Traumatic spinal cord injury





Abstract:


This chapter provides a general overview for the management of individuals with spinal cord injury (SCI) throughout inpatient and postacute phases of the rehabilitation continuum. The information is intended to aid health care professionals in the treatment of individuals with SCI by providing guidelines to maximize each individual’s return to their pre-injury lifestyle.




Keywords:

American Spinal Injury Association (ASIA), autonomic dysfunction, autonomic dysreflexia, body-weight–supported treadmill (BWST), bulbocavernosus reflex, complete lesion, deep vein thrombosis (DVT), dual diagnosis, Venous thromboembolism (VTE), discomplete, Functional Independence Measure (FIM), incomplete lesion, intermittent catheterization, locomotor training, lower motor neuron, mobile arm support (MAS), paraplegia, pressure injury, pulmonary embolism (PE), robotic exoskeleton, spinal cord injury (SCI), spinal shock, tenodesis, tetraplegia, upper motor neuron

 




Objectives


After reading this chapter the reader will be able to:



  • 1.

    Describe the demographics, etiology, and mechanism of injury of spinal cord injury.


  • 2.

    Discuss the acute medical management of people with spinal cord injury.


  • 3.

    Describe the secondary conditions of spinal cord injury, the appropriate interventions, and the impact of complications on the rehabilitation process.


  • 4.

    Identify the basic components of the examination process.


  • 5.

    Identify patient problems based on the examination, establish appropriate goals, and plan individualized treatment programs for patients with a spinal cord injury.


  • 6.

    Describe adaptive equipment available to increase function.


  • 7.

    Discuss progression of each individual and the process of discharge planning throughout the rehabilitation process.


  • 8.

    Describe functional expectations for individuals with complete spinal cord injuries.


  • 9.

    Identify equipment needs for a given spinal cord injury lesion.


  • 10.

    Describe various principles of neuroplasticity to promote recovery after spinal cord injury.





Spinal cord injury (SCI) is a catastrophic condition that, depending on its severity, may cause dramatic changes in a person’s life. SCI usually happens to active and independent people who at one moment are in control of their lives and in the next moment are paralyzed. Loss of sensation and loss of bodily functions can lead to dependence on others for even the most basic needs. To reduce negative impact, individuals with SCI need a well-coordinated, specialized rehabilitation program to assist them in maximizing the development of skills necessary to live a satisfying and productive postinjury life.




Fig. 14.62


Vibration therapy is a modality with a wide range of purposes including tone or spasticity management and muscle recruitment.



Fig. 14.63


Power assist wheels added to a manual wheelchair meet the needs of users who may need supplemental support in the community while also requiring the ease of transportation that a manual chair provides. Power assist wheels help users with energy conservation and shoulder maintenance long term.


A successful rehabilitation program requires a team of health care professionals who work in collaboration to address alterations in body function, increase the individual’s independence in all daily activities, ensure long-term health and wellness, and return the individual to the highest level of community participation specific to that individual’s life situation. Ideally, the team should include a physician, a case manager, an occupational therapist, a physical therapist, a recreational therapist, a prosthetist or orthotist, a nurse, a speech-language pathologist, a dietician, an assistive technologist, a respiratory care practitioner, a psychologist, a social worker, a vocational counselor, a rehabilitation engineer, and a chaplain. The most important element determining success in any rehabilitation program is the patient’s and caregiver’s active participation throughout the rehabilitation process.


This chapter provides a general overview for the management of individuals with SCI throughout inpatient and postacute phases of the rehabilitation continuum. The information is intended to aid health care professionals in the treatment of individuals with SCI by providing guidelines to maximize each individual’s return to their preinjury lifestyle.




Spinal cord lesions


SCI occurs when the spinal cord is damaged as a result of trauma, disease processes, vascular compromise, or congenital neural tube defect. The clinical manifestations of the injury vary depending on the extent and location of the damage to the spinal cord.


Tetraplegia


Tetraplegia (preferred to quadriplegia ) refers to impairment or loss of motor and/or sensory function as a result of damage to the cervical segments of the spinal cord. Function in the upper extremities (UEs), lower extremities, and trunk is affected. It does not include brachial plexus lesions or injury to peripheral nerves outside the neural canal.


Paraplegia


Paraplegia refers to impairment or loss of motor or sensory function as a result of damage to the thoracic, lumbar, or sacral segments of the spinal cord. Depending on the level of the damage, function may be impaired in the trunk and/or lower extremities. Also, the term paraplegia can be used to refer to cauda equina and conus medullaris injuries but not to lumbosacral plexus lesions or injury to peripheral nerves, which are considered outside of the central nervous system.


Complete, discomplete, and incomplete lesions


In a complete lesion, sensory and motor function in the lowest sacral segments (S4-S5) is absent postinjury. The American Spinal Injury Association (ASIA) classification for this type of injury is the ASIA Impairment Scale (AIS) A. The ASIA Impairment Scale is determined by completion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) assessment.


Discomplete injury is a relatively new term in SCI research and practice. It is defined as a lesion that is “clinically complete but which is accompanied by neurophysiological evidence of residual brain influence on spinal cord function below the level of the lesion.” Studies of people whose spinal cord injuries were considered complete under ASIA standards have shown that in a large percentage (84%), there was residual brain influence on the spinal cord below the level of the lesion. The current gold standard for testing, the ISNCSCI, does not examine this aspect of SCI.


With incomplete lesions, there is detectable residual sensory or motor function below the neurological level and specifically in the lowest sacral segment. According to ASIA standards, any sensation in the anal mucocutaneous junction or deep anal pressure indicates that the lesion is incomplete. If only sensation is preserved, the injury is classified as AIS B. If motor function in key muscles is maintained to some degree, patients may achieve level AIS C, D, or E classification. This testing will be reviewed further in this chapter. ,




Demographics


The number of people living in the United States today with SCI is between 247,000 and 358,000. The incidence of SCI in the United States is approximately 17,700 new cases per year, 78% of which are males. The average age at the time of SCI has increased steadily from 29 years to 43 years since the mid-1970s. Vehicle crashes and falls are the top two causes of SCI and account for close to 70% of new cases each year. Table 14.1 lists additional demographics.



TABLE 14.1

Spinal Cord Injury Demographics

Data from National Spinal Cord Injury Statistical Center. Spinal Cord Injury: Facts and Figures at a Glance. February 2018, Birmingham, AL, 2018, University of Alabama, National Spinal Cord Injury Statistical Center. Available at https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%20-%202018.pdf


























Mean age at injury 43 years
Gender
Male
Female
78%
22%
Race/Ethnicity
Non-Hispanic White
Non-Hispanic Black
Hispanic Origin
Asian
Other
Native American
60.6%
21.9%
12.8%
2.7%
1.3%
0.7%
Causes of Injury
Motor vehicle accident
Falls
Violent acts
Sports injuries
Medical or Surgical
Other
38.3%
31.6%
13.8%
8.2%
4.6%
3.5%
Common Injury Sites
Incomplete tetraplegia
Incomplete paraplegia
Complete paraplegia
Complete tetraplegia
Normal
47.2%
20.4%
20.8%
11.5%
0.08%


In 2015, the average length of inpatient stay was 45 days (11 days in an acute care facility and 34 days in rehabilitation). This was a slight decline from 2005, where the average length of inpatient stay was 50 days (12 days in an acute care facility and 38 days in rehabilitation), and a substantial decline from the 1970s when the average length of inpatient stay was 122 days (24 days in an acute care facility and 98 days in rehabilitation). The average yearly health care and living expenses vary according to severity of injury. In the first year, individuals with high tetraplegia spend an average of $1,102,403 (up from $829,843 in 2005), whereas individuals with paraplegia spend an average of $537,271 (up from $303,220 in 2005). Approximately 30% of individuals living with SCI are rehospitalized, with the average rehospitalization lasting 22 days. Genitourinary disease is the leading cause of hospitalization, followed by skin, respiratory diseases, digestive, circulatory, and musculoskeletal issues as other leading causes. Additionally, the life expectancy for patients with SCI continues to increase but is still below the national average of persons without SCI. Mortality rates are significantly higher during the first year after injury, especially for severely injured persons. According to the National SCI Database, the leading causes of death after an SCI are pneumonia, pulmonary emboli, and septicemia.




Sequelae of traumatic spinal cord injury


As stated previously, most spinal cord injuries occur as a result of trauma, be it motor vehicle accidents, falls, violence, or sports-related injury. The degree and type of forces that are exerted on the spine at the time of the trauma determine the location and severity of damage to the spinal cord. Injuries to the vertebral column can be classified biomechanically as flexion or flexion-rotation injuries, hyperextension injuries, and compression injuries. Penetrating injuries to the cord are usually the result of gunshot or knife wounds.


Spinal cord damage can also be caused by nontraumatic mechanisms. Circulatory compromise to the spinal cord resulting in ischemia causes neurological damage at and below the involved cord level. This can be caused by a thrombus, swelling, compression, or vascular malformations and dysfunction. Degenerative bone diseases can cause compression of the spinal cord by creating a stenosis of the spinal canal and intervertebral foramina. Stenosis can also result from the prolapse of the intervertebral disc into the neural canal. The encroachment of tumors or abscesses within the spinal cord, the spinal canal, or the surrounding tissues also can lead to SCI. Congenital malformation of the spinal structures, as in spina bifida, can compromise the spinal cord and its protective layers of connective tissue. Some of the more common diseases and conditions that result in compromise of the spinal cord include Guillain-Barré syndrome, transverse myelitis, amyotrophic lateral sclerosis, and multiple sclerosis.


After the spinal cord has sustained trauma, cellular events occur in response to the injury and are classified in three phases of progression: acute, secondary, and chronic responses. The acute process begins on occurrence of an injury and continues for 3 to 5 days. Abrupt necrosis or cell death can result from both mechanical and ischemic events. The impact of an SCI often causes direct mechanical damage to neural and other soft tissues as well as severe hemorrhaging in the surrounding gray and white matter, resulting in immediate cell death. In the next few minutes after the insult, injured nerve cells respond with trauma-induced action potentials, which lead to increased levels of intracellular sodium. The result of this influx is an increase in osmotic pressure, or movement of water into the area. Edema generally develops in as many as three levels above and below the original insult and leads to further tissue deconstruction. , , Increased levels of extracellular potassium and intracellular concentrations of calcium also result in an electrolyte imbalance that contributes to a toxic environment. Abnormal concentrations of calcium within the damaged cells disrupt their functioning and cause breakdown of protein and phospholipids, leading to demyelination and destruction of the cell membrane. The cascade of these events consequently contribute to a dysfunctional nervous system.


During this acute phase, evidence of spinal shock and neurogenic shock may be present. Spinal shock may begin 30 to 60 minutes after spinal trauma and is characterized by flaccid paralysis and absence of all spinal cord reflex activity below the level of the spinal cord lesion. The length of time this condition lasts can range from about 24 hours after injury to several weeks. Spinal shock represents a generalized failure of circuitry in the spinal neural network and is thought to be directly related to a conduction block resulting from leakage of potassium into the extracellular matrix. Accurately determining the completeness of the lesion may be difficult until spinal shock is resolved. The signs of spinal shock resolution are controversial; however, the return of reflexes may be a good indication. Neurogenic shock, on the other hand, refers to a life-threatening condition . It consists of hypotension, bradycardia, and peripheral vasodilatation caused by severe central nervous system damage resulting in loss of sympathetic stimulation to the blood vessels and unopposed vagal activity. This is common in patients with a SCI at the level of T6 or higher. An important goal of treatment in the first week after sustaining an SCI is to maintain a mean arterial pressure (MAP) of 85 to 90 mm Hg. ,


The secondary phase of the injury occurs within the course of minutes to weeks after the acute process and is characterized by the continuation of ischemic cellular death, electrolytic shifts, and edema. Extracellular concentrations of glutamate and other excitatory amino acids reach concentrations that are six to eight times greater than normal within the first 15 minutes after an injury. In addition, lipid peroxidation and free radical production also occur. Apoptosis (a secondary programmable cell death) occurs and involves reactive gliosis. There is also an important immune response that adds to the secondary damage that may be a result of a damaged blood-brain barrier, microglial activation, and increased local concentrations of cytokines and chemokines. The lesion enlarges from the initial core of cell death, expanding from the perilesional region to a larger region of cell loss.


In the chronic phase, which occurs over a period of days to years, apoptosis continues both rostrally and caudally. Receptors and ion channels are altered, and with penetrating injuries, scarring and tethering of the cord occurs. Conduction deficits persist due to demyelination, and permanent hyperexcitability develops with consequential chronic pain syndromes and spasticity in many individuals with SCI. Changes in neural circuits result from alterations in excitatory and inhibitory inputs, and axons may exhibit some limited regenerative and sprouting responses.




Clinical syndromes


Some incomplete lesions have a distinct clinical picture with specific signs and symptoms. An understanding of the various syndromes can be helpful to the patient’s team in planning the rehabilitation program. However, using a syndrome for classification is not recommended due to the fact that many clinical cases present as a variation of a syndrome versus presenting as a true syndrome. Additionally, there are no clear objective guidelines by which to define an incomplete injury from a syndrome. Fig. 14.1 depicts the anatomy of the spinal cord, which can be referred to as the various syndromes are described.




Fig. 14.1


Cross-Sectional Anatomy of the Spinal Cord.


Central cord syndrome


Central cord syndrome is the most common of the SCI syndromes and accounts for about 9% of traumatic SCIs in adults. In adults 45 to 50 years of age, hyperextension injuries in the presence of cervical spondylosis or spinal stenosis is the most common cause during a low impact accident or injury. Younger patients are more likely to have a flexion-compression injury during a high impact accident or injury, causing fracture or disc herniation. However, it is suggested that injury occurs in the white matter of the lateral corticospinal tracts with diffuse axonal injury, and there is sparing of the central gray matter. Additionally, Wallerian degeneration may occur in axons nearby the injury site causing neurological impairment. Although the prognosis for functional recovery is good for individuals with central cord syndrome, the pattern of recovery is such that intrinsic hand function is the last thing to return. Most people with central cord syndrome will recover some level of ambulatory function, and over half will experience spontaneous voiding and bladder emptying. Slightly under half may gain some form of hand function. ,


Brown–Séquard syndrome


Occasionally, as a result of penetrating injuries (gunshot or stab wounds), only the lateral half of the spinal cord is damaged. Brown–Séquard syndrome occurs in 1% to 4% of traumatic SCIs and is characterized by ipsilateral loss of motor function and position sense and contralateral loss of pain and temperature sensation several levels below the lesion. , The prognosis for recovery is good. Nearly all patients attain some level of ambulatory function, 80% regain hand function, 100% have bladder control, and 80% have bowel control. While rare in its pure form, this syndrome more commonly presents with features of central cord syndrome, sometimes called Brown–Sequard–plus syndrome.


Anterior cord syndrome


Anterior cord syndrome, also known as anterior spinal artery syndrome, occurs in 2.7% of traumatic SCIs, and is often caused by flexion injuries in which bone or cartilage spicules compromise the anterior spinal artery, thereby impairing the blood supply to the anterior two-thirds of the spinal cord. Motor function and pain and temperature sensation are lost bilaterally below the injured segment, whereas light touch and proprioception are preserved. The prognosis is extremely poor for return of bowel and bladder function, hand function, and ambulation. ,


Posterior cord syndrome


Posterior cord syndrome is rare, with an incidence of less than 1%. This results from compression by disc or tumor, infarction of the posterior spinal artery, or vitamin B12 deficiency. Clinically, proprioception, stereognosis, two-point discrimination, and vibration sense are lost below the level of the lesion; and motor function and pain and temperature sensation are preserved. , Additionally, patients presenting with posterior cord syndrome may have bowel and bladder continence, allowing for increased functional return home.


Cauda Equina syndrome


Damage to the cauda equina involves the lumbosacral nerve roots, often sparing the cord itself. This syndrome is commonly caused by a burst fracture of a lumbar vertebrae or a centrally herniated disc and results in a lower motor neuron lesion that is usually incomplete. This lesion results in flaccid paralysis with no spinal reflex activity present. Sensation may be partially or completely lost, and sacral reflexes will be absent, affecting the lower urinary tract, distal bowel, and sexual function. , Bladder outcomes worsen the longer the cauda equina is compressed. Due to the potential of lumbosacral nerve roots to regenerate, there is a more favorable prognosis for recovery.


Conus medullaris syndrome


Typically caused by trauma and tumors, this syndrome is similar to cauda equina syndrome; however, the injury is more rostral and may involve the cord and be related to an L1-L2 bony injury. Clinically the presentation may appear mixed with characteristics of both upper and lower motor neuron lesions due to possible involvement of both the conus and the nerve roots. Sacral reflexes may be preserved depending on the level of the lesion and therefore may be overactive or acontractile. , ,




Dual diagnosis: Co-occurring brain and spinal cord injury


Incidence reports of co-occurring brain and SCI range from 15% to 70%. The significant variation in reporting of this co-occurrence is due to the diagnostic factors utilized by physicians immediately following injury. When imaging is the primary resource used to determine co-occurrence of brain injury with SCI, rates range from 16% to 24%. When posttraumatic amnesia is added as a diagnostic factor, rates increase to 42% to 50%. According to the International Classification of Diseases, codes to classify brain injury are based on loss of consciousness and posttraumatic amnesia. Despite the frequency of co-occurring brain and SCI, this dual diagnosis tends to be undiagnosed or undocumented and therefore is often not adequately addressed during SCI rehabilitation.


Co-occurring traumatic brain injuries are missed when the SCI or any other injury is prioritized for lifesaving needs. Frequently, the initial paramedic and emergency department reports do not include information regarding the loss of consciousness and duration of posttraumatic amnesia. This lack of reporting leads to an underdiagnosis of brain injury. Unless significant cognitive deficits or a medical status change indicate the need for further diagnostic testing, the patient progresses through the continuum of care without a formal diagnosis of brain injury.


The rehabilitation team often notes signs, symptoms, and behaviors of brain injury in their documentation and team meetings. The rehabilitation process involves working with a team over an extended period of time, novel task training, and a holistic approach, which increases the likelihood that the patient will endorse behaviors, signs, and symptoms of brain injury. If the patient with a co-occurring brain and SCI is not managed and identified properly, they are commonly misperceived as being noncompliant, unable to learn, and/or having poor coping abilities, poor motivation, or a bad attitude.


Patients with co-occurring brain and SCI require a longer inpatient rehabilitation length of stay to reach expected outcomes based on their SCI level. This allows for the opportunity to learn adaptive and compensatory techniques, which are typically acquired by their non brain–injured peers. If length of stay is not adjusted, evidence indicates that this population will experience a significant reduction in short- and long-term functional outcomes. This population will endorse difficulties in functional motor tasks such as transfers, bed mobility, dressing, etc., due to poor motor planning, spatial awareness, and decreased executive functioning. , The therapy team should utilize the Rancho Los Amigos Brain Injury Severity Scale (Rancho Level) to guide the introduction of errorless learning versus errored learning.


Successful progression of the patient with a co-occurring brain and SCI requires the rehabilitation team to understand how the patient’s cognitive status (Rancho Level) influences their stage of motor learning. Refer to the Box 14.1 for more information on the Rancho Los Amigos Brain Injury Severity Scale. Correctly identifying the stage of motor learning and crafting therapy to meet the patient’s stage maximizes long-term functional gains ( Box 14.2 ). Errorless learning is the ideal method for patients who meet criteria suggesting Rancho VII or less, because they are in the cognitive stage and just emerging to the associative phases of learning. Error-based learning (also known as trial and error learning) should occur later in the rehabilitation process, with individuals who are categorized as Rancho VIII or greater. It is important to note that continuing with errorless learning with patients who have the capacity to progress through the associative and autonomous stages of motor learning will result in reduced functional gains.



BOX 14.1

Fulk GD. Traumatic brain injury. In: O’Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia, PA: F. A. Davis Company; 2007:895–935).

Rancho Los Amigos Brain Injury Severity Scale






































I No Response Completely unresponsive to stimuli
II Generalized Response Inconsistent and nonpurposeful response to stimuli
III Localized Response Specifically, but inconsistently to stimuli
IV Confused-Agitated Behavior is bizarre and nonpurposeful relative to immediate environment
V Confused-Inappropriate Responds to simple commands fairly consistently
VI Confused-Appropriate Goal directed behavior but is dependent on external input or direction
VII Automatic-Appropriate Appears oriented and appropriate within hospital and home setting, goes through routine automatically
VIII Purposeful-Appropriate Recalls and integrates past and recent events, responsive to environment



BOX 14.2

Stages of Motor Learning























Stage Patient Presentation Ideal Environment for Patients in Stage
Cognitive Stage Understanding the task is compromised and task performance has lots of variability Quiet environment, extra time, and external cues
Associative Stage Performance is refined but some errors or variability persist, internal cues from the learner are present Environment can be distracting
Autonomous Stage Performance of tasks achieved with few errors Learning can be assessed formally with standardized measures


From Pohl PS. Motor Learning. Topics in Physical Therapy: Neurology. An APTA Professional Development Home Study Course . APTA; January 2002.



Proper management of patient with co-occurring brain and SCI requires a holistic approach, increased length of stay, and carefully crafted approach to learning. Establishing a patient-centered approach to care, adapting the environment, and the activity based on the patient’s presentation are essential. In addition to these basic alterations, individuals working with an adult population with co-occurring brain and SCI need to be mindful to avoid language that may be perceived as patronizing, such a pet names, slowed speech, overly simplistic sentence structure, etc., to maintain the dignity of the patient and their family. With a comprehensive approach, patients with co-occurring brain and spinal cord injuries can make significant progress toward independence postinjury.




Medical management


Medical treatment for the acute SCI includes anatomical realignment and stabilization interventions, pharmacological management to lessen/prevent further neurological trauma and enhance neural recovery, as well as to support all organ systems affected by this potentially catastrophic event ( Box 14.3 ).



BOX 14.3

Principal Elements for Initial Medical Management of the Patient With Acute Traumatic Spinal Cord Injury , ,





  • Resuscitate (maintain the airway)



  • Immobilize at the scene—Emergency Medical Services (EMS)



  • Rapid transport to the nearest spinal cord injury care facility



  • Maintain airway and maintain mean arterial pressure (MAP)



  • Steroids not recommended—consider steroids ONLY within the first 8 h post injury



  • Radiographical assessment (computed tomography is initial study of choice)



  • Immediate realignment of the spine; closed vs. open reduction



  • Immobilize-external or internal orthosis



  • Maintain MAP perfusion



  • Magnetic resonance imaging for mass lesion, extent of cord injury



  • Operative decompression early. Delay only for medical stabilization




Immobilization/transportation


The injured person should be triaged and immobilized at the accident scene by trained emergency medical personnel and transported to a level one trauma center. Immobilization is recommended for all trauma patients with a cervical spine or SCI or with a mechanism of injury having the potential to cause further damage. Immobilization for persons with penetrating injuries is not recommended due to increased mortality from delays in resuscitation. Additionally, immobilization is not recommended for trauma patients who are awake, alert, not intoxicated, without neck pain, without any abnormal sensory or motor changes, and are without any additional significant associated injuries. Once stabilized, transportation to a specialized SCI treatment center is recommended. ,


Surgical stabilization


In the emergency department, definitive radiological assessment and neurological assessment are the key factors to determine the medical course. Specific diagnostic studies are used to determine the severity, type, and degree of spine instability. Indications for surgical intervention include, but are not limited to, signs of progressive neurological involvement, type and extent of bony lesions, and degree of spinal cord damage.


Cervical spine


In the presence of instability and neurological compromise, surgical stabilization is usually indicated after a thorough radiological and neurological assessment. High-quality computerized tomography (CT) imaging is the recommended radiological assessment. The ISNCSCI examination is the preferred neurological assessment tool. If high-quality CT is not available, routine 3-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended. Common surgical procedures include posterior and anterior approaches or a combination of both. Fig. 14.2 shows radiographs of a person who had an anterior cervical fusion at C3-C4. Unstable compression injuries are usually managed by a posterior procedure except when there is a deficient anterior column. Anterior approaches are indicated for patients with evidence of residual anterior spinal cord or nerve root compression and persistent neurological deficits.




Fig. 14.2


(A) Radiograph of a person who had an anterior cervical fusion at C3-C4. (B) Lateral radiological view of anterior fusion C3-C4.




After cervical surgical stabilization, the use of a cervical orthosis is recommended. Examples of these orthotic devices are Philadelphia collar ( Fig. 14.3 ), Miami collar, sternal-occipital-mandibular immobilizer (SOMI) brace (not pictured), and Aspen collar ( Fig. 14.4 ). These orthotic devices are used until there is radiographical evidence of solid bony fusion, which usually takes 6 to 8 weeks, and/or at the physician’s discretion. When surgery is not indicated but external stabilization is needed to provide immobilization, halo vest immobilization may be used for closed reduction of the cervical spine. , The halo orthotic device restricts more movement in the upper cervical spine compared with the lower cervical spine. The halo device consists of three parts: the ring, the uprights, and the jacket ( Fig. 14.5 ). The ring fits around the skull, just above the ears. It is held in place by four pins that are inserted into the skull. The uprights are attached to the ring and jacket by bolts. The jacket is usually made of polypropylene and lined with sheepskin. This equipment is left in place for up to 12 weeks until bony healing is satisfactory. The advantage of using the halo device is the ability to mobilize the patient as soon as the device has been applied without compromising spinal alignment. This allows the rehabilitation program to commence more rapidly. It also allows for delayed decision making regarding the need for surgery.




Fig. 14.3


Philadelphia Collar.

It is fabricated of polyethylene foam with rigid anterior and posterior plastic strips; it is easily applied via Velcro closures, and it limits flexion, extension, and rotary movements of the cervical spine.



Fig. 14.4


The Aspen collar (formerly known as the Newport collar) encircles the neck, is somewhat open, and provides cervical motion restriction. It is rigid yet flexible at its edges to conform to each patient’s anatomy. Pads and shells are removable and washable.



Fig. 14.5


Halo Orthosis.

Basic components are the halo ring, distraction rods, and jacket (jacket not pictured).


The disadvantage of the halo device is that pressure and friction from the vest or jacket may lead to altered skin integrity. Special attention must be given to ensure the skin remains intact. During more active phases of the rehabilitation process, the halo device may slow functional progress because of added weight and interference with the middle-to-end range of upper-extremity movement. In a small percentage of patients, there are complications of dysphagia and temporomandibular joint dysfunctions associated with wearing the halo device.


It should be noted that cervical traction using Gardner Well Tongs (not pictured) has been used much less in the last 25 to 30 years due to improved surgical techniques but may be indicated when surgery is delayed due to life-threatening trauma in other areas of the body. The reader should be aware that the management of the pediatric SCI patient is more specialized and will not be addressed in this chapter.


Thoracolumbar spine


Thoracic level SCIs account for approximately 35% of all SCI. Internal fixation of the thoracolumbar region is necessary when stability and distraction cannot be maintained by other means. The timing of surgery has been a topic of debate. However, the consensus is that surgery should occur as soon as the patient is hemodynamically and respiratorily stable within the first 24 to 48 hours after the injury. The surgical approach may be either anterior, posterior, or a combination of both based on the patient’s radiological and neurological assessments. A commonly used thoracic stabilization procedure is transpedicular screws ( Fig. 14.6 ). Surgeons may use the Thoracolumbar Injury Classification and Severity Score (TLICS) as well as the American Orthopedic Spine Group recommendations in the decision making process for surgical intervention. ,




Fig. 14.6


Radiograph of Transpedicular Screws.

(Courtesy Dr. H. Herndon Murray, Assistant Medical Director, Shepherd Spinal Center, Atlanta, Georgia.)


The goals of the operative procedures at any spinal level are to reverse the deforming forces by decompression, restore proper spinal alignment, and stabilize the spine. , All these procedures have advantages and disadvantages. The surgeon, patient, and family must be involved in the decision making process to select the most appropriate method of treatment. Assuring spinal stability sets the stage for a successful therapeutic rehabilitation process.


Postoperatively, an external trunk support may be necessary to limit excessive vertebral motion and to maintain proper thoracic and lumbar alignment. This may be achieved by a custom thoracolumbosacral orthosis ( Fig. 14.7 ), Jewett brace ( Fig. 14.8 ), or other appropriate orthotic device at the discretion of the surgeon. Spine precautions may be warranted following surgical intervention to allow for a complete fusion to take place and to minimize the possibility of surgical failure. The use of and specificity of postoperative precautions vary and are surgeon specific.




Fig. 14.7


Custom Thoracolumbosacral Orthosis.

This molded plastic body orthosis has a soft lining. It controls flexion, extension, and rotary movements until healing of the bone has occurred.



Fig. 14.8


Jewett Hyperextension Brace.

A single three-point force system is provided by sternal pad, suprapubic pad, and thoracolumbar pad. Forward flexion is restricted in the thoracolumbar area.


Clinical trials and ongoing research


Much scientific work has been done in an effort to manage the cascade of cellular events following the primary SCI injury. The results of previous large phase II and III landmark investigations , , aimed at neuroprotection , , have been discredited through several meta analyses over the past decade. However, there is some consensus that the use of corticosteroids within the first 8 hours of injury is supported by level III scientific evidence and should be considered in appropriate instances. Knowledge gained from past research has laid the foundation for ongoing investigations. Present research includes but are not limited to studies aimed at neuroprotection, neuroregeneration, spinal cord stimulation, cell-based therapies, and the use of biomaterials ( Table 14.2 ). ,



TABLE 14.2

Summary of Current Topics in Spinal Cord Injury Research Related to Regeneration, Restoration, Recovery, and Neuroprotection (USA)











































































Category Intervention Goal Description Example/Location
Regeneration Biological: autologous human Schwann cells Safety; repair myelin to improve axon function and improve neural plasticity Schwann cells harvested from the sural nerve of the participant will be autologously transplanted into the epicenter of the participant’s spinal cord injury Miami project: Safety of Autologous Human Schwann Cells (ahSC)
Biological: human embryonic stem cells Safety; neurological recovery Use stem cells to promote partial repair of spinal cord tissue Asterias Biotherapeutics: Biological AST-OPC1
Device: neural-spinal scaffold Safety; facilitate repair of the spinal cord An investigational bioresorbable polymer scaffold that is designed for implantation at the site of injury within a spinal cord contusion to provide structural support to the spared spinal tissue and a matrix to facilitate endogenous repair InVivo Therapeutics: Inspire Study for Neuro-Spinal Scaffold
Restoration Device: brain-machine interface Safety of individual and efficacy of electrodes, improve function and restore movement Brain-machine interface (BMI) technology is based on the finding that with intact brain function, neural signals are generated even though they are not sent to the arms, hands, and legs. By implanting electrodes in the brain, individuals can be trained to send neural signals, which are interpreted by a computer and translated to movement University of Pittsburgh, University of Miami
Device: implantable neuroprosthetic Restore grasp and trunk function Network of implantable systems to help increase functional independence Cleveland, Ohio
Drug and device Develop new approaches to restore upper limb function Paired pulse induced spike-timing dependent plasticity (STDP) enhances synaptic strength between residual corticospinal tract (CST) axons and spinal motoneurons (SMNs) resulting in temporary improvements in upper-limb function in humans with incomplete cervical SCI. Motor training will be combined with paired-pulse STDP stimulation to further enhance plasticity and behavioral recovery Veterans Administration Office of Research Drug: Seromycin, Dextromethorphan; Device STDP
Recovery Noninvasive brain stimulation:
(electrical)
Restoration of upper-extremity (UE) function Transcranial direct current stimulation (tDCS) or transcranial pulsed current stimulation (tPCS) provides regional brain polarization for neuromodulation; low voltage to increase brain excitability in order to make brain and nervous system respond to training or with activity Shepherd Center, Burke Medical Research Institute: transcranial pulsed and direct current stimulation (tPCS and tDCS)
Transcutaneous spinal cord stimulation (TSCS) Improve muscle activity and function Transcutaneous electrical stimulation applied over the cervical or thoracic spinal cord to target upper or lower extremities Kennedy Krieger, University of Washington (UE), Shepherd Center (LE)
Epidural spinal cord stimulation , Facilitate volitional movement, stepping Establish the disinhibitory effect of spinal cord stimulation University of Minnesota, University of Louisville
Acute intermittent hypoxia (AIH) Improve lower-extremity (LE) function and walking Subjects breath lower levels of oxygen to trigger a cascade of events in the SC, which improve sensitivity and circuitry necessary for breathing and walking Spaulding Rehabilitation Hospital; AIH
Neuroprotection Drug , Preserve neuro tissue and improve recovery Administered early after injury to help prevention of cell death associated secondary injury that progresses after initial trauma University of Miami, Ohio State University
Diet: Ketogenic Determine if ketogenic diet vs. standard diet significantly improves motor, sensory, and gut function Determine if ketogenic diet (high fat, low carb) can be a neuroprotection against secondary injury cascade University of Birmingham

U.S. National Library of Medicine. Published: January 1, 1993. Updated July 5, 2018. Available at: www.clinicaltrials.gov . Accessed September 4, 2018.




Therapeutic rehabilitation continuum of care


Therapeutic rehabilitation can be effectively delivered beginning in an acute-care setting at the time of injury and continuing on through a lifetime of care. Rehabilitation teams may use one of three models: multidisciplinary, interdisciplinary, and transdisciplinary. The standards set forth by the Commission on Accreditation of Rehabilitation Facilities (CARF) suggest that the interdisciplinary model of team structure is optimal in the rehabilitation setting.


The continuum of care may be divided into several phases that include medical management (previously described), acute care (including the intensive care unit), inpatient rehabilitation, and postacute services (including day program rehabilitation, outpatient rehabilitation, and home health). The continuum also includes returning the patient into wellness programs and community reentry outreach programs. The progression of a patient through the rehabilitation process will vary greatly from one person to the next. The patient may also move back and forth throughout the continuum of care.


Inpatient (acute care and rehabilitation)


Inpatient rehabilitation begins during the critical and acute-care stages after an SCI. The primary emphasis of early rehabilitation is to lessen the adverse effects of neurotrauma and immobilization. This focus may last from a few days to several weeks, depending on the severity and level of injury and other associated injuries. Although therapeutic intensity may be limited, patients may begin participating in early therapy, which should include—but should not be limited to—out-of-bed activities, gaining upright tolerance, range-of-motion (ROM) exercises, early strength training, skin management, and education. Goals during this phase should focus on the prevention of secondary conditions and preparation of the patient for full rehabilitation participation. Discharge planning and caregiver training is initiated by the treatment team in this phase in order to ensure a smooth transition back into the community. Comprehensive discharge planning typically looks at discharge location, supervision or care needs, community resources, circle of support, advocacy, and insurance benefits for postacute referrals.


As the acute phase progresses, out-of-bed activities are tolerated for longer periods of time and the patient begins to work toward specific long-term goals. In accordance with Medicare guidelines for inpatient rehabilitation, the patient is able to participate in therapeutic programs a minimum of 3 hours a day. The intensity of therapy may continue to be limited according to unresolved medical issues. As medical issues resolve and endurance improves, the patient will progress to a higher and more active level of participation. During inpatient rehabilitation, the patient gains varying levels of independence in activities of daily living (ADLs) and functional mobility. Community outings are used to refine advanced skills, identify further needs, and foster community reintegration and participation. Other aspects of rehabilitation during this phase are continuation of caregiver training, home exercise programs, assistive technology (AT) referrals, home and school or work evaluation, driving and dependent passenger evaluations, delivery and fitting of discharge equipment, and referrals for continued services.


Postacute rehabilitation


Postacute rehabilitation and discharge from an inpatient rehabilitation program mark only the beginning of the lifelong process of adjustment to changes in physical abilities, community reintegration, and participation in life activities. Due to the shortened lengths of hospitalization and the reduction of inpatient and outpatient insurance benefits, services provided after discharge are becoming increasingly important. A direct consequence of shorter hospitalization results in patients who have more acuity, greater care needs, and fewer skills attained in the inpatient rehabilitation program before entry into the postacute arena. Services provided after inpatient discharge may include home health services, day program, single-service outpatient therapy visits, wellness programs, and routine follow-up visits and services.


Home health referrals are often selected when home services are needed or when the medical acuity requires ongoing nursing assessment. The benefits of receiving care in the home allow for ADL and mobility training in that specific environment, whereas day program or outpatient therapy typically has more equipment and tools for skill progression. Common day program or outpatient therapy treatment programs have included advanced transfer training, advanced wheelchair skills, locomotor training, progression of ADL, home exercise programs, and finalization of durable medical equipment (DME).


There are a variety of outpatient rehabilitation options for individuals, and depending on the facility, the programs may be described as day program, outpatient therapy, or single-service outpatient therapy visits. One common thread for virtually all outpatient settings is that the patients are medically stable and do not require skilled nursing services during the night. The “day program” concept has emerged to meet the demand for more comprehensive rehabilitation services. The primary purpose of these services is to provide a coordinated effort for the patient to return to full reintegration into the community, with the focus on performance of functional skills, and on the transference of these skills into the community. Other outpatient rehabilitation options are “single-service,” which indicates the patient has goals specific to a single discipline, such as physical therapy, occupational therapy, or speech therapy. Goals within each discipline are met, and there is a lesser degree of coordination of services. Wellness programs have emerged as an option for promotion of lifelong health. Typically, these programs are offered as a self-payment option and may not be tied directly to functional goals related to ADLs or mobility performance.


Regardless of what services the patient is referred for after the inpatient discharge, patients may progress from one option to another or may be appropriate to move in and out of services in a less linear fashion. Each stage of rehabilitation requires an examination of the patient’s body function and structure, activity, participation levels, and personal and environmental factors. This is known as the International Classification of Functioning, Disability and Health (ICF), which is a framework from the World Health Organization.




Examination and evaluation of body function and structure


Regardless of where the patient begins the rehabilitation process, an examination is completed on admission. The examination and evaluation will assist in establishing the diagnosis and the prognosis of each patient as well as determining the appropriate therapeutic interventions. The patient and caregivers participate by reporting activity performance and functional ability. , Any pertinent additions to the history stated by the patient should be described. The patient’s statement of goals, problems, and concerns should be included. The main areas of the examination are outlined here.


History


The history should include general demographics, social history, occupation and employment status, pertinent growth and development, living environment, health history and history of current condition, functional status and activity level, completed tests and measures, medications, family history, reported patient and family health status, and social habits. Reviewing the medical chart is a vital step and should be conducted prior to hands on examination. If the history suggests a loss of consciousness or brain injury, the clinician should consider the possibility of compromised cognition and should include appropriate tests and measures during the examination.


Systems review


The physiological and anatomical status should be reviewed for the cardiopulmonary, integumentary, musculoskeletal, and neuromuscular systems. In addition, communication, affect, cognition, language, and learning style should be reviewed.


Tests and measures


Depending on the data generated during the history and systems review, the clinician performs tests and measures to help identify impairments, activity limitations, and participation restrictions as well as to establish the diagnosis and prognosis of each patient. Tests and measures that are often used for persons with SCI are included in Box 14.4 . For more detail related to specific tools, refer to the Guide to Physical Therapist Practice ( http://www.apta.org/Guide/ ) , ANPT Outcome Measures Recommendations (EDGE), Rehab Measures Database, or Spinal Cord Injury Rehab Evidence (SCIRE).



BOX 14.4

Tests and Measures


Body system and structure





  • Aerobic capacity and endurance



  • Anthropometric characteristics



  • Circulation (arterial, venous, lymphatic)



  • Cognitive functioning



  • Integumentary integrity



  • Joint integrity and mobility



  • Motor function



  • Muscle performance, including abnormal muscle tone



  • Neurological examination, including cranial and peripheral nerve integrity



  • Orthotic, protective, and supportive devices



  • Pain



  • Skeletal integrity and posture



  • Range of motion



  • Reflex integrity



  • Sensory integrity



  • Ventilation and respiration



  • Diagnosis of impairment and disabilities



Activity or participation





  • Assistive and adaptive devices assessment



  • Community, social, and civic life (including educational level and work/school status)



  • Environmental barriers



  • Gait, locomotion, and balance



  • Self-care, domestic life, and home management




Neurological examination


American spinal cord injury association examination


It is recommended that the ISNCSI be used for the specific neurological examination after an SCI. See Fig. 14.9 for the ASIA motor and sensory examination form. Assessment of muscle performance allows for specific diagnosis of the level and completeness of injury. The examination of muscle performance includes each specific muscle and identifies substitutions from other muscles.




Fig. 14.9


American Spinal Injury Association Motor and Sensory Evaluation Form.




Along with the strength of each muscle, the presence, absence, and location of muscle tone should be described. The Modified Ashworth Scale is a common tool used to describe hypertonicity. , The patient’s sensation is described by dermatome. The recommended tests include (1) sharp-dull discrimination or temperature sensitivity to test the lateral spinothalamic tract, (2) light touch to test the anterior spinothalamic tract, and (3) proprioception or vibration to test the posterior columns of the spinal cord. Sensation is indicated as intact, impaired, or absent per dermatome. A dermatomal map is helpful and recommended for ease of documentation.




Functional examination for activity


It is recommended that a complete functional assessment is performed on initial examination and thereafter, in order to document progress. A myriad of standardized tools exists to assess functional skills that address home, community, and institutional mobility and ADL functional skills. The Functional Independence Measure (FIM) is one of the more commonly used tools that is currently applied for many impairment diagnostic groups, including SCI. Another tool that is recognized as a primary outcome measure to assess functional recovery for the patient with SCI is the Spinal Cord Injury Independence Measure III (SCIM III). This tool was specifically designed for the functional assessment of individuals with SCI. The SCIM III has been shown to be valid, reliable, and easily administered. Other tools, such as the Quadriplegia Index of Function (QIF) and the Craig Handicap Assessment and Reporting Technique (CHART), are options. Additional assessments for patients with SCI are described in Table 14.3 .



TABLE 14.3

Assessment of Function Summary

























































Overall Functional Assessments Description
Spinal Cord Injury (SCI) Functional Assessments
Spinal Cord Injury Independence Measure (SCIM) Designed for the functional assessment of individuals with spinal cord injury in the categories of self-care, respiratory, sphincter management, and mobility skills
Quadriplegia Index of Function (QIF) Assesses function for individuals with tetraplegia in the categories of transfers, grooming, bathing, feeding, dressing, wheelchair mobility, bed activities, bowel, bladder, and knowledge of personal care
Capabilities of upper extremity (CUE) instrument Assesses the action of grasp, release, and reaching in individuals with tetraplegia by measuring reaching and lifting, pulling and pushing, wrist action, hand and finger actions, and bilateral action
Walking Function Assessments
Spinal cord injury functional ambulation inventory (SCI-FAI) Observational gait assessment that assesses gait, assistive device use, and walking mobility
Walking Index for Spinal Cord Injury (WISCI) An ordinal scale describing walking function that takes into consideration level of independence, assistive device use, and lower-extremity orthotic use
Six-minute walk test An endurance walking test that measures the distance walked over a 6-min period of time
Ten-meter walk test Measures walking speed by measuring how fast an individual walks a distance of 10 m
Timed Up-and-Go Test Assesses standing, walking, turning, and sitting
Wheelchair Function Assessments
Wheelchair circuit Assesses the performance of various wheelchair propulsion skills by measuring ability, performance time, and physical strain for eight standardized skills
Wheelchair assessment tool Measures the ability and time to perform 6 mobility and wheelchair skills for individuals with paraplegia
Wheelchair skills test Assesses the ability to perform 50 separate skills in the areas of wheelchair handling, transfers, maneuvering the wheelchair, and negotiating obstacles
Obstacle course assessment of wheelchair user performance Assesses the wheelchair user’s performance in 10 difficult environmental situations
Wheelchair users functional assessment (WUFA) A 13-item assessment of wheelchair skills in individuals who primarily use a manual wheelchair for their mobility
Wheelchair physical functional performance (WC-PFP) Assesses the ability to complete various tasks from the wheelchair by measuring upper body strength, upper body flexibility, balance, coordination, and endurance
Functional evaluation in a wheelchair Assesses functional performance from a manual and/or power wheelchair via a self-administered questionnaire




Goal setting for activity and participation skills


Goal setting is a dynamic process that directly follows the examination. Each activity limitation identified should be addressed with specific short- and long-term goals. The clinician must interpret new information continuously, which leads to continuing reevaluation and revision of goals. Goals should always be individualized and directed by the patient and should be established in collaboration with the treatment team, the patient, and the caregiver, along with realistic consideration of anticipated needs on return to the home environment. Factors to consider in the goal-setting process include age, body type, associated injuries, premorbid medical conditions, additional orthopedic injury, cognitive ability, psychosocial issues, spasticity, endurance, strength, ROM, funding sources, family and social roles, work and school status, and level of participation or motivation.


Long-term goals for the rehabilitation of patients with SCI reflect functional outcomes and are based on the strength of the remaining innervated or partially innervated musculature. Short-term goals identify components that interfere with functional ability and are designed to “address these limiting factors while building component skills” of the desired long-term goals.


Functionally based goals are established in the following areas: bathing, bed mobility, bladder and bowel control, communication, environmental control and access, feeding, dressing, gait, grooming, home management, ROM and positioning, skin care management, transfers, transportation and driving, wheelchair management, and wheelchair mobility. Refer to Table 14.4 for anticipated goals for each level of injury. Information presented in this table should be recognized as general guidelines because variability exists. These guidelines are most usefully applied to patients with complete SCI. Goal setting for individuals with incomplete SCI is often more challenging, given the greater variability of patient presentations and the uncertainty of neurological recovery. As with any patient, continual reevaluations provide additional insight into functional limitations, progression, and potential, thereby directing the goal-setting process. In addition to specific functional goals and expectations, other factors impacting goals should be considered, such as caregiver training, home, work, or school modifications, and community reentry.



TABLE 14.4

Functional Expectations for Complete Spinal Cord Injury Lesions










































































































































































































































































































































































Functional Component Outcome Potential Anticipated Equipment to Achieve Outcomes
C1-4



  • Sitting tolerance




  • 80–90 degrees for 10–12 h per day




  • Power wheelchair with power tilt, recline



  • Wheelchair cushion




  • Communication





  • Mouth stick writing




    • ECU



    • Page turning



    • Computer operation



    • Call-system use



    • Cuff-leak speech (ventilator dependent)





  • Minimal assistance



  • Setup



  • Minimal assistance to setup



  • Minimal assistance to setup



  • Setup



  • Up to 6 h




  • Mouth sticks and docking station



  • ECU



  • Book holder



  • Computer



  • Call system or speaker phone




  • Feeding




  • Dependent, but verbalizes care




  • Grooming




  • Dependent, but verbalizes care




  • Bathing




  • Dependent, but verbalizes care




  • Reclining shower chair




  • Dressing




  • Dependent, but verbalizes care




  • Bowel management




  • Dependent, but verbalizes care




  • Bladder management




  • Dependent, but verbalizes care




  • Bed mobility




    • Rolling side to side



    • Rolling



    • Supine, prone



    • Supine to and from sitting



    • Scooting



    • Leg management





  • Dependent, but verbalizes care




  • Four-way adjustable hospital bed to assist caregiver with task




  • Transfers




    • Bed



    • Tub, toilet



    • Car



    • Floor





  • Dependent, but verbalizes care




  • Overhead lift system



  • Hydraulic lift



  • Slings




  • Power wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs





  • Modified independent



  • Modified independent



  • Modified independent



  • Dependent, but verbalizes




  • Power wheelchair with power recline or tilt system



  • Lap tray



  • Armrests, shoulder supports, and lateral trunk supports




  • Manual wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs



    • Stairs





  • Dependent, but verbalizes




  • Manual reclining or tilt wheelchair with same options as power wheelchair




  • Skin




    • Weight shift



    • Padding, positioning



    • Skin checks





  • Modified independent with power wheelchair



  • Dependent, but verbalizes



  • Dependent, but verbalizes




  • Recline or tilt wheelchair



  • Wheelchair cushion



  • Pillow splints, resting splints



  • Mirror




  • Community: ADL-dependent passenger evaluation




  • Dependent, but verbalizes




  • Modified van




  • ROM exercises to scapula, upper extremity, lower extremity, and trunk




  • Dependent, but verbalizes




  • Exercise program




  • Independent for respiratory and neck exercises




  • Portable or bedside ventilator (C1-3 only)

C5



  • Sitting tolerance




  • 90 degrees for 10–12 h per day




  • Power recline or tilt wheelchair



  • Wheelchair cushion




  • Communication




    • Telephone use



    • ECU



    • Page turning



    • Computer operation



    • Writing, typing





  • Modified independent



  • Setup



  • Setup



  • Supervision



  • Setup




  • Telephone adaptations



  • ECU



  • Book holder, wrist support with cuff



  • Computer



  • Long Wanchik brace




  • Feeding




  • Minimal assist to setup




  • Mobile arm support



  • Adaptive ADL equipment




  • Grooming




    • Wash face



    • Comb or brush hair



    • Oral care





  • Minimal assistance to setup



  • Minimal assistance



  • Minimal assistance to setup




  • Mobile arm support



  • Wrist support with adapted cuff



  • Adaptive ADL equipment




  • Bathing




  • Dependent, but verbalizes care




  • Upright or tilt shower chair




  • Dressing




  • Dependent, but verbalizes care




  • Bowel management




  • Dependent, but verbalizes care




  • Bladder management




  • Dependent, but verbalizes care




  • Automatic leg bag emptier




  • Bed mobility




    • Rolling side to side



    • Rolling



    • Supine, prone



    • Supine to and from sitting



    • Scooting



    • Leg management





  • Dependent to maximal assistance




  • Four-way adjustable hospital bed to assist caregiver with care




  • Transfers




    • Bed



    • Tub, toilet



    • Car



    • Floor





  • Dependent to maximal assistance for level transfers, verbalizes unlevel transfers




  • Overhead or hydraulic lift and slings



  • Possible transfer board




  • Power wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs





  • Recommended mode of locomotion



  • Modified independent



  • Modified independent



  • Modified independent



  • Dependent, but verbalizes




  • Power wheelchair with power recline or tilt system



  • Recommend lap tray



  • Armrests, shoulder supports, and lateral trunk supports




  • Manual wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs



    • Stairs





  • Dependent to minimal assistance for short distances on smooth surface



  • Dependent, but verbalizes care



  • Dependent, but verbalizes care



  • Dependent, but verbalizes care



  • Dependent, but verbalizes care




  • Upright or reclining wheelchair with special back and trunk supports



  • Consider manual wheelchair with power assist pushrims




  • Skin




    • Weight shift






  • Padding, positioning



  • Skin checks




  • Modified independent with power wheelchair



  • Maximal assistance to dependent with manual wheelchair



  • Dependent, but verbalizes



  • Dependent, but verbalizes




  • Recline or tilt wheelchair and wheelchair cushion



  • Pillow splints or resting splints



  • Mirror




  • Home management




    • Prepare snack





  • Maximal to moderate assistance




  • Wrist support with cuffs



  • Adaptive ADL equipment




  • Community ADL




    • Drive van



    • Dependent passenger evaluation





  • Independent



  • Dependent




  • Highly adapted vehicle



  • Modified van




  • ROM exercises to scapula, upper extremity, lower extremity, and trunk




  • Dependent, but verbalizes




  • Exercise program




  • Airsplints or light cuff weights




  • Upper extremity and neck




  • Minimal assistance




  • E-stim unit

C6



  • Sitting tolerance




  • 90 degrees for 10–12 h per day




  • Communication




    • Telephone use



    • Page turning



    • Writing, typing, keyboard





  • Modified independent




  • Adaptive ADL equipment



  • Tenodesis splint



  • Short opponens splint




  • Feeding




  • Modified independent




  • Adaptive ADL equipment




  • Grooming




  • Minimum assistance to modified independent




  • Adaptive ADL equipment



  • Tenodesis splint




  • Bathing




    • Upper body



    • Lower body





  • Minimal to modified independent assistance



  • Moderate assistance




  • Upright shower chair



  • Various bathing equipment




  • Dressing




    • Upper body



    • Lower body (bed)





  • Modified independent



  • Maximum to minimal assistance




  • Adaptive ADL equipment




  • Bowel management




  • Maximum to modified independent




  • Dil stick



  • Adaptive ADL equipment




  • Bladder management




  • Male: moderate assistance to modified independent



  • Female: moderate assistance to dependent




  • Tenodesis



  • Adaptive ADL equipment




  • Bed mobility




    • Rolling side to side



    • Rolling



    • Supine, prone



    • Supine to and from sitting



    • Scooting



    • Leg management





  • Independent to minimal assistance



  • Minimum assistance to dependent




  • Four-way adjustable hospital bed or regular bed with loops or straps; or no equipment




  • Transfers




    • Bed



    • Tub, toilet



    • Car



    • Floor





  • Minimal assistance



  • Moderate assistance



  • Maximal to moderate assistance



  • Dependent, but verbalizes procedure




  • Transfer board




  • Power wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs





  • Recommended mode of locomotion



  • Modified independent



  • Modified independent



  • Modified independent



  • Dependent, but verbalizes




  • Power upright wheelchair for weak C6




  • Manual wheelchair mobility



  • Smooth surfaces



  • Ramps



  • Rough terrain



  • Curbs



  • Stairs




  • Modified independent



  • Modified independent



  • Moderate to minimal assistance



  • Dependent, but verbalizes procedure



  • Dependent, but verbalizes procedure




  • Ultralight upright wheelchair (recommended as primary only if scapulae grades are 3 or better)



  • May need adaptations to facilitate more efficient propulsion (i.e., push pegs and plastic-coated handrims)



  • Consider manual wheelchair with power assist pushrims




  • Skin




    • Weight shift



    • Pad, positioning



    • Skin checks





  • Modified independent



  • Moderate to minimal assistance



  • Moderate to minimal assistance




  • Upright wheelchair with push handles



  • Mirror




  • Home management




    • Light home management



    • Heavy home management





  • Minimal assistance



  • Dependent to moderate assistance




  • Various adaptive ADL equipment




  • Community ADL




    • Driving vehicle





  • Modified independent




  • Modified vehicle




  • ROM exercises to scapula, upper extremity, lower extremity, and trunk




  • Minimal assistance




  • Leg lifter to assist with lower-extremity ROM




  • Exercise program




  • Minimal assistance




  • Cuff weights



  • Air splints



  • E-stim unit

C7-8



  • Sitting tolerance




  • 90 degrees for 10–12 h per day




  • Communication




    • Telephone use



    • Page turning



    • Writing, typing, keyboard





  • Modified independent




  • Adaptive ADL equipment




  • Feeding




  • Modified independent




  • Adaptive ADL equipment




  • Grooming




  • Modified independent




  • Adaptive ADL equipment




  • Bathing




    • Upper body



    • Lower body





  • Modified independent



  • Modified independent




  • Upright shower chair



  • Various bathing equipment




  • Dressing (upper and lower body)




    • In bed



    • In wheelchair





  • Modified independent for upper-body dressing



  • Minimal assistance to modified independent for lower-body dressing




  • Adaptive ADL equipment




  • Bowel management




  • Modified independent




  • Dil stick




  • Bladder management




    • Bed



    • Wheelchair





  • Male: modified independent



  • Female: moderate assistance to modified independent



  • Male: modified independent




  • Various bladder management or adaptive ADL equipment




  • Bed mobility




    • Rolling side to side



    • Rolling



    • Supine, prone



    • Supine to and from sitting



    • Scooting



    • Leg management





  • Modified independent




  • Leg lifter




  • Transfers




    • Bed



    • Tub, toilet



    • Car



    • Floor





  • Modified independent



  • Modified independent



  • Minimal assistance for loading wheelchair



  • Maximal assistance




  • Transfer board



  • May not need transfer board for even surfaces




  • Power wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs





  • Modified independent



  • Modified independent



  • Modified independent



  • Dependent, but verbalizes




  • Power upright wheelchair




  • Manual wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs



    • Stairs





  • Modified independent



  • Modified independent



  • Modified independent



  • Minimal to moderate assistance



  • Maximal assistance




  • Upright wheelchair




  • Skin




    • Weight shift



    • Pad, positioning



    • Skin checks





  • Modified independent



  • Minimal assistance to modified independent



  • Minimal assistance to modified independent




  • Upright wheelchair with push handles



  • Mirror




  • Home management




    • Light home management



    • Heavy home management





  • Modified independent



  • Moderate assistance




  • Various ADL equipment




  • Community ADL




    • Driving vehicle





  • Modified independent




  • Modified vehicle




  • ROM exercises to scapula, upper extremity, lower extremity, and trunk




  • Modified independent




  • Leg lifter to assist with lower-extremity ROM




  • Exercise program




  • Modified independent




  • Cuff weights or e-stim unit

Paraplegia



  • Sitting tolerance




  • 90 degrees for 10–12 h per day




  • Communication




  • Independent




  • Feeding




  • Independent




  • Grooming




  • Independent




  • Bathing




    • Upper body



    • Lower body





  • Independent



  • Modified independent




  • Upright tub chair



  • Long-handled sponge and hand-held shower hose




  • Dressing (upper and lower body)



  • In bed



  • In wheelchair




  • Adaptive ADL equipment



  • Modified independent



  • Modified independent




  • Bowel management




  • Modified independent




  • Dil stick if positive bulbocavernous reflex




  • Suppositories if negative bulbocavernous reflex




  • Bladder management




  • Modified independent




  • Bed mobility




    • Rolling side to side



    • Rolling



    • Supine, prone



    • Supine to and from sitting



    • Scooting



    • Leg management





  • Modified independent




  • Transfers




    • Bed



    • Tub, toilet



    • Car



    • Floor



    • Upright wheelchair





  • Modified independent




  • May need a transfer board




  • Manual wheelchair mobility




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs



    • Stairs (three or four)





  • Modified independent



  • Moderate assistance to modified independent




  • Upright wheelchair




  • Ambulation




    • Smooth surfaces



    • Ramps



    • Rough terrain



    • Curbs



    • Stairs





  • Depends on level of injury



  • Modified independent for T12 injuries and below



  • Will vary with higher thoracic injuries




  • Appropriate orthotics and assistive device(s)




  • Skin




    • Weight shift



    • Pad, positioning



    • Skin checks





  • Modified independent




  • Mirror




  • Home management




    • Light home management



    • Heavy home management





  • Modified independent



  • Modified independent




  • Various adaptive ADL equipment




  • Community ADL




    • Driving vehicle





  • Modified independent




  • Hand controls for vehicle




  • ROM exercises to left extremity and trunk




  • Modified independent




  • Leg lifter to assist with lower-extremity ROM




  • Exercise program




  • Modified independent




  • Cuff weights and e-stim if any weakened lower-extremity muscles


ADL , Activity of daily living; ECU , environmental control unit; ROM , range of motion.


Rehabilitation teams may elect to hold a goal-setting or interim conference for each patient, during which team members, including the patient, have the opportunity to discuss the long-term goals that have been established. It may be useful to request that the patient sign a statement acknowledging his or her understanding of, and agreement to, all long-term goals.




Early rehabilitation and complication prevention


Early rehabilitation of the patient with SCI begins with prevention. Of individuals living with SCI, 70% will have at least one complication or secondary condition (nonneurological) during their inpatient rehab stay; those with high cervical injuries (C1-4) are 2.2-times more likely to have at least one. Preventing secondary conditions speeds entry into the rehabilitation phase and improves the possibility that the patient will become a productive member of society.


Table 14.5 describes an overview of the primary complications that can arise after an SCI. In this table, known causes and common management activities are reviewed. Tests and measures commonly used to determine the complication and the recommended medical and/or therapeutic interventions are listed in the table. Although various reports of incidences are published, the largest database is the Model Spinal Cord Injury Care Systems report. Because of their high incidence and potential effect on long-term outcomes, the following conditions require further discussion: skin compromise, loss of ROM or joint contractures, respiratory compromise after SCI, and urinary tract infections (UTIs).



TABLE 14.5

Complications After Spinal Cord Injury






























































































































































Complication Cause Diagnostic Tests and Measures Medical Treatment or Intervention Therapeutic Intervention
Cardiopulmonary
Pneumonia Atelectasis Bacterial or viral infection, prolonged immobilization, prolonged artificial ventilation, and general anesthesia Radiographical studies and diagnostic bronchoscopy Antibiotics, bronchodilator therapy, therapeutic bronchoscopy, suctioning Chest physical therapy: percussion, vibration, postural drainage, mobilization, and inspiratory breathing exercises
Ventilatory failure Weakness or paralysis of the inspiratory muscles and unchecked bronchospasm Pulmonary function tests (PFTs), arterial blood gases (ABGs), end-tidal CO 2 monitoring, and pulse oximetry Artificial ventilation and supportive therapy, management of underlying cause (e.g., pneumonia), and oxygen therapy Airway and secretion management treatment as above, early mobilization once stabilized, and biofeedback to assist with ventilator weaning as appropriate
Venous thromboembolism, including deep vein thrombosis (DVT) a Venous stasis, activation of blood coagulation, pressure on immobilized lower extremity, and endothelial damage , Doppler studies, leg measurements, extremity visual observation and palpation, and low-grade fever of unknown origin Subcutaneous heparin ,
Prophylactic anticoagulation can decrease incidence to 1.3% ,
Vena cava filter for failed anticoagulant prophylaxis
Early mobilization and range of motion (ROM) for prevention, centripetal massage for prevention, compression garments, education about smoking cessation, weight loss, and exercise; avoid constricting garments and monitor overly tight leg bag straps and pressure garments (PVA 2016)
Pulmonary embolus Dislodging of DVT Ventilation-perfusion lung scan, signs and symptoms, including chest pain, breathlessness, apprehension, fever, and cough Vena cava filter
Anticoagulation therapy
None
Orthostatic hypotension Vasodilation and decreased venous return and loss of muscle pump action in dependent lower extremities and trunk Monitor blood pressure with activity and changes in position and observation for signs and symptoms Medications to increase blood pressure and fluids in the presence of hypovolemia Gradient compression garments: Ace wraps, abdominal binders, and appropriate wheelchair selection to prevent rapid changes in position early in rehabilitation
Apneic bradycardia True origin unknown; believed to be caused by sympathetic disruption resulting in vagal dominance in response to a noxious stimulus or hypoxia , Electrocardiogram
Heart rate
Respiratory rate
Hyperventilation Remove noxious stimulus
Integumentary System
Pressure injury Prolonged external skin pressure exceeding the average arterial or capillary pressure Wound measurements, staging classification, and nutritional assessment Nutritional support as needed, surgical or enzymatic debridement, surgical closure, muscle flap, skin flap or graft, and antibiotics as appropriate Irrigation and hydrotherapy, dressing management, and electrotherapy
Shearing Stretching and tearing of the blood vessels that pass between the layers of the skin See pressure injury See pressure injury Add protective padding during functional activities, skill perfection, and correct handling techniques
Moisture Excessive sweating below the level of injury, urinary and bowel incontinence, and poor hygiene See pressure injury See pressure injury, treat possible urinary tract infection, and medications for bladder incontinence Protective barrier ointments and powders establish effective bowel and bladder programs, educate for improved hygiene, and refine activity of daily living (ADL) skills
Neuromuscular and Musculoskeletal
Spasticity Upper motor neuron lesion
Deep tendon reflex spasticity scale evaluation
Ashworth or Modified Ashworth Scale
Baclofen pump insertion
Antispastic pharmacological agents: baclofen, diazepam (Valium), dantrolene
Surgical intervention: myelotomy, rhizotomy, peripheral neurotomy
Botox injection
Prolonged stretching; inhibitive positioning or casting
Cryotherapy, weight-bearing exercise, and aquatic therapy
Flaccidity Lower motor neuron lesion. Most often in injuries at L1 level and below Deep tendon reflexes (would be absent) None None for treating flaccidity; however, secondary treatments that need to be considered include positioning to improve postural support, education for skin protection, and bracing and splinting to maintain joint integrity
Autonomic dysreflexia Triggering of an uncontrolled hyperactive response from the sympathetic nervous system by a noxious stimulus; noxious stimuli may include bowel or bladder distention, urinary tract infection, ingrown toenail, tight clothing, and pressure sore Sudden rise in systolic blood pressure of 20-40 mm Hg above baseline observation of signs and symptoms:
Sweating above level of injury
Goosebumps
Severe headache
Flushing of skin from vasodilation above level of injury ,
Catheterization of the bladder, irrigation of indwelling catheter, pharmacological management if systolic blood pressure is greater than 150 mm Hg
Remove ingrown toenail if present
Immediately position the patient in upright position, identify and remove noxious stimuli, check clothing and catheter tubing for constriction, and perform bowel program if fecal impaction is suspected
Contractures Muscle imbalance around joint; prolonged immobilization, unchecked spasticity, pain Goniometric measurements Tendon release; Botox injection for isolated spasticity ROM functional use of extremity, casting or splinting, achieving and maintaining optimal postural alignment
Heterotopic ossification (HO) Unknown Alkaline phosphatase levels (increase after 6 weeks) , ; observation for sudden loss of ROM, local edema, heat, erythema, and nonseptic fever Etidronate disodium (Didronel): use prophylactically or during inflammatory stage
Surgical resection
Maintain available ROM; avoid vigorous stretching during inflammatory stage; and achieve and maintain optimal wheelchair positioning
Osteoporosis and joint changes degenerative Bone demineralization Bone scan None; calcium supplement for prevention Weight-bearing techniques: amount and type unknown, specific to spinal cord injury
Spinal deformities Muscle imbalance or weakness around spinal column; poor postural support; and asymmetrical functional activities Posture evaluation and seating evaluation If severe: surgical fixation and thoracic orthosis Restore postural alignment, avoid repetitive asymmetrical activities, and control spasticity
Genitourinary and Gastrointestinal
Urinary tract infections Presence of excessive bacteria in urine Urinalysis, urine culture and sensitivity, temperature Antibiotics Monitor fluid intake and educate for proper technique during bladder care
Gastroduodenal ulcers, gastrointestinal bleeding Acute: disruption of central nervous system, abdominal trauma or stress response to neuroendocrine system
Chronic: impairment of autonomic nervous system
Hematocrit and hemoglobin; observation of gastrointestinal fluids Surgical intervention; restore normal gastrointestinal function Establish effective bowel program, establish high-fiber diet, and provide education and stress management
Neurogenic bowel Refer to bowel management section Positive bulbocavernosus reflex: indicates reflexic bowel Oral laxative, suppositories, and enemas Establish comprehensive bowel program
Other
Thermoregulation problems Interruption between communication with autonomic nervous system and hypothalamus
Lack of vasoconstriction and inability to shiver or perspire61
Body temperature Cooling or warming blanket if extreme Education about risk and proper protection from elements; behavior modification, and education for proper hydration and appropriate clothing
Pain Radicular pain originating from the injury, kinematic or mechanical pain, direct trauma, and referred pain , Pain scales, functional assessment, and taxonomy Immobilization and rest, pain medications, injections for pain, or antiinflammatory measures Restore ideal alignment and posture, thermal modalities and electromodalities, manual therapy as well as improve movement patterns
Edema Dependent position of extremity with loss of muscle pump; venous insufficiency; IV infiltrate; lymphatic system overload; trauma i.e., fracture; and systemic edema i.e., organ failure Rule out VTE; circumferential measurements; volumeter; pitting scale Medications to increase fluid return; review of medications contributing to edema Elevation of extremity above heart; gradient compression garments; and complete decongestive therapy (CDT) with certified lymphedema therapist
Cardiometabolic
Syndrome (exists when 3 of the following risk factors present): central obesity, hypertriglyceridemia, low-plasma high-density lipoprotein cholesterol (HDL-C), hypertension, and fasting hyperglycemia
Decrease in physical activity, hypercaloric diet, and changes in metabolism Screen for metabolic syndrome:
• Waist circumference
• Lipid profile
• Plasma glucose
• Blood pressure
Prescription medications exist to treat hyperglycemia, hypertension, dyslipidemia, and obesity Lifestyle interventions including diet, exercise, behavioral modifications, smoking cessation, and nutritional counseling

a Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury. Washington, D.C., 2016, Paralyzed Veterans of America. b Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Neurogenic Bowel Management in Adults with Spinal Cord Injury. Washington, D.C., March 1998, Paralyzed Veterans of America.



Preventing and managing pressure injury and skin compromise


After SCI and during the period of spinal shock, patients are at greater risk for the development of pressure injury. The use of backboards at the emergency scene and during radiographic procedures contributes to potential skin compromise; therefore immediate concern for tissue death, especially at the sacrum, should be taken into account. Recently, padded spine boards have become available and are recommended to reduce the risk of skin complications. In addition to this immediate risk factor of immobility associated with severe injury, completeness of injury and age can increase the risk of pressure injury , ; some studies show a relationship between pneumonia and the incidence of skin compromise.


Preventive skin care begins with careful inspection and a risk assessment. , Soft tissue areas over a bony prominence are at greatest risk for acquiring a pressure sore. , Key areas to evaluate include the sacrum, ischia, greater trochanters, heels, malleoli, knees, occiput, scapulae, elbows, and prominent spinous processes. A turning schedule should be initiated immediately. Even if the patient has unstable fractures or is in traction, he or she can be turned and positioned with flat pillows using the logroll technique. Even small changes off the sacrum and coccyx are helpful. The patient’s position in bed should be initially established for turns to occur at least every 2 hours. This interval can be gradually increased to 6 hours with careful monitoring for evidence of skin compromise. A reddened round area over the bone that does not disappear after 15 to 30 minutes is the hallmark start of a pressure sore, and action to avoid or minimize pressure in the area must be taken immediately to avoid progression. Turning positions include prone, supine, right and left side-lying, semi prone, and semi supine positions. Secondary injuries such as fractures and the presence of vital equipment, such as ventilator tubing, chest tubes, and arterial lines, should be considered when choosing turning positions. The prone position is the safest position for maintaining skin integrity but may not always be feasible. Additionally, skin integrity and body type should be considered. Someone with fragile skin may require more frequent turns or weight shifts; an obese individual with excess skin folds may be at risk for moisture buildup, whereas someone with little soft tissue may have increased pressure on bony areas. A history of smoking or diabetes are other examples that impact skin health. ,


Pillows or rectangular foam pads may be used to bridge off the bony prominences and relieve potential pressure. This is especially helpful above the heels. Padding directly over a prominent area with a firm pillow or pad may only increase pressure and should be avoided. Great care should be taken for regular checks if this bridging technique is used in the trunk or buttocks region while the patient is in bed, owing to eventual shifting of the foam. In the presence of an open wound cutouts and donut-type cushions should be avoided, as the edges of the cushion would increase pressure on the already compromised area.


Keeping the head of the bed as low as tolerated minimizes the risk for shearing and excessive sacral pressure. For individuals not able to turn themselves, or who are not appropriate for rigorous turning schedules (e.g., patients with unstable fractures), an active support surface such as an alternating pressure mattress is recommended. Low air loss, alternating pressure, or even air-fluidized mattresses are available for those who require the head of the bed to be elevated more than 30 degrees for prolonged periods and have other extenuating conditions such as multiple wounds, recent skin flap surgery, respiratory distress, diabetes, and/or low prealbumin.


While the patient is sitting, a customized seating system with appropriate pressure redistribution (relief) cushion is ideal to provide optimal postural support while preventing increased areas of pressure. Wheelchair footrest height should be assessed, as increased footrest height can lead to increased pressure under the ischial tuberosities ; a pressure relief (weight shift) schedule should be established and strictly enforced. Bathroom equipment also should be appropriately padded, and the patient should be able to perform weight shifts. To encourage compliance with weight shifts, options such as using timers, personal technology devices, and patient education on the need for weight shift schedules are utilized.


Although pressure is one of the most prevalent causes of skin compromise, other forces may lead to problems, including friction, shearing, excessive moisture or dryness, infection, and bruising or bumping during activities. This is especially true of patients with SCI because of altered thermoregulation, changes in mobility, decreased or absent sensation, and incontinence of bowel and bladder. In addition, as patients begin to learn functional skills, they may have poor motor control and impaired balance, and must be carefully monitored to avoid injury. Other SCI-related considerations for risk are incontinence, as it may cause moisture buildup on the skin; nutrition, as adequate fluid and nutrition is needed to maintain skin health; and vascular integrity, as blood flow also impacts skin health. When making recommendations for equipment that a spinal cord injured individual needs, skin integrity, appropriate pressure relief, and reduction of heat and moisture should always be considered. ,


Should skin compromise occur, the first intervention is to identify and remove the source of the compromise. Modifications to the seating system or changing to a more pressure-reducing mattress system or cushion may be necessary. Examination and treatment will then need to focus on healing the wound and preventing other secondary conditions that may occur as a result of potential immobility and delayed physical rehabilitation. The reader is encouraged to refer to The National Pressure Ulcer Advisory Panel for educational and clinical resources.


Treatment interventions may include hydrotherapy, specialty wound dressings, electro-modalities, and thermal modalities to increase circulation. , Mechanical, autolytic, enzymatic, or surgical debridement may be necessary to obtain and maintain a viable wound bed. If the wound does not heal, surgical interventions with myocutaneous or muscle flaps may be necessary for closure. Coordinated return-to-sit programs or protocols after such medical interventions are necessary to prevent opening of the surgical site. Such surgical procedures are costly and significantly delay functional rehabilitation.


After closure and healing of the wound, education becomes a priority to maintain skin integrity. The patient must adhere to a more rigorous skin check program as rehabilitation continues, giving special attention to the affected area. Education for a nutritious diet and teaching patients to advocate for themselves is critical. Problem-solving equipment and lifestyle issues that may affect their skin condition will reduce the recurrence rate. Alcohol, tobacco, and drug use (both recreational and prescription) should be managed for long-term success. Prevention of skin compromise is critical and cannot be stressed enough to health care providers, patients, and caregivers.


Prevention and management of joint contractures


The development of a contracture may result in postural misalignment or impede potential function. Daily ROM exercises, proper positioning, and adequate spasticity management may help prevent contractures. Contracture prevention includes the use of splints ( Fig. 14.64 ) for proper joint alignment, techniques such as weight bearing, ADLs, and functional exercises. Patients exhibiting spasticity may require more frequent ROM intervention.




Fig. 14.64


A volar based forearm thumb spica splint can help maintain soft-tissue length and thumb integrity while providing the user with the ability to complete fine motor tasks with digits II-IV.


Adaptive shortening or adaptive lengthening of muscles


Although isolated joint ROM should be normal for all patients, allowing adaptive shortening or adaptive lengthening of particular muscles is recommended to enhance the achievement of certain functional skills. Likewise, unwanted shortening or lengthening of muscles should be prevented. The following section reviews a few examples of these concepts as they relate to SCI.


Tenodesis is described as the passive shortening of the two-joint finger flexors as the wrist is extended. This action creates a grasp, which assists performance of ADLs ( Fig. 14.10 ). , A patient with mid to low tetraplegia may rely on adaptive shortening of these long finger flexors to replace active grip. If the finger flexors are stretched across all joints during ROM exercises, the achievement of some functional goals may be limited as their tenodesis may be ineffective if they become overstretched. ROM to the finger flexors should be applied only while the wrist is in a neutral position. There is controversy over shortening of the flexor tendons. Some clinicians argue that the patient can develop a fixed flexion contracture of the proximal interphalangeal joints (IP), interfering with future surgical attempts to restore finger function. It is recommended to promote tenodesis functioning via adaptive shortening while maintaining joint suppleness.




Fig. 14.10


Tenodesis Grasp Utilizing a Short Opponens Splint.


In the presence of weakened or paralyzed elbow extensors, patients are at risk of flexion-supination contracture due to the unopposed strength of the elbow flexors. The shortening of the elbow flexors in a supinated position will limit participation in ADL function and transfer skills ( Fig. 14.11 ). Contracted elbow flexors (which contribute to supination) in a patient with an SCI level of C6 can cost this patient his or her independence. Likewise, the rotator cuff and the other scapular muscles should be assessed for their length-tension relationships and their ability to generate force. Normal length of these muscles should be maintained. For example, achieving external rotation of the shoulder (active and passive) is critical for patients with low-level tetraplegia. Shortening of the subscapularis, an internal rotator, and other structures can quickly result in a decrease in motion, limiting bed mobility, transfers, feeding, and grooming skills.




Fig. 14.11.


Supination Contraction of a Patient With C5 Level of Injury.


Appropriate length of lower extremity (LE) and trunk muscles are also important for function. Hamstrings should be lengthened to allow 110 to 120 degrees of a straight leg raise. If adequate hamstring length does not exist, it is important to make modifications to prevent overstretching of the low back muscles during functional activities. The combination of lengthened hamstrings and adaptive shortening of the back-extensor muscles provides stability for balance in the short- and long-sitting positions. Balance in short sitting aids in the efficiency of transfers and bowel and bladder management while balance in long sitting assists with lower-extremity dressing and other ADLs. It is also important to maintain functional ROM in hips, knees, and ankles as limited ROM in any of these joints can impact the ability to achieve standing and ambulation goals.


Splinting to prevent joint deformity


Deformity prevention is the first goal of splinting. Patients with cervical spinal cord injuries may have lost normal neural input to musculature in their wrists and hands. Other patients may have partial motor control, which may lead to muscle imbalances and loss of ROM. In the absence or weakness of elbow extensors, a bivalve cast or an elbow extension splint at night may be beneficial to prevent joint contractures. At the wrists, a volar wrist support is commonly used initially and may be progressed to a longer-term option of a definitive wrist orthosis or custom wrist orthosis fabricated by an orthotist. Other splints often used for deformity prevention of the hands include resting hand splints with proper positioning to maintain the support of the wrist and web space ( Fig. 14.12 A). Another hand-based option is the intrinsic plus splint (see Fig. 14.12 B), which places the metacarpophalangeal (MP) joints between 70 and 90 degrees of flexion and decreases intrinsic hand muscle tightness. The intrinsic plus splint position promotes joint motility for tenodesis and is the preferred position.




Fig. 14.12


(A) Resting hand splint. (B) Volar intrinsic plus splint maintains alignment of the wrist and fingers to promote metacarpophalangeal flexion for tenodesis grasp.




Another goal of splinting in the SCI population is to increase function. Patients with tetraplegia at the C5 level rely on an orthosis to be independent with communication, feeding, and hygiene. They must have joint stability and support at the wrist and the hand to perform these skills. The splint is often adapted with a utensil slot or cuff so the patient can effectively perform the skills mentioned previously.


Patients who are not strong enough to use their wrists for tenodesis may require splinting to support their wrists until they can perform wrist extension against gravity. Long opponens splints can be used to position the thumb for function and support the weak wrist ( Fig. 14.13 ). Once the wrist muscles strengthen, the long opponens splint can be cut down to a hand-based short opponens to maintain proper web space and thumb positioning while maximizing tenodesis.




Fig. 14.13


Long Opponens Splint.


As mentioned previously, patients with injuries at the C6 level can use their wrists for a tenodesis grasp. , , Critical components of the splint assessment for these patients are the positioning of the thumb, web space, and index finger observed during the grasp. It is recommended that the patient’s hand be positioned with the thumb in a lateral pinch position because this is the most commonly used prehension pattern to pick up objects. Patients who are not splinted may not have the proper positioning to pick up objects because their tenodesis is “too tight” or “too loose.”


Patients with C8 to T1 injuries or patients who have incomplete injuries may have “clawing” or hyperextension of the metacarpophalangeal joints. This is caused by finger extensor musculature that is stronger than finger flexor musculature. To prevent this, a splint can be made to block the metacarpophalangeal joints and promote weak intrinsic muscle function. Depending on the extent of the imbalance, these splints can be used during function or worn only at night. Alternatively, the splinting position of composite finger extension (MPs and IPs simultaneously) with wrist extension may be considered for a prolonged stretch.


Cost, time, material, and clinician experience are important considerations when deciding between custom and prefabricated splints. A well-fitting, prefabricated splint can be as effective as a custom-fabricated splint in certain situations. Custom splints require additional resources and clinician expertise. One way to minimize time spent in the fabrication of splints is to use a good pattern and premade straps. Finally, educating the patient on the splint-wearing schedule, skin checks, and splint care is important for preventing skin breakdown.


Treatment for joint deformity


If a joint contracture occurs despite preventive measures, more aggressive treatments are necessary. This may include more aggressive use of splinting, plaster or fiberglass casting techniques, or injections of neurolytics, such as botulinum toxin type A (Botox). When splinting is not effective, casting may be indicated. The patient with minimal ROM limitations may require only one cast. The patient with significant limitations may require multiple casts, called serial casting. This process involves the application of several casts that are removed and reapplied over a period of weeks to increase extensibility in the soft tissues surrounding the casted joint. With each cast, the involved joint is placed at submaximal ROM. Once the cast is removed, the joint should have an increase of approximately 7 degrees of ROM. This process continues until the deformity is minimized or resolved. The final cast is fabricated into a bivalve splint by cutting the cast into a top half and bottom half and adding strapping. The bivalve splint acts as a positioning device to promote ROM gains made during serial casting. It can be easily applied and removed ( Fig. 14.14 ). Casting contraindications include the following: skin compromise over the area to be casted, heterotopic ossification, edema, decreased circulation, severe fluctuating hypertonicity, and inconsistent monitoring systems.


Apr 22, 2020 | Posted by in NEUROLOGY | Comments Off on Traumatic spinal cord injury

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