SPINAL CORD INJURIES

Introduction :
Management of spinal cord injured patient requires
specialized knowledge beyond the scope of any single person ,
so the team effort is required including –(the primary managing
physician, physical therapist, occupational therapist , nurse),
social worker , psychologist , vocational counselors and trainers
This team should work throughout the patients rehabilitation ,
including outpatient follow –up .The excellent environment for
such management is the spinal cord injury center , where
patients can be treated from the day of injury to the ultimate
vocational rehabilitation.

Spinal cord injury considered as an insult to the spinal cord

that resulted in a change, either temporary or permanent, in its
normal motor, sensory, or autonomic function. (Dawodu, et al.,
2008).
:Functional classification of spinal cord injuries
 Spinal cord injuries are divided typically into two broad
functional categories; quadriplegia and paraplegia

"Quadriplegia" refers to partial or complete paralysis of

all four extremities and trunk, including respiratory muscles. It
results from lesion of the cervical cord.

"Paraplegia" refers to partial or complete paralysis of both

lower extremities with or without trunk involvement. It results
from lesion of the thoracic or lumber cord or sacral roots.
Common manifestations of:
C1- 3
Usually fatal
Loss of phrenic innervations
(Ventilator dependent)
No Bowel & Bladder control
Spastic type of paralysis
Chin & mouth control
C6
Week grasp
Has shoulder/biceps to transfer
No Bowel & Bladder control
Spastic type of paralysis
Considered level of independence
 T1--6
Full use of upper extremities ,Transfer
Drive car with hands control & do ADL.
No Bowel & Bladder control, Spastic type of paralysis
Designation of lesion level:
The most commonly used method to determine the level of
SCI is to indicate the most distal uninvolved or partially
involved nerve root i.e. Sensory level &the power of muscles
supplied by that root is at least grade 3+ according to manual
muscle testing.
Classification of Spinal Cord Injuries
1) Complete: Complete – characterized as complete loss of
motor and sensory function below the level of the
traumatic lesion

2) Incomplete: characterized by variable neurological

findings with partial loss of sensory and/or motor function
below the lesion

Clinical picture:
1- Spinal shock:
Immediately following SCI, there is a period of areflexia. It
results from abrupt withdrawal of connections between
higher centers and the spinal cord. It is characterized by
absence of all reflex activity, flaccidity and loss of sensation
below the level of lesion.
2- Motor deficits and sensory loss:
Following spinal cord injury, there will be either complete or
partial loss of muscle function below the level of the lesion.
Disruption of the ascending sensory fibers following SCI
results in impaired or absent sensation below the lesion level.
The clinical presentation of motor and sensory deficits is
dependent on the specific features of the lesion. These
include the neurologic level, the completeness of the lesion,
the symmetry of the lesion (transverse or oblique) and the
presence or absence of sacral sparing.

3- Impaired temperature control:

After damage to the spinal cord, the hypothalamus can no

longer control cutaneous blood flow or level of sweating.
This autonomic (sympathetic) dysfunction results in loss of
internal thermoregulatory responses. The ability to shiver is
lost; vasodilatation does not occur in response to heat nor
vasoconstriction in response to cold.

4- Respiratory impairment:

Respiratory dysfunction varies depending on the level of the

lesion. In lesions between Cl and C3, phrenic nerve is
significantly impaired or lost. An artificial ventilator or
phrenic nerve stimulation is required to sustain life. In
contrast, lumber lesions present with full innervation of
both primary (diaphragm) and secondary (neck, intercostals
 and abdominal) respiratory muscles. All patients with
quadriplegia and those with high level paraplegia
demonstrate some compromise in respiratory function. The
level of respiratory impairment is directly related to the lesion
level and the residual respiratory muscle function.

5-Spasticity:
It typically occurs below the level of lesion after spinal
shock subsides. There is a gradual increase in spasticity during
the first six months and usually reaches a plateau one year after
injury.

6- Bladder dysfunction:
The spinal integrating center for micturition is the conus
medullaris The type of bladder function remaining depends on
the location of the lesion – whether it is at , above , or below the
conus medullaris.
Spastic _ upper motor neuron bladder _ reflexly empties
when bladder is full and occurs in injuries above T12 (similar to
an infant's bladder ) . The reflex arc is intact.
Flaccid _ lower motor neuron bladder ¬ emptying is
initiated by pressure on abdomen , straining , A flaccid bladder
occurs in complete L1 paraplegics (cauda equine injury)
7- Sexual dysfunction:
Function depends on the presence or absence of reflex activity
and is closely linked to the type of bladder the patient exhibits .
Spastic _ upper motor neuron bladder patient _ males may
have non psychic erections that are reflex in nature . they may
be spontaneous or set off by mechanical stimulation , they may
or may not ejaculate and father children. Females may conceive
and give birth.
Flaccid _ lower motor neuron bladder patient _ Males
usually do not have erections or ejaculations and , therefore ,
demonstrate less function than spastic patients .

*Secondary complications:
1. Pressure sores: Pressure sores are subjected to infection
which may migrate to bone. It is a major cause of delayed
rehabilitation and may lead to death. *The most important
factors in the development of pressure sores are:
a) Impaired sensory function
b) Inability to make appropriate positional changes
c) Loss of vasomotor control, which lowers tissue resistance to
pressure.
d) Spasticity, with resultant shearing forces between bony
surfaces.
e) Skin maceration from exposure to moisture (e.g. urine).
f) Nutritional deficiencies as low serum protein and anemia.
g) Secondary infections.
Areas susceptible to pressure in recumbent position.

Supine Prone Side-lying

Occiput Ear (head rotated) Ears
Scapulae Shoulders (Anterior Shoulders (lateral
aspect) aspect)
Sternum Lateral epicondyle
Symphesis pupis of elbow
Styloid process of
ulna
Elbows Illiac crest Greater trochanter
Sacrum Male genital region Head of fibula
Coccyx Patella Knees
Heels Dorsum of feet Medial &Lateral
malleolus
2. Autonomic dysreflexia:
Autonomic dysreflexia is a pathologic autonomic reflex that
occurs in lesions above T6 (above sympathetic outflow). This
clinical syndrome
produces an acute onset of autonomic activity from noxious
stimuli below the level of the lesion. Owing to lack of inhibition
from higher centers, hypertension will persist and pounding
headache. if not treated promptly. The most common stimuli for
this pathologic reflex are bladder or rectal distention, pressure
sores, urinary stones, bladder infections and noxious cutaneous
stimuli.
3. Postural hypotension:
Postural hypotension is a decrease in blood pressure,
which occurs when a patient is moved from a horizontal to a
vertical position. It is caused by a loss of sympathetic
vasoconstriction control. The problem is enhanced by lack of
muscle tone, causing peripheral venous blood pooling. the
cardiovascular system, over time, gradually reestablishes
sufficient vasomotor tone to allow assumption of the vertical
position.

4. Heterotopic (Ectopic) bone formation:

Bone can form in the soft tissues below the level of the
injury. Usually, heterotopic bone develops adjacent to a large
lower limb joints such as the hip or knee. Early symptoms
including swelling, decreased range of motion, erythema and
local warmth near a joint.

5. Contractures:
Contractures develop with prolonged shortening of
structures across and around a joint, resulting in limitation in
motion. Contractures initially produce alterations in muscle
tissue but rapidly progress to involve capsular and pericapsular
changes.
6. Deep venous thrombosis (DVT): They may block pulmonary
vessels and result in death. In SCI, DVT is due to loss of the
normal pumping mechanism provided by active contraction of
lower extremity musculature. This slows the flow of blood,
allowing higher concentrations of pro-coagulants (thrombin) to
develop in localized areas.

Prognosis

The potential for recovery from SCI is directly related to

the extent of damage to the spinal cord and/or nerve roots.

There are three main factors that affect potential for

recovery:

(1) the degree of pathologic changes imposed by the trauma.

(2) The precautions taken to prevent further damage during
rescue.
(3) prevention of additional compromise of neural tissue from
hypoxia and hypotension during acute management.
*When the plateau is reached; and no new muscle activity is
observed for several months, no additional recovery can be
expected in the future.
 Physical Therapy Assessment
Physical Therapy Assessment During The Acute Phase:
A general assessment of the patient is indicated, including
respiratory function, muscle strength, tone and skin condition.
Results will assist the therapist in determining the lesion level,
identifying general functional expectation and formulating
appropriate goals.
I . Respiratory assessment :
Details of respiratory states and function are essential.
a. Function of respiratory muscles: Muscle strength, tone and
atrophy of the diaphragm, abdominals and intercostals should be
assessed and respiratory rate should be noted.
b. Chest expansion. Circumferential measurements are at the
level of the axilla and xiphoid process. Normally, chest
expansion is 2.5 to 3 inches at the xiphoid process.
c. Breathing pattern: by manual palpation over the chest and
abdominal region or by observation. Particular attention should
be directed toward use of accessory neck muscles.
d. Cough:
Vital capacity: Initial measure may be taken with a handheld
spirometer.
2 . Skin assessment :
-Regular skin inspection.
-Frequent position changes and skin inspection is necessary
-The patient's entire body should be observed regularly
with particular attention to areas most susceptible to
pressure.
-Palpation is useful for identifying skin temperature
changes, redness, local warmth, local edema, and small open
or cracked skin areas. If the patient is wearing vest or other
orthotic devices, contact points between the body and the
appliance must also be inspected.

3 .Sensory assessment: A detailed assessment of superficial,

deep and cortical sensations should be completed. It should
be noted that the sensory level of injury may not correspond
to the motor level of injury (i.e., incomplete lesions).
4. Tone and deep tendon reflexes: Muscle tone should be
assessed. The reflexes most commonly assessed are the
biceps(C-6), triceps (C-7), quadriceps (L–3–4) and gastronomies
(S-1)
5- Manual muscle test and range of motion assessment.
Standard techniques should be used for MMT and ROM.
Mobility will be limited during the acute phase, deviations from
standard positioning will be necessary and should be carefully
documented.
6- Functional assessment:
Accurate and specific determination of functional skills
usually must be delayed until the patient is cleared for activity.
Once activity is allowed, a more detailed assessment of function
can be made.
Physical Therapy Treatment During The Acute Phase :
During the acute phase of rehabilitation emphasis is placed
on respiratory management, prevention of secondary
complications, maintaining range of motion, and facilitating
active movement in available musculature.
I- Respiratory management :
Respiratory care will vary according to the level of injury and
individual respiratory status. Primary goals of management
include improved ventilation, increased effectiveness of cough,
prevention of tightness and of ineffective substitute breathing
patterns, the following treatment activities may be appropriate.
a- Deep breathing exercises: Diaphragmatic breathing should
be encouraged to facilitate diaphragmatic movement and to
increase vital capacity, the therapist can apply light pressure
during both inspiration and expiration. Manual contacts can be
made just below the sternum. This will assist the patient to
concentrate on deep breathing patterns. This creates a
compressive force on the thorax, resulting in a more forceful
expiration followed by a more efficient inspiration. Inflation
hold and incentive spirometry are also useful adjuncts to deep
breathing exercises.
b- Glossopharyngeal breathing: This activity is often
appropriate for patients with high – level cervical lesions. The
technique utilizes accessory muscles of respiration to improve
vital capacity. The patient is instructed to inspire small amounts
of air repeatedly.
c- Air-shift maneuver: This technique provides the patient with
an independent method of chest expansion. This maneuver is
accomplished by closing the glottis after a maximum inhalation,
relaxing the diaphragm and allowing air to shift from the lower
to upper thorax. Air-shifts can increase chest expansion by 0.5
to 2 inches (1.3 to 5.1 cm)
d- Strengthening exercises: Progressive resistive exercises can
be used to strengthen the diaphragm. This can be accomplished
by manual contacts over the epigastric area below the xiphoid or
by use of weights. Strengthening exercises for innervated
abdominal and accessory musculature are also indicated.
e- Assisted coughing: To assist the coughing and movement of
secretions, Manual contacts are placed over the epigastric area.
The therapist pushes quickly in an inward and upward direction
as the patient attempts to cough
f- Abdominal Support: An abdominal corset or binder is
indicated for patients whose abdomens protrude, allowing the
diaphragm to "sag" into a poor position for function. Abdominal
supports provide the benefits of maintaining intrathoracic
pressure and decreasing postural hypotension.
g- Stretching: Mobility and compliance of the thoracic wall can
be facilitated by manual stretching of pectoral and other chest
wall muscles.

2- Range of motion and positioning: While the patient is

immobilized in bed or on turning frame, full ROM exercises
should be completed daily except for those areas which are
contraindicated or require selective stretching With
quadriplegia, motion of the head and neck is contraindicated
pending orthopedic clearance .Stretching of the shoulders should
be avoided during the acute period; however, the patient should
be *positioned out of the usual position of comfort, which is
internal rotation, adduction and extension of the shoulders,
elbow flexion, forearm pronation, and wrist flexion. Full ROM
exercises are generally included for both lower extremities.
Patients do not require ROM in all joints. In some instances
allowing tightness to develop in certain muscles will enhance
function. For example, with quadriplegia, tightness of the lower
trunk musculature will improve sitting posture by increasing
trunk stability; tightness in the long finger flexors will provide
an improved tenodesis grasp.
Conversely, some muscles require a fully lengthened range.
After the acute phase, the hamstrings will require stretching to
achieve a straight leg raise of approximately 120 degrees. This
ROM is required for many functional activities such as sitting,
transfers, lower extremity dressing, dressing and self ROM
exercises.
Positioning splints for the wrist, hands, and fingers are an
important early consideration. For high –level lesions the wrist
is positioned in neutral, the web space is maintained, and the
fingers flexed.
Ankle boots or splints are indicated to maintain alignment and
to prevent heel cord tightness and pressure sores Sandbags or
towel rolls also may be required to maintain a position of
neutral hip rotation.
Following orthopedic clearance, the patient typically is placed
on a schedule to increase tolerance to the prone position. For
patients wearing a halo device, one or two pillows under the
chest will allow assumption of the prone position. The ankles
should be position at a 90 degree angle. Tolerance to the prone
position should be increased gradually until the patient is able to
sleep all, or at least part of the night in this position. This
routine will assist with prevention of pressure sores on
posterior aspects of the body and development of flexor
tightness at the hips and knee.
3- Selective strengthening:
All remaining musculature will be strengthened maximally.
However, during the acute phase, certain muscles must be
strengthened very cautiously to avoid stress at fracture site.
During the first few weeks following injury application of
resistance may be contraindicated to:
*Musculature of the scapula and shoulders in quadriplegia
* Musculature of the trunk and hips in paraplegia.
*Several forms of strengthening exercises are appropriate
during this early phase:
-Bilateral manually resisted motions,
-Bilateral upper extremity proprioceptive neuromuscular
facilitation (PNF) patterns.
-Progressive resistive exercises using cuff weights or dumbbells.
*With quadriplegia, emphasis should be placed on
strengthening the anterior deltoid, shoulder extensors, biceps,
and lower trapezius. If present, the radial wrist extensor, triceps,
and pectoralis should also be emphasized because they will be
of key importance in improving functional capacity.

With paraplegia, all upper extremity musculature should be

strengthened, with emphasis on shoulder depressors, triceps, and
latissmus dorsi, which required for transfers and ambulation.
*Many activities afford the important benefit of progressive
strengthening. For example, self – feeding will assist with
strengthening the shoulder and elbow flexors. Another example
of a functional activity with important strengthening benefits is
wheelchair propulsion (deltoids, biceps, and shoulder rotators)
4- Orientation to the vertical position : Once radiographic
findings have established stability of the fracture site the patient
is cleared for upright activities .the patient typically will
experience symptoms of postural hypotension if approach to
management has required prolonged immobility
A very gradual acclimation to upright posture is most
effective. The use of an abdominal binder and elastic stokings
will retard venous pooling. During early upright positioning,
elastic wraps are often used in combination with the elastic
stockings.
*Initially, upright activities can be initiated by elevating the
head of the bed and progressing to a reclining wheelchair with
elevating leg rests.
Use of the tilt table provides another option for orienting the
patient to a vertical position. Vital signs should be monitored
carefully and documented during this acclimation period.
 Subacute Phase :
Physical Therapy Assessment During The Sub-acute Phase :
All the assessment procedures completed during the acute phase
will be continued at regular intervals during the sub-acute phase
of rehabilitation. During this phase of management , the patient
will be instructed gradually to assume responsibility for skin
inspection.
Physical Therapy Treatment During The Sub-acute Phase :
I ) Bed and Mat activities
1- Rolling over.
2- Moving side ward – supine.
3- Sitting up.
4- Sitting balance.
5- Push-ups in sitting.
6- Moving forward and backward while sitting.
7- Placing legs over the edge of bed while sitting.
8- Balancing on hands and knees. 9- Crawling.
10- Raising arms alternately in a four–legged position.
II ) Wheel Chair activities
1- Sitting balance.
2- Push-ups.
3- Crossing legs.
4- From wheel chair to mat and back.
III) Transfer activities :-
1) From bed to wheel chair and back.
2) From wheel chair to chair and back.
3) Control of wheel chair.

IV – Ambulation:

a)Parallel –bar ex's

b) Crutch balance

c- Crutch walking

I ) Bed and Mat activities: Purpose :

1- To develop strength, mobility and balance.

2- To perform self-care activities in bed and wheel chair.

3- To prepare him for crutch walking.

Purpose: To move from place to place in bed, to prevent

pressure sores and to increase mobility.
Preparation For: Sitting up, dressing, getting in and out from
bed, toilet activities.
Starting position: Supine and arms beside the patient, knees
extended.
Helpful remarks: Therapist can start the exercise by putting one
leg over the other. Also, side railing can be put to avoid falling
2) Moving Sideward – Supine
Purpose: To increase mobility, to handle lower extremities.
Preparation For : Sitting up, sitting with leg over the edge of
bed, dressing, toilet activities, getting in and out of bed,
handling of braces.
Starting position: Supine, arms beside body and knees
extended.
Helpful remarks:
- Grasping mattress or head of bed help in moving sideward.
3) Sitting Up
Purpose: - To sit up without help.
- To handle lower extremities.
Preparation For: Push-ups, all self care activities.
Starting position: Supine.
A) Sitting up –pushing on hands: as shown in fig (3).
B) Sitting up –placing leg over the edge of bed:
Done for spastic lower limbs to release tightness of hamstring as
shown in fig (4).
C) Sitting up – holding on:
Done for flaccid paralysis in lower limb as shown in fig (5).
D) Sitting up-holding on to two ropes:
Done for spastic lower limbs.
The 2nd rope used for heavy patients and patients who were
braces. As shown in fig (6).

A) Sitting up –pushing on hands

B) Sitting up –placing leg over the edge of bed

C) Sitting up – holding on
D) Sitting up-holding on to two ropes

4) Sitting balance Purpose: To Maintain balance in

sitting while moving arms & trunk.
Preparation For: All self-care activities.
Starting position: Sitting position.
Steps: A) Sitting balance: With back support

B) Sitting balance: With back unsupported

Graduations of balancing exercises:

1- Hands beside the hip.
2- Hands side way.
3- Hands forward 90 o.
4- Hands over the head.
5- Lean forward till hands on knees.
6- Lean forward till finger reach the ankle.
 5) Push – ups in sitting
Purpose: To strength arm and shoulder muscles (crutch
muscles).
Preparation For: All ADL & for transfer and for crutch
walking.
Starting position: Sitting with palms fists or fingers down on
mat.

6) Moving forward and backward with sitting

Purpose: To strength arm and shoulder muscles (crutch
muscles).
Preparation For: All ADL& for transfer and for crutch walking.
Starting position: Sitting with palms fists or fingers down on
mat.
7) Placing legs over edge with sitting
Purpose: To maintain balance while handling lower extremities
Preparation For: Transfere from bed to wheel chair and vice
versa , transfere from wheel chair to car and vice versa .
Starting position: Sitting
8) Balancing on hands and knees
Purpose: To strength hands and knees.
To shift & distribute weight between hands and knees
Preparation For: Crutch walking.
Starting position: Prone with elbow flexed beside shoulder
&using sand bags under feet to prevent pressur

9) Crawling
Purpose: To strength arm, shoulder and thigh muscles.
To maintain balance while moving forward
Preparation For: Crutch walking.
Starting position: Quadribed.
10) Raising arms Alternately in a 4 legged position
Purpose: To maintain balance on knees and one hand.
Preparation For: Crutch balance, Crutch walking.
Starting positio : Quadribed position

II ) Wheel Chair:-
Description of wheel chair:
Wheel chair prescription will vary according to the level of
lesion.
• Seat depth: 2.5cm back from popliteal fossa.
• Floor –to- seat height: 2 inches clearance from the
floor to the foot pedals and 90o knee flexion.
• Back height: low back for paraplegia, high back that is
below the inferior angle of the scapula to provide push-
ups activities.
• Seat width: hand's width between the hips and the sides
of the chair.
Wheel chair activities :
Exercise's done on wheel chair:-
1- Sitting balance.
2- Push-ups.
3- Crossing legs.
4- From wheel chair to mat and back.
4) From wheel chair to mat
a) using 6 balances b) directly
Purpose: To strength, balance to able to get down on mat or
floor without being lefted.
Preparation For: Transfer from wheel chair to toilet seat and
back.
Starting position: Sitting on wheel chair , graduated 6 balances

III) Transfer activities:-

1) From bed to wheel chair and back:
a)Wheel chair facing bed: heel chair facing bed:

b) Using board (wheel chair with non-removable arm rest):

c) Using board (wheel chair with removable arm rest):

d) Using Chair:
e) Wheel chair at angle (non removable arm rest):
f) wheel chair alongside bed (removable arm rest):
3) Control of wheel chair:
- lock wheel chair.
- Put sandbags behind wheels if there is no brakes.
-Raise and lower the foot –rest.
- Propelling wheel chair.
- Wheel chair over carpet.

IV – Ambulation:

a) Parallel–bar ex's: The wrist must be extended- The

elbow must be bend 25 o – 30 o.
1- Getting up from and wheel chair withen parallel bars.
2- Standing balance. 3- Jack – knifing.
 4- Push-ups. 5- Hand forward and backward.
6- Turning around. 7- Gait.
b) Crutch balance:
1- Crutch balance against wall:
Side waying, Lifting one crutch, Lefting both crutchs, Pushing up
on crutch, Jack knifing,
2- Crutch balance a way from wall:
Jack knifing. Crutches forward and backward.
c- Crutch walking :
- Four point gait.
- Two point gait:
• Shuffling gait.
• Swing to gait.
• Swing through gait .
-Four point and two-point gaits require hip flexion or hip hiking.
Patients with high lesions may learn this movement using the secondary
hip-hikers. Those with low lesions will have the primary hip-hikers.
Trunk rotation on the swing side or lateral flexion toward the stance side
will facilitate forward progression.
- Swing-to and swing-through gaits require varying degree of body
elevation and push off. These gait patterns involve some jackknifing and
recovery.