SPINAL
CORD INJURY (SCI)
FACT SHEET
A
spinal cord injury disrupts the communication between the brain and other parts
of the body and messages no longer flow past the damaged area of the spinal
cord.
CHARACTERISTICS
An individual with a spinal cord injury may experience a
loss of function, such as mobility or feeling.
CAUSE
The primary causes of SCI from trauma are:
·
Motor vehicle accident – 44%
·
Acts of violence – 24%
·
Falls – 22%
·
Sports injuries – 8%
Spinal cord damage
can also occur from diseases such as polio, spina bifida, Friedreich’s
Ataxia. The extent of the communication
breakdown is dependent on the severity and location of the injury. The spinal cord does not have to be severed
in order for a loss of functioning to occur. For most people with SCI, the
spinal cord is intact, but the damage to it results in loss of
functioning. SCI is very different from
back injuries such as ruptured disks, spinal stenosis, or pinched nerves.
ETIOLOGY
AND PROGNOSIS
The effects of SCI depend on the type of injury and the
level of the injury. SCI can be divided into two types of injury - complete and
incomplete. A complete injury means that there is no function 
below the level of
the injury; no sensation and no voluntary movement. Both sides of the body are
equally affected. An incomplete injury means that there is some functioning
below the primary level of the injury. A person with an incomplete injury may
be able to move one limb more than another, may be able to feel parts of the
body that cannot be moved, or may have more functioning on one side of the body
than the other. With the advances in acute treatment of SCI, incomplete
injuries are becoming more common.
The level of injury is very helpful in predicting what parts
of the body might be affected by paralysis and loss of function. Remember that
in incomplete injuries there will be some variation in these prognoses.
Cervical (neck) injuries usually result in quadriplegia.
Injuries above the C-4 level may require a ventilator for the person to
breathe. C-5 injuries often result in shoulder and biceps control, but no
control at the wrist or hand. C-6 injuries generally yield wrist control, but
no hand function. Individuals with C-7 and T-1 injuries can straighten their
arms but still may have dexterity problems with the hand and fingers. Injuries
at the thoracic level and below result in paraplegia, with the hands not
affected. At T-1 to T-8 there is most often control of the hands, but poor
trunk control as the result of lack of abdominal muscle control. Lower
T-injuries (T-9 to T-12) allow good truck control and good abdominal muscle
control. Sitting balance is very good. Lumbar and Sacral injuries yield
decreasing control of the hip flexors and legs.
Besides a loss of sensation or motor functioning, individuals
with SCI also experience other changes. For example, they may experience
dysfunction of the bowel and bladder,. Sexual functioning is frequently
with SCI may have their fertility affected, while women's fertility is
generally not affected. Very high injuries (C-1, C-2) can result in a loss of
many involuntary functions including the ability to breathe, necessitating
breathing aids such as mechanical ventilators or diaphragmatic pacemakers.
Other effects of SCI may include low blood pressure, inability to regulate
blood pressure effectively, reduced control of body temperature, inability to
sweat below the level of injury, and chronic pain.
Project Inspire, The
National Spinal Cord Injury Association, Spinal Cord Injury Resource Center
Possible
Complications Associated with Spinal Cord Injury
·
Skin Breakdown:
Skin breakdowns (also termed “pressure sores”) are a major complication
associated with spinal cord injury. They occur as a result of excessive
pressure, primarily over the bones of the buttock (particularly the ischial
tuberosities and the trochanters at the hip).
·
Osteoporosis and Fractures:
The majority of people with SCI develop osteoporosis. In people without SCI,
the bones are kept strong through regular muscle activity or by bearing weight.
When muscle activity is decreased or eliminated and the legs no longer bear the
body's weight, they begin to lose calcium and phosphorus and become weak and
brittle.
·
Pneumonia, Atelectasis,
Aspiration: Patients with spinal cord injuries
above the T4 level of injury are at risk to develop restriction in respiratory
function, termed restrictive lung disease. This occurs five to 10 years
following spinal cord injury and can be progressive in nature.
·
Heterotopic Ossification:
Heterotopic ossification is a condition not well understood that occurs in
acute spinal cord injury and consists of the laying down of bone outside the
normal skeleton, usually occurring at large joints such as the hips or knees.
The primary problem with heterotopic ossification, or HO, is the risk for joint
stiffening and fusion.
·
Spasticity: Spasticity is an exaggeration of the normal
reflexes that occur when the body is stimulated in certain ways. After spinal
cord injury, when nerves below the injury become disconnected from those above,
these responses become exaggerated.
·
Autonomic Dysreflexia:
Autonomic dysreflexia (AD) is a condition that can occur in anyone who has a
spinal cord injury at or above the T6 level. It is related to disconnections
between the body below the injury and the control mechanisms for blood pressure
and heart function. It causes the blood pressure to rise to potentially
dangerous levels.
·
Deep vein thrombosis: (DVT)
or pulmonary embolism is a potentially severe complication of spinal cord
injury. As mentioned above, there are changes in the normal neurologic control
of the blood vessels that can result in stasis or "sludging".
·
Cardiovascular Disease:
Cardiovascular disease is a major long-term risk of spinal cord injury. SCI
individuals live in general rather sedentary lives and are at higher risk for
cardiovascular disease than the able-bodied population.
·
Neuropathic/Spinal Cord Pain: Neuropathic (nerve-generated) pain is a
significant problem in some spinal cord-injured patients. Varying types of pain
are described in spinal cord injury. Damage to the spine and soft tissues
surrounding the spine can cause aching at the left of the injury. Nerve root
pain is described as sharp or may be described as having an electric shock-type
quality.
·
Respiratory Dysfunction: Respiratory complications and infection
predominate as post-SCI complications. When the injury involves the upper
thorax, the normal breathing pattern is permanently altered. When the intercostal and abdominal muscles
are paralyzed, the entire load is taken by the diaphragm. This results in poor
coughing and a high risk of pneumonia.
Spinal
Cord Injury Resource Center
IMPLICATIONS FOR PHYSICAL EDUCATION
Exercise is good for everyone, regardless
of functional capabilities. Fitness and recreation not only provide health
benefits, they promote the inclusion of people, enhancing social connections,
motivation, and self-esteem. Many individuals with SCI can participate in
almost all physical activities with some modifications. However, the adapted
equipment is essential for participation to ensure safety and success.
Adaptation and equipment should be based on the individual’s functional
abilities and personal preferences.
Support staff (physical education teacher, PT, physician) should discuss
adaptations and modifications with the individual. Based on the nature of the
injury, there are many functional levels of what people with SCI can do. It is
important to empower the individual, and stress the importance of physical
activity. Many opportunities are available for individuals with SCI to
participate in the community. When prescribing an exercise program and
participation in physical activity for individuals with SCI, there are some
important considerations to make.
Important Safety Considerations
·
Get physician consent.
·
Regularly monitor blood pressure, heart
rate, RPE, and symptoms.
·
Stop exercising if you feel pain or
discomfort
·
Don’t exercise if you are ill (i.e.,
cold, flu, bladder infection, pressure ulcer, unusual spasticity).
·
Check medications and their effect on
exercise tolerance.
·
Extended periods of inactivity may
cause osteoporosis.
Important
Considerations When Exercising
·
Incontinence
(flaccid or neurogenic bowel/bladder): Individuals with
lesions above the sacral level experience a loss of control with their bowel or
bladder.
·
Spasticity:
characterized by high muscle tone and hyperactive stretch reflexes, it
typically occurs in the muscles below the site of injury and is exacerbated by
exposure to cold air, urinary tract infections and physical exercise. Stretch
spastic muscle groups and avoid exercises that cause excessive spasticity.
·
Autonomic
Dysreflexia:
A sudden rise in blood pressure resulting from an
exaggerated autonomic nervous system response to noxious stimuli below the
level of injury, usually due to bladder/bowel overdistension or blocked
catheter. Symptoms include profuse sweating, sudden elevation in blood
pressure, flushing, shivering, headache, and nausea. KEY: Seek medical
attention immediately when it occurs.
·
Orthostatic
hypotension: A drop in blood pressure (greater
than 20 mmHg for systolic blood pressure and greater than 10 mmHg for diastolic
blood pressure). It occurs in upright postures, especially moving from supine
to upright sitting/standing/head-up tilt. Symptoms include nausea, dizziness
and lightheadedness. KEY: Monitor blood pressure throughout exercise, avoid
quick movements, perform othostatic training (if available), maintain proper
hydration, and use compression stockings and an abdominal binder. If
orthostatic hypotension occurs, lie in a supine position with your feet
elevated.
·
Thermoregulation:
Irregular body temperatures are often experienced by individuals with SCI. KEY:
Wear appropriate clothing, drink plenty of fluids and take precautions in
certain environments; in warm environments, a fan and water spray will aid in
cooling, and in cold environments, wear extra layers.
·
Pressure
sores (decubitis ulcers): Damage to the skin or underlying tissue
caused by prolonged sitting, using old wheelchair cushions, sitting on hard
surfaces, shear forces or as a result of a fall. Check skin regularly and
perform wheelchair push-ups.
·
Transfers: Be
sure to follow appropriate guidelines.
·
Balance:
Use physical assistance devices to hold body in position during upright
exercise.
Importance of Exercise
·
Prevents secondary conditions such as
cardiovascular disease, diabetes, pressure sores, carpal tunnel syndrome,
chronic obstructive pulmonary disease, hypertension, urinary tract infections,
and respiratory disease.
·
Prevents deconditioning and obesity
·
Provides psychological and/or
recreational benefits
RECOMMENDED
ACTIVITIES
·
Aerobic exercise to maintain cardiovascular health
Ř The American College of Sports
Medicine (ACSM) recommends performing 20 to 60 minutes of continuous aerobic
exercise or multiple sessions of short duration (approximately 10 minutes) for
three to five sessions per week. For individuals just starting an exercise
program, a circuit-training program is effective. Aerobic exercise can be monitored using an
individual’s maximal heart rate (MHR) or rating of perceived exertion (RPE).
MHR for individuals with SCI is significantly lower than for individuals
without SCI while RPE should be moderate to somewhat strong.
·
Strength
training to maintain the ability to perform activities of daily
living and mobility, as well as to prevent injury through muscular balance
Ř
Training sessions should be held three
days per week.
Ř
Refrain from training the same muscle
groups on consecutive days.
Ř
Upper-body pushing and pressing
exercises (bench press, overhead press) will help transfers and wheeling, while
pulling/rowing exercises will help prevent shoulder overuse injuries and
improve sitting posture.
Ř
Perform wheelchair push-ups every 10 to
30 minutes and hold for 30 to 60 seconds. When doing wheelchair push-ups, be
sure to bend the elbows slightly.
Ř
Use straps or a partner for
stabilization and balance.
Ř
Vary exercises to reduce over-use
injuries and emphasize muscle groups that are still functional.
Ř
Types of strength training that benefit
individuals with SCI are free weights, weight machines (Nautilus, for example),
medicine ball, wall
pulley, and theraband.
·
Flexibility
training to improve range of motion and reduce spasticity
Ř Flexibility training is important to
prevent contractures (permanently shortened muscles). Paralyzed muscles should
be passively stretched by an exercise specialist; specifically, the hamstrings,
adductors, hip flexors, plantar flexors, and lumbar extensors.
Ř Types of flexibility training are
passive resistance, theraband and standing in a standing frame (if not
medically contraindicated).
Quadriplegia
MHR typically does not exceed 100 to
125 bpm, and training intensity should be between 50% and 70% maximal heart
rate. Therefore, average target heart rate (THR) falls between 65/91bpm. Arm ergometry is a preferred type of exercise
training for individuals with quadriplegia. Be sure the wheelchair is locked,
the hands are secured to the equipment (straps can be used for stability and
balance) and the ergometer is in a fixed position.
Paraplegia
The MHR of individuals with a lesion
T1 to T6 is suppressed; however, for lesions below T6, the MHR is closer to the
age-predicted maximum. Training intensity should not go above 70%. Types of cardiovascular training that benefit
individuals with paraplegia are wheelchair ergometry, upper-body calisthenics,
rowing machine, sports: (basketball, track, swimming, quad rugby), and
functional electrical stimulation-leg cycle ergometer (FES-LCE).
Project Inspire
Christopher and Dana
Reeve Paralysis Resource Center
The National Center
on Physical Activity and Disability
RESOURCES & REFERENCES