Rehabilitation of Patients with Spinal Cord Injury, and Problems Associated with Such Injury
Essentials
At the initial stage, rehabilitation is aimed towards neurological, mental and social adaptation.
Lifelong follow-up is carried out at outpatient spinal cord injury clinics.
Any associated problems should be identified and actively treated.
Definition, epidemiology and classification
The term traumatic spinal cord injury refers to damage to the nerve structures within the vertebral canal resulting from an external force and causing a disturbance of motor and/or sensory function.
Diseases may also cause spinal cord injury.
The most common causes of traumatic spinal cord injury are falling from standing or from a height.
Nearly one traumatic spinal cord injury in three occurs under the influence of alcohol.
The diseases most commonly causing spinal cord injury are spinal stenosis and various tumours.
Some patients with spinal cord injury may be discharged immediately after treatment on the acute ward. In that case, physiotherapy and/or occupational therapy is arranged on an outpatient basis, as necessary.
The aims of initial rehabilitation of patients with spinal cord injury on a hospital ward include optimizing neurological recovery, achieving the highest possible functional independence in the person's own living environment after discharge from hospital, and making integration back into the society smoother.
Areas of rehabilitation
Prevention and treatment of problems and complications associated with spinal cord injury
Multiprofessional rehabilitation by means of physiotherapy, occupational therapy, speech therapy, neuropsychological rehabilitation and rehabilitation nursing, for example, can be used to practise everyday activities, such as moving, locomotion, eating, getting dressed, washing, and control of bowel and bladder function.
Assessment of the need for aids, their choice, acquisition and user training
Provision of information about spinal cord injury and associated issues to both patients and their relatives
Assessment of any need for adaptation in the home or workplace
Review of the patient's social situation, including the life situation, social security and assessment of the need for services
Support of mental adaptation
Peer support
Introduction of leisure-time activities and various types of tailored physical exercise, in particular
Lifelong follow-up
Lifelong follow-up is done at outpatient spinal cord injury clinics.
At follow-up visits, the patient's state of health, functional ability and need for rehabilitation should be assessed from the point of view of the spinal cord injury, and treatment, rehabilitation and service plans written or updated, as necessary. In other respects, the health care of patients with spinal cord injury should follow the normal treatment chains.
The rehabilitation plan should be written in public health care in cooperation between the client and physician or multiprofessional team and always be based on the client's individual needs and functional ability.
Associated problems
Respiratory insufficiency
Significant spinal cord injury in the region of the cervical spine and upper thoracic spine often causes respiratory insufficiency Respiratory Failure due to impaired respiratory muscle activity, increased bronchial contractility and mucus secretion. Insufficient function of respiratory muscles impairs ventilation and coughing force, which, in turn, increases mucus production, predisposes to pulmonary inflammation and impairs chest mobility.
Spinal cord injury in the region of the cervical spine may also involve difficulty swallowing, which, in association with respiratory insufficiency, increases the risk of lung infections, such as pneumonia, particularly in the acute phase after the injury.
After high-level spinal cord injury, respiratory physiotherapy is used to maintain respiratory function.
Bladder function
Changes to bladder function are very common after spinal cord injury.
A spinal cord injury will influence the function of both the detrusor muscle and the sphincter. They may become over- or underactive, and various combinations of the two are also possible.
Incomplete voiding is a functional disorder increasing the risk of urinary tract infections (UTI) and upper urinary tract and renal damage. Any changes depend partly on the level of injury but more accurate assessment of bladder and sphincter function always requires a urodynamic test.
Regular urological follow-up is important.
One of the most important aims of treating disturbances of bladder function is to prevent renal damage, incontinence and infections.
The most important treatment of neurogenic bladder is regular emptying of the bladder, primarily by intermittent catheterization if spontaneous voiding is impossible or insufficient to completely empty the bladder.
Intermittent catheterization should be done sufficiently often to ensure that the amount of urine obtained at a single instance does not exceed 450 ml.
After the acute stage, most patients with spinal cord injury are capable of performing catheterization by themselves.
Patients using repeated catheterization or an indwelling catheter often have asymptomatic bacteriuria which need not be treated.
In patients with spinal cord injury, the symptoms of UTI Urinary Tract Infections are atypical and unspecific. Burning and lower abdominal pain, for example, may be missing.
The most common symptoms are changes in bladder emptying, urinary sediment and odour, and various general symptoms, such as nausea, fatigue, increased spasticity and symptoms of autonomic dysreflexia.
The amount of uropathogenic growth will not help to distinguish asymptomatic bacteriuria from UTI.
If UTI is suspected, chemical screening of urine, particle count in urine and bacterial culture of urine should be requested. If the patient has fever, blood culture should also be performed.
The range of organisms causing UTI and of drug resistances is extensive, and treatment should be based on culture.
Bowel function
In consequence of spinal cord injury, bowel function will slow down and sphincter control may be impaired or absent. This depends on the level of injury; in low-level injury, the bowel and the sphincter are often more flaccid.
The bowel should be emptied regularly, the aim being a regularly emptying, continent bowel.
Suitable laxatives include products increasing bowel water content and mass (e.g. macrogol) or bowel content (e.g. ispaghula). Lactulose and bowel-stimulating laxatives should be used rarely and only after due consideration.
Active bowel emptying should usually be done every morning on a toilet seat. A micro-enema combined with rectal stimulation and abdominal massage usually provides sufficient relief. If necessary, patients should be given instructions for using bowel lavage equipment at home.
Insufficient bowel emptying may lead to faecal incontinence Faecal Incontinence, increased spasticity and symptoms of autonomic dysreflexia, for instance.
Sexual functions
Changes in genital functions (hypesthesia, in particular) are common in both women and men.
Depending on the level and extent of the injury, men may achieve reflexogenic or psychogenic erection but this is often insufficient for successful sexual intercourse Erectile Dysfunction (Impotence). Oral medication for erectile dysfunction is usually effective; topical products can be tried, as necessary.
Guidance on sexual and reproductive health and on assistive devices should be provided, as necessary.
Anejaculation and impaired semen quality cause male infertility after spinal cord injury.
It is usually possible to obtain a sufficient amount of sperm by various types of treatment (e.g. by using a vibrator or by testicular biopsy). In vitro fertilization is often needed.
In women, a significant spinal cord injury will usually cause transient amenorrhoea at the acute stage. Otherwise, spinal cord injury will not usually affect female fertility.
Skin
Impaired sensation and more difficult change of position make the skin susceptible to pressure sores Prevention and Treatment of Pressure Ulcers immediately after injury. Later on, the risk of pressure sores may increase due to muscle atrophy or spasticity, for instance.
Observation and good basic treatment of the skin, sufficiently frequent change of position and release of pressure by the choice of mattress and wheelchair seat cushions, for instance, as well as attention to a healthy and varied diet are important for preventing pressure sores.
Thermoregulation and sweating
A spinal cord injury also affects thermoregulation. Body temperature may react more easily to changes in environmental temperature, leading to hypothermia in a cold environment, for example.
A spinal cord injury may also cause sweating disorders. Most commonly, sweating decreases or is totally absent below the injury level, whereas excessive sweating may occur above the injury level. A sweating disorder may increase the risk of hyperthermia on exertion, for example.
Blood pressure regulation
As a result of spinal cord injury, blood pressure may be lower than normal, and orthostatic hypotension commonly occurs in the upright position. Normal response of the circulatory system to exertion may be impaired.
Hypotension can be prevented by using supportive bandaging of the lower limbs or trunk or compression socks. Blood pressure raising medication can be used either regularly or as necessary (etilefrine).
Autonomic dysreflexia (AD)
A syndrome due to injury to the autonomic system. There is a risk of AD in patients with spinal cord injury at or above the T6 level.
Any stimulus below the level of injury may trigger AD symptoms. AD is most commonly caused by some factor associated with bladder or bowel function or causing pain.
AD may cause greatly raised blood pressure or arrhythmia (typically with a lowered heart rate), which can even be life-threatening. Other possible symptoms include a pounding headache, cold shivers and body hairs standing on end (goose bumps), blurring of vision, erythema and excessive sweating above the injury level, nasal obstruction, restlessness, anxiety and nausea.
In a hypotensive patient with spinal cord injury, a blood pressure rise of as little as 20-40 mmHg may suggest AD. If so, systolic pressure exceeding 150 mmHg will require immediate action.
As first aid, the patient should sit up and any tight clothing or supports should be loosened. The triggering factor should be eliminated quickly (e.g. catheterization of a full bladder, emptying the bowel). If the blood pressure cannot be lowered this way, medication may be given, such as chewing 10 mg of nifedipine or using a nitrate spray.
Spasticity
Muscle tone may increase either evenly or reflexively, causing muscle stiffness or involuntary movements.
At the chronic stage after spinal cord injury, spasticity Spasticity may increase in association with various problems, such as infections. In case of greatly increased spasticity, it is therefore good to exclude urinary tract infection, signs of skin pressure, constipation, etc.
Any factor increasing spasticity should be treated, as far as possible. Otherwise, treatment consists of physiotherapy, positional therapy and medication (baclofen, tizanidine). Botulinum toxin injections can be used for local spasticity, and in the case of severe, extensive spasticity baclofen can be administered directly into the intrathecal space.
Pain
Various pain states Chronic Pain are common after spinal cord injury.
Spinal pain is a pain state originating in the CNS that most typically occurs below the level of injury and may sometimes develop as late as a few months after the acute injury. It is one of the most challenging pain states to treat.
Over the years, various pains in the musculoskeletal system become more common with uneven loading of the upper limbs, for instance, as the function of the lower limbs is impaired or nonexistent. Appropriate attention should be paid to symptoms in the upper limbs and neck-shoulder region in people using a wheelchair because their functional ability and independent coping are at risk.
The diagnosis of visceral pain may be difficult due to hypesthesia, for example. In unclear cases, further examinations (such as abdominal ultrasound examination) should be readily done.
Pain should be treated according to the general principles.
Posttraumatic syringomyelia
The development of a cavity/cyst within the spinal cord, or syringomyelia, may occur several years after injury and should therefore be kept in mind in long-term follow-up.
The most common symptoms are disturbances in various sensory modalities, neuropathic pain in the limbs or the trunk, increased muscle weakness and spasticity, symptoms of the autonomic nervous system (such as autonomic dysreflexia) and changes in bladder or bowel function.
Spinal cord MRI should be performed, as necessary. This should be considered particularly if new disturbances of sensory modalities or neurological level changes in the classification of spinal cord injuries are observed at a follow-up visit.
The treatment is surgical and the need for treatment should be assessed by a neurosurgeon.
Heterotopic ossification
In heterotopic ossification, or bone formation in connective tissue, bone forms in soft tissue below the injury level, most commonly around joints, causing oedema in soft tissue and restricting joint ranges.
If heterotopic ossification is suspected, the nearest outpatient spinal cord injury clinic should be contacted.
Osteoporosis
Osteoporosis Osteoporosis develops quite commonly after significant spinal cord injury and considerably increases the risk of fractures of the lower limbs, in particular.
Sufficient calcium and vitamin D intake should be ensured. If low-energy fractures develop, the patient should be referred for more detailed investigations of osteoporosis and planning of treatment.