Management of paraplegia complications after Spinal cord injury

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Paraplegia leads to a major negative impact on functional independence of patients. It affects the person in areas of occupational performance (namely basic and instrumental activities of daily living, work and play), performance skills (namely motor skills) and social participation (barriers in home and environment). Performance components mainly affected in spinal cord injury are neuro-musculoskeletal (voluntary motor control) and sensory functions from injured segment level. Paraplegia leads to serious disability in patients resulting in loss of job, which  brings economical and psychosocial problems.

Paraplegic patient’s recovery is possible by inter-disciplinary team approach working to achieve a goal of making patient functionally independent in daily living at its maximum level possible through retraining, adaptation or modification of surrounding and by making use of adaptive devices or orthosis. The rehabilitation process for paraplegia is expensive, long-term and exhausting for both patient and relative, which requires patience and motivation. Early rehabilitation in necessary to prevent joint contractures, loss of muscle strength and conserve bone density of lower-limbs. Thus, chances of  severe musculoskeletal disability is decreased. 

 

Specific Assessment :

1) ASIA scale : Impairment scale of the American Spinal Injury Association (ASIA scale) created so that the clinicians and researchers could better communicate the degree of impairment of individuals with spinal cord injuries.

• A = Complete injury, no motor or sensory function is preserved in the sacral segments S4 to S5
• B = Incomplete: Sensory but no motor function is preserved below the neurological level and includes the sacral segments S4 to S5
• C = Incomplete: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have muscle grade less than 3.
• D = Incomplete: motor function is preserved below the neurological level , And atleast half of key muscles below the neurological level have a muscle grade of 3 or more.
• E = motor and sensory function is normal. 

2) Spinal Cord Independence Measure (SCIM) : it has been developed to address 3 specific areas of function in patients with spinal cord injuries. 

• It measures the areas of self-care (feeding, grooming, bathing and dressing), respiration and sphincter management, and patient's mobility abilities (mobility in rooms and toilets, transfers, mobility indoors and outdoors) of spinal cord injury patients.
  
• This scale has been validated and found to be highly reproductive to make functional assessments of patients with paraplegia.
•  It can be used assess the baseline condition and guide therapists or clinicians in making treatment goals and objectives by helping in determining areas of limitations of paraplegic  patients.

TREATMENT
Emergency care ( Acute medical management)

At the site of accident :

• All suspected spinal injuries are to be considered unstable unless stability is confirmed on subsequent investigations.
• The basic principle being is to avoid any movements at the injured segment. Movement of the spine can be averted by strapping the patient to a spinal backboard or a full body adjusted backboard and assistance from multiple personnel in moving the patient to safety.

At the emergency department:

• The patient should not be moved from the trolley on which he is first received until stability of spine is confirmed.
• A complete neurological examination is performed and patient is stabilized medically. Cardiac, hemodynamic, and respiratory status are monitored.
• Unstable spinal fracture requires early reduction and fixation.
• Symptoms of instability may include pain and tenderness at the fractures site, radiating pain, increasing neurological signs, and decreasing motor control.

 Definitive care : Depends upon the stability of the spine and presence of a neurological deficits.

The aim of treatment is 

1. to avoid any deterioration of the neurological status.
2. to achieve the stability of spine by conservative or operative methods and,
3. to rehabilitate the paralyzed patient to the best possible extent.

TREATMENT OF THORACIC AND LUMBAR SPINE INJURIES: Conservative treatment is sufficient for stable injuries. Recently, a more aggressive approach is adopted i.e. operative methods.

Stable injuries:  needs period of bed rest and analgesics followed by mobilization. Initially mobilization may be by some external support, like brace etc, but gradually these are discarded and an active program of rehabilitation continued till full function are achieved. During, period of bed rest, one must take special care of possible complications such as bed sores, chest infection, UTIs etc.

Unstable injuries:  are associated with neurological deficit or are likely to develop it during treatment. ORIF gives the best choice of recovery. Operative methods includes : Harrington instrumentation_  bilateral, Luque instrumentation, Hartshill rectangle fixation, Pedicle screw fixation, Moss Miami system

 Injury with no neurological deficits : 

• If spine stable---- rest for 3 weeks---- Brace for 3 to 4 months
• If spine unstable--- rest for 6 weeks or operative stabilization---- Brace for 3 to 4 months.

Injury with neurological deficit (partial or complete) : 

• MRI---- canal not compromised---- bed rest for 6 weeks---- Brace
• MRI---- canal compromised---- decompression and internal fixation.  

BLADDER DYSFUNCTION AND MANAGEMENT :

Urinary tract infections are among the most frequent medical complications during initial medical rehabilitation period. The spinal integration center for micturition is the conus medullaris.
Primary micturition control : originates from sacral segment S2,3,4 within conus medullaris.

Fig : Primary micturation center

Bladder management:

·       For spastic or Automatic bladder (UMN lesion) : Reflex emptying may be triggered by manual stimulation techniques such as stroking, tapping the suprapubic region or thigh, and lower abdominal stroking , pinching or hair pulling.

·       For flaccid or autonomous bladder(LMN lesion): This type of bladder can be emptied by increasing intra-abdominal pressure using Valsalva maneuver ( moderately forceful exhalation of air against the closed Airways by pinching the nose and tightly closing the mouth with hands) or by manually compressing the lower abdomen using Crede maneuver (Executed by applying manual pressure on the abdomen at the location of bladder just above the navel)
Avoid Valsalva maneuver in Patients with known case of  myocardial infarction.

•  Characteristics of Spastic and flaccid bladder :
  

	Spastic bladder	Flaccid bladder
Level of cord lesion	Occur above micturition reflex center located above conus medullaris (above T11,12 vertebra)	Involves micturition reflex center(S2,3,4)in conus medullaris and sacral nerve roots in cauda equina
Result of pathology	Loss of UMN innervation, intact micturition reflex and parasympathetic innervation to detrusor muscles and internal sphincter.	Loss of LMN innervation, loss of final common pathway for transmission of impulses between CNS and detrusor muscles and bladder sphincter
Prognosis of bladder control	Bladder training is aimed at using micturition reflexes and trigger stimulus to establish planned reflex voiding	Unable to establish reflex voiding, intermittent bladder catheterization may be best method for bladder management

Bladder training programs:

1)      For reflex bladder: 

• Intermittentcatheterization : establish emptying at regular or predictable intervals in response to certain level of filling.
• Establish fluid intake pattern restricted to approximately 2000ml/day. Fluid intake monitored at 150 to 180ml/h from morning until evening. 
• Intake is stopped late in the day to reduce the need for catheterization during the night.
• Prior to catheterization, the patient attempts to void in combination of manual stimulation. The catheter is then inserted and residual volume drained. A record is maintained of voided and residual volumes of urine. As bladder emptying becomes more effective, residual volumes will decrease and time interval between catheterization can be expanded.

2)      For autonomous or nonreflex bladder:

• Timed Voiding program : This program involves first establishing the patient's pattern on incontinence. The residual urine volume is then checked to ensure that it is within safe limits.
• The bladder gradually becomes trained to empty at regular, predictable intervals.
• As incontinence decreases, the schedule is readjusted to expand the interval between voiding.  Fluid intake is avoided late in the night to decrease the risk of nocturia.

BOWEL DYSFUNCTION AND MANAGEMENT: 

• Reflex bowel management : requires use of suppositories and digital stimulation techniques to initiate defecation. Digital stimulation involves manual stretch of anal sphincter, either with the lubricated gloves finger or orthotic digital stimulator. This stretch stimulate peristalsis of the colon and evacuation of rectum . Responsive to laxatives and stool softeners (docusate) and suppositories(dulcolax).
• Nonreflex bowel management : relies heavily on straining with available musculature and manual evacuation techniques. Response to medications less effective and also for digital stimulation. Valsalva maneuver or crede maneuver in sitting position. 
• The major goal of a bowel program for the patient with SCI is establishment of a regular pattern of evacuation. This is achieved through multiple interventions, including diet, fluid intake, stool softeners, suppositories, digital stimulation and manual evacuation.

 

AUTONOMIC DYSREFLEXIA OR HYPERREFLEXIA 

• It is a pathological autonomic reflex that typically occurs in lesion above T6(above sympathetic splanchnic outflow). However, it has been reported in patients with injuries at T7 and T8.
• High level paraplegic and tetraplegia experience this problem during course of rehabilitation.  Episode of Autonomic Dysreflexia gradually subsides over the time and are relatively uncommon, but not rare, 3 years following injury.
• Seen in both patients with complete and incomplete lesion. It produces an acute onset of autonomic activity from noxious stimuli below the level of lesion.  Afferent input from these stimuli reach the lower spinal cord and initiate a mass reflex response resulting in elevation of BP . Normally, carotid sinus and aorta checks this by readjusting the peripheral resistance and vasomotor center. Following SCI  vasomotor center cannot pass the site of lesion counteract the hypertension by vasodilation.
• Initiating stimuli: most common cause of this pathological reflex is bladder distention(urinary retention). Other includes pressure sores, urinary stones, rectal distention, bladder irritation and environment temperature change and tight clothing.
• Symptoms: hypertension, bradycardia, headache, profuse sweating, increased spasticity, restlessness, vasoconstriction below the level of lesion and vasodilation (flushing) above the level of lesion, nasal congestion, piloerection(goosebumps) and blurred vision.
• Interventions: 

1. Prevention by education of patient and care givers about bowel and bladder management,
2. skin care.
3. Treat by placing patient in upright position, 
4. remove precipitating stimuli, 
5. sublingual nifedipine, for persistent increase in BP nitroprusside given.

Fig : Autonomic Dysreflexia

PRESSURE SORE MANAGEMENT

It is the term used for taking care of all of these things

• redistributing or shifting your weight
• avoiding friction and shear
• eating healthy food and drinking enough liquids
• keeping your skin clean and dry.

LOOK FOR:  redness, bruising, or any change of colour, changes in texture (such as rashes, dryness, or swelling), cracks, scabs, and blisters

FEEL FOR: a difference in skin temperature from surrounding  areas, hardness or softness different from the surrounding skin.

1) Use a mirror or phone :

• use long-handled mirror to check parts of your skin you can’t see.
•  ask someone else to hold the mirror
• Some people use their phones to check places on their skin they cannot see, by having someone take photos.

2) Preventing sores while lying down check under the :

• Sitting bone : Make sure your mattress isn’t wearing down in the places where your bones make contact. Use of pressure relieving mattress, air cushion, water beds etc.
• Protect your heels : Lift your heels up with a wedge cushion or let them rest over the edge of the mattress
• Sit up in a chair and not in bed : Don’t raise the head of the bed more than 30 degrees. Transfer to a chair with proper support for your bottom by using . Make sure patient feels comfortable.
• Use pillows for support on your side and stomach : it takes pressure off your knees and hips with by placing them between thighs in supine , thus preventing adductors spasticity. 
• Medical management :(stage 3 onwards)

1. regular cleaning (clean open sores with saline solution each time the dressing is changed)  and dressing. Give antibiotics, analgesics.
2.  surgical debridement, mechanical debridement in late cases.
3. Hyperbaric oxygen
4. Oral nutrition supplementation(ONS)enriched with arginine, vitamin C, and zinc has positive effect on  pressure ulcers.            

3) When sitting on wheelchair :

• Making use of pressure relieving cushions :  foam cushion, gel-based cushion, air cushion, honeycomb cushion
• Push-up : If you are able to, using your wheels to push up from your chair is a good way to change your position for comfort, for stretching, and to correct your posture.
• Shift weight leaning to the side : For people who have enough muscle control, this is a good way to get pressure off one buttock at a time.
• Leaning forward : This is fairly easy for many people to do and it is effective in relieving sitting pressure. It also looks quite normal to be in this position for two minutes, so you don’t  have to be self-conscious about it. You can support yourself if needed with a table in front of you.
•  Leg lift : Take pressure off the back of the knees by lifting each leg away from the wheelchair surface by using upper-limbs.

 

RESPIRATORY IMPAIRMENT: 

• All patients of high level paraplegia shows some compromise in respiratory functioning. Level of respiratory involvement is directly related to level of cord lesion.
• For this purpose various exercises like :

1. Deep breathing exercises, glossopharyngeal breathing (utilizes accessory muscles of respiration--- using gulping pattern and gradually inspired air improves chest expansion.
2. Respiratory muscles strengthening exercises by spirometry, diaphragmatic strengthening with resistance. This will aid in improving tidal volume, lung capacity and decrease patients fatigability. 
3. Assisted coughing to facilitate removal of secretion.

  NORMALIZE TONE OR SPASTICITY:

•      Drug therapy: muscle relaxants and spasmolytic agents such as diazepam, baclofen, and dantrolene sodium.
•     Orthopedic surgical procedures includes myotomy (a sectioning or release of muscles). Neurotomy (a partial or complete severance of nerve) and tenotomy(a sectioning of tendon that allows subsequent lengthening) ex. Tendo Achilles tendon.
•     Injected chemical agents: two approaches used are peripheral nerve block( for selective blocking motor nerve to spastic muscles) and intrathecal injection.
•       Management for spasticity includes specific inhibition techniques like:

1.   Neutral warmth (affects temperature receptors of the hypothalamus and stimulate parasympathetic nervous system).
2.     Light joint compression : approximation of joint surface together usually by applying pressure less than body weight, which is slow, rhythmic hold and relax technique.
3.       Tendinous pressure: Golgi tendon organ plays the role.
4.    Maintained stretch: positioning spastic muscles in elongated position to cause lengthening of muscle spindles. This increases the threshold of the muscle spindle and becomes less sensitive to stretching and simultaneously facilitate opposite (antagonist) muscle group.
5.      PNF hold relax and contract relax techniques of relaxation.

 SEXUAL DYSFUNCTION :

Today, sexual disturbance are recognized as a complex rehabilitation issue which is characterized by physiological dysfunction, sensory and motor impairment. These disturbance are often accompanied by social and psychological distress. Sexual counsellor should be referred to also.

Many rehabilitation centers also offers structured programs to assist patients with sexual adjustments. Format of these program varies: 

1. direct patient care including examination, prognosis, treatment and counselling,
2. education of the patient and his or her partners,
3.  preparation of staff Members to deal with sexual concerns

Male response : Sexual response is directly related to level and completeness of injury.  Sexual capacity is also classified into UMN (damage to cord above conus medullaris) and LMN (damage to conus medullaris or cauda equina). Erectile capacity is greater in UMN lesion than LMN lesion and greater in incomplete lesions than in complete lesion.

In all, after UMN lesion there is impaired psychogenic but preserved reflexogenic penile erection. In LMN lesion, there is impaired reflexogenic penile erection and altered or absent psychogenic erection

To compensate for sensory loss - stimulation of other erotogenic zone of body to be explained. Verbal expression, sounds or music can set the mood. Imagination and sharing fantasies with your partner. Try looking at arousing images. 

Female response: In UMN lesion, there is reflexogenic response with engorgement of blood flow and lubrication of genital but impaired psychogenic response. In LMN lesion, psychogenic response will be preserved and impaired or altered reflexogenic responses.

To compensate for sensory loss - stimulation of other erotogenic zone of body to be explained. Verbal expression, sounds or music can set the mood. Imagination and sharing fantasies with your partner. Try looking at arousing images. 

Medications: For erectile dysfunction: drug like phospodiesterase inhibitor such as sildenafil, which work by increasing blood flow to penis to improve erectile function. Penile injection therapy (ones a week) and medicated urethral system erection (MUSE) which is a form of transurethral therapy.

REHABILITATION : THERAPEUTIC EXERCISES

 Interventions for spinal cord injury patients can be divided into inpatient care, outpatient care and extended care programs.

Phases of Rehabilitation

1. Phase 1: immobilization required during this phase lasting from a few days to several weeks and depending on the recovery the patient may even be started on activities outside the bed. Focus still remains on the prevention of secondary disabilities, reduction of hypertonicity and psychological counselling.
2. Phase 2: Early rehabilitation phase, during which patient is mobilized out of his bed for longer and he works towards long-term goals like standing and walking. Robot assisted gait training by using body weight support treadmill training for patients with higher level spinal cord with greater impairments. Whereas, for patients with subacute or less impairments task-specific and over-ground gait training can be started if lower-limb muscle power of hip and knee is grade 3 and above.
3. Phase 3: rewarding phase when paraplegic learns to be more self-reliant and begins to look forward to life with disability. Patient now is skilled in transferring, wheelchair mobility, selfcare and other ADLs. If after maximum recovery, patient has developed permanent irreversible impairment and deformity then they can be educated to apply for disability certificate and avail its benefits.
4. Phase 4: smooth change in home environment. In some centers there is half way home which replicates the surrounding of the patient domestic environment. For example : Paraplegic Foundation is an NGO in Sion, which is attached to LTMC Municipal hospital in Mumbai. It provides rehabilitation, total health care and motivational counselling for paraplegics admitted there.
5. Phase 5: Follow up services with rehabilitation center can be done on a outpatient basis. The patient becomes integrated to community and go back to office or school and resume his family responsibilities.

Thankyou for reading!!!

( Dr.Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe)