Spinal Cord Injury by Physiotherapists
Jonathan Blood-smyth asked:
Spinal cord injury (SCI) is an uncommon but very serious condition usually from a high velocity incident but can also be caused by tumours, infections and loss of blood supply to the spinal cord. It occurs predominantly in younger persons who undertake more risky activities but can present at any age, with motor vehicle accidents the most common cause. SCI needs intensive and skilled management from a multidisciplinary team to achieve the best outcome of independence for the patient. The resulting injuries from this condition are known as paraplegia or quadriplegia.
The initial medical evaluation is performed to establish the respiratory status of the patient and deal with any other of the likely multiple injuries. Once the patient is stabilised the doctors try and work out the level in the spine where the damage has occurred, an important fact as it relates closely to medical and therapy management. A low lumbar fracture will have no effect on the arms or the ability to breathe so the patient will have good trunk and arm power and the aerobic ability to develop independence. Cervical and upper thoracic injuries impair the respiratory ability of the patient and limit arm function, making rehabilitation much harder.
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.
Once the emergency treatment has been provided and the medical condition of the patient is stable they can be transferred to a ward. Spinal surgery may be performed, using internal fixation and bone grafting, to stabilise the fractured spinal segments. Once the segments are stable the patient can begin early rehabilitation without waiting for fracture healing which for the spine can take up to 12 weeks. Physiotherapists review the patient’s respiratory coping, teach range of movement and strengthening exercises for unaffected parts and put the paralysed areas through full passive range of movement several times every day to maintain the joint ranges.
The physiotherapist will ensure good positioning of the patient to protect the site of the fracture, ensure good skin pressure care and prepare the patient to be able to adopt and maintain the postures they will need to be independent. The physiotherapist will place the patient in the frog position, with the hips abducted and flexed and the soles of the feet together. This position is very important for the patient to be able to sit upright with good balance, manage the care of their feet, lean forward and move their legs and manage their bladder care by catheterising themselves.
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.
By this time the patient will have learned trunk control in sitting, wheelchair transfers and strengthening work, so at this stage they should be routinely transferred to a unit specialising in spinal injuries. Experienced advice from the multidisciplinary team about the large number of skills they need to learn is available there to foster the highest level of independence. Many factors impact on whether the patient can lead a fully independent life including their age, other medical difficulties, family support, motivation and attitude and the spinal level affected. Some people with higher lesions may need routine care from a pool of carers throughout the day.
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