A Spinal Cord Injury (SCI) is a non-traumatic or traumatic event that causes neural damage affecting sensory, motor, respiratory function, bladder function, bowel function, and sexual function. Neurological interruption also influences skin integrity, blood pressure, and temperature regulating ability.
Mostly, spinal cord injury, leads to,
Paraplegia: Loss in motor and/ or sensory function in the lower limbs
Tetraplegia: The upper limbs to the motor and/ or sensory loss of the lower limbs and legs
For SCI patients during, rehabilitation and management is done based on type and level of injury. SCI patients mostly need initial ICU care, and the process of rehabilitation typically begins in the acute care setting. This is preceded by treatment for an extended period in some specialised Spinal Injury Unit. Duration of inpatient management could be between 8-24 weeks. This would be followed by outpatient rehabilitation of 3 to 12 months. Finally, there will be functional and medical reviews on an annual basis.
The approach of patients during spinal cord injuries treatment in Hebbal, Bangalore is lifelong, complex, and needing a multidisciplinary approach. This will help the individual to lead an independent and full life to the most extent. A rehabilitation Physician or Physiatrist heads a team of occupational therapy, physiotherapy, language and speech therapy, social workers, psychologists, rehabilitation nurses, and other social care and health professionals. Along with the individual, they come up with a plan for discharge that suits the circumstances and level of injury of the individual.
Critical steps of SCI patient management are,
Assessing the individual’s participation restrictions, activity limitations and impairments
Fixing goals that match the participation restrictions and activity limitations
Identifying all key impairments posing hindrance in goal achievement
Identifying physiotherapy treatments and administering the treatments, such as joint mobility, strengthening, development of motor skills, cardiovascular fitness, pain management, and respiratory functioning
Measuring how well the treatments are working
There are three phases in the management of SCI individuals,
2. Chronic (Long Term)
3. Sub-acute (Rehabilitation)
In the acute and subacute treatment phases, the key focus of the rehabilitation strategies is on secondary complication prevention, neuro recovery promotion, underlying impairments treatment, and function maximisation. The chronic phase is addressed with assistive and compensatory approaches.
This early phase after the injury involves physiotherapy management mainly for management and prevention of circulatory and respiratory problems and to bring down the impact on the individual of immobilisation, such as contracture development and pressure ulcer.
Acute Phase Treatment Objectives
The objectives are,
Instituting a prophylactic respiratory treatment that manages respiratory resulting from SCI and other associated conditions, such as decrease incidence atelectasis and enhance clearance of secretions
Achieving independent respiratory status
Maintaining the movement’s full range for all joints within the existing limitations
Monitoring and managing individual’s neurological status
Maintaining and strengthening every innervated muscle groups
Facilitating functional activity patterns
Educating and supporting the individual, the caregiver, staff, and family
Levels of Intervention
The levels of innervations include,
Patients having C1-3 tetraplegia need to be put on mechanical ventilation and those with C4 tetraplegia will generally have independent breathing. Patients having SCI C4 to T12 breathe independently but could have decreased vital capacity and problems with raising intra-abdominal pressure for coughing effectively or performing Forced-expiratory Techniques (FETs).
Postural suctioning and drainage
Increased Ventilatory Techniques
Deep breathing exercises
Inspiratory muscle training
Equipment often used for improving ventilation,
Bi-level Positive Airway Pressure (BiPAP).
Continuous Positive Airway Pressure (CPAP)
Range of Movement
Common hypertonic treatments (heat, compression, sustained deep pressure)
Positioning in an elevated position
Sub-acute (rehabilitation) Phase
Rehabilitation of SCI persons has to look at the psychological, physical, social and vocational standing. Rehabilitation is a time bound and goal oriented process that has to provide the highest level of possible reintegration and independence for the individuals to be part of their chosen lifestyle and community role.
Physiotherapy interventions in this phase are for,
Body structure and function
Activity limitation prevention
Participation restriction prevention
Treatment objectives for sub-acute phase,
Setting up a patient-focused interdisciplinary coordinated and comprehensive processes
Using early management and intervention to prevent more complications via handle physical motor functional activities
Improving daily activities of the individual, for example, mobility, grooming, dressing, eating, and bathing
Achieving functional independence, both verbal and physical
Gaining and maintaining successful community reintegration
Common Individual Treatments
Patients with high-level tetraplegia,
Range of stretching / movement
Patients with low-level tetraplegia,
Stress on transfers
Less stress on strengthening
Patients with paraplegia,
Stretching / range of movement
For successfully performing a motor, sufficient balance, strength, skill / knowledge of that motor task is needed and can be gained via frequent progressive training.
Bed Mobility and Transfers
Patients with C6 and lower level SCI can attain 5 motor skills,
1. Rolling (applying momentum)
2. Mobilising from supine to long sitting
3. Sitting without support (long and short term)
4. Vertically lifting
While greater challenges are there for C6 tetraplegia the above 5 motor skills can be attained with a few modifications,
Rolling: Rotate shoulders and swing arms across body
Unsupported Sitting: Externally rotate shoulders and lock elbows in extension for balance
Vertical Lifting: Passively extend elbows, externally rotate shoulders and depress shoulders for weight bearing with hands placed anteriorly to the pelvis.
Mobility with Wheelchair
C1-4 tetraplegia patients need wheelchairs that are powered and controlled with using sip and puff, chin movements, or head array.
C5 tetraplegia patients mostly employ hand movement controlled powered wheelchairs.
C6-8 tetraplegia patients can mobilise independently using a manual wheelchair. They might go for a hand-controlled wheelchair.
C8 or lower SCI patients can mobilise independently by using a manual wheelchair.
For independent and safe mobility, SCI persons have to be trained to,
Open and close doors
Go up an incline and down
Go over and around obstacles
Be mobile outdoors and indoors
Standing and Gait
For persons having AIS D Spinal Cord Injury, the most common physiotherapy exercises are for balance, strength, and gait training. Strengthening is the foremost activity for types and levels of SCI.
Standing is vastly beneficial even if it is not independent. Some of its benefits are,
Bone mineral density
How to Attain a Standing Posture?
Standing is attainable in various ways, such as employing assistive devices (tilt tables, standing frames / and/ or wheelchair and for persons with paraplegia use of parallel bars with knee-extension splints or orthoses).
It is possible to achieve gait training for patients having complete paraplegia to partially paralysed lower extremities with the help of orthoses and walking aids, like knee-ankle-foot and hip-knee-ankle-foot orthoses.
Best practice for long term management,
Active case management by case managers who have clinical expertise, appropriate training, and knowledge of services for co-coordinating post initial rehabilitation care and can ensue ongoing personalised case management for patients who have ongoing and complex needs
Objectives for treatment of long-term phase patients include,
Attaining goals of high-level mobility needed for community participation
Monitoring function recovery
Reinforcing carrier and family training
Book an appointment at Manipal Hospitals to know more about treatments with the help of experts in Bangalore.