spinal cord injury anatomy diagram

spinal cord rehabilitation physiotherapy exercises

ASIA impairment scale spinal cord neurological classification

mkdir -p /home/daytona/workspace/spinal-cord-injury-ppt && ls /home/daytona/work…

~/spinal-cord-injury-ppt/generate.js

const pptxgen = require("pptxgenjs");

// Fetch images as base64
const { execSync } = require("child_process");

const imageUrls = [
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_e515f7b452f7167a694825d356745c7d8e161b7c13a74ed8399896bc49cc30b8.jpg",
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_8189a286e16e4fd6a45e65571f68cea91ba45a58809b4808b36ac41c424b8703.jpg",
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_3c133639b6f71a599004acc78010b5c5b122c8f1cbeb9d93f8b6e59355817274.jpg",
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_7988d38d75be87aa9c99a898f09461884decb705fe0b923d16bb0289ab2e7825.jpg",
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_c8c18531ce203ff4fe5e5888b6e5f44038dece02d5453fae1e3ccb9bb1aa108b.jpg"
];

let images = [];
try {
  const raw = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString();
  images = JSON.parse(raw);
} catch(e) {
  console.error("Image fetch error:", e.message);
  images = imageUrls.map(() => ({ base64: null, error: "fetch failed" }));
}

// Color palette — deep navy + teal accent + white
const NAVY   = "0A1628";
const TEAL   = "1ABCB0";
const AMBER  = "F5A623";
const WHITE  = "FFFFFF";
const LIGHT  = "E8F4F3";
const GRAY   = "5A6A7A";
const DARK_TEAL = "0F8C82";

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Spinal Cord Injury & Physical Rehabilitation";

// ─── helper: navy slide with teal accent bar ───────────────────────────────
function navySlide(title, subtitle) {
  const s = pres.addSlide();
  // Background
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: NAVY } });
  // Accent bar left
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: TEAL } });
  // Title
  s.addText(title, {
    x: 0.35, y: 0.25, w: 9.3, h: 0.65,
    fontSize: 22, bold: true, color: TEAL, fontFace: "Calibri",
    margin: 0
  });
  // Thin separator
  s.addShape(pres.ShapeType.line, {
    x: 0.35, y: 0.92, w: 9.2, h: 0,
    line: { color: TEAL, width: 1.2 }
  });
  if (subtitle) {
    s.addText(subtitle, {
      x: 0.35, y: 0.95, w: 9.2, h: 0.4,
      fontSize: 11, color: "A0BFC0", fontFace: "Calibri", italic: true, margin: 0
    });
  }
  return s;
}

// ─── helper: bullet block ──────────────────────────────────────────────────
function addBullets(slide, items, opts = {}) {
  const { x = 0.35, y = 1.45, w = 9.2, h = 3.8, fontSize = 13 } = opts;
  slide.addText(
    items.map((item, i) => ({
      text: item,
      options: { bullet: { type: "bullet", indent: 15 }, color: WHITE, fontSize, fontFace: "Calibri", breakLine: i < items.length - 1 }
    })),
    { x, y, w, h, valign: "top", lineSpacingMultiple: 1.25 }
  );
}

// ─── helper: highlight box ─────────────────────────────────────────────────
function addHighlight(slide, text, x, y, w, h, bgColor = TEAL) {
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: bgColor }, line: { color: bgColor } });
  slide.addText(text, { x, y, w, h, align: "center", valign: "middle", fontSize: 11, bold: true, color: NAVY, fontFace: "Calibri", margin: 4 });
}

// ─── helper: two-column layout ─────────────────────────────────────────────
function addTwoCol(slide, leftItems, rightItems, yStart = 1.45) {
  const colH = 3.7;
  // Left column header bg
  slide.addShape(pres.ShapeType.rect, { x: 0.35, y: yStart, w: 4.5, h: colH, fill: { color: "0D2240" }, line: { color: TEAL, width: 0.8 } });
  slide.addShape(pres.ShapeType.rect, { x: 5.05, y: yStart, w: 4.6, h: colH, fill: { color: "0D2240" }, line: { color: AMBER, width: 0.8 } });
  
  slide.addText(
    leftItems.map((t, i) => ({ text: t, options: { bullet: true, color: WHITE, fontSize: 12, fontFace: "Calibri", breakLine: i < leftItems.length - 1 } })),
    { x: 0.45, y: yStart + 0.1, w: 4.3, h: colH - 0.2, valign: "top", lineSpacingMultiple: 1.3 }
  );
  slide.addText(
    rightItems.map((t, i) => ({ text: t, options: { bullet: true, color: WHITE, fontSize: 12, fontFace: "Calibri", breakLine: i < rightItems.length - 1 } })),
    { x: 5.15, y: yStart + 0.1, w: 4.4, h: colH - 0.2, valign: "top", lineSpacingMultiple: 1.3 }
  );
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: NAVY } });
  // Large accent block
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.22, h: 5.625, fill: { color: TEAL } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 4.5, w: 10, h: 1.125, fill: { color: DARK_TEAL } });
  
  s.addText("SPINAL CORD INJURY", {
    x: 0.45, y: 0.7, w: 9.1, h: 1.0,
    fontSize: 42, bold: true, color: WHITE, fontFace: "Calibri",
    charSpacing: 4, margin: 0
  });
  s.addText("Understanding the Injury & Physical Rehabilitation After Postoperative Care", {
    x: 0.45, y: 1.7, w: 8.5, h: 0.85,
    fontSize: 18, color: TEAL, fontFace: "Calibri", italic: true, margin: 0
  });
  s.addShape(pres.ShapeType.line, { x: 0.45, y: 2.62, w: 7, h: 0, line: { color: TEAL, width: 1.5 } });
  s.addText([
    { text: "A multidisciplinary perspective for clinicians, therapists & students", options: { color: "A0C4C2", fontSize: 13, fontFace: "Calibri" } }
  ], { x: 0.45, y: 2.75, w: 8, h: 0.5, margin: 0 });

  s.addText("Sources: Bailey & Love's Surgery 28e  ·  Bradley & Daroff's Neurology  ·  Rockwood & Green's Fractures", {
    x: 0.45, y: 4.55, w: 9, h: 0.45,
    fontSize: 9, color: "C8E8E6", fontFace: "Calibri", italic: true, margin: 0
  });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 2 — WHAT IS SPINAL CORD INJURY?
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("WHAT IS SPINAL CORD INJURY?", "Definition & Epidemiology");
  addBullets(s, [
    "Damage to the spinal cord resulting in temporary or permanent changes in motor, sensory, or autonomic function",
    "Approximately 250,000–500,000 new SCI cases occur worldwide each year (WHO)",
    "Most common causes: road traffic accidents, falls, violence, sports injuries",
    "Cervical injuries (tetraplegia) account for ~55% of traumatic SCIs",
    "Males are disproportionately affected — male:female ratio approximately 4:1",
    "Life expectancy remains below normal; median survival post-injury ~33 years",
    "Before modern treatments, renal failure was the leading cause of SCI death — now largely preventable"
  ], { fontSize: 12.5 });

  // Stat boxes
  addHighlight(s, "~500K\nNew cases/yr", 0.35, 4.95, 2.1, 0.55, TEAL);
  addHighlight(s, "~55%\nCervical", 2.55, 4.95, 2.1, 0.55, AMBER);
  addHighlight(s, "4:1\nM:F Ratio", 4.75, 4.95, 2.1, 0.55, TEAL);
  addHighlight(s, "33 yrs\nMedian survival", 6.95, 4.95, 2.7, 0.55, AMBER);
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 3 — ANATOMY & MECHANISMS
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("ANATOMY & INJURY MECHANISMS", "How the cord is damaged");
  
  // Left: bullets
  const leftBullets = [
    "Primary injury: mechanical force causing direct cord disruption — contusion, laceration, compression",
    "Secondary injury cascade: ischemia, inflammation, excitotoxicity, oxidative stress, apoptosis (hours–days)",
    "Na⁺/Ca²⁺ channel dysfunction worsens excitotoxic damage",
    "Types: complete transection, hemisection (Brown-Séquard), central cord, anterior cord, posterior cord, cauda equina"
  ];
  
  s.addText(
    leftBullets.map((t, i) => ({ text: t, options: { bullet: true, color: WHITE, fontSize: 12, fontFace: "Calibri", breakLine: i < leftBullets.length - 1 } })),
    { x: 0.35, y: 1.45, w: 5.3, h: 3.9, valign: "top", lineSpacingMultiple: 1.35 }
  );

  // Right: image
  if (images[0] && !images[0].error) {
    s.addImage({ data: images[0].base64, x: 5.85, y: 1.35, w: 3.9, h: 3.8 });
    s.addText("SCI injury models (cross-section)", {
      x: 5.85, y: 5.15, w: 3.9, h: 0.3, fontSize: 8, color: GRAY, fontFace: "Calibri", italic: true, align: "center"
    });
  } else {
    s.addShape(pres.ShapeType.rect, { x: 5.85, y: 1.35, w: 3.9, h: 3.8, fill: { color: "0D2240" }, line: { color: TEAL } });
    s.addText("SCI Cord\nAnatomy\nDiagram", { x: 5.85, y: 1.35, w: 3.9, h: 3.8, align: "center", valign: "middle", color: TEAL, fontSize: 16, bold: true });
  }
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 4 — CLASSIFICATION: ASIA SCALE
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("NEUROLOGICAL CLASSIFICATION — ASIA SCALE", "American Spinal Injury Association Impairment Scale (AIS)");

  // ASIA grade boxes
  const grades = [
    { grade: "A", label: "COMPLETE", desc: "No motor or sensory function preserved in sacral segments S4–S5", col: TEAL },
    { grade: "B", label: "SENSORY", desc: "Sensory preserved, no motor function below neurological level", col: TEAL },
    { grade: "C", label: "MOTOR <3", desc: "Motor preserved below NLI; >50% key muscles grade <3/5", col: AMBER },
    { grade: "D", label: "MOTOR ≥3", desc: "Motor preserved below NLI; ≥50% key muscles grade ≥3/5", col: AMBER },
    { grade: "E", label: "NORMAL", desc: "Normal motor and sensory function in all segments", col: "4CAF50" },
  ];

  grades.forEach((g, i) => {
    const x = 0.35 + i * 1.88;
    s.addShape(pres.ShapeType.rect, { x, y: 1.45, w: 1.7, h: 2.8, fill: { color: "0D2240" }, line: { color: g.col, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y: 1.45, w: 1.7, h: 0.62, fill: { color: g.col } });
    s.addText(`AIS ${g.grade}`, { x, y: 1.45, w: 1.7, h: 0.62, align: "center", valign: "middle", fontSize: 18, bold: true, color: NAVY, fontFace: "Calibri", margin: 0 });
    s.addText(g.label, { x, y: 2.1, w: 1.7, h: 0.45, align: "center", valign: "middle", fontSize: 11, bold: true, color: g.col, fontFace: "Calibri", margin: 2 });
    s.addText(g.desc, { x: x + 0.08, y: 2.58, w: 1.55, h: 1.55, align: "left", valign: "top", fontSize: 9.5, color: WHITE, fontFace: "Calibri", margin: 4 });
  });

  // Note
  s.addText("Only 4% of AIS-A patients recover walking ability  ·  ≥70% of AIS-C patients achieve unlimited walking  ·  AIS-D patients have excellent rehabilitation potential", {
    x: 0.35, y: 4.45, w: 9.3, h: 0.6,
    fontSize: 10, color: TEAL, fontFace: "Calibri", italic: true, align: "center", valign: "middle",
    fill: { color: "0D2240" }, margin: 5
  });

  // image right
  if (images[1] && !images[1].error) {
    // show on next slide
  }
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 5 — CLINICAL SYNDROMES
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("CLINICAL CORD SYNDROMES", "Incomplete injury patterns with distinct prognoses");

  const syndromes = [
    { name: "Central Cord", features: "Most common incomplete SCI. Disproportionate weakness in arms > legs. Common in elderly with cervical spondylosis.", prog: "~80% regain ability to walk ≥25 feet" },
    { name: "Brown-Séquard\n(Hemisection)", features: "Ipsilateral motor loss + proprioception loss; contralateral pain/temperature loss below lesion.", prog: "Best prognosis of incomplete syndromes" },
    { name: "Anterior Cord", features: "Motor paralysis + loss of pain/temperature bilaterally below lesion. Preserved vibration/proprioception.", prog: "Worst prognosis — 10–20% motor recovery" },
    { name: "Posterior Cord", features: "Loss of proprioception, vibration, discriminative touch. Motor function preserved.", prog: "Ambulation usually preserved" },
    { name: "Cauda Equina", features: "Lower motor neuron injury (L2–S5 roots). Flaccid paralysis, saddle anesthesia, bladder/bowel involvement.", prog: "Better recovery than true SCI" },
  ];

  syndromes.forEach((syn, i) => {
    const col = i % 2 === 0 ? "0D2240" : "091A30";
    const y = 1.45 + i * 0.77;
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 9.3, h: 0.72, fill: { color: col }, line: { color: col } });
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 0.08, h: 0.72, fill: { color: TEAL } });
    s.addText(syn.name, { x: 0.55, y: y + 0.06, w: 2.0, h: 0.6, fontSize: 11, bold: true, color: AMBER, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(syn.features, { x: 2.65, y: y + 0.06, w: 4.6, h: 0.6, fontSize: 10, color: WHITE, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(syn.prog, { x: 7.35, y: y + 0.06, w: 2.2, h: 0.6, fontSize: 9.5, color: TEAL, fontFace: "Calibri", italic: true, margin: 0, valign: "middle" });
  });

  // Column headers
  s.addText("SYNDROME", { x: 0.55, y: 1.38, w: 2.0, h: 0.3, fontSize: 9, bold: true, color: GRAY, fontFace: "Calibri", margin: 0 });
  s.addText("FEATURES", { x: 2.65, y: 1.38, w: 4.6, h: 0.3, fontSize: 9, bold: true, color: GRAY, fontFace: "Calibri", margin: 0 });
  s.addText("PROGNOSIS", { x: 7.35, y: 1.38, w: 2.2, h: 0.3, fontSize: 9, bold: true, color: GRAY, fontFace: "Calibri", margin: 0 });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 6 — SURGICAL MANAGEMENT
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("ACUTE SURGICAL MANAGEMENT", "Stabilization, decompression & timing");

  const leftItems = [
    "Immobilization — rigid cervical collar & spine board immediately post-injury",
    "STASCIS trial: surgical decompression within 24 hours improves neurological outcomes",
    "Surgical options: anterior cervical discectomy/fusion, posterior laminectomy, thoracolumbar fixation",
    "Spinal instability requires instrumented fixation (screws, rods, cages)",
    "High-dose methylprednisolone: controversial — now generally NOT recommended (increased infection risk)"
  ];
  const rightItems = [
    "Postoperative monitoring: ICU, neurological observations q1h–q4h",
    "Hemodynamic targets: MAP 85–90 mmHg × 5–7 days to maintain cord perfusion",
    "Respiratory: ventilatory support often needed for cervical injuries (C4 and above)",
    "DVT prophylaxis: pneumatic compression + LMWH (DVT occurs in ~30% of SCI patients)",
    "Bladder: intermittent catheterization protocol initiated immediately"
  ];

  s.addText("Surgical Goals", { x: 0.5, y: 1.38, w: 4.3, h: 0.28, fontSize: 10, bold: true, color: TEAL, fontFace: "Calibri", margin: 0 });
  s.addText("Postoperative Care", { x: 5.2, y: 1.38, w: 4.5, h: 0.28, fontSize: 10, bold: true, color: AMBER, fontFace: "Calibri", margin: 0 });
  addTwoCol(s, leftItems, rightItems, 1.65);
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 7 — COMPLICATIONS TO MANAGE
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("COMPLICATIONS REQUIRING ACTIVE MANAGEMENT", "Must address proactively for rehabilitation success");

  const comps = [
    { icon: "🫁", title: "Respiratory", text: "Diaphragm dysfunction (C3–C4), secretion clearance, pneumonia prevention — assisted cough, ventilator weaning" },
    { icon: "🫀", title: "Autonomic Dysreflexia", text: "Paroxysmal hypertension, bradycardia, flushing in T6 and above injuries — triggered by bladder distension or fecal impaction" },
    { icon: "🩹", title: "Pressure Ulcers", text: "2-hourly turning, pressure-relieving mattress, skin surveillance — particularly sacrum, heels, occiput" },
    { icon: "💊", title: "Pain & Spasticity", text: "Neurogenic pain managed with gabapentin/pregabalin; spasticity: baclofen (oral or intrathecal in resistant cases)" },
    { icon: "🩸", title: "Thromboembolic Events", text: "DVT in ~30% of SCI patients; PE risk high — LMWH + compression stockings for 8–12 weeks" },
    { icon: "🧠", title: "Post-traumatic Syringomyelia", text: "Occurs in ~28% within 30 years — ascending weakness/pain; MRI assessment; surgical shunting if expanding" },
  ];

  comps.forEach((c, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i % 3;
    const x = col === 0 ? 0.35 : 5.2;
    const y = 1.45 + row * 1.32;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 1.2, fill: { color: "0D2240" }, line: { color: col === 0 ? TEAL : AMBER, width: 0.8 } });
    s.addText(c.title, { x: x + 0.15, y: y + 0.05, w: 4.3, h: 0.35, fontSize: 12, bold: true, color: col === 0 ? TEAL : AMBER, fontFace: "Calibri", margin: 0 });
    s.addText(c.text, { x: x + 0.15, y: y + 0.38, w: 4.3, h: 0.75, fontSize: 10, color: WHITE, fontFace: "Calibri", margin: 0, valign: "top" });
  });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 8 — PHYSICAL REHABILITATION FRAMEWORK
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("PHYSICAL REHABILITATION — FRAMEWORK", "Multidisciplinary, goal-directed, phase-based approach");

  // Three phases
  const phases = [
    {
      num: "01",
      name: "Acute Phase\n(Days 0–14)",
      color: TEAL,
      items: [
        "Bed positioning to prevent pressure sores",
        "Passive range-of-motion exercises",
        "Respiratory physiotherapy — breathing exercises, assisted cough",
        "Prevention of contractures",
        "Sensory stimulation",
        "Psychological support"
      ]
    },
    {
      num: "02",
      name: "Subacute Phase\n(Weeks 2–12)",
      color: AMBER,
      items: [
        "Active-assisted & active exercises",
        "Strengthening preserved muscle groups",
        "Trunk stabilization training",
        "Wheelchair skills & transfers",
        "Orthotic prescription (KAFO, AFO)",
        "Bladder/bowel retraining"
      ]
    },
    {
      num: "03",
      name: "Rehabilitation Phase\n(Months 3–24+)",
      color: "4CAF50",
      items: [
        "Gait training with orthoses or parallel bars",
        "Body-weight supported treadmill training (BWSTT)",
        "Functional electrical stimulation (FES)",
        "Activities of daily living retraining",
        "Vocational & community reintegration",
        "Long-term outpatient follow-up"
      ]
    }
  ];

  phases.forEach((p, i) => {
    const x = 0.35 + i * 3.15;
    s.addShape(pres.ShapeType.rect, { x, y: 1.4, w: 2.95, h: 0.55, fill: { color: p.color } });
    s.addText(`Phase ${p.num}`, { x, y: 1.4, w: 2.95, h: 0.55, align: "center", valign: "middle", fontSize: 13, bold: true, color: NAVY, fontFace: "Calibri", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x, y: 1.95, w: 2.95, h: 0.52, fill: { color: "0D2240" }, line: { color: p.color } });
    s.addText(p.name, { x, y: 1.95, w: 2.95, h: 0.52, align: "center", valign: "middle", fontSize: 10, bold: true, color: p.color, fontFace: "Calibri", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x, y: 2.48, w: 2.95, h: 2.9, fill: { color: "0A1A2E" }, line: { color: p.color, width: 0.8 } });
    s.addText(
      p.items.map((it, j) => ({ text: it, options: { bullet: true, color: WHITE, fontSize: 10, fontFace: "Calibri", breakLine: j < p.items.length - 1 } })),
      { x: x + 0.12, y: 2.55, w: 2.75, h: 2.75, valign: "top", lineSpacingMultiple: 1.3 }
    );
  });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 9 — REHABILITATION TECHNIQUES (with image)
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("PHYSICAL REHABILITATION TECHNIQUES", "Evidence-based modalities used in SCI recovery");

  const techBullets = [
    "Locomotor Training (BWSTT): body-weight support harness + treadmill promotes spinal plasticity",
    "Functional Electrical Stimulation (FES): externally evokes muscle contractions to assist gait & upper limb use",
    "Resistance & Strength Training: hypertrophy of preserved muscle groups critical for wheelchair propulsion",
    "Proprioceptive neuromuscular facilitation (PNF): diagonal movement patterns to enhance residual motor control",
    "Aquatic therapy: buoyancy reduces gravitational load, enabling earlier active movement",
    "Robot-assisted gait (Lokomat®, Ekso®): consistent task-repetitive practice accelerates neuroplasticity",
    "Orthoses (KAFO/AFO): support ambulation; community ambulators need at least MRC 3/5 hip flexors + knee extensor"
  ];

  s.addText(
    techBullets.map((t, i) => ({ text: t, options: { bullet: true, color: WHITE, fontSize: 11.5, fontFace: "Calibri", breakLine: i < techBullets.length - 1 } })),
    { x: 0.35, y: 1.45, w: 5.75, h: 4.0, valign: "top", lineSpacingMultiple: 1.3 }
  );

  // Image
  if (images[2] && !images[2].error) {
    s.addImage({ data: images[2].base64, x: 6.3, y: 1.3, w: 3.45, h: 4.0 });
    s.addText("Gait training with orthoses and parallel bars", {
      x: 6.3, y: 5.3, w: 3.45, h: 0.25, fontSize: 8, color: GRAY, fontFace: "Calibri", italic: true, align: "center"
    });
  } else {
    s.addShape(pres.ShapeType.rect, { x: 6.3, y: 1.3, w: 3.45, h: 4.0, fill: { color: "0D2240" }, line: { color: TEAL } });
    s.addText("Rehabilitation\nTechniques\nImage", { x: 6.3, y: 1.3, w: 3.45, h: 4.0, align: "center", valign: "middle", color: TEAL, fontSize: 15, bold: true });
  }
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 10 — FUNCTIONAL OUTCOMES BY LEVEL
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("FUNCTIONAL OUTCOMES BY INJURY LEVEL", "Expected independence goals for cervical & thoracolumbar SCI");

  const rows = [
    { lvl: "C3–C4", goal: "Power wheelchair (mouth/chin control), verbal care direction, possible ventilator dependence" },
    { lvl: "C5", goal: "Power wheelchair, upper body dressing, self-feed with aids, assisted face washing" },
    { lvl: "C6", goal: "Propel manual wheelchair, upper body dressing, self-groom, bladder care with assistance, can drive with adaptations" },
    { lvl: "C7", goal: "Manual wheelchair independent, independent transfer, dressing with aids, self-care" },
    { lvl: "C8–T4", goal: "Independent in most ADLs and bladder/bowel care" },
    { lvl: "T5–T12", goal: "Full independence in all self-care; potential for therapeutic ambulation" },
    { lvl: "L1–L5", goal: "Independent ambulation with short/long leg braces (KAFO/AFO)" },
    { lvl: "S1–S5", goal: "Independent walking (may need brace at S1); bladder/bowel/sexual function may remain impaired" },
  ];

  rows.forEach((r, i) => {
    const y = 1.4 + i * 0.52;
    const bg = i % 2 === 0 ? "0D2240" : "091A30";
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 9.3, h: 0.48, fill: { color: bg }, line: { color: bg } });
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 1.05, h: 0.48, fill: { color: i < 4 ? TEAL : AMBER } });
    s.addText(r.lvl, { x: 0.35, y, w: 1.05, h: 0.48, align: "center", valign: "middle", fontSize: 12, bold: true, color: NAVY, fontFace: "Calibri", margin: 0 });
    s.addText(r.goal, { x: 1.5, y: y + 0.04, w: 8.0, h: 0.42, valign: "middle", fontSize: 10.5, color: WHITE, fontFace: "Calibri", margin: 0 });
  });

  // Header row
  s.addText("LEVEL", { x: 0.35, y: 1.35, w: 1.05, h: 0.28, align: "center", fontSize: 9, bold: true, color: GRAY, fontFace: "Calibri", margin: 0 });
  s.addText("FUNCTIONAL REHABILITATION GOAL", { x: 1.5, y: 1.35, w: 8.0, h: 0.28, fontSize: 9, bold: true, color: GRAY, fontFace: "Calibri", margin: 0 });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 11 — AMBULATION & MOTOR RECOVERY MILESTONES
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("AMBULATION & MOTOR RECOVERY MILESTONES", "Prognostic indicators from the SCI Locomotor Trial (Dobkin et al., 2006)");

  const leftBullets = [
    "ASIA Lower Extremity Motor Score (LEMS) at 1 month is the key predictor of ambulatory outcome",
    "LEMS ≥10 at 1 month → community ambulator with crutches + orthoses by 1 year",
    "LEMS 20–30 → limited ambulation at slower velocities with higher energy cost",
    "LEMS >30 → near-effortless community ambulation achieved",
    "LEMS >40 → highest walking speeds attained",
    "Community ambulators need: pelvic control + hip flexors + one knee extensor (MRC ≥3/5)"
  ];

  const rightBullets = [
    "AIS-A cervical/thoracic: only ~10% improve ≥1 ASIA grade during inpatient rehab",
    "AIS-B: 40% regain walking; no motor gains by 16 weeks → poor prognosis",
    "AIS-C: highly likely to continue making motor gains; >70% achieve unlimited walking",
    "For AIS-A at C4 and above: power wheelchair + assistive devices essential",
    "Patients with ≥high school education far more likely to return to work post-SCI",
    "1 in 4 patients with 20+ year injury evolve greater need for physical assistance"
  ];

  s.addText("LEMS-Based Ambulation Predictions", { x: 0.5, y: 1.35, w: 4.3, h: 0.28, fontSize: 10, bold: true, color: TEAL, fontFace: "Calibri", margin: 0 });
  s.addText("AIS Grade Recovery Patterns", { x: 5.2, y: 1.35, w: 4.5, h: 0.28, fontSize: 10, bold: true, color: AMBER, fontFace: "Calibri", margin: 0 });
  addTwoCol(s, leftBullets, rightBullets, 1.62);
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 12 — TRUNK & CORE REHABILITATION (with image)
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("CORE & TRUNK STABILIZATION", "Foundation of functional independence in SCI rehabilitation");

  const bullets = [
    "Trunk stability is prerequisite for all upper and lower limb rehabilitation tasks",
    "Prone cobra extension — paraspinal activation with bolster support",
    "Quadruped (all-fours) position with manual cues for lumbar engagement",
    "Assisted sit-ups and crunch exercises for trunk flexor strengthening",
    "Progressive sitting balance from supported to unsupported on therapy surface",
    "Swiss ball / stability ball exercises for dynamic postural control",
    "Goal: maximize SCIM (Spinal Cord Independence Measure) scores"
  ];

  s.addText(
    bullets.map((t, i) => ({ text: t, options: { bullet: true, color: WHITE, fontSize: 12, fontFace: "Calibri", breakLine: i < bullets.length - 1 } })),
    { x: 0.35, y: 1.45, w: 5.5, h: 4.0, valign: "top", lineSpacingMultiple: 1.35 }
  );

  if (images[3] && !images[3].error) {
    s.addImage({ data: images[3].base64, x: 6.1, y: 1.3, w: 3.65, h: 4.0 });
    s.addText("Trunk stabilization physiotherapy protocol", {
      x: 6.1, y: 5.3, w: 3.65, h: 0.25, fontSize: 8, color: GRAY, fontFace: "Calibri", italic: true, align: "center"
    });
  } else {
    s.addShape(pres.ShapeType.rect, { x: 6.1, y: 1.3, w: 3.65, h: 4.0, fill: { color: "0D2240" }, line: { color: TEAL } });
    s.addText("Core\nRehabilitation\nImage", { x: 6.1, y: 1.3, w: 3.65, h: 4.0, align: "center", valign: "middle", color: TEAL, fontSize: 15, bold: true });
  }
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 13 — MULTIDISCIPLINARY TEAM
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("THE MULTIDISCIPLINARY REHABILITATION TEAM", "Coordinated care across all domains");

  const members = [
    { role: "Physiatrist\n(Rehab Physician)", icon: "👩‍⚕️", desc: "Leads rehabilitation, manages complications, prescribes assistive technology, coordinates team" },
    { role: "Physical\nTherapist", icon: "🏃", desc: "Gait training, strengthening, balance, orthotic training, hydrotherapy, FES, BWSTT" },
    { role: "Occupational\nTherapist", icon: "🖐️", desc: "ADL retraining, upper limb function, adaptive equipment, home modification, driving assessment" },
    { role: "Speech\nTherapist", icon: "🗣️", desc: "Dysphagia management (ventilator-dependent patients), communication devices for high cervical SCI" },
    { role: "Urologist /\nNurse Specialist", icon: "🩺", desc: "Bladder program, catheter management, urodynamics, prevention of UTI and upper tract damage" },
    { role: "Psychologist /\nSocial Worker", icon: "💬", desc: "Depression, adjustment disorders, vocational rehab, financial support, caregiver training" },
  ];

  members.forEach((m, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i % 3;
    const x = col === 0 ? 0.35 : 5.2;
    const y = 1.4 + row * 1.32;
    const accent = col === 0 ? TEAL : AMBER;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 1.18, fill: { color: "0D2240" }, line: { color: accent, width: 0.8 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 0.08, h: 1.18, fill: { color: accent } });
    s.addText(m.role, { x: x + 0.18, y: y + 0.05, w: 1.75, h: 0.55, fontSize: 11, bold: true, color: accent, fontFace: "Calibri", margin: 0 });
    s.addText(m.desc, { x: x + 0.18, y: y + 0.55, w: 4.3, h: 0.58, fontSize: 9.5, color: WHITE, fontFace: "Calibri", margin: 0, valign: "top" });
  });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 14 — NEUROPROTECTION & EMERGING THERAPIES
// ══════════════════════════════════════════════════════════════════
{
  const s = navySlide("NEUROPROTECTION & EMERGING THERAPIES", "Current evidence & future directions");

  const items = [
    { cat: "PHARMACOLOGICAL", color: TEAL, bullets: ["Riluzole (Na⁺ channel blocker): phase II/III trials ongoing", "Minocycline: anti-inflammatory; limited benefit in RCTs", "Methylprednisolone: NO longer recommended routinely (NASCIS III — increased complications)", "Ibuprofen, Rho-antagonist (Cethrin): experimental neuroprotection"] },
    { cat: "CELLULAR / REGENERATIVE", color: AMBER, bullets: ["Mesenchymal stem cell transplantation: preclinical promise, early clinical trials", "Neural stem cells (NSCs): limited phase I safety data", "Schwann cell transplants (MIAMI Project)", "BDNF, GDNF: neurotrophic factors to support axonal regrowth"] },
    { cat: "NEUROMODULATION", color: "4CAF50", bullets: ["Epidural spinal cord stimulation (eSCS): enables voluntary movement in AIS-A patients (Angeli et al., 2014)", "Transcutaneous spinal cord stimulation: non-invasive form under investigation", "Functional electrical stimulation (FES): restores grasp, standing, cycling", "Brain-computer interfaces (BCI): bypass injury level to restore voluntary control"] },
  ];

  items.forEach((item, i) => {
    const x = 0.35 + i * 3.15;
    s.addShape(pres.ShapeType.rect, { x, y: 1.38, w: 2.95, h: 0.5, fill: { color: item.color } });
    s.addText(item.cat, { x, y: 1.38, w: 2.95, h: 0.5, align: "center", valign: "middle", fontSize: 10.5, bold: true, color: NAVY, fontFace: "Calibri", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x, y: 1.88, w: 2.95, h: 3.5, fill: { color: "0A1A2E" }, line: { color: item.color, width: 0.8 } });
    s.addText(
      item.bullets.map((b, j) => ({ text: b, options: { bullet: true, color: WHITE, fontSize: 10, fontFace: "Calibri", breakLine: j < item.bullets.length - 1 } })),
      { x: x + 0.1, y: 1.95, w: 2.78, h: 3.35, valign: "top", lineSpacingMultiple: 1.3 }
    );
  });
}

// ══════════════════════════════════════════════════════════════════
// SLIDE 15 — SUMMARY & KEY TAKEAWAYS
// ══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: NAVY } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.22, h: 5.625, fill: { color: TEAL } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 4.85, w: 10, h: 0.775, fill: { color: DARK_TEAL } });

  s.addText("KEY TAKEAWAYS", {
    x: 0.45, y: 0.22, w: 9.1, h: 0.65,
    fontSize: 26, bold: true, color: TEAL, fontFace: "Calibri", charSpacing: 3, margin: 0
  });
  s.addShape(pres.ShapeType.line, { x: 0.45, y: 0.9, w: 9.1, h: 0, line: { color: TEAL, width: 1 } });

  const takeaways = [
    { num: "01", text: "SCI severity is classified by the ASIA Impairment Scale (A–E) — this drives all rehabilitation goal-setting and prognosis" },
    { num: "02", text: "Early surgical decompression (within 24 hours) improves neurological outcomes — STASCIS trial evidence" },
    { num: "03", text: "Postoperative care focuses on MAP ≥85 mmHg, respiratory support, DVT prophylaxis, and early bladder/bowel programs" },
    { num: "04", text: "Physical rehabilitation is phase-based (acute → subacute → functional) and requires a full multidisciplinary team" },
    { num: "05", text: "LEMS ≥10 at 1 month predicts community ambulation; BWSTT, FES, and robotic gait systems leverage spinal plasticity" },
    { num: "06", text: "Complications (spasticity, dysreflexia, pressure ulcers, syringomyelia) must be anticipated and managed proactively" },
    { num: "07", text: "Emerging therapies — epidural stimulation, stem cells, BCI — show early promise in restoring voluntary function even in complete injuries" },
  ];

  takeaways.forEach((t, i) => {
    const y = 1.0 + i * 0.53;
    s.addShape(pres.ShapeType.rect, { x: 0.45, y, w: 0.5, h: 0.43, fill: { color: i % 2 === 0 ? TEAL : AMBER } });
    s.addText(t.num, { x: 0.45, y, w: 0.5, h: 0.43, align: "center", valign: "middle", fontSize: 12, bold: true, color: NAVY, fontFace: "Calibri", margin: 0 });
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  });

  s.addText("Sources: Bailey & Love's Surgery 28e  ·  Bradley & Daroff's Neurology in Clinical Practice  ·  Rockwood & Green's Fractures 10e  ·  Sabiston Textbook of Surgery", {
    x: 0.45, y: 4.9, w: 9, h: 0.35,
    fontSize: 8, color: "C8E8E6", fontFace: "Calibri", italic: true, margin: 0, valign: "middle"
  });
}

// ─── write file ─────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/spinal-cord-injury-ppt/Spinal_Cord_Injury_Rehabilitation.pptx" })
  .then(() => console.log("✅ Done: Spinal_Cord_Injury_Rehabilitation.pptx"))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

cd /home/daytona/workspace/spinal-cord-injury-ppt && node generate.js 2>&1

ls -lh /home/daytona/workspace/spinal-cord-injury-ppt/Spinal_Cord_Injury_Rehabil…