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[edit | edit source]

Spinal cord injury impacts an individual’s physical, psychological, and social well-being and places a substantial financial burden on health care systems worldwide. While historically spinal cord injury has been associated with very high mortality rates, development of effective treatment and management including better positioning, skin and pressure care, bladder and bowel management, the prevailing 80% mortality rate for spinal cord injury began to decline. With increased survival rates functional outcomes became more important and have improved significantly with implementation of rehabilitation including physiotherapy, occupational therapy, speech and language therapy, assistive technology and more holistic care. [1]  Today spinal cord injury is survivable, with individuals able to live and flourish after injury with a good quality of life and full contribution to society.[1] 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. [2][3]

In low resource, disaster and conflict settings spinal cord injury continues to result in poorer outcomes and has shown a three fold increased risk of mortality [4] during the acute phase of management with primary causes of death reported as respiratory dysfunction (42%), [5][6] [7][8][9] 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. [5][10][11] Tetraplegia and ventilator dependency were the strongest predictors of mortality 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. As such respiratory management and prevention of infections in people with tetraplegia in the acute phase are vital in reducing morbidity and mortality.[11] While accurate data is scarce, spinal cord injury remains one of the most serious injuries and is a common neurological consequence following disasters and conflicts, resulting from direct crush injury, crush injury with traction/rotation (particularly in the pre-hospital recovery phase when extracted from a building or vehicle with limited understanding of spinal precautions), falling from a height or blast injuries, which involve a fall or direct trauma to the spine from shrapnel or bullet wounds.[2][4] 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, as it is 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 can be common either as a result of scare resources [12] 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, [13] which can further impact on outcomes post spinal cord injury.[4]

Individuals with spinal cord injury face long-term physical impairments with residual neurological deficits, and are increased risk of developing secondary medical complications, all resulting in lifestyle consequences, which necessitate comprehensive interdisciplinary management, including medical, surgical and rehabilitation, which will 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 to increase the likelihood of survival and optimal functional outcomes.[14]

Immediate Emergency Care[edit | edit source]

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. [15] 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.

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. [16] 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


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. [15][17]

Emergency Medical Teams[edit | edit source]

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.

Rehabilitation[edit | edit source]

The overriding objective of spinal cord injury care in disaster and conflict settings has now extended well beyond survival and acute management to include implementation of rehabilitation structures which 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 recommendations 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. Rehabilitation is a vital element of the treatment and management process post spinal cord injury in a disaster and conflict settings and should prepare individuals with long-term impairment, their care providers and local rehabilitation personnel to manage ongoing needs over a longer term and should be started early.

Assessment and Monitoring[edit | edit source]

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


Please 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. [14][18]

Clinical Guidelines[edit | edit source]

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.

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

Goals[edit | edit source]

The goal 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 an emphasis on patient and care giver education about realistic expectations and self-management strategies.[14]

Summary[edit | edit source]

Resources[edit | edit source]

References [edit | edit source]

  1. ↑ 1.0 1.1 World Health Organization, International Spinal Cord Society. International Perspectives on Spinal Cord Injury. World Health Organization; 2013.
  2. ↑ 2.0 2.1 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. ↑ Furlan JC, Sakakibara BM, Miller WC, Krassioukov AV. Global Incidence and Prevalence of Traumatic Spinal Cord Injury. Canadian Journal of Neurological Sciences. 2013 Jul;40(4):456-64.
  4. ↑ 4.0 4.1 4.2 Chamberlain JD, Meier S, Mader L, von Groote PM, Brinkhof MWG. Mortality and longevity after a spinal cord injury: systematic review and meta-analysis. Neuroepidemiology. 2015;44:182–98.
  5. ↑ 5.0 5.1 Berlly M, Shem K. Respiratory management during the first five days after spinal cord injury. J Spinal Cord Med. 2007;30:309–18.
  6. ↑ Brown R, DiMarco AF, Hoit JD, Garshick E. Respiratory dysfunction and management in spinal cord injury. Respir Care. 2006;51:853–68. Discussion 869–70.
  7. ↑ Cao Y, Krause JS, DiPiro N. Risk factors for mortality after spinal cord injury in the USA. Spinal Cord. 2013;51:413–8.
  8. ↑ Grossman RG, Frankowski RF, Burau KD, Toups EG, Crommett JW, Johnson MM, et al. Incidence and severity of acute complications after spinal cord injury. J Neurosurg Spine. 2012;17(Suppl):119–28.
  9. ↑ Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal cord injury. J Neurotrauma. 2011;28:1479–95.
  10. ↑ Garshick E, Kelley A, Cohen SA, Garrison A, Tun CG, Gagnon D, Brown R. Original article: a prospective assessment of mortality in chronic spinal cord injury. Spinal Cord. 2005;43:408–16.
  11. ↑ 11.0 11.1 Chhabra HS, Sharawat R, Vishwakarma G. In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India—a retrospective analysis. Spinal Cord. 2021 Jun 25:1-6.
  12. ↑ Sheng ZY. Medical support in the Tangshan earthquake: a review of the management of mass casualties and certain major injuries. The Journal of trauma. 1987 Oct 1;27(10):1130-5.
  13. ↑ Gautschi OP, Cadosch D, Rajan G, Zellweger R. Earthquakes and trauma: review of triage and injury-specific, immediate care. Prehospital and disaster medicine. 2008 Apr;23(2):195-201.
  14. ↑ 14.0 14.1 14.2 Lathia C, Skelton P, Clift Z. Early Rehabilitation in Conflicts and Disasters. Handicap International: London, UK. 2020.
  15. ↑ 15.0 15.1 Regens JL, Mould N. Prevention and treatment of traumatic brain injury due to rapid-onset natural disasters. Frontiers in public health. 2014 Apr 14;2:28.
  16. ↑ Harrison P, editor. Managing Spinal Cord Injury: The First 48 Hours: the Initial Management of People with Actual Or Suspected Spinal Cord Injury from Scene of Accident to A&E Department: Information for Accident & Emergency Departments and Emergency Care Providers. Spinal Injuries Association; 2007.
  17. ↑ Vasudevan V, Amatya B, Chopra S, Zhang N, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury specialist rehabilitation teams in sudden-onset disasters (for Disaster Rehabilitation Committee special session). Annals of Physical and Rehabilitation Medicine. 2018 Jul 1;61:e120.
  18. ↑ Catz A, Itzkovich M. Spinal cord independence measure: comprehensive ability to rating scale for the spinal cord lesion. JRRD. 2007;44(1):65-68.
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