Spinal Cord Injury Overview

Spinal Cord Injuries occur when a traumatic event results in damage to cells within the spinal cord or severs the nerve tracts that relay signals up and down the spinal cord. Spinal cord injuries can result from a multitude of causes ranging from physical injuries caused by automobile accidents, sporting accidents, gun shot wounds, slips and falls, disease or viruses.

Spinal cord injuries occur in approximately 12,000 to 15,000 people per year in the U.S. About 10,000 of these people are permanently paralyzed, and many of the remainder die as a result of their injuries.

The majority of victims of spinal cord injuries are young, healthy individuals. Males between 15 and 35 years old are most commonly affected. There are currently 400,000 people living with spinal cord injuries in the US alone and hundreds of thousands more world wide.

Types of Spinal Cord Injuries

A Spinal Cord Injury (SCI) is caused by damage to the spinal cord that results in a loss of function, such as mobility or feeling.

The spinal cord does not have to be severed in order for a loss of functioning to occur. In fact, in most people with SCI, the spinal cord is intact, but the damage to it results in loss of functioning. SCI is very different from back injuries such as ruptured disks, spinal stenosis or pinched nerves.

A person can "break their back or neck" yet not sustain a spinal cord injury if only the bones around the spinal cord (the vertebrae) are damaged and the spinal cord is not affected. In these situations, the individual may not experience paralysis after the bones are stabilized.

Classification and Terminology

The effects of SCI depend on the type and the level of the injury. SCI’s can be divided into two types - complete and incomplete.

1 Complete: A complete injury means that there is no function below the level of the injury, no sensation and no voluntary movement. Both sides of the body are equally affected.

2 Incomplete: An incomplete injury means that there is some functioning below the primary level of the injury. A person with an incomplete injury may be able to move one limb more than another, may be able to feel parts of the body that cannot be moved, or may have more functioning on one side of the body than the other. With the advances in acute treatment of SCI, incomplete injuries are becoming much more common.

The following terminology is used in the classification of SCI:

1 Tetraplegia (formerly called quadriplegia) - Injury to the spinal cord in the cervical region with associated loss of muscle strength in all 4 extremities

2 Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris

Symptoms and Diagnosis

Symptoms of damage to the spinal cord usually appear immediately after the injury. Symptoms, however, can develop slowly if an infection or tumor gradually increases pressure on the spinal cord.

These symptoms include: weakness, poor coordination or paralysis; numbness and tingling; loss of bowel or bladder control; and pain. Doctors generally perform imaging studies to determine whether the spine has been damages and the

extent of the damage. These include x-rays, CT (computed tomography) scans, MRI’s (magnetic resonance imaging) and myelograms (x-rays after injection of dye into the spine canal).

Injuries / Prognosis

The types of disabilities associated with SCI vary greatly depending on the severity of the injury, the segment of the spinal cord at which the injury occurs, and which nerve fibers are damaged. Most people with SCI regain some functions between a week and 6 months after injury, but the likelihood of spontaneous recovery diminishes after 6 months. Rehabilitation strategies can minimize long-term disability.

The level of injury is very helpful in predicting what parts of the body might be affected by paralysis and loss of function. Remember that in incomplete injuries there will be some variation in these prognoses.

1) Neck: Cervical (neck) injuries usually result in quadriplegia.

2 C-1 to C-4: These very high injuries (C-1, C-2) can result in a loss of many involuntary functions including the ability to breathe, necessitating breathing aids such as mechanical ventilators or diaphragmatic pacemakers.

3 C-5: C-5 injuries often result in shoulder and biceps control, but no control at the wrist or hand. 4 C-6: C-6 injuries generally yield wrist control, but no hand function.

5 C-7 and T-1: Individuals with C-7 and T-1 injuries can straighten their arms but still may have dexterity problems with the hand and fingers. Injuries at the thoracic level and below result in paraplegia, with the hands not affected.

6 T-1 to T-8: At T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control.

7 T-9 to T-12: Lower T-injuries (T-9 to T-12) allow good truck control and good abdominal muscle control. Sitting balance is very good. Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs.

Besides a loss of sensation or motor functioning, individuals with SCI also experience other changes.

For example, they may experience dysfunction of the bowel and bladder, Men with SCI may have their fertility affected, while women's fertility is generally not affected.

Other effects of SCI may include low blood pressure, inability to regulate blood pressure effectively, reduced control of body temperature, inability to sweat below the level of injury, and chronic pain.

Treatment

A spinal cord trauma is a medical emergency requiring immediate treatment to reduce the long-term effects. The time between the injury and treatment is a critical factor affecting the eventual outcome.

Medication

Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression is caused by a mass (such as a hematoma or bony fragment) that can be removed or brought down before there is total destruction of the nerves of the spine, paralysis may in some cases be reduced or relieved. Ideally, corticosteroids should begin as soon as possible after the injury.

Surgery

Surgery may be necessary. This may include surgery to remove fluid or tissue that presses on the spinal cord (decompression laminectomy). Surgery may also be needed to remove bone fragments, disc fragments, or foreign objects or to stabilize fractured vertebrae (by fusion of the bones or insertion of hardware).

Bedrest

Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal.

Traction / Immobilization

Anatomic realignment is important. Spinal traction may reduce dislocation and/or may be used to immobilize the spine. The skull may be immobilized with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body).

Physical Therapy / Rehabilitation

Extensive physical therapy, occupational therapy, and other rehabilitation interventions are often required after the acute injury has healed. Rehabilitation helps a person to live with the disability that results from spinal cord trauma.

Exercise Programs – Wellness Routines

Once the spinal cord injury has been stabilized and the individual has been rehabilitated to his or her fullest potential, establishing a wellness routine can be beneficial to staying well and maintaining functional capacity. This overall approach encompasses many issues, including exercise.

Exercise programming may range from therapeutic standing to progressive resistive exercise and should be tailored to meet the unique needs of each individual. Prior to beginning an exercise program, it is important to work under the consultation of a physician who specializes in spinal cord injury.

Choosing a facility with experienced personnel and adaptive equipment is also essential. A well rounded exercise program should include components, which promote fitness and help to maintain functional independence. As in any exercise program, consistency is essential. A three to four day per week commitment is necessary. Some components of the exercise program can be incorporated into a home program, while others may necessitate special equipment or supervision. Exercise participation may be limited depending on the level of function and/or adaptability of equipment. It may also be difficult to find a facility with the support and equipment necessary to carry out an effective exercise program.

Types of Programs:

Cardiovascular Conditioning is essential to maintaining a healthy heart muscle and to having the endurance to meet our daily activity needs. Often people will make the mistake of trying too quickly to reach recommended intensities and duration of continuous aerobic exercise. Ways to successfully initiate cardiovascular conditioning is through circuit training and/or interval training. Again, functional ability may dictate level of participation.

Circuit training involves cycling through weight lifting and aerobic exercise. With spinal cord injured populations, a program alternating between stations of a multi-station weight machine and arm ergo meter can successfully sustain heart rate and blood pressure so that an aerobic benefit can be achieved.

Interval training can be performed in various combinations of work/rest intervals. Examples of aerobic conditioning equipment adapted to spinal cord injured populations are: arm/bicycle ergo meters, rowing machine and treadmills (includes those adapted for wheelchair use). Cross training, across one or all of the above-mentioned pieces of equipment, allows for a variety of muscle groups to be utilized, thus avoiding overuse injuries. It also reduces the risk of boredom by providing a more stimulating environment.

Muscular strength and endurance are also important aspects of fitness. Depending on the level and severity of injury, adaptations may be made to the design of program and equipment utilized.

Developing muscular strength can be beneficial in lifting increased intensities of weight. It is also essential to maintaining balance between muscular groups, thus preventing overuse injuries. Lifting too much, too soon, should be avoided. Proper form should be emphasized, utilizing visual feedback and/or assistance from another person.

Recommended Equipment: Equipment utilized to perform strengthening can include multistation weight machines. The "Equalizer" and "Upper tone Gym" are two such pieces adapted for individuals in wheelchairs with limited fine motor movement. Easily transportable types of equipment utilized to build and maintain muscular endurance include elastic tubing, free weights and weights with Velcro attachments for wrapping around an individual's wrists or ankles.

Range of motion is a series of exercise performed in which the joints of the extremities are moved within their capacity. Depending on the level of function total assistance or some assistance may be required. Maintaining the flexibility of individuals with spinal cord injury is important when seeking to avoid pressure sores, pain or injury. In doing so, joint contractures are prevented and the integrity of the joint maintained.

Balance exercise should always be performed with qualified personnel and with appropriate spotting techniques. Standing balance can be effectively carried out between two bars or rails (parallel bars) enabling an individual to hold onto them while standing. A standing frame, described as a frame, which fully supports an individual in a standing position, can also be helpful in enhancing proper posture and in strengthening muscles of the leg. Therapeutic standing is also beneficial in preventing muscle wasting (atrophy), maintaining joint integrity and in promoting circulation. Other benefits may be seen in the reduction of spasticity and in the promotion of a general sense of well being. A "Swiss Ball" can be utilized to help improve trunk balance.

Sports Programs

Incorporating sports and recreation programs in one's routine can be instrumental in maintaining both the psychological and physical welfare of individuals. Sport participation can be utilized as an extension of fitness programming. It allows an individual to utilize enhanced physical capacities in a social setting and with other individuals of similar abilities. Today, there are many resources and organizations, which lend themselves to working with physically challenged individuals in sports and recreation programs.

Exercise Precautions:

As with any exercise programming, certain precautions must be adhered to. Those most specific to individuals with spinal cord injury are described below.

Autonomic Dysreflexia is a complication that occurs in spinal cord populations having sustained injuries at the 6th thoracic level and above. Generally, it is brought on by a stimulus that prior to the injury would have been recognized as uncomfortable. Due to limited communication between the injured spinal cord and brain, many individuals are unable to identify and respond to uncomfortable stimuli. As a result, blood pressure, heart rate and an overall sense of well being becomes disrupted.

The changes in blood pressure and heart rate may be life threatening if not responded to appropriately.

It is imperative that the signs and symptoms of autonomic dysreflexia are understood by all involved prior to beginning an exercise program.

Maintaining skin integrity can be challenging. No longer do the same warning signals of discomfort exist as they did prior to the spinal cord injury. Decreased circulation due to prolonged pressure can cause skin breakdown. Bony areas such as the hips, heels and tailbone are most vulnerable. Providing pressure relief with frequent weight shifts can maintain blood flow to areas at risk.

Blood Pressure - One major effect spinal cord injury has on circulation is that of lowered blood pressure (hypotension). This may be of great concern during exercise participation as individuals may feel faint or dizzy. Low blood pressure, which occurs as a result of positional changes, is called orthostatic hypotension. Proper hydration, changing positions slowly and wearing compression stockings can be effective in avoiding orthostatic hypotension.

Individuals who have sustained spinal cord injury are at risk for the following conditions:

1) Joint contractures or permanent limitations of joint movement usually due to poor positioning, lack of movement and/or muscle spasticity.

2) Muscle atrophy, a shrinking or wasting of musculature due to lack of use.

3) Osteoporosis, deterioration of the bone that may occur due to decreased weight bearing, as well as factors related to the injury itself.

There are many facets to wellness. Staying well involves a commitment to a healthy lifestyle. Exercise is one vital component which if properly carried out can enhance the functional capacity of an individual who has sustained a spinal cord injury. It also can promote self-esteem and well being. In conjunction with an exercise program, dietary habits involving good nutrition and proper hydration are

essential. It is best to consult with qualified personnel regarding dietary concerns.

Coping with a Spinal Cord Injury

A Spinal Cord Injury often provokes a profound emotional response in the patient, family members and friends.

Denial, depression, hopelessness, and fear are the normal reactions. No single response, however, is either expected or unexpected.

A lack of understanding of what’s in store should be met by thoughtful, straightforward, and frequent discussions between physician, nurse, patient and family. An inability to work, tend to business affairs, care for one’s family and interact with friends in the usual manner, all contribute to emotional distress. Thorough explanations about the prognosis and plans for future usually bring emotional relief as the patient focuses on the treatment ahead and the prospect of rehabilitation and recovery.

Family members or loved ones also have important questions about medical treatment. It is best for them to speak directly with physicians regarding specific issues, and they should discuss any problems or reactions they may have with treatment providers. Often, nurses and other health professionals better understand the complexity of emotions and special ongoing needs of those living with a spinal cord injury. They generally spend a great deal of time with patients, become their confidants and can be very helpful in providing emotional support.

Rehablitation Units

Rehabilitation Units are places where those injured can find hope, strength, inspiration and the specialized medical care needed for spinal cord rehabilitation.

A Rehabilitation Unit should provide long-term rehabilitative care and intensive physical, occupational and recreational therapy, to help those with spinal cord injuries to relearn the basic skills of everyday life. Counseling is also provided to the patients, helping them to cope with their injury and rediscover the fulfilling life that lies ahead for them. The rehabilitative programs often are intense. Patients spend several hours each day relearning the skills of everyday life — how to dress, brush their teeth and feed themselves.

Becoming Independent

Developing independence is especially important. Many SCI Rehabilitation Units include kitchens and laundry facilities and other equipment so patients can learn independent living skills, such as cooking meals or ironing clothes.

Teaching Self Care Skills

After a spinal cord injury, many things change. It is not just being unable to walk or move your arms. A spinal cord injury can also affect the nerves and muscles and can cause bowel and bladder problems and skin problems. Patients should be taught the self-care skills needed to deal with these problems.

Spouses, parents or family members of spinal cord injured patients should not be left out; they too must learn how to take care of their loved one. Children have special needs and so it is important that these needs are addressed by loved ones and healthcare providers. Fortunately, there are a number of programs that specifically address SCI injuries for pediatric patients.

It is important to remember that having a spinal cord injury should not mean that those injured must stop participating in fun activities. Many hospitals have recreational therapists on staff to show patients that the fun times can begin again. From wheelchair basketball, volleyball and tennis, to specially adapted Nintendo games, often all that required is a little ingenuity.

Finding the Right Rehab Center / What to Ask?

It is very important to find the right rehabilitation center for your loved one. What follows are questions that may aid in making the right decision:

1 Are the beds for people with SCI in the same area of the facility? Are there people in the SCI program of the same age and sex as the person considering admission?

2 Do the people in the SCI program have similar levels and kinds of spinal cord injury e.g., quadriplegia, paraplegia, incomplete and complete?

3 What is the average number of people admitted annually to the SCI program? (Program staff should treat people with SCI on a regular basis to acquire and maintain expertise.)

4 Is the SCI program accredited by the Commission on the Accreditation of Rehabilitation Facilities (CARF) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)? Has it been designated as a Model Spinal Cord Injury Center by the National Institute of Disability Research and Rehabilitation (NIDRR)?

5 Is the SCI program part of a SCI rehabilitation system operated by the state?

6 Will the treatment team develop a rehabilitation plan with both short and long term goals?

7 Will an experienced case manager be assigned to help family members obtain medical payments and other benefits from public and private insurance? Will a team member be assigned to coordinate treatment and act as a contact for staff and family members?

Program Elements

1 Is the physician in charge a Physiatrist (a physician specializing in physical medicine and rehabilitation)? If not, what credentials does he/she have? How long has the physician in charge been directing programs specializing in SCI? Is there physician coverage seven days a week?

Twenty-four hours a day?

2 Do the regular nursing staff and other specialists responsible for providing treatment in the SCI program have specific training in treating SCI? Is the nursing staff employed by the hospital or employed through an outside agency?

3 Does the program ensure the availability of rehabilitation nursing and respiratory care on a twenty-four hour basis?

4 How often and for how long each day will participants get treatment by specialists such as occupational and physical therapists? Treatment should be no less then three hours per day.

5 Are other specialties such as driver education, rehabilitation engineering, chaplaincy, and therapeutic recreation available if needed?

6 Are activities planned for SCI program participants on weekends and evenings?

7 How much time is spent teaching SCI program participants and their families about sexuality, bowel and bladder care, skin care and other essential self-care activities?

Clinical Trials

Studies of promising new or experimental treatments in patients are known as clinical trials. There are some risks to participating in clinical trials. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. (Keep in mind, though, that even standard treatments have side effects.) Depending on various factors, you may decide that a clinical trial will be beneficial in your case.

To find out more about clinical trials, ask your spinal care team. Among the questions you should ask are:

1 What is the purpose of the study?

2 What kinds of tests and treatments does the study involve?

3 What does this treatment do?

4 What is likely to happen in my case with, or without, this new research treatment?

5 What are my other choices and their advantages and disadvantages?

6 How could the study affect my daily life?

7 What side effects can I expect from the study? Can the side effects be controlled?

8 Will I have to be hospitalized? If so, how often and for how long?

9 Will the study cost me anything? Will any of the treatment be free?

10 If I were harmed as a result of the research, what treatment would I be entitled to?

11 What type of long-term follow-up care is part of the study?

12 Has the treatment been used to treat other types of spinal cord injuries?

Stem Cell Research

Stem cells are cells that can multiply without changing, that is, self-renew, or can differentiate to produce specialized cell types. Stem cells have been derived from both embryonic and nonembryonic tissues, and these cells have different characteristics. Both embryonic and nonembryonic stem cells show potential for developing treatments for human diseases and injuries.

The most obvious potential application of human stem cells would be the generation of cells and tissues for cell-based therapies. Stem cells, directed to differentiate into specific cell types, offer the possibility of a renewable source of replacement cells and tissues to treat a number of common diseases and disorders, including Parkinson’s disease, spinal cord injury, stroke, burns, heart disease, diabetes, osteoarthritis, and rheumatoid arthritis. Currently, scientists are also using stem cells from a variety of sources to help animals with spinal cord injuries regain movement. Human embryonic stem cells have been coaxed into becoming a type of cell that repaired damaged nerve fiber insulation called. Human non-embryonic neural stem cells helped replace damaged rat spinal cord nerve cells and myelin NIH-supported scientists now report that they can use mouse embryonic stem cells to make functional motor neurons, which are the spinal cord cells that send long nerve fibers called axons (the threadlike extensions on a neuron, or nerve cell, which conducts nerve impulses) to connect with leg muscles and other muscles used to move the body.

Previously paralyzed rats treated with the motor neurons were able to move their legs again, although they could not walk or grip with their feet as well as uninjured rats. This research gives scientists insight on how they might one day replace human motor neurons damaged by spinal cord injuries and motor neuron diseases.