Physiotherapy Management of Individuals with Spinal Cord Injury

Original Editor - Naomi O'Reilly

Top Contributors - Eugenie Lamprecht, Naomi O'Reilly, Vidya Acharya, Admin, Ewa Jaraczewska, Kim Jackson, Simisola Ajeyalemi and Rucha Gadgil  

Introduction

Spinal Cord Injuries (SCI) can be defined as a traumatic or non-traumatic event that leads to neural damage that influences motor-, sensory - and respiratory function, as well as bladder -, bowel - and sexual function. The neurological interruption also affects the individual's blood pressure, skin integrity and ability to regulate temperature.

SCIs don't only have an impact on the individuals' physical - and emotional well-being, but it also has a considerable impact on families, communities and healthcare systems worldwide. Literature indicates the peak age between 12 and 30 years, with an average life span as 30.2 years following injury. The total prevalence for the USA, Australia, Iceland and Europe was estimated to range between 250 and 721 per million.

SCI, most commonly, results in paraplegia or tetraplegia. Paraplegia is the loss in motor and/ or sensory function in the lower limbs (LLs) and trunk. While tetraplegia includes the upper limbs (ULs) to the motor and/ or sensory loss of the LLs and trunk.

Important concepts for Physiotherapists

It's important that all Physiotherapists understand the following concepts and their relevance to the management process.

1. Vertebral injuries (acute phase - affects the intensity of therapy)
2. Spinal shock (reflexes are temporarily absent for 3 days to 3 months)
3. Autonomic dysreflexia (SCI above T6 - leads to increased sympathetic activity
4. Postural hypotension (blood pressure associated dizziness due to postural changes - mobilising from supine to sitting)
5. Deep venous thrombosis (DVTs) and Pulmonary embolus (PE) (know the signs and symptoms of these conditions to ensure safe therapy)
6. Bladder- & Bowel dysfunction
7. Pressure ulcers (prevention forms part of therapy sessions)
8. Heterotopic ossification (calcification of soft tissue that can lead to contractures)
9. Psychological and emotional distress (notice signs and symptoms and refer to appropriate team members

Physiotherapy management

The acute management and rehabilitation of SCI depend on the level and type of injury to the spinal cord. Individuals with a SCI often require initial treatment in an intensive care unit with the rehabilitation process typically starting in the acute care setting, followed by extended treatment in a specialised Spinal Injury Unit. Inpatient management can last from 8 - 24 weeks, with follow up outpatient rehabilitation from 3 - 12 months, generally followed by yearly medical and functional reviews. 

The management of an individual with SCI is complex and lifelong requiring a multidisciplinary approach. A functional, goal-oriented, interdisciplinary, rehabilitation programme should enable the individual with a spinal cord injury to live as full and independent a life as possible. Physiotherapy, occupational therapy, speech and language therapy, rehabilitation nurses, social workers, psychologists and other health and social care professionals work as a team under the coordination of a Physiatrist or Rehabilitation Physician to decide on goals with the individual and develop a plan of discharge that is appropriate for the individuals level of injury and circumstances. 

Five key steps in the management of individuals with SCI are;

• Assessing impairments, activity limitations and participation restrictions
• Setting goals relevant to activity limitations and participation restrictions
• Identifying key impairments that are limiting achievement of goals
• Identifying and administering physiotherapy treatments (strengthening, joint mobility, motor skill development, cardiovascular fitness, respiratory functioning, pain managing)
• Measuring the outcome of treatments

The management of individuals with a SCI can be divided into 3 Phases;

1. Acute,
2. Subacute (Rehabilitation), and
3. Chronic (Long Term).

During the acute and subacute phases of treatment, rehabilitation strategies focus more on prevention of secondary complications, promoting neuro recovery, addressing underlying impairments and maximizing function. In the chronic phase, compensatory or assistive approaches are often used.

Acute Phase

The prevention of complications arising from spinal instability or neurological compromise involves all members of the multi-disciplinary team. In this early phase post-injury, physiotherapy management is predominantly involved in the prevention and management of respiratory and circulatory complications, as well as minimising the impact of immobilization on the individual e.g. pressure ulcer - and contracture development.

Objectives

Treatment objectives in the acute phase include:

• to institute a prophylactic respiratory regimen to manage respiratory conditions and any complications as a result of the spinal cord injury or associated conditions e.g. decrease incidence 
atelectasis, enhance clearance of 
secretions 

• to achieve independent respiratory status where possible
• to maintain full range of movement of all joints within the limitations determined by the stability of the fracture  
• to monitor and manage neurological status 
• to maintain and strengthen all innervated muscle groups 
• to facilitate functional patterns of activity
• to support and educate the patient, carer’s, family and staff

Rehabilitation Phase

The rehabilitation needs of individuals with a spinal cord injured people are best at a specialised Spinal Cord Injury Unit, but often rehabilitation begins in the Acute or Trauma Hospital while the individual is awaiting transfer to a Spinal Injuries Unit. Rehabilitation requires consideration of the whole person, their physical, psychological, vocational and social background. The rehabilitation process is a goal-directed, and time-limited process aimed at facilitating maximal independence and optimal reintegration back into the individual’s chosen community role and lifestyle. 

Physiotherapy is a key component during the rehabilitation process following spinal cord injury and includes a variety of interventions that address multiple domains in the International Classification of Functioning, Disability and Health (ICF) including body function and structure, activity limitation, and participation, with many interventions directed at preventing, rather than treating, impairments, activity limitation and participation restrictions. 
Quality of Life including community participation, gainful employment, interpersonal relationships, and leisure activities have become the overriding focus of management.

Objectives

Treatment objectives of the rehabilitation phase include:

• to establish an interdisciplinary process which is patient-focused, comprehensive and co-ordinated
• to address physical motor functional activities with early intervention and management to prevent further 
complications
• to improve an individual’s independence in activities of daily living, such as bathing, eating, dressing, grooming, and mobility
• 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.

The range of therapy activities used by physiotherapists during rehabilitation varies depending on the level and type of injury. The three most common individual therapy activities for individuals with high-level tetraplegia were - range of movement/stretching, strengthening, and transfers; while for those with low tetraplegia, more time was spent on transfers than strengthening. Similarly, in individuals with paraplegia, the most common individual physiotherapy activities were transfers, followed by range of movement/stretching, and strengthening. Gait training, strengthening, and balance exercises were the most common physiotherapy activities in individuals with an AIS D spinal cord injury. Overall strengthening was the most common group therapy activity across all levels and types of spinal cord injury.

Long Term Phase

Individuals with a spinal cord injury, depending on the level and type of lesion, may have many complex needs and face wide-ranging, long-term restrictions in their ability to live independently, drive or use public transport, return to work or education, participate in leisure and social activities. To ensure successful long term management coordinated community rehabilitation services and long-term support is required to meet the long-term and on-going needs of individuals with a spinal cord injury. Best practice in long term management includes active case management with case managers with the appropriate training, clinical expertise and knowledge of services to co-ordinate care post initial rehabilitation and ensure on-going personalised case management for patients with complex or on-going needs. 


Objectives

Treatment objectives of the long term phase include:

• to achieve high-level mobility goals 
required for community participation 

• to monitor the recovery of function 
 

• to reinforce family and carer training

 


References