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Physiotherapy and Spinal Cord Injury

High velocity accidents and sporting incidents carry a risk of causing a spinal cord injury (SCI), a serious but uncommon condition which can also be caused by ischaemia, infections or tumours. Younger people are the biggest group likely to suffer this injury due to their risky pursuits but it can occur in someone of any age, road accidents accounting for the greatest proportion. Due to the complex nature of the condition a multi-disciplinary approach is essential, involving several health care professionals, to facilitate the highest degree of independence in the patient. Paraplegia and quadriplegia are the terms used for the resulting conditions.

The initial medical evaluation is performed to establish the respiratory status of the patient and deal with any other of the likely multiple injuries. Once the patient is stabilised the doctors try and work out the level in the spine where the damage has occurred, an important fact as it relates closely to medical and therapy management. A low lumbar fracture will have no effect on the arms or the ability to breathe so the patient will have good trunk and arm power and the aerobic ability to develop independence. Cervical and upper thoracic injuries impair the respiratory ability of the patient and limit arm function, making rehabilitation much harder.

Assessment of the patient's respiratory status is the initial concern of the physiotherapist, often in the intensive care unit. The physiotherapist will attempt to encourage the patient to expand their lungs, deep breathe and cough any secretions up to clear their chest. Paralysis of the lower trunk can reduce propulsive force and thereby the effectiveness of coughing, a process which the physiotherapist helps by stabilising the lower abdomen during attempted coughing. Suction may be needed in severe cases and coughing can be promoted by using a cough assist machine.

Once the emergency treatment has been provided and the medical condition of the patient is stable they can be transferred to a ward. Spinal surgery may be performed, using internal fixation and bone grafting, to stabilise the fractured spinal segments. Once the segments are stable the patient can begin early rehabilitation without waiting for fracture healing which for the spine can take up to 12 weeks. Physiotherapists review the patient's respiratory coping, teach range of movement and strengthening exercises for unaffected parts and put the paralysed areas through full passive range of movement several times every day to maintain the joint ranges. 

If the spine is unstable, which it often is in spinal trauma resulting in paraplegia, a spinal surgeon will stabilise the spine, usually with instrumentation and bone grafting. This allows the patient to start their rehabilitation without the long wait for the spinal fractures to heal naturally. Initial physiotherapy management is to monitor the respiratory status, encourage active movement of unaffected areas and perform passive movements of paralysed body parts to retain and improve the ranges of motion which will be required later for independence.

After lying flat for some time during the early period the patient needs to be progressed by the physiotherapist to sitting upright in a wheelchair. This is a gradual process as moving the patient into the upright position too quickly can cause a severe blood pressure drop. A wheelchair with elevating leg rests and a sloping back is used initially until the patient is able to tolerate an upright chair. Regular practice of sitting balance is vital under the close supervision of the physiotherapist as trunk control is needed for independent living. Once sitting is mastered transfers into a wheelchair and strengthening can be worked on.

The first stages of learning good sitting balance, muscle strengthening and wheelchair transfers have now been mastered and it is time for the remaining rehabilitation to take place in a Spinal Injury Unit. Only such a specialised unit with a multi-disciplinary team can teach the large number of remaining skills necessary for independent living. The degree of independence a patient can achieve depends on many factors such as the level of the spinal injury, the age of the person, any co-existing medical conditions and motivation and family support.

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