Pharmacological Management of Spinal Cord Injuries

Introduction

Every year there are around 17,700 new cases of spinal cord injuries in the United States of America, most commonly from vehicular accidents and falls[1]. The primary injury in these events is a compression, tear, or dissection of the spinal cord in the spinal column. Often, there is a secondary injury to the peripheral nerves off of the dorsal and ventral roots, an inflammatory response, and subsequent axonal degeneration[2]. These injuries carry a high price for care, as lifetime costs can range from $1.6 to $4.9 million if injury occurs at age 25. Life expectancy has not improved substantially since the 1980s, and the leading causes of death are pneumonia and septicemia[1].

The symptoms of spinal cord injury are managed with pharmacological interventions that target: pain, spasticity and inflammation[3]. Controlling these symptoms can help limit further complications such as autonomic dysreflexia, initiate tissue repair, and help patients and physical therapists preserve or restore function[4]

In addition to pharmacological interventions, physical therapists play a critical role in the lives of those that suffer spinal cord injuries. The average initial rehabilitation includes over 55 hours of physical therapy. Typical activities include but are not limited to: strengthening and stretching exercises, facilitating transfers, and wheelchair or gait training[5]

Both pharmacological and PT interventions are integral to the care of spinal cord injury patient. The PT must be aware of how to enhance rehabilitation by capitalizing on the therapeutic benefit of medications and considering adverse effects that may impact the plan of care.   What follows is a review of some common drugs used in the treatment of spinal cord injuries and implications on physical therapy. These  drugs  include opioids, benzodiazepines, second generation antiepileptics, skeletal muscle relaxants, and glucocorticoids. The mechanisms of action, pharmacokinetics, pharmacodynamics, and adverse effects of each will be covered. 

Opioids

Benzodiazepines

Gabapentin

Baclofen

Corticosteroids

Overall Implications for Physical Therapy

For physical therapists treating patients with spinal cord injuries, it is imperative to stay up-to-date on the latest pharmacological treatment for the symptoms and sequelae of the injury. A review of each patient’s prescriptions and adherence should be conducted while working with the patient during rehab sessions. Making this review a routine aspect of care will improve patient safety and the effectiveness of the sessions.

Many of these drugs have adverse side effects that impact therapy. Of note are the drugs that threaten the safety physical therapy, such as dizziness seen in benzodiazepines and skeletal muscle relaxants[6], which could result in falls and injury. Lethargy and drowsiness are common side effects[6], impacting the patient’s engagement level during the therapy session, thus limiting the effectiveness of any intervention requiring the patient's active participation. Coordinating appointments to avoid peak adverse effects while ensuring the optimal positive effects of the drug will require careful collaboration between the physical therapist, patient, and physician. As the patient’s drug regimen becomes more standardized and understood, predicting the optimal timing for appointments will be easier. Of special note is the addictive nature of opioids. Because physical therapists will be seeing the patient more than the prescribing physician, it is important to monitor for signs of addiction or abuse and take appropriate action.

The medications listed in this piece are not an all-encompassing list, but rather a summary of the common drugs used in the treatment of spinal cord injuries and their implications for physical therapy. Physical therapists should review any unfamiliar medication prescribed and consider how could affect treatment plan. By integrating the effects of these drugs, their use should complement physical therapy and improve patient outcomes.

This entry is part of the Winston-Salem State University Pharmacology Project.


  1. 1.0 1.1 Spinal Cord Injury Facts and Figures at a Glance. National Spinal Cord Injury Statistical Center. https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%20-%202018.pdf. Published 2017.
  2. Kabu S, Gao Y, Kwon BK, Labhasetwar V. Drug delivery, cell-based therapies, and tissue engineering approaches for spinal cord injury. Journal of Controlled Release. 2015;219:141-154. doi:10.1016/j.jconrel.2015.08.060
  3. Fehlings M, Singh A, Tetreault L, Kalsi-Ryan S, Nouri A. Global prevalence and incidence of traumatic spinal cord injury. Clinical Epidemiology. 2014:309. doi:10.2147/clep.s68889
  4. Noller CM, Groah SL, Nash MS. Inflammatory Stress Effects on Health and Function After Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation. 2017;23(3):207-217. doi:10.1310/sci2303-207
  5. Taylor-Schroeder S, Labarbera J, Mcdowell S, et al. Physical therapy treatment time during inpatient spinal cord injury rehabilitation. The Journal of Spinal Cord Medicine. 2011;34(2):149-161. doi:10.1179/107902611x12971826988057
  6. 6.0 6.1 Ciccone CD. Davis's Drug Guide for Rehabilitation Professionals. Philadelphia: F.A. Davis; 2013.