Management of Spinal Cord Injury in Low Resource Settings

Original Editor - Habibu Salisu Badamasi

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Introduction[edit | edit source]

Spinal cord injury (SCI) is a devastating condition which is associated with permanent disability and decreased life expectancy. In low-income countries and in many middle-income ones many people with spinal cord injury (SCI) are likely to live with limited access to appropriate health care and rehabilitation services creating barriers that increase the risk of contracting harmful pressure sores and infections leading to premature death. People with spinal cord injury (SCI) in low income countries face serious challenges in their daily lives as a result of lack of appropriate wheelchairs and services, limited knowledge about SCI among health care staff, limited access to health care and rehabilitation services, loss of employment and lack of financial resources worsen the daily challenges.[1] Low and middle-income countries (LMICs) are often also described as "low resourced settings" or simply LMICs.[2]

Epidemiology/Etiology[edit | edit source]

The incidence of SCI in developing countries is 25.5/million/year and ranges from 2.1 to 130.7/million/year. Males comprised 82.8% of all SCIs. The two leading causes of SCI were found to be motor vehicle crashes and falls. Complete SCIs were found to be more common than incomplete injuries. Similarly, paraplegia was found to be more common than tetraplegia.[3] The life expectancy for individuals with SCI in low income settings is shorter than for the average population and also with respect to individuals with SCI in high income countries [1]

Preventable secondary conditions (e.g. infections from untreated pressure ulcers) are no longer among the leading causes of death of people with spinal cord injury in high-income countries, but these conditions remain the main causes of death of people with spinal cord injury in low-income countries.[4]

  1. Traumatic spinal cord injury-Traumatic SCI can result from several different mechanisms, e.g. road traffic crashes, falls, violence, while undertaking different activities, e.g. at work, during sport or while at home.
  2. Non-traumatic spinal cord injury-non-traumatic causes of spinal cord dysfunction include:
  • noncommunicable conditions − cancer, degenerative diseases such as osteoarthritis leading to spinal stenosis, cardiovascular disease;
  • complications of medical care.

Management of spinal cord injury[edit | edit source]

Spinal cord injury clinical guidelines have shown to improved outcomes in the developed country, less effective in low resource settings, possibly due to lack of infrastructure, equipment, and trained personnel[5]

Acute stage[edit | edit source]

management of spinal cord injury (SCI) patient during acute stage is primarily to treat and prevent respiratory and other complications associated with bed rest and sudden onset of paralysis.[6]

Respiratory management; After spinal cord injury the mechanics of respiration will be altered for injuries above Sternum skeletal level T12. If a person has tetraplegia or high paraplegia then the chest and stomach muscles will be paralyzed and coughing will be difficult without help. Coughing keeps the lungs clear of secretions.The following procedure keeps the lungs clear.

  1. Assisted coughing

This is when the SCI person is unable to clear their own chest without help. Their cough is ineffective due to paralysis of the chest and stomach muscles. Coughing with the help of another person  is called an assisted cough. Assisted coughing can be performed in bed or in the wheelchair, by a helper or sometimes by the person with SCI. There are various techniques that can be used in the bed or in the chair.

  • One man assisted cough in be
  • Assisted cough on bed
  • Two man assisted cough in bed
  • One man assisted cough in the chair

2. Turning and positioning

Turning keeps the secretions moving which makes them easy to cough up with assistance. If phlegm starts to collect in the lungs, the foot end of the bed can be raised (e.g. with two bricks) so that the  feet are a little higher than the head. This will help to drain the phlegm from the lungs so that it can be coughed up and spat out. The foot end of the bed should be raised up twice per day for about 20 minutes each time. It is best to do this when they Self cough in chair are lying on their side.

Rehabilitation stage[edit | edit source]

Spinal cord injury rehabilitation are best described within the conceptual framework of the International classification of functioning,Disability and Health (ICF) .[7] The impairment that commonly impose activity limitations and participation restriction on people with SCI. These impairments  can be managed by available local resources

Strength[edit | edit source]

Voluntary strength of neurally intact muscle can be improved with strength training.[6]

Para lifting iscis.jpg

Joint mobility[edit | edit source]

poor joint mobility can cause contractures: are a common complication of spinal cord injury (SCI)

They are characterised by a reduction in joint range of motion or an increased resistance to passive joint movement both limiting joint mobility.[6]

They are undesirable because they can cause:


Simple strategies to treat and prevent some of the common types of contractures include:

Encouraging patients to stand on a regular basis to stretch or maintain length of the lower limb muscles.

motor skill[edit | edit source]

A key component of gaining functional independence is learning how to perform motor tasks following SCI. The common ways of performing each motor task are best described in terms of sub-tasks. Sub-tasks are the critical steps required for successful performance of a task. For example, transferring from wheelchair to bed for a person with C6 tetraplegia includes key sub-tasks. These sub-tasks are different depending on the method used to transfer.[6]

Self-Management Practices[edit | edit source]

Prior to discharge at outpatients, knowledge about self-care preventive measures are told to Spinal cord injured patients. This strengthens patients’ self-management abilities and also enhance patients’ self-efficacy. The family caregivers should also be involved in this empowerment to ensure continuous support of the patients at home. lack of knowledge on self management , will negatively affect pressure ulcer prevention practices.[7]

Community-Based Rehabilitation[edit | edit source]

In low-income countries and particularly in rural areas, the range of rehabilitation services available and accessible is often limited. There may only be one rehabilitation center in the major city of a country, for example, or therapists may be available only in hospitals or large clinics. Therefore, community-based strategies such as CBR are essential to link and provide people with disabilities and their families with rehabilitation services. A mixed study shows that a community-based intervention using regular telephone calls and home visits over the first two years after discharge was found to be a feasible approach, culturally appropriate, and valued by the participants and healthcare professionals. It helped in prevent and manage pressure injuries, reduced patients' sense of social isolation, and developed trust in physiotherapists who addressed the complex clinical, psychological, and social problems[8].

Vocational Training and Supported Employment[edit | edit source]

Vocational rehabilitation is very relevant in low-resource settings where there is generally more reliance on informal support networks .Vocational rehabilitation is multidisciplinary approach that aims to return a worker to gainful employment or to facilitate participation in the workforce, usually includes more specialized services such as vocational guidance and counselling, vocational training, and job placement to optimize the chances of employment. The need for general social support for people with SCI is recognized as a significant factor for successful re-entry into employment. After a traumatic injury, many believe that they are no longer capable of performing tasks necessary for work. psychosocial support from SCI peers, family members and close friends can be highly effective in encouraging the individual to continue the journey back to employment.[5]

Wheelchair Man Sitting.jpg

Prevention[edit | edit source]

The leading causes of spinal cord injury are road traffic crashes, falls and violence. A significant proportion of traumatic spinal cord injury is due to work or sports-related injuries. Effective interventions are available to prevent several of the main causes of spinal cord injury, including improvements in roads, vehicles and people’s behaviour on the roads to avoid road traffic crashes, window guards to prevent falls,and access to firearms to reduce violence.[4]


Improving care and overcoming barriers[edit | edit source]

Many of the consequences associated with spinal cord injury do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments.[4]

Implementation of the UN Convention on the Rights of Persons with Disabilities (CRPD) requires action to address these gaps and barriers.

Essential measures for improving the survival, health and participation of people with spinal cord injury include the following.

  • Timely, appropriate pre-hospital management: quick recognition of suspected spinal cord injury, rapid evaluation and initiation of injury management, including immobilization of the spine.
  • Acute care (including surgical intervention) appropriate to the type and severity of injury, degree of instability, presence of neural compression, and in accordance with the wishes of the patient and their family.
  • Access to ongoing health care, health education and products (e.g. catheters) to reduce risk of secondary conditions and improve quality of life.
  • Access to skilled rehabilitation and mental health services to maximize functioning, independence, overall well being and community integration. Management of bladder and bowel function is of primary importance.
  • Access to appropriate assistive devices that can enable people to perform everyday activities they would not otherwise be able to undertake, reducing functional limitations and dependency. Only 5-15% of people in low- and middle-income countries have access to the assistive devices they need.
  • Specialized knowledge and skills among providers of medical care and rehabilitation services

Resources[edit | edit source]

International Classification of Functioning, Disability and Health (ICF)

WHO international perspectives on SCI

Guidelines on the provision of manual wheelchairs in less resourced settings.

Community-based rehabilitation: CBR guidelines

References[edit | edit source]

  1. 1.0 1.1 Øderud T. Surviving spinal cord injury in low income countries. African Journal of Disability. 2014;3(2)
  2. World Bank. World Bank Country and Lending Groups. Available from: (accessed 12/09/2020)
  3. Rahimi-Movaghar V, Sayyah MK, Akbari H, Khorramirouz R, Rasouli MR, Moradi-Lakeh M, Shokraneh F, Vaccaro AR. Epidemiology of traumatic spinal cord injury in developing countries: a systematic review. Neuroepidemiology. 2013;41(2):65-85
  4. 4.0 4.1 4.2 McDonald JW, Sadowsky C. Spinal-cord injury. The Lancet. 2002 Feb 2;359(9304):417-25.
  5. 5.0 5.1 Bickenbach J, Officer A, Shakespeare T, von Groote P, World Health Organization. International perspectives on spinal cord injury. World Health Organization; 2013.
  6. 6.0 6.1 6.2 6.3 Chhabra HS. ISCoS textbook on comprehensive management of spinal cord injuries. Wolters kluwer india Pvt Ltd; 2015.
  7. 7.0 7.1 Gosselin RA, Coppotelli C. A follow-up study of patients with spinal cord injury in Sierra Leone. International orthopaedics. 2005 Oct 1;29(5):330-2.
  8. Liu H, Hossain MS, Islam MS, Rahman MA, Costa PD, Herbert RD, Jan S, Cameron ID, Muldoon S, Chhabra HS, Lindley RI. Understanding how a community-based intervention for people with spinal cord injury in Bangladesh was delivered as part of a randomised controlled trial: a process evaluation. Spinal cord. 2020 Nov;58(11):1166-75.