High velocity accidents and sporting incidents carry a risk of causing a spinal cord injury (SCI), a serious but uncommon condition which can also be caused by ischaemia, infections or tumours. Younger people are the biggest group likely to suffer this injury due to their risky pursuits but it can occur in someone of any age, road accidents accounting for the greatest proportion. Due to the complex nature of the condition a multi-disciplinary approach is essential, involving several health care professionals, to facilitate the highest degree of independence in the patient. Paraplegia and quadriplegia are the terms used for the resulting conditions.
When a person is involved in an incident with potential spinal trauma the immediate management is to maintain their vital signs and not to move them unnecessarily. If the spine is unstable, for example if a fracture could allow inappropriate movement to occur, moving the patient could cause a spinal cord injury. Patients are immobilised to prevent spinal movement and transferred to an acute hospital unit. Doctors then assess the injury and deal with the immediate, life threatening consequences.
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.
Transfer of the patient to the ward follows the intensive care period and by now they should be medically stable. The patient may undergo spinal fusion surgery with internal fixation to stabilise the fractured segments, avoiding the need to wait for the typical healing period of the spine which is three months. Now the early rehabilitation of the patient can begin, with the physiotherapist checking closely on the patient's respiratory ability, exercising the non-paralysed areas for strength and mobility and undertaking regular passive movements to the paralysed limbs to keep and to increase the ranges of motion.
If the spine is unstable, which it often is in spinal trauma resulting in paraplegia, a spinal surgeon will stabilise the spine, usually with instrumentation and bone grafting. This allows the patient to start their rehabilitation without the long wait for the spinal fractures to heal naturally. Initial physiotherapy management is to monitor the respiratory status, encourage active movement of unaffected areas and perform passive movements of paralysed body parts to retain and improve the ranges of motion which will be required later for independence.
The physiotherapist will progress the patient gradually into a more upright posture by putting the back of the bed up. If got up too quickly, the patient's blood pressure can drop suddenly and this must be avoided, so the patient is eventually transferred into a wheelchair with a sloping back and elevating leg rests. Gradually they become more upright and can start practising sitting balance on a plinth as trunk control is often poor and must be mastered before arm and trunk strengthening and wheelchair transfers can be safely practised.
The first stages of learning good sitting balance, muscle strengthening and wheelchair transfers have now been mastered and it is time for the remaining rehabilitation to take place in a Spinal Injury Unit. Only such a specialised unit with a multi-disciplinary team can teach the large number of remaining skills necessary for independent living. The degree of independence a patient can achieve depends on many factors such as the level of the spinal injury, the age of the person, any co-existing medical conditions and motivation and family support. - 16004
When a person is involved in an incident with potential spinal trauma the immediate management is to maintain their vital signs and not to move them unnecessarily. If the spine is unstable, for example if a fracture could allow inappropriate movement to occur, moving the patient could cause a spinal cord injury. Patients are immobilised to prevent spinal movement and transferred to an acute hospital unit. Doctors then assess the injury and deal with the immediate, life threatening consequences.
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.
Transfer of the patient to the ward follows the intensive care period and by now they should be medically stable. The patient may undergo spinal fusion surgery with internal fixation to stabilise the fractured segments, avoiding the need to wait for the typical healing period of the spine which is three months. Now the early rehabilitation of the patient can begin, with the physiotherapist checking closely on the patient's respiratory ability, exercising the non-paralysed areas for strength and mobility and undertaking regular passive movements to the paralysed limbs to keep and to increase the ranges of motion.
If the spine is unstable, which it often is in spinal trauma resulting in paraplegia, a spinal surgeon will stabilise the spine, usually with instrumentation and bone grafting. This allows the patient to start their rehabilitation without the long wait for the spinal fractures to heal naturally. Initial physiotherapy management is to monitor the respiratory status, encourage active movement of unaffected areas and perform passive movements of paralysed body parts to retain and improve the ranges of motion which will be required later for independence.
The physiotherapist will progress the patient gradually into a more upright posture by putting the back of the bed up. If got up too quickly, the patient's blood pressure can drop suddenly and this must be avoided, so the patient is eventually transferred into a wheelchair with a sloping back and elevating leg rests. Gradually they become more upright and can start practising sitting balance on a plinth as trunk control is often poor and must be mastered before arm and trunk strengthening and wheelchair transfers can be safely practised.
The first stages of learning good sitting balance, muscle strengthening and wheelchair transfers have now been mastered and it is time for the remaining rehabilitation to take place in a Spinal Injury Unit. Only such a specialised unit with a multi-disciplinary team can teach the large number of remaining skills necessary for independent living. The degree of independence a patient can achieve depends on many factors such as the level of the spinal injury, the age of the person, any co-existing medical conditions and motivation and family support. - 16004
About the Author:
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Hertfordshire or elsewhere in the UK.
