Spinal Cord Injury

General Information
Case no.	18.A Spinal Cord Injury
Authors	Pamela Bartlo, PT, DPT, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Kevin Jenney, PT, DPT Board Certified Clinical Specialist in Neurologic Physical Therapy
Diagnosis	Spinal cord injury (SCI)
Setting	Acute care hospital
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☑ Treatment session
Learner objectives	Describe at least three important aspects of physical therapy evaluation for this patient. Explain the primary goals of physical therapy in the acute management of this patient. Detail the components and parameters for physical therapy interventions for this patient.

Medical
Chief complaint	Back pain, numbness in bilateral lower extremities (BLEs).
History of present illness	The patient is a 25-year-old man admitted to the emergency department status post motor vehicle accident. His car rolled over and he was trapped inside. Emergency Medical Services (EMS) arrived at the scene within 15 minutes and extrication took approximately 30 minutes. In the field, the patient was placed on a long board with a cervical collar. He reported no feeling in his lower back, abdomen, or legs. He reported pain in mid-back and left chest (Glasgow Coma Scale [GCS] = 14). Transportation time from the scene to the emergency department was 10 minutes.
Past medical history	None
Past surgical history	Tonsillectomy at age 8 years.
Allergies	Seasonal allergies to pollen.
Medications	None

Social history
Home setup	Resides in a third -floor apartment alone. Two steps into building—no railings. Three flights of stairs to apartment with left railing for ascension (no elevator in building). Parents live in a two-story house in the area.
Occupation	Full-time manager of a corporate pharmacy store.
Prior level of function	Independent with functional mobility and activities of daily living (ADLs). (+) driver
Recreational activities	Played recreational sports and exercised at least 3 days per week for at least 30 to 60 minutes.

Vital signs	Hospital day 0: emergency department
Blood pressure (mmHg)	112/70
Heart rate (beats/min)	69
Respiratory rate (breaths/min)	12
Pulse oximetry on 2 L nasal cannula (NC; SpO₂)	97%
Temperature (°F)	98.9 °F

Diagnostic test	Hospital day 0: emergency department	Hospital day 2: surgical intensive care unit (SICU)
Chest X-ray	(+) posterior fractures at ribs 5 and 6 (–) for signs of pleural effusion, pneumothorax, or internal hemorrhage in thoracic cavity.	Not reordered
Spine computed tomography (CT) scan	(+) fractures at the vertebral body and right pedicle of T7 (+) fractures at the transverse processes of T5 and T6. (+) Diffuse edema noted at T5–T8 region of spine.	Post-op day 1: (+) surgical fusion of T6–T8. Good fixation of plates and screws.
Magnetic resonance imaging (MRI)	(+) spinal compression and ischemia at T7.	Not reordered

Fig. 18.1

Fig. 18.1 A visual representation of levels of potential spinal cord injuries and associated areas of the body affected. (Adapted from Bähr M, Frotscher M, eds. Spinal Cord Syndromes. In: Topical Diagnosis in Neurology: Anatomy, Physiology, Signs, Symptoms. 6th ed. New York, NY: Thieme; 2019.)

Medical management	Hospital day 0: emergency department	Hospital day 2: SICU
Medications	1. Intravenous (IV) fluids. 2. Oxycodone 5 mg every 4 hours. 3. Norepinephrine 1 mcg/kg/min.	1. Continued per medical plan of care. 2. Oxycodone 5 mg every 4 to 6 hours until hospital day 5, then change to acetaminophen 325 mg every 6 hours. 3. Metoclopramide (Reglan) 1 mg/kg.
Respiratory	1. Placed on 2 L O₂ NC.	1. Continue per medical plan of care.
Procedures	1. Spine stabilization until surgery. 2. Foley catheter placed.	1. Continue per medical plan of care.
Precautions/Orders	1. Bed rest 2. Telemetry	1. Out of bed as tolerated. 2. Telemetry 3. Spinal fusion surgery precautions (no bending forward past 90 degrees, no twisting/rotation through thoracic spine, no lifting > 5 lbs). 4. Physical therapy consultation

Lab		Reference range	Hospital day 0: emergency department	Hospital day 2: SICU
Arterial blood gas	pH	7.35–7.45	7.42	7.38
	PaCO₂	35–45	36	45
	PaO₂	75–95	77	94
	HCO₃ ^–	23–29	25	26
Complete blood count	White blood cell	5.0–10.0 × 10⁹/L	8.1	8.8
	Hemoglobin	14.0–17.4 g/dL	15.1	15.8
	Hematocrit	42–52%	43.7	44.2
	Red blood cell	4.5–5.5 million/mm³	4.6	4.9
	Platelet	140,000–400,000/μL	152	162
Electrolytes	Calcium	8.6–10.3 mg/dL	8.9	9.7
	Chloride	98–108 mEq/L	101	98
	Magnesium	1.2–1.9 mEq/L	1.3	1.4
	Phosphate	2.3–4.1 mg/dL	3.4	3.2
	Potassium	3.7–5.1 mEq/L	4.2	4.2
	Sodium	134–142 mEq/L	135	137
Other	Blood urea nitrogen	7–20 mg/d	18.2	Not reordered
	Creatinine	0.5–1.4 mg/dL	1.1	Not reordered
	Glucose	60–10 mg/dL	201	116
Coagulation	Prothrombin time	10–14 seconds	10.1	10.8
	Partial thromboplastin time	25–35 seconds	25.2	26.4
	International normalized ratio	2.0–3.0	1.8	2.1

Pause points
Based on the above information, what are the priorities? Examination tests? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priorities?

Examination tests?
Outcome measures?
Treatment interventions?

Hospital Day 3, SICU: Physical Therapy Examination
Subjective
“My back hurts right where they did the surgery” Patient with complaints of left posterior rib pain from fractures as well. Patient reports that he hasn’t been out of bed yet but has sat up with the head of the bed raised.
Objective
Vital signs	Pre-treatment		During treatment	Post-treatment
Vital signs	Supine		Sitting	Sitting
Blood pressure (mmHg)	118/70		98/65	108/65
Heart rate (beats/min)	72		90	76
Respiratory rate (breaths/min)	12		16	12
Pulse oximetry on 2 L NC (SpO₂)	96%		94%	97%
Borg scale	6/20		15/20	11/20
Pain	6/10 at back 4/10 at ribs		8/10 at back 5/10 at ribs	5–6/10 at back 4/10 at ribs
General	Patient supine in bed. Lines/equipment notable for telemetry, urinary catheter, 2 L O₂ via NC, BLE compression stockings, and bilateral sequential compression devices Fig. 18.2.
Head, ears, eyes, nose, and throat (HEENT)	No discernable abnormalities present.
Cardiovascular and pulmonary	Heart sounds: normal S1 and S2 with no murmurs or abnormal sounds noted. Breathing pattern: notable for diaphragmatic breathing. Breath sounds: slight decrease in inspiratory sounds in bilateral basilar lung segments anteriorly and posteriorly. No other adventitious sounds noted. Pedal pulses: 2 + bilateral dorsalis pedis and posterior tibialis.
Gastrointestinal	No discernable issues
Genitourinary	(+) foley catheter
Musculoskeletal	Range of motion (ROM)	Bilateral upper extremity (BUE): within functional range. Bilateral lower extremity (BLE): passive ROM (PROM)—within functional limit (WFL); no active ROM noted.
	Strength	B shoulder flexors and abductors: 4/5 due to pain in back. B shoulder extensors, adductors, internal rotators, and external rotators: 5/5. B elbow flexors, extensors, supinator, and pronator: 5/5. B wrist and hand: 5/5 BLE: 0/5 throughout all muscle groups. Abdominals: 0/5
	Aerobic	Unable to perform standardized test at this time. Able to complete bed mobility and transfers with minimal to moderate shortness of breath.
	Flexibility	No abnormal issues found with flexibility at this time. Spinal motion not tested due to postsurgical restrictions.
Neurological	Balance	Static unsupported sitting: minimal assistance with BUE support. Dynamic unsupported sitting: minimal assistance with BUE support. Standing balance: not appropriate at this time.
	Cognition	Alert and oriented × 4
	Coordination	Finger to nose: intact bilaterally Heel to shin: unable to perform bilaterally.
	Cranial nerves	I–XII: intact
	Reflexes	Babinski’s reflex: (+) bilaterally No other reflexes present below T7 level.
	Sensation	BUE: intact to light touch, pain, temperature, and proprioception. BLE: absent for light touch, pain, temperature, and proprioception. Trunk: sensation intact until about T6–T7 level, absent distally.
	Tone	BUE: normal BLE: hypotonic/flaccid throughout No clonus elicited during PROM assessment.
Functional status
Bed mobility	Rolling either direction: contact guard assistance with LE preparation and management; using BUEs, bedside rails, and momentum. Supine to/from sit: moderate assistance with LE management and trunk.
Transfers	Bed to/from chair: moderate assistance with slide board.
Ambulation	Not applicable
Stairs	Not applicable
Task specific	Wheelchair mobility: patient unable to propel wheelchair at this time. Will assess after discharge from ICU.
Sport specific	N/A

Fig. 18.2 Lower extremity intermittent pneumatic compression device.

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop
Goals
Patient’s	“I want to get out of here.” “I’d love to walk again.”
Short term	1. Goals left blank for learner to develop 2.
Long term	1. Goals left blank for learner to develop 2.

Plan
☐ Physician’s ☑ Physical therapist’s ☐ Other’s	Will continue to see patient five to seven times a week to progress functional mobility. Will continue to progress balance, bed mobility, transfers, wheelchair mobility, and safety through strengthening and endurance interventions and education on respiratory mechanics, airway clearance, and positioning. Will coordinate functional plan with occupational therapy and rehabilitation plan with physician and discharge planner.

Plan

☐ Physician’s

☑ Physical therapist’s
☐ Other’s

Will continue to see patient five to seven times a week to progress functional mobility. Will continue to progress balance, bed mobility, transfers, wheelchair mobility, and safety through strengthening and endurance interventions and education on respiratory mechanics, airway clearance, and positioning. Will coordinate functional plan with occupational therapy and rehabilitation plan with physician and discharge planner.

Bloom’s Taxonomy Level	Case 18.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. Discuss the physical therapist’s evaluation findings with occupational therapist in order to devise an interprofessional plan of care.
Analyze	5. Explain concern about pH, PaCO₂, and PaO₂ levels in a person with acute SCI and why it is important to follow those blood values. 6. Why is it important to track the patient’s electrolytes?
Apply	7. Describe at least two functional mobility interventions for the initial treatment sessions in acute care with physical therapist. Be specific as to the parameters and position of interventional techniques. 8. Design and implement two interventions to improve respiratory capacity and airway clearance. 9. What interventions could the physical therapist provide if the patient became symptomatic due to a decrease in blood pressure and a recovery was not seen within 3 to 5 minutes?
Understand	10. Did the patient’s vital signs respond appropriately to the physical therapy interventions performed on day 3? Why is it important to monitor vital signs before, during, and after physical therapy sessions with this patient?
Remember	11. What are the implications of the spinal surgery precautions to mobility in the physical therapy sessions? 12. What are the two pulmonary complications that are most likely to occur at this point in the patient’s care?

Bloom’s Taxonomy Level	Case 18.A Answers
Create	1. The patient is a 25-year-old man who presented to the hospital status post motor vehicle accident. The patient was diagnosed with an incomplete SCI at the T7 level—American Spinal Injury Association (ASIA) classification B—and posterior rib fractures of ribs 5 and 6. The patient underwent T6–T8 spinal fusion and will follow post-op spinal fusion precautions of forward flexion, lifting, and spinal rotation. As a result of his spinal injury, the patient presents with lack of motor and sensory nerve function below T7 at this time. He is using 2 L O₂ via NC to maintain proper oxygen saturations. All other lab findings are appropriate at this time. He would benefit from continued physical therapy to improve above deficits to maximize functional mobility and safety. Will continue to follow and progress as tolerated. 2. Short-term goals: Patient will perform rolling in either direction without use of bed rails with contact guard assistance within 3 days to promote independence with bed mobility. Patient will perform slide board transfer from bed to/from chair with minimal assistance within 3 days to promote independence with transfers. 3. Long-term goals: Patient will perform slide board transfer bed to/from chair with contact guard assistance within 7 days to promote independence with transfers. Patient will independently propel wheelchair a minimum of 100 feet on level surface, avoiding 100% of obstacles, to promote independence.
Evaluate	4. The physical therapist should discuss the findings regarding UE strength, lack of LE motor and sensory function, and mobility. The physical therapist and occupational therapist should develop a plan to optimize the patient’s skills for bed mobility, endurance, transfers, wheelchair mobility, wheelchair prescription, pulmonary education and interventions, and education regarding other ancillary complications (bowel and bladder, etc.). At a minimum, the physical therapist should take the lead on pulmonary interventions, wheelchair prescription, wheelchair mobility, endurance, and flexibility/maintaining ROM.
Analyze	5. The patient is likely to have a decrease in inspiratory volumes. The thoracic cage muscles are involved although most are intact. This will lead to some decrease in inspiratory volumes, at least early on in the rehab process. All mobility will also take more effort for the patient placing even more demand on the pulmonary system. Therefore, it is important to monitor vital signs to make sure that the patient is still getting enough PaO₂ volumes to sustain the body’s demand and that the lack of inspiration isn’t leading to decrease volumes, hence increase PaCO₂, which could cause problems with the body’s pH. 6. An SCI can impact the patient’s sympathetic nervous system, which in turn can impact organ function, including production and regulation of fluid electrolyte levels. Since the electrolytes can impact the patient’s cardiovascular system, renal system, and liver, it is important for the medical team to monitor these lab values, and for the physical therapist to watch for any adverse signs and symptoms pre-, peri-, or postrehabilitation.
Apply	7. Two functional mobility interventions for the initiation of physical therapy include: Bed mobility: The physical therapist should be specific about teaching the patient how to position LEs, how to use UEs to develop momentum, and, of course, safety precautions, especially within the confines of the spinal precautions. Anecdotally, the patient should practice these techniques at least three times to each side during each session. Supine to sit should also be practiced at least three to four times per session. Transfers: the physical therapist should work with the patient on sliding board transfers. Education and practice on the placement of the board, positioning of LEs and UEs, safety issues, and strategies should be implemented. These should be practiced at least three to four times during each session. 8. The patient should be educated on the need to maintain or improve inspiratory volumes. Interventions to promote this include deep breathing, diaphragmatic breathing, inspiratory hold, breath stacking, or other inspiratory breathing techniques. Again, anecdotally, these should be performed for at least 1 to 3 minutes each session and the patient should be educated to perform them at least once or twice a day. For airway clearance, the patient should be educated on how to produce an effective and efficient cough and why maintaining an upright posture is important. For coughing, splinting technique or other self-assisted cough techniques may need to be implemented if the patient is unable to generate a strong enough cough independently. This should only need to be taught once and then have the patient demonstrate them once or twice over the first few physical therapy sessions to ensure they are being performed accurately and effectively. 9. In the short term, the physical therapist should elevate the patient’s LEs, but for a more long-term solution, an abdominal binder, and/or compression stockings may be added to assist with blood pressure regulation. Initially, generic off-the-shelf stockings can be used. However, if it is determined that the patient will need them long term to maintain venous return, then custom progressive resistance stockings should be prescribed and obtained for the patient.
Understand	10. The patient’s vital signs did respond appropriately to the physical therapy interventions performed on day 3. It is important to watch heart rate due to increased physical demand on the patient since he is unable to use his LEs. The physical therapist needs to ensure that motion and mobility aren’t placing too high of a demand on the patient’s cardiac system. Blood pressure is also important to monitor to assess for tolerance to physical demands. However, it is important to be mindful that the patient has lost muscle contractions to assist with venous return, and therefore he is at risk of developing postural hypotension. Respiratory rate and O₂ saturations give the physical therapist the ability to monitor that physical activity isn’t placing too high of a pulmonary demand on the patient either.
Remember	11. The physical therapist will need to educate the patient on the spinal surgery precautions and evaluate that the patient understands them. During interventions, the physical therapist must make sure that the patient is not flexing or rotating the spine. 12. The patient is at risk of developing a pulmonary embolism, atelectasis, or pulmonary infection (most likely pneumonia). The patient is at a lower risk of developing a pneumothorax, pleural effusion, or pulmonary edema.

Key points
1. It is important for the physical therapist to evaluate motor and sensory nerve function regularly for this patient as there may be some improvement with time, to fully evaluate patient’s mobility, and to assess how other body systems are being impacted by the SCI and how those reactions may impact the patient’s rehab with physical therapy.
2. Primary goals for physical therapy management of this patient in the acute care setting are to stabilize his pulmonary system and prevent complications, encourage mobility and upright activities, and prepare the patient for the next phase of rehabilitation.
3. Program parameters should include mobility, functional movements, and pulmonary training as the main types of rehab. Duration should be about 15 to 20 minute in total with multiple rests for the patient. Intensity will be determined based on patient’s subjective complaints and vital sign responses. Frequency should be most days of the week to prepare for the next phase of rehab.