Spinal cord injuries (SCI) are one of the most serious consequences of high speed accidents or sporting activities, a rare but devastating injury which can also occur after infections, tumours or ischaemic damage. The largest risk group are younger people due to their propensity to perform risky activities but a person of any age can suffer from SCI. Car and motorcycle accidents account for the highest proportion of injuries and due to the complicated picture after this injury a multi-disciplinary team of professionals is vital to ensure the patient reaches the highest level of independence for their particular condition. The terms quadriplegia and paraplegia are used to describe the resulting disability.
The initial medical evaluation is performed to establish the respiratory status of the patient and deal with any other of the likely multiple injuries. Once the patient is stabilised the doctors try and work out the level in the spine where the damage has occurred, an important fact as it relates closely to medical and therapy management. A low lumbar fracture will have no effect on the arms or the ability to breathe so the patient will have good trunk and arm power and the aerobic ability to develop independence. Cervical and upper thoracic injuries impair the respiratory ability of the patient and limit arm function, making rehabilitation much harder.
The first thing to establish is the level of the injury, a diagnosis that is very important as it indicates the whole path of medical and physiotherapy management. If the spine is fractured low down in the back there should be few, if any, respiratory consequences and the patient will have full power in their arms and chest to achieve independence. If the injury is high, in the thorax or the neck, this may compromise the patient’s ability to breathe spontaneously and will mean a much more difficult rehabilitation period with limited independence overall.
Respiratory physiotherapy consists of assessing the patient’s respiratory ability, teaching the patient to deep breathe and expand the lungs fully, and cough to expectorate. If the lower abdomen is paralysed the patient may need to stabilise the area with their arms to allow a propulsive cough. In more disabled patients the physiotherapist may stabilise, helping the air to exit suddenly in coughing. A cough assist machine can be used to provoke a cough, and initial management in intensive care may also involve respiratory suction.
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
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.
By this time the patient will have learned trunk control in sitting, wheelchair transfers and strengthening work, so at this stage they should be routinely transferred to a unit specialising in spinal injuries. Experienced advice from the multidisciplinary team about the large number of skills they need to learn is available there to foster the highest level of independence. Many factors impact on whether the patient can lead a fully independent life including their age, other medical difficulties, family support, motivation and attitude and the spinal level affected. Some people with higher lesions may need routine care from a pool of carers throughout the day.