Physiotherapy in Spinal Cord Injury

Physiotherapy assessment and treatment should be carried out as soon as possible after injury. During the early acute stage,care of the chest and paralysed limbs is of prime importance.
Chest complications may occur as a result of the accident—for example, from inhaling water during diving incidents, from
local complications such as fractured ribs, or from respiratory insufficiency caused by the level of the injury. Pre-existing lung disease may further complicate respiration.






Figure 1 Patient with incomplete paraplegia using arm weights.
Bilateral arm strengthening exercises must be done in supine positionto maintain vertebral alignment.

Respiratory management
All patients receive prophylactic chest treatment, which includes deep breathing exercises, percussion and coughing,
assisted if necessary. Careful monitoring is essential for tetraplegic patients as cord oedema may result in an ascending
level of paralysis, further compromising respiration.
Patients with tetraplegia or high level paraplegia may have paralysed abdominal and intercostal muscles and will be unable to cough effectively. Assisted coughing will be necessary for effective lung clearance. Careful coordination and communication between physiotherapist and patient is vital for assisted coughing to be successful. Forced expiration may be achieved by the placement of the therapist’s hands on either side of the lower ribs or on the upper abdomen and ribs, producing an upward and inward pressure as the patient attempts to cough. Two people may be needed to treat the patient with a wide chest or tenacious sputum.
Passive movements
All paralysed limbs are moved passively each day to maintain a full range of movement. Loss of sensation means that joints and soft tissues are vulnerable to overstretching, so great care mustbe taken not to cause trauma. Provided that stability of the bony injury is maintained, passive hip stretching with the patient in the lateral position, and strengthening of nonparalysed muscle groups, is encouraged.
Once the bony injury is stable patients will start sitting, preferably using a profiling bed, before getting up into a wheelchair. This is a gradual process because of the possibility of postural hypotension, which is most severe in patients with an injury above T6 and in the elderly.



Figure 2 Passive movements to a patient’s arm. Good support must be given to the paralysed joints and a full range of movement achieved.

Mobilisation into a wheelchair
Once a patient is in a wheelchair regular relief of pressure at the ischial, trochanteric, and sacral regions is essential to prevent the development of pressure sores in the absence of sensation.
Patients must be taught to lift themselves to relieve pressure every 15 minutes. This must become a permanent habit. Paraplegic patients can usually do this without help by lifting on the wheels or arm rests of their wheelchairs. Tetraplegic patients should initially be provided with a cushion giving adequate pressure relief, but may in time be able to relieve pressure themselves.

Wheelchairs
Wheelchair design has been much influenced by technology. Lightweight wheelchairs are more aesthetically acceptable,
considerably easier to use, and often adjustable to the individual user’s requirements. An appropriate wheelchair
should be ordered once an assessment of the patient’s ongoing needs has been made.



Figure 3 Left: patient correctly seated in wheelchair—erect and well back in the chair; footplates are level and adjusted to allow thighs to be fully supported on wheelchair cushion and for weight to be evenly distributed. Right: patient seated incorrectly—“slumped” and with poor trunk posture. Footplates are too high so there is excessive pressure on the sacrum—a potential pressure problem.

Rehabilitation

Physical rehabilitation includes the following:
• Familiarity with the wheelchair. The patient has to be taught how to propel the chair, operate the brakes, remove the footplates and armrests, and fold and transport the wheelchair. Basic skills include pushing on level and sloping ground and turning the chair.
• Relearning the ability to balance. The length of time this takes will depend on the degree of loss of proprioception and on trunk control.
• Strengthening non-paralysed muscles.
• Learning to transfer from wheelchair to bed, toilet, bath, floor, easy chair, and car. Teaching these skills is only
possible once confidence in balance is achieved and there is sufficient strength in the arms and shoulder girdles. The
degree of independence achieved by each patient will depend on factors such as the level of the lesion, the degree
of spasticity, body size and weight, age, mental attitude, and the skill of the therapist. Patients who cannot transfer
themselves will require help, and patient and helpers will spend time with therapists and nurses learning the
techniques for pressure relief, dressing, transferring, and various wheelchair manoeuvres. The level of independence
achievable by tetraplegic patients is shown on Box 1.
Close cooperation between physiotherapists and occupational therapists helps patients to reach their full potential.
• Learning advanced wheelchair skills: backwheel balancing to allow easier manoeuvrability over rough ground and provide a means of negotiating kerbs; jumping the chair sideways for manoeuvrability in a limited space; and lifting
the wheelchair in and out of a car unaided.


Box 1 Functional ability and anticipated level of independence of patients with complete tetraplegia

Complete lesion below C3:
• Diaphragm paralysed requires tracheostomy with permanent ventilation or diaphragm pacing
• Dependent on others for all personal and domestic care
• Able to use powered wheelchair with chin, head or breath control
• Able to use voice-activated computer
• Able to use electrically powered page-turner with switch
• Able to use environmental control equipment with switch, usually mouthpiece

Complete lesion below C4:
• Able to breathe independently using diaphragm
• Able to shrug shoulders
• Dependent on others for all personal and domestic care
• Able to use a powered wheelchair with chin control
• Able to use computer, either voice activated or using head switch or mouthstick
• Able to use environmental control equipment with mouthpiece as switch

Complete lesion below C5:
• Has shoulder flexion and abduction, elbow flexion and supination
• Able to participate in some aspects of personal and domestic care, i.e. eating, cleaning teeth using a wrist support and universal cuff
• Able to make signature using individually designed splint and wrist support
• Able to propel manual wheelchair short distances on level uncarpeted ground wearing pushing gloves and/or wrist supports
• Able to use powered wheelchair with joystick control for functional use
• May be able to assist with transfer from wheelchair onto level surfaces using a sliding board and an assistant
• Able to drive from wheelchair in an accessible vehicle
• Able to use environmental control equipment using a switch

Complete lesion below C6:
• Able to extend wrists
• Able to perform some aspects of personal and domestic care using a universal cuff
• Able to make a signature using an individually designed splint
• Able to dress upper half of body independently, but may require some assistance with dressing lower half of body
• Able to propel wheelchair, including slopes
• May be independent in bed, car, and shower chair transfers
• Able to drive an automatic car with hand controls

Complete lesion below C7:
• Full wrist movement and some hand function, but no finger flexion or fine hand movements
• Able to be independent in bed, car, shower chair, and toilet transfers
• May require assistance/equipment to assist with wheelchair to floor transfers
• Able to dress and undress independently
• Able to drive an automatic car with hand controls

Complete lesion below C8:
• All hand muscles except intrinsics preserved
• Wheelchair independent but may have difficulty going up and down kerbs
• Able to drive an automatic car with hand controls



Complete lesion below T1:
• Complete innervation of arms
• Wheelchair independent
• Able to drive an automatic car with hand controls

These expectations are general and depend upon the patient’s age,physical proportions, physical stamina and agility, degree of spasticity and motivation. In incomplete spinal cord lesions, where there can be variable potential for neurological recovery, it may not be possible to predict functional outcome, which can lead to increased anxiety for the patient.
The level of independence achieved by children not only depends on their size and functional ability but the attitude of their parents.
As the adult with a spinal cord lesion becomes older their ability to maintain their level of independence may diminish and require review.



Figure 4 Patient with incomplete paraplegia below T6 transferring on to the bed. Having first lifted legs up on to the bed the patient then
lifts rest of body horizontally from chair to bed. Hand position is important to achieve a safe lift, avoiding contact with wheel.



Figure 5 Patient with incomplete paraplegia below T6 transferring on to the toilet. Toilet seat must be well padded. Chair and legs must be carefully positioned to ensure a safe lift. Patient has to lift and rotate in one movement, so balance must be good and shoulder strength maximal.







Figure 6 Patient going up kerb unaided. Patient must be able to balance on the rear wheels and travel forwards while maintaining this
position and have enough strength to push chair up kerb.





Figure 7 Patient coming down kerb unaided.

• Regular standing, may help to prevent contractures, reduce spasticity, and minimise osteoporosis. In patients subject to postural hypotension the vertical position must be assumed gradually, and patients may be helped by the use of an abdominal binder. For these patients the tilt table is used initially, progressing later, if appropriate, to an Oswestry standing frame or similar device.
Patients with low thoracic or lumbar lesions may be suitable for gait training using calipers and crutches, but success will
depend on the patient’s age, height, weight, degree of spasticity, and attitude. Orthotic devices such as the reciprocating gait orthosis (RGO), advanced reciprocating gait orthosis (ARGO), hip guidance orthosis (HGO), or Walkabout may be considered for patients including those unsuitable for traditional calipers and crutches. Instruction in the use of these devices requires specialist input and checks should be made on the patients and their orthoses at regular intervals.
Recreation
Sporting activities can be a valuable part of rehabilitation as they encourage balance, strength, and fitness, plus a sense of camaraderie and may well help patients reintegrate into society once they leave hospital. Archery, darts, snooker, table tennis, fencing, swimming, wheelchair basketball, and other athletic pursuits are all possible and are encouraged.
Incomplete lesions
Patients with incomplete lesions are a great challenge to physiotherapists as they present in various ways, which necessitates individual planning of treatment and continuing assessment. Patients with incomplete lesions may remain severely disabled despite neurological recovery. Spasticity may restrict the functional use of limbs despite apparently good isolated muscle power. The absence of proprioception or sensory appreciation will also hinder functional ability in the presence of otherwise adequate muscle power. Patients with a central cord lesion may be able to walk, but weakness in the arms may prevent them from dressing, feeding, or protecting themselves from falls. Recovery may well continue over several months, if not years, so careful review and referral to the patient’s district physiotherapy department may be necessary to enable full functional potential to be achieved.
Children
Spinal cord injury in children is rare. The most important principles in the physical rehabilitation of the growing child with a spinal cord injury are preventing deformities, particularly scoliosis, and encouraging growth of the long bones. To achieve these aims the child requires careful bracing and full-length calipers to maintain an upright posture for as much of the day as possible. The child should be provided with a means of walking such as brace and calipers with crutches or rollator, a swivel walker, hip guidance orthosis, or reciprocating gait orthosis.
Sitting should be discouraged to prevent vertebral deformity. A wheelchair should be provided, however, to facilitate social activity both in and out of the home. Return to normal schooling is encouraged as soon as possible.



Figure 8 Tetraplegic patient standing on tilt table. Straps support patient’s chest, lower trunk, and knees. Table is operated by therapist, the fully upright position being achieved gradually.



Figure 9 Oswestry standing frame enables paraplegic patient to stand by providing support through suitably placed padded straps at toes and heels, knees, and gluteal region. Uprights and two further straps supporting the trunk allow a tetraplegic patient to stand in the frame.


Figure 10 Swimming enables freedom of movement and independence, demonstrated here by a C6 tetraplegic.


Young children have arms that are relatively short in relation to the trunk, so they should not attempt independent transfers. The child may therefore need to be readmitted and taught transfer skills at a later stage. Continued follow up is necessary throughout childhood, adolescence, and early adult life to ensure that adjustments are made to braces, calipers, and wheelchair to maintain good posture and correct growth.


Autores: Trudy Ward, David Grundy


Further reading
• Association of Swimming Therapy. Swimming for people with disabilities. London: A & C Black, 1992
• Bromley I. Tetraplegia and paraplegia. A guide for physiotherapists, 5th edition. Edinburgh: Churchill
Livingstone, 1998
• Ward T. Spinal injuries. In: Pryor JA, Webber BA, eds.
Physiotherapy for respiratory and cardiac problems, 2nd edition. Edinburgh: Churchill Livingstone, 1995, pp 429–38