SPINAL CORD LESIONS Sagar Naik, PT

Spinal Cord Lesions

SAGAR NAIK, PT
Spinal cord damage resulting from either injury or disease may produce
tetraplegia/tetraparesis or paraplegia/paraparesis depending upon the level at which the
damage has occurred, and the lesion may be complete or incomplete.

 Anatomical Considerations:
⮞ There are 30 segments in the spinal cord:
 8 cervical
 12 thoracic
 5 lumbar
 5 sacral
⮞ In the early stage of development the spinal cord is approximately the same length as
the vertebral canal and the spinal nerves pass out horizontally through the intervertebral
foramina.
⮞ During development in utero the vertebral column and the spinal cord grow at different
rates and eventually the cord finishes at the lower border of the L1 or the upper border
of L2 vertebra.
⮞ As the spinal cord terminates opposite the first lumbar vertebra, there is a progressive
discrepancy between spinal cord segments and vertebral body levels.
⮞ All cervical nerve roots pass through the intervertebral foramen adjacent to the vertebra
of equivalent number.
⮞ Roots C1 to C7 inclusive leave above the appropriate vertebral body, whereas root C8
and the remainder exit below the appropriate vertebral body.
⮞ The higher the root, more laterally it is situated within the spinal cord.
⮞ Although there is little difference between spinal cord segments and vertebral body
levels in the cervical area, the nerve roots below C8 travel increasing distance in the
canal before exiting.
⮞ The 12 thoracic segments lie within the area covered by the upper 9 thoracic vertebrae;
the lumbar segments lie within that covered by vertebrae T10 and T11; and the 5 sacral
segments lie within T12 and L1 vertebrae.

⮞ Blood Supply of Spinal Cord:

 Anterior spinal artery supplies anterior two-thirds of spinal cord.
 Paired posterior spinal arteries supply posterior third of spinal cord.
 Both are supplied via radicular arteries, the largest of which is the artery of
Adamkiewicz, which enters the spinal canal in the lower thoracic segments but
sends branches as high as the T4 level.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Ascending & Descending Tracts of Spinal Cord:

 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Spinal Reflexes:

 C5 – Biceps reflex
 C6 – Brachioradialis reflex
 C7 – Triceps reflex
 T6 to T12 (abdominal) – Superficial abdominal reflex
 L1 & L2 – Cremasteric reflex
 L4 – Patella reflex
 S1 – Achilles reflex
 S3 & S4 – Bulbocavernosus reflex
 S3 to S5 – Anal wink
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Dermatomes:
 SPINAL CORD LESIONS Sagar Naik, PT

 Etiology:
⁂ Inherited Causes:
- Hereditary spastic paraplegia
- Spinocerebellar degeneration

⁂ Congenital Causes:
- Dysraphism
- Arnold-Chiari malformation
- Spina Bifida
- Cerebral palsy
- Syringomyelia

⁂ Traumatic Causes:
- Vertebral fractures
- Vertebral dislocations
- Disc protrusions
- Spondylolysthesis
- Radiation damage
- Road traffic accidents
- Gunshot injuries
- Whiplash injuries
- Fall or diving in shallow water
- Industrial injuries
- Contact sports such as rugby or riding accidents

⁂ Infectious Causes:
- Epidural abscess
- Tuberculous abscess & Pott’s disease of spine
- Syphilis
- HIV
- Tropic spastic paraparesis

⁂ Inflammatory Causes:
- Multiple sclerosis
- Postviral transverse myelitis
- Poliomyelitis
- Sarcoid, lupus, other vasculitides
- Spondylitis with cord compression
- Gullian-Barre syndrome
 SPINAL CORD LESIONS Sagar Naik, PT

⁂ Metabolic Causes:
- Compression due to Paget’s disease
⁂ Neoplasm:
- Vertebral metastasis compressing spinal cord
- Benign extrinsic tumours
- Intrinsic cord tumours

⁂ Vascular Causes:
- Infarct of spinal cord
- Arteriovenous malformation
- Epidural Haematoma compressing the spinal cord
- Thrombosis, embolism or hemorrhage

⁂ Degenerative or Demyelinating Causes:

- Motor neuron disease with cord compression (spinal cord)
- Sub-acute combined degeneration of the cord (caused by deficiency of vitamin B12)
- Spondylosis with cord compression (vertebral column)
- Subluxation secondary to rheumatoid arthritis or other degenerative joint disease

 Classification of Spinal Cord Injuries:

⁂ Neurological Classification:
Spinal cord injuries typically are divided into two broad functional categories:
 Tetraplegia:
⮞ This term refers to impairment or loss of motor and/or sensory function in the
cervical segments of the spinal cord due to damage of neural elements within the
spinal canal.
⮞ Tetraplegia results in impairment of function in the arms as well as in the trunk
(including respiratory muscles), legs, and pelvic organs.
⮞ It does not include brachial plexus lesions or injury to peripheral nerves outside the
neural canal.
 Paraplegia:
⮞ This term refers to impairment or loss of motor and/or sensory function in the
thoracic, lumbar or sacral (but not cervical) segments of the spinal cord, secondary
to damage to neural elements within the spinal canal.
⮞ With paraplegia, arm function is spared, but depending on the level of injury, the
trunk, legs and pelvic organs may be involved.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ The term is used in referring to cauda equina and conus medullaris injuries, but not
to lumbosacral plexus lesions or injury to peripheral nerves outside the neural
canal.

⁂ Designation of Level of Lesion:

⮞ The method used to designate level of lesion is to indicate the most distal uninvolved
nerve root segment with normal function together with the skeletal level.
⮞ The term normal function has a precise meaning:
 The muscles innervated by the most distal nerve root segment must have at least a
fair+ or 3+ grade on manual muscle testing. This grade generally indicates
sufficient strength for functional use.
E.g. – In the patient has an intact C7 nerve root segment (with no sensory or motor
function below C7), the condition would be classified as a C7 complete
Tetraplegia. However, if spotty sensation and some muscle function (with
less than a fair+ muscle grade) were evident below the C7 nerve root
segment, the lesion would be classified as a C7 incomplete tetraplegia.
⮞ Oblique injuries to the cord present asymmetric sensory and/or motor function.
These lesions are classified in same manner. However, they require designating the
most distal nerve root segment with normal function on each side of the patient’s
body.
E.g. – The designation for an oblique lesion would be recorded as C6 complete on
the right [C6(R)] and C7 complete on the left [C7(L)].

 Complications:
⁂ Autonomic Dysreflexia:
⮞ Autonomic dysreflexia is a massive uncompensated cardiovascular reaction of the
sympathetic division of the autonomic nervous system to noxious stimuli (usually
visceral) below the level of lesion.
⮞ It is characterized by severe paroxysmal hypertension, pounding headache, sweating,
nasal congestion, facial flushing, piloerection, and reflex bradycardia.
⮞ It is a pathological autonomic reflex that typically occurs in lesions above T6 (above
sympathetic splanchnic outflow).
⮞ Most of the tetraplegia and high-level paraplegia experience this problem during the
course of rehabilitation. Episodes of autonomic dysreflexia gradually subside over
time and are relatively uncommon, but not rare, 3 years following injury.
⮞ Autonomic dysreflexia occasionally is seen in persons with injury levels as low as
T10. It is seen in patients with both complete and incomplete lesions.
⮞ Most persons do not experience signs and symptoms in the first 2 months postinjury.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ All patients with injuries above the midthoracic spinal cord levels will exhibit
autonomic dysregulation, with low baseline blood pressures and orthostatic
hypotension.

 Causes:
 Bladder (most common) - from overstretch or irritation of bladder wall
 Urinary tract infection (cystitis)
 Urinary retention
 Urethral or bladder irritation
 Blocked catheter
 Overfilled collection bag
 Non-compliance with intermittent catheterization program
 Bladder spasms
 Urinary stones
 Bowel - over distention or irritation
 Constipation / impaction
 Distention during bowel program (digital stimulation)
 Hemorrhoids or anal fissures
 Infection or irritation (e.g. appendicitis)
 Skin-related Disorders
 Any direct irritant below the level of injury (e.g. - prolonged pressure by
object in shoe or chair, cut, bruise, abrasion)
 Pressure sores (decubitus ulcer)
 Ingrown toenails
 Burns (e.g. - sunburn, burns from using hot water)
 Tight or restrictive clothing or pressure to skin from sitting on wrinkled
clothing
 Tight shoes and leg bag straps
 Sexual Activity
 Over stimulation during sexual activity (stimuli to the pelvic region which
would ordinarily be painful if sensation were present)
 Menstrual cramps
 Labor and delivery
 Other
 Heterotopic ossification
 Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
 Skeletal fractures
 Passive stretching at the hip
 Environmental pressure changes
 Cystometrography
 Extracorporeal shock wave lithotripsy
 SPINAL CORD LESIONS Sagar Naik, PT

 Pathophysiology:
⮞ This condition is generated by spinal cord and splanchnic reflex mechanisms that
remain operative despite the spinal cord injury.
⮞ The triggering events produce afferent impulses that are transmitted to the dorsal
column and spinothalamic tracts.

⮞ As these tracts ascend, they synapse with sympathetic neurons in the

intermediolateral columns and generate a generalized sympathetic reflex
response.
⮞ Normally, descending supraspinal inhibitory signals modulate these autonomic
reflexes, but because of the spinal lesion above the sympathetic outflow,
inhibitory impulses cannot effectively descend in the sympathetic chain to block
the autonomic response.
⮞ The result is peripheral and splanchnic vasoconstriction and the development of
acute hypertension.
⮞ Sweating and piloerection also occur as a result of the mass sympathetic
discharge.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ With increase in blood pressure, the aortic arch and carotid sinus receptors are
stimulated, which can result in reflex bradycardia and vasodilatation above the
level of lesion.

Triggering events

Afferent impulses transmitted to the dorsal column and spinothalamic tracts

They synapse with sympathetic neurons

Generate a generalized sympathetic reflex response

Inhibitory impulses cannot effectively descend in the sympathetic chain to block the
autonomic response because of spinal lesion above sympathetic outflow

Peripheral and splanchnic

vasoconstriction Development of acute

hypertension

Aortic arch and carotid sinus receptors are stimulated due to increase blood pressure

Reflex bradycardia and vasodilatation

(Above the level of lesion)

 Clinical Features:
 Above the level of lesion
 Paroxysmal hypertension of greater than 40 mm Hg over basal pressure
(Normal systolic BP in patients with spinal cord injury remains around 90 –
100 mm Hg)
 Severe, pounding headache
 Profuse sweating
 SPINAL CORD LESIONS Sagar Naik, PT
 Flushing
 Nasal congestion
 SPINAL CORD LESIONS Sagar Naik, PT

 Anxiety
 Bradycardia
 Below the level of lesion
 Pallor
 Chills without fever (goose bumps)
 Penile erection
 Cold skin

 Complications:
⮞ Complications that develop from autonomic dysreflexia are usually secondary to
severe hypertension. The elevated blood pressure can result in life-threatening
complications including
 Confusion
 Visual disturbances
 Loss of consciousness
 Encephalopathy
 Intracerebral hemorrhage
 Seizures
 Electrocardiographic changes
 Atrial fibrillation
 Acute myocardial failure
 Pulmonary edema
 Intracerebral hemorrhage and death (during labor)

 Treatment:
⮞ The onset of symptoms should be treated as a medical emergency.
⮞ Treatment of an acute episode generally focuses on identifying and eliminating
the cause.
⮞ The first action taken is to place the patient in an upright sitting position with, if
possible, the legs dangling over the bedside.
⮞ This maneuver makes use of the natural orthostatic hypotensive response in
spinal cord injury patients and can lower the blood pressure and reduce headache
symptoms.
⮞ Because bladder distention is a primary cause of autonomic dysreflexia, the
drainage system should be assessed immediately.
⮞ If the patient is wearing a clamped catheter, it should be released.
⮞ The drainage tubes also should be checked for internal or external blockage or
twisting.
⮞ The patient’s body should be checked for irritating stimuli such as tight clothing,
restricting catheter straps, or abdominal binders.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ If these steps do not result in a reduction in blood pressure, rectal impaction

should be suspected.
⮞ Pharmacological management should be considered at this point because stool
removal digitally can exacerbate the episode.
⮞ Rapid-onset, short-duration antihypertensive medications can be used to lower
the blood pressure which includes nitrates, nifedipine, prazosin, hydralazine, and
mecamylamine.
⮞ Once the blood pressure is lowered, examination for the cause can be done.
⮞ Headaches can persist for hours after hypertension is treated.
⮞ Oral medications and regional, spinal, and epidural anesthesia have been used as
pretreatment for episodes that are anticipated in association with surgical or
diagnostic procedures.
⮞ Most episodes of autonomic dysreflexia are easily remedied; patient who
experiences recurrent episodes can be treated with ganglionic blocking agents.
⮞ Prevention of recurrent episodes includes
 Proper bladder and bowel management
 Keep catheter clean and draining freely
 Emptying bladder routinely
 Following regular bowel program
 Skin care
 Wearing loose fitting clothes
 Check for painful stimuli, if present removes it
 Patient and family education regarding the prevention, causes,
presentation, and treatment of autonomic dysreflexia

⁂ Respiratory Impairment:
⮞ Respiratory complications are a common and potentially life-threatening problem
related to spinal cord injury and may occur acutely or at any time after the initial
injury.
⮞ All patients with tetraplegia and those with high-level paraplegia demonstrate some
compromise in respiratory function.
⮞ The level of respiratory impairment is directly related to
 Level of lesion
 Residual respiratory muscle function
 Additional trauma sustained at the time of injury
 Fractures (Ribs, sternal or extremities)
 Lung contusion
 Soft tissue damage
 Premorbid respiratory status
 Existing pulmonary disease
 Allergies
 SPINAL CORD LESIONS Sagar Naik, PT

 Asthma
 History of smoking
⮞ There is a progressively greater loss of respiratory function with increasingly higher
level of lesions.

 High Level Injury:

⮞ With high spinal cord lesions between C1 and C3 (above C4), phrenic nerve
innervation and spontaneous respiration are significantly impaired or lost and
will require artificial ventilation or phrenic nerve stimulation. The inspiratory
muscles are as follows:
 Primary Inspiratory Muscles
 Diaphragm
 Intercostals muscles
 Accessory Inspiratory Muscles
 Sternocleidomastoid
 Upper trapezius
 Scalenes
 Pectoralis major
⮞ With diaphragm sparing, patients with C4 tetraplegia may be able to sustain life
without artificial means, but may always have marginal ventilatory capacities.

 Intercostal Paralysis:
⮞ C5 – T12 lesions result in intercostal paralysis affecting both inspiratory &
expiratory function and patient may demonstrate weakness in the accessory
inspiratory muscles as well.
⮞ In the first weeks after injury, flaccid intercostal muscle paralysis can result in
paradoxical collapse of the rib cage during inspiration, further reducing
ventilatory efficiency.
⮞ As spasticity develops after few weeks, this paradoxical movement is reduced
and function improves.

 Abdominal Muscles Paralysis:

⮞ Injuries between T7 and T12 impair abdominal muscle function, reducing
forceful expiration and cough.
⮞ When fully innervated, the abdominal muscles play an important role in
maintaining intrathoracic pressure for effective respiration.
⮞ They support the abdominal viscera and assist in maintaining the position of the
diaphragm.
⮞ They also function to push diaphragm upward during forced expiration.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ With paralysis of the abdominals this support is lost, causing the diaphragm to
assume an unusually low position in the chest.
⮞ This lowered position and lack of abdominal pressure to move the diaphragm
upward during forced expiration results in a decreased expiratory reserve
volume.
⮞ This subsequently decreases cough effectiveness and the ability to expel
secretions.

⮞ Paralysis also results in the development of an altered breathing pattern. This pattern
is characterized by flattening of the upper chest wall, decreased chest wall
expansion, and a dominant epigastric rise during inspiration. With relaxation of the
diaphragm, a negative intrathoracic pressure gradient moves air into the lungs. Over
time, this breathing pattern will lead to permanent postural changes.
⮞ The chief pulmonary concerns during the acute phase of care are
 Ventilation
 Oxygenation
 Secretion management
 Atelectasis
 Segmental collapse
⮞ Pulmonary complications which might lead the patient to death are
 Ventilatory failure
 Atelectasis
 Aspiration pneumonia
 Bronchopneumonia
 Pulmonary embolism
⮞ In the chronic phase of spinal cord injury, pulmonary complaints of breathlessness
and wheezing are most common and bronchial hypersensitivity.
⮞ Development of kyphoscoliosis can result in a reduction in lung compliance and
vital capacity.
⮞ Night-time oxygen desaturation is often noted in patients with chronic tetraplegia,
presumably because of the reduced use of accessory muscles during sleep.

 Treatment:
⮞ A tracheostomy tube is commonly inserted to facilitate airway suctioning and
secretion clearance.
⮞ Cough assistance maneuvers produce a modest increase in expiratory flow.
⮞ Patients must be kept well hydrated to avoid drying of the secretions which
increases risk if mucus plugging, but overzealous hydration can result in
pulmonary edema.
⮞ Body positioning is also important to facilitate ventilation. Patients with
tetraplegia exhibit higher vital capacities when positioned flat in bed. The
 SPINAL CORD LESIONS Sagar Naik, PT

mechanism underlying this phenomena is likely relate to improved diaphragm

function as the abdominal contents splint the lower rib cage.
⮞ The reduction in vital capacity seen when these patients are seated upright can be
counteracted to some extent by placement of an elastic abdominal binder.
⮞ Pulmonary function can improve steadily over the acute course, even without
concurrent neurological recovery. By 3 months, most tetraplegic patients can be
expected to attain 60% of predicted vital capacity.
⮞ Patients with injuries above the segments innervating the phrenic nerve are
candidates for phrenic nerve pacemaker implantation. This technique is
expensive and requires life long tracheostomy. Benefits include reducing the
need for heavy ventilator equipment, a reduction in sinus symptoms through
better humidification of the upper airway, and improved taste sensation.
⮞ Resistive inspiratory muscle training can be useful in reducing respiratory
complaints and complications.
⮞ Smoking cessation and vaccination programs are important components of long-
term care.

⁂ Spasticity:
⮞ Following a spinal cord injury, the nerve cells below the level of injury become
disconnected from the brain at the level of injury.
⮞ This is due to scar tissue which forms in the structure of the damaged area of the
spinal cord, blocking messages from below the level of injury reaching the brain.
⮞ Spasticity does not occur immediately following a spinal cord injury.
⮞ When an injury occurs to the spinal cord, the body goes into spinal shock, and this
may last several weeks.
⮞ During this time changes take place to the nerve cells which control muscle activity.
⮞ Once spinal shock wears off, the natural reflex which is present in everyone
reappears.
⮞ Spasticity is an exaggeration of the normal reflexes that occur when the body is
stimulated in certain ways. In an normal person, a stimulus to the skin is sensed, and
a sensory signal is sent to the reflex arch where it travels to the brain via the spinal
cord, the brain then assesses the stimulant, and if the stimulant is thought not to be
dangerous, an inhibitory signal is set down the spinal cord, and cancels the reflex
from moving the muscle.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ In a person with a spinal cord injury this inhibitory signal is blocked by the structural
damage in the cord, and the natural reflex is allowed to continue resulting in a
contraction of the muscle.
⮞ Muscle spasms can occur in a person with a spinal cord injury any time the body is
stimulated below the level of injury.
⮞ This is usually noticeable when a muscle is stretched, or there is a painful stimulant
below the level of injury.
⮞ Because of the injury to the spinal cord, these sensations can trigger the reflex
resulting in the muscle to contract or spasm.
⮞ Clinical manifestations of spasticity are
 Velocity-dependent increase in tonic stretch reflexes (increased resistance to
passive stretch)
 Exaggerated deep tendon reflexes
 Impaired voluntary control of skeletal muscles
 Clonus
⮞ It typically occurs below the level of lesion after the spinal shock subsides.
⮞ There is gradually increase in spasticity during first 6 months and a plateau is usually
reached 1 year after injury.
⮞ Spasticity is increased by multiple internal and external stimuli, including
 Positional changes
 Cutaneous stimuli
 SPINAL CORD LESIONS Sagar Naik, PT

 Environmental temperatures
 Tight clothing
 Bladder or kidney stones
 Fecal impactions
 Constipation
 Catheter blockage
 Urinary tract infections
 Urolithiasis
 Decubitus ulcers
 Emotional stress
⮞ Severe spasticity often causes
 Pain
 Loss of range of motion
 Decreased functional independence
 Increased risk for skin breakdown
 Difficulty performing routine hygiene
 Bowel & bladder dysfunction
⮞ Spasticity is usually considered negative side effect of spinal cord injury, it may
offer several advantages. These advantages are as follows:
 It helps to prevent muscle atrophy
 Patients use extensor tone to assist with standing, transfers, and ambulation
 Improve circulation thereby decreasing venous stasis
 Assist with clearing of secretions
 Warning mechanism to identify pain or problems in areas where there is no
sensation
 Helps to maintain muscle size and bone strength
 Help to some degree in preventing osteoporosis
⮞ Treatment is indicated only if the spasticity interferes with the performance of self-
care, gait, wheelchair positioning, and transfer activities, disrupts sleep, or causes
excessive pain or joint deformity.
⮞ Spasticity also contributes to the development of pressure ulcers.
⮞ An unexplained worsening of spasticity can signal the development of a secondary
condition such as spinal instability or syringomyelia.

⁂ Pressure Sore:
⮞ Pressure sores are ulcerations of soft tissue (skin or subcutaneous tissue) caused by
unrelieved pressure and shearing forces.
⮞ A pressure sore develops when the blood supplying the tissue with oxygen and
nutrients is cut off, and the tissue no longer receiving oxygen and nutrients dies. The
oxygen and nutrients are essential to maintain healthy tissue.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Pressure sores are a serious medical complication, a major cause of delayed

rehabilitation, and may even lead to death.
⮞ A decubitus ulcer can greatly increase length of stay and hospital costs as well as
have far reaching consequences for independent functioning.
⮞ Following are the predisposing factors for the development of pressure sores:
 Loss of sensory function
 Inability to make appropriate positional changes
 Loss of vasomotor control, which results in a lowering of tissue resistance to
pressure
 Spasticity with resultant shearing forces between surfaces
 Skin maceration from exposure to moisture (e.g. urine)
 Trauma such as adhesive tape or sheet burns
 Prominent nails in shoes
 Failure to dry the skin carefully after washing
 Nutritional deficiencies (low serum protein and anemia will reduce tissue
resistance to pressure)
 Poor general skin condition
 Secondary infections
 Impaired bladder and bowel function (Incontinence)
 Pressure over bony prominences
 Excessive sitting / lying
 Improper fitting garments
 Burns from hot water
 Extremes of temperature
 Smoking
 Overweight or Obese
 Diabetes
 Weight loss & Anemia

 Pathophysiology:
⮞ When pressure exerted on skin exceeds average arterial capillary pressure,
ischemia occurs.
⮞ If the pressure continues long enough, cellular death and, ultimately, skin
breakdown occur.
⮞ There is a direct relationship between the length of time and amount of pressure
required to produce damaging tissue changes.
⮞ Inverse pressure-time relationship i.e., low pressure over long periods is more
damaging than high pressure for short periods.
⮞ The higher the intensity of pressure, the shorter the time required for anoxia of
the skin and soft tissues to occur.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Normally in an able bodied person, if you are uncomfortable in your seating

position, messages from nerves in the skin will be sent via your spinal cord to the
brain to indicate discomfort.
⮞ However in a person with a spinal cord injury, these messages are blocked at the
level of injury, and the disabled person may not even be aware at the level of
potential damage the skin is in.
⮞ Improper handling of the person with spinal cord injury during functional
activities such as transfers can cause shearing of the skin.
⮞ This produces stretching and tearing of the blood vessels that pass between the
layers of the skin and the muscle beneath it.
⮞ Impaired oxygenation and nourishment of the skin may result, leading to
breakdown.
⮞ In the presence of impaired pain perception and proprioception, the individual
may be unaware that tissue damage is occurring.
⮞ Additional loss of vasomotor tone can result in peripheral edema and poor
cellular oxygenation, predisposing the tissues to damage.
⮞ Many individuals with spinal cord injury experience excessive diaphoresis which,
combined with incontinence, exposes the skin to extended periods of moisture.

 Common Sites for Pressure Sores:

⮞ Pressure sores will develop over any bony prominences subjected to excessive
pressure.
⮞ Among the most common sites of involvement are
 Sacrum
 Heels
 Trochanters
 Ischium
⮞ Other areas susceptible to skin breakdown are
 Scapula
 Elbows
 Anterior superior iliac spines
 Knees
 Malleoli
 Fibulae
 Fifth metatarsals
 Occiput
 SPINAL CORD LESIONS Sagar Naik, PT

Areas Most Susceptible to Pressure in Recumbent Positions

Supine Prone Sidelying

Occiput Ears (head rotated) Ears
Scapulae Shoulders (anterior aspect) Shoulders (lateral aspect)
Vertebrae Iliac crest Greater trochanter
Elbows Male genital region Head of fibula
Knees (medial aspect from
Sacrum Patella
contact between knees)
Coccyx Dorsum of feet Lateral malleolus
Medial malleolus (contact
Heels
between malleoli)

⮞ If the patient is placed in a plaster cast, sores may also develop over the ribs,
spinous processes and anterior and posterior superior iliac spines.
⮞ Pressure sores also readily occur under splints, plasters, calipers and braces
applied over paralyzed areas.
 SPINAL CORD LESIONS Sagar Naik, PT

 Pressure Ulcer Classification:

Stage I

essure-related area of intact skin with Nonblanchable erythema compare with adjacent or opposite area on bod
hanges in skin temperature, tissue consistency or sensation can be seen
cer appears as defined area of redness in light skin or red, blue or purple hues in darker skin
he redness or change in color does not fade within 30 minutes after pressure is removed

Stage II

 Partial-thickness skin ulcer, superficial lesion resembling abrasion, blister, or shallow

crater, involving less than total loss of epidermis and/or dermis
 Drainage may or may not be present

Stage III

 Full-thickness skin loss with damage or necrosis of underlying tissue

 It extends down to, but not through, underlying fascia
 Resembles deep crater with or without undermining of adjacent tissue
 The break in the skin extends through the dermis (second skin layer) into the subcutaneous
and fat tissue
 SPINAL CORD LESIONS Sagar Naik, PT

Stage IV

 Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle,
tendon, bone, or supporting structures
 Undermining and tunneling should be expected and rigorously assessed
 Usually lots of dead tissue and drainage are present

 Prevention of Pressure Sore:

⮞ Turning the patient every 2 hours day and night and avoiding pressure on the sore
using the supine and side-lying positions.
 Besides preventing the effects of prolonged pressure, regular turning also aids
renal function by preventing stagnation in the urinary tract.
⮞ Use of a special mattress or bed designed to relieve pressure:
 Water bed which provides even pressure over all parts of the body
 Ripple mattress which continually alters the pressure points
 Net bed – an open mesh net provides reduced pressure and is suspended
between two wooden rollers allowing easy turning of the patient
 Air fluidized bed – air is pumped through a sand medium giving complete
floatation. The fluidization can be switched off giving a solid surface for ease
of handling
 Low-air-loss bed – consists of waterproof sections filled with air to different
pressures providing even pressure distribution
 Sorbo packs which can be positioned to keep susceptible areas pressure free
⮞ Sheepskins can help to keep skin dry and reduce friction but are not suitable for
incontinent patients. They can vary in size from a small square to one which
protects the whole body. Boots lined with sheepskin help to prevent pressure
sores on the feet.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Roho cushion – an air-filled cushion which moulds to any shape and spreads
pressure evenly.
⮞ To allow adequate circulation to be maintained in the areas of maximum
pressure, relief of pressure at regular intervals is essential, regardless of the type
of cushion used. Patients are instructed to relieve pressure every 10 minutes for
10-15 seconds.
 Weight shifting or relief depending on level of lesion any one of the following
techniques can be used.
- Press up weight shifting technique (Lifting)
- Lateral weight shifting technique (Leaning side to side)
- Anterior weight shifting technique (Leaning forward)
- Power tilt or reclining mechanism, which allows relative independence in
weight shifting
⮞ Patient must learn to turn himself regularly in bed, to reposition pillows between
the legs and to ensure as far as possible that he is not lying on any crease in the
bed linen.
⮞ Care of the desensitized and paralyzed areas of the body must form an integral
part of the patient’s daily life.
 He must learn to inspect his skin night and morning for pressure marks,
abrasions and septic spots.
 Special attention should be given to the most vulnerable areas. i.e., sacral,
ischial, and trochanteric areas, plus the knees, malleoli and toes.
 A mirror is used to inspect any areas the patient cannot view directly.
 Those patients who are unable to inspect their own skin must be responsible for
requesting that this is done.
 If a mark is discovered it should be treated, the cause of it must be determined
in order to prevent it happening again.
⮞ Great care must be taken in lifting the limbs whenever the patient transfers.
Avoid sliding patient’s body across the surfaces.
⮞ As the vasomotor system does not allow adjustments of the circulation, care must
be taken also to ensure that the desensitized areas are protected from excessive
heat or cold.
⮞ A balanced diet to maintain patient’s general health is essential. High-protein,
high-calorie diet including all vitamins and iron improves the patient’s general
health and promotes healing.

 Do’s and Don’ts:

⮞ Do relieve pressure in the chair for 1.5 – 2 minutes every half an hour.
⮞ Do lift the paralyzed limbs when transferring.
⮞ Do use a mirror for detection of marks, abrasions, blisters and redness on
buttocks, back of legs and malleoli.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Do watch for marks on the penis from the sheath.

⮞ Do have the bath water ready and not too hot.
⮞ Don’t open the hot tap when having a bath in case hot water drips on the toes.
⮞ Don’t have a hot bottle in bed.
⮞ Don’t expose the body to strong sunlight; tetraplegic patients must wear a hat.
⮞ Don’t knock the limbs against any hard object.
⮞ Don’t carry hot drinks on the lap.
⮞ Don’t rest the paralyzed limbs on hot water pipes or radiators.
⮞ Don’t sit too close to the fire.
⮞ Don’t leave the legs, particularly the feet, unprotected against car heaters.

⁂ Pain:
⮞ Pain is a common occurrence following spinal cord injury. The classifications of
pain are related to the source and type of pain as well as to the length of time since
onset.
 Traumatic Pain
 Nerve Root Pain
 Spinal Cord Dysesthesias
 Musculoskeletal Pain

 Traumatic Pain:
⮞ Initially, pain experienced following acute traumatic injury is related to the extent
and type of trauma sustained as well as to the structures involved.
⮞ Pain may arise from fractures, ligamentous or soft tissue damage, muscle spasm,
or early surgical interventions.
⮞ This acute pain generally subsides with healing in 1 to 3 months.
⮞ Management for this type of pain includes immobilization and use of analgesics.
⮞ Transcutaneous Electrical Nerve Stimulation (TENS) can also be used in
reducing this type of postinjury pain.

 Nerve Root Pain:

⮞ Pain or irritation may arise from damage to nerve roots at or near the site of cord
damage.
⮞ Pain can be caused by
 Acute compression or tearing of the nerve roots
 Secondary to spinal instability, periarticular scar tissue and adhesion formation,
or improper reduction
⮞ Nerve root pain, which can be unilateral or bilateral, is often described as sharp,
stabbing, burning, or shooting and typically follows a dermatomal pattern.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Nerve root blocks offer pain relief, which includes nerve root sections
(neurectomy) and posterior rhizotomies.
⮞ Segmental pain is bilateral in many instances and ha also been described as
border zone pain, associated with hyperalgesia and hypersensitivity in 2 or 3
dermatomes adjacent to the level of spinal cord injury.
⮞ Pain with cauda equina syndrome is a well-recognized variant of segmental pain,
often described as a burning or tingling in the buttocks, anus, genitals, and feet.
⮞ A constricting band can be felt around the trunk in persons with thoracic injuries.
⮞ Another form of segmental pain, ‘burning hands syndrome or stingers’, is
experienced in many persons with incomplete tetraplegia or minor cord
contusions. This is often difficult to distinguish from complex regional pain
syndrome.
⮞ Conservative management involves pharmacological therapy and TENS.
⮞ Surgical interventions for more severe, debilitating pain include nerve root
sections (neurectomy) and posterior rhizotomies.

 Spinal Cord Dysesthesias:

⮞ Spinal cord dysesthesia is also known as deafferentation central pain or central
cord pain.
⮞ It is characterized by vague, diffuse, nondermatomal symptoms originating
caudal to the cord lesion that lacks reliable nociceptive precipitants.
⮞ It is described as burning, numbness, pins & needles, tingling feelings, scalding,
or shooting / stabbing and patients with this type of pain have autonomic
instability.
⮞ Occasionally, they involve abnormal proprioceptive sensations, causing the
individual to perceive a limb in order than its actual position.
⮞ They occur in body parts that otherwise lack sensation.
⮞ The acute pain usually lasts a few seconds and is often followed by paroxysms of
another type of pain which can be cramping in character.
⮞ Symptoms can be worsened by a variety of events like changes in body position,
bladder infection or pressure ulcers but are neither precipitated by them nor
relieved when these secondary conditions are remediated.
⮞ Dysesthesias have been described as phantom pain or sensations similar to those
experienced following amputation.
⮞ The number of attacks per day varies considerably from patient to patient and
even from day to day in the same patient. There is no association between the
severity of pain and level or completeness of injury.
⮞ Patients with complete lesions of the midthoracic and Thoracolumbar cord
sometimes develop a band of hyperpathia around the level of the lesion. The
patient complaints that there is a tight band around his chest, and occasionally it
is so hypersensitive that he cannot bear anything to touch his skin.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Dysesthesia pain is particularly resistant to treatment. It is important that the

complaints be acknowledged as real and that the patient be educated as to
legitimacy of the pain.
⮞ Gentle handling of the patient’s limbs and careful positioning frequently make
the pain more tolerable.
⮞ Pharmacological management includes anticonvulsant drugs like carbamazepine
and phenytoin, antidepressants and TENS can be used.
⮞ Narcotic analgesics are usually discouraged because of the danger of addiction.
⮞ Intensive physiotherapy may be useful, including some form of sport. The
condition may show some spontaneous improvement as the patient learns to
tolerate his pain by diversional activities.

 Musculoskeletal Pain:
⮞ The pain is always found above the level of the lesion and most frequently
involves shoulder joint.
⮞ It is most frequently seen in complete lesions of the cervical cord.
⮞ Trauma to the cervical roots may cause some root irritation initially, but
continuing pain appears to be due to tightening of the capsule and contractures
around shoulder and shoulder girdle due to faulty positioning and lack of
movement.
⮞ In addition, the shoulder muscles are excessively challenged in their role as tonic
stabilizers to substitute for lack of trunk innervation.
⮞ This situation may be complicated by muscle imbalances around the joint,
inflammation, or upper extremity fractures sustained at the time of injury.
⮞ Prevention of secondary shoulder involvement is critical, considering the
importance of this joint in self-care and functional activities.
⮞ Shoulder pain and limitation of ROM will significantly delay the rehabilitation
process.
⮞ The most important preventive measures include
 Regular program of ROM exercise
 Positioning program designed to facilitate full motion at shoulder
 With the patient in supine position, the side boards (which can be slid
under a mattress with pillows used to alter the height of the supporting
surface) will allow positioning of the shoulders in 90° of abduction with
elbows extended.
 With the patient in supine position, place the arm above the patient’s head
for a short period of time, which will encourage external rotation and
abduction beyond 90°. The elbows should be in approximately 80° of
flexion.
 In side-lying, with the lower arm in 90° of shoulder flexion, place an
axillary pillow under the chest to help relieve pressure on the acromion
 SPINAL CORD LESIONS Sagar Naik, PT

process and head of humerus. Place the uppermost arm in extension,

abduction and well supported with pillow.

 Referred Pain:
⮞ Patients with cervical and high thoracic lesions can experience pain in the
shoulder region when any abnormal visceral activity occurs.
⮞ Impulses are carried from the paralyzed to the non-paralyzed area via the phrenic
nerve.
⮞ Patients with cervical lesions can suddenly develop severe frontal headache. This
may be due to overdistension of the bladder.

⁂ Bladder & Bowel Dysfunction:

 Bladder Dysfunction:
⮞ Disturbance of bladder function can produce many complications which
constitute a lifelong threat to the patient.
⮞ Urinary tract infections (UTIs) are among the most frequent medical
complication during the initial medical-rehabilitation period.
⮞ Most of the patients with UTI are asymptomatic. General malaise and a slight
fever are common and may prevent the individual from participating fully in
activities.
⮞ Chills, spiking fever, nausea, vomiting, sweating, abdominal discomfort,
increased spasticity, increased spontaneous voiding, larger residual volumes and
cloudy malodorous urine may indicate various urinary tract infections.
⮞ The effect on the bladder depends upon the length of time after injury, as well as
the level of cord injury and the degree of cord damage.
⮞ During the stage of spinal shock, the urinary bladder is flaccid.
⮞ During this period of spinal areflexia, all bladder reflexes and muscle action are
abolished.
⮞ Patient will develop acute retention, followed by passive incontinence due to
overflow from the distended bladder.
⮞ Treatment will be directed to:
 Achieving a satisfactory method of emptying the bladder
 Maintaining sterile urine
 Enabling the patient to remain continent
⮞ During the period of spinal shock, bladder may be emptied in several ways:
 Urethral catheterization
 Intermittent
 Indwelling
 Suprapubic drainage
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ For acute lesions, intermittent catheterization is the most favored treatment of

choice.
⮞ This method allows some distension of the bladder, which represents the
physiological stimulus for micturition and triggers the appropriate impulses to
the spinal bladder center.
⮞ This promotes return of detrusor activity.
⮞ A long term indwelling catheter is likely to be the source of bladder infection,
vesical calculi, urethral strictures, diverticula and fistula and periurethral
abscesses.
⮞ As spinal shock weans off, which may take from few days to several weeks, two
types of bladder condition develop:
 Automatic Bladder
 Autonomous Bladder

 Automatic (Reflex) Bladder:

⮞ Patients with lesions that occur within the spinal cord above the conus
medullaris typically develop a spastic (UMN) or reflex or automatic bladder.
This type of bladder develops with transverse spinal cord lesions above T10 –
T11.
⮞ As reflex tone returns, the detrusor muscle contracts in response to a certain
degree of filling pressure.
⮞ The returning power of the sphincter is overcome and micturition occurs.
⮞ The reflex arc is intact. This reflex detrusor action may be triggered off by
stroking, kneading or rhythmic tapping over the abdominal wall above the
symphysis pubis, or by stimulating other trigger points like stroking the inner
aspect of the thigh or pulling the pubic hair.

 Autonomous (Non-Reflex) Bladder:

⮞ This bladder is virtually atonic i.e., flaccid because there is no reflex action of
the detrusor muscle and occurs where the reflex action is interrupted, i.e. with
a longitudinal lesion of the spinal cord or a lower motor neuron (LMN)
lesion.
⮞ The patient is taught to catheterize himself to empty the bladder.
⮞ If the abdominal muscles are innervated the patient can raise the intra-
abdominal pressure by straining i.e., using a Valsalva maneuver or by
manually compressing the lower abdomen using the Crede maneuver, when
the pressure on the kidneys is the same as that on the bladder.
⮞ The disadvantage is that high pressure is also put on the rectum.
 SPINAL CORD LESIONS Sagar Naik, PT

Spastic (Automatic) Urinary Flaccid (Autonomous) Urinary

Dysfunction (UMN) Dysfunction (LMN)
Level of cord injury Occurs above micturition reflex Involves micturition reflex center (S2
center (S2 – S4) located within the - S4) in the conus medullaris and/or
conus medullaris. sacral nerve roots in the cauda equina.
Same as for UMN.
Level of innervation
 Local Stretch receptors in bladder wall and  Same as for UMN.
afferent neuron intact.
 Spinal micturition reflex Micturition reflex intact. Micturition reflex center in conus
(S2 – S4) Parasympathetic innervation to medullaris and/or sacral nerve roots
detrusor muscle and bladder neck destroyed.
sphincter (internal) intact.
 Sympathetic innervation Reflexes may be intact depending  Same as for UMN.
cord segments T1 to on level of cord injury.
T12
Brain / Higher centers
 Motor Nerve pathways between brain and Loss of final common pathway for
spinal micturition reflex center (S2- transmission of impulses between
S4) interrupted; loss of inhibiting CNS and detrusor muscle and
influences on spinal reflexes from bladder sphincters (internal and
higher centers. external).
 Sensory  Ascending sensory pathways  Same as for UMN.
interrupted; loss of sensation of
bladder distention and urge to
urinate.
Results of pathology  Loss of UMN innervation.  Loss of LMN innervation.
 Intact micturition reflexes.  Loss of micturition reflexes.
 Spastic bladder dysfunction.  Flaccid bladder dysfunction.
Prognosis for bladder Bladder training is aimed at using Unable to establish reflex voiding;
control micturition reflexes and "trigger" intermittent bladder catheterization
stimulus to establish planned reflex may be best method for bladder
voiding. management.

 Bladder Training Programs:

⮞ The primary goal of bladder training programs is to allow the patient to be free of
a catheter and to control bladder function.

 Automatic (Reflex) Bladder:

⮞ The bladder training program most frequently used with a reflex bladder is
intermittent catheterization.
⮞ The purpose of this program is to establish reflex bladder emptying at regular
and predictable intervals in response to a certain level of filling.
⮞ The program involves establishing a fluid intake pattern restricted to
approximately 2000 ml/day.
⮞ Fluid intake is monitored at 150 to 180 ml/hour from morning until early
evening.
⮞ Intake is stopped late in the day to reduce the need for catheterization during
the night.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Initially, the patient is catheterized every 4 hours. Prior to catheterization, the

patient attempts to void in combination with one or more of the manual
stimulation techniques.
⮞ These manual stimulation techniques include stroking, kneading or rhythmic
tapping over the abdominal wall above the symphysis pubis, or by stimulating
other trigger points like stroking the inner aspect of the thigh or pulling the
pubic hair.
⮞ The catheter is then inserted and residual volume drained. A record is
maintained of voided and residual urine.
⮞ As bladder emptying becomes more effective, residual volumes will decrease
and time intervals between catheterizations can be expanded.

 Autonomous (Non-Reflex) Bladder:

⮞ A timed voiding program is a method of bladder training used for autonomous
or non-reflex bladder.
⮞ This program involves first establishing the patient’s pattern of incontinence.
⮞ The residual urine volume is then checked to ensure that it is within safety
limits.
⮞ Once the pattern of incontinence has been established, it is compared with the
patterns of intake.
⮞ This information provides basis for establishing a new intake and voiding
schedule.
⮞ The bladder gradually becomes accustomed or trained to empty at regular,
predictable intervals.
⮞ As incontinence decreases, the schedule is readjusted to expand the intervals
between voiding.
⮞ Fluid intake is avoided late in the day to decrease the risk of nocturia.
⮞ Stimulation techniques are also incorporated into this type of training program
using Valsalva maneuver or by manually compressing the lower abdomen
using the Crede maneuver.

⁂ Sexual Dysfunctions:
⮞ Sexual dysfunctions are recognized as a complex rehabilitation issue characterized
by physiological dysfunction, and sensory and motor impairment, these disturbances
are often accompanied by social and psychological distress.

 Male Response:
⮞ Male patients with high lesions often have priapism for hours or several days
after injury.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Subsequently all sexual function is abolished during the stage of spinal areflexia.
⮞ Later return of sexual function is directly related to level and completeness of
injury.
⮞ Sexual capabilities are broadly divided between UMNL (damage to the cord
above the conus medullaris) and LMNL (damage to the conus medullaris or
cauda equina).

 Erectile Capacity:
⮞ Sexual response of erectile capacity after spinal cord injury presents two
consistent findings:
 Erectile capacity is greater in UMNL than in LMNL
 Erectile capacity is greater in incomplete lesions than in complete lesions
⮞ There are two types of erections:
 Reflexogenic Erections occurs in response to external physical stimulation
of the genitals or perineum. An intact reflex arc is required mediated
through S2, S3, and S4.
 Psychogenic Erections occur through cognitive activity such as erotic
fantasy. They are mediated from the cerebral cortex through the
thoracolumbar or sacral cord centers.
⮞ For patients with complete lesions above the reflex center in the conus
medullaris, automatic erections occur in response to local stimuli but there
will be no sensation during sexual intercourse.
⮞ Patients with low cord lesions above the sacral reflex center may have not
only reflex erections but also psychogenic erections if the sympathetic
pathways are intact.
⮞ Mechanical assistive devices are now available, as well as various
pharmacological agents which enhance erections.

 Ejaculation & Orgasm:

⮞ There is higher incidence of ejaculation with
 LMNL than with UMNL
 Lower-level cord lesions versus higher-level cord lesions
 Incomplete lesions as compared to complete lesions
⮞ The low level of fertility after spinal cord injury is associated with impaired
spermatogenesis and an inability to ejaculate.
⮞ Occasionally patients with low cord lesions may be accompanied by
ejaculation. The seminal fluid will pass through the urethra only if there is an
associated contraction of the internal bladder sphincter. Otherwise it refluxes
into the bladder.
⮞ Vibratory stimulation may improve ejaculatory response and higher semen
quality.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ The semen samples produced are used for intrauterine inseminations.

⮞ Orgasm and ejaculation are two separate events. Orgasm is a cognitive,
psychogenic event, whereas ejaculation is a physical occurrence.

 Female Response:
⮞ Sexual functions of women following spinal cord injury have been considered
relatively unimpaired.
⮞ Female sexual responses also follow a pattern related to location of lesion.
⮞ In patients with UMNL, reflex arc will remain intact. Therefore, components of
sexual arousal i.e., vaginal lubrication, engorgement of the labia, and clitoral
erection will occur through reflexogenic stimulation, but psychogenic response
will be lost.
⮞ Conversely, with LMNL, psychogenic responses will be preserved and reflex
responses lost.

 Menstruation:
⮞ Interruption of the menstrual cycle occurs in the majority of women with
complete or incomplete lesions who are not taking a contraceptive pill.
⮞ The menstrual cycle typically is interrupted for a period of 1 to 3 months
following injury.
⮞ After this time normal menses return.

 Fertility & Pregnancy:

⮞ The potential for conception remains unimpaired.
⮞ Apart from lacking genital sensation, sexual function is unimpaired for female
patients with complete lesions.
⮞ Pregnancy is possible under close medical supervision in as much as the
patient is placed at high risk for impaired respiratory function.
⮞ Each uterine contraction in patients with complete lesions above T6 causes
autonomic dysreflexia.
⮞ Patients with complete lesions at T9 and below have uterine pain, but patients
with complete lesions at T6, T7 or T8 may not be aware that labor has
commenced, especially if it occurs during sleep.
⮞ Consequently, patients are frequently hospitalized for a period of time prior to
the expected delivery date to monitor cervical dilation.
⮞ Although uterine contractions are hormonally controlled and not affected by
paralysis, patients with an inability to bear down during the final stages of
delivery or who experience prolonged or difficult labor may go for cesarean
section.
 SPINAL CORD LESIONS Sagar Naik, PT

⁂ Postural Hypotension:
⮞ Postural hypotension (orthostatic hypotension) is a decrease in blood pressure that
occurs when assuming an erect or vertical position i.e., lying-to-sitting or sitting-to-
standing.
⮞ Orthostatic hypotension and lower extremity edema occurs as a result of loss of
sympathetic influences that bring about vasoconstriction.
⮞ Vasodilatation results in hypotension which, combined with the loss of muscle pump
action of lower extremity and abdominal muscles, produces venous and splanchnic
bed pooling.
⮞ Reduced blood cerebral flow and decreased venous return to the heart typically
occurs, producing symptoms of lightheadedness, dizziness, or fainting.
⮞ Depending on the amount of sympathetic disruption in lesions above the mid-
thoracic level and the amount of skeletal muscle paralysis after spinal cord injury,
there will be varying degrees of edema and problems with orthostatic hypotension.
⮞ There is edema of the legs, ankles, and feet, which is usually symmetric and pitting
in nature. It occurs secondary to the above problems and is complicated by
decreased lymphatic return.
⮞ To minimize this effect cardiovascular system should be allowed to adapt gradually
by a slow progression to the vertical position.
⮞ This frequently begins with elevation of the head of the bed and progresses to a
reclining wheelchair with elevating leg rests and use of a tilt table.
⮞ Vital signs should be monitored carefully, and the patient should always be moved
very slowly.
⮞ Use of compressive stockings and an abdominal binder will further minimize these
effects.
⮞ Pharmacological therapy may be indicated i.e., ephedrine to increase blood pressure
or low-dose diuretics to relieve persistent edema of legs, ankles, or feet.
⮞ As vasomotor stability returns, tolerance to the vertical position will gradually
improve.

⁂ Heterotopic (Ectopic) Ossification:

⮞ Heterotopic ossification also known as para-articular calcification is osteogenesis in
soft tissues below the level of the lesion.
⮞ The development of bone in the connective tissue always occurs below the level of
the lesion and rarely after the first 6 months post-injury with the most common
occurrence between 1 and 4 months.
⮞ It may occur due to tissue hypoxia secondary to circulatory stasis, abnormal calcium
metabolism, local pressure, and microtrauma related to overly aggressive range of
motion exercises.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Heterotopic ossification is always extra-articular and extracapsular. It may develop

in tendons, connective tissue between muscle, aponeurotic tissue, or peripheral
aspects of muscles.
⮞ It is extra-articular, often leaving the joint capsule intact. It forms in the connective
tissue between the muscle planes and not within the muscle itself. The bone can be
contiguous with the skeleton but generally does not involve the periosteum.
⮞ Heterotopic ossification occurs more frequently in cervical and mid-thoracic motor
complete lesions.
⮞ The most commonly involved areas, in decreasing order, are the hips, knees,
shoulders, elbows and medial aspect of femur. Involvement of the axial skeleton
and smaller joints in the extremities is very rare.
⮞ The joints themselves are not affected but the ossification can become massive
enough to cause an extra-articular ankylosis.
⮞ Early symptoms of heterotopic ossification resemble those of thrombophlebitis,
including
 Swelling
 Decreased ROM
 Erythema
 Local warmth
 Pain
 Elevated serum alkaline phosphatase
 Negative radiological findings
⮞ Swelling in the extremity is usually localized, and within several days a more
circumscribed, firm mass can be noted within the area of edema.
⮞ Early X-ray evidence shows cloudy patches in muscles involved but this may not
show up for a further 2-3 weeks. As the disease progresses, X-rays show calcerous
deposits in the para-articular tissues and finally dense ossification of the ligaments,
fasciae and muscles surrounding the joints.
⮞ Management of ectopic bone formation utilizes several approaches, including
pharmacological therapy, physical therapy, and, with severe functional limitations,
surgery.
⮞ Disodium etidronate is effective in limiting the extent of heterotopic ossification
when treatment is started early in the course. It appears to be much less effective
when used later in the disease course.
⮞ In the initial stage when the joint feels spongy and the area may be red, swollen,
passive movements to that joint are discontinued until inflammation has subsided.
This will take approximately a week; passive movements are then recommenced.
⮞ The limb is moved slowly and carefully two or three times only, through as full a
range as possible.
⮞ No forced movements are given, but every effort is made to maintain the range.
⮞ Vigorous stretching exercises should be avoided to prevent the formation of a
pseudoarthrosis.
 SPINAL CORD LESIONS Sagar Naik, PT

⮞ Activities that may traumatize the area should be avoided to reduce the chance of
increasing the inflammatory mass.
⮞ When the disease become less active, after approximately 4 to 8 weeks, the passive
movements and general activity are increased and careful effort is made to increase
the joint range.
⮞ As it is possible that vigorous passive movements causing a small tear in a muscle
may lead to heterotopic ossification, all passive movements must be given with
extreme care.
⮞ Surgical intervention is indicated when heterotopic ossification
 Limits joint motion
 Interferes with independence (Impairing function)
 Causing abnormal pressure distribution
⮞ A wedge resection is made to remove only the amount of bone needed to provide
functional joint motion and is more successful if performed on mature bone so
surgery is only considered after disease has completely burnt itself out, which is
usually 18 months to 2 years after onset.
⮞ Recurrence of ossification is not uncommon even after surgery.
⮞ The complications of heterotopic ossification can include
 Peripheral nerve entrapment
 Development of pressure ulcers
 Increased risk of Deep Vein Thrombosis
 Extra-articular joint ankylosis

⁂ Contractures:
⮞ Contractures develop secondary to prolonged shortening of structures across and
around the joint, resulting in limitation in motion.
⮞ Contractures occur during acute and initial rehabilitation phases as a result of
spasticity, muscle weakness, muscle imbalance, immobility and pain.
⮞ Contractures initially produce alterations in muscle tissue but rapidly progress to
involve capsular and pericapsular changes. Once the tissue changes have occurred,
the process is irreversible.
⮞ A combination of factors places the patient with spinal cord injury particularly high
risk for developing joint contractures:
 Lack of active muscle function eliminates the normal reciprocal stretching of a
muscle group and surrounding structures as the opposing muscle contracts.
 Spasticity often results in prolonged unopposed muscle shortening in a static
position.
 Flaccidity may result in gravitational forces maintaining a relatively
consistent joint position.
 Other factors
- Faulty positioning
 SPINAL CORD LESIONS Sagar Naik, PT

- Heterotopic ossification
- Edema
- Imbalances in muscle pull (either active or spastic)
⮞ The hip joint is particularly prone to flexion deformities and typically includes
components of internal rotation and adduction.
⮞ The shoulder may develop tightness in flexion or extension depending on early
position. Both patterns at the shoulder are associated with internal rotation and
adduction.
⮞ All joints of the body are at risk for contractures, including the elbows, wrist and
fingers, knees, ankles, and toes.
⮞ When contractures are left unmanaged, joint ankylosis may result.
⮞ The most important management consideration related to the potential development
of contractures is prevention.
⮞ Following spinal cord injury, daily ROM exercises, proper body positioning, and
patient education must occur to prevent contractures.
⮞ Conservative treatment of established contractures:
 Passive movements in conjunction with a passive stretch should be given in the
position of maximum correction.
 Prolonged passive stretching can be given for flexion contractures of the hips
and knees and adduction contractures of the hips by strapping the limbs in the
corrected position.
- In bed, the corrective position is maintained by using pillows and padded
straps.
E.g. – 1) When knee flexors are contracted, legs are kept in extension with a
strap over the knees.
To avoid pressure, pillows are placed
 Under the lower legs to keep the heels off the bed
 Between the knees to prevent the apposition of skin surfaces
 Over the knees, underneath the strap
2) When there is flexion contracture of hips, patient lies prone on the
plinth.
 Two or three pillows are placed under the knees and similarly
under the trunk, with a gap at the level of the hip joints.
 Pillow is placed between the knees, and the toes must be over the
end of the plinth.
 Correction is obtained by strapping the hips down to the plinth.
 Care must be taken to arrange the two groups of pillows so that the
stretch is given to the hip flexors.
 If the space between the pillows is too wide, the stretch merely
increases the lumbar lordosis.
 Ankles can also be tied down with a padded strap if there are
flexion contractures of knees.
 SPINAL CORD LESIONS Sagar Naik, PT

 The stretch is normally maintained for 20 – 30 minutes.

 Active exercises – Hold relax techniques are used to obtain relaxation where the
muscle groups are innervated and resisted work is always given to the antagonists.
 Splinting – To avoid excessive pressure, it is advisable to make serial splints and
not try to obtain maximum correction initially.
- The contracture may involve more than one joint. In this case, maximum
correction is obtained firstly in the joint principally controlled by the major
muscle involved.
E.g. – Where the elbow, wrist and fingers are flexed, biceps is the major
muscle and maximum correction is given at the elbow joint.
- Air-filled plastic splints are commercially available and can be useful in some
cases.
 Passive & active exercises in a heated pool – The hot water aids relaxation, and
is especially beneficial if there is severe spasticity.
 Ice Therapy & Ultrasound can also be used for the treatment of contractures.
⮞ When no improvement has occurred for approximately 6 weeks in spite of intensive
therapy, surgery may be considered. Surgical interventions may be indicated
including bone resection, capsular releases, and/or tendon lengthening.