Physiotherapy Management of Individuals with Spinal Cord Injury

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Introduction

The acute management and rehabilitation of spinal cord injury depends on the level and type of injury to the spinal cord. Individuals with a spinal cord injury often require initial treatment in an intensive care unit with the rehabilitation process typically starting in the acute care setting, followed by extended treatment in a specialised Spinal Injury Unit. Inpatient management can last from 8 - 24 weeks, with follow up outpatient rehabilitation from 3 - 12 months, generally followed by yearly medical and functional reviews. [1][2][3]

The management of an individual with spinal cord injury is complex and lifelong requiring a multidisciplinary approach. A functional, goal-oriented, interdisciplinary, rehabilitation programme should enable the individual with a spinal cord injury to live as full and independent a life as possible. Physiotherapy, occupational therapy, speech and language therapy, rehabilitation nurses, social workers, psychologists and other health and social care professionals work as a team under the coordination of a Physiatrist or Rehabilitation Physician to decide on goals with the individual and develop a plan of discharge that is appropriate for the individuals level of injury and circumstances. [2][3][4]

The management of individuals with a spinal cord injury can be divided into 3 Phases: Acute, Subacute (Rehabilitation), and Chronic (Long Term). During the acute and subacute phases of treatment, rehabilitation strategies focus more on prevention of secondary complications, promoting neurorecovery and maximizing function. In the chronic phase, compensatory or assistive approaches are often used, whereas in the acute and subacute phases, there is a greater emphasis on techniques that address underlying impairments. [1][4] 

Acute Phase

The prevention of complications arising from spinal instability or neurological compromise involves all members of the multi-disciplinary team.In this early phase post injury, physiotherapy management is predominantly involved in the prevention and management of respiratory and circulatory complications, and in minimising the impact of immobilization on the individual e.g. pressure area development and contracture development. [2][3]

Objectives

Treatment objectives in the acute phase include: [1]

  • to institute a prophylactic respiratory regimen to manage respiratory conditions and any complications as a result of the spinal crod injury or associated conditions e.g. decrease incidence 
atelectasis, enhance clearance of 
secretions 

  • to achieve independent respiratory status where possible
  • to maintain full range of movement of all joints within the limitations determined by the stability of the fracture  
  • to monitor and manage neurological status 
  • to maintain and strengthen all innervated muscle groups 
  • to facilitate functional patterns of activity
  • to support and educate the patient, carer’s, family and staff

Rehabilitation Phase

The rehabilitation needs of individuals with a spinal cord injured people are best at a specialised Spinal Cord Injury Unit, but often rehabilitation begins in the Acute or Trauma Hospital while the individual is awaiting transfer to a Spinal Injuries Unit. Rehabilitation requires consideration of the whole person, their physical, psychological, vocational and social background. The rehabilitation process is a goal directed, and time limited process aimed at facilitating maximal independenceand optimal reintegration back into the individual’s chosen community role and lifestyle. [1][4]

Physiotherapy is a key component during the rehabilitation process following spinal cord injury, and includes a variety of interventions that address multiple domains in the International Classification of Functioning, Disability and Health (ICF) including body function and structure, activity limitation, and participation, with many interventions directed at preventing, rather than treating, impairments, activity limitation and participation restrictions. 
Quality of Life including community participation, gainful employment, interpersonal relationships, and leisure activities have become the overriding focus of management. [1][4]

Objectives

Treatment objectives of the rehabilitation phase include:

  • to establish an interdisciplinary process which is patient-focused, comprehensive and co-ordinated
  • to address physical motor functional activities with early intervention and management to prevent further 
complications
  • to improve an individual’s independence in activities of daily living, such as bathing, eating, dressing, grooming, and mobility
  • to achieve functional independence, whether physical or verbal, and equipment provision in order to 
facilitate this independence
  • to achieve and maintain successful reintegration 
into the community.

The range of therapy activities used by physiotherapists during rehabilitation varies depending on the level and type of injury. The three most common individual therapy activities for individuals with high level tetraplegia were range of movement / stretching, strengthening, and transfers; while for those with low tetraplegia, more time was spent on transfers than strengthening. Similarly in individuals with paraplegia the most common individual physiotherapy activities was transfers, followed by range of movement / stretching, and strengthening. Gait training, strengthening, and balance exercises were the most common physiotherapy activities in individuals with an AIS D spinal cord injury. Overall strengthening was the most common group therapy activity across all levels and types of spinal cord injury.

Long Term Phase

Individuals with a spinal cord injury, depending on the level and type of lesion, may have many complex needs and face wide-ranging, long-term restrictions in their ability to live independently, drive or use public transport, return to work or education, participate in leisure and social activities. To ensure successful long term management coordinated community rehabilitation services and long-term support is required to meet the long-term and on-going needs of individuals with a spinal cord injury. Best practice in long term management includes active case management with case managers with the appropriate training, clinical expertise and knowledge of services to co-ordinate care post initial rehabilitation and ensure on-going personalised case management for patients with complex or on-going needs. 


Objectives

Treatment objectives of the long term phase include:

  • to achieve high level mobility goals 
required for community participation 

  • to monitor recovery of function 
 

  • to reinforce family and carer training

 


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References

  1. 1.0 1.1 1.2 1.3 1.4 Stack E, Stokes M, editors. Physical Management for Neurological Conditions. Elsevier Churchill Livingstone; 2012.
  2. 2.0 2.1 2.2 Lu X, Battistuzzo CR, Zoghi M, Galea MP. Effects of Training on Upper Limb Function after Cervical Spinal Cord Injury: A Systematic Review. Clinical Rehabilitation. 2015 Jan;29(1):3-13.
  3. 3.0 3.1 3.2 Mehrholz J, Kugler J, Pohl M. Locomotor Training for Walking after Spinal Cord Injury. Cochrane Database of Systematic Reviews. 2012 (11).
  4. 4.0 4.1 4.2 4.3 Harvey L. Management of Spinal Cord Injuries: A Guide for Physiotherapists. Elsevier Health Sciences; 2008 Jan 10.