CHAPTER 84 Spinal Cord Injury Rehabilitation
Spinal cord injury (SCI) is a catastrophic event that results in impairments that affect almost every aspect of a person’s bodily function. SCI is virtually unmatched in the level of devastation it brings to a person’s life and the social and financial cost it levies to society. SCI plunges the injured person, most often a young previously healthy individual, into a world of emergency care, intensive medical and surgical care, and total dependency. The SCI patient then arrives on the rehabilitation unit and is expected to relearn the most basic of bodily functions despite seeing slow or no neurologic recovery. Finally, the SCI patient is expected to learn to perform once simple and now complex tasks of daily living independently so that he or she can return home in increasingly shorter amounts of time.
SCI is defined as an injury to the spinal cord that partially or completely interrupts the three main functions of the cord: motor, sensory, and reflex activities. Before World War I, SCI inevitably resulted in early death. Egyptian physicians long ago labeled SCI as an ailment not to be treated at all because they feared the pharaoh would kill them if they let a patient die under their care.1 However, advances in treatment that began during World War II and have progressed since have allowed many persons with SCI to live much longer. Today in many cases, patients with SCI can expect to live an almost normal lifespan. As a result, the numbers of persons alive today with SCI in the United States has increased to more than 200,000.2
In 1970 the first federally funded Model Spinal Cord Injury Care Systems (MSCICS) were developed. Currently there are 14 such centers (there were 18 before funding was cut) as designated by the National Institute on Disability and Rehabilitation Research (NIDDR). Each center represents a comprehensive interdisciplinary service delivery integrating all aspects of care for the SCI patient from the initial injury to lifelong follow-up. The model centers are based on the principles set forth by Sir Ludwig Guttman, a British physician who pioneered advances in the care of SCI patients during World War II1:
The 14 MSCICS centers and 8 previously designated centers have been contributing clinical information to a national database following a jointly agreed-upon protocol. They have been able to report results on the basis of an estimated 13% of all SCI injuries in the United States occurring since 1973. The database contains information on about 25,000 spinal cord injured persons.3 The end result is a wealth of information regarding injury trends from 1973 to1998 and some recent updates that include information through the year 2004. The data not only allow physicians to know the current status of SCI patients but also give physicians the ability to spot trends in the demographic data. These changes in the demographics of SCI have allowed rehabilitation programs and centers to “change with the times” to reduce the cost and ultimately improve the quality of medical rehabilitative care for their patients with SCI.4
Incidence, Race, Age, and Gender
On the basis of information from the national database, there are approximately 11,000 new cases (40 per million in the U.S. population) each year. However, this number is based on older data from the 1970s. The prevalence is estimated to be 225,000 to 296,000 persons and growing.3 The recently updated national SCI Statistical Center statistics put the prevalence at 255,702.
Between 1973 and 2004, 66% of patients were Caucasian, 21% were African American, and 9.7% were Hispanic.3
Cervical injuries resulting in tetraplegia occur in 54% of SCI patients. Lumbar and thoracic injuries causing paraplegia comprise the rest (45%). A few (1%) were discharged as “normal” or indeterminate. Since 1990, the numbers of patients with complete SCI has been higher than incomplete injuries (56% vs. 44%).3 Since 2000, however, the most frequent injury has been incomplete tetraplegia (34.7), followed by incomplete paraplegia (23.0), complete tetraplegia (18.5), and complete paraplegia (18.5).
SCI affects young adults most often. Population-based data show the highest incidence, nearly 51.6% of injuries, occurs in the 16- to 30-year age group.3 However, the most recent trends suggest that SCI is occurring with increasing frequency in older persons. The result is that the fastest growing population of new SCI patients is older than 60 years of age. Since 1990, the incidence of SCI in persons older than 60 has increased to 12% from 4.5% in the 1970s.3 The average age at SCI has increased from 28.7 to 38.9 as of 2007. Additionally, while SCI is an injury that occurs primarily in males (81.6% since 1973), some centers are reporting increasing numbers of females suffering SCI.
Life expectancies for persons with SCI that were so low many years ago continue to steadily increase. Mortality rates, however, while improving, continue to be highest during the first year after injury. Complete injuries still have lower ultimate survival rates than incomplete injuries. The degree of neurologic impairment, as measured by the Frankel Grade or the American Spinal Injury Association (ASIA) Impairment Scale, and level of injury were significantly correlated with mortality risk. For example, the average life expectancy of a 20-year-old who suffers complete paraplegia is 66 years. This compares with 61 years for a C5 to C8 SCI, 57 years for a C1 to C4 SCI, and 43 years for a ventilator-dependent patient. This compares with the normal life expectancy in the general population of 77 years and in a patient with incomplete SCI of 72 years.5 The factors that can increase life expectancy are favorable circumstances for good health, community integration, and higher income.6
Many years ago, the leading cause of death among persons with SCI was renal failure. Pulmonary embolus (PE) usually in the first few weeks after injury, and most often associated with a deep vein thrombosis (DVT), was another frequent cause of death. Advances in urologic management, DVT and PE prevention, and early mobilization have reduced the number of early deaths. Today, renal failure rarely occurs in the acute SCI setting. Because more SCI patients live not only through their first year after injury but also survive to old age, cardiovascular disease has become a more frequent cause of death (Fig. 84–1). Nash and colleagues7 demonstrated that SCI is an independent risk factor for developing multiple risks for cardiovascular disease such as increased cholesterol. Respiratory illness, particularly pneumonia, is now the leading cause of death among older SCI patients with cervical injuries.8 The cause of death in persons with paraplegia is more varied. In addition to heart disease, cancer, suicide, and septicemia are the leading causes.
The causes of spinal cord injury are typically divided into traumatic and nontraumatic. The top five causes of traumatic SCI in males are auto accidents, falls, gunshot wounds, diving, and motorcycle accidents.3 The top three remain the same in women, but the final two are medical causes and diving3 (Fig. 84–2).
FIGURE 84–2 Etiology of spinal cord injury by gender of patients.
(Adapted with permission from Jackson AB, Dijkers M, DeVivo MJ, Poczatek RB: A demographic profile of new traumatic spinal cord injuries: Change and stability over 30 years. Arch Phys Med Rehab 85:1740-1748, 2004.)
The major trend is that violent injuries have decreased from 20% in the 1990s to 9.8% in 2000s.3 Geographic variations occur depending on the state or city. In the older SCI patients, in addition to falls, nontraumatic causes of SCI such as cancer, vascular injuries, and infection make up a larger proportion of injuries.
Etiology is also reported in terms of major groups. Figure 84–3 illustrates the frequency that each of these groups causes SCI.
Classification of Spinal Cord Injury
The spinal cord has three basic physiologic functions. The ascending tracts in the cord receive sensory information from the somatic and visceral receptors through dorsal root ganglia and transmit this information to higher centers. The descending tracts receive signals from higher centers and ultimately transmit these signals to target sites via the ventral roots. The other basic function of the spinal cord is to modulate these signals via a variety of local mechanisms.
Assessment, treatment, and classification of spinal cord injury flow directly from the anatomy, physiology, and topography of the spinal cord. Classification or grouping of patients allows the rehabilitation physician to predict the outcome and ultimate function in a majority of patients on the basis of others with similar injuries. This allows the rehabilitation team to design a rehabilitation program appropriate for individual SCI patients to give them the best opportunity to maximize their potential functional outcome.
The most accurate way to assess a patient who has suffered an SCI is to perform a standardized physical examination as outlined by the American Spinal Injury Association. The neurologic examination includes two key components—the motor and sensory examination with required and optional elements. The result allows the clinician to compile a score and determination of the completeness of injury. The neurologic level is also determined by rules set forth in the ASIA examination. From these data a functional classification is assigned to each patient. This information can then be used to design each patient’s rehabilitation program and predict his or her functional outcome on the basis of previous patients with similar injury classifications.
Two assessment tools are used in the evaluation of patients after SCI.9 One is the neurologic classification of SCI using the ASIA impairment scale. The other is the functional score, or Functional Independence Measure (FIM) score.
The ASIA impairment scale measures the degree of completeness of injury using categories from A to E (Table 84–1). Complete paralysis is defined as the absence of sensory and motor function in the lowest sacral segments and incomplete paralysis as preservation of sensation below the level of the injury including the lowest sacral segments. Sacral sparing is defined as voluntary anal contraction or presence of dull touch and pinprick sensation in the rectal and perianal area.
|A||Complete—No motor or sensory function is preserved in the sacral segments S4-5.|
|B||Incomplete—Sensory but not motor function is preserved below the neurologic level and includes the sacral segments S4-5.|
|C||Incomplete—Motor function is preserved below the neurologic level, and more than half of key muscles below the neurologic level have a muscle grade less than 3.|
|D||Incomplete—Motor function is preserved below the neurologic level, and at least half the key muscles below the neurologic level have a muscle grade of 3 or more.|
|E||Normal—Motor and sensory function is normal.|
In addition to the ASIA impairment scale is a scoring system that measures the strength of each muscle on a 6-point scale (0 to 5) and sensation for pinprick and dull touch on a 3-point scale (0 to 2). The motor level of SCI is defined as the lowest normal motor segment that has a grade 3 or more, providing the muscles above that level are graded as a 5. The motor level best reflects the severity of impairment and disability during rehabilitation.
FIM score is a widely accepted functional assessment tool and is currently used as an indicator of function in patients with SCI. FIM is an 18-item scale. There are two categories of items, motor and cognitive. Individual items in each category score from 1 to 7, from “total assistance” to “complete independence.” There are 13 items of motor scoring important in determination of self-care, sphincter control, and mobility (Box 84–1). Scores falling below 6 indicate that the patient requires another person for assistance. Many rehabilitation units now use FIM scores to measure patient outcomes. Quality assurance units use these data from groups of patients to draw inferences on the effectiveness of the rehabilitation unit.
BOX 84–1 Functional Independence Measure (FIM) Scale
In addition to classifying patients on the basis of their individual motor and sensory injury levels, the following specific clinical syndromes have been identified in the literature: central cord, anterior cord, posterior cord, Brown-Séquard, conus medullaris, and cauda equina syndromes.10,11
Central Cord Syndrome
The most common type of incomplete SCI in the elderly, central cord syndrome also carries with it a relatively favorable prognosis for recovery. The mechanism of injury is usually hyperextension of an already stenotic cervical canal producing central hematomyelia.12 Because the lumbar and sacral motor tracts are located in the periphery of the white matter, the syndrome is characterized by motor weakness of the upper extremities greater than the lower extremities and sacral sparing. Recovery occurs more favorably in younger patients. Between 87% and 97% of patients younger than 50 will eventually ambulate, versus 31% to 41% of those older than 50. Hand intrinsic function is last to recover, usually incompletely in all ages.
Anterior Cord Syndrome
This is an injury to the anterior two thirds of the spinal cord including both gray and white matter. The posterior columns are preserved. The mechanism of injury is either due to thoracic fractures with retropulsion of disc or bone fragments or lesions of the anterior spinal artery. The resulting SCI is most commonly complete paralysis with spasticity. In the lower extremities deep pressure and proprioception are preserved. However, the prognosis for motor recovery is relatively poor.13
Posterior Cord Syndrome
The least common incomplete SCI is characterized by absence of position sense. There is usually preservation of pain, temperature, and touch. Motor function is impaired in varied amounts.
This injury occurs with a literal or functional hemisection of the spinal cord. The most common cause is a bullet or knife wound. The classic presentation is ipsilateral loss of motor function, ipsilateral loss of dorsal column sensation, and contralateral loss of pain and temperature below the level of the lesion. Overall, these patients have the greatest potential for functional outcome and ambulation (75% to 90%).14 Bowel and bladder continence is regained in 82% and 89%, respectively.
Conus Medullaris, Epiconus, and Cauda Equina Syndromes
Patients with these lesions present with similar motor and sensory deficits but are also different in a few distinct ways. Patients present with patchy lower extremity weakness, saddle anesthesia, and incontinence of stool. Urinary retention is more common than incontinence. Lesions of the cauda equina are clearly lower motor neuron with decreased lower extremity motor tone, absent lower extremity and bulbocavernosus reflexes, flaccid bladder, and asymmetric weakness. High conus (epiconus) lesions may have upper motor neuron (UMN) findings mixed with the lower motor neuron findings.
Cauda equina lesions carry a much more favorable prognosis for functional motor and sensory recovery, especially when surgical/medical treatment occurs promptly. Bowel, bladder, and sexual function return less frequently, often leading to adjustment and psychologic difficulties. The long-term difficulties in patients with cauda injuries are compounded by a high incidence of severe neuropathic lower extremity pain not usually seen in conus injuries. Thus patients recovering from cauda equina injuries may have long-term physical and emotional disabilities despite their seemingly “normal” outward appearance even after successful physical rehabilitation.
As stated earlier, rehabilitation of the SCI patient begins from the moment of injury. Quick response, transfer to a level I trauma center, and prompt medical and surgical treatment results in a minimizing of medical complications and preservation of neurologic function. In the acute hospital setting, important recommendations given on consultation with the SCI specialist include treatment of neurogenic bowel and bladder, prophylaxis of DVT and PE, prophylaxis of gastric ulcer, preventing atelectasis and pneumonia via proper pulmonary management, and preventing skin ulcers with proper positioning in bed and turning every 2 hours. Physical and occupational therapies are initiated in the acute hospital unit once the spine is stabilized. Range of motion (ROM) is performed to the shoulders, hips, elbows, and heel cords. ROM should be performed twice daily to prevent joint contractures and can be taught to family members. Splints are made for the upper extremities for the same reason. The patient begins to build tolerance to sitting and is taught weight shifting to prevent pressure ulcers. The goal is to achieve medical stability so that the injured patient can be admitted as quickly as possible to a multidisciplinary inpatient rehabilitation hospital that specializes in SCI treatment.
Once the acute treatment is completed and the patient is deemed “medically stable,” the rehabilitation course is assisted with the quickest possible transfer to the rehabilitation unit. In cases of high tetraplegia, medical stability may be achieved while the patient is still on a ventilator. The result of a shorter length of stay in the acute hospital and quicker move to rehabilitation is to lower the cost to the “health care system” and improve the ability of patients to quickly see functional recovery.
Moving patients quickly through rehabilitation has some negative consequences, too. Sometimes patients do not have a chance to psychologically adjust to their injury fully. Additionally, shorter lengths of stay have also moved to the rehabilitation hospital.
Unfortunately, these shorter lengths of stay that are often forced on patients and rehabilitation providers by insurance company mandates continue a trend that patients will need to complete their physical, functional, and psychologic rehabilitation as outpatients. Therefore it is imperative then that the rehabilitation be focused and aggressive to accomplish as much as possible in a shorter amount of time. The challenge is to provide SCI patients with the highest quality rehabilitative care despite these imposed constraints so that they leave the hospital with the highest possible outcome.
On the rehabilitation unit, the SCI patient begins a new journey. The basic skills of mobility, self-care, and bladder/bowel functions are relearned regardless of the severity of the injury—sometimes quickly but other times painfully slowly. Patients try to achieve independence in each area, although sometimes only modified or partial independence is possible. The level of neurologic injury best predicts the level of independence and mobility each patient can achieve,15 even though individual differences occur. SCI patients use a significant time in rehabilitation to review a variety of handbooks and computer programs to become educated on their injury. Most patients also receive counseling for emotional and psychologic adjustment, discover initial vocational options for their future, and participate in recreational and leisure activities that ease their reintegration into society. A subset of SCI patients who suffered concurrent head trauma receives cognitive testing and retraining. Another subset of SCI patients who remain on ventilators receives breathing and communication training. Finally, each patient is discharged to the most independent living situation possible. Usually they can only go home after multiple modifications are built and after a myriad of adaptive equipment is prescribed.
Because the tasks of rehabilitation can be so daunting and involve so much of the “whole person” with all organ systems including the psychosocial system affected, only a dedicated multidisciplinary team can accomplish a successful comprehensive rehabilitation. Each member of the multiple rehabilitation disciplines functions together as a team to optimize each patient’s outcome.16 Historically the leader of the team has been the rehabilitation physician, or physiatrist, who would create the rehabilitation goals, lead weekly team meetings, and decide when the program is complete. More recently, most rehabilitation programs have shifted to a more patient-centered approach with the interdisciplinary team working toward goals set forth together.17 All disciplines focus their treatments on the patient, so teamwork and treatment overlap are encouraged. With this approach the patient, and often his or her family, is intimately involved in deciding the direction of the rehabilitation and the date of discharge. The individual disciplines are listed in Table 84–2.18
|Psychiatrist||Medical care, coordination of rehabilitation, team leader|
|Rehabilitation nurse||Daily care, medication, education, reinforce skills, transfers|
|Physical therapist||Gross motor skills, transfers, mobility (wheelchair, standing, ambulation)|
|Occupational therapist||Fine motor skills, activities of daily living (e.g., feeding, dressing, bathing)|
|Recreational therapist||Leisure activities, community reintegration, assistive technology use|
|Social worker||Obtain community resources; assist with disposition planning; communicate with insurance companies|
|Speech therapist||Assess cognitive status; provide communication, swallowing, and cognitive training|
|Respiratory therapist||Manage patients on respirator; provide respiratory treatments|
|Prosthetist/orthotist||Design and fabricate upper/lower extremity braces and prosthesis; fit spine braces|
|Vocational counselor||Test skills and interest; recommend training and assist with placement|
|Vendor||Wheelchair procurement and fitting, adaptive equipment|
Recent advances in rehabilitation techniques have led to both increased functional outcomes and decreased lengths of stay. One of the most influential advances has been in surgical stabilization. Historically, large bulky cervical braces including halos dominated rehabilitation units. Now, better internal fixation has allowed patients to come onto the rehabilitation units almost immediately after surgery and usually with only a hard collar.19 The less intrusive bracing allows patients to progress more quickly in their mobility training.
Newer medications have also allowed SCI patients to progress more quickly. Patients who were having difficulty with postural hypotension can get upright sooner and for longer time periods. Other medications have decreased the incidence of DVT, pulmonary embolism, and spasticity. Those SCI patients slowed by neuropathic pain now benefit from new pain medications and procedures. Aggressive percussive lung treatments have decreased the incidence of pneumonia and “down time” on the unit.
The functional rehabilitation program begins with a comprehensive assessment of medical impairments, functional deficits, and environmental setup. Then, on the basis of the findings, appropriate goals can be set and a treatment approach to reach those goals can be initiated and completed. Persons with complete SCI share the common situation that in most cases their impairment remains static or permanent.
Therapists may choose from a number of treatment approaches to achieve the goal of functional independence or achieving maximum function. More than one different type of approach may also be used if felt appropriate by the therapist. Additionally, although therapy sessions and tasks are divided by discipline (e.g., transfer training by physical therapy, activities of daily living [ADL] to occupational therapy), all therapists must use expertise from other specialists on the team to maximize functional restoration and treatment. Within that framework, treatment can be either restorative or compensatory. The goal of restorative treatment is simply to reverse the disability, even if the impairment cannot be reversed. The individual is encouraged to perform the ADL task the same way as before the injury. Compensatory treatment aims to reverse the disability and even the handicap by finding other means of traversing the divide created by the impairment without directly restoring the function. Either way, the functional task gets done independently or at least with the least dependence possible leading to the point of discharge.
The choice of which method to use depends on the underlying condition of the patient. Most persons with complete SCI may gain one or two levels of neurologic function but are unlikely to gain any more neurologic return in their immediate future. Therefore therapists most often use compensatory strategies to create independent function. However, persons with incomplete SCI may see tremendous neurologic recovery over time and are more appropriate for restorative therapy immediately. Therefore therapists must carefully observe their patient and try to project the amount and speed of the recovery. If recovery is occurring quickly, restorative treatment strategies are more appropriate. One example would be employing standing balance strategies at the kitchen even when the patient cannot yet ambulate but should in the near future. Areas of focus on the inpatient rehabilitation stay are as follows: