The Northern Network of International Rehabilitation (NNIR) held a lecture on Spinal Cord Injuries (SCI) on Wednesday 11th July. The Lecture was based at Leeds Beckett University and was in partnership with the Leeds Beckett Physio Society.
The evening was split into two sections: 1. Acute management of SCI, and 2. Rehabilitation of the SCI patient. Dr Ram Hariharan discussed the acute management of SCI including physiological changes, neurological assessment, and complications seen with SCI. Ram also spoke about his work in Madagascar helping set up and develop a SCI centre. Sarah Leighton discussed the rehabilitation of SCI patients and functional expectations. Both Ram and Sarah work at the SCI Rehab Centre at Sheffield Teaching Hospitals.
An Overview of SCI- Dr Ram Hariharan
Ram explained that most SCI’s are due to Trauma. Common incidences of SCI are often due to high velocity road traffic accidents, falls from height, sporting injuries, minor falls in the elderly population, or minor falls in people with Ankylosing Spondylitis. In the elderly population, the spinal canal is often already narrowed, with the fall causing further damage and leading to SCI. Ankylosing Spondylitis patients are at higher risk of SCI due to the flexed spinal position.
Pathophysiology of SCI
Mechanical damage to the spinal cord causes oedema/swelling and vascular damage resulting in ischaemic necrosis.
The spine should be immobilised with a cervical hard collar and spinal board. Log rolling should be used when turning the patient. With Ankylosing Spondylitis patients, cervical collars are not used, instead the neck should be brought back to its normal flexed position by placing a pillow under the patient’s head. The final outcome of a SCI is dependent on the accuracy, adequacy, and speed of first aid, diagnosis, and treatment within the first few hours.
Airway: Care should be taken when suctioning, passing NG tubes, intubation, and turning too quickly to prevent bronchospasm by stimulation of the vagal nerve.
Breathing: Assess respiratory pattern, ability to cough, auscultate chest, monitor SpO2, and ABG’s. SCI patients will be more comfortable lying down than being sat up.
Circulation: Lesions at and above the Spinal Cord level of T6 lead to loss of sympathetic flow. This means that SCI patients will often have a lower Blood pressure (hypotension) and Heart Rate (Bradycardia).
Autonomic Dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with SCI’s that involve the thoracic nerves of T6 or above. Autonomic Dysreflexia can lead to a stroke due to the increase in blood pressure. Autonomic Dysreflexia is often triggered by an afferent stimulus such as an inability to empty the bladder or bowels. The patient may also complain of a headache, it is important to check the patient’s blood pressure and if this is high, this may be the first signs of Autonomic Dysreflexia.
Classification of SCI
The classification of a SCI is divided into 2 main components: neurological level (motor and sensory), and impairment scale (A-E). The American Spinal Injury Association (ASIA) impairment scale is an internationally recognised tool used to classify the level of spinal injury. The neurological level of injury is the lowest level with normal sensory and motor function.
SCI in Madagascar
Ram then discussed his work in Madagascar where he helped in the set up and development of an SCI centre back in 2013. Ram often returns to Madagascar to review the centre and offer teachings to medical and therapy staff.
Ram advised that when working overseas, it is important to keep an open mind as the culture may be different to what you are used to at home. Think about what you can learn from those based overseas, rather than simply what you can teach. Listen to those you are working with to determine what you can give and gain from your experiences.
Ram also advised on teaching methods such as using the ‘Train the Trainer’ model. This will lead to empowerment of those you are teaching, and enable them to pass on your teachings in future, therefore leaving a longer legacy of teachings and training. Peer education is also a good method used to allow students to consolidate their learning. Ram encouraged the use of presentations, making posters or leaflets, and group work to consolidate knowledge gained.
Complete Spinal Cord Injuries- Functional Expectations: Sarah Leighton
Sarah Leighton is a Clinical Specialist Physiotherapist based at the SCI Rehab centre in Sheffield Teaching Hospitals. Sarah began her session by explaining that the ultimate aim of SCI rehabilitation is the restoration of functional independence, be it verbal or physical.
Sarah divided her lecture into levels of SCI and expected outcomes for that level of injury:
C1,2,3,4: Innervates the diaphragm and respiratory muscles. Patients with this level of injury may require full or partial ventilation. These patients will struggle to cough, therefore cough assist machines or the assisted cough technique is required to maintain a clear airway and expectorate secretions.
C5: Innervates the biceps, and deltoid muscles. Patients with C5 SCI will be able to self-propel a wheelchair, may be able to complete assisted transfers, and can have upper limb function with adapted devices.
C6: Innervates wrist extensors. Patients with C6 SCI will use tenodesis grip which is a functional grasp allowing the patient to complete transfers, bed mobility, wheelchair skills, and even driving with adapted cars!
C7: Innervates the triceps and wrist flexors. Patients with C7 SCI will be able to complete split level transfers, bed mobility, and wheelchair propelling. C7 SCI patients will have no active finger flexion.
C8: Patients with C8 SCI will have weak interossei and lumbricals. Their hand will rest in a lumbrical position.
Thoracic Lesions: Patients with Thoracic level injuries should be completely independent depending on measurements and proportions of the patient’s body. For example, if the patient has a short body and longer arms, this will make transfers and self-propelling a wheelchair easier.
Lumbar Lesions: Patients with Lumbar level injuries can potentially mobilise with use of KAFOS or callipers. They must be able to ‘hang’ on their hip flexors to allow a functional gait pattern.
Complications with SCI
Sarah explained that there are a number of factors which may affect a patient’s expected functional outcome post SCI. These factors include:
- Past medical history
- Motivation levels
- Respiratory complications
- Pressure sores
I am planning to go to Madagascar next March 2019 to work alongside the physiotherapists currently working there. I am aiming to learn from their practice, and offer assistance where needed to develop the physiotherapy service in Antanarivo (the Capital city), and Antsirabe. I organised a cake sale at the lecture and will be organising lots of ideas for future fundraising events!
The lecture was very informative, well attended, and considered a great success on the evening! Thank you to Ram and Sarah for speaking at the event, and for all those who came on the evening. If you are interested in joining the NNIR committee or attending future lectures, please email email@example.com, or follow our facebook page- Northern Network of International Rehabilitation.