WHAT IS SPINAL CORD INJURY?
Spinal cord injury is a serious neurological injury that may affect movement and sensation below the level at which the spinal cord has been damaged.
It may also affect important bodily functions, including bladder and bowel function, sexual function, breathing, blood pressure regulation and other functions of the autonomic nervous system.
The injury may be traumatic, for example following a road traffic accident, fall, work-related or sporting accident, or other major trauma, or non-traumatic, as a result of vascular, inflammatory, infectious, neoplastic or other conditions affecting the spinal cord.
When the injury involves the thoracic, lumbar or sacral segments of the spinal cord, with preservation of upper-limb function, the term paraplegia is used.
When the injury involves the cervical spinal cord and also affects upper-limb function, the term tetraplegia is used.
The clinical picture depends primarily on the neurological level of injury, its severity and whether the injury is complete or incomplete.
The neurological level of injury is determined by neurological examination and does not necessarily correspond to the anatomical level of injury to the spinal column.
For this reason, assessment of the functional consequences of the injury and Rehabilitation planning are based primarily on the neurological level and completeness of the injury, rather than on the anatomical level of spinal column injury alone.
WHAT DO COMPLETE AND INCOMPLETE SPINAL CORD INJURY MEAN?
Neurological status is assessed according to the internationally accepted ISNCSCI – International Standards for Neurological Classification of Spinal Cord Injury and the ASIA Impairment Scale (AIS).
The assessment examines motor and sensory function, establishes the neurological level of injury and classifies its severity.
The distinction between complete and incomplete injury depends specifically on whether sensory or motor function is preserved in the lowest sacral segments, S4–S5, known as sacral sparing.
The injury is classified as complete – AIS A when no sensory or motor function is preserved in the S4–S5 sacral segments.
In incomplete injuries, AIS B denotes a sensory incomplete injury, while AIS C and AIS D denote motor incomplete injuries of differing severity.
This distinction is important for accurately describing the neurological injury, monitoring change over time and assessing the patient’s functional abilities.
WHAT PROBLEMS CAN SPINAL CORD INJURY CAUSE?
Spinal cord damage may cause:
- muscle weakness or paralysis,
- numbness or loss of sensation,
- spasticity,
- neuropathic or musculoskeletal pain,
- difficulty with balance, standing and walking,
- impaired upper-limb and hand function in cervical injuries,
- impaired breathing and effective coughing, particularly in high cervical injuries,
- swallowing disorders, particularly in patients with cervical spinal cord injury and in those who have required intubation, tracheostomy or cervical spine surgery,
- bladder and bowel dysfunction,
- sexual dysfunction,
- orthostatic hypotension and other disturbances of blood pressure regulation,
- disturbances of sweating and body temperature regulation.
In injuries with a neurological level of T6 or above, autonomic dysreflexia may also occur. This is a sudden and potentially dangerous disturbance of the autonomic nervous system, characterised mainly by a marked rise in blood pressure and requiring immediate recognition and treatment.
Prolonged immobility and reduced sensation further increase the risk of pressure ulcers, urinary tract infections, respiratory infections, deep vein thrombosis, contractures, loss of bone mass and fractures.
BONE HEALTH
Following Spinal Cord Injury, significant loss of bone mass may occur below the level of the injury, particularly in the lower limbs, increasing the risk of fractures. Bone health is assessed on the basis of the patient’s history and risk factors and, when indicated, with appropriate laboratory and imaging investigations. Prevention and management are individualised according to the findings and the patient’s fracture risk.
WHY IS REHABILITATION IMPORTANT?
Rehabilitation is an integral part of the overall management of spinal cord injury and should begin early, as soon as the patient’s condition allows.
Rehabilitation is not simply about restoring walking.
It includes comprehensive management of the consequences of the injury, prevention of complications, optimal use of preserved function and training to help the patient achieve the greatest possible degree of independence.
Therapeutic goals differ from one patient to another and are determined by the neurological level and extent of the injury, AIS classification, preserved functions, general medical condition and the individual’s everyday needs.
For one patient, the main goal may be to regain or improve walking. For another, it may be independent wheelchair mobility, safe transfers, self-care, upper-limb and hand function, or returning home or to work.
HOW DO WE MANAGE SPINAL CORD INJURY AT ANAPLASI?
At ANAPLASI, the Multidisciplinary Rehabilitation Team systematically assesses each patient’s neurological and functional status and develops an individualised rehabilitation programme with specific, measurable therapeutic goals and regular reassessment of progress.
Assessment includes the neurological level and AIS classification, muscle strength, sensation, spasticity, pain, range of movement, respiratory and autonomic function, balance, transfers, standing and walking, upper-limb and hand function, and the ability to perform activities of daily living.
Functional progress may be recorded using measures specifically developed for spinal cord injury, such as the Spinal Cord Independence Measure – SCIM III, which assesses self-care, respiration and sphincter management, as well as mobility.
In patients undergoing gait retraining, the Walking Index for Spinal Cord Injury – WISCI II may also be used, together with objective walking tests, to document functional progress more accurately.
The programme includes:
- physiotherapy,
- occupational therapy and training in activities of daily living,
- progressive strengthening and endurance exercise,
- transfer and mobility training,
- standing and, where feasible, gait training,
- training of upper-limb and hand function,
- specialised aquatic therapy in the Hydrotherapy Pool,
- management of spasticity and pain,
- training in the use of a wheelchair and other assistive devices,
- dietetic assessment and follow-up,
- psychological support for the patient and family,
- assessment and management of sexual dysfunction,
- information, education and guidance for the patient and their family on the course of recovery and how to manage functional difficulties safely.
For inpatients, respiratory physiotherapy is provided from the time of admission, with the aim of maintaining and improving respiratory function, promoting better lung expansion and facilitating the mobilisation and clearance of bronchial secretions.
When a swallowing disorder is present, specialist assessment and treatment are provided.
At the ANAPLASI Dysphagia Unit, when clinically indicated, Flexible Endoscopic Evaluation of Swallowing – FEES is performed.
The examination uses a thin, flexible endoscope introduced through the nose, allowing direct assessment of swallowing function, secretion management and airway protection.
This enables assessment of the safety and efficiency of swallowing, and the findings are used to guide the individualised planning of treatment, feeding and hydration.
When required, dietetic assessment and follow-up are also provided to help ensure adequate and safe feeding and hydration.
SPECIALISED AQUATIC THERAPY IN THE HYDROTHERAPY POOL
Specialised aquatic therapy in the Hydrotherapy Pool, where the patient’s general condition allows, uses buoyancy and other physical properties of water to facilitate movement with reduced loading.
It may be used for mobilisation, strengthening, trunk control and balance and, in selected patients, for functional training in standing and walking.
MANAGEMENT OF SPASTICITY
Spasticity following Spinal Cord Injury is treated when it causes pain, restricts movement or function, interferes with care or contributes to the development of contractures and deformities.
Spasticity is always assessed in relation to the patient’s functional ability and specific therapeutic goals.
Management may include physiotherapy, appropriate positioning and mobilisation, the use of suitable aids and orthoses, specialised aquatic therapy in the Hydrotherapy Pool and medication.
In selected patients with focal spasticity, botulinum toxin type A may be injected under electromyographic guidance as part of the overall rehabilitation programme.
This is followed, according to individual needs and therapeutic goals, by physiotherapy, occupational therapy and, when indicated, the use of appropriate aids and orthoses.
ROBOTIC REHABILITATION
In appropriately selected patients, modern robotic rehabilitation technology may be used.
A robotic exoskeleton can provide controlled, repetitive practice of standing and walking, with the level of assistance adjusted to the patient’s neurological and functional status.
In incomplete injuries, where sufficient motor function is preserved, it may be used as part of gait retraining.
In patients with more severe or complete motor impairment, the goals may relate primarily to standing, repetitive assisted walking practice, physical exercise and reducing prolonged sitting time rather than necessarily achieving independent walking.
In cervical injuries with impaired upper-limb and hand function, robotic retraining of the upper limb and hand may also be used according to the patient’s abilities and specific functional goals.
Robotic systems are used as an adjunct and do not replace active therapeutic exercise.
NEUROMODULATION WITH navigated rTMS
In selected patients with incomplete spinal cord injury, repetitive Transcranial Magnetic Stimulation is being investigated as an adjunctive intervention for improving motor function.
At ANAPLASI, rTMS is delivered with neuronavigation – navigated rTMS – allowing accurate, individualised localisation of the target area.
This remains an investigational adjunct and is not an established treatment for spinal cord injury itself or a substitute for a structured rehabilitation programme.
CARE OF THE SEVERELY AFFECTED PATIENT
In patients with tetraplegia or major limitations in mobility, Rehabilitation and the prevention of complications begin early, as soon as the patient’s medical condition permits, even before the patient is able to get out of bed.
In the Inpatient Rehabilitation Unit at ANAPLASI, advanced therapeutic beds are used, allowing controlled and programmed changes of position, alternating lateral rotation, specialised pressure management, full-chair positioning and, when indicated, gradual progression towards a more upright position.
These functions also contribute to both the prevention and management of pressure ulcers.
Percussion and vibration functions may also be incorporated into respiratory care where clinically appropriate.
These functions form part of the overall medical, nursing and therapeutic management and do not replace active mobilisation or a structured rehabilitation programme.
For patients who require substantial assistance with transfers, electrically powered patient hoists may be used to support safer movement from bed to wheelchair and to treatment areas.
BLADDER, BOWEL, SKIN AND EVERYDAY LIFE
Particular attention is given to the safe and systematic management of neurogenic bladder and bowel dysfunction, prevention of urinary tract infections and other complications, and training the patient to participate actively, wherever possible, in their long-term care.
Neuro-urological assessment includes a bladder diary, urinalysis and laboratory assessment of renal function, measurement of post-void residual urine, ultrasound of the urinary tract and urodynamic testing.
In spinal cord injury, urodynamic testing has a particularly important role, as it provides an objective assessment of bladder function and helps guide appropriate management and protect the urinary tract.
Urodynamic testing is performed as early as possible after the critical acute phase of the injury, generally within the first three months, and is subsequently repeated according to the findings, the risk of urinary tract complications and the patient’s clinical course.
Prevention of pressure ulcers includes regular skin inspection, regular repositioning, appropriate mattress, seating, wheelchair and cushion, and pressure-relief training.
For patients at risk of autonomic dysreflexia, particular emphasis is placed on educating the patient and family to recognise the symptoms and understand the need for immediate action.
If autonomic dysreflexia is suspected, blood pressure should be measured immediately.
Common triggers include bladder or bowel distension, urinary catheter problems, and irritation or pressure affecting the skin. Prompt identification and treatment of the trigger are essential.
SEXUAL FUNCTION AND REHABILITATION
Spinal Cord Injury may affect sexual desire, sensation, erectile function, ejaculation, lubrication and orgasm and, in some patients, reproductive function.
Sexual rehabilitation is individualised according to the neurological level and severity of the injury, the patient’s functional abilities, needs and wishes. It may include information and practical guidance, management of spasticity, pain and bladder or bowel dysfunction, psychological support and, where required, specialist medical treatment.
The involvement of the patient’s partner may be helpful if the patient wishes.
RETURNING HOME AND TO EVERYDAY LIFE
Before returning home, the patient’s needs and living environment are assessed, and any necessary adaptations, assistive devices and equipment are recommended to improve safety and independence.
Rehabilitation may be provided through Inpatient Rehabilitation, Day Rehabilitation or Rehabilitation at Home, according to the patient’s neurological and functional status and individual needs.
CREATIVE ACTIVITIES, SPORT AND SOCIAL PARTICIPATION
At ANAPLASI, creative activities, sport and social participation complement the Rehabilitation programme and are adapted to each patient’s neurological level, functional abilities, interests and therapeutic goals.
Activities include painting, arts and crafts, cooking, music and group activities, adapted sport, and participation in cultural and social activities both within and outside ANAPLASI.
The aim is to promote active participation, social interaction, the use of the patient’s functional abilities and reintegration into everyday and social life.
WHAT IS THE AIM OF THE REHABILITATION PROGRAMME?
At ANAPLASI, the aim is to enable each patient to make the fullest possible use of their functional abilities, achieve the greatest possible independence and support their active return to personal, family, social and working life.
