What is SCI?
The spinal cord is a band of nerves that act as a transporter of the information between the brain and the body parts. Any injury to the spinal cord (Congenital or acquired) is called spinal cord injury.
The spinal cord is protected by vertebrae or spine. It is referred to as cervical, thoracic, and lumbar spine. Many times, there is an injury to the vertebrae or soft tissues (muscles or ligaments) around it. This kind of injury is not classified as spinal cord injury.
Acquired injuries are a result of Motor vehicle accident, falls, or gunshot wounds. SCI can also happen due to medical or surgical complications or falling an object on back.
What body part or functions are affected with SCI?
As I mentioned earlier, the spinal cord connects the brain with the rest of the body. Different body parts are innervated at different levels of spinal nerves. So depending on the level of injury, you can see particular areas being affected or preserved with intact functions.
Additionally, the injury can be complete or incomplete. This is a way to describe if all the nerve fibers are damaged or only parts are damaged. So in other words, when there is a damage of all the nerve fibers, it is classified as a complete injury and vice versa. Even with the incomplete injury, a person needs a consistent rehabilitation to regain the muscle control and so the ability to use the limbs.
The intensity and amount of loss of the function depend on the area as well as completeness of the injury.
As the injury goes high up in the cord (cervical area), a person see more deficits and needs more aggressive rehab. It also takes longer to recover compared to the lower level of SCI like lumbar level. A person with higher SCI (cervical area) may not recover completely, or even may not survive. As the Cervical area (C3 – C5) is responsible for control of visceral organs like breathing. A person with this injury may need some external support (like ventilator or tracheostomy) to survive.
How long does it take to recover from SCI?
Recovery from SCI varied widely based on the severity of SCI, level of injury, the extent of the injury and how quickly a person was able to get medical help. It also depends on the age of a patient as well as the prior level of function.
ASIA scale is usually used to classify the spinal cord injury. Usually, ASIA A injury takes longer than ASIA D injury. Also, ASIA A injury may or may not get complete recovery and may have some residual effects.
Functional Progression after SCI depends on participation in rehab as well as the patient’s motivation and psychological status. A person may face many complications on their road of recovery. A constant aggressive rehab with good social support helps patient to stay on right track and perform the exercise regime.
Medical Management of SCI:
Management of SCI is a complex situation and it varies depending on type, severity, and level of injury. A person may need many medicines to manage symptoms like muscle tone, breathing, infection, pain etc. Depending on the mechanism of injury, a person may even need a few surgical interventions. Rehabilitation after SCI is the main treatment approach. Recovery from SCI depends not only on how quickly a person starts the rehabilitation program but also how actively he or she is able to participate in the rehabilitation program.
The main goal of SCI rehabilitation is to retrain the motor neuron pattern and strengthen the neural connection by practicing and repeating muscle movement. A clinician usually starts with simple muscle movements like active assisted or passive range of motion, stretching, tone management, and PNF patterns. As a next step, a clinician gradually progresses to complex movements – which are a combination of movements at few joints involving few muscular contractions (very well different kind of contraction in the same movement.). At this point, it is safer to progress the patient to functional task performance which includes tasks like bed mobility, transfer, sitting at the edge of the bed, performing facial grooming or even wheelchair mobility etc.
Few points to Consider for SCI Rehabilitation:
It is crucial not to rush the patient to start a complex movement when they are not ready, as it will only create frustration on the patient’s part due to the inability to perform the movement. The important thing to remember with SCI patients is the majority of the times they are cognitively intact but may be either in denial, anxious or impulsive. Patients just want to perform the movement and they usually are trying hard, but when they do not see any visible movement happening, they get affected psychologically. This in turns, affects not only their behavior but also rehab participation and so the progression in rehab.
That is why, a clinician decide to go step by step, give a patient a chance to feel the success of the performance before rushing to do the next major task. This aids in positive reinforcement as well as active participation in rehabilitation.
Treatment Approaches for SCI:
Managing the tone is crucial at early stages. Not all SCI patients, will show the high or low tonicity in the affected area. It is important to differentiate whether a patient demonstrates hypotonicity or hypertonicity. The management of both are different and they show up at different stages of the rehabilitation. It is also not uncommon to see patient progress from hypotonicity to hypertonicity to spasticity and developing some contractures. This usually occurs in high cervical spinal cord injury.
A clinician will perform passive range of motion, proper anatomical position in bed and in the chair to manage hypotonicity.
The repeated range of motion, stretching, icing, massage, splinting, as well as muscle relaxants are the usual treatment options to manage hypertonicity. A chronic, high cervical spinal cord injury patient may need antispastic medication like baclofen to manage muscle tone.
A person may receive antispastic medications orally or by intrathecal pump depending on needs.
The range of Motion Exercises:
The range of motion exercises is important for all SCI patients. This can be a passive, active assisted or active range of motion of all joints, including the trunk. When a person is able to perform full active range of motion against gravity, a clinician will progress the range of motion to progressive resistance exercises of the joints or progress to complex movements like PNF (Proprioceptive Neuromuscular Facilitation).
Stretching exercises are important to improve and maintain muscle strength. It is especially needed when a person is able to perform active range of motion and with high tonicity. Stretching helps prevent the contracture development. A slow, gentle, and prolonged stretching is recommended in SCI management.
PNF pattern & Complex multiple joints movement:
When a person is able to perform a certain range of motion independently, a clinician can progress the exercise session to PNF pattern. This is a movement that occurs at multiple joints. Research supports the repetitions of PNF patterns the strengthen the neuromuscular pattern that helps in functional task performance. This is very useful not only in SCI management but also in the rehabilitation of brain injury cases. Both upper and lower extremities are found to be helpful with PNF pattern.
Performing and repeating specific functional tasks makes a patient better at that particular tasks. This builds muscle memory for that particular tasks. Since with the ability to perform a functional task, patient and family see that as a direct progression from the rehab, this also aids in the psychological reassurance and boosts patient’s confidence.
Many neuro rehabilitation theories like NDT, Bobath etc support the performance and repetition of the specific task. These are based on neuroplasticity principles to strengthen the neural connections and improve the neuromuscular pattern.
Training and timing for the mobility tasks differ not only on the level of injury but also other comorbidities. For instance, a patient with low cervical injury (C 5- C 6) may receive the mobility training at the last and mostly a good candidate for alternative methods for mobility like a motorized chair. On the other hand, a patient with incomplete low lumbar SCI (L4 – L5) will be able to perform assisted and even unassisted ambulation relatively quicker – usually in 6 to 8 weeks post-injury.
Other comorbidities like fractures, weight-bearing status, cardiopulmonary status, any surgeries after the SCI also determines the progression to the mobility tasks. Usually, mobility tasks are the most important for the patient as this defines their independence in the community. These tasks also affect the psychological status of the patient the most.
Finding and preparing for Alternative Independence:
It is quite common that a person after SCI, may not regain his complete independence. Sometimes, a patient needs to work on alternative methods of independence but gradually be able to get to the prior level of function. The alternative methods of independence are nothing but using assistive devices to be as independent as possible functionally when your body is unable to perform the mobility tasks. A person can use a walker, wheelchair, motorized chair etc as other means to stay independent in the house and community.
There are many alternative methods in the market that makes a person be able to perform almost every task independently in the house and in the community.
There are electrical lifts available that can help a person walk inside the house with a harness attached to a patient’s lower back area. This kind of lifts is usually attached to the ceiling of the house so it takes a good amount of home modifications. Since there are some weight limits and criteria for safety, this advanced technology may not work in every type of house.
Similarly, a person with SCI, can be independent in steps with stair glides, can perform car transfers with transfer lifts as well as be able to drive the car!!
This is a modified independent for a person who lost his or her ability to perform any tasks by himself.
I will emphasize the fact that even though the above options sounds cool, it may not be true for every patient with SCI. Recovery from SCI and lifestyle status post-SCI significantly relies on the level of injury and type of injury.
For an example, a person with complete C5 to C6 SCI, may not be able to perform any of the above tasks. For this person, the first and foremost goal is to be able to manage their breathing, manage the secretions, be able to eat and be safe is a priority.
The most important goal for a patient and clinician after SCI is to regain as much as muscle work as possible and to attempt to perform any task independently. It is a step by step progression and unfortunately, may not happen for everyone.
Using Assistive Devices or Adaptive Equipment:
It can also include different orthosis on lower extremities to facilitate certain movements and inhibit certain groups of muscles to gain particular activities. This helps in the performance of functional transfers as well as gait training. With the very poor progression of SCI, or chronic SCI, braces, and splints are used to manage or prevent the development of contractures.
Use of adaptive equipment also helps with many other self-care activities like dressing, or feeding. Use of dressing stick, socking aid, shoehorn, modified utensils can help achieve independence and lower the help from other persons.
In nutshell, SCI management usually progresses as follow:
Regaining functional independence:
- The passive or active assisted range of motion
- Bed mobility, Rolling, bridging, mat exercises
- Work on sitting balance and sitting tolerance
- Preparing for transfers on different surfaces
- Assessing and training for an appropriate wheelchairs
- Perform standing, standing balance, standing tolerance.
- Gait training.
Again, this is just a general guideline. SCI management is a team approach. Physician and nursing team is constantly working to manage muscle tone, contractures, secretion, pain, sleep etc. Speech therapy and respiratory therapy work on speech, diet, swallow strategies, breathing techniques, secretion management, as well as cognition aspect.
Also, rehabilitation of SCI does not follow this simple roadmap as it is described above. The medical team is constantly managing many complications that a patient can develop. Some common complications that an SCI patient can develop are as follow:
Other side blocks on the roads:
- Poor Psychological status: depression, anxiety, denial.
- Fighting with infections like UTI, Pneumonia etc.
- Development of pressure sores or wound
- G-I complications due to medications or poor mobility
- Falls due to poor balance
That is why it sometimes, feel like taking a step forward in rehab and facing two steps backward with medical complications.
Few other things that a clinician concentrate during rehab on are:
Involving families in the management is important and leads to positive performance. Training the family to perform some exercises encourages them to be a part of the treatment. This also aids in patient’s psychological wellbeing positively. I mentioned earlier that the repetition of tasks is important in speedy recovery. Educating family to perform few exercises or stretching just does that!
Family involvement also helps when a patient is in denials or needs a confidence boost to perform “homework” on regular basis. That is why family education regarding patient’s functional status is crucial. Keeping family in the loop regarding patient’s ability also helps to determine a safer discharge place.
Home Exercises Program:
A clinician may give a patient an exercise program to perform during the nonrehab time. This is a lower intensity exercise that a person can either perform by himself or family helps with that.
As the name suggests, home exercise program also includes a thorough exercises program for a patient or family after discharge from hospital or inpatient rehab. Since SCI rehabilitation takes a long time, many clinicians prescribe the exercise program for nonrehab days that can help with repetition and muscle memory.
In the end, discharge from rehabilitation includes involvement of the full interdisciplinary team including the patient and his family. Patient’s level of function, as well as family support, mainly determines the place of discharge. It is a good idea to always follow up on a patient a few days and even weeks after the discharge.
This ends major treatment approaches in SCI management.
Resources for SCI management: