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 significantly declined. These increased survival rates has led to an increased focus on functional outcomes, which have significantly improved with implementation of rehabilitation in the form of physiotherapy, occupational therapy, psychology, speech and language therapy, social work 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 sepsis (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 and common neurological consequence following disasters and conflicts resulting from direct crush injury, crush injury with traction/rotation, falling from a height or blast injuries, which involve a fall or direct trauma to the spine from shrapnel or bullet wounds. In the case of a crush injury with traction/rotation, these tend to occur 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 disasters and conflicts, as was evident during the 2015 Nepal Earthquake, when 62 new patients were admitted in addition to the 38 patients already undergoing rehabilitation for spinal cord injury within the first three weeks following the earthquake, with subsequent daily admissions continuing to challenge spinal cord injury rehabilitation services. Women represent the largest portion of people with a spinal cord injury following disasters with a ratio of 1.3:1, while in conflicts spinal cord injury is more common in men. In both disaster and conflicts paraplegia is more common than tetraplegia. Treatment by surgical fixation is common, with evidence from the Nepal and Iranian Earthquakes suggesting greater than 70% underwent surgery to stabilize the spine following spinal cord injury, while 75% underwent surgical stabilization in conflict settings. Pressure ulcers had already developed in 28 - 33% on admission to an acute hospital, and common following an earthquake where there were often a delay in extracting patients and in accessing medical care.

Given the many potential sources of spinal cord injury, disaster preparedness planners and emergency medical responders 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 and are at an increased risk of developing secondary medical complications, all resulting in lifestyle consequences. This necessitates comprehensive interdisciplinary management, including medical, surgical and rehabilitation, that are required 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 immobilization and maintenance of cervical alignment are especially important . Additionally, rapid referral to a multidisciplinary care facility with appropriate rehabilitation services is essential for optimal outcome. Early diagnosis and treatment of spinal cord injury can be challenging even under normal circumstances. In the aftermath of disaster and conflicts these challenges are exacerbated. It is mainly due to the chaotic and austere environment surrounding disasters and conflicts including damage to infrastructure, poor communication and shortages of relevant health and rehabilitation workers, particularly neuro-trauma specialists. During early stages of an injury, immediate diagnosis and management is key to minimizing further neurological damage and development of secondary complications. This can be a more difficult, specially in low resource settings where medical infrastructure and availability of state-of-the-art neurological care is already scare and further limited due to disaster or conflict.

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

Emergency Medical Teams

Emergency Medical Teams with specialized 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. However, timeframes for arrival of these teams may vary significantly within disaster and conflict settings dependent on the safety of the environment. Rehabilitation professionals cover a range of professions comprising 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 the spinal cord injury patients. Teams generally deploy into existing spinal specialist centers 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. Such a specialized 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 Specialized 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. Therefore, such professionals 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. It 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 the early phases following disaster or conflict rehabilitation professionals need to be aware that in-field hospital situation of beds and chairs for sitting out may not always be appropriate for individuals with a spinal cord injury. This may increase the risk for development of pressure ulcers. To manage this effectively rehabilitation professionals should work with the nursing staff. Together they can ensure appropriate pressure relief materials (sourced or adapted to your needs) and a two-hourly turning and positioning schedule to monitor for pressure areas. The patient and their caregivers should also be educated on pressure care early on and wherever 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 Organization's minimum standards for rehabilitation for managing patients with spinal cord injury following a disaster, may vary based on the level of Emergency Medical Team but mainly includes:

• Neurological Assessment
• Pain Management
• Functional Re-training
• Patient and Care Provider education to include self-care, bladder and bowel management, pressure relief and other precautions.
• Providing temporary wheelchair and assistive technology involving pressure relieving equipment with onward referral to local provider for long-term assistive technology
• Refer onwards according to Nationalized protocol or to a specialized care team for on going rehabilitation
• Rehabilitation Follow-Up

Regardless of context, the fundamentals and management principles of spinal cord injury rehabilitation are globally similar. Rehabilitation continues to remains a vital element of the treatment and management process post spinal cord injury in a disaster and conflict settings. It should start early and prepare individuals and their caregivers to assist ongoing patient 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. Thus creating 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 injury treatment are focused on medical management. This includes avoidance of secondary injury and hemodynamic instability. Generally, most clinical guidelines regardless of the phase of management recommend that, all individuals with a spinal cord injury have access to a lifetime of personalized care. Such care is guided by a specially designed spinal cord injury center. 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. Also, we should always be aware of the long-term rehabilitation needs for such individuals 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.This includes a record of the neurological and functional limitations, in order to allow development of an individualized rehabilitation plan with specific functional goals. The key areas of assessment for patients with a spinal cord injury, both initially and later on consist of:

• 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
• The Spinal Cord Independence Measure (SCIM III)

( which provides assessment of self-care, respiration, sphincter management and mobility)

Both of these assessment tools 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. 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, those with an incomplete spinal cord injury will maintain some chance for 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 minimizing secondary complications. This requires patient and caregiver involvement in both the setting and a regular review of their goals is also vital. Functional outcomes are varied in spinal cord injury, but are generally guided by the level and completeness of the spinal cord injury. 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 utilized 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. We should always consider the environment and context in which the spinal cord injury has occurred in order to achieve best possible outcomes.

Rehabilitation interventions commonly used in disaster and conflict settings include:

• Range of movement exercises
• Muscle strengthening exercises
• Transfers training
• Training in activities of daily living
• Mobility training (including walker and wheelchair training) 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 vary significantly based on the level and completeness of injury and time delay before accessing rehabilitation, in those with complete injury and tetraplegia longer periods of rehabilitation may be required.

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. Research has shown that many with sudden onset of spinal cord injury will exhibit extreme negative emotions that can impact on their psychological as well as social integration after an injury. Anxiety, depression, post-traumatic stress disorder among others may also be more prevalent in people with spinal cord injury .Psychological and social factors play an important role 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 part of treatment time with patients and develop a close rapport. Still, they also need to be aware when they need to refer the patient onwards to other team members to provide further support.

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 be considered at each phase of treatment. Evidence suggests that spinal cord injuries are best managed in specialized spinal injury centers. This remains true even in case of disaster and conflict settings because, earlier access to specialized care has been shown to reduce complications, hospital length of stay and maximize neurological outcomes.

In determining transfer needs of the patient, the team need to consider primarily how stable the patient is. Along with this 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 stabilization. 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 specialized units for spinal cord injury where they exist should be organized as soon as possible. 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.

A foremost 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 patients 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. These needs 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 registration record and tracking mechanisms. This in turn allows for easy follow-up, which should include referral to local organizations for support. Also wherever possible patients are utilized as peer mentors and peer support groups. Prior to discharge, development of educational and/or occupational plan with vocational training opportunities has proved beneficial for many patients in returning to education or work post discharge.

We have to understand 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. Also possibly preventing or lessening the burden of chronic impairment amongst patients after the emergency phase. This is due to our major strength being focus on functional outcomes combined with the ability to carry out thorough assessments, often with limited resources.

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

In conclusion, provision of effective rehabilitation for spinal cord injury is possible in complex humanitarian emergency situations. The multidisciplinary approach, including psychological support along with partnerships with local and international organizations with specialized expertise is it's key to success.

Resources

Rehabilitation in Conflict and Disasters Field Support

• Responding Internationally to Disasters: Do’s and Don’ts
• Early Rehabilitation in Conflicts and Disasters - Chapter.8 Early Rehabilitation in Spinal Cord Injury Pages. 169 - 190
• Rehabilitation in Sudden Onset Disasters - Chapter.4 Spinal Cord Injury Pages.79 - 130
• Rehabilitation Treatment Planning Tool for Common Conflict and Emergency Related Injuries

Technical Standards for Medical Teams

• Minimum Technical Standards and Recommendations for Rehabilitation in Emergency Medical Teams

Articles

• 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.