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Improvement in functional mobility and respiratory function after diaphragm pace-maker implant: a case study.

(1) Cohen, Meryl; (2) Godsea, Stephanie L. (1) Physical Therapy, University of Miami Miller School of Medicine, Miami, FL, United States; (2) Physical Therapy, Jackson Memorial Hospital, Miami, FL, United States.

Background & Purpose: High level spinal cord injury (SCI) often results in patient dependence on mechanical ventilation for effective respiration. In 1948, Sarnoff and colleagues discussed electrical pacing of the diaphragm. Currently, patients are considered candidates for phrenic nerve pacing if nerve cell bodies of C3, C4 and C5 are intact. Trauma at these levels or disruption of the lower motor neurons (LMNs) is contraindicated for phrenic nerve pacing. In 2008 the FDA approved a device pioneered by Onders and colleagues that stimulates the diaphragm muscle, rather than the phrenic nerve. The purpose of this study is to report the rehabilitation process before and after diaphragm (not phrenic nerve) pacemaker implantation in a ventilator dependent patient with tetraplegia. Case Description: The subject is a 70 year old male who sustained a C2 incomplete spinal cord injury as a result of a chiropractic manipulation. The MRI revealed ischemia from C2-C5 along with C5-6 cord compression and stnosis. The subject's past medical history included hyper-tension, depression, sleep apnea, and prior cigarette use. A pacemaker was laparoscopically implanted to directly stimulate the diaphragm muscle in this ventilator supported patient a year post injury. Method: This case study is a retrospective chart review. Data collection included a review of the respiratory and physical therapy documents during acute hospitalization and initial rehabilitation (3 months), skilled nursing facility (SNF) admission (9 months), rehabilitation following the diaphragm pace-maker placement (2.5 months) and with family follow up at home (3 months). Outcomes: Over the hospitalized observation periods, functional mobility (FIM Scores) and respiratory independence improved. FIM scores improved during initial admission from total assistance to modified independence with the greatest improvement in wheelchair locomotion (FIM 1 to 6). Respiratory function progressed from total ventilator dependence to 9 hours of independent breathing. All respiratory and FIM values returned to complete dependence during the subsequent SNF admission. After pacemaker implantation, both FIM and breathing independence returned to the same levels as when the patient was discharged from initial hospitalization. Once at home, FIM and breathing independence continued to improve with the greatest gains in transfers and ventilator independence for 19 hours. Discussion: This patient experienced generalized deconditioning during the SNF admission. After receiving the diaphragm pacemaker, his generalized deconditioning and not diaphragm weakness severely compromised his functional mobility. Subsequently he required a lengthy interval of reconditioning for functional mobility gains. In conclusion, Use of a diaphragm pacemaker in individuals early after sustaining an acute SCI might reduce dependence on mechanical ventilation and minimize systemic and diaphragm deconditioning.

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Author:Cohen, Meryl; Godsea, Stephanie L.
Publication:Cardiopulmonary Physical Therapy Journal
Article Type:Case study
Date:Dec 1, 2011
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