Rehabilitation of Spinal Cord Injury in Disasters and Conflicts

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Original Editors - Naomi O Reilly

Top Contributors - Naomi O'Reilly, Sonal Joshi, Kim Jackson and Jess Bell      

Introduction

Spinal cord injury impacts an individual’s physical, psychological, and social well-being and places a substantial financial burden on health care systems worldwide. Historically spinal cord injury has been associated with very high mortality rate. However, with gradual development of effective treatment and management consisting of better positioning, skin and pressure care, bladder and bowel management, the prevailing 80% mortality rate for spinal cord injury has began to decline. This increased survival rate has led to functional outcomes becoming more important. In addition, these outcomes showed significant improvement with implementation of rehabilitation in the form of physiotherapy, occupational therapy, speech and language therapy, assistive technology and more holistic care.   Today spinal cord injury is survivable, with individuals able to live and flourish after injury with a good quality of life and fully contribute to society. While this change reflects better medical provision in higher-income countries, in many low-income countries and disaster and conflict settings this situation can be very different.

In low resource and disaster and conflict settings, spinal cord injury continues to result in poorer outcomes. Studies have shown a three fold increased risk of mortality during the acute phase of management. The primary causes of death reported as respiratory dysfunction (42%), comprising mainly of pulmonary embolism (22%) and chest infection (14%), followed by septicemia (28%) and cardiovascular disorders (18%), all which occur more commonly in individuals with tetraplegia. The strongest predictors of mortality were found to be tetraplegia and ventilator dependency followed by greater age and presence of associated injuries to the head, chest, abdomen, pelvis, and limb, which are common in disaster and conflict settings. For people with tetraplegia in the acute phase, respiratory management and prevention of infections are vital in reducing morbidity and mortality.

While accurate data is scarce, spinal cord injury remains one of the most serious injuries. It is especially a common neurological consequence following disasters and conflicts resulting from direct crush injury, crush injury with traction/rotation , falling from a height or blast injuries, all of which involve a fall or direct trauma to the spine from shrapnel or bullet wounds. In case of a crush injury with traction/rotation, they occur particularly in the pre-hospital recovery phase when a person is extracted from a building or vehicle with limited understanding of spinal precautions. Surges in spinal cord injury are common in disaster and conflict zones. This was evidently seen during the 2015 Nepal Earthquake, when spinal cord injury patient admission increased from 38 already existing to 62 patients in total for undergoing rehabilitation. It was within the first three weeks following the earthquake, with subsequent daily admissions. Women represent the largest portion of people with a spinal cord injury following disasters with a ratio of 1.3:1. Meanwhile in conflict areas, spinal cord injury is more common in men with paraplegia more common than tetraplegia. Treatment by surgical fixation is common, with evidence from the Nepal Earthquake suggesting greater than 70% underwent surgery to stabilize the spine following spinal cord injury, while 75% underwent surgical stabilization in conflict settings. Pressure ulcers would have already developed in 28 - 33% on admission to an acute hospital, which were both following an earthquake where delay in accessing patients was common.

Given the many potential sources of spinal cord injury, disaster preparedness planners and emergency medical personnel face a major challenge in preventing and managing neuro-trauma within these contexts. It is also frequently complicated by the presence of poly-trauma such as closed and open fractures, open wounds, internal injuries and crush injuries. Delayed access to treatment and surgery are common, either as a result of scare resources or due to spinal cord injury being seen as a low priority secondary to decreased probability of survival, particularly if when a high level injury. This also further impacts the outcomes post spinal cord injury.

Individuals with spinal cord injury face long-term physical impairments with residual neurological deficits. They are at an increased risk of developing secondary medical complications, all resulting in lifestyle consequences. This necessitates a comprehensive interdisciplinary management, including medical, surgical and rehabilitation. The secondary medical complications tend to persist far beyond the initial acute stage. All rehabilitation professionals working in disasters and conflicts should be able to complete a spinal cord injury assessment, provide basic information about expected outcomes and be prepared to address the complex needs of individuals with a spinal cord injury. This increases the likelihood of survival and optimal functional outcomes.

Immediate Emergency Care

Spinal cord injury is one of the most serious injuries seen in disaster and conflict settings and as such proper care and knowledge regarding spinal cord injury is critical in any emergency response; in particular moving and handling principles including on-scene spinal immobilisation, and maintenance of cervical alignment which are critical. In addition, rapid referral to a multidisciplinary care facility with appropriate rehabilitation services is essential for optimal outcomes. Early diagnosis and treatment of spinal cord injury can be challenging under normal circumstances, and these challenges are exacerbated in the aftermath of disaster and conflicts due to to the chaotic environment including damage to infrastructure, poor communication and shortages of relevant health and rehabilitation workers, particularly neuro-trauma specialists. During this early stage, immediate diagnosis and management is key to minimising further neurological damage and development of secondary complications; which can be a massive challenge, particularly in low resource countries where medical infrastructure and availability of state-of-the-art neurological care is already scare and further limited as a result of the disaster or conflict.

Given the challenges in disaster and conflicts, early deployment of specialised emergency medical teams, including national and international, to meet the immediate needs is often a key element of the initial emergency response, and is guided by a range of World Health Organization initiatives, including the Emergency Response Frameworks (Standards and Guidelines); Coordination Mechanisms, and the Emergency Medical Team Accreditation Process ensuring that only rehabilitation professionals, with appropriate experience and skills, form part of the Emergency Medical Teams.

Emergency Medical Teams

Emergency Medical Teams. with specialist spinal care capacity can play a vital role in supporting the care of individuals with spinal fractures and spinal cord injuries following disasters and conflicts. Generally, teams will be required in the first week of a disaster and stay for an extended period of time, but timeframes for arrival of these specialised teams may vary significantly within disaster and conflict settings dependant on the safety of the environment. Rehabilitation professionals cover a range of professions, including physical therapy, physiotherapy, occupational therapy, orthotics and prosthetics, rehabilitation nursing, physical rehabilitation medicine, psychology, speech and language therapy, nutrition and social work. These professionals ideally work collaboratively in a multidisciplinary team, each contributing their specialty to achieve comprehensive care and management of spinal cord injury. Teams generally deploy into existing spinal specialist centres where they are available, or into large referral hospitals or Type 3 Emergency Medical Teams where not available. They may also be useful in advising other surrounding local hospitals and Emergency Medical Teams on standards of care for spinal fractures and spinal cord injury during the emergency response. A specialised care team that is focused on spinal cord injury rehabilitation in a disaster or conflict setting should include:

Table.1 Minimum Technical Standards for Spinal Cord Injury Specialist Team in Emergency Medical Teams

Rehabilitation	General Applicability of Recommendations in Disaster Settings
Team Composition	Minimum Technical Standard; A spinal cord injury specialised rehabilitation team should be multidisciplinary and include at least one physiotherapist as well as other rehabilitation discipline(s) (occupational therapy, rehabilitation medicine doctor, and/or rehabilitation nursing)
Qualification and Experience	Minimum Technical Standard; Rehabilitation professionals in a spinal cord injury specialised care team should have at least 6 months’ experience working in a spinal cord injury unit or with spinal cord injury patients in a major trauma center and at least 3 years of post qualification clinical experience At least one team member, preferably the team leader, should have experience in emergency response and all team members should have undergone training in working in austere environments
Rehabilitation Equipment	Minimum Technical Standard; Specialised care teams should have capability to rapidly provide the following equipment.
Length of Stay	Minimum Technical Standard; A spinal cord injury specialised rehabilitation team that embeds into a local facility should plan to stay for at least 1 month with evidence of a exit strategy and release mechanism.

Moving and Handling

During early acute phase rehabilitation professionals may often have a role to play with other multidisciplinary team members for moving and handling patients with either a suspicion of or diagnosis of spinal cord injury, so need to have an understanding of specific precautions for an unstable spinal cord injury when moving or handling including carrying out their assessments and treatments to protect the spine from instability. Careful handling, positioning and turning, on every occasion, can prevent or significantly reduce patient pain and discomfort and will also reduce the potential for skin damage and secondary spinal cord trauma. For further information you can review the Multidisciplinary Association for Spinal Cord Injury Professionals (MASCIP) Guidelines for Moving and Handling Patients with Actual or Suspected Spinal Cord Injuries, which provide detailed pictorial guidelines for safe moving and handling practices.

Number of Persons required for turning a patient with an Unstable Spinal Cord Injury, according to MASCIP Guidelines, are:

• Injury T9 and Above: A Five Person Turn
• Injury T10 and Below: A Four Person Turn

Pressure Ulcer Prevention

In these early phases following disaster or conflict rehabilitation professionals also need to be aware that in field hospital situations beds and chairs for sitting out may not always be appropriate for individuals with a spinal cord injury, and may increase the risk for development of pressure ulcers. To manage this effectively rehabilitation professionals should work with nursing staff to ensure appropriate pressure relief materials are sourced or adapted to your needs, and 2-hourly turning and positioning schedules put in place including monitoring for pressure areas. The patient and their caregivers should also be educated on pressure care early, and where possible involved in turning and positioning.

Please read the linked articles to review your knowledge of the Guidelines on Prevention and Management of Pressure Ulcers

Rehabilitation

The overriding objective of spinal cord injury care in disaster and conflict settings has extended beyond survival and acute management to include implementation of rehabilitation structures that work towards reintegration of the individual with a spinal cord injury back into home and community. The World Health Organisation's Minimum Standards for Rehabilitation for managing patients with spinal cord injury following a disasters vary based on the level of Emergency Medical Team but include:

• Neurological Assessment
• Pain Management
• Functional Re-training
• Patient and Care Provider Education to include Self-care, Bladder and Bowel Management, Pressure Relief, and Precautions.
• Provide Temporary Wheelchair and Assistive Technology including pressure relieving equipment with onward referral to local provider for Long-term Assistive Technology
• Refer onwards according to Nationalised Protocol or Specialised Care Team for on going Rehabilitation
• Rehabilitation Follow-Up

Regardless of context, the fundamentals and management principles of spinal cord injury rehabilitation are similar and rehabilitation remains a vital element of the treatment and management process post spinal cord injury in a disaster and conflict settings. Rehabilitation should start early and prepare individuals and their caregivers to manage ongoing needs with a focus on management.

You can read the linked articles to review your knowledge of Spinal Cord Anatomy and Overview of Spinal Cord Injuries

Clinical Guidelines

While the evidence base for spinal cord injury management and rehabilitation is increasing, substantial gaps still remain with an ongoing need for more research to improve both service delivery and more importantly patient outcomes. Many of the Clinical Guidelines related to spinal cord injuries treatments are focused on medical management such as avoidance of secondary injury and hemodynamic instability. Overall though most clinical guidelines, regardless of phase of management, recommend that all individuals with a spinal cord injury should have access to a lifetime of personalised care that is guided by a specialised, spinal cord injury centre. So while there are currently no specific guidelines for the management of spinal cord injury within disaster and conflict settings, as rehabilitation professionals we should be aware of the relevant clinical guidelines for rehabilitation, and always be aware of the long term rehabilitation needs for individuals with spinal cord injury that will exist long after the disaster and conflict.

You can read the linked articles to review your knowledge of Spinal Cord Injury Clinical Guidelines

Assessment and Monitoring

Early rehabilitation should focus on comprehensive assessment for spinal cord injury assessment including neurological and functional limitations in order to allow development of an individualised rehabilitation plan with specific functional goals. The key specific areas of assessment for patients with a spinal cord injury, both initially and ongoing, are:

• Identification of Complications
• Autonomic Function
• Respiratory Function
• Swallow Function
• Motor Function
• Sensory Function
• Bladder and Bowel Function
• Activities of Daily Living (ADLs)
• Psychological and Emotional Wellbeing

Always ensure you consider and monitor for any injuries, such as fractures, that may have been missed as a result of altered sensation in individuals in spinal cord injury.

You can read the linked articles to review your knowledge of spinal cord injury assessment remembering the importance of following a systematic approach in order to identify or monitor any spinal cord injury specific complications, while also being aware of other complications that may occur in disaster and conflict settings.

It is vital that assessments, as a minimum, include the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI), formally known as the ASIA Assessment, and the Spinal Cord Independence Measure (SCIM III), which provides assessment of self-care, respiration, sphincter management and mobility, both of which can be used to guide rehabilitation professionals in determining treatment goals and objectives for patients with a spinal cord injury.

Prognosis and Goals

Accurate prediction of clinical outcomes following a spinal cord injury based on early examination is limited and it is very difficult for the medical and surgical teams to provide an accurate prognosis in the first few weeks after injury. Most individuals regain one level of motor function from their initial spinal injury classification completed within 72 hours of injury, with the majority of recovery of function occurring in the first 6 months, while the chance of marked recovery in people with a complete spinal cord injury (AIS grade A and no Zone of Partial Preservation) is very low, while those with an incomplete spinal cord injury will maintain some chance for some recovery.

The goals of early rehabilitation in a disaster and conflict settings is to improve functional outcomes and restore as much independence in the patient as possible, while minimising secondary complications with patient and caregiver involvement in both the setting and regular review of their goals vital. Functional outcomes are varied in spinal cord injury, but generally are guided by the level and completeness of the spinal cord injury but factors such as age, medical complications, contractures, cognitive dysfunction, motivation, cultural factors, environment etc. can all impact on the actual functional outcome achieved by each individual.

You can read the linked articles to review your knowledge of Prognosis and Goal Setting in Spinal Cord Injury.

Interventions

Physiotherapists treat an array of different problems related to spinal cord injury, including paralysis, bladder, bowel, respiratory, cardiovascular and sexual function as well as social, financial and psychological implications. A wide range of therapeutic interventions addressing these problems are utilised in spinal cord injury rehabilitation and can be implemented across a wide range of contexts including disaster and conflicts. Emphasis on patient and caregiver education about realistic expectations and self-management strategies are vital within disaster and conflict settings, while always considering the environment and context in which the spinal cord injury has occurred i order to achieve best possible outcomes.

Rehabilitation interventions commonly used in disaster and conflict settings include range of movement exercises, muscle strengthening, transfers training, training in activities of daily living, and mobility training (including walker and wheelchair training) and was supported with prescription of appropriate assistive technology.Education focused on the bladder and bowel management, skin care, prevention of complications. Patients received rehabilitation intervention for approximately 3 months prior to discharge to the community, although these timeframes varied significantly based on the level and completeness of injury, and time delay before accessing rehabilitation, with those with complete injury and tetraplegia requiring longer periods of rehabilitation.

You can read the linked articles to review your knowledge of Therapeutic Interventions for Spinal Cord Injury and Category:Spinal Cord Injuries.

Psychological and Psychosocial Implications

Spinal cord injury has the potential of resulting in devastating consequences after the occurrence and research has shown that many with sudden onset of spinal cord injury will exhibit extreme negative emotions that can impact on psychological as well as social integration after an injury. Anxiety, depression, post-traumatic stress disorder among others may also be at an elevated level for people with spinal cord injury, with psychological and social factors having a role to play in both the incidence and progression of these mental health conditions. Thus, it is necessary to pay attention to these psychosocial factors which may have extreme consequences on achieving optimal rehabilitation goals and improving the quality of life of people with spinal cord injuries,Rehabilitation professionals often play a key role in supporting this as they spend large portions of time with patients and develop a close rapport but they also need to be aware of when they need to refer onwards to other team members to provide further support for patients around this.

You can read the linked article to review your knowledge of Psychosocial Considerations in Spinal Cord Injury

Transfer and Discharge Planning

Planning for a patient’s discharge from hospital is a key aspect of effective care. In the case of spinal cord injury discharge options need to considered at each phase of treatment. Evidence suggests that spinal cord injury are best managed in specialist spinal injury centres, and this remains true even within disaster and conflict settings where available, where earlier access to specialist care has been shown has been shown to reduce complications, reduce hospital length of stay and maximise neurological outcomes.

In determining transfer needs of the patient the team need to consider how stable the patient is, and whether the risk of transportation of the patient in the midst of infrastructural chaos and poor health systems outweigh the benefit of having early surgical stabilisation? For those with higher level spinal cord injuries, particularly those who require ventilation, transfer of these patients to Type 3 Emergency Medical Teams, advanced health facilities, or Specialist Units for Spinal Cord Injury where they exist, should be organised as soon as possible once the patient. If they can maintain their own respiratory effort, then conservative management in a facility with good quality nursing and rehabilitation care may provide them with the best long term outcome. over quick transfer.

A primary goal of rehabilitation is successful community reintegration. The reality of this goal in many disaster and conflict settings is questionable, with a high hospital readmission rate seen in many individuals with spinal cord injury as a result of pressure ulcers and urinary tract infections. Many patients who are discharged from hospital will have ongoing care needs that must be met in the community, which often present a significant challenge within disaster and conflict settings, where infrastructure and environments are often inaccessible to individuals with mobility impairment. During discharge planning rehabilitation professionals should ensure they have adequate patient registries and tracking mechanisms allowing for follow-up, which should include referral to local organisations for support and where available utilise patients as peer mentors, and peer support groups. Prior to discharge development of educational and/or occupational plan with vocational training opportunituies prior to discharge were beneficial for many patients in returning to education or work post discharge.

Be aware that discharge planning post disaster and conflict may require more work on the part of the rehabilitation teams to ensure that the individual is able to achieve best possible functional outcomes.

Summary

Current advances in disaster and conflict response and management have improved survival rates for those with spinal cord injury, resulting in increased number of survivors. Spinal cord injury is one of the more complex injuries following disasters and conflicts resulting in long-term physical impairments, residual neurological deficits, medical complications and lifestyle consequences, which necessitate comprehensive interdisciplinary management, and access to long term rehabilitation.

“Rehabilitation can greatly increase survival and enhance the quality of life for those with spinal cord injury in disasters and conflicts”

Rehabilitation professionals are now considered key health care members and as such are involved in all phases following disasters and conflicts, including early involvement with emergency medical teams. Several unique areas of skill are offered by rehabilitation professionals, including those of assessing and treating casualties with acute injuries, and possibly preventing or lessening the burden of chronic impairment amongst patients after the emergency phase, with a major strength being our focus on functional outcomes combined with the ability to carry out thorough assessments, often with limited resources.

While spinal cord injury assessment and management principles remain the same in disaster and conflict settings, rehabilitation professionals need to ensure they have a good understanding of these principles while also being aware of the implications of delayed access to treatment, scarce resources and inaccessible environments have on their rehabilitation interventions and more importantly on the implications for discharge planning and re-integration back in to their community and the ongoing role of community based rehabilitation and mobile rehabilitation teams in supporting individuals within their community.

Provision of effective rehabilitation for spinal cord injury is possible in complex humanitarian emergency situations through a multidisciplinary approach, including psychological support along with partnerships with local and international organisation's with specialised expertise, key to success.

Resources

• Early Rehabilitation in Conflicts and Disasters - Chapter.8 Pages. 169 - 190
• Rehabilitation in Sudden Onset Disasters - Chapter.4 Pages.79 - 130 and Appendix. Cheat Sheets - UKIETR Spinal Cord Injury
• Burns AS, O'Connell C, Rathore FA. Meeting the Challenges of Spinal Cord Injury Care following Sudden Onset Disaster – Lessons Learned. Journal of Rehabilitation Medicine. 2012 May 5;44(5):414-20.
• Yue JK, Winkler EA, Rick JW, Deng H, Partow CP, Upadhyayula PS, Birk HS, Chan AK, Dhall SS. Update on Critical Care for Acute Spinal Cord Injury in the Setting of Polytrauma. Neurosurgical Focus. 2017 Nov 1;43(5):E19.