Data detailed are taken from the summary in De Vivo (2007). The ratio of male to female cases is approximately 3:1, with greater male preponderance in young age groups. Spinal cord damage can be traumatic or non-traumatic. The main causes of traumatic injury are shown in Figure 4.1. Gunshots and stabbings also make small but increasing contributions (Harrison, 2000; Whalley Hammell, 1995). A significant number of patients with mental health problems will sustain injury from jumping from a height. The level of injury at the time of discharge from hospital is illustrated in Figure 4.2.

Figure 4.1 Causes of traumatic spinal cord injury. The percentages illustrated were obtained from the references cited in the text.

Figure 4.2 Spinal cord injury level at discharge from hospital. C, cervical; T, thoracic.

The American Spinal Injury Association (ASIA) has produced a classification system for SCI, which is explained below and the classification of injury at discharge is also detailed below (see ‘Diagnosis’).

Non-traumatic aetiology is more common than traumatic. Reported incidence of nontraumatic SCI varies depending on which conditions are included in the study population. Non-traumatic most commonly result from degenerative disc disease and spinal canal stenosis, developmental anomalies (e.g. spina bifida) and congenital anomalies (e.g. angiomatous malformations); inflammation (e.g. multiple sclerosis); ischaemia (e.g. cord stroke); pressure on the cord due to expanding lesions (e.g. abcess or tumour extrinsic or intrinsic to the spinal cord) (New & Sundrajan, 2008). Each condition has distinct management needs and features. Their management will benefit from the knowledge and skills derived from an understanding of traumatic SCI, which is the focus of this chapter.

Terminology

Terms used to describe these patients indicate the general level of the spinal injury listing body functions and structure and a list of domains of activity and participation (International Classification of Functioning, Disability and Health; World Health Organization, 2001).

Paraplegia

Paraplegia refers to the impairment or loss of motor, sensory and/or autonomic function in thoracic, lumbar or sacral segments of the spinal cord. Upper-limb function is spared but the trunk, legs and pelvic organs may be involved.

Tetraplegia

Tetraplegic patients have impairment or loss of motor, sensory and/or autonomic function in cervical segments of the spinal cord. The upper-limbs are affected as well as the trunk, legs and pelvic organs. In high cervical injuries the function of respiration will be affected. The term does not include the brachial plexus or injury to peripheral nerves. ‘Quadraparesis’ and ‘paraparesis’ were terms used previously to describe incomplete lesions and are now discouraged.

Types of spinal cord injury

SCI damages a complex neural network involved in transmitting, modifying and coordinating motor, sensory and autonomic control of organ systems. This dysfunction of the spinal cord causes variable loss of homeostatic and adaptive mechanisms which keep people naturally healthy. Any damage to the spinal cord results in deficits that can only be partly predicted, as described below. The pathology of the cord will influence the presenting impairment and the resulting prognosis. It can be precisely correlated with the neurological picture because of the segmental nature of the spinal cord (Kakulas, 2004). Complete transection of the cord is uncommon. It is useful to note that whilst the incidence of SCI in the population as a whole has largely remained the same, the overall prevelence is increasing. There are an increasing number of older people with SCI, reflecting the increasing ageing of the general population, in addition there are more people surviving with SCI into old age (Box 4.1 & Box 4.2).

Box 4.1 Trends

• Increasing age at time of incidence onset

• Increasing survival of those with high tetraplegia

• Falls increasing as a percentage of the overall aetiology due to the increase in ageing population

Box 4.2 Basic facts and figures

(Data from De Vivo, 2007.)

• Mean age 37 years

• 13% over 60 years old

• Small increase in percentage of females over last 10 years

Over the years there has been a significant reduction in mortality and preservation of neurology in new lesions (Grundy & Swain, 2002; Whalley Hammell, 1995). There are many reasons accounting for this, including:

• changes in vehicle design and usage, as well as greater public knowledge and awareness of the dangers of moving an injured person

• improved medical interventions: broad-spectrum antibiotics, neuroprotective agents and advances in respiratory care

• better paramedical retrieval: improved accident and emergency resuscitation procedures and medical interventions to maintain blood pressure and oxygenation.

A previous trend towards increasing incomplete lesions has now lessened. Recent incidence at time of injury has moved closer to equal numbers of incomplete and complete lesions. It is suggested that people with the more serious injuries are surviving, including a higher number of long-term ventilator-dependant patients. It is thought that the accumulative benefits of improved advanced life support and early interventions have now become fully established. It appears that there are no further influences currently increasing the trend towards an incomplete presentation, although the outcomes of new early restorative interventions will be eagerly awaited. There is a significant trend in the reduction in length of stay in the American Model Managed Care Systems, which also reflects a lower Functional Independence Measure (FIM) score at time of discharge and an increase in complications during the first year post discharge (De Vivo, 2007).

Pathogenesis

A brief outline of the pathological changes that occur with SCI is now given; further details can be found in other texts such as Tator (1998).

Immediate/primary damage

Most traumatic injuries involve contusion or tearing of the underlying cord by displaced bony fragments, disc or ligaments. This results primarily in loss of axons due to damage of the white matter.

Secondary damage

Secondary damage, particularly loss of cells in the grey matter, results from a secondary process comprising changes in the cell membrane permeability, leakage of cell contents, release of chemical factors and arrival of blood cells and agents involved in the response to injury and subsequent repair. This process leads to swelling and increasing cord pressure, affecting the venous and arterial supply, and results in ischaemia, lack of necessary proteins and failure to remove the debris of injury.

Later problems

After some weeks, there is evidence of astroglial scarring with cyst formation producing distorted neural architecture. In some cases, months or years later, a syrinx, an expanding cavity within the spinal cord probably associated with disordered cerebrospinal fluid (CSF) flow, may extend rostrally to produce further spinal cord damage. This posttraumatic syringomyelia may require drainage by shunt to prevent further extension. In view of this possibility, the neurological status should be reassessed periodically (Illis, 1988) and appropriate magnetic resonance imaging (MRI) scanning performed at intervals to minimize further neurological loss.

Spinal cord plasticity

When peripheral nerve is damaged, repair can lead to significant return of function (Battiston et al., 2009; Dahlin, 2008). It has been demonstrated that the central nervous system (CNS) has the capacity to regenerate and recover. It has similarly been hypothesized that there is capacity within the spinal cord to regenerate through a number of mechanisms. Research is ongoing to identify axonal budding, unmasking and interspinal spinal circuits (central pattern generators). For further reading on neuroplasticity see Chapter 11, Adkins et al. (2006), Kleim (2009), and Schwartz and Begley (2003). A summary of research aiming to establish new treatments in the management of spinal cord damage is discussed briefly below.

Treatment approaches in immediate post-injury management

There are four main approaches currently being considered to develop treatments for SCI (Ronsyn et al., 2008):

1. Cell and tissue culture and transplantation, which includes adult and embryonic stem cells, schwann cells and olfactory ensheathing cells

2. Production and provision of nerve growth stimulating factors

3. Elimination of blocking factors which inhibit neuro-regeneration

4. Techniques aimed at modifying the inflammatory response, minimizing neuronal death and scar formation.

Understanding axonal guidance systems that will be required for directed outgrowth and functional reconnection will be essential if useful functional activity is to be regained. Although much progress has been made in the laboratory setting, no techniques applied to humans, despite having been through well researched trials (Fawcett et al., 2007; Lammertse et al., 2007; Steeves et al., 2007; Tuszynski et al., 2007) have yet to emerge showing any consistent results (Johnston, 2001; Ramer et al., 2000; Ronsyn et al., 2008; Tator, 1998).Claims for successful regeneration of the chronically injured spinal cord through late repair, remain contentious. Most studies lack robust pre- and post-intervention measures with many appearing to rely on associated intensive rehabilitation to demonstrate small functional improvements.

Diagnosis

Incomplete versus complete injury classification

It is important to clarify these terms, depending on the context in which they are used. From a therapeutic point of view, a patient can be called functionally incomplete when he or she presents with some motor or sensory sparing below the level of the cord lesion. The therapist should acknowledge such sparing as potential activity, which may offer important functional benefits to the patient.

ASIA Impairment Scale

In terms of diagnosis and prognosis, the classification of SCI has important ramifications. The ASIA Impairment Scale (ASIA, 2008) is the latest updated criteria for assessing and classifying functional levels of SCI, including the definitions of complete and incomplete lesions. The assessment is completed with the patient in supine, to enable testing in the acutely unstable injured person. The assessment comprises of 10 key myotomes and 28 dermatomes (Figure 4.3). Each dermatome is tested for light touch and pin prick sensation. The full description for these classifications will not be detailed here and it is available at www.asia-spinalinjury.org, with the impairment scale and classification outlined in Figure 4.4.

Figure 4.3 The American Spinal Injury Association (ASIA) Dermatome Chart and Impairment Scale.

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, reprint 2008; Chicage, Il. Reprinted with permission.

Figure 4.4 ASIA classification guide.

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, reprint 2008; Chicage, Il. Reprinted with permission.

The ASIA system defines that a patient can have neurological sparing below the injury level, but in the absence of the sacral sparing, this is classified as a complete lesion, ASIA A, with zones of partial preservation. Where there is sensory preservation of S4–S5, the patient is classified sensory incomplete, ASIA B. This implies the preservation of the long tracts through the lesion. The classification of incomplete versus complete lesions indicates the presence of sensation in the lower sacral segments S4-S5, which implies significant prognostic indication of potential for neurological improvement. To be classified ASIA C, the patient must be assessed to have preserved S4-S5 sensation and voluntary anal sphincter motor activity. If the voluntary anal activity is absent then there must be preservation of motor function in some muscles innervated more than three levels below the motor classification level. In addition, more than half the key muscles below the neurological level must be grade 1-2/5. Similarly if half the key muscles are grade 3-5/5 then the classification will be ASIA D. The classification of SCI on discharge from hospital is shown in Figure 4.5.

Figure 4.5 American Spinal Injury Association (ASIA) classification at discharge from hospital.

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, reprint 2008; Chicage, Il. Reprinted with permission.

From a prognostic point of view, research suggests that 72 hours post injury (Brown, 1994; Maynard et al., 1979), and 1 month post injury are good time points for this classification (Waters et al., 1994a, 1994b). Further assessment is advised at 3 months post injury. All patients are assessed immediately on hospital admission, to gain baseline data. The wealth of prognostic statistics is based on data obtained using these time periods.

Incomplete lesions and prognostic indicators

There are recognized patterns of incomplete cord injury which tend to present clinically as combinations of syndromes rather than in isolation. The signs and symptoms are related to the anatomical areas of the cord affected (Figures 4.6 & 4.7). Clinically, patterns of incomplete lesions are referred to as a syndrome.

Figure 4.6 Cross-section of the spinal cord illustrating the main ascending and descending nerve tracts. The functions affected by damage to these tracts are indicated.

Figure 4.7 Spinal column with spinal nerve levels.

Recent statistics show the common patterns of incomplete lesions to be the following:

• Central cord syndrome (44%)

• Cauda equina (25%)

• Brown–Séquard syndrome (17%)

• Anterior cord syndrome around 10%

• Pure posterior cord syndrome being very rare

(McKinley et al., 2007).

Prognosis

Recovery of the incomplete spinal cord injury

It is essential to refer to the evidence of ongoing recovery in SCI and to bear this in mind when treating these patients. Recovery will be at the forefront of a patient’s mind when participating in rehabilitation.

Ninety per cent of incomplete SCI patients have some recovery of a motor level in their upper-limbs, compared to 70–85% of the complete injuries (Ditunno et al., 2000). Pinprick sparing in a dermatome is an excellent indicator of increased recovery of motor strength (Poynton et al., 1997) and it has been found that pinprick preservation below the level of the injury to the sacral dermatomes is the best indicator of useful recovery, with 75% of patients regaining the ability to walk. Fifty per cent of patients who had no sacral sparing regained some motor recovery but not of functional use (Katoh & El Masry, 1995).

Studies have found that incomplete SCI patients showed ongoing improvement in their motor activity, although this tended to slow during the second year post injury, with the exception of incomplete tetraplegics who lacked sharp/blunt discrimination and failed to demonstrate any lower-limb motor recovery. In incomplete paraplegics, there was evidence of 85% of the muscles recovering from a flicker to an antigravity grade within the first year, but if there was no activity initially, only 26% gained an antigravity grade (Waters et al., 1994a, 1994b).

It is widely accepted that incomplete SCI patients will only make useful recovery within the first 2 years post injury, but from the authors’ experiential observation, recovery can continue to occur slowly for at least 5 years or more, particularly in incomplete tetraplegics.

Ambulation recovery

Between 44 and 76% of people with incomplete SCI, with preserved sensation but no motor function, have been reported to achieve ambulation (Maynard et al., 1979; Waters et al., 1994a, 1994b).

Crozier et al. (1991) reported, using ASIA assessment at 72 hours, that 89% of ASIA B–E patients with pinprick preservation went on to ambulate, compared with 11% having preserved light touch but not pinprick.

• The theory behind the significance of sacral preservation is the proximity of the spinothalamic tracts that mediate pinprick to the lateral corticospinal tracts and their shared blood supply. At 1 year post injury, 76% incomplete paraplegics (ASIA B–E) become community ambulators by 2 years, compared to 46% of incomplete tetraplegics who ambulate, probably due to upper-extremity weakness compromising the ability to perform gait (Waters et al., 1994a, 1994b). Age is a significant factor in indication of outcome (Burns & Ditunno, 2001; Ditunno et al., 1994).

Summary of changes in ASIA impairment scale from admission to discharge

• From the number of patients assessed at the time of injury found to be classified as an ASIA A, 8.5 /10 remain ASIA A at time of discharge.

• From the same ASIA A group, only 2 /100 go on to become a functional ASIA D.

• From the group of ASIA B patients, 40 /100 become ASIA C.

• From the group of ASIA C patients, more than 60 /100 become grade D.

• From the group of ASIA B patients, 20 /100 remain grade B but 1 in 5 become grade D at time of discharge

(De Vivo, 2007).

Acute general management

Although the primary damage is to the spinal cord, every organ system can be affected. Antecedent and posttraumatic psychological and social conditions must also be given full consideration as they play their inevitable parts in the success or failure of rehabilitation. Acute and rehabilitation specialties and disciplines are necessary to provide a holistic approach, in which all team members work towards common goals, agreed between the patient and team.

Trauma management

SCI presentation remains a key issue for all professionals, who should be vigilant about the risks of activities in which they may be involved, such as on rugby fields or at swimming pools.

Immediate management

When an accident occurs involving a SCI, other injuries should be suspected and the incident history recorded; pain, bruising and/or palpable spinal deformity are likely features. This is a crucial time for appropriate management to ensure the best chances possible for survival of the spinal cord fibres.

Proper handling will avoid unnecessary further damage, and the following simple advice can be immensely valuable:

• The patient should be advised not to move.

• The airway and breathing should be checked.

• If removal to another site is necessary, the transfer should be gentle, avoiding any twisting. Lifting should be performed by at least four people, with one acting as leader to coordinate the team.

• The patient should be placed in a supine position with the head and body kept strictly in alignment.

• If unconscious, the patient should be strapped to, and supported on, a board to allow tilt and avoid aspiration.

• Normal spinal curvature should be supported by a rolled-up cloth.

• The skin should be protected from pressure and ulceration by removing objects from pockets or by removing clothes.

• Point pressure from heels on hard surfaces, or ‘knocking knees’, should be avoided.

• Various spinal immobilization boards, e.g. the scoop stretcher, and collars are available in ambulances for moving patients.

• Maintenance of oxygenation and blood pressure is essential.

• If possible, a motor and sensory charting should be performed for a baseline neuroassessment with diagrammatic recording.

Continuity of care

It is crucially important that continuity it maintained from site of injury, immediate first aid through ambulance/helicopter retrieval, to A&E/trauma unit, resusitation, investigation and stabilization, with appropriate surgical/non-surgical interventions, then onto admission to specialist continuing care.

Admission to hospital

Currently in the UK, after sustaining an SCI the person is admitted to the local A&E or trauma unit. A full physical and neurological assessment is carried out and a decision is made about referral to a specialist unit. Spinal imaging can provide reliable evidence of stability (X-ray, MRI and/or computed tomography (CT)). The decision for management (conservative or surgical) is made after the appropriate diagnostic testing.

Summary of immediate management

• Immobilization

• Advanced trauma life support

• Decompressive and stabilizing surgery if necessary

• Recent introduction of membrane-stabilizing agents and neuroprotective agents, including steroids. Naloxone and Tirilazad have been investigated. Most recently, ganglioside GM-1 has appeared to be partly helpful, but none have yet achieved the outcome hoped for (McDonald et al., 2002).

Acute hospital management

Acute trauma management guidelines are well established (Moore et al., 1991). Management of the patient with an SCI has special features resulting from spinal cord shock. Full details are described by Grundy and Swain (2002).

Breathing

Paralysis of respiratory muscles may be a feature. Patients with acute cervical cord injuries can fatigue in their breathing. Pulse oximetry is a crude indicator of respiratory distress because it measures only haemoglobin saturation and not partial pressure of oxygen (Po₂) (Hough, 2001). Any evidence of desaturation or of falling saturation should be proactively addressed by the critical care team to maintain oxygenation and prevent further cord damage. Monitoring patients’ breathing rate, pattern and colour, and noting agitation, drowsiness or distressed behaviour, is vital. Arterial blood-gas analysis may be the critical factor in deciding whether to provide ventilatory support. Respiratory failure remains one of the main causes of death in acute tetraplegia, whilst pneumonia is the leading cause of death in all persons with SCI (Jackson et al., 1994). The principles of respiratory management are covered in Chapter 15.

Circulation

The sympathetic nerve supply to the heart is via cervical, cervical thoracic and upper thoracic branches of the sympathetic trunk. Cervical and upper thoracic injuries may produce sympathetic disruption, with impairment of tachycardia response. Therefore, pulse rate may mislead in the presence of circulatory shock. There is skin vasodilation within the dermatomes caudal to the injury. This causes a lowering of blood pressure. Injudicious fluid replacement to augment the blood pressure can cause pulmonary oedema. Pharyngeal suction, urethral catheterization or simply repositioning of the patient can produce vagal overstimulation and lead to bradycardia; intravenous atropine may be required to restore normal heart rate. Tetraplegic patients are unable to maintain their body temperature due to the autonomic disruption, resulting in them taking up the surrounding temperature. This is known as a poikilothermic reaction.

Spinal cord shock

This is the phenomenon of cessation of nervous system function below the level of damage to the cord and may be due to the loss of descending neural influences. It is usually expected that after several seconds to months, the flaccid paralysis and areflexia of spinal shock are replaced by hyperexcitability, seen clinically as hyperreflexia, spasticity and spasms. More recently this has been identified as a critical period when the timing of potential interventions can influence recovering neurological systems. Studies have shown that there is competetive synaptic growth into the synaptic spaces that have been vacated. These transient vacant sites become open to repopulation by spared axons. It is at this moment that interventions should ideally target synapse growth mediating voluntary movement rather than local segmental neurons mediating spasticity and hyperreflexia (Ditunno et al., 2004; McDonald et al., 2002).

Stauffer (1983) noted that it is rare to see patients in total spinal shock and totally areflexic. Strong spasticity almost immediately post injury is indicative of an incomplete SCI. In these patients assessment of voluntary movement requires careful differentiation. In the authors’ experience, development of increased muscle tone and involuntary movements may mislead patients to believe they have functional return of activity. It is important for the therapist to anticipate such reactions and to assess carefully in order to avoid confusion and disappointment.

Skin care

Denervated skin is at risk from pressure damage within 20–30 minutes of injury. If this occurs, it can cause distress and delay in the rehabilitation process. Clinical staff attending should be vigilant in monitoring the skin and should report red marks.

Gastrointestinal tract

SCI can produce ileus and gastric distension that can restrict movement of the diaphragm, further compromising breathing. A nasogastric tube should be placed for decompression if bowel sounds are absent. Gastric stress ulcers can occur and prophylactic treatment with mucosal protectors is recommended.

Bladder

Spinal shock causes retention of urine; the bladder should, therefore, be catheterized routinely in order to monitor fluid output and to protect it from overdistension damage.

Spinal stabilization versus conservative management

Spinal fractures may be classified as stable, unstable or quasistable (i.e. currently stable but likely to become unstable in the course of everyday activity). Disagreement continues between protagonists and antagonists of surgical stabilization of the spine, but surgery is increasingly used (Collins, 1995).

Definition of instability or stability of a spinal lesion has now achieved substantial agreement based on the three column principles (Dennis, 1983). There is general agreement that restoration of the anatomy of the canal is sensible in terms of giving the cord the best opportunity for recovery.

It is debated whether neurological recovery or degree of spinal stability in the long term differs with surgical or conservative management. Surgery aims to minimize neurological deterioration, restore alignment and stabilization, facilitate early mobilization, reduce pain, minimize hospital stay and prevent secondary complications (Johnston, 2001). Review of evidence over the last decade does not identify any specific timing or role for early surgical decompression. Surgical intervention within the first 72 hours after injury has been shown to be safe and a role for urgent decompression has been identified in certain circumstances and may improve neurological outcomes (Fehlings & Perrin, 2006).

From a physiotherapy and psychological point of view, the ability to mobilize a patient against gravity early seems to be a desirable outcome from surgery. This can be achieved by 7–10 days after surgery and results in a shorter inpatient stay.

Management of acute lesions at T4 and above

Surgical stabilization may be achieved by anterior or posterior fixation, or a combination of the two (e.g. Collins, 1995). Patients managed conservatively are immobilized with bed rest; depending on the degree of instability, they may have to be maintained in spinal alignment by skull traction. Traction is applied usually by halo traction, Gardner–Wells or cone calipers (Grundy & Swain, 2002).

Early mobilization may be indicated and can be achieved using a halo brace (Hossain et al., 2004). Care in handling and positioning during physiotherapy is discussed below (see ‘Acute physical management’).

Length of immobilization will vary depending on the extent of bony injury and ligamentous instability, in addition to whether surgery has been performed. There may be several spinal segments affected and this will also influence the length of bed rest. Multiple-level fractures in the cervical spine are usually treated conservatively by halo traction and a period of immobilization in a hard collar. Bed rest is usually for 3 months. On starting mobilization, patients with all levels of injury will usually wear a collar of some type, depending on their stability.

Management of acute lesions at T4 and below

Thoracolumbar fractures are most common at the L1 level, this being the level of greatest mobility. Patients with unstable lesions at T9 and below must not have their hips flexed greater than 30° in order to avoid lumbar flexion (CSP, 1997).

Stable wedge fractures are usually treated conservatively with a brace or plaster of Paris (or similar) jacket. Unstable burst fractures, with cord compression, will justify surgical decompression and fixation. Generally, an anterior and posterior fixation technique will require a brace to be worn for 3 months postoperatively. If the spine is stable anteriorly, it may be sufficient to stabilize posteriorly. In this situation, a brace will be recommended for 6 months.

Bracing techniques vary greatly between institutions. A moulded hard plastic (subortholen) jacket can be made from an individual casting of plaster. Many braces are commercially available ‘off the shelf’ or other materials are used to form a brace, e.g. leather jackets.

Special problems in spinal cord injury

Osteoporosis

Osteoporosis is a loss in bone mass without any alteration of the ratio between mineral and the organic matrix. A text by (Jiang et al., 2006) provides a comprehensive overview of osteoporosis. It is thought that immobilization for long periods and a sedentary life lead to an increase in bone reabsorption, thus causing osteoporosis.

Rapid loss of bone minerals occurs during the first 4 months following SCI. A range of data available from studies include: at 1 year bone mass density reduces in the femoral neck by 27%, mid femoral shaft by 25% and distal femur by 43%. The reduction continues in the pelvis and lower limbs over the 10 years after injury and can reduce by 50%. Tetraplegics can lose up to 16% on their bone mass density in their upper limbs. The osteoporosis may cause fractures of long bones during relatively simple manoeuvres, such as transfer or passive movements (Belanger et al., 2000). The rate of incidence of fractures has been documented to be 1% in the first year post injury, 1.3% per year at 1–9 years, 3.4% per year at 10–19 years, 4.6% per year at 20–29 years (Jiang et al., 2006).

It has been shown that early mobilization with weight bearing might prevent or slow bone-mineral loss (De Bruin et al., 1999). Bone mineral density can be preserved in bones below the level of the lesion (Frey-Rindova et al., 2000). The question is frequently asked whether a patient who has not stood for several years should recommence standing. There is a variety of opinion on how to proceed, either returning straight to standing or commencing a weight-bearing programme using a tilt table, usually combined with bone-enhancing agents, and monitoring using bone densitometry, before returning to standing in a frame. Such advice is empirical and, as yet, despite many studies, no clear guidance has been produced.

Heterotopic ossification

Calcification in denervated or UMN-disordered muscle remains an ill-understood process and commonly occurs in patients with SCI (David et al., 1993). It may be confused in the early stages with deep venous thrombosis, when it presents as swelling, alteration in skin colour and increased heat, usually in relation to a joint. During the active process, analysis of plasma biochemistry shows a raised alkaline phosphatase. It can result in loss of range of movement (ROM) and difficulty in sitting. If ossification occurs around the hips it may lead to further skin pressure problems. Treatment of this condition is discussed by David et al. (1993). It must be emphasized that stretching should be gentle, as overstretching may be a predisposing factor for this condition.

The bladder

Urological complications of SCI are major mortal and morbid risks and the reader is referred to Fowler and Fowler (1993) for a review. Spinal cord damage disrupts the neural controls of bladder function. The objectives of bladder management are to provide a system ensuring safety, continence and least social disruption.

In the acute stage the bladder is catheterized to allow free drainage, to accommodate any fluid input and output fluctuations and to avoid bladder distension. Intermittent catheterization is then established. After spinal shock passes, urodynamic studies are used to identify the emergent bladder behaviour.

Anterior sacral root electrical stimulation may be used, primarily for controlling urinary voiding, but it may also facilitate defecation and penile erection separately. Reflex micturition (by tapping the abdominal wall or stroking the medial thigh) is not favoured because the bladder is unprotected from hyperreflexic complications.

The bowel

Although morbid complications rarely arise in the bowel, social embarrassment is common and often perceived by patients as more devastating than limb paralysis. Laxatives can achieve a bowel frequency within the normal range. For intractable constipation, occasional enemas can be useful. Increasing use of anterior sacral root stimulators and other surgical techniques may be beneficial. The mainstay of bowel care is to produce a predictable pattern, to minimize incontinence, impaction and interference with activities of daily living.

Fertility

Fertility is usually maintained in women, with the ovulatory cycle being normal within 9 months after injury. Fertility in men is, however, a problem (Brindley, 1984). Improvements in fertility rates for men after SCI have been made due to several important technical advances. These include improved methods in the retrieval and enhancement of sperm, such as electroejaculation, and improved means of achieving fertilization with limited sperm quality and numbers through in vitro techniques.

Autonomic dysreflexia

Autonomic dysreflexia can be described as a sympathetic nervous system dysfunction producing hypertension, bradycardia and headache with piloerection and capillary dilation and sweating, above the level of the lesion. Some or all of these can result from any noxious stimulus such as bladder or rectal distension. If it occurs, the patient should be sat up, given appropriate medication and the underlying cause treated. Patients and therapists should be aware that the hypertension can rise sufficiently to induce cerebral haemorrhage, so this should be treated as an emergency. Mild autonomic dysreflexic symptoms act as signals to patients for toiletting and induction of symptoms has been used foolishly, in the authors’ view, to enhance sporting performance.

Acute physical management

In the early post-injury phase, physical management will mainly involve prevention of respiratory and circulatory complications, and care of pressure areas. As spinal shock starts to resolve, other physical sequelae must be addressed, such as pain, weakness and hyperreflexia leading to hypertonus and contracture.

Principles of impairment assessment

Assessment must be carried out as soon after admission as possible to obtain an objective baseline measurement of function, to identify where specific problems are likely to develop and to instigate prophylactic treatment. History of the injury is taken, including the results of relevant tests, e.g. lung function. Medical history is also noted. It is important to be aware of associated injuries, as these may influence management. The principles of assessment are discussed in Chapter 1 and a physiotheray assessment database is shown in Table 4.1.

Table 4.1 Physiotherapy assessment database

Database

• Spinal fractures

• Spinal level of lesion

• Spinal stability

• Associated injuries

• Respiratory status

• Spinal shock – absent reflexes

Subjective

• Pre morbid musculo-skeletal problems

• PMH: relevant respiratory factors

Objective

• Respiratory status (including FVC and cough) (Hough, 2001)

• Passive range of movement of all joints

• Active movement

• Muscle strength: standard muscle chart (MRC, 1978) (Oxford grading scale and ASIA Chart (2002))

• Tone: modified Ashworth scale (Bohannon & Smith, 1987)

• Sensory especially pin prick sensation (ASIA, 2002).

• Joint range

• Other injuries

Commonly used measurement tools

• ASIA (2002)

• FVC (Pryor & Webber, 1998)

• Modified Ashworth Scale (Bohannon & Smith, 1987)

• Oxford Muscle Chart (MRC, 1978)

FVC, forced vital capacity.

Easy mistakes in sensory assessment

When assessing sensation of a patient with a cervical lesion, sensory levels are tested down the anterior aspect of the trunk. The patient could confirm some sensation over the front of the chest above the nipple line. This has commonly been mistaken for T1-2 sensory preservation but is actually C3/4 innervation of the “bib” area by the supraclavicular nerve.

Treatment objectives in the acute phase

The main objectives are:

• to institute a prophylactic respiratory regimen and treat any complications

• to achieve independent respiratory status where possible

• to maintain full ROM of all joints within the limitations determined by fracture stability

• to monitor and manage neurological status as appropriate

• to maintain/strengthen all innervated muscle groups and facilitate functional patterns of activity to assist in restoration of function where possible

• to support/educate the patient, carers, family and colleagues.

Spasticity: a reminder!

Since the spinal cord is shorter than the vertebral column, lower-vertebral injuries will not involve damage to the cord, but there will be nerve root damage which will determine the presence of spasticity. The spinal cord usually extends to the first or second lumbar vertebra (Williams, 1995). Below this level, the nerve roots descend as the cauda equina and emerge from their respective vertebral levels. Injuries at these lower levels, therefore, are peripheral nerve (LMN) injuries.

A patient with a lesion at the conus or above i.e. an upper motor neuron (UMN) injury, may present with a varied amount of spasticity. Partial or total weakness occurs, but there may be preservation of muscle bulk to some extent due to the increased tone. A patient with an LMN injury, i.e. below the level of T12, will present with flaccid paralysis or weakness only. Obviously, this cut-off level of T12 is a general rule, as an individual’s anatomy may vary from the usual.

Cervical injuries and potential for brachial plexus lesions

In the immediate period of patient assessment, after an admission following a SCI, it is very difficult to determine the pathology causing the resulting loss of movement. This is especially difficult in cervical lesions where there is a reasonable possibility of brachial plexus involvement. On assessment, muscles of the upper limb could be weak or flaccid and may be presumed to result from spinal shock. If the mechanism of injury or MRI scans suggest more extensive tissue damage, it would be highly advisable to assess for a LMN injury. This can be done extensively using nerve conduction studies but may be difficult to obtain in the acute/intensive therapy unit (ITU) setting. A more rapid and broad test is to apply neurotrophic electrical stimulation to the muscles innervated by the injured nerve roots. Only an intact peripheral nerve will conduct and produce a muscle contraction. Hence this is a useful diagnostic tool in determining a brachial plexus lesion. It is most important to identify such an injury at the earliest opportunity in order to facilitate a primary repair of the brachial plexus (Birch, 1993).

Respiratory management

Effect of cord injury on the respiratory system

Respiration is a complex motor activity using muscles at various levels (see below). Patients with lesions of T1 and above will lose some 40–50% of their respiratory function, but most patients with cervical injuries have an initial vital lung capacity of only 1.5 litres or less. Thus, all patients with cervical injuries should be fully evaluated for respiratory efficiency by monitoring spirometry and Po₂ in the initial weeks after injury. For an overview of respiratory physiology with an explanation of the tests mentioned here and normal values, the reader is referred to relevant textbooks (e.g. Hough, 2001; Smith & Ball, 1998).

Given the aetiology of SCI, many patients sustain associated injuries affecting respiration. Lung contusion or pneumo- or haemopneumothorax is common in patients with thoracic lesions, often associated with steering-wheel impact. They present at 24–48 hours post injury with deteriorating respiratory function, with a falling Po₂ and rising Pco₂. This is a serious development and mechanical ventilation may be required, occasionally for a number of weeks.

In other patients, deterioration of respiratory function in the first days after injury may be associated with an ascending cord lesion of two to three spinal levels, due to oedema or extending hypoxia in the cord or possibly due to fatigue. This again may lead to the need for mechanical ventilation for a period and then subsequent weaning from the ventilator as cord function returns. Occasionally the higher ascended level may become the permanent level. If significant hypoxia persists, particularly with associated low blood pressure, further damage to the cord may occur. These patients do improve their respiratory capacity with respiratory training (see below).

Atelectasis is common in patients with SCI. Subsequent infection and pneumonia still account for considerable morbidity and some mortality in tetraplegics. Prophylactic tracheostomy is often advised to assist in effective clearance of secretions. High cervical injuries are prone to bronchospasm and bronchial hypersecretion due to disrupted sympathetic response. Appropriate treatment with bronchodilators in conjunction with manual techniques will be required to maintain adequate ventilation (see Ch. 15). Chest and head injuries are commonly associated with spinal injury and provide their own respiratory problems, which must also be assessed and treated appropriately (see Ch. 3).

Muscles affecting respiratory function

The abdominal muscles are essential for forced expiration and effective coughing. They also stabilize the lower ribs and assist the function of the diaphragm. The intercostal muscles have a predominantly inspiratory function as prime movers but also as fixators for the diaphragm. These muscle groups comprise about 40% of respiratory motor effort.

The diaphragm is the main inspiratory muscle but relies on other muscles to maximize efficiency. The accessory muscles (innervated by C1–C8 nerves and cranial nerve XI) include the trapezius, sternomastoid, levator scapulae and scalenii muscles; they can act as sole muscles of inspiration for short periods, but if the diaphragm is paralysed they cannot maintain prolonged adequate ventilation unassisted (see inspiratory muscle training in sections ‘Acute respiratory care and management of complications’ and ‘Rehabilitation: ongoing respiratory management’, below) (see Box 4.3).

Box 4.3 Respiratory muscles and nerve innervation

Accessory muscles	C1 – C8
Diaphragm	C3 – C5
Intercostal muscles	T1 – T11
Abdominal muscles	T6 – L1

Chest movement

The use of accessory muscles and diaphragm function can be assessed by palpation at the lower costal border. Muscle paralysis results in altered mechanics of respiration. Studies have shown chest wall compliance in tetraplegic patients can be reduced by more than 50% of the normal value (De Troyer & Estenne, 1995). In lesions involving paralysis of the abdominal and intercostal muscles, the lower ribs will be drawn in on inspiration in a paradoxical movement (Pryor & Webber, 1998). These abnormalities reduce the efficiency of the diaphragm in producing negative intrathoracic pressure, hence causing reductions in lung volume and efficiency of ventilation. On assessment any asymmetry of chest wall movement and respiratory rate is noted.

Extreme ventilatory compromise in spinal injury is caused by one or more of the complications listed in Table 4.2.

Table 4.2 Spinal cord lesions and the effects on forced vital capacity

Spinal cord lesion	Complication	FVC % of normal
Lumbar and low thoracic	• Able to cough • Some decreased chest wall compliance

100–70% High thoracic

• Loss of effective cough

• Further decrease in chest wall compliance

• Basal collapse

• Atelectasis

• Increased work of breathing and paradoxical chest wall movement

• Reduced expansion

• Autonomic dysfunction

30–50% Low cervical

• Diaphragm plus accessory

• Inspiratory and expiratory muscle paralysis leading to decreased lung volume

• Respiratory muscle fatigue

• Reduced chest wall mobility

• Sputum retention – infection

• Collapse/consolidation

• Autonomic dysfunction

20% Upper cervical

• Accessory only – ventilated

5–10%

FVC, forced vital capacity.

Routine auscultation

Techniques are the same as for any other patient. The assessment can be hindered by the inability to move the patient easily to assess all lung regions. Timing of the assessment should be coordinated with the patients turning routine wherever possible.

Forced vital capacity

The forced vital capacity (FVC) is a readily available objective measurement of respiratory muscle function, as is peak expiratory flow rate. As mentioned earlier, it is used acutely to monitor respiratory status. If the FVC is less than 1 L, the therapist may choose to instigate either intermittent positive-pressure breathing (IPPB), e.g. the Bird respirator, or bilevel intermittent positive airway pressure (BIPAP), as discussed by Hough (2001). This assisted ventilation can be used prophylactically to maintain and increase inspiratory volume and aid clearance of secretions. It is a useful adjunct to active manual techniques for patients with sputum retention and lung collapse, and can be used to administer bronchodilators (Pryor & Webber, 1998). Elective ventilation is normally undertaken if the FVC falls below 500 ml but may be considered in some patients if FVC is around 1 L, depending on other complications that can impair the active cycle of breathing.

In cases of severe pain from rib fractures and associated soft-tissue injuries, a mixture of nitrous oxide and oxygen (Entonox) may be used and, if applicable, entrained into the IPPB circuit. Trancutaneous electrical nerve stimulation (TENS) has also been found to be effective in assisting pain management (see Ch. 12).

Breathing exercises and respiratory muscle training may also include the use of IPPB and incentive spirometry in the acute phase. Evidence to support the use of these modalities is inconclusive; however, from the experience of the authors they have been found to be beneficial adjuncts to manual treatments.

Cough

A patient with a lesion above T6 will not have an effective cough as he or she will have lost the action of the abdominal muscles. The physiotherapist can compensate for this loss by the use of assisted coughing, in order that the patient can clear secretions (Bromley, 2006). The Emerson Cough Assist Insufflator-Exsufflator is used to produce a cough by introduction of positive pressure then withdrawing negative pressure via a facemask, in order to assist secretion clearance.

Precautions in treating unstable spinal cord injury

These precautions in treating unstable SCI are outlined in Box 4.4 (CSP, 1997) and are for guidance only. They are widely accepted in many centres, but the point 2 lacks clear evidence to support this guidance. In a recent informal survey there was no agreement nationally or internationally, amongst the spinal surgeons questioned, to determine whether it is necessary to hold down the patient’s shoulder (termed a shoulder hold) during some treatment techniques. There are some centres that advocate that the patient’s head is stabilized and their shoulders held down onto the bed, whilst leg movements are performed and during chest physiotherapy. This stabilization is also recommended when moving the shoulders above 90°, particularly if the patient has high levels of spasticity.

Box 4.4 Precautions in treating unstable spinal cord injury

1. Unstable paraplegic SCIs: T9 and below-limit hip flexion to 30° (tailor position)

2. Unstable tetraplegic SCIs: Shoulder hold for lesions at the level of T4 and above during lower limb movements and upper limb movements above 90° glenohumeral flexion and abduction

3. Severe spasms during limb movements may cause loss of spinal alignment. Recommend shoulder hold

4. Respiratory techniques should be applied bilaterally and with a shoulder hold

5. Extreme range of movement must be avoided

Acute respiratory care and management of complications

If no other respiratory complications are present, the physiotherapist will teach prophylactic breathing exercises to encourage chest expansion and improve ventilation. Incentive spirometry is useful for patients with mid thoracic lesions and above, to give the patient and family positive feedback during breathing exercises. Care is necessary to maintain the stability of the spine. It is advised that shoulders are held for patients with unstable lesions of T4 and above when performing an assisted cough. In these circumstances, bilateral techniques should always be used in order to maintain spinal alignment. Adapted postural drainage for an unstable lesion is performed using specialized turning beds that maintain spinal alignment.

Ventilation

Assisted ventilation may be necessary. Proactive intervention before the patient becomes exhausted will make subsequent management easier. Elective intubation is potentially less damaging to the spinal cord than intubation following cardiac arrest. Respiratory therapy for the spinally injured ventilated patient is similar to that for other ventilated patients (Hough, 2001; Smith & Ball, 1998), apart from added vigilance to protect the fracture site.

Weaning from the ventilator should start as soon as the patient’s condition stabilizes. It is important to avoid fatigue whilst weaning, so careful monitoring ensures that FVC does not fall by more than 20%, or respiratory rate rise above 25–30 breaths/minute. Patients who fail to wean – usually those with a greater degree of diaphragm paralysis – require long-term ventilation (see ‘The long-term ventilated patient’, below).

Suctioning

This should always be undertaken with care in patients with SCI and is not recommended in the cervical non-intubated patient, as the neck cannot be extended to open the airway. It is important to assist the cough when stimulating the cough reflex, as merely stimulating the reflex will not produce an effective cough.

In patients with lesions above T6, the thoracolumbar sympathetic outflow is interrupted. During suction the vagus nerve is unopposed and the patient may become hypotensive and bradycardiac, possibly resulting in cardiac arrest. Endotracheal intubation may produce a similar response. Suction causes vagal stimulation via the carotid bodies, which pass impulses to the brain via the glossopharyngeal nerves and are sensitive to lack of oxygen (Williams, 1995). It is, therefore, wise to preoxygenate the patient, monitor heart rate and have atropine on standby.

Active assisted facilitation of movement and passive movements

As the majority of SCI patients have an incomplete injury, it is important to facilitate and utilize any active movement available. During the acute phase, whilst the patient is immobilized in bed, the physiotherapist can assist in exploiting the potential for functional return. Where patients have any active movement they should be encouraged to participate in activity and it should be purposeful if possible.

In order to produce a remembered coordinated movement pattern during assisted movements, attempts should be made to position joint girdles in functional alignment, prior to moving the limbs. During a period of sustained bed rest, an SCI individual’s body schema, the internal three-dimensional, dynamic representation of the spatial and biomechanical properties of one’s body, is lost from the parietal area of the brain. This means that the different joints of the body are not clearly identified during movement. On attempting a functional activity, the individual cannot differentiate the different parts of a movement resulting in an abnormal mass pattern. Care should be taken to activate each joint movement to achieve the maximum outcome possible and feed into the preparation of the body for the changes in postural adjustments resulting from voluntary movement (Mouchnino et al., 1992; Schepens et al., 2008).

Cortical mapping has demonstrated change, by the performance of passive movements with the patient visualizing the movement and in the presence of some sensory feedback (Reddy et al., 2001).

Splints may be used to provide joint support and maintain joint range of movement and muscle length. This may be essential in reducing joint pain, providing stability during movement and preventing contracture. It can also be argued that splinting may hinder activity by ‘dulling’ afferent input due to blanket sensation and restriction of movement.

Functional electrical stimulation (FES) is a useful adjunct to improve a movement where only a flicker is first available (see Ch. 12). Similarly, electromyographic (EMG) biofeedback can assist the patient to move in the absence of full sensation (see Ch. 12). The aims of all such movements are to:

• assist circulation

• maintain muscle length, preventing soft-tissue shortening and contracture

• maintain full ROM of all joints

• maintain and remember movement patterns.

Movements are commenced immediately after injury and features specifically important for SCI patients are now discussed. Shoulder movements are usually performed at least twice a day and leg movements once a day, in order to monitor any return of movement. For lumbar and low thoracic fractures, hip flexion should be kept to below 30°, to avoid lumbar flexion, until stability is established. Knee flexion must, therefore, be performed in Tailor’s position, i.e. ‘frogging’ (Figure 4.8).

Figure 4.8 The ‘frogging’ or Tailor’s position. This position is used to prevent movement of the lumbar spine during passive movements of the knees. It is also used to prevent mass extensor tone.

Special emphasis should be put on the following:

• Stretching the finger flexors with wrist in neutral to preserve tenodesis grip (Bromley, 2006)

• Ensuring a full fist can be attained with wrist extension

• Pronation and supination in elbow flexion and extension

• Full elevation and lateral rotation of the shoulder from day 1

• Stretching the long head of the triceps – arm in elevation with elbow flexion

• Stretch the rhomboids bilaterally – avoid twisting cervical spine

• Stretching the upper fibres of the trapezius muscle.

Where there is no active flexion of the fingers and thumb, it is appropriate to allow shortening of the long flexors. The ROM of individual joints at the wrist, fingers and thumb must be maintained. When the wrist is actively extended, the fingers and thumb are pulled into flexion to produce a functional ‘key-type’ grip, the tenodesis grip. If this contracture does not occur naturally, it can be encouraged by splinting whilst in the acute phase.

During recovery, the handling principles apply to facilitate normal movement and not to elicit spasm and reinforce the spastic pattern. Extreme ROM must be avoided, especially at the hip and knee, as microtrauma may be a predisposing factor in the formation of periarticular ossification (see above). Passive movements of paralysed limbs are continued until the patient is mobile and thus capable of ensuring full mobility through his or her own activities, unless there are complications, such as excessive spasm or stiffness. See Box 4.5 for key points in acute management.

A complication that may occur over the few days after injury and remain a risk for some months is the development of pulmonary emboli associated with deep venous thrombosis (DVT). Prophylactic measures, including frequent passive movement, wearing pressure stockings and early mobilization, are important. The use of antithrombolytic agents has become mandatory. Extreme vigilance with regard to leg size and other signs of DVT by all team members is important, as there is a 1–2% incidence of mortality from massive pulmonary embolus each year.

Turning and positioning/tone management

Whilst managed on bed rest patients will require frequent turning. Turning charts can be used to assist staff with a regimen over each 24-hour period, to avoid pressure-marking of anaesthetic skin and offering an opportunity to check skin tolerance. This regimen can be used in conjunction with postural drainage positions. Turning beds can be used to reposition a patient, and the choice of bed depends on the individual unit’s policy.

Upper-limb positioning of the tetraplegic patient is very important during bed rest. Incomplete cervical lesions are particularly prone to shortening of soft tissues due to muscle imbalance, resulting in partial shoulder subluxation and pain.

Waring and Maynard (1991) reported that 75% of tetraplegics had shoulder pain, 60% lasting 2 weeks or more. Of the patients with pain, 39% had unilateral and 61% bilateral symptoms. In over one-third, onset was within the first 3 days postinjury and 52% within the first 2 weeks postinjury. Pain may result from muscle imbalance, spasticity, and direct trauma to the shoulder girdle, combined with the joint immobilization, central and peripheral sources of nerve pain.

Patients who are delayed in the initiation of shoulder exercises beyond 2 weeks post injury are significantly at risk of shoulder pain.

Scott and Donovan (1981) described special positioning to prevent loss of range: 90° abduction, combined with other positioning techniques, leads to decreased frequency and severity of shoulder pain.

Positioning is used to minimize spasticity similarly to patients with other conditions. When the patient is exhibiting mass muscle tone in flexion or extension, the limbs and trunk may be placed into reflex-inhibiting positions. Some examples of positioning are shown in Figures 4.8 and 4.9. Positioning is also discussed in Chapter 14 and by Pope (2002).

Figure 4.9 Side-lying. This position provides a comfortable resting position for the shoulders in side-lying, whilst still maintaining abduction of the shoulder and a supported biceps stretch.

Antispasmodic agents may be prescribed at this stage to assist in the management of high tone and reduce the complications of contracture. Botulinum toxin can be injected into specific muscles to offer the opportunity to gain muscle length, reduce pain and improve joint range of movement. This is particularly useful in the management of shoulders, as they are vulnerable to problems of pain and impingement, resulting from muscle imbalance and hypertonicity in the shoulder girdle musculature.

Preparation for and initiation of mobilization

Patient education should be intergrated into acute management, with the explanation of treatment interventions and jointly developed goals. Rehabilitation should start as soon as patients are well enough and should be encouraged to lead their goal planning.

Once radiographs have confirmed spinal stability, mobilization is initiated by progressively sitting the patient up in bed. Postural hypotension will be the main problem and patients with lesions at T6 and above will require an elasticated abdominal binder. This helps to maintain intrathoracic pressure and reduce pooling of the blood resulting from lack of abdominal tone. Once the patient starts to sit up he or she will be supported in a hard or soft collar, or a brace. Antithrombotic stockings will still be worn. Special adaptations to wheelchairs can help to reduce hypotensive fainting, e.g. reclining back and raised-leg supports. When patients can sit up for an hour they can initiate the more active phase of rehabilitation working towards the restoration of functional activities.

Pressure lifting

This is a technique in which patients lift themselves in their wheelchairs to relieve pressure. It is recommended that they lift every half-hour, for approximately 30 seconds. Where a patient cannot lift, a modified position in forward-leaning or side-to-side tilt is used.

Rehabilitation

The following section outlines management from the start of the mobilization phase through to discharge. Much of this information has been gained from the authors’ experience; procedures may vary between centres but the principles are similar (Bromley, 2006; Whalley Hammell, 1995).

Aims of rehabilitation

• To establish an interdisciplinary process which is patient-focused, comprehensive and coordinated

• Physical motor functional activities with early intervention and prophylaxis to prevent further complications

• To learn new information to equip the individual with knowledge to achieve independence

• To achieve functional independence, whether physical or verbal, and equipment provision in order to facilitate this independence

• To achieve and maintain successful reintegration into the community.

• To achieve psychological adaptation to the newly acquired physical condition.

Goal-planning and outcome measures

Evaluation of progress by review of goal achievement is advised. The goals can be divided into achievable targets and should be patient-focused, appropriate and objective. It is recommended that they are created in a team environment, led by the patient, with interdisciplinary cooperation. It is at this point that patients are fully encouraged to take the locus of control for their rehabilitation. This theme is extended into the philosophy of their future reintegration. Chapter 11 discusses the issues of patient-centred practice in goal-setting and treatment, using a problem-solving approach.

There are several measures used to evaluate patient progress, applicable to an intervention or management technique. In general the World Health Organization recognizes Functional Independence Measures (FIM; Hamilton & Granger, 1991), Spinal Cord Independance Measure (SCIM: Catz A et al., 2007) and Craig Handicap Assessment and Reporting Technique (CHART; Whiteneck et al., 1992) as appropriate validated measures. Other outcome measures are discussed by Stokes (2009).

Objectives of rehabilitation

The progression of objectives as the patient gains more ability is outlined below. These objectives need to be set in relation to the level of spinal injury and the appropriate functional goals (Table 4.3). These expectations for function, depending on level of SCI, can only be a guide, especially in the light of the prevalence of incomplete lesions.

Table 4.3 Functional goals of rehabilitation in relation to the level of the spinal cord lesion

Key elements of the rehabilitation process are considered below.

Psychological aspects

Management of psychological and social issues must take place in parallel with early medical and rehabilitation aspects. It is recognized that patients will experience symptoms of stress and anxiety, and these should be treated specifically. In the early weeks and months after injury, the patient may present with rapid and dramatic changes in mood state and may express denial of his or her situation, anger at what has happened and depression, which may include stating the desire to die.

Although all the members of the MDT will play a role in supporting a patient, advice and guidance from a qualified psychologist are essential and, at times, one-to-one direct patient therapy by the psychologist is necessary. The process of adaptation to spinal paralysis, reflected as integration back into the community, is a gradual one. Maintaining a positive approach with realistic expectations is essential for the patient’s wellbeing (see Ch. 17).

Breaking bad news

It is important that all members of the MDT understand the implications of breaking bad news when undertaking the assessment of a new SCI patient. Often, the physiotherapist is one of the first professionals to compile a thorough physical examination and will be asked for information by the patient. It is an inevitable part of each team member’s role to contribute to discussions of prognosis. A planned team approach is the best way to manage such conversations within the context of the process of information giving. This may not always be possible during a treatment session when the patient may ask about ‘hopeful signs‘. In this case any discussion should be based on accurate assessment with evidence-based reasoning where possible. It is unlikely that an exact answer can be given, in which case a positive emphasis on progressive goals will help the patient to focus on each phase of their rehabilitation.

Pain management

Pain can be a problem initially during movements, notably due to neurodynamics, which is impairment of movement and/or elasticity of the nervous system (Shacklock, 2005). Chronic pain is a common problem in SCI. Between 65 and 85% of patients will experience significant pain and one-third of these will be classified as severe. A modern classification of pain following spinal cord injury has been proposed by Siddall (2009). This divides pain into nociceptive and neuropathic. Nociceptive is subdivided into musculoskeletal and visceral, whilst neuropathic is divided into above, at level and below level. The comprehensive review paper by Siddall (2009) goes on to describe the mechanisms of neuropathic pain and its management with sections on general principles, surgical approaches, pharmacological options, neurostimulation, and psychological and environmental management. With such a wide range of approaches it is clear that none are uniformly successful in pain control. Further research into management systems, with particular emphasis on cognitive systems, is proceeding.

Skin care

Common sites of pressure sores are ischial (from prolonged sitting), sacral (from sheer loading), trochanteric, malleolar, calcaneal and plantar surfaces (from prolonged loading or direct trauma). Spasticity producing contractures and postural deformity are potential risk factors. Although poor nutrition, ageing, incontinence and comorbid factors increase the risk of decubitus ulceration, without ischaemia the ulcers do not arise. Therefore, patients are taught about risk management and provided with pressure redistributing mattresses and cushions.

Spasticity

SCI patients presenting with an upper motor neurone syndrome will exhibit both negative and positive symptoms. Spasticity will be a feature in this patient group, presenting a challenge in all aspects of patient management (Satkunam, 2003). It is a very large subject and requires more consideration than this chapter allows (see Ch. 14). Spasticity is difficult to define and more recently is described as a sensori-motor phenomenon related to the integration of the nervous system motor responses to sensory input. It is related to the hypersensitivity of the reflex arc resulting from the loss of descending inhibition (Ivanhoe & Reistetter, 2004). A further definition states that the disordered sensory-motor control presents as intermittent or sustained involuntary activation of muscles (Pandyan et al., 2005).

In incomplete cord lesions, depending on the pattern, spasticity tends to occur earlier and may present immediately. When severe, it will inhibit any underlying voluntary movement and create ‘wrong’ synaptic connections in the recovering nervous system. In complete spinal cord lesions, it most commonly becomes apparent about 3 months after the injury. It tends to reach a maximum between 6 and 12 months after injury and then diminishes, becoming more manageable. However, in a minority it remains at a high level and presents a major problem affecting function, posture and joint movement (Sheean, 1998).

A moderate amount of spasticity will assist with standing transfers, maintain muscle bulk, protect the skin to some extent and may contribute to prevention of osteoporosis. It is when the spasticity is excessive that problems occur.

Spasticity management

The management of spasticity should be undertaken by a coordinated multidisciplinary team rather than by clinicians in isolation (Barnes et al., 2001). Spinal cord spasticity presents in different patterns to that usually seen in stroke patients (Ch. 2).

The best management is prevention in the first few months after injury (Ditunno et al., 2004). Essentially in the first few days the opportunities for functional connections should be maximized.

It is also important to avoid triggering factors, such as urinary tract infection, constipation or skin breakdown. A collaborative assessment and evaluation tool to determine the best management of spasticity in SCI patients is currently being developed to accompany the document by Barnes et al. (2001).

The main medical approach is through pharmacology, although none of the drugs commonly used (baclofen, dantrolene and tizanidine) is universally effective or indeed predictable in its effect. Nerve blocks have been used for many years, usually using either phenol or alcohol. All of the above drugs have significant and numerous side-effects (see Martindale, 2007). An Intra thecal baclofen pump system can be used to deliver the baclofen directly into the spinal fluid. A small refillable pump is inserted under the skin delivering a regular treatment dose to maintain reduced levels of spasticity. As the use of intramuscular botulinum toxin increases, the use of other nerve blocks will diminish.

Surgery has some place in treatment, in the form of tendon release and nerve divisions, e.g. obturator neurectomy. These techniques can be successful, particularly where the procedure has been carried out for hygiene and posture reasons.

Functional mobility

Bed mobility

Rolling from side to side is taught first, then lying to sitting, and sitting to lying. Function is dependent upon the level of the lesion, e.g. C5, rolling side to side; C6, rolling, lying to sitting and sitting to lying; C7, independent in all aspects of bed mobility.

Experience in using a variety of wheelchairs is helpful when a patient is developing their confidence in wheelchair mobility. Essential principles of safety and wheelchair skills are taught. As the patient progresses they should be given the opportunity to develop advanced skills, such as varied height kerbs, slopes, uneven terrain, tight corners and, if possible, stairs and escalater techniques. Adaptations, such as extended brakes and a modular supportive backrest, are required for higher lesions. Skills in powered chairs are based around safe use of the chair functions, manouvering and experience of outdoor terrain. These chairs may have kerb climbing functions and standing systems.

Transfers

Depending on the level of the lesion and functional ability, a sliding board may be used for legs-up and legs-down transfers on to the bed. This is progressed without a board where possible. Transfers then progress to lifting from various levels for functional activities: high to low; low to high; between two plinths; floor to plinth; floor to chair; chair to car, bath and to easy chair.

Standing programme

Care must be taken when initiating standing. The autonomic disturbance present in patients with cervical and thoracic injuries can result in significant problems with hypotension which in the early stages may affect cord perfusion. Blood pressure studies and monitoring of pressures in sitting and gradual tilt table standing have been suggested (Kassioukov et al., 2009). These problems will usually resolve as the venous return improves.

Bone loss after SCI is greatest in the lower limbs. There is some evidence, although limited, to support standing by any means can improve preservation of bone mass density in the femoral shaft and proximal femur of complete SCI individuals (Goemaere et al., 1994). However the early weight-bearing mobilization of patients might be important in preventing or slowing the bone mineral loss after injury (de Bruin et al., 1999). In practice tilt table standing is commenced as soon as possible. This has many other benefits: respiratory psychological and improved systemic body functions. Standing is of great value in retaining neuromuscular flexibility and in reduction of spasticity (Bohannon & Larkin, 1985; Eng et al., 2001; Goemaere et al., 1994; Golding, 1994).

An abdominal binder and compression stockings are recommended for patients with lesions of T6 and above. Once the patient can stand with no ill effect, progression is made to a standing frame, e.g. Oswestry Standing Frame (OSF), working up to standing for 1 hour, three times a week. Patients with lesions of C5 and below should be capable of standing into a hoist-assisted OSF. There are many standing systems commercially available which will lift the patient into a standing posture. Some wheelchairs also offer this facility. Whilst standing, trunk balance work can be re-educated, for example, removing hand support, throwing and catching a ball. Once good balance is achieved, the paraplegic patient may go on to develop gait with orthoses or actively.

There has been a variety of studies to identify the time and regularity necessary for a patient to stand. It is suggested that the amount of time will influence the reduction in spasticity and at least half an hour every day is recommended (Walter et al., 1999).

Upper-limb management

This activity is continued from the acute phase using a variety of techniques (see Chs 12 & 18). Once the patient has begun to mobilize in the wheelchair there are many options for strengthening during functional activities.

The evidence of shoulder pain in wheelchair users is undeniable – 78% of tetraplegics and 59% of paraplegics, although studies vary in numbers. Specific exercises to address muscle imbalance and maintenance of full range have been shown to reduce this incidence (Curtis et al., 1999).

Other specific exercises can be useful, e.g. assisted/resisted arm bike, resistance circuits and sporting activities. This is an enjoyable adjunct to rehabilitation and encourages reintegration.

Hydrotherapy is used for strengthening and as preparation for swimming. Patients are taught how to roll in the water and to swim. If the patient is wearing a brace, this will limit activities in the water. Anyone with an FVC of less than 1 L will need careful consideration before swimming is introduced.

Strengthening and cardiovascular fitness

The rehabilitation process incorporates components of strengthening and fitness, as part of restoration of function. An average SCI patient is eight times less active than a middle-aged sedentry man. Wheelchair users have an increased risk of secondary disabilities such as coronary heart disease, obesity, hypertension and diabetes (Finley et al., 2002). The changes in muscle function resulting from SCI lead to reduced energy expenditure and decreased strength.

Patients are motivated to achieve their physical goals in a variety of ways. Fitness training using adapted equipment is useful, e.g. an arm-powered ergonomic bike may be used for endurance. Wheelchair circuits and advanced skills are encouraged. Hydrotherapy can lead on to swimming, an enjoyable activity that can improve cardiovascular fitness. The emphasis on education for patients and the establishment of an ongoing fitness programme for SCI individuals has become a priority within the Spinal Cord Injury Centres.

The value of sports activities cannot be underestimated, even for those people who did not enjoy sports previously. The known benefits of group or sports activities translate into the rehabilitation process. Patients will often sustain an activity for much longer when engaged in a sport.

There are many charities and organizations available to promote these opportunities and to support equipment funding for SCI individuals. Activities can eventually progress to more competitive sports and clubs, as well as encouraging attendance at the many fully integrated fitness centres available. Cardiovascular fitness after SCI has been reviewed (Finley et al., 2002; Jacobs & Nash, 2001) and in general for neurological conditions in Chapter 18.

Functional electrical stimulation effects on muscle and fitness

Many studies have investigated the effects of using FES to support exercise in SCI individuals. The positive effects of FES exercise are well established, although intensity, duration and frequency of these interventions all vary (Giangregorio & McCartney, 2006). FES exercise can produce isometric contractions resulting in an increase in muscle cross-sectional area. FES cycle ergonometry (Figure 4.10) has demonstrated increases in muscle fibre area and capillary bed (Belanger et al., 2000) in addition to increasing whole body metabolism and cardiovascular fitness (Davis et al., 2008).

Figure 4.10 Patient using functional electrical stimulation (FES) a leg cycle ergometer.

Functional electrical stimulation in restoration of function and gait

Research and technologies have influenced our clinical practice, e.g. body weight support treadmill gait training (Figure 4.11) is based around the central pattern generator (CPG) theory (see below). Research to incorporate FES with this training is underway. In the future methods that use the concept of activity-dependent neuroplasticity will most likely play an increasing role in the rehabilitation of SCI.

Figure 4.11 Patient using body weight support gantry and treadmill.

FES and its role in functional activities and gait requires further evaluation. A comprehensive review by Ragnarsson (2008) identifies the current state-of-the-art and future therapeutic potential. It has been used as a neuroprosthesis in activities of daily living (ADL) to restore upper-limb function. Surface FES systems that aim to assist paraplegic patients to walk are already approved in the USA – Parastep System (Sigmedics, Inc., IL, USA) and for incomplete injuries the Odstock Drop Foot Stimulator is widely used. The implanted devices for foot drop have been developed and are curently being used in clinical practice (Chae et al., 2000).

Despite promising advances in technology, the physiological limitations of the neuromuscular system prohibit the clinical use of FES alone to achieve a realistic and successful functional outcome. Gait remains inefficient, needing high energy levels. It has been demonstrated that function achieved through an external locus of control will always be of limited value to patients (Bradley, 1994). The recent research is seeking to provide cortical patterns of activity to trigger the stimulation for movement (Grill et al., 2001).

Some patients choose to use FES to maintain muscle bulk for cosmesis and others to maintain bulk or leg circulation for reduction of pressure over bony areas. Patients who are very slim with bony prominences are predisposed to pressure marking and the maintenance of muscle bulk by FES can help to reduce this problem and allow them to sit for longer in their wheelchair.

Ongoing respiratory management

Tetraplegic and some high thoracic paraplegic patients will benefit from ongoing respiratory monitoring and from respiratory training. Respiratory capacity is impaired by motor weakness, spasticity and pain. Inspiratory muscle-training devices provide resistance through a variety of devices or valves. Some studies have demonstrated some limited benefit for improving FVC (Hough, 2001; Van Houtte et al., 2006). More recently devices have been developed to produce training through the ‘Test of Incremental Respiratory Endurance (TIRE) protocol. This system produces inspiratory muscle training working at 80% of the maximum performance (Figure 4.12). The visual display provides a goal-orientated programme for the individual to try to beat during each exercise session (www.trainair.co.uk).

Figure 4.12 Respiratory Training Device.

(From TRAINAIR, Inspiratory Muscle Training, with permission.)

Education/advice to carers/family

Carers are actively involved in the rehabilitation process and are taught how to assist with normal daily activities, to support the patient in independent living. Assisted exercises, standing programme and chest care are taught in addition to moving and handling the patient, whilst paying attention to skin care and their own safety and back care. This support is within a holistic educational advocacy provided by case mangers during rehabilitation.

Wheelchairs

The variety of wheelchairs available increases each year, including some that enable the patient to rise into standing. Initially, patients are mobilized in a standard wheelchair offering greatest support and stability, following a comprehensive assessment to ensure it is correctly fitted and adjusted. Adaptations are made to provide a well-supported, evenly balanced seating position (Harvey, 2008; Pope, 2002). Tension adjustable canvas systems and modular backrests are all valuable in producing postural control.

The key to good stability is achieved by support and alignment at the pelvis. The cushion is equally important and should be assessed in a similar way, also taking into account the need for protection of pressure areas. Various pressure assessment tools are used to evaluate skin viability when sitting and these aid cushion prescription (Barbenel et al., 1983). Later in rehabilitation, it will be appropriate to try a variety of wheelchairs to offer greater mobility and independence according to an individual’s needs. In view of the incidence of shoulder pain in wheelchair users (Ballinger et al., 2000), it is appropriate to consider adaptations and weight of the wheelchairs. There are many light-weight wheelchairs available and the use of assisted wheeling systems can ease the effort of wheeling. A battery-powered third wheel or trike adaptation can be fitted onto the front of a light weight manual wheelchair to provide assisted mobility outdoors.

Powered chairs

All tetraplegic patients should always be provided with a powered chair, even if they chose a manual light-weight chair initially. This should also be considered for some paraplegics, depending on their age and expected functional activities.

Rehabilitation of incomplete lesions

The management of the incomplete patient presents many challenges, not least because experience has shown that the expected outcomes are unknown. This can affect the psychological adjustment of the patient and, as physical changes extend over many years, may delay patients in moving on with their life.

Emphasis is placed on managing muscle imbalance, spasticity and tone, and sensory loss. As incomplete lesions present with a wide range of loss of functional activity, treatment will depend on the level of disability and specific physical problems.

Treatment may include: facilitation of normal movement patterns; muscle strengthening (see Ch. 18); addressing muscle imbalance and compensations; and inhibition of spasticity (see Ch. 14). Balance re-education, gait re-education, wheelchair skills and functional activities are performed as appropriate to the patient’s level of ability.

Research suggests that patterned neural activity may be an important mechanism for developing and maintaining inhibitory circuitry (McDonald et al., 2002). There have been many studies exploring gait facilitation using a partial weight-bearing system on the treadmill. This approach is based on the principles of CPGs and repeated exercise of gait motion to increase strength, coordination and endurance (Ladouceur et al., 1997). There is evidence from animal studies that neural networks in the isolated spinal cord are capable of generating rhythmic output (reciprocally organized between agonists and antagonists) in the absence of efferent descending and movement-related afferent sources (Duysens & Van de Crommert, 1998). This is postulated to be similar in humans. Spinal systems contribute to the control of locomotion by local segmental and intersegmental spinal circuits (Grillner & Wallen, 1985).

In normal walking, it has been shown that muscle activity patterns are not centrally generated by reflex-induced activity, e.g. through stretch reflexes (Prochazka et al., 1979). The gait facilitation on the treadmill system is thought to be influenced by three main sensory sources acting on the CPGs:

1. Load/proprioceptive feedback from the extensor muscles

2. Exteroceptive afferents from the mechanreceptors of the foot

3. Joint position and muscle stretch from the hip flexors and ankle plantarflexors.

Some outcome measures being assessed as evaluation tools for this work in the national spinal injuries centres are: Walking Index for Spinal Cord Injury (WISCI; Ditunno et al., 2000) and WISCI II (Ditunno et al., 2001).

There have been concerns from physiotherapists against gait exercise too early, causing the development of ‘wrong patterns’. The motion of the hip is helped by the harness so as to move almost entirely within normal range limits. Therapists helping to guide foot placement manually found this an effective way of controlling motion and blocking abnormal harmful patterns. FES has been introduced as an adjunct to assist with the gait pattern (see Ch. 12). The advantages of this gait training would be to improve systemic functions and stimulate the vegetative nervous sequelae. Early training with some weight-bearing may help reduce osteoporosis and patients have been shown to need less support after training (Abel et al., 2002).

Questions remain if this treatment is effective: is progress due to other factors, e.g. muscle plasticity or spontaneous recovery, or can the cord learn from the increased demands of loading the limbs? The supraspinal and afferent influences on the cord are not yet understood in humans.

Patients with LMN damage require early diagnosis and may benefit from acute surgical and later restorative interventions, and also provision of orthoses to accommodate for the weakness.

Assisted gait, calipers and orthoses

During rehabilitation, the patient may be assessed for suitability for walking with orthoses. Depending on the fracture, gait training will normally commence about a year after surgery, or earlier if no fixation surgery was indicated or if the patient is incomplete. There should be surgical review on an individual basis. Some patients may require a temporary orthosis during their recovery.

It should be recognized that, even if a patient has the ability to walk with calipers, he or she may not choose to or may be advised not to try. Techniques used for gait training have been discussed in detail by Bromley (2006) and an outline of the progression of training is given below.

The gait-training process is physically demanding and requires commitment. Criteria which should be considered include:

• appropriate risk assessment

• sufficient upper-limb strength to lift body weight

• full ROM of hips and knees, and no contracture

• cardiovascular fitness sufficient to sustain walking activity

• assessment of spinal deformity, e.g. scoliosis, that may hinder standing balance

• motivation of the patient

• assessment of spasticity that may make walking unsafe.

Experience has shown that many patients complete their training with calipers, only to discard them a few months or years later as walking has become too much effort. Wheelchair use may be preferable, as the hands are free for functional activities whereas they are not when walking with calipers.

Orthoses

The ability to walk with calipers and the degree of support required depend on the functional level of injury. The following are examples of orthoses used for different levels of injury:

• C7–L1: hip guidance orthosis (HGO), advanced reciprocal gait orthosis (ARGO), RGO, Walkabout

• T6–T12: caliper walk/Walkabout with rollator; progress to crutches depends on patient’s function

• T9–L3: caliper walk with comfortable handle crutches

• L3 and below: appropriate orthoses or walking aid.

Initial gait work

Caliper training is commenced in backslabs of fibreglass (Dynacast) or similar light-weight casting material. The backslabs are bandaged on and toe springs applied. For all orthotic gait training adjustable training orthoses are used. Standing balance is achieved in the parallel bars, in front of a mirror, by standing in extension and resting back on the tension of the iliofemoral ligaments. The lifting technique is taught in the standing position, lifting the whole body weight with full control. Lift from sitting to standing and back to sitting is also taught.

Once the patient has achieved standing balance and the appropriate degree of support required, dynamic balance work is started. This includes turning safely, swing-to and swing-through gait patterns, and the four-point gait technique for stepping practice.

Transfers

Transferring in backslabs is then practised, from plinth to chair, chair to plinth, and from chair to standing.

Middle stage of gait work

Progression to a rollator or crutches is begun at this stage. Balance is achieved using one parallel bar and one crutch, or with a rollator and one person to assist. Gait patterns and transfers (described above) are then practised. Depending on the functional level, four-point gait with crutches is taught, then kerbs, slopes and stairs. Video assessment for problem-solving and improvement of gait techniques may be useful at this stage.

Late stage of gait work

On completion of training, the patient is measured for the definitive othoses. For patients using reciprocal gait orthoses, gait re-education is practised in the parallel bars then progressed to a rollator and possibly crutches, as outlined above.

A home standing programme for caliper patients is devised to improve confidence. This entails using backslabs daily to maintain strength and cardiovascular fitness and to improve mobility. Goals are decided mutually as to how calipers and walking aids will be used at home and at work, to achieve optimum function.

The long-term ventilated patient

Increased survival of patients with high lesions is now expected, especially in the young. Resettlement into the community requires domiciliary ventilation and a complex care package.

Once past the acute phase, their individual needs are ascertained. Specialized wheelchairs are available which can be mouth- or head-controlled. Prophylactic chest management is vital, with tracheostomy, regular bagging and suction to reduce atelectasis and prevent infection (see Ch. 15). FES for the abdominal muscles has been evaluated as a method to assist coughing (Linder, 1993).

Non-invasive ventilation may be appropriate for some patients and some others may be candidates for diaphragmatic pacing. Usually those with lesions above C3 are most successful. Lesions of C4 segmental level tend to have involvement of the anterior horn and cannot be stimulated, as stimulation relies on an intact lower motor neuron system.

Assessment involves nerve conduction studies and may include fluoroscopic examination to visualize diaphragmatic excursion (Zejdlik, 1992). Electrodes are placed around the phrenic nerve either in the thorax or neck. An external pacing box is attached to external transmitter antennae; these are placed over the implanted receivers and when stimulated provide diaphragmatic contraction (Buchanan & Nawoezenski, 1987). There is no set regime for training but some patients have managed to achieve 24-hour pacing. Others use the ventilator part-time.

Initially, physiotherapy will aim to maximize strength in all innervated muscles to assist in head control and strengthen accessory respiratory muscles. Glossopharyngeal breathing techniques and use of a biofeedback training system can allow the patient to manage for short periods off the ventilator. Regular tilt table standing is recommended in addition to passive movements. Management of spasticity is also an important consideration (see Ch. 14) and may involve medication.

The aim for these patients is to achieve verbal independence and control of their environment. Technology offers systems linked to computerized environmental controls, operated by a head or mouth control, or voice-activated.