Spinal Cord Injuries

Spinal Cord Injuries treatment in Hebbal, Bangalore

A Spinal Cord Injury (SCI) is a non-traumatic or traumatic event that causes neural damage affecting sensory, motor, respiratory function, bladder function, bowel function, and sexual function. Neurological interruption also influences skin integrity, blood pressure, and temperature regulating ability. 

Mostly, spinal cord injury, leads to,

• Paraplegia: Loss in motor and/ or sensory function in the lower limbs

• Tetraplegia: The upper limbs to the motor and/ or sensory loss of the lower limbs and legs

Physiotherapy Management

For SCI patients during, rehabilitation and management is done based on type and level of injury. SCI patients mostly need initial ICU care, and the process of rehabilitation typically begins in the acute care setting.  This is preceded by treatment for an extended period in some specialised Spinal Injury Unit. Duration of inpatient management could be between 8-24 weeks.   This would be followed by outpatient rehabilitation of 3 to 12 months. Finally, there will be functional and medical reviews on an annual basis. 

The approach of patients during spinal cord injuries treatment in Hebbal, Bangalore is lifelong, complex, and needing a multidisciplinary approach. This will help the individual to lead an independent and full life to the most extent. A rehabilitation Physician or Physiatrist heads a team of occupational therapy, physiotherapy, language and speech therapy, social workers, psychologists, rehabilitation nurses, and other social care and health professionals. Along with the individual, they come up with a plan for discharge that suits the circumstances and level of injury of the individual. 

Critical steps of SCI patient management are,

• Assessing the individual’s participation restrictions, activity limitations and impairments

• Fixing goals that match the participation restrictions and activity limitations

• Identifying all key impairments posing hindrance in goal achievement

• Identifying physiotherapy treatments and administering the treatments, such as joint mobility, strengthening, development of motor skills, cardiovascular fitness, pain management, and respiratory functioning

• Measuring how well the treatments are working

There are three phases in the management of SCI individuals,

1.   Acute

2.   Chronic (Long Term)

3.   Sub-acute (Rehabilitation)

In the acute and subacute treatment phases, the key focus of the rehabilitation strategies is on secondary complication prevention, neuro recovery promotion, underlying impairments treatment, and function maximisation. The chronic phase is addressed with assistive and compensatory approaches.

Acute Phase

This early phase after the injury involves physiotherapy management mainly for management and prevention of circulatory and respiratory problems and to bring down the impact on the individual of immobilisation, such as contracture development and pressure ulcer.

Acute Phase Treatment Objectives

The objectives are, 

• Instituting a prophylactic respiratory treatment that manages respiratory resulting from SCI  and other associated conditions, such as decrease incidence atelectasis and enhance clearance of secretions

• Achieving independent respiratory status

• Maintaining the movement’s full range for all joints within the existing limitations

• Monitoring and managing individual’s neurological status

• Maintaining and strengthening every innervated muscle groups

• Facilitating functional activity patterns

• Educating and supporting the individual, the caregiver, staff, and family

Levels of Intervention

The levels of innervations include,

• C5-T1 Pectoralis

• T1-11 Intercostalis

• C3-5 Diaphragm

• C3-8 Scalenes

• T6-12 Abdominals.

Patients having C1-3 tetraplegia need to be put on mechanical ventilation and those with C4 tetraplegia will generally have independent breathing.  Patients having SCI C4 to T12 breathe independently but could have decreased vital capacity and problems with raising intra-abdominal pressure for coughing effectively or performing Forced-expiratory Techniques (FETs).

Treatment

Secretion Clearance

• Percussions

• Postural suctioning and drainage 

• Shaking

• Vibrations

Increased Ventilatory Techniques

• Abdominal binders

• Deep breathing exercises

• Incentive spirometry

• Inspiratory muscle training

• Positioning

Equipment often used for improving ventilation,

• Bi-level Positive Airway Pressure (BiPAP).

• Continuous Positive Airway Pressure (CPAP)

Range of Movement

• Common hypertonic treatments (heat, compression, sustained deep pressure)

• passive stretches

• Positioning in an elevated position

Sub-acute (rehabilitation) Phase

Rehabilitation of SCI persons has to look at the psychological, physical, social and vocational standing. Rehabilitation is a time bound and goal oriented process that has to provide the highest level of possible reintegration and independence for the individuals to be part of their chosen lifestyle and community role.

Physiotherapy interventions in this phase are for,

• Body structure and function

• Activity limitation

• Participation

• Impairment prevention

• Activity limitation prevention

• Participation restriction prevention

• Community participation

• Interpersonal relationships

• Leisure activities

Treatment Objectives

Treatment objectives for sub-acute phase,

• Setting up a patient-focused interdisciplinary coordinated and comprehensive processes 

• Using early management and intervention to prevent more complications via handle physical motor functional activities

• Improving daily activities of the individual, for example, mobility, grooming, dressing, eating, and bathing

• Achieving functional independence, both verbal and physical

• Gaining and maintaining successful community reintegration

Common Individual Treatments

Patients with high-level tetraplegia,

• Range of stretching / movement

• Strengthening

• Transfers

Patients with low-level tetraplegia,

• Stress on transfers

• Less stress on strengthening

Patients with paraplegia,

1. Stretching / range of movement

2. Strengthening

For successfully performing a motor, sufficient balance, strength, skill / knowledge of that motor task is needed and can be gained via frequent progressive training.

Bed Mobility and Transfers

Patients with C6 and lower level SCI can attain 5 motor skills,

1.   Rolling (applying momentum)

2.   Mobilising from supine to long sitting

3.   Sitting without support (long and short term)

4.   Vertically lifting

5.   Transfers

While greater challenges are there for C6 tetraplegia the above 5 motor skills can be attained with a few modifications,

• Rolling: Rotate shoulders and swing arms across body 

• Unsupported Sitting: Externally rotate shoulders and lock elbows in extension for balance

• Vertical Lifting: Passively extend elbows, externally rotate shoulders and depress shoulders for weight bearing with hands placed anteriorly to the pelvis.

Mobility with Wheelchair

C1-4 tetraplegia patients need wheelchairs that are powered and controlled with using sip and puff, chin movements, or head array.

C5 tetraplegia patients mostly employ hand movement controlled powered wheelchairs.

C6-8 tetraplegia patients can mobilise independently using a manual wheelchair. They might go for a hand-controlled wheelchair.

C8 or lower SCI patients can mobilise independently by using a manual wheelchair.

For independent and safe mobility, SCI persons have to be trained to,

• Turn

• Open and close doors

• Go up an incline and down

• Go over and around obstacles

• Be mobile outdoors and indoors

Standing and Gait

For persons having AIS D Spinal Cord Injury, the most common physiotherapy exercises are for balance, strength, and gait training. Strengthening is the foremost activity for types and levels of SCI.

Standing is vastly beneficial even if it is not independent. Some of its benefits are,

• Bladder function

• Bone mineral density

• Bowel function

• Emotional wellbeing

• Orthostatic hypotension

• Spasticity

How to Attain a Standing Posture?

Standing is attainable in various ways, such as employing assistive devices (tilt tables, standing frames / and/ or wheelchair and for persons with paraplegia use of parallel bars with knee-extension splints or orthoses).

It is possible to achieve gait training for patients having complete paraplegia to partially paralysed lower extremities with the help of orthoses and walking aids, like knee-ankle-foot and hip-knee-ankle-foot orthoses.

Long-term Phase

Best practice for long term management,

Active case management by case managers who have clinical expertise, appropriate training, and knowledge of services for co-coordinating post initial rehabilitation care and can ensue ongoing personalised case management for patients who have ongoing and complex needs

Treatment Objectives

Objectives for treatment of long-term phase patients include,

• Attaining goals of high-level mobility needed for community participation 

• Monitoring function recovery

• Reinforcing carrier and family training

Book an appointment at Manipal Hospitals to know more about treatments with the help of experts in Bangalore.