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.
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.
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.
The physiotherapist will ensure good positioning of the patient to protect the site of the fracture, ensure good skin pressure care and prepare the patient to be able to adopt and maintain the postures they will need to be independent. The physiotherapist will place the patient in the frog position, with the hips abducted and flexed and the soles of the feet together. This position is very important for the patient to be able to sit upright with good balance, manage the care of their feet, lean forward and move their legs and manage their bladder care by catheterising themselves.
After lying flat for some time during the early period the patient needs to be progressed by the physiotherapist to sitting upright in a wheelchair. This is a gradual process as moving the patient into the upright position too quickly can cause a severe blood pressure drop. A wheelchair with elevating leg rests and a sloping back is used initially until the patient is able to tolerate an upright chair. Regular practice of sitting balance is vital under the close supervision of the physiotherapist as trunk control is needed for independent living. Once sitting is mastered transfers into a wheelchair and strengthening can be worked on.
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. - 16650
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.
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.
The physiotherapist will ensure good positioning of the patient to protect the site of the fracture, ensure good skin pressure care and prepare the patient to be able to adopt and maintain the postures they will need to be independent. The physiotherapist will place the patient in the frog position, with the hips abducted and flexed and the soles of the feet together. This position is very important for the patient to be able to sit upright with good balance, manage the care of their feet, lean forward and move their legs and manage their bladder care by catheterising themselves.
After lying flat for some time during the early period the patient needs to be progressed by the physiotherapist to sitting upright in a wheelchair. This is a gradual process as moving the patient into the upright position too quickly can cause a severe blood pressure drop. A wheelchair with elevating leg rests and a sloping back is used initially until the patient is able to tolerate an upright chair. Regular practice of sitting balance is vital under the close supervision of the physiotherapist as trunk control is needed for independent living. Once sitting is mastered transfers into a wheelchair and strengthening can be worked on.
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. - 16650
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. 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 Kent.
