Thread: Physiotherapy in spinal cord injury

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.

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 must be 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.

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.
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.

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. 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.
• 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.
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.


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• Respiratory complications are a common and potentially life-threatening problem related to spinal cord injury and may occur acutely or at any time after the initial injury.
  
• All patients with tetraplegia and those with high-level paraplegia demonstrate some compromise in respiratory function.
  
• The level of respiratory impairment is directly related to

- Level of lesion
- Residual respiratory muscle function
- Additional trauma sustained at the time of injury
 Fractures (Ribs, sternal or extremities)
 Lung contusion
 Soft tissue damage
- Premorbid respiratory status
 Existing pulmonary disease
 Allergies
 Asthma
 History of smoking

• There is a progressively greater loss of respiratory function with increasingly higher level of lesions.

High Level Injury:

• With high spinal cord lesions between C1 and C3 (above C4), phrenic nerve innervation and spontaneous respiration are significantly impaired or lost and will require artificial ventilation or phrenic nerve stimulation. The inspiratory muscles are as follows:

- Primary Inspiratory Muscles
 Diaphragm
 Intercostals muscles
- Accessory Inspiratory Muscles
 Sternocleidomastoid
 Upper trapezius
 Scalenes
 Pectoralis major

• With diaphragm sparing, patients with C4 tetraplegia may be able to sustain life without artificial means, but may always have marginal ventilatory capacities.

Intercostal Paralysis:

• C5 – T12 lesions result in intercostal paralysis affecting both inspiratory & expiratory function and patient may demonstrate weakness in the accessory inspiratory muscles as well.
  
• In the first weeks after injury, flaccid intercostal muscle paralysis can result in paradoxical collapse of the rib cage during inspiration, further reducing ventilatory efficiency.
  
• As spasticity develops after few weeks, this paradoxical movement is reduced and function improves.

Abdominal Muscles Paralysis:

• Injuries between T7 and T12 impair abdominal muscle function, reducing forceful expiration and cough.
  
• When fully innervated, the abdominal muscles play an important role in maintaining intrathoracic pressure for effective respiration.
  
• They support the abdominal viscera and assist in maintaining the position of the diaphragm.
  
• They also function to push diaphragm upward during forced expiration.
  
• With paralysis of the abdominals this support is lost, causing the diaphragm to assume an unusually low position in the chest.
  
• This lowered position and lack of abdominal pressure to move the diaphragm upward during forced expiration results in a decreased expiratory reserve volume.
  
• This subsequently decreases cough effectiveness and the ability to expel secretions.

• Paralysis also results in the development of an altered breathing pattern. This pattern is characterized by flattening of the upper chest wall, decreased chest wall expansion, and a dominant epigastric rise during inspiration. With relaxation of the diaphragm, a negative intrathoracic pressure gradient moves air into the lungs. Over time, this breathing pattern will lead to permanent postural changes.
  
• The chief pulmonary concerns during the acute phase of care are

- Ventilation
- Oxygenation
- Secretion management
- Atelectasis
- Segmental collapse

• Pulmonary complications which might lead the patient to death are

- Ventilatory failure
- Atelectasis
- Aspiration pneumonia
- Bronchopneumonia
- Pulmonary embolism

• In the chronic phase of spinal cord injury, pulmonary complaints of breathlessness and wheezing are most common and bronchial hypersensitivity.
  
• Development of kyphoscoliosis can result in a reduction in lung compliance and vital capacity.
  
• Night-time oxygen desaturation is often noted in patients with chronic tetraplegia, presumably because of the reduced use of accessory muscles during sleep.

Treatment:

• A tracheostomy tube is commonly inserted to facilitate airway suctioning and secretion clearance.
  
• Cough assistance maneuvers produce a modest increase in expiratory flow.
  
• Patients must be kept well hydrated to avoid drying of the secretions which increases risk if mucus plugging, but overzealous hydration can result in pulmonary edema.
  
• Body positioning is also important to facilitate ventilation. Patients with tetraplegia exhibit higher vital capacities when positioned flat in bed. The mechanism underlying this phenomena is likely relate to improved diaphragm function as the abdominal contents splint the lower rib cage.
  
• The reduction in vital capacity seen when these patients are seated upright can be counteracted to some extent by placement of an elastic abdominal binder.
  
• Pulmonary function can improve steadily over the acute course, even without concurrent neurological recovery. By 3 months, most tetraplegic patients can be expected to attain 60% of predicted vital capacity.
  
• Patients with injuries above the segments innervating the phrenic nerve are candidates for phrenic nerve pacemaker implantation. This technique is expensive and requires life long tracheostomy. Benefits include reducing the need for heavy ventilator equipment, a reduction in sinus symptoms through better humidification of the upper airway, and improved taste sensation.
  
• Resistive inspiratory muscle training can be useful in reducing respiratory complaints and complications.
  
• Smoking cessation and vaccination programs are important components of long-term care.