Spinal Cord Injuries and Physio Management

Spinal Cord Injury (SCI)

Impairment of motor, sensory, and autonomic functions.

Potential causes of SCI

Trauma, disease, infection, or congenital defects.

New spinal cord injuries recorded in 2017/2018

318 new spinal cord injuries, with 58% being traumatic.

Average age at time of injury in 2007/2008

42 years.

Average age at time of injury in 2017/2018

43 years.

Male:Female ratio for SCI

4:1.

Percentage of traumatic SCI cases that were male in 2017/2018

80%.

Approximate range for new cases of traumatic SCI in Australia each year

Approximately 350-400.

Contributing factors for decline in incidence of traumatic SCI since early 80's

Legislative changes, random breath testing, and educational programs.

Percentage of new injuries related to trauma according to QLD statistics 2024

43%.

Leading specific mechanisms of injury in QLD statistics

42 road related accidents and 41 falls.

Demographic most likely to suffer an SCI

Young men.

Severity of bony injury and SCI severity

No, the severity of bony injury does not dictate the severity of SCI.

Anatomical location of spinal cord extension and termination

It extends from the foramen magnum to approximately the first lumbar vertebrae, terminating in a cone shape called the conus medullaris.

Approximate length and diameter of the spinal cord

Approximately 43-45 cm long and the diameter of the human finger.

Reason most SCI cases do not involve transection

Neurological damage is primarily due to secondary vascular and pathogenic events, including oedema, inflammation, and changes to the blood-spinal cord barrier.

Most commonly injured level of the spinal cord

C5, followed by C4, C6, and T12.

Type of motor neuron lesion from injuries above the conus medullaris

Upper Motor Neuron (UMN) lesions, resulting in spastic paralysis.

Type of motor neuron lesion from injuries involving the cauda equina

Lower Motor Neuron (LMN) lesions, resulting in the loss of spinal cord mediated reflexes and flaccid paralysis.

Information carried by the Posterior (dorsal) columns

Light touch and proprioception; the fibers cross in the brainstem.

Sensations carried by the Lateral spinothalamic tract

Pain and temperature.

Percentage of fibers crossing over in corticospinal tracts

Approximately 85% cross over and travel in the lateral corticospinal tract.

Location of UMNs for cervical segments relative to sacral segments

Cervical UMNs are located centrally and sacral UMNs are located peripherally.

Four clinical syndromes associated with incomplete SCIs

Central cord lesion, Sacral sparing, Anterior cervical cord syndrome, and Brown-Sequard syndrome.

Cause and typical pattern of paralysis in Central Cord Lesion

Hyperextension injury of the cervical spine, common in elderly people who fall; resulting in more severe paralysis of the upper limbs than the lower limbs.

Neurological functions preserved in Sacral Sparing

Motor and sensory function of the sacral segments.

Anterior Cervical Cord Syndrome

Preservation of light touch and proprioception below the level of the lesion.

Brown-Sequard syndrome

Damage to one side of the spinal cord (lateral hemi-section), usually due to penetrating injuries.

Neurological deficits in Brown-Sequard syndrome (same side)

Loss of light touch, proprioception, and motor function.

Neurological deficits in Brown-Sequard syndrome (opposite side)

Loss of pain and temperature sensation.

Three steps following primary SCI injury

1. Inflammatory process causes oedema leading to ischemia via compression, resulting in spinal cord cell death. 2. Spinal shock. 3. Cells recover, and reflexes and tone return.

Spinal shock

Flaccidity, areflexic, with all systems (gut, bowels, etc.) shut down.

Heterotopic Ossification (HO)

A condition associated with trauma where the body lays down bony tissue instead of tendons.

Autonomic Dysreflexia (AD)

Sudden hypertension, common for injuries above T6.

Blood pressure in SCI with Autonomic Dysreflexia

Individuals with SCI are normally hypotensive (e.g., 90/60), so a moderate elevation may be significantly higher than their normal baseline.

Signs or symptoms of Autonomic Dysreflexia

Severe pounding headaches, bradycardia, blotch rash/flushing of skin above the level, sweating/goose bumps, shortness of breath, anxiety, nasal stuffiness, or blurred vision.

Immediate interventions for Autonomic Dysreflexia

Sit the patient up and loosen tight clothing.

Primary concerns for physiotherapist in acute medical chart

Whether the injury involved flexion, extension, or salt water (which suggests inflammatory process within the lungs).

Position aiding respiratory function in new SCI patient

Supine.

Reasons for difficulties clearing secretions in new cervical SCI

Weak abdominals and inability to take a big enough breath.

Primary neural supply for the diaphragm

C3-C5.

Interventions for 'loss of volume' in acute respiratory management

1. Use optimal position for ventilation. 2. Add positive pressure (e.g., IPPD, BiPAP). 3. Utilise own effort (e.g., deep inhalation/holds, straws).

Timeframe for full neurological assessment after SCI hospital admission

Within 24 hours.

ASIA

American Spinal Injury Association.

Key muscles tested in ASIA assessment

5 key muscles for Upper Limbs (UL) and 5 key muscles for Lower Limbs (LL).

ASIA Impairment Scale (AIS) Grade A

No sensory or motor function is preserved in the sacral segments S4-S5.

Criteria for AIS B (Sensory Incomplete)

Sensory function is preserved below the neurological level, including S4-S5, AND no motor function is preserved below the neurological level.

Difference between AIS C and AIS D

AIS C: More than half of the key muscles below the neurological level have a muscle grade less than 3. AIS D: More than half of the key muscles below the neurological level have a muscle grade greater than or equal to 3.

Voluntary Anal Contraction (VAC)

Presence of Voluntary Anal Contraction (VAC) of the external anal sphincter upon digital examination.

Neurological Level of Injury (NLI)

The lowest segment with normal sensory and motor function on both sides (the most cephalad of the sensory and motor levels determined in steps 1 and 2).

Light touch appreciation score

1 (Impaired) if the patient reports that the sensation 'feels different' compared to the reference point.

C5 key muscle group

Elbow Flexors (C5). Total paralysis is Grade 0.

Motor level grade requirement

At least 3/5, provided the key muscles above that level are tested to be normal (graded 5).

Zone of Partial Preservation (ZPP)

It refers to those dermatomes and myotomes below the neurological level that remain partially innervated. It is only applied to complete injury (AIS A).

Primary aim of physiotherapy

To optimise quality of life by enhancing their physical capabilities.

Aerobic activity level for adults with SCI

20 minutes of moderate to vigorous intensity, 2 times a week.

General principles for SCI physiotherapy

Facilitate development of problem-solving skills, break the task down into components, focus on impairment and functional skills retraining, offer variety, motivate/make things achievable, encourage active participation, honesty, set goals, and emphasize FUNCTIONAL CARRYOVER.

Maximum permitted degrees for lumbar movement

30 degrees.

Maximum permitted degrees for thoracic movement

45 degrees.

Maximum permitted degrees for cervical movement

90 degrees.

Selective contracture promoted for cervical SCI

Tenodesis (a selective contracture of the finger flexors).

Key Upper Limb muscles for seated transfer

Shoulder stability muscles, anterior deltoids, and Lats for shoulder depression.

Gold standard frequency for pressure redistribution

Every 20-30 minutes.

Action for red mark on skin during wheelchair check

Require the patient to remain Rest in Bed (RIB).

Advanced strength-training guidelines for adults with SCI

3 sets of 10 reps for each major muscle group, 2 times a week.

Functional Electrical Stimulation (FES)

The application of electrical current to paralysed muscles to restore or improve their function, specifically applied to achieve a functional task (e.g., breathing, coughing, walking).

FES cycling frequency for strength and endurance

30-60 minutes of exercise, 3 times per week.

Benefits of FES cycling

Increase muscle mass and reverse muscle atrophy, increase blood flow during and immediately after FES cycling, improvements in cardiovascular fitness, and reduced reported incidence of spasticity.

Key focuses of early rehabilitation

Engagement, problem solving, and maintaining skin integrity.

Long-term considerations related to life impact of SCI

Health management (including bowel & bladder care), finances (cost of equipment/paying bills), impact on carers, change of life roles, specific equipment needs, or home maintenance.