulking agents. Uh, like high fiber. Often we don't typically use them in the inpatient side, but on the outpatient side, bulking agents like high fiber agents like Metamucil, etcetera, bowel irritant center, castor oil, stool softeners, coolest or document eight, uh, oral stimulants, which is along the castor oil type. Suppositories and lack stiffs. Uh, and all of them combine a different sort of recipe. Uh, can create a good ball program. The hard part is getting there. You can get there and manage it. The hard part is getting there because it's trial and error. Everyone's response is different. Um, and at the same time realized an inpatient setting. They have 1000 things going on, right? They might be going on for C T M R I X ray. They've got procedures going on. They've got other medications and, you know, day night schedule and all that is not straight. And so it's hard to manage on the impatient side. But if you can get them at least to a stable point in the in patient side. It's a huge benefit when they get out of the acute setting into the post acute and home in terms of quality of life and reducing readmissions for those patients. Uh, and then the other part is, uh, that did seem a lot of times with the bow. We need local stimulation because, you know, in the central, from brain to spinal cord or brain to direct them, that connection is disrupted with the spinal cord injury. So local stimulation with digital stimulation is vitally important for, uh, starting the process of defecation and then cuadrilla apathy. UH, 4700% of patients. Let's see, I developed DVT at least one DVT. Um, now that's a wide range. The reason It's why it is because it really depends on the level of injury. The higher the level, the higher the risk and then also what pre morbid conditions they have. Do they have a history of cancer? Do they have diabetes, hypertension, et cetera, And those things all increase the risk. So that's a wide range, but it's dependent on level and pre morbid status and then 7% develop API, which is really the number one cause of death for patients in the acute phase. And so it's a really preventable cause of death that we can do for patients. And the highest risk is in the first two weeks, Um, and the risk decreases 82 weeks out, and we don't have a good idea on research. Why, as to why, all of a sudden, the risk goes down, But it does. After that, 8-12 weeks and maybe inflammatory response may be other factors, but it does go down at that point. And so the chemo prophylaxis in typically Lovenox or an ox aspirin, um, for 12 weeks 8 to 12 weeks and 12 in the higher risk populations in mechanical prophylaxis, meaning pneumatic devices in the early phase. And then we typically recommend adopting at least one week after the injury, just to make sure they don't have a D. V T. And if so, than, uh, considering treatment at that point higher level treatment level, Lovenox or, um, obviously filter other things that may be needed and then other comorbidities. I'm not going to get into these just interest of time, but for awareness, their skin breakdown and wound care issues, electrolytes and mineral imbalances head a topic classification, which is the formation of bone in places that it should not form, like soft tissue like clutter steps in other areas. And so you'll see that you want to fix that In the inpatient side, it takes about 8 to 12 weeks to develop. So you see them the post acute or, uh a military side, more, more often than the acute side osteoporosis and fractures. Now that one of the ways to prevent osteoporosis and bone density loss is to put weight on your bones, right, walking around when your spine according to your patient and you're not walking now you don't have the same level of bone density and osteoporosis and fractures are huge. Uh, sexual dysfunction, infertility that you can imagine that specificity meaning the having, um, contracting the muscles and what really is will also be dependent. Uh um, uh, resistance to movement is the true definite specificity, but on a practical level, it's the ability to move even passively at a joint because the muscles are so tight. Pain management, Uh, and various different types of pain management. You'll have higher levels of no suspected pain and higher levels of, uh, neuropathic pain both, and you may often see what you know. It's called Phantom pain when there's amputee. But it's the same concept for spinal cord injury patients with the disconnection, the injury to the spinal cord. And so it gets really complex. Uh, and there's other comrades, but years from the main ones that we often treat and and want to get better for the patients. So summary spine according to is a complex injury. I think there's a lot going on. I think you've seen that when you see patients there, but medically and surgically and otherwise, it's very complex. Requires a full team effort, right? It's not a one person job it requires. The full teams were involved in various different ways, you know, see the therapy sided from Mr Campaign, coming up in a second, and then the physical exam is really vital in terms of determining the needs of the patient. Radiology alone is not sufficient for all the reasons we talked about and then full status pulmonary neurasthenic, following coagulation really critical in the early stages, And then they're often counterintuitive to the way most of us have been educated about medical care for patients who don't have a spinal cord injury because that's the majority of the population, so it makes sense to have that be a majority. But when it comes to this, this don't say niche but really important population. It's very counterintuitive, and things are really opposite to what you would expect for other reasons. We talked about physiologically so that's it from my site. Thank you again for having me. Yeah, in our theme of team based care, I'd like to introduce Emily Campana, who's an occupational therapist that's going to discuss therapeutic interventions. Hello, I'm Emily. Um, I have been an o. T at U H C M C for the last about 10 years on the last five or so have been primarily in the ICU setting, um, so with spinal cord in parks, our primary goals are to improve respiratory function, prevent secondary pulmonary complications. We want to achieve and maintain functional pain free range of motion appropriate to their injury level. We want to a clinic patient to upright positioning for improved interaction with environment. It can also help to prevent delirium and then eventually get them out of the hospital bed. Um, our focus is to maintain and increase strength, endurance and balance, and then, just overall, to improve functional independence in all aspects of mobility and ideals. Um, a lot of what I'm talking about is ot specific because that's what I do. But there is a lot of overlap. Um, like you heard earlier between the therapies, especially early on in the recovery process. So improving pulmonary function here is a chart kind of describing, um, how the level of injury will affect respiratory muscles. So anyone see three or above likely will require mechanical ventilation or they have are partial accessory muscles. Um, you move from C four to C eight. They'll have some diaphragm involved. Um, they'll have some shallow breathing. They will not have a cough. And they will do, um, paradoxical breathing, which is the opposite of how you and I. Typically, when we breathe, we expand with inhalation contract with exhalation and these patients, they will actually contract with inhalation and expand with exhalation um C eight to t six, um, is where they might have some partial intercostal muscles, but they will still have shallow breathing. Um, weaker. Absent cough, Um, 6-12. They will have intercostal muscles. However, their cough will still be weak. Anything below T- 12 should not have effect on their breathing. Um, so how to improve pulmonary function? A lot of times, we will, um, place an abdominal binder during our therapy sessions to help, um, with upright activity, the binders will passively hold their abdominal conference tense against the diaphragm, improving its vestal resting position of vital capacity. Um, we can also help with assisted or quad cough. It's similar to the Heimlich maneuver where you're pushing up on the diaphragm during their cough or exhalation. Um, it helps, um, replace the function of paralyzed muscles and to clear secretions. And then we can also educate and complete breathing exercises with patients. Um, you want to put them in supine, ask them to breathe in as deeply as possible, hold and then exhale. They can do about six during each, um, session, and then, if you wanna make it a little bit more challenging, you add some weight to them, and then it's kind of a visual to where you ask them to breathe in, watch the wait, wait, wait. Rise and then exhale and watch it fall. Okay, so achieving, um, and maintaining range of motion will depend on the level of injury. Um, if it needs to be passive range of motion, then we'll need to get family or caregiver involved. Um, or the patients might be able to do their own active range of motion either against gravity. Or you can add some resistance if they're strong enough. Um, so scapular stability is really important, um, to achieve functional use of their arms. Typically, you need about 100 degrees of shoulder flexion and 80° of shoulder extension to really have, um, functional use of your arms in addition to wrist and elbow extension. And this is really important when you're working towards sitting balance, whether it's static or dynamic sliding and scooting for transfer training and just kind of any everyday functional activity. Um, that's kind of the range that you'd like for their range of motion. Um, full hamstring strength is important for patients to be able to a long sit in bed. This can be useful for a DL such as lower body dressing and bathing. Um, also helps with my mobility and transfers. Tina DCIS grip is when you have risked extension against gravity and your fingers flex so it can give you some functional grasp. Um, and that can help you do many activities of daily living. Um, sometimes it can be, um, promoted with sprinting, and there's a picture of that in a couple slides. And then we can also splint for arresting hand position. Um, if someone has high tone or spasticity. So that's where Otey can kind of get involved as well. We also can splint. If there's any tightness in the foot or ankle, we can kind of prevent some foot drop whisp lynching as well. Okay, So improving upright tolerance. Um, typically, we start with the head of bad elevation and then moving to full chair position prior to sitting edge of bed the first time. And that's important because we want to watch and monitor their vitals pretty closely. Um, if they don't have an a line or anything, we want to take their blood pressure every five minutes during upright activity because, like we just heard, um, their fluids can kind of be off they can be hypertensive, and sometimes there's delayed onset hypertension with upright mobility. Um, so we sometimes can place Ted Hose or SC DS ace wrap their legs in addition with the abdominal binder. Um, and obviously you always want to check if they have any blood pressure map goals and make sure we're maintaining those schools during therapy. Um, so once they are stable, um, with upright positioning in the bed, then we progress to sitting edge of bed once they're good edge of bed, and then we can talk about transferring out of bed. Um, there's a few different ways we can do it dependent. Hoyer Lift, um, using a slide board or pivot transfer to a wheelchair. Um, and I can't tell you how important and exciting it is for the patient to be able to get out of bed for the first time. I actually had someone this morning not a spinal cord injury, but he's been in the hospital for over a month, a new trick. He hasn't been out of bed yet, and so we went in and said, Hey, you want to get out of bed and his face just lit up. Got so excited. We hurried her into the chair and then everyone passing by like it was this whole big to do and his face He got all excited every time someone was, like, so good seeing you out of bed. So this is exciting the first time getting patients up. Um, typically, you don't want to leave someone up more than about a couple hours, especially if they can't, um, weight shift to relieve any pressure. Every 30 minutes or so, patients should be either doing, um, like weight shifting to relieve pressure or, if possible, like a chair. Push up. Okay. Um, so improving functional independence early rehab improves functional independence and maximizes recovery, which you've probably been hearing all day. Um, earlier is better as long as they're medically stable. So, like I said, we work closely with physical therapists, speech therapists, respiratory therapist, along with the medical team, um, to make the patients as independent and as strong as possible. Um, getting the families on board is also really important. Especially if the patient does not have active movement. Um, they're gonna need help with that passive range of motion. Okay. And then this was also already talked about, but, um, something we've been using it. Uhh more recently is the ICU diary. Um, the first section is getting to know the patients so likes and dislikes, which we like to incorporate with therapy sessions, whether it's music, um, an activity that they like to do that we can incorporate, um, and then use of like, if it's helpful to know if they have glasses hearing aids, that sort of thing, that can help with our sessions. Um, and then it helps the patient remember us. It's really hard when you have 2030 people coming into the room every day to remember people's names and what their role is. Um, it helps prevent delirium. It can be helpful keeping track of their therapy milestones and just kind of the basics of what they've done each and every day. Um, that's it. All right. Any questions? Hi. Yes, thank you. I just wanted to ask a question about spinal cord injury. Um, what would be your advice to recognize symptoms for spinal cord stroke symptoms if a patient worth their bilaterally. Yeah. Yeah, that's a great question. Um, so for stroke symptoms, you know, typically, if the lower injury, meaning that paraplegic can set a quadriplegic. Um, then the, uh Then you go off the same. You know what? Forget I always forget the acronym, but it's, you know, the facial droop and the, uh, think fast. Think fast. Sorry. Uh, think fast. Aphasia, that kind of stuff. Storing words, um, and then mobility changes in one side or the other. Uh, if it's higher level injury, whether it's symmetrical and they have already, um, uh, motor issues already more deficits already. It is a lot harder to diagnose. And that patient, uh, and you have to go off of some of the facial recognition speech, uh, group and cranial nerves. So I movement and that kind of stuff, but it is a lot harder to do. So my advice is, if you suspect it, then go to the e. D and get it taken care of. Um, because it's it's one of those things where you don't want to wait too long and find out too late. Uh, and so the earlier find out. Call the ambulance, get him to the e d. Get them evaluated. And if it's not stroke, I know it's a cost But in that setting, if you're uncertain, the cost of missing it is higher than the you know, the cost of going to the e D and having a negative exam were negative evaluation. And so, um, with cervical of injury, I'd say, be a lot more aggressive, getting them to the E D. And whatever the appropriate care would be in that setting. Whereas if it's a lower level, ensure you can still look for the traditional signs. You know, unilateral changes, uh, think fast and that kind of stuff. And so, um, it's a great question because it is a hard question for a lot of people. And, uh, even if you're trained Hispanic cord injury, you can be wrong often. So great question. Can you talk a little bit about, like, the time course of tone and spasticity, and is there anything you can do to reduce that developing, or do you want it to develop? Is it beneficial? Good question. That's a sort of Are you on the left? The right side of things? Uh, and so it's a great question. Um, so in terms of timing, it can start, you know, it's really dependent on the level of injury and more upper motor lower motor neuron injury. But it can start in the acute setting as early as a few days. Um, and it's, um, in terms of treatment. It's tricky because at that point that we're not going on pain medication and, you know, delirium and those things. And typically the treatment for spinal cord injury with specificity is often back, often as the first level agent. But that can also consultation other issues. You want to be careful in the acute setting in T B I and stroke. We tend to back off of that as much as possible. In the acute setting, you have a choice. And so a little bit different ways to manage it, depending on diagnosis. Um, and then is it advantageous? You know, sometimes it actually can be advantageous to have some specificity because it can help you with, um uh, with gate. It can help you with balance and coordination. And so there is, uh, depending on the level injury and how the patient is. That can certainly be advantages. It's very smart. Very astute question. Yeah. Is there any way that you leverage this plasticity when you're trying to mobilize people. And yeah, like you said, um, sometimes it can be helpful with if they have some, like, extension tone. And like the trunk and legs, it can be beneficial. Kind of withstanding, um, and things like that. The arm is a little bit harder to work with because they really need that extension to do functional transfers. But it can be helpful. Kind of in the lower half. All right, well, thank you so much.