Physiotherapy and Spinal Cord Injury



Posted: Friday, January 30, 2009

by Jonathan Blood Smyth

High velocity accidents and sporting incidents carry a risk of causing a spinal cord injury (SCI), a serious but uncommon condition which can also be caused by ischaemia, infections or tumours. Younger people are the biggest group likely to suffer this injury due to their risky pursuits but it can occur in someone of any age, road accidents accounting for the greatest proportion. Due to the complex nature of the condition a multi-disciplinary approach is essential, involving several health care professionals, to facilitate the highest degree of independence in the patient. Paraplegia and quadriplegia are the terms used for the resulting conditions.

The emergency medical situation is dealt with first, keeping the person alive and ensuring their breathing is clear. Once in the hospital the doctors test the patient to find out what spinal level has been damaged as this determines much of the physiotherapy and medical management. Low spinal injury such as in the lumbar area will not have consequences for the patient's ability to breathe and they will have good arm and trunk power to work on independence. A high thoracic or cervical injury paralyses some of the rib muscles, reducing the ability for spontaneous breathing and limiting arm power, making rehabilitation much more difficult.

Assessment of the patient's respiratory status is the initial concern of the physiotherapist, often in the intensive care unit. The physiotherapist will attempt to encourage the patient to expand their lungs, deep breathe and cough any secretions up to clear their chest. Paralysis of the lower trunk can reduce propulsive force and thereby the effectiveness of coughing, a process which the physiotherapist helps by stabilising the lower abdomen during attempted coughing. Suction may be needed in severe cases and coughing can be promoted by using a cough assist machine.

Transfer of the patient to the ward follows the intensive care period and by now they should be medically stable. The patient may undergo spinal fusion surgery with internal fixation to stabilise the fractured segments, avoiding the need to wait for the typical healing period of the spine which is three months. Now the early rehabilitation of the patient can begin, with the physiotherapist checking closely on the patient's respiratory ability, exercising the non-paralysed areas for strength and mobility and undertaking regular passive movements to the paralysed limbs to keep and to increase the ranges of motion.

If the spine is unstable, which it often is in spinal trauma resulting in paraplegia, a spinal surgeon will stabilise the spine, usually with instrumentation and bone grafting. This allows the patient to start their rehabilitation without the long wait for the spinal fractures to heal naturally. Initial physiotherapy management is to monitor the respiratory status, encourage active movement of unaffected areas and perform passive movements of paralysed body parts to retain and improve the ranges of motion which will be required later for independence.

Positioning the spinal cord injured patient is very important for safety of the fracture site, for pressure care of the skin and for preparing the patients body for the positions they will need to live as independently as possible. The frog position is one of the postures the physiotherapist will place the patient in, with the hips bent up and the knees placed out to the side so the soles of the feet are touching. The patient will need this position to manage their sitting balance to lean forward to move the legs, to self-catheterise and to get to their feet to put on socks and manage foot care.

The next stage of rehabilitation involves getting the patient up into a wheelchair but initially the patient's blood pressure can react badly by dropping strongly so they are sat gradually up in bed and then transferred to a chair with the back on a slope and with elevating leg rests. Tolerance of being upright is gradually extended and sitting balance practised on the edge of a plinth, with the physiotherapist closely monitoring any poor trunk control. The physiotherapist will move on to strengthening and to teaching transfers into a wheelchair and once the patient has developed reasonable sitting balance and accustomed themselves to transfers and being out in a wheelchair for periods of time it is appropriate for them to be transferred to a spinal injuries unit where they can receive specialised help from a multi-disciplinary team for the many aspects of their condition they need to master to be as independent as possible.

Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Kent.
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