Management of Spinal Cord Injury in Low Resource Settings

Introduction

Spinal cord injury (SCI) is a devastating condition which is associated with permanent disability and decreased life expectancy. Although more than 80% of the world's population live in more than 100 developing countries and as a consequence of poverty, many people with spinal cord injury (SCI) are likely to live with limited access to appropriate health care and rehabilitation services creating barriers that increase the risk of contracting harmful pressure sores and infections leading to premature death. People with spinal cord injury (SCI) in low income countries face serious challenges in their daily lives as a result of  lack of appropriate wheelchairs and services, limited knowledge about SCI among health care staff, limited access to health care and rehabilitation services, loss of employment and lack of financial resources worsen the daily challenges.  Low and middle-income countries (LMICs) are often also described as "low resourced settings" or simply LMICs.

Epidermiology/Etiology

The incidence of SCI in developing countries is 25.5/million/year and ranges from 2.1 to 130.7/million/year. Males comprised 82.8% of all SCIs. The two leading causes of SCI were found to be motor vehicle crashes and falls. Complete SCIs were found to be more common than incomplete injuries. Similarly, paraplegia was found to be more common than tetraplegia. the life expectancy for individuals with SCI in low income settings is shorter than for the average population and also with respect to individuals with SCI in high income countries

1. Traumatic spinal cord injury-Traumatic SCI can result from several different mechanisms, e.g. road traffic crashes, falls, violence,w hile undertaking different activities, e.g. at work, during sport or while at home.
2. Non-traumatic spinal cord injury-non-traumatic causes of spinal cord dysfunction include:

• communicable
• diseases − tuberculosis (TB) and human immunodeficiency virus (HIV);

• noncommunicable conditions − cancer, degenerative diseases such as osteoarthritis leading to spinal stenosis, cardiovascular disease;

• nutritional deficiencies – neural tube defects, vitamin B12 deficiency;

• complications of medical care.

Management of spinal cord injury

spinal cord injury clinical guideline

Acute stage

management of spinal cord injury (SCI) patient during acute stage is primarily to treat and prevent respirotry and other complications associated with bed rest and sudden onset of paralysis.

Respiratory management

After spinal cord injury the mechanics of respiration will be altered for injuries above Sternum skeletal level T12.

If a person has tetraplegia or high paraplegia then the chest and stomach muscles will be paralyzed and coughing will be difficult without help. Coughing keeps the lungs clear of secretions.The following procedure keeps the lungs clear.

1. Assisted coughing

This is when the SCI person is unable to clear their own chest without help. Their cough is ineffective due to paralysis of the chest and stomach muscles. Coughing with the help of another person  is called an assisted cough. Assisted coughing can be performed in bed or in the wheelchair, by a helper or sometimes by the person with SCI. There are various techniques that can be used in the bed or in the chair.

• One man assisted cough in bed

• 2 man assisted cough on bed.

• Two man assisted cough in bed

• One man assisted cough in the chair

1. Turning and positioning

Turning keeps the secretions moving which makes them easy to cough up with assistance. If phlegm starts to collect in the lungs, the foot end of the bed can be raised (e.g. with two bricks) so that the  feet are a little higher than the head. This will help to drain the phlegm from the lungs so that it can be coughed up and spat out. The foot end of the bed should be raised up twice per day for about 20 minutes each time. It is best to do this when they Self cough in chair are lying on their side.

Rehabilitation stage

Spinal cord injury rehabilitation are best described within the conceptual framework of the International classification of functioning,Disability and Health (ICF) .

Self-Management Practices

prior to discharge  at outpatients, knowledge about self-care preventive measures are told to Spinal cord injured patients.This strengthen patients’ self-management abilities and also  enhance patients’ self-efficacy. The family caregivers should also be involved in this empowerment to ensure continual support of the patients at home. lack of knowledge on self management , will negatively affect pressure ulcer prevention practices.

community based rehabilitation

In low-income countries and particularly in rural areas, the range of rehabilitation services available and accessible is often limited. There may only be one rehabilitation centre in the major city of a country, for example, or therapists may be available only in hospitals or large clinics. Therefore community-based strategies such as CBR are essential to link and provide people with disabilities and their families with rehabilitation services.

Vocational training and supported employment

Vocational rehabilitation is very relevant in low-resource settings where there is generally more reliance on informal support networks .Vocational rehabilitation is multidisciplinary approach that aims to return a worker to gainful employment or to facilitate participation in the workforce, usually includes more specialized services such as vocational guidance and counselling, vocational training, and job placement to optimize the chances of employment. The need for general social support for people with SCI is recognized as a significant factor for successful re-entry into employment. After a traumatic injury, many believe that they are no longer capable of performing tasks necessary for work. psychosocial support from SCI peers, family members and close friends can be highly effective in encouraging the individual to continue the journey back to employment.

Resources

International Classification of Functioning, Disabi