Article topic: Physiotherapy Intervention for Spinal Cord Injury
Author: Yara Abu Al Halaweh
Editors : Ethar Hazaimeh, Adam M Abdallah 
Keywords: Trauma, physiotherapy, spinal cord.

 

Introduction

Traumatic spinal cord injury (TSCI) is a devastating, life-altering condition usually correlated with morbidity, continued disability and dependency, psychological issues, and financial load ⁽¹⁾. Worldwide spinal cord injury prevalence has been increasing over 30 years and varies from 236 to 1298 patients per million in several countries ⁽²⁾.

Types of (TSCI)

Spinal cord injuries are either complete or incomplete cuts, depending on the International Standards for the Neurological SCI1 Classification and the American Spinal Injuries Association Impairment Scale (AIS). Complete injuries are described as AIS A, and incomplete injuries are described as AIS B, AIS C, AIS D, or AIS E. Frankel system whereby a patient was categorized as having an incomplete injury if they had any motor or sensory preservation more than three levels below the level of injury. The International Standards for the Neurological Classification of SCI ⁽³⁾ differentiate between complete and incomplete injuries on the presence of sensory and motor preservation in the S4/5 segments. An injury is described as complete if a patient has no voluntary anal contraction (indicative of S4/5 motor preservation) and/or sensation in or all over the anus (indicative of S4/5 sensory preservation).

 

Spinal cord injuries syndromes

There are various spinal cord syndromes involving injuries to a single segment that has a much more diverse and delicate presentation. These syndromes can be missed or misdiagnosed if an overall neurologic examination and well-differential diagnosis are not done. ⁽⁴⁾ Table 1 represent the cause, diagnosis, and management of the most common syndromes. The managing doctor must be aware of this Central cord syndrome is almost a flexion/extension injury in an elderly patient with existing spinal stenosis. In spite of the fact that spinal immobilization is preserved because of the presence of neurologic deficits, it is usually not an unstable spine injury, and there is no proven evidence of immobilization with a neck collar. Brown-Se´quard (or “cord hemisection”) is rare and mainly seen after a direct penetrating injury to the spinal cord that affects different unilateral and contralateral manifestations. Anterior cord syndrome is usually a vascular cause leading to injury or hindering of flow through the anterior spinal artery. All of the spinal cord syndromes presented with fixed and settled defects, management is mostly predictable and aimed at treating pain and symptoms. ^(5,6) Yet, for any patient with a gradual worsening neurologic deficit, urgent consultation with a neurosurgeon for possible decompression is a must.

Table 1 syndromes, cause, findings, examination, and management

Syndrome	Cause	Findings & Examination	Management
Central cord	Extension or hyperflexion	sacral sensory sparing with Motor weakness of arms > legs	Physical therapy and rehabilitation Spinal decompression
Anterior cord	Direct injury or ischemia from anterior 2/3 spinal artery injury	Loss of pain temperature function And motor function with kept light touch sensation and proprioception	Bad prognosis with a low chance of muscle recovery Physical and occupational therapy
Brown-Se´quard (cord hemisection)	Spinal hemisection is usually gunshot or knife wound	Loss of motor on the same side and proprioception; opposite  loss of pain and temperature sensation	Spinal stabilization if needed Physical therapy Course of steroids
Conus medullaris	Injury to sacral cord and lumbar nerve roots, upper lumbar (L1) fractures, tumors, disk herniation	normal leg motor function. Bowel, bladder, and sexual dysfunction with areflexia, bulbocavernosus present with high lesion	Urgent surgical decompression Course of steroids intravenous (IV) training for Bowel/bladder
Cauda equina	Injury to lumbar/sacral nerve roots, lumbar (L2 or lower), or sacral fractures, also pelvic tumors, herniated disk	Flaccid leg paralysis or weakness, high lesions spare bowel/bladder, bulbocavernosus absent	Surgical decompression Course of steroids Bowel/bladder training

Acute care management

Treatment begins on the spot and a streamlined program for management in the acute phase is a must. Check figure(2)⁷ 

Diagnostic Assessments tools

Once the patient is medically stable, clinical assessment using the ASIA International Standards for Neurological Classification of SCI (ISNCSCI) must be done to classify the level of injury and range of functional impairment⁸. This detailed baseline examination is essential for treatment options, observation of recovery, clinical trial worthiness, and prognosis. The ISNCSCI determines SCI as neurologically complete injury when there is no sacral sparing or sensory and/or motor function at the lowest sacral level (sensory function in dermatome S4-5, deep anal pressure [DAP], or voluntary anal contraction [VAC])⁹.

Spinal shock

Immediately in the period following critical SCI, the spinal shock has been defined as complete loss of sensory and motor function below the level of injury, loss of sphincter reflex, and loss of deep tendon reflexes. The absence of the sphincter reflex indicates spinal shock making attempts at prognostication inaccurate. Recurrence of the bulbocavernosus reflex usually indicates the end of spinal shock and persistent complete motor and sensory loss is an indication of complete spinal cord injury at that time⁷. In the beginning, the phase of missing or reduced reflexes occurs in the first 24 hours post-injury where the deep tendon and cutaneous reflexes below the level of injury are both missed. The second phase is seen between 1 to 3 days after the injury and is defined by an initial presence of cutaneous reflexes such as the bulbocavernosus reflex. After this and lasting up to one month, a phase of early hyperreflexia results in the return of deep tendon reflexes as an outcome of axon-mediated synapse growth. The terminal phase of spinal shock lasts between 1 to 12 months post-injury and is described by hyperreflexia and spasticity of cutaneous and deep tendon reflexes.

Respiratory interventions

The need for proper airway management is essential for patients with cervical level SCIs. Most patients with high cervical SCIs present with quadriplegia and respiratory discomfort or arrest and surely need intubation. Respiratory issues consider a serious cause of morbidity and mortality in patients with acute spinal cord injury. High cervical level injuries can affect phrenic innervation of the diaphragm which leads to being ventilator dependent. Injuries below C5 can still contribute to the weakness of respiratory muscles. It’s important to prevent mucous plugs, atelectasis, and pneumonia. Vibration, Percussion, or assisted suctioning may be helpful in secretions mobilization¹⁰. There is a high possibility of deep vein thrombosis(DVT) and pulmonary embolus in patients with SCI because of prolonged immobility period¹¹.

Cardiovascular issues

Autonomic dysreflexia (AD) is most common in patients with T6 level injury or above and is defined by unexpected, sudden hypertension that can be life-threatening. the sympathetic release triggered by a stimulus below the level of injury leads to peripheral vasoconstriction with a strong parasympathetic response above the level of injury resulting in headaches, sinus congestion, and sweating. Common stimulators such as bowel or bladder distension and so appropriate voiding and bowel prober regimens are a critical role in preventing AD events. Treatment of AD includes conservative methods such as upright positioning and removing any stimulators or possible noxious stimuli. If SBP stays high although conservative methods, fast-acting antihypertensive agents such as instantly release nifedipine, captopril or nitroglycerine should be given¹².

Musculoskeletal Complications

Charcot Joints or neuropathic arthropathy is defined by progressive damage of a joint that has diminished sensation because of unchecked recurrent microtraumas and local hyperemia in response to changes in autonomic innervation. Charcot spinal arthropathy (CSA), despite its rare, can proceed fast and carry crucial morbidity.

With the presence of spinal deformity, sitting imbalance and backache are suspected by the present of disco-vertebral deterioration, vacuum discs, and osseous joint wrack¹³. Conservative management includes a multimodality program with physiotherapy, Bracing for stability, and pain management. Surgeries might be required in advanced cases to correct the deformity and improve stability¹⁴.

Pressure Sores

Pressure sores are a usual complication post-SCI that morbidity/ can cause significant mortality, long period of hospitalization, and act as a stimulus for autonomic dysreflexia. The most common site is on the buttocks (31%), over the greater trochanter (26%), and on the sacrum (18%)¹⁵. Prevention techniques have to be started instantly post injury and accurate adherence should be established for the long-term Daily skin check. It’s highly recommended that individuals should change their position every 2 hours in the initial phases of injury.

Physiotherapy intervention

Classical rehabilitation techniques post SCI contain a range of motion and strengthening exercises, transfer and bed mobility exercises along with locomotor training. Passive and soon mobilization is a critical tenet of rehabilitation post-SCI. Body-weight supported treadmill training (BWSTT) improves task-specific sensory input and is a proven strategy to promote locomotor function after SCI¹⁶. Weakness is the most apparent impairment that limits patients with SCI from practicing motor tasks. Thus, strengthening training is well administered by physiotherapists. Diminished strength in patients with SCI can be neurologically caused, as in patients with Grade 2 or 3 strength in the quadriceps muscle who are training to walk. Otherwise, affected strength might be due to diminished muscle mass¹⁷. The patient needs a progressive resistance training program and the load is appropriately and progressively elevated. This training is usually best performed in the context of functional skills, giving the basics of progressive resistance training can be preserved. Functional Electrical Stimulation (FES) depends on the idea of providing electrical currents to the nerve and muscles that give movements in order to improve their activation for the short and long term. Used as a complement during the rehabilitation process to improve movements that way rising sensory feedback and muscle function, and provide a degree of cardiorespiratory conditioning¹⁸. Stimulation for trunk muscles using FES has been shown to enrich trunk posture and stability¹⁹.

Walking post spinal cord injury

The determination of return to walking after (SCI) depends on the initial level and seriousness of the injury, the extent of lower extremity motor function, and the age of the patient. Other common complications include balance, spasticity, truncal control, and proprioception, with cognition, which also affects walking. In 1973, Hussey and Stauffer²⁰ showed that a reciprocatory gait type may be used when there was pelvic muscle control with minimum of 3/5 strength in both hip flexors and 1quadriceps (knee extensor) with more than or equal to 3/5 in minimum of one leg.

Motor tasks

Physiotherapy intervention is focused on enhancing patients’ wellness to do different motor tasks such as transferring, walking, pushing a wheelchair, and using the upper limbs. Intervention is mainly based on the basics of motor learning. Repeating practice is an essential element. For example, if a patient has overall paralysis and the goal was to walk with walking aids and orthosis, this means the patient has to practice walking with orthoses and walking aids¹⁷. Robotic devices and treadmills could be used to make gait training easier and to provide a chance for intensive repetitive practice using a gait strategy that is similar to an able-bodied person.

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