Physiotherapy Management of Individuals with Spinal Cord Injury

Introduction

Spinal Cord Segments and body representation.png
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.[1]

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[2].

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[1].

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. Orthostatic 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[1]

For more in-depth explanation regarding common complications among individuals with spinal cord injuries, see; 'Medical Complications in Spinal Cord Injury'.

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. [3][4][5]

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. [4][5][6]

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[1]

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

  1. Acute,
  2. Sub-acute (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[3][6].

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. [4][5]

Objectives

Treatment objectives in the acute phase include: [3]

  • 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 an independent respiratory status where possible
  • to maintain the full range of movement of all joints within the limitations determined by the stability of the fracture  
  • to monitor and manage the 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

Respiratory function[1]

Common secondary complications include hypoventilation, atelectasis, secretion retention and pneumonia.

The respiratory function is affected due to disruption in the spinal cord relevant to the neurological level of the SCI.

Levels of innervations are; C3-5 Diaphragm, C3-8 Scelenes, C5-T1 Pectoralis, T1-11 Intercostalis and T6-12 Abdominals.

Individuals with C1-3 tetraplegia requires mechanical ventilation, while most individuals with C4 tetraplegia will be able to breathe independently. Although individuals with SCI C4 to T12 can breathe independently, they might still have reduced vital capacity and difficulty in raising intra-abdominal pressure for an effective cough or other forced-expiratory techniques (FETs).

Physiotherapy interventions should always include secretion clearance and increased ventilatory techniques. Secretion clearance techniques include percussions, vibrations and shaking, as well as postural drainage and suctioning. Treatment to improve ventilation includes abdominal binders, positioning, deep breathing exercises, incentive spirometry and inspiratory muscle training. Other medical equipment often used to improve ventilation are continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP).

Full range of movement (FROM) of all joints[1]

Reduced ROM may lead to contractures due to immobility and poor positioning, as well as increased tone and spasticity.

Treatment techniques should include passive stretches, positioning in the lengthened position and other common hypertonic treatment techniques such as compression, heat and sustained deep pressure.

Prevention of pressure ulcers[1]

Areas prone to pressure ulcers include; the occiput, scapulas, sacrum and the heels when lying in supine. While the greater trochanter and malleoli are more prone in side-lying.

In the acute phase, interventions include passive pressure care, such as frequent rolling regimes and mobilizing, as well as adequate skin moisturizing, nutrition and monitoring.

Later, in the sub-acute and long-term phases, individuals will be taught how to perform frequent self-lift techniques in order to relieve pressure.

Maintaining and strengthening innervated muscles[1]

Progressive resistance training and functional strength training is clinically identified to achieve favourable results in maintaining and strengthening innervated muscle groups.

Dosage for strengthening (progressive resistance training):

  • one to three sets of 8-12 reps (rest 1-3mins between sets)
  • load 60-70% of one-rep max
  • 2-3x per week

In order to target endurance; reduce load and increase repetitions.

Sub-acute (Rehabilitation) Phase

The rehabilitation needs of individuals with a SCI 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. [3][6]

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. [3][6]

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 equipment 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.

Individuals with different levels of SCI perform different motor tasks differently and it's important for physiotherapists to understand which functions are obtainable relevant to the SCI level. All motor tasks should be divided into sub-tasks in order to perform activities optimally. In order to perform motor tasks successfully individuals should have sufficient strength, balance, ROM and knowledge or skill regarding the specific motor task. All these aspects can be achieved through frequent progressive training.

Bed mobility and transfers[1]

C6 and lower level SCI have the ability to attain 5 motor skills;

  1. rolling (using momentum) -
  2. mobilizing from supine to long-sitting
  3. unsupported sitting (short- & long sitting)
  4. lifting vertically
  5. transfers

C6 tetraplegia may have some challenges, but these 5 motor skills are still possible with some modifications. With rolling, C6 tetraplegia should externally rotate shoulders and swing arms across their body instead of over-head. During unsupported sitting, C6 tetraplegia should externally rotate shoulders and lock elbows in extension to maintain balance. Vertical lifting for individuals with C6 tetraplegia can be possible by passively extending elbows, externally rotating shoulders and depressing shoulders to weight bear with hands placed anteriorly to the pelvis.

Wheelchair (WC) mobility[1]

Individuals with C1-4 tetraplegia requires powered-WCs. These WCs may be controlled by chin-movements, sip and puff or head array.

Individuals with C5 tetraplegia most commonly use powered-WCs controlled by hand movement.

Most individuals with C6-8 tetraplegia are able to independently mobilise with a manual-WC, however, might use hand-controlled WC as alternatives.

Individuals with SCI lower than C8 will be able to independently mobilise with a manual-WC.

Individuals with SCI should be orientated to their new way of mobilisation. Turning, opening and closing doors, going up and down inclines, going around and over obstacles, as well as mobilising indoors and outdoors are important activities to practice in order to ensure safe and independent mobility.

The recent study concludes that participants with SCI predict the importance of fall prevention initiatives that extend beyond the offered strategies, suggesting a need for the structure and content of future fall prevention strategies for wheelchair users. Further research is required to examine the efficacy of specific fall prevention initiatives by collecting feedback from community-dwelling wheelchair users with SCI.[12]

Gait and standing[1]

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.

The ability to stand or walk is dependent on several factors however, standing has many benefits even if independent standing might never be a possibility. Benefits include emotional wellbeing, orthostatic hypotension, bone mineral density, spasticity, bladder and bowel function. Standing can be attained by using assistive devices such as; tilt tables, standing WCs and/ or standing frames. Individuals with paraplegia might be able to stand in parallel bars using knee-extension splints or orthoses.

Gait training is possible among individuals with complete paraplegia to partially paralysed LLs by using orthoses and walking aids such as; knee-ankle-foot and hip-knee-ankle-foot orthoses.

Other important aspects of rehabilitation is;

Cardiovascular fitness and pain management.

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. A prospective longitudinal study suggests the need for screening of efficacy of patients and their family members to help prevent personal and family adjustment problems as low self-efficacy of the patients/family members appears to be a risk factor for adjustment problems in individuals with spinal cord injuries [14].

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

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Elearnsci.org. (2020). eLearnSCI :: Modules. [online] Available at: http://www.elearnsci.org/intro.aspx?id=4&category=Physiotherapists [Accessed 19 Feb. 2020].
  2. Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global prevalence and incidence of traumatic spinal cord injury. Clinical epidemiology. 2014;6:309.
  3. 3.0 3.1 3.2 3.3 3.4 Stack E, Stokes M, editors. Physical Management for Neurological Conditions. Elsevier Churchill Livingstone; 2012.
  4. 4.0 4.1 4.2 Lu X, Battistuzzo CR, Zoghi M, Galea MP. Effects of Training on Upper Limb Function after Cervical Spinal Cord Injury: A Systematic Review. Clinical Rehabilitation. 2015 Jan;29(1):3-13.
  5. 5.0 5.1 5.2 Mehrholz J, Kugler J, Pohl M. Locomotor Training for Walking after Spinal Cord Injury. Cochrane Database of Systematic Reviews. 2012 (11).
  6. 6.0 6.1 6.2 6.3 Harvey L. Management of Spinal Cord Injuries: A Guide for Physiotherapists. Elsevier Health Sciences; 2008 Jan 10.
  7. SpinalHub. How to assist cough a person with spinal cord injury. Available from: https://www.youtube.com/watch?v=lp-LBgD5Y5M [last accessed 2/20/2020]
  8. UWSpinalCordInjury. Manual Assisted Cough for Spinal Cord Injury: SCI Empowerment Project. Available from: https://www.youtube.com/watch?v=cmzZkdACei4 [last accessed 2/20/2020]
  9. Vincent Long. Rolling for a patient with C6 Tetraplegia. Available from: https://www.youtube.com/watch?v=qGA53hWgYgc [last accessed 2/20/202]
  10. Vincent Long. Supine to long sit walk around method for a patient with C6 Tetraplegia. Available from: https://www.youtube.com/watch?v=PXiijkpp_1c [last accessed 2/20/2020]
  11. Vincent Long. Transfer technique for a patient with C6 Tetraplegia. Available from: https://www.youtube.com/watch?v=tDETBkJIUJ8 [last accessed 2/20/2020]
  12. Singh H, Scovil CY, Bostick G, Kaiser A, Craven BC, Jaglal SB, Musselman KE. Perspectives of wheelchair users with spinal cord injury on fall circumstances and fall prevention: A mixed methods approach using photovoice. PLoS one. 2020 Aug 28;15(8):e0238116.
  13. Helen Hayes Hospital. Spinal Cord Injury Rehabilitation & Recovery: A Range of Therapies. Available from: https://youtu.be/ZPsjb43wO2c[last accessed 30/10/18]
  14. Scholten EW, Ketelaar M, Visser-Meily JM, Stolwijk-Swüste J, van Nes IJ, Gobets D, van Laake-Geelen CC, Stolwijk J, Dijkstra CA, Agterhof E, Gobets D. Self-efficacy predicts personal and family adjustment among persons with spinal cord injury or acquired brain injury and their significant others: A dyadic approach. Archives of physical medicine and rehabilitation. 2020 Nov 1;101(11):1937-45.