Spinal Cord Injuries: Classifications and Etiology

• Spinal cord injuries result from direct or indirect damage to the spinal cord, causing paralysis or loss of sensation.
• The injury can be considered a UMN Lesion characterized by increased reflexes

Classifications of Spinal Cord Injuries

• Direct injuries involve trauma directly to the spinal cord.
• Indirect injuries involve damage to surrounding tissues and bones.
• Primary damage occurs immediately from the trauma.
• Secondary damage is delayed, resulting from complications.
• Complete lesions result in total motor and sensory loss below the lesion.
• Incomplete lesions result in partial sensory and motor function loss.

Etiology of Spinal Cord Injuries

• Trauma is a major cause of spinal cord injuries.
• Non-traumatic injuries include spinal hematoma, infection, radiation, or neoplasm, vascular complication like cardiac arrest.
• Motor vehicle accidents are the most common traumatic cause; 97% of patients weren't wearing seatbelts.
• Diving accidents often lead to quadriplegia and paraplegia.
• Contact sports like American football and rugby may cause injuries.
• Violent trauma, such as gunshot/stab wounds, the incidence is increasing in relevance.

Specific Incomplete Spinal Cord Injuries

• Central Cord Syndrome
• Brown-Sequard Syndrome
• Anterior Cord Syndrome

Central Cord Syndrome

• Damage occurs to the center of the spinal cord, with the periphery unaffected.
• It is the most common incomplete injury.
• Hyperextension or arthritic changes to the C-spine are common causes.
• Upper limbs are more affected, motor and sensory abilities impaired with mm weakness, flaccidity.
• Lower limbs are less affected.
• Bowel and bladder control are usually normal or only partially affected.

Brown-Sequard Syndrome

• Damage occurs to one side of the spinal cord.
• Stabbing/gunshot wounds are typical causes.
• Ipsilateral impairment includes motor function, proprioception, and sensation (vibration, 2-point discrimination) loss.
• Pain and temperature perception are normal on the ipsilateral side.
• Contralateral impairment includes loss of pain and temperature perception.
• Motor function is typically normal on the contralateral side.

Anterior Cord Syndrome

• Damage to the anterior spinal artery/anterior spinal cord affects the corticospinal & spinothalamic tracts.
• Hyperflexion injuries are a common cause.
• Bilateral loss of motor function and perception (pain, temperature, crude touch) occurs.
• Fine touch remains intact.

Signs & Symptoms by Injury Level

• C1-C3 injuries result in no maintained function from the neck down and require a ventilator to breathe.
• C4-C5 injuries affect the diaphragm and allow some arm and chest muscle function.
• C6-C7 injuries provide intact arm function.
• T1-T3 injuries control the trunk above the umbilicus.
• T4-T9 injuries affect most thigh muscles, allowing walking with long leg braces.
• T10-L1 injuries involve most leg muscles, allowing walking with short leg braces.
• L1-L2 injuries mean most rotational portion of c-spine

Areas Vulnerable to Injury

• The most vulnerable part of the spine is C4-C6, where the spinal canal loses stability; most rotational are in the c-spine.
• T12-L1 is also commonly injured.

Types of Plegia

• Monoplegia: paralysis of one limb
• Diplegia: paralysis of both upper or lower limbs
• Paraplegia: paralysis of both lower limbs
• Paraparesis: muscle weakness in the legs
• Hemiplegia: paralysis of the upper limb, trunk, and lower limb unilaterally
• Quadriplegia: paralysis of all four limbs
• Quadriparesis: muscle weakness in all limbs

Autonomic Dysreflexia

• It is an acute exaggerated sympathetic response.
• People with a lesion at or above T6 are generally at risk.
• Painful or uncomfortable stimuli in the abdomen or pelvic area can trigger it, such as distention of a full bladder.
• Mm spasms, an extensive stretch placed on the muscle can trigger the sympstoms
• A kink in the catheter bag or the presence of infection can cause it e.g. decubitus ulcers.
• Symptoms include severe hypertension (300/160), bradycardia, sudden pounding headache, vasospasms, piloerector response, skin pallor, flushed skin, and sweating.
• The stimulus sends nerve impulses to the spinal cord but are blocked by the lesion, activating the sympathetic portion of the ANS, resulting high bp.
• It is considered a medical emergency and is potentially life-threatening - Contact 911

Massage & Spinal Cord Injuries

• Adapt massage techniques to clients' needs and abilities, most clients are wheelchair-bound.
• Clients are generally inactive, increasing their risk of bone density loss and blood clots.
• Avoid deep pressure over bones and forceful PROM due to the risk of fractures.
• Avoid vigorous massage techniques due to the risk for clots.
• Assess for contractures and decubitus ulcers.

General Guidelines for Transfer Techniques

• Safety is always the top priority.
• Preparation and clear communication are essential when assisting or supervising a patient transfer.

Approach

• Respect: Be mindful of the patient's pride, and avoid insensitive terms.
• Communicate: Ensure the patient understands and agrees with your intentions. Explain and demonstrate, inviting questions.
• Lead: Act as a leader, not a pusher, balancing authority and courtesy. Listen to the client's opinions and avoid being confrontational.

Preparation

• Choose the appropriate type or level of transfer.
• Ensure the patient fully understands what is about to happen.
• Remove potential hazards like rugs and clutter.
• Equipment: Ensure brakes are on and foot/armrests are removed as needed.
• Clothing: Ensure free movement.
• Posture: Maintain a walking stance, bent knees, and pelvic tilt.
• Lifting: Use both hands, holding the client close to your body.
• Movement: Use body weight and momentum, counting 1-2-3-LIFT.
• Turns: Pivot or step around to avoid twisting.
• Lifts: Avoid lifting above the patient's waist level.
• Safety: Ensure the transfer can be safely aborted at any stage.

Execution

• Move slowly and be prepared for unexpected situations.
• If slipping, gently guide the patient back to the chair or control their descent.
• Encourage maximum patient participation.
• Use whole-body momentum for weight shifting.
• Support the patient's shoulder and pelvic girdle; do not pull on their shoulders.
• Use the bottom sheet as a turning sheet to improve biomechanics and prevent skin damage.

Lateral Shift

• The therapist faces the table, slightly wider than shoulder width, or with one knee on the table.
• Bend over the patient, grab the turning sheet close to the patient at the hip and shoulder level.
• Shift body weight from the front leg to the back leg and gently pull on the count of 3.

Pull Turn to Side Lying

• The patient's far leg is flexed and crossed over the near leg.
• Push Turn to Side Lying: The therapist grasps the patient at the hip and shoulder, and on the count of 3, pulls the patient towards them.
• Position is the same as above, with the leg flexed over the far leg.
• Grasp the hip and shoulder, and have a pillow for the patient's knee to land on.
• On the count of 3, push the patient on their shoulder and make sure their arm doesn't get caught up.

Transfers and Lifts

• Over Side of Bed: Position your patient in side lying facing the edge of the table, knees bent, feet clear of the table, upper hand in a fist in front of their abdomen.
• The therapist faces the patient in a lunge, bent knee nearest the patient's head, one hand on the scapula, the other on the SI region.
• Count 1-2-3-UP; the patient pushes down on their fisted hand as they rise, the therapist helps by guiding them up, then draws them to the table's edge.

Positioning in Chair

• To center your patient in their chair, the therapist crouches, facing the patient and stabilizes the patient's knees with their own.
• One hand supports the thorax on the side opposite to the movement direction, and the other is beneath the patient's buttocks.
• Rock the patient sideways to a count of three while lifting the client's buttock and applying sideways pressure at the thorax level.

Moving Patient Back in Chair

• The therapist crouches facing the client, grips the patient's knees between their own.
• Lock your hands behind the patient's low back, tilt the patient forward, and place their arms across the therapists shoulders.
• The therapist rocks the patient forward, taking the weight off their buttocks, and pushes back on their knee.

Hemi Transfer

• Lock the wheelchair on the patient's strong side at a 45-degree angle to the table.
• The patient sits forward on the edge of the table, feet on the floor (weak leg slightly further back).
• Stand on the patients weaker side, facing them and blocking the weaker foot and knee while the therapist supports the patient around the waist.
• The patient leans forward and grasps the far arm of the chair with their sound hand.
• Rocking in time to a count of 1-2-3-UP, the patient stands on UP, gains their balance, then turns and sits into the chair.
• When moving from the chair to the bed, ensure the patient's strong side is closest to their destination.
• Repeat the above technique, except that the patient pivots before reaching back with their sound side.

Standing Step Around

• Lock wheelchair in a parallel position.
• Patient sits forward, feet on the floor, their hands on the side of the bed.
• Faces the patient, in a walking stance, one foot on either side of the patients feet, ready to prevent slipping; the therapists knees are bent securing the patient's knees between their own, grasp patients waistband or around the low back.
• Patient leans forward, with their hands around the therapists shoulders, gently rock for momentum, counting 1-2-3-stand.
• Stand briefly to gain balance, before the patient steps around and sits.

Moving Patient from Chair to Table

• From the same positioning, get the patient leaning on table with their backside then cradle them on to the table with one hand on the patients shoulder and the other under the patients knees.