Spinal Cord Injury Physiotherapy Treatment Principles
Introduction[edit | edit source]
Spinal cord injury (SCI) physiotherapy treatment is a very complex, and it must take into account not only paralysis, but also much wider consequences of impaired body functions. These include functions of the bladder, bowel, respiratory, and cardiovascular systems. As well as this, social and personal factors, participation and the environment all influence the recovery of persons with a spinal cord injury. This course aims to introduce basic treatment ideas during various stages of rehabilitation after a spinal cord injury.
SCI Physiotherapy Treatment Basic Principles[edit | edit source]
- Initial medical care and rehabilitation are focused on minimising additional neurological damage to the spinal cord and enhancing recovery
- The multidisciplinary team should be involved and a patient-centered approach should be developed
- The patient should have ongoing access to follow-up specialised care, equipment, and advanced technology
- The goals of treatment should be linked to the patient’s likes, goals, and passions, the drivers in their life and to the expected outcomes for different levels of injury
- Treatment of neurological and musculoskeletal injuries should focus on the presence of weakness, contracture and poor motor control
- Outcome measures should be used to measure treatment progression
Early Management[edit | edit source]
The early management of a spinal cord injury begins as soon as the patient is medically stable. This could be days or weeks after the injury depending on the primary cause of the injury and subsequent medical and/or respiratory complications. Paramedic assessment documentation can serve as a valid source of information for the physiotherapist regarding the mechanism of the patient's injury when physiotherapy care is being planned in this stage.
Neurological Recovery[edit | edit source]
Neurological recovery after traumatic spinal cord injury depends on the severity, level and mechanism of the injury. Neurological recovery is not, however, associated with the treatment a patient receives or the country where the treatment is delivered. The first three months after the spinal cord injury are crucial for the recovery of individuals with a complete ASIA A spinal cord injury when their level of injury can change to ASIA B, C, D, or E; the highest number of conversions are from ASIA A to ASIA B (5.6.%). These conversions are more frequently observed for patients with tetraplegia as compared to those with paraplegia. Even though most of the recovery occurs during the first three months, it can continue up to one year after the injury.
The following initial assessment results are considered predictors for neurological recovery:
- The lower the level of cervical injury, the higher percentage of recovery: 85% of patients with C6 SCI will convert to C7
- Biceps strength greater or equal to 3/5 predicts motor recovery for wrist extensors
- Muscles with a 1–2.5/5 grade initially will reach a recovery plateau within one year. Muscles with 0/5 grades during the initial assessment will continue their motor recovery for up to 24 months.
More information on the ASIA scale is available here.
Prevention of Complications[edit | edit source]
Respiratory Complications[edit | edit source]
Respiratory and ventilatory functions are impaired in over 50% of individuals with a spinal cord injury. As a result, patients can experience difficulties with breathing or an inability to breathe. Pneumonia can impact a patient's length of hospital stay and neurological outcome. It is also considered a major cause of morbidity and mortality in SCI patients. Other respiratory complications include: atelectasis, sputum retention, and respiratory failure.
Physiotherapy role in preventing respiratory complications:
- Initiating respiratory muscle training
- Instruction on assisted coughing and nose blowing
- Providing active chest physiotherapy
Diaphragm pacing is a new method to help patients with SCI reduce their dependence on a mechanical ventilator. Other benefits include promoting neuromuscular plasticity, improvements in spontaneous diaphragm activation and respiratory function, and improvement in breathing, speech and quality of life for people with spinal cord injuries. You can find more information on diaphragm pacing here.
You can find more information on respiratory management in a spinal cord injury here.
Integumentary (Skin) Complications[edit | edit source]
Decubitus ulcers can develop within 6 hours or less from an injury. Prevention of decubitus ulcers becomes the responsibility of the entire healthcare team.
Multidisciplinary team role in preventing pressure ulcers:
- Patient education on pressure relief
- Encouraging the patient to follow a pressure relief regime. All team members can be involved in this. For example, speech-language therapists must know how to assist the patient with pressure relief during their therapy sessions
- Teaching the patient the steps for pressure relief. Patients must learn how to instruct others on pressure relief
- Spasticity management is important because spasticity can lead to pressure ulcers
Cardiovascular Complications[edit | edit source]
Cardiovascular complications among individuals with a spinal cord injury include orthostatic hypotension and autonomic dysreflexia.
Autonomic dysreflexia is sudden and extreme hypertension in response to afferent stimuli from below the level of injury. It can occur in up to 90% of individuals with tetraplegia or high paraplegia, and may result in vascular dysfunction, seizures, cardiac arrest, cerebral vascular accidents, and death.
Orthostatic hypotension occurs when a patient transitions to an upright position and there is a drop of at least 20mmHg in their systolic blood pressure or 10mmHg in their diastolic blood pressure. Wang et al. have found, however, that a decrease in blood pressure is not sufficient to define orthostatic hypotension. To confirm autonomic dysfunction after a spinal cord injury, both blood pressure and heart rate responses need to be quantified. Alterations in systolic and diastolic function which manifest as fluctuations in blood pressure (hyper and hypotension) can lead to vascular cognitive impairment in individuals with SCI.
- Venous stasis after injury
- Endothelial vessel wall injury from surgery
- An increased tendency to develop blood clots associated with trauma
Physiotherapy role in preventing cardiovascular complications:
- Deep vein thrombosis (DVT) prophylaxis: early limb mobilisation, intermittent compression
- Management of postural hypotension, bradycardia and autonomic dysreflexia
You can read more about cardiovascular complications associated with spinal cord injury here.
Musculoskeletal Complications[edit | edit source]
Musculoskeletal problems are frequent in individuals with spinal cord injury. Activities performed with poor biomechanics will lead to shoulder and neck pain. Patients who remain in one position for a prolonged period of time will develop contracture. Spasticity can decrease flexibility and cause shortening of the soft tissue. The consequences of these complications are severe. For example, when a patient develops shoulder pain, he or she will not be able to propel a wheelchair or perform transfers.
Physiotherapy role in preventing musculoskeletal complications:
- Prevent lower and upper extremities contracture - consider ankle, knee, hip, shoulder joints to allow for: wheelchair positioning (ankles, knees), bed mobility, transfers, and dressing (shoulders, hips)
- Facilitate elbow extension in patients with a C5/6 SCI and wrist extension in patients with a C6 SCI
- Educate on positions in bed and/or wheelchair that can reduce spasticity
- Reinforce good posture - use only one or no pillow/s under the neck in supine, early assessment for wheelchair seating and positioning
- Position for functional shortening of the long finger flexors to facilitate tenodesis grip (patients to be in pronation with finger flexion and wrist extension)
Urologic Complications[edit | edit source]
Patients with a spinal cord injury are at greater risk for developing urologic complications. At higher risk are males, individuals with cervical SCI, and patients using a condom catheter. Upper urinary tract complications (UTI) affect 20 – 30% of patients with a spinal cord injury, 49% develop bladder stones, 47% will experience from hydronephrosis (i.e. urine build-up causing the kidneys to stretch and swell), and 33% will be diagnosed with vesicoureteral reflux causing the urine to flow backwards from the bladder to one or both ureters and sometimes to the kidneys. The following issues can increase the risk of UTI:
- Incomplete voiding
- Catheter use
- Increased tension of the bladder muscle
Physiotherapists can help prevent UTIs and bladder overfilling in patients with a spinal cord injury by:
- Encouraging the patient to drink enough water
- Working with an occupational therapist on the proper equipment to facilitate independent hydration (wheelchair cup holder with a cup and a long drinking straw)
- Following aseptic procedures with catheter care, keeping the catheter off the floor during therapy
- Maintaining the schedule for timely catheterisation
Gastrointestinal[edit | edit source]
Spinal cord injury may lead to significant gastrointestinal and bladder dysfunction, which have a serious impact on general health, quality of life, and the social participation of individuals with a spinal cord injury. A number of patients experience constipation, abdominal pain, nausea, or bloating. Colorectal dysfunction is the most common gastrointestinal complication. Individuals with a spinal cord injury need to be educated and instructed on an appropriate bowel programme - one that allows for continence and prevents faecal impaction.
The following are additional activities to help prevent gastrointestinal comorbidities that the physiotherapist can be a part of:
- Assist with bowel regime to prevent constipation and to prevent distension of the abdomen
- Educate on balancing activity level and intake
- Educate patients on obesity prevention
- Follow up on calorie counts
Preparing for Function[edit | edit source]
Early introduction of physiotherapy interventions during the acute phase of rehabilitation after a spinal cord injury should focus on:
- Teaching trick movements for individuals with a C5/6/7 spinal cord injury, including elbow extension without triceps, and tenodesis grip
- Strengthening innervated and partially innervated muscles for function
- Facilitation of weak or paralysed muscles
- Maintaining full joint range of motion
- Educate patient on how to do functional activities and why stretches, muscle strengthening, positioning and skills training are important - give them the vision.
- Educate patient about their condition, complications, possible outcomes and length of stay and goals. This needs constant repeating, as patients are not always ready to hear the information given.
- Make sure the patient has the cognitive ability for the level of education being given. Pictures should be provided for those who cannot read, consider language (mother tongue or competent translator) and education should match a patient's educational level.
- Assisting with spasticity management
You can read more on physical techniques in the management of spasticity here.
Rehabilitation Phase[edit | edit source]
A person-centred approach to spinal cord injury rehabilitation is well known and well advocated in healthcare systems, although the choice of rehabilitation goals may vary depending on the country and its system. This type of approach to rehabilitation focuses not only on the physical functioning of a person with a spinal cord injury, but their financial, vocational and social needs and challenges following the injury as well. However, patients and health professionals report that the goal-setting in SCI rehabilitation too often addresses only physical functioning, without considering the psychosocial component, e.g., family issues, a change of roles etc. When goal-setting during the rehabilitation phase, it is important to address issues related to a patient's everyday life while they are still in hospital. During the spinal cord injury rehabilitation phase, emphasis should be placed on: "having definite goals as to where you are headed, what is possible for the neurological level and make it patient-specific". In addition, it is important to:
- Mobilise the patient as soon as possible
- Assess the need for an abdominal binder for postural hypotension
- Design a graded progressive sitting programme to build patient's sitting endurance
Seating and Mobility[edit | edit source]
An appropriate wheelchair and seating system is a basic human right for a person with a spinal cord injury. It allows independence, health, function, and social participation. It is an essential tool to maximise the quality of life of an individual with a spinal cord injury. When choosing the seating and mobility system, the patient and healthcare provider must consider what barriers there are when entering the patient's home / community facilities, a patient's primary mode of transportation (own car vs community transportation), the patient's current health status (which can decline or improve during the course of rehabilitation), as well as pain and difficulties while using a current seating and mobility system. In addition, the user's age, level of injury, body size, gender, motivation, way of life, family and social roles, and cognitive abilities must be considered.
Each seating and mobility system includes a wheelchair base (manual or power) and seating components (cushion, backrest, head and arm support). For an individual with a spinal cord injury, equitable and long-term access to adequate wheelchair services and assistive technology should be a priority when preparing this person for discharge from rehabilitation. It includes seating assistive technology assessment, delivery, training, maintenance, and follow-up.
Outcomes[edit | edit source]
Functional Independence Measure (FIM): allows for quantification of the amount of assistance the patient requires for:
- Respiratory function, bladder and bowel
- Bed mobility and transfers
- Eating, dressing, grooming, bathing
- Wheelchair propulsion or ambulation/transportation
- Communication and home making
Spinal Cord Independence Measure (SCIM): addresses
- Self-care (feeding, grooming, bathing, and dressing)
- Respiration and sphincter management
- Patient’s mobility abilities (bed and transfers and indoors/outdoors).
The SCIM is used to guide clinicians in determining treatment goals and objectives for patients with an SCI.
Functional Approach[edit | edit source]
When addressing a patient's functional ability, the clinician should consider the following principles:
- Treat the impairments
- Don’t stick to normal functional levels (i.e. rolling before sitting up), but focus on the patient's current abilities
- Use activities as an exercise
- Understand all the components of an activity you need for a specific function
- Break activities into smaller components and work on them
- Stretching, strengthening and maintaining range of motion are crucial for good function
- Use peer supporters to inspire the patient
- Make patients feel they have achieved something in a session, end with something they do well or enjoy
The following tools can be used to facilitate function:
- Tilt table, standing frame, parallel bars standing with a long leg orthoses, treadmill, Lokomat to facilitate ambulation
New Technologies[edit | edit source]
New technologies available in the management of SCI are still in their early stages of development. Large scale clinical trials need to be done for these technologies to be proven successful.
The following are examples of various technologies used in recovery after a spinal cord injury:
- Neuromodulation: i.e. modulation of neuronal activity. This can be done via pharmacological modulation, electrical modulation, and optogenetics modulation. Examples of electrical modulations include:
- Brain stimulation: transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (TMS), direct motor cortex stimulation (MCS), deep brain stimulation (DBS)
- Spinal cord stimulation: epidural electrical stimulation (EES) and transcutaneous spinal cord stimulation (tcSCS)
- Peripheral stimulation: functional electrical stimulation (FES)
- Brain-machine interface (BMI)
- Stem cell-based therapies - you can read more about cell-based therapies for spinal cord injury here.
Later Stage[edit | edit source]
The changing needs of individuals with a spinal cord injury include changes in health status, changes in the level of participation, and changes in socio-economic status as a result of the financial burden following a spinal cord injury.
Health Status[edit | edit source]
Changes in health status include, but are not limited to:
- Normal ageing complications: overuse injuries, osteoarthritis, osteoporotic fractures, cardiovascular problems, diabetes, scoliosis
- Diminished energy levels
- Changes in skin integrity with an increased risk for pressure ulcers
- Altered sleep patterns
- Increased risk for falls
Participation[edit | edit source]
When considering participation / changes in participation over time, it may be necessary to modify current leisure activities or explore new ones. A study by Charlifue and Gerhart shows that the availability of resources, social support, and continued involvement in leisure activities as a person with a spinal cord injury ages correlate well with a higher quality of life.
The healthcare provider's role in increasing participation for ageing persons with a spinal cord injury includes:
- Helping to modify leisure activities
- Providing strategies to overcome environmental barriers
- Promoting and prescribing physical activity to this population
- Long-term involvement of health care professionals in the form of telerehabilitation and outreach group programmes
Resources[edit | edit source]
- Khamnon N, Amatachaya S, Wattanapan P, Musika N, Jitmongkolsri P, Kongngoen N, Haisirikul M, Jaikarsen K, Thaweewannakij T, Namwong W. Reliability and concurrent validity of the Spinal Cord Independence Measure III among rehabilitation professionals. Spinal Cord. 2022 Apr 27:1–7.
- Physiotherapy Management of Individuals with Spinal Cord Injury
- Therapeutic Interventions for Spinal Cord Injury
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