Tetraplegia+and+Paraplegia by Ida Bromley

2006, Elsevier Ltd First edition 1976 Second edition 1981 Third edition 1985 Fourth edition 1991
Fifth edition 1998 The right of Ida Bromley to be identied as author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elseviers Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: healthpermissions@elsevier. com. You may also complete your request on-line via the Elsevier homepage (http:// www.elsevier.com), by selecting Support and contact and then Copyright and Permission.
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Contributors
Ebba Bergstrm MCSP MPhil Clinical Specialist Physiotherapy, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury Sarah Brownlee MCSP Formerly Senior Staff Member, Stoke Mandeville Hospital, Aylesbury Susan Edwards FCSP
Clinical Specialist, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury and Sessional Physiotherapist, The Bobath Centre, London and Honorary Lecturer, University College, London
Roger Ellis MCSP

Superintendent Physiotherapist, Yorkshire Regional Spinal Injuries Centre, Pinderelds General Hospital, Wakeeld and Honorary Lecturer, Universities of Leeds and York
Lone S. Rose MCSP

Clinical Specialist Physiotherapy, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury
Dot Tussler MCSP MSc

Superintendent Physiotherapist, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury
vii
Preface
6th edition
The purpose of this book has always been to act as a manual for physiotherapists faced with the challenge of treating patients with tetraplegia and paraplegia. It is written particularly for those who have little experience in this eld or who do not have the benet of working in a spinal injuries centre. The text is therefore not exhaustive but suggests methods of treatment which have been used for many years and found valuable for a large number of patients. The principles of treatment were originally laid down by Sir Ludwig Guttmann at the National Spinal Injuries Centre, Stoke Mandeville, in England where his interest in and enthusiasm for physiotherapy are well known. Unlike many other textbooks on this subject, this book outlines a rehabilitation programme from the day of the patients admission as an acute lesion to the achievement of individual maximum independence and includes treatment for patients with incomplete lesions, those with lesions above C2 and the particular problems encountered in treating children. The layout of the material may seem repetitious but it is intended to facilitate the use of the book for those who are involved in handling the patients and believe as I do that efcient treatment depends upon attention to detail. For clarity in the sections involving specic actions of patient and therapist, his is always used for the patient and her for the therapist. Both ordinal and metric systems of measurement have been given in this edition. The most commonly used system (such as that by the manufacturer) is placed rst. The biomechanical principles of transferring have now been included as a basis for the chapters which follow in the hope that they may prove useful to both students and others. Additions to this volume reecting developments over the past few years include current approaches to repairing the spinal cord, ageing with spinal cord injury, pressure and related problems, with a detailed assessment of the posture of the seated patient and the latest in wheelchair design. The role of the patient as the centre of the rehabilitation team has been given greater emphasis. I am deeply indebted to many people for their contribution to this and previous volumes. Without the support of my long standing colleagues and friends this edition would never have been published. I am doubly indebted therefore to Ebba Bergstrm, Susan Edwards, ix
PREFACE
Lone Rose, Dot Tussler and Roger Ellis not only for their contributions but for their encouragement and for giving their time unstintingly to discuss various issues with me. I am grateful once again to Mr El Masry for his warm hospitality on my visit to his unit at Oswestry and for assisting me to revise the medical chapter. My thanks also to the staff of all the spinal units I visited in the UK for their friendly welcome and the time they gave to discuss their work. For giving up their precious retirement hours to assist me I would also like to thank Liz Hubbard for her extensive work with the references and Lois Dyer for her comments and suggestions when reading and re-reading the text. Without the excellent illustrations it would have been difcult for this book to full its function and I am especially grateful for the contribution of the artists over the years Janet Plested, Jane Upton and in this edition Paul Banville. It has been interesting for me to work with a new publisher and I have been in contact with many of the staff of Elsevier during the various stages of production. Without exception they have all been helpful, charming, consoling and amusing as necessary. Many thanks to all of them for their assistance and for making me feel an integral part of the initial stages of the publication of this book.
Spinal cord injury
CHAPTER
1
Denition of the level of lesion 3 Measurement scales 4 Repairing the spinal cord 7
Spinal cord injury is not a notiable disease and therefore gures for the annual incidence are inaccurate and may vary according to the source. The estimated incidence of spinal cord injury worldwide is between 11 and 53 cases per million inhabitants (Tator 2004). In general, road trafc accidents account for the largest number followed by falls, sports injuries and violence, although causes vary considerably according to the prevailing circumstances in the country in which they occur. The numbers are augmented by the group of people with spinal cord damage caused by disease or other forms of injury, e.g. stab wounds. The non-traumatic cases have a different demographic prole and a lower prevalence of many of the complications that affect those with traumatic lesions (New et al 2002). Until Sir Ludwig Guttmann pioneered a positive approach to the treatment of spinal cord lesions at Stoke Mandeville Hospital in the mid-1940s, most people died of the resultant complications (Guttmann 1946). Regrettably this can still happen today where appropriate skills, knowledge and facilities are not readily available. Spinal injury units now exist worldwide and international symposia on the treatment of those with spinal cord lesions take place regularly. The life expectancy of this group of people has steadily increased over the last six decades, and with constantly improving methods of treatment this trend should continue. Patients with spinal cord injury are initially totally dependent on those around them and need expert care if they are once again to become independent members of the community. It is an exciting and rewarding challenge to be involved in and contribute to the metamorphosis which occurs when a tetraplegic or paraplegic patient evolves into a spinal man (Fig. 1.1). In this book, maximum detail has been given in the sections dealing with the tetraplegic patient. Solutions to the majority of problems facing those with paraplegia have now been found, whereas many of the social, professional and industrial rehabilitation problems of those with tetraplegia have still to be solved. The tetraplegic patient needs a longer period of rehabilitation to achieve maximum independence and overcome the sometimes apparently insurmountable obstacles. With the increased expertise of paramedical personnel in the ambulance service, the lives of patients who have fractures as
TETRAPLEGIA AND PARAPLEGIA
Rehabilitation Injury Postural reduction Correct positioning Chest therapy Passive movements Fracture healed Pressure consciousness Strength Balance Mobility Wheelchair management Standing Transfers Walking in bars Car Transport Walking on crutches Chair manoeuvres
Social activities outside the hospital
Home for week-ends for assessment
Bed Dress
Bath Wash
Toilet Bladder and bowel care
Institutional care Training for relatives in patient care Self-care Mobility in the environment
Community
Home Spinal man re-integrated at home, at work and in local community
Employment
Figure 1.1 Dependence to independence.
SPINAL CORD INJURY
high as C1/C2 are saved at the scene of the accident and they now reach hospital alive. Of the cases admitted to spinal units, the majority are traumatic, and about half of these involve the cervical spine. The major causes of the approximately one-thousand new traumatic cases of spinal cord injury per year in the UK are road trafc accidents, industrial accidents, sporting injuries and accidents in the home. The majority of the traumatic cases are found to have fractures/dislocations, fewer than a quarter have fractures only, and a very small number are found to have involvement of the spinal cord with no obvious bony damage to the vertebral column, e.g. those with whiplash injuries. The most vulnerable areas of the vertebral column would appear to be:

lower cervical, C5C7 mid-thoracic, T4T7 thoracolumbar, T10L2.
The non-traumatic cases are mainly the result of transverse myelitis, tumours and vascular accidents. Thrombosis or haemorrhage of the anterior vertebral artery causes ischaemia of the cord with resulting paralysis. Spinal cord damage resulting from either injury or disease may produce tetraplegia or paraplegia depending upon the level at which the damage has occurred, and the lesion may be complete or incomplete. 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, 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 of 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. 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. (Ditunno et al 1994)
DEFINITION OF THE LEVEL OF LESION

There are 30 segments in the spinal cord: 8 cervical, 12 thoracic, 5 lumbar and 5 sacral. As the spinal cord terminates between the rst and second lumbar vertebrae, 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, the 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 distances in the canal before exiting. The 12 thoracic segments lie within the area covered by the upper 9 thoracic vertebrae; the 5 lumbar segments lie within that covered by vertebrae T10 and T11; and the 5 sacral segments lie within T12 and L1 vertebrae. Several methods of classication of the level of lesion are in use throughout the world. The system most often used in the UK is to give the most distal uninvolved segment of the cord together with the skeletal level, e.g. paraplegia, complete or incomplete, below T11, due to fracture/dislocation of vertebrae T9T10 (Fig. 1.2). A lesion may not be the same on both sides, e.g. C5L/C7R. To give some idea of the neurological involvement in incomplete lesions, the most distal uninvolved segment is given together with the last segment transmitting any normal function, e.g. incomplete below C5, complete below C7. In this case, some motor power or sensation supplied by C6 and C7 is present.
MEASUREMENT SCALES
The inadequacy of the neurological level to dene function and disability has long been recognized. The degree of paralysis, loss of sensation and the inability to perform activities of daily living demonstrate the severity of an injury, and in order to identify that level of disability measurements are required in all these areas. Such measures are necessary not only for the comparison of research results but also to facilitate communication between clinicians. The International Standards for Neurological and Functional Classication of Spinal Cord Injury were published in 1994 (Ditunno et al 1994). These standards provide a tool to determine neurological level and to calculate a motor, sensory and functional score for each patient. They represent a valid, precise and reliable minimum data set. The neurological levels are determined by examination of the following:

a key sensory point within 28 dermatomes on each side of the body a key muscle within each of 10 myotomes on each side of the body. The sensation and motor power present are quantied, giving a nal numerical score.
This is achieved by using the spinal cord injury scale of the American Spinal Injury Association (the ASIA scale) to grade impair-
SPINAL CORD INJURY
1
I I II II III IV V VI VII I II III IV V IV V VI VII VIII IX VI VI VIII IX X XI XII I I II II III IV III IV V VI VII I II III
Cervical segments 1-8
2 3 4 5 6 7 8
Cervical roots
Thoracic segments 1-12
1 2 3 4 5 6 7 8 9 10 11 12
Thoracic roots
Lumbar segments 1-5 Sacral segments 1-5
X XI XII
1 2 3 4 5 Sacral roots Lumbar roots
Coccygeal segment
III IV V I II III IV V V II III IV I V
1 2 3 4 5
Coccygeal root
Figure 1.2 Topographical correlation between spinal cord segments and vertebral bodies, spinous processes and intervertebral foramina. (From Haymaker 1969.)
ment of sensation and motor power (Appendix 1), and the Functional Independence Measure (FIM) to measure disability and grade function (Appendix 2). The ASIA impairment scale (Table 1.1; see also Appendices 1 and 2) is based on the Frankel scale (Capaul et al 1994) (Table 1.2). The letters A to E are used to denote degrees of impairment. The Frankel scale has broader bands than the ASIA scale, so unless there is marked improvement or deterioration it is more difcult to show change.
Table 1.1 The ASIA impairment scale

Grade Description A B Complete: no motor or sensory function is preserved in the segments Incomplete: sensory (but not motor) function is preserved below the neurological level and extends through the sacral segments S4S5 Incomplete: motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade less than 3 Incomplete: motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3 Normal: motor and sensory function are normal
Table 1.2 The modied Frankel scale

Grade A B C D E Description Complete Sensory only Motor non-functional Motor functional Recovered
The FIM, as its name states, is devised to measure function for any disability. Each area of function is evaluated in terms of independence using a seven-point scale. A total score from all these measures is calculated each time an assessment is carried out and progress can be readily seen. Clinicians are using the ASIA scale and reporting that its accuracy is greater than the Frankel scale in classifying injuries and monitoring progress (Capaul et al 1994, Tetsuo et al 1996). Others suggested amendments (El Masry et al 1996). The Spinal Cord Independence Measure (SCIM) (Catz et al 1997) (Appendix 3) was developed to provide a more sensitive measure than the FIM scale for assessing changes in function (Catz et al 2001a). The SCIM covers self-care, respiratory and sphincter management and mobility. A revised version, SCIM II, combines the scores on the ASIA and the SCIM scales (Catz et al 2001b). Catz et al (2004) have developed the Spinal Cord InjuryAbility Realization Measurement Index (SCI-ARMI). The difference between the expected and actual function achieved is used to predict and assess the success of the rehabilitation programme. Measuring the success of rehabilitation is extremely difcult. The Needs Assessment Checklist (NAC) has been developed to measure the outcome of rehabilitation and takes a much wider view of what is required than the other scales (Kennedy & Hamilton 1999). The outcome of the patients rehabilitation is assessed on the goals the patient and the multidisciplinary team have set together. It is completed when the patient is rst up in the wheelchair and again prior to discharge. Indicators have been set in nine areas: activities of daily living, skin management, bladder management, bowel management, mobility, wheelchair and equipment, community preparation, discharge coordination and psychological issues. Questions in each area are
SPINAL CORD INJURY
Table 1.3 The Ashworth scale

Grade 0 1 2 3 4 Description Normal muscle tone Slight increase in muscle tone, catch when limb is moved More marked increase in muscle tone, but limb easily exed Considerable increase in muscle tone Limb rigid in exion or extension
marked from 0 to 3. No distinction is made between verbal and physical independence, enabling each patient to have the potential to achieve 100% independence. Those with high level disability must be able to exert control, articulate their own needs and organize their programme of activities. It has so far proved to be clinically relevant and patient friendly (Berry & Kennedy 2003). In addition to these measures, some therapists and other professionals are using the Ashworth scale of muscle spasticity (Table 1.3). Therapists now have tools to measure the outcome of treatment and to identify landmarks in the recovery of patients with spinal cord lesions. Interesting data should be collected within units, both nationally and internationally, which will undoubtedly determine future therapy.
REPAIRING THE SPINAL CORD

The development of a nervous system is one of the most complex embryogenetic tasks, so it is not surprising that repairing any damage is extremely difcult (Fawcett 2002). Experiments have shown that features in the environment of the central nervous system (CNS) inhibit axon regeneration. This is particularly so when scarring has occurred in the spinal cord (Fournier et al 2001, Grandpre et al 2000). In addition, degeneration of cells occurs in the spinal cord after injury (Buss et al 2004). To nd a cure for spinal cord injury requires an extensive knowledge of the disorder in neuropathological terms and an appreciation of the complexity of the spinal cord (Kakulas 2004). Central axonal regeneration and restoration of normal function motor, sensory and autonomic is a massive task. Nevertheless throughout the world innovative clinical approaches to the management of spinal cord injuries are being investigated with the aim of reversing or improving the neurological decit. For example, research has been undertaken into the possibility of therapeutic roles in spinal cord injury using:
neural stem cell biology grafted peripheral nerve tissue rerouting nerves from above the level of the lesion to the nerve root that controls the function to be restored below the lesion grafted tissue from the omentum reconstructive surgery to revascularize the injured cord medication to stabilize spinal cord trauma and overcome conductive decits due to demyelination (Johnston 2001) therapeutic strategies designed to maximize adaptation in cortical plasticity to aid function (Hayes et al 2004).
Basic scientic research in animals has identied several procedures that may benet humans with spinal cord injury. These inevitably fall far short of offering full repair (Raineteau et al 2002). Grafts, transplants and cellular therapy are at the forefront of current research, offering hope for a cure by delivering cells to the damaged area which have the ability to differentiate and migrate. For example:

peripheral nerve transplants to deliver the myelin from the Schwann cells (Harvey & Plant 1995, Pearse 2004) bridging grafts using the hippocampus (Raisman 2003) olfactory ensheathing cells which continually replace nasal epithelial cells (Moreno-Flores et al 2002, Plant et al 2003) primitive bone marrow cells (Lemoine 2002, Hess et al 2004) embryonic stem cells (Lemoine 2002, Tai & Svendsen 2004).
It is not currently known which type of cells will ultimately be the most effective and each will need to be thoroughly evaluated in an animal model. The Cambridge Stem Cell Institute has been recently established at Cambridge University for research in this eld. It has been suggested that treatment leading to recovery of signicant function may require a combination of approaches such as manipulation of nerve growth and inhibitory factors, insertion of bridging grafts and the deployment of cell types (Ramer et al 2005). It is considered by many researchers that treatments which return function over two spinal segments would be of sufcient benet to be worth offering to those with spinal cord injury. Initially interventions will probably be applied to the thoracic spine to minimize loss of any function which might occur from damage to surviving connections. Although major benet over one or two segments would be most likely to occur in the cervical spine, should treatment cause further damage the consequences would be extremely serious. Treatments to the thoracic spine would be safer though the improvement more modest. In spite of this the trials will be worthwhile as a test for future treatment at cervical level. It is possible that trials in humans will start within a few years. A satisfactory means of measuring recovery is required if the efcacy in humans is to be adequately assessed. Current systems of measurement are not sensitive enough to evaluate changes at segmen-
SPINAL CORD INJURY
tal level. A range of clinical and physiological tests of sensory, motor and autonomic function, which are practical to administer, will be required to monitor recovery and function reliably. A review of the progress made into improving methods for detecting change and recovery in spinal cord injury in humans has been undertaken by a group set up and nanced by the International Spinal Research Trust. Though incomplete as yet a number of advances in techniques for assessment have already emerged (Ellaway et al 2004). Charitable organizations have been promoting research that will cure paralysis associated with spinal cord injury for over 20 years. Now that encouraging signs are emerging many of these organizations have formed an alliance, the International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP), to determine ways in which their collaboration can hasten progress (Adams & Cavanagh 2004). The rst ICCP international meeting on clinical trials was held in Vancouver in February 2004. The meeting brought together a variety of disciplines together with non-governmental organizations, foundations and representatives of the spinal cord injury community and introduced them to the progress in clinical trials and the complexities involved in effective clinical trial design. A working committee was set up to consider more detailed guidelines on how to develop the most accurate and effective spinal cord injury clinical trials (Steeves et al 2004).
References
Adams M, Cavanagh J F R 2004 International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP): another step forward for spinal cord injury research. Spinal Cord 42:273280 Berry C, Kennedy P 2003 A psychometric analysis of the Needs Assessment Checklist (NAC) Spinal Cord 41:490501 Buss A, Brook G A, Kakulas B et al 2004 Gradual loss of myelin and formation of an astrocytic scar during Wallerian degeneration in the human spinal cord. Brain 127:3444 Capaul M, Zollinger H, Satz N et al 1994 Analyses of 94 consecutive spinal cord injury patients, using ASIA denition and modied Frankel score classication. Paraplegia 32:583587 Catz A, Itzkovich M, Agranov E et al 1997 SCIM Spinal Cord Independence Measure: a new disability scale for patients with spinal cord lesions. Spinal Cord 35:850856 Catz A, Itzkovich M, Agranov E et al 2001a The Spinal Cord Independence Measure (SCIM): sensitivity to functional changes in subgroups of spinal cord lesion patients. Spinal Cord 39:97100 Catz A, Itzkovich M, Steinberg F 2001b The CatzItzkovich SCIM: a revision of the SCIM. Disability and Rehabilitation 23:263268 Catz A, Greenberg E, Itzkovich M et al 2004 A new instrument for outcome assessment in rehabilitation medicine: Spinal Cord Injury Ability Realization Measurement Index. Archives of Physical Medicine and Rehabilitation 85:399404
10
Ditunno J F, Young W, Donovan W H, Creasey G 1994 The international standards booklet for neurological and functional classication of spinal cord injury. American Spinal Injury Association. Paraplegia 32:7080 Ellaway P H, Anand P, Bergstrom E M K et al 2004 Towards improved clinical and physiological assessments of recovery in spinal cord injury: a clinical initiative. Spinal Cord 42:325337 El Masry W S, Tsubo M, Katoh M et al 1996 Validation of the American Spinal Injury Association (ASIA) Motor Score and the National Acute Spinal Cord Injury Study (NASCIS) Motor Score. Spine 21(5):614619 Fawcett J 2002 Repair of spinal cord injuries: where are we, where are we going? Spinal Cord 40:615623 Fournier A E, Grandpre T, Strittmatter S M 2001 Identication of a receptor mediating Nogo-66 inhibition of axonal regeneration. Nature 409:341346 Grandpre T, Nakamura F, Vartamian T, Strittmatter SM 2000 Identication of the Nogo inhibitor of axon regeneration as a reticulon protein. Nature 403:439444 Guttmann L 1946 Rehabilitation after injury to spinal cord and caudal equina. British Journal of Physical Medicine 9:130160 Harvey A R, Plant G W 1995 Schwann cells and foetal rectal tissue cografted to the midbrain of newborn rats: fate of Schwann cells and their inuence on host retinal innervation of grafts. Experimental Neurology 134:179191 Hayes K C, Davies A L, Potter P J 2004 Restorative neurological approaches to the rehabilitation of individuals with longstanding spinal cord injury. Topics in Spinal Cord Injury Rehabilitation 10(1):5162 Haymaker W 1969 Bings local diagnosis in neurological diseases, 15 edn. Mosby, St Louis Hess D C, Hill W D, Carroll J E, Borlongan C V 2004 Do bone marrow cells generate neurons? Archives of Neurology 61:483485. Johnston L 2001 Human spinal cord injury: new and emerging approaches to treatment. Spinal Cord 39:609613 Kakulas B A 2004 Neuropathology: the foundation for new treatments. Spinal Cord 42:549563 Kennedy P, Hamilton L R 1999 The Needs Assessment Checklist: a clinical approach to measuring outcome. Spinal Cord 37:136139 Lemoine N R 2002 The power to deliver: stem cells in gene therapy. Gene Therapy 9:603605 Moreno-Flores T, Diaz-Nido J, Wandosell F, Avila J 2002 Olfactory ensheathing glia: drivers of axonal regeneration in the central nervous system? Journal of Biomedicine and Biotechnology 2:3743 New P W, Rawicki H B, Bailey M J 2002 Non-traumatic spinal cord injury: demographic characteristics and complications. Archives of Physical Medicine and Rehabilitation 83:9961001 Pearse D D 2004 cAMP and Schwann cells promote axonal growth and functional recovery after spinal cord injury. Nature Medicine 10:610616 Plant G W, Christensen C L, Oudega M, Bunge M B 2003 Delayed transplantation of olfactory ensheathing glia promotes sparing/ regeneration of supraspinal axons in the contused adult rat spinal cord. Journal of Neurotrauma 20:116
SPINAL CORD INJURY
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Raineteau O, Fouad K, Bareyere F M, Schwab M E 2002 Reorganisation of descending motor tracts in the rat spinal cord. European Journal of Neuroscience 16:17611771 Raisman G 2003 A promising therapeutic approach to spinal cord repair (editorial) Journal of the Royal Society of Medicine 96:259261 Ramer L M, Ramer M S, Steeves J D 2005 Setting the stage for functional repair of spinal cord injuries: a cast of thousands. Spinal Cord 43: 134161 Steeves J, Fawcett J, Tuszynski M 2004 Report of International Clinical Trials Workshop on Spinal Cord Injury, February 2021, 2004 Vancouver, Canada. Spinal Cord 42:591597 Tai Y-T, Svendsen C N 2004 Stem cells as a potential treatment of neurological disorders. Current Opinion in Pharmacology 4:98104 Tator C H 2004 Current primary to tertiary prevention of spinal cord injury. Topics in Spinal Cord Injury Rehabilitation 10(1):114 Tetsuo O, Kagulo A, Masaaki N et al 1996 Functional assessment of patients with spinal cord injuries measured by the motor score and the FIM. Spinal Cord 34:531535
Physiological effects and their initial management

CLINICAL EFFECTS OF SPINAL CORD INJURY
Severe injury to the vertebral column can occur from any direction and result in dislocation, fracture or fracture/dislocation with or without resultant displacement. As a result, extensive trauma can occur to the spinal cord as it is compressed, crushed or stretched within the spinal canal (Hughes 1984). Yet there appears to be no absolute relationship between the severity of the damage to the vertebral column and that to the spinal cord and roots. A patient may sustain a severe fracture/dislocation and yet the spinal cord may be undamaged or only partially damaged. Another may exhibit no obvious vertebral damage on X-ray and yet have sustained an irreversibly complete tetraplegia. The spinal cord conveys impulses to and from the brain, and through its various afferent and efferent pathways provides a vital link in the control of involuntary muscle. Transection of the cord will result in loss of:

CHAPTER
2
Clinical effects of spinal cord injury 13 Early complications 14 AIMS OF MANAGEMENT 15 Management of the spine 15 Postural reduction 16 Correct positioning of the patient 18 Turning the patient 18 Multisystems impairment 18 Management of the bladder 18 Management of the bowels 23 Sexual dysfunction 24 Male 24 Female 25 Autonomic dysreexia 26
motor power deep and supercial sensation vasomotor control bladder and bowel control sexual function.
Frequently, at the actual level of the lesion there is complete destruction of nerve cells, disruption of the reex arc and accid paralysis of the muscles supplied from the destroyed segments of the spinal cord. This segmental reex loss is of little importance when the lesion involves the mid-thoracic region, but when the cervical or lumbar enlargements are involved, some important muscles in the upper or lower limbs are inevitably affected with accid paralysis. In the same way, a lesion at the level of the lumbar enlargement or cauda equina may destroy the reex activity of the bladder and rectum and thus deprive the paraplegic person not only of voluntary, but also of involuntary (or automatic) control. Lesions may be complete, where the damage is so extensive that no nerve impulses from the brain reach below the level of the lesion, or incomplete, where some or all of the nerves escape injury (see Ch. 15). 13
14
Immediately after injury the patient will be in a state of spinal areexia. The nerve cells in the spinal cord below the level of the lesion (i.e. the isolated cord) do not function. No reexes are present and the limbs are entirely accid. This depression of nerve cell activity can last for a few hours or days (particularly in young people), or up to 6 weeks. Gradually the cells in the isolated cord recover function, although they are no longer controlled by the brain. The reexes return and the stage of spasticity ensues. If complications exist, the return of reex activity can be delayed (Guttmann 1970). As the spinal cord terminates at the level of the lower border of L1, vertebral lesions below this level do not cause spasticity. The damage in these cases occurs to nerve roots only or is due to direct injury of the conus terminalis. Occasionally a cord lesion of higher level may also cause sustained accidity. This is due to injury in the longitudinal as well as the transverse plane, or to longitudinal vascular damage. Oedema or bleeding within the spinal cord may cause the level of the lesion to ascend one or even two segments within the rst few days after injury. This is nearly always temporary, and the nal neurological lesion will probably be the same as or even lower than that found immediately after injury. Other skeletal or internal injuries are often present in addition to the spinal injury. Diagnosis of these injuries is rendered more difcult by the lack of sensation. The most common associated injuries are those of the long bones, head and chest. Head injuries are frequently found in conjunction with cervical fractures. Crush injuries of the chest with fractured ribs, pneumothorax or haemopneumothorax are commonly associated with fractures of the thoracic spine (Frankel 1968). Abdominal injuries also occur in some cases.
Early complications
Chest complications
The paralysis of the muscles of respiration, including the abdominal muscles, can give rise to serious problems (see Ch. 5).
Deep venous thrombosis

Deep venous thrombosis is recognized clinically by characteristic swelling of the leg. Erythema and low grade temperature may also occur. Unless contraindicated, patients are given prophylactic anticoagulant therapy (Silver 1975, Thumbikat et al 2002). Some advocate a combined approach using, in addition to anticoagulant therapy, pneumatic compression of the lower limbs for the rst 30 days, plus elastic stockings (Aito et al 2002). The swelling is frequently discovered by the physiotherapist when examining the limbs before giving passive movements. If a deep
PHYSIOLOGICAL EFFECTS AND THEIR INITIAL MANAGEMENT
15
venous thrombosis is diagnosed in either one or both legs, passive movements to both lower limbs are discontinued until the anticoagulation has been stabilized.
Pulmonary embolism
This usually occurs between the second and fourth week, occasionally later, but most commonly between the 10th and 15th days. If an undiagnosed deep venous thrombosis is present, it may give rise to an embolus when the physiotherapist begins to move the leg. Many patients have pulmonary embolism without prior evidence of deep venous thrombosis.
AIMS OF MANAGEMENT
In spinal cord injury centres, the aim of management is the simultaneous treatment of the spinal injury, the multisystems impairment and the non-medical effects of paralysis.
MANAGEMENT OF THE SPINE

The principles of management of the spine are to:

enhance neurological recovery avoid neurological deterioration achieve biomechanical stability of the spine at the site of the fracture, preserving spared neural tissue until healing occurs.
Some neurological recovery is expected in patients with incomplete spinal cord lesions, provided the physiological instability of the spinal cord and the biomechanical instability of the spinal column are well controlled. Any major complications from the paralysis, such as pressure ulcers, septicaemia or hypoxia, can further destabilize a physiologically unstable spinal cord which has lost its bloodbrain barrier and its autoregulatory mechanisms. This can result in lack of neurological recovery or further neurological deterioration (El Masry 1993). In order to prevent further mechanical damage of the neural tissues due to displacement at the fracture site, it is important that the biomechanical stability of the spinal column is contained by either conservative or surgical means. If, however, biomechanical stability is to be obtained through surgery, it is important that the physiologically unstable spinal cord is not further destabilized by hypoxia hypotension during or after the surgical procedure. Reduction of the spine can be achieved by conservative as well as surgical means and with or without traction depending on the type of injury. Oedema within the spinal cord is probably at a maximum
16
48 hours after injury. In view of this, some clinicians believe that it is dangerous to actively reduce the fracture dislocation after this time, especially in elderly people or in patients with degenerative changes in the spine. As some reduction of the size of the spinal canal is inevitable during the process of spinal reduction, the oedematous and swollen cord may be further damaged during the procedure. Early reduction is therefore particularly important. To date there is no evidence that realignment results in improvement of neurological recovery (Kakulas 2004). Computerized tomography and, in particular, magnetic resonance imaging (MRI) now enable clinicians to assess impingement on the cord within the spinal canal and the longitudinal extent of cord pathology. MRI is a useful tool in determining and re-evaluating different management procedures for different patterns of injury (El Masry et al 1993). Clinical trials have shown that corticosteroids (methylprednisolone) given in the acute phase conserve neurological function to a slight degree by limiting axonal damage. Bracken et al (1992) suggest it should be given within 8 hours of injury. Some spinal units are giving this treatment (Bracken et al 1992, Kakulas 2004). As it is not yet known if the benet is sustained long term or whether there may be serious consequences, others are more cautious (El Masry & Short 1997, Quain et al 2005).
Postural reduction
Various surgical procedures are used to stabilize the fracture in spinal injury centres throughout the world. In other centres, the initial treatment of the fracture dislocation is usually conservative, i.e. by postural reduction (Guttmann 1945, Frankel et al 1970, Ersmarke et al 1990). Postural reduction, with or without traction, is aimed at aligning the fractured vertebra and restoring and maintaining the normal curvature of the spine. After the initial X-rays are taken, pillows and/or a roll are used to place the spine in the optimum position to reduce the dislocation and allow healing of the fracture. The majority of injuries are the result of acute exion, exion/rotation or extension of the spine, and the position has to be adjusted accordingly. Control X-rays are taken over the next few days and weeks to check that the position is achieving the desired results. Plaster jackets or beds are never used because of the grave risk of pressure ulcers.
Fractured cervical spine

A rm, small roll made of wool and covered with linen or tube gauze is used to support the fracture. This roll is placed on top of a single
17
pillow which extends under the shoulders as well as under the head. If further extension is needed, the pillow is placed under the shoulders and the head is allowed to rest on a sheepskin pad on the bed. Two pillows are used to support the thorax and a single one is placed under the glutei and thighs, with a gap of approximately 8 cm (3 inches) in between the pillows to prevent pressure on the sacrum. A pillow is placed underneath the lower legs to avoid pressure on the heels by keeping them off the bed. A double pillow or several pillows bound together are set against the footboard to support the feet and toes in dorsiexion. If skull traction is necessary, as is the case in the majority of cervical injuries, the weights are moderate, i.e. 2.76.8 kg (615 lb) for 6 weeks on average.
Fractured thoracic or lumbar spine

Two pillows are usually sufcient to extend and support fractures of the dorsolumbar spine. Occasionally, a third pillow or a roll may be necessary to obtain the correct degree of hyperextension. Pillows have to be adjusted in such a way that the bony prominences are always free of pressure. The patient must be handled very carefully at all times. He must be lifted by four people or rolled in one piece with the fracture site well supported and the spine in correct alignment. Flexion and rotation particularly must be avoided. There appears to be no difference in the outcomes of conservative or surgical treatment (Kakulas 2004) The complications can be greater following surgical intervention (Bravo et al 1996). In particular, there is less interference with the blood supply of the spinal cord using conservative methods. Avoiding the possibility of further neurological damage is crucial whatever method is used. Occasionally a late surgical stabilization procedure may be indicated where a spinal fracture remains unstable in both complete or incomplete lesions (Brooke et al 2003). Even when conservative management is preferred, there will be occasions when surgery is indicated, for example when further neurological decit or gross bony displacement occurs which does not respond to conservative management in the rst few days (Frankel et al 1987). A person with spinal cord injury depends on spinal mobility in certain respects more than the able-bodied person. For example, a tetraplegic patient in a wheelchair relies on rotation of the neck to look behind. This requires approximately 67% rotation in normal subjects (Bennett 2002). To full their potential in the activities of daily life all paralysed people require good spinal mobility. Wang et al (2003) suggest that surgical stabilization of more than two functional spinal segments in the mobile (cervical, thoracolumbar and lumbar) sections of the spine poses a high risk of restriction of spinal mobility and this needs to be borne in mind when planning major surgery.
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Correct positioning of the patient

Correct positioning of the patient in bed (see Ch. 4) is important in order to:

obtain correct alignment of the fracture prevent contractures prevent pressure ulcers inhibit the onset of severe spasticity.
Turning the patient

Patients are turned every 3 hours, day and night. The supine and side-lying positions are used for the acute lesion. In cervical and upper thoracic injuries, the prone position is unsuitable as it may cause further embarrassment to the respiratory system by inhibiting the excursion of the diaphragm. This can result in hypoxia. Immediately prior to discharge home, the turning interval may be increased to 4 and then to 6 hours.
MULTISYSTEMS IMPAIRMENT
The aims of treatment for the multisystems impairment are to:

prevent death by resuscitation and maintenance of respiration (Ch. 5) prevent avoidable complications such as pressure ulcers (Ch. 6) institute a regimen of treatment for the care of the paralysed bladder and bowels.
Management of the bladder

Disturbance of bladder function can produce many complications which constitute a lifelong threat to the patient. Statistics have shown that renal disease was responsible for the majority of deaths among patients with spinal lesions. This is not now the case, but assiduous and continuing bladder care is essential if complications are to be prevented. Modern management of the bladder has successfully reduced renal related mortality in spinal cord injuries from 95% in the rst half of the 20th century to 3% at the beginning of the 21st (Jamil 2001).
The acute lesion

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.
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Paralysis of the bladder during the rst few days after acute spinal damage is total and accid. During this period of spinal areexia, all bladder reexes and muscle action are abolished. The patient will develop acute retention, followed by passive incontinence due to overow 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 areexia, the bladder may be emptied in several ways, including:
urethral catheterization intermittent indwelling suprapubic drainage.
For acute lesions from whatever cause traumatic, vascular or viral the treatment of choice at the Stoke Mandeville Centre and other centres throughout the world is intermittent catheterization (Frankel 1974, Green 2004). This method allows some distension of the bladder, which represents the physiological stimulus for micturition and triggers the appropriate impulses to the spinal bladder centre. This promotes return of detrusor activity. A long-term indwelling catheter is likely to be the source of bladder infection, vesical calculi, urethral strictures, diverticulae and stulae, and periurethral abscesses. A ne-bore suprapubic catheter is often the most appropriate treatment for female patients during the rst 2 months post-injury, and for tetraplegic patients they are sometimes left permanently. Patients with total transection of the spinal cord no longer feel the specic sensations which indicate that the bladder needs emptying. Many patients, however, feel other sensations related to bladder lling and learn to interpret these as an indication that the bladder is full. The most common of the substitute sensations is a vague feeling of abdominal fullness which is the result of an increase in intravesical and/or intra-abdominal pressure.
Bladder training
As spinal areexia wears off, which may take from a few days to several weeks, two main types of bladder condition develop:

the automatic bladder the autonomous bladder.
The automatic (or reex) bladder

This type of bladder develops in most patients with transverse spinal cord lesions above T10T11. As reex tone returns, the detrusor muscle contracts in response to a certain degree of lling pressure.
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The returning power of the sphincter is overcome and micturition occurs. This reex detrusor action may be triggered by stroking, kneading or rhythmic tapping over the abdominal wall above the symphysis pubis, or by stimulating other trigger points, e.g. stroking the inner aspect of the thigh or pulling the pubic hair. With training, this reex action will occur on stimulation of the trigger points and not at other times, so that the patient can learn to empty his bladder every 2 or 3 hours and remain dry in between.
The autonomous (or non-re ex) bladder

This bladder is virtually atonic and occurs where the reex action is interrupted, i.e. with a longitudinal lesion of the spinal cord or a lower motoneurone lesion. There is no reex action of the detrusor muscle. 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, 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. Both the automatic and autonomous bladders may be emptied provided their function is understood, gradual training takes place and active infection of the bladder is avoided. When out of bed, the general increase in muscular activity, especially of the abdominal muscles if innervated, may make it more difcult to keep dry. Consequently, it may be necessary to express the bladder every hour at rst. Bladder training takes up a great deal of time and the patient may get discouraged, but it is important to persevere, for gradually the bladder will become trained and the time between emptying lengthened to 1, 2, 3 and in some cases even 4 hours. The same training is carried out for both sexes, but it is essential for the female patient as there is no satisfactory urinal at present on the market. Pads and incontinence pants are the only protection in case of leakage between expressions or catheterizations. With encouragement, patience and perseverance, this method is successful for many patients and it is well worth the effort involved. Where bladder training is ineffective, the patient is taught to catheterize himself on an intermittent though not necessarily regular basis. Selfcatheterization is most commonly used with female patients and children (Hill & Davies 1988).
Male urinals
There are several types of male urinals available. The best for any individual is that which he nds most convenient to use, but the following conditions must be ful lled:
21
it must not cause pressure ulcers it must contain a non-return valve if not disposable, it must be easily cleaned and sterilized.
Urinary sheath
The sheath is rolled onto the penis and an integral band, or collar, of non-irritant adhesive at the top of the sheath ensures that it remains in place. A non-return valve prevents a backow of urine along the penile shaft, keeping the penis dry. A plastic tube connects the sheath to the leg bag which can have expandable side pleats. These allow outward expansion, enabling a greater volume of urine to be contained in a shorter bag (Fig. 2.1).
Condom urinal
Where a proprietary brand of urinary sheath is not available, the condom urinal can be used. This consists of the condom, a nylon connector, a piece of rubber tubing and a bag for drainage (Fig. 2.2). The nylon connector is rst placed inside the end of the condom and the connection tube is pushed over from the outside. This clamps the condom, which is then pierced where it stretches across the lumen of the connector. An orange stick is useful for this purpose. The shaft of the penis is smeared with a suitable adhesive and the condom sheath is rolled on and held in place for at least 30 seconds when the heat from the hand should ensure that the glue becomes effective. The condom should extend at least 2.5 cm (1 inch) beyond the end of the penis. A nger stall may be more suitable than a condom for young boys. The connecting tube is then attached to the urine bag, which may be strapped to the leg when the patient is up, and hung from the frame of the bed at night. Disposable bags can be used or the more durable suprapubic bag. If the suprapubic bag is used, each patient must have at least two and use them alternately so that each
Figure 2.1 Urinary sheath.
Figure 2.2 Condom urinal.
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can be thoroughly disinfected after use. The bag should be washed in warm soapy water, rinsed and soaked in, for example, Dakins solution (16%) for 2 hours, rinsed well and hung up to dry for 1214 hours.
Female pads
Incontinence garments with protective pads are available from many sources. When these are unavailable, pads can be made up by the patient. Size and thickness can be adjusted to suit individual needs, thin ones for use at home when the patient is in easy reach of the toilet, and thicker ones for travelling and visiting. The pads consist of 20 cm (8 in) gauze tissue, white wool and cellulose tissue, and are approximately 1215 cm (57 in) wide and 30 cm (13 in) long. To make up the pad, use the following procedure: 1. Cut the wool and cellulose to the required size and the gauze tissue approximately 15 cm (6 in) longer. 2. Open out the gauze tissue on a at surface and ensure that it is free from creases. 3. Place the cellulose and the cotton wool, layered in that order, onto the gauze and fold the gauze over until the pad is completely enclosed. 4. Tuck the end of the gauze neatly into the layers of wool. The pad is worn with the white wool side next to the skin. Using an incontinence pad changes the distribution of pressure between the patient and the support surface. Folds or creases in the pad further increase the rise in pressure. This may be of clinical importance and the subject needs further investigation (Fader et al 2004).
Urinary hygiene
All patients must be taught urinary hygiene to avoid smell and must learn to watch for skin abrasions, redness and septic spots. If damage to the skin on the penis occurs, the urinal should not be worn until the lesion is fully healed. Severe pressure ulcers and stulae can occur very rapidly if the urinal is applied over damaged skin. Difcult patches of adhesive may be removed with ether, but frequent use irritates the skin. Daily washing with soap and water and careful drying should be all that is required. In order to have self-condence, the incontinent patient must be prepared to cope either alone or with minimal help at all times, not only at home but also when a suitable toilet may not be available. For the female patient, receivers or bedpans can be useful and expression of the bladder can be successfully carried out on a suitable bedpan in a wheelchair. The incontinent female patient will nd it essential to have a small travelling case containing:
23
a plastic bedpan or receiver in a cover clean pads several plastic bags to receive soiled pads one plastic container of water for cleansing talcum powder.
Sacral anterior root stimulators

This is an alternative method of bladder stimulation for micturition. Radio-linked implants are successfully used to stimulate S2, S3 and S4. By activating these, the patient can empty the bladder at will. Resection of the posterior roots of S2, S3 and S4 has been found to improve the effectiveness of stimulation by amongst other things increasing the bladder capacity and preventing reex action when it is not wanted. This form of treatment is prescribed for female patients who are unsuccessful with simpler methods such as regular toileting and self-catheterization (Brindley 1984, Brindley & Rushton 1990) and is particularly useful for female patients with upper motoneurone lesions. In male patients, stimulation will produce erectile function but irreversibly abolishes reex action including micturition. The procedure has become increasingly unpopular with patients in view of their hope that a cure might be found for spinal cord injury. Alternative approaches are being investigated such as the stimulation of sacral afferent nerves which modulate inappropriate reex action and increase bladder capacity (Kirkham et al 2002). Brindley (1994, 1995) found that 479 of the rst 500 patients were still using their sacral anterior root stimulation implants (SARSIs) from 3 to 16 years after implantation. During the last 20 years over 2000 devices have been implanted worldwide (Popovic 2002).
Management of the bowels

Immediately after the onset of paralysis, uids alone are given because of the danger of a paralytic ileus of neurogenic origin. The bowel training regimen is instituted once the patient is on a full diet.
Bowel training
The aim is to deliver the bowel contents to the rectum at the same time either daily or every second day and remove them by reex defecation when the patient is prepared for it. This is achieved by:

mild aperients in the evening, e.g. senna tablets (Senokot) two glycerine suppositories the following morning followed half an hour later by digital evacuation with a gloved nger correct diet and uids.
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Evacuation in bed
The previous evening senna tablets are given, 30 mg or as necessary depending on the results. Bulking agents may also be used. The following morning, the patient is put on his left side and supported with sandbags and pillows. A plastic sheet and one or two disposable incontinence pads are placed under the buttocks. Two glycerine suppositories are inserted into the rectum as high as the gloved nger can reach. Care is taken to avoid overstretching the anus or damaging the rectal mucosa. The patient is kept warm and given a hot drink. Reex defecation usually occurs within 2030 minutes but may take up to an hour. If the bowel has not emptied or not emptied completely, digital stimulation may be indicated. A gloved nger is inserted into the rectum. The anus contracts when the nger is inserted. It then relaxes and the bowel empties. It may be necessary to stimulate the anus in this way during bowel training but subsequently it becomes unnecessary for most patients.
Toilet training
When the patient is out of bed, he is taught to do his own evacuation on the toilet, once he has sufcient balance in sitting and is able to transfer with assistance. A bar is needed beside the toilet so that the patient can support himself whilst leaning forwards. Aperients and/or suppositories are continued as required. The development of a regular habit of bowel opening, usually every second day, is essential and with patience and perseverance it is possible to establish a satisfactory programme for all patients. Tetraplegic patients continue evacuations on the bed unless they can get onto a commode or toilet chair. Prior to the patients discharge, the relatives or the community nurse are instructed in the procedure. A patient with acute constipation may present with spurious diarrhoea, the impacted faeces allowing only liquids to pass through the gut. Although enemas as a routine are avoided, in this case they may be given before starting the bowel regimen.
SEXUAL DYSFUNCTION Male

Male patients with high lesions often have priapism for hours or several days after injury. Subsequently all sexual function is abolished during the stage of spinal areexia. Later return of function will depend upon the level and completeness of the lesion. For patients with complete lesions above the reex centre in the conus, 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 reex centre may have not only reex erections but also
25
psychogenic erections if the sympathetic pathways are intact. Occasionally these may be accompanied by ejaculation. The seminal uid will pass through the urethra only if there is an associated contraction of the internal bladder sphincter. Otherwise it reuxes into the bladder. Mechanical assistive devices are now available, as well as various pharmacological agents which enhance erections. Sexual function varies widely in patients with incomplete lesions, according to the degree of cord damage sustained. Any form of sensation on the penis may indicate some preservation of genital sex. Problems may remain in relation to locomotor and voluntary muscle activity. Tests can be carried out to assess potency and fertility. Patients can now undergo semen procurement predictably and safely. However, most couples will need assisted pregnancy techniques such as intrauterine insemination (Brindley 1984, Hirsch et al 1990). Patients may benet from attending a specialized fertility clinic, which offers a comprehensive approach with education, fertility assessment and a range of assisted reproductive options (Rutkowski 1999). This may be most appropriate up to 6 months after discharge during which time the major changes in sexual activity appear to occur (Fisher et al 2002).
Female
Menstruation
Interruption of the menstrual cycle occurs in the majority of women with complete or incomplete lesions who are not taking a contraceptive pill. This can last from a few months to more than a year. Eventually the menstrual cycle returns to normal.
Pregnancy
Apart from lacking genital sensation, sexual function is unimpaired for female patients with complete lesions. Both paraplegic and tetraplegic women can become pregnant and have normal babies. These can be delivered vaginally or by caesarean section if indicated. Uterine contractions occur normally. Each uterine contraction in patients with complete lesions above T6 causes autonomic dysreexia. Patients with complete lesions at T9 and below have uterine pain, but patients with complete lesions at T6, 7 or 8 may not be aware that labour has commenced, especially if it occurs during sleep. Therefore these patients should be kept under careful observation and are usually admitted to hospital before the expected delivery date. A large number of women with spinal cord injury throughout the world now have children. A study evaluating how mothers and their
26
families adjust to the mothers disability showed no signicant differences between the mothers or the children in each group. The individual adjustment of the children, their attitudes to their parents, self-esteem and gender roles did not appear to be affected by being brought up with mothers with spinal cord injury (Alexander et al 2002).
AUTONOMIC DYSREFLEXIA
The pathophysiology of autonomic dysreexia is not fully understood. It is a vascular reex which usually occurs in response to a stimulus from the bladder, bowel or other internal organ below the level of the lesion in a patient with a high lesion, i.e. above T6. Overdistension of the bladder caused by a blocked catheter can give rise to this reex activity, which presents quickly and which, if not dealt with immediately, can rapidly precipitate cerebrovascular accident (Valls et al 2005), epileptic ts and even death (Calachis 1992). It can also be caused by strong spasms and by sudden changes of position. Degenerative changes of the lower spine are common amongst wheelchair users and in some patients changes progress to form Charcots joints (Shwartz 1990). When autonomic dysreexia occurs during changes in posture or transfers, Charcots joints of the lumbar spine may be the cause (Thumbikat et al 2001, Selmi et al 2002). Selmi et al also suggest that heterotopic ossication can be responsible for autonomic dysreexia, and Thumbikat et al that surgical procedures involving the vertebrae may have an effect on the formation of Charcots joints in the lumbar spine. Three cases of autonomic hyperreexia were reported in the USA in 1980 which were precipitated by passive hip exion. This occurred in young men with lesions at C5, C6 and T1. It was suggested that this response was evoked by stretching the hip joint capsule or proximal leg muscles innervated by L4, L5 and S1 (McGarry et al 1982). Silver (2000) suggests that autonomic dysreexia can occur during the period of spinal shock. Autonomic dysreexia is perhaps more common than is realized. In a survey of 213 patients with lesions above T6 admitted to a spinal cord injury centre, 48% were shown to have experienced autonomic dysreexia (Lindan et al 1980). A scientic review of this syndrome was undertaken by Karlsson (1999) and includes valuable further information on all aspects of the syndrome, such as incidence and prevalence, triggering factors and treatment. The physiotherapist must be alert to recognize the symptoms of autonomic dysreexia, which are an outburst of sweating on the head, neck and shoulders, raised blood pressure, slow pulse and throbbing headache. Tilting the body with the head up will reduce the blood pressure until further treatment can be given. The treatment is to remove the cause; antihypertensive drugs may be given as a temporary measure.
27
Caution
All those involved in the care of patients with spinal cord lesions should be able to recognize the symptoms of autonomic dysreexia and know what to do in an emergency.
References
Aito S, Pieri A, DAndrea M et al 2002 Primary prevention of deep venous thrombosis and pulmonary embolism in acute spinal cord injury. Spinal Cord 40:300303 Alexander C J, Hewang K, Sipski M L 2002 Mothers with spinal cord injury: impact on marital, family and childrens adjustment. Archives of Physical Medicine and Rehabilitation 83(2):430 Bennett S E, Schenk R J, Simmons E D 2002 Active range of motion utilised in the cervical spine to perform daily functional tasks. Journal of Spinal Disorders and Techniques 15(4):307311. Bracken M B, Shepard M J, Collins W F Jr et al 1992 Methylprednisolone or naxolone treatment after acute spinal cord injury: 1 year follow-up data. Results of the second National Acute Spinal Cord Injury Study. Journal of Neurosurgery 76:2331 Bravo P, Labarta C, Alcaraz M A et al 1996. An assessment of factors affecting neurological recovery after spinal cord injury with vertebral fracture. Paraplegia 34:164166 Brindley G S 1984 The fertility of men with spinal injuries. Paraplegia 22:326337 Brindley G S 1994 The rst 500 patients with sacral anterior root stimulator implants: general description. Paraplegia 32:795805 Brindley G S 1995 The rst 500 patients with sacral anterior root stimulators: implant failures and their repair. Paraplegia 33:59 Brindley G S, Rushton D N 1990 Long-term follow up of patients with sacral anterior root stimulator implants. Paraplegia 28:469475 Brooke D S, Anderson P A, Newell D W et al 2003 Comparison of anterior and posterior approaches in cervical spinal cord injury. Journal of Spinal Disorders and Techniques 16(3):229235 Calachis S C 1992 Autonomic hyperreexia with spinal cord injury. American Paraplegia Society 15(3):171186 El Masry W S 1993 Physiological instability of the spinal cord following injury. Paraplegia 31:273275 El Masry W S, Short D 1997 Current concepts: spinal cord injuries and rehabilitation. Current Opinion in Neurology 10:484492 El Masry W S, Katoh S, Khan A 1993 Reections on the neurological signicance of bony canal encroachment following traumatic injury of the spine in patients with Frankel CDE presentation. Journal of Neurotrauma 10(Suppl 1):70. Ersmarke H, Dalan N, Kalan R 1990 Cervical spine injuries: a follow-up of 332 patients. Paraplegia 28:2540 Fader M, Bain D, Cottenden A 2004 An investigation into the effects of absorbent incontinence pads on pressure management mattresses. Journal of Advanced Nursing 48(6):569574 Fisher T L, Laud P W, Byeld M G et al 2002 Sexual health after spinal cord injury: a longitudinal study. Archives of Physical Medicine and Rehabilitation 83(8):10431051
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Frankel H L 1968 Associated chest injuries. Paraplegia 5:221225 Frankel H L 1974 Intermittent catheterization. Urologic Clinics of North America 1(1):115124 Frankel H L, Hancock D O, Hyslop G et al 1970 The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 7:179192 Frankel H L, El Masry W S, Ravichandran G 1987 Non-operative treatment: rehabilitation and outcome. In: Advances in Neurotraumatology, vol 2. Springer-Verlag, Vienna. Green B G 2004 Changes in bladder management of spinal cord-injured patients through the years: Have we succeeded in keeping our patients catheter free? Topics in Spinal Cord Injury Rehabilitation 42:7985 Guttmann L 1945 New hope for spinal cord sufferers. New York Medical Times 73:318 Guttmann L 1970 Spinal shock and reex behaviour in man. Paraplegia 8:100111 Hill V B, Davies W E 1988 A swing to intermittent clean self-catheterisation as a preferred mode of management of the neuropathic bladder for the dextrous spinal cord person, Paraplegia 26:405412 Hirsch I H, Sager S W J, Seder J et al 1990 Electro-ejaculatory stimulation of quadriplegic man. Archives of Physical Medicine and Rehabilitation 71:5457 Hughes J T 1984 Regeneration in the human spinal cord: a review of the response to injury of the various constituents of the human spinal cord. Paraplegia 22:131137 Jamil F 2001 Towards a catheter free status in neurologic bladder dysfunction: a review of bladder management options in spinal cord injury. Spinal Cord 39:355361 Kakulas B A 2004 Neuropathology: the foundation for new treatments in spinal cord injury. Spinal Cord 42:550563 Karlsson A K 1999 Autonomic dysreexia scientic review. Spinal Cord 37:383391 Kirkham A P S, Knight S L, Craggs M D et al 2002 Neuromodulation through sacral nerve roots 2 to 4 with a Finetech-Brindley sacral posterior and anterior root stimulator. Spinal Cord 40:272281 Lindan R, Joiner E, Freehafer A A, Hazel C 1980 Incidence and clinical features of autonomic dysreexia in patients with spinal cord injury. Paraplegia 18:285292 McGarry J, Woolsey R, Thompson C W 1982 Autonomic hyperreexia following passive stretching to the hip joint. Physical Therapy 62(1):3031 Popovic M R 2002 Sacral root stimulation. Editorial. Spinal Cord 40:431 Quain T, Guo X, Levi AD et al 2005 High-dose methylprednisolone may cause myopathy in acute spinal cord injury patients. Spinal Cord 43: 199203 Rutkowski S B 1999 A comprehensive approach to the management of male fertility following spinal cord injury. Spinal Cord 37(7):508514. Selmi F, Frankal H L, Kumaraguru A P, Apostopoulos V 2002 Charcot joint of the spine, a cause of autonomic dysreexia in spinal cord injured patients. Spinal Cord 40(9):481483 Shwartz H S 1990 Traumatic Charcot spine. Journal of Spinal Disorders and Techniques 3:269275 Silver J R 1975 The prophylactic use of anticoagulant therapy in the prevention of pulmonary emboli in one hundred consecutive spinal patients. Paraplegia 12:188196
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Silver J R 2000 Early autonomic dysreexia. Spinal Cord 38:229233 Thumbikat P, Ravichandran G, McClelland M R 2001 Neuropathic lumbar spondylolisthesis a rare trigger for posture induced autonomic dysreexia. Spinal Cord 39:564567. Thumbikat P, Poonnoose P M, Balasubrahmaniam P et al 2002 A comparison of heparin/warfarin and enoxaparin thromboprophylaxis in spinal cord injury: the Shefeld experience. Spinal Cord 40:416420 Valls M, Benito J, Portell E, Vidal J 2005 Cerebral haemorrhage due to autonomic dysreexia in a spinal cord injury patient. Spinal Cord 43: 738740 Wang D, Bergstrom E, Clarke M et al 2003 Mobility of the spine after spinal surgery in acute spinal cord injury. Spinal Cord 41(11):593599
Patient-centred practice
Dot Tussler
CHAPTER
3
Introduction 31 Background to patient-centred rehabilitation 31 Acute management 32 Initial rehabilitation 33 Perceived personal control 34 Adjustment model following spinal cord injury 35 Rehabilitation and goal planning 37 Returning home 38 Conclusion 38
INTRODUCTION
Traumatic spinal cord injury suddenly reduces an individual enjoying normal health and activity to a state of complete immobility and dependence upon others. There may be initial concern for his survival. He is precipitated into an unknown and unreal world full of fears, problems and multiple anxieties. He will experience pain, disorientation, lack of sleep, sensory deprivation, immobility and prolonged hospitalization. There will be stress from the effort to sustain relationships, manage nances, and prepare for an uncertain future whilst also coping with the demands of a physical rehabilitation programme and the challenges of relearning all basic care needs. Existing attitudes, behaviour, beliefs, knowledge, skills, family support and coping strategies will be drawn on by the individual with spinal cord injury to dene and manage this new situation, both in the immediate period following injury and in the ensuing months of rehabilitation and return to the community. The consequences of spinal cord injury will also affect family, friends and social network. Psychological support for the patient and his family throughout rehabilitation is essential. Knowledge and awareness of the psychological responses to spinal cord injury will affect the planning of care by the interdisciplinary team, the patients participation in rehabilitation and future reintegration into the community. If rehabilitation is to be patient-centred it cannot just focus on the learning of physical skills.
BACKGROUND TO PATIENT-CENTRED REHABILITATION

Rehabilitation following spinal cord injury evolved historically from the disciplined approach to managing the physical consequences (Guttmann 1976). This medical model of management entailed the treatment of symptoms according to a dened set of principles of best practice determined by the healthcare professionals. However, this approach is limited when dealing with a long-term disability. This method can lead to dependence on the healthcare professionals as 31
32
the determiners of rehabilitation, as the attainment of independence is focused on physical goals and functions. Whalley Hammell (1995) proposes that independence should be seen in relation to decisionmaking and problem-solving skills. She states Independence is not so much a physical state but a state of mind an attitude. This view is of specic relevance to those individuals whose neurological level is such that physical goals are limited. She goes on to describe an educational approach to rehabilitation that is grounded in psychological theories and is based on dynamic interaction with the patient as an active participant learning to live with his disability in his own environment. This is a vast and evolving subject and brief consideration only is given here.
ACUTE MANAGEMENT
The immediate consequences of spinal cord injury may focus on the life-threatening impact of a high level lesion or any associated injuries and complications, so the patient and his family may not consider the longer-term impact on the individual. This may appear as an inability to appreciate the condition and its consequences, and healthcare professionals caring for the patient may think that the individual is in denial of his disability. In the early days following spinal cord injury the individual is exposed to numerous factors that will affect his judgement and rational thought and which may prevent him learning new information (Horn 1989). Disorientation, interrupted and reduced sleep, effect of medication, pain, anaesthesia and immobility can lead to sensory and perceptual deprivation, which will result in intellectual and cognitive impairment and intolerance to the present situation (Krishnan et al 1992). Anoxia from respiratory dysfunction or an associated head injury may also be present. It is important that healthcare professionals do not misunderstand ongoing hope expressed by the patient as the adverse response of denial. Consistent communication between all members of the team when dealing with the patient and his family is essential. For most patients a supercial awareness and realization of their disability becomes apparent in the rst week. This knowledge gradually deepens and the patient begins to realize the enormity of what the loss of movement and sensation, bladder, bowel and sexual function will mean in daily life. Involvement of family and friends from the outset has been shown to provide valuable support to the patient (Treischmann 1988). The emotional reaction and psychological responses in facing the disability will vary for each individual, and will be inuenced by their pre-injury coping style and personal resources (Duff & Kennedy 2003). There is no right way an individual will adjust. Some people nd the situation hard to believe and so resist hearing the news that they will be paralysed: I just did not
PATIENT-CENTRED PRACTICE
33
believe it. It took a month of total disbelief. Others just face up to it: This has happened. Lets get on with it (Oliver et al 1991). For some there is a need to understand what has happened and to try and make sense of the situation.
INITIAL REHABILITATION
Mobilization in a wheelchair for the rst time is often a difcult period for a newly injured patient. While on bedrest his care needs were undertaken by others and the extent of his physical limitations were restricted by his environment. Mobilization in a wheelchair can highlight the extent of his disability. For some this situation is overwhelming and engagement in rehabilitation is difcult. Support is needed at this time, with a consistent team approach to address the problem. The change in emphasis from caring to rehabilitation can be particularly difcult for nursing staff (Pellatt 2003). For other patients the time of mobilization represents the opportunity to start to resume control over the situation and acquire the skills and knowledge that will lead to independence. Nordholm & Westbrook (1986) identied that negative attitudes of healthcare professionals who consider the situation of an individual with spinal cord injury as intolerable, can adversely inuence newly injured people who are seeking cues to de ne their disability. Studies have described staffs perception of the patients situation to be worse than that reported by the patients themselves and as a consequence, optimism and positive attitude are disregarded. No member of the team must contribute to a sense of powerlessness or hopelessness in the patient (Whalley Hammell 1995). Each member of the team is responsible for their contribution to an atmosphere of hope and condence in which the patient can learn to manage his disability and regain self-condence. The expectations of the rehabilitation staff have a signicant inuence on this outcome (Bodenhamer et al 1983). The importance of a clinical psychologist as a member of the rehabilitation team should not be underestimated. The psychologist will assist the patient in utilizing effective coping strategies and personal resources, whilst supporting the staff in delivering effective rehabilitation. The application of psychological theory to rehabilitation practice by all team members is essential in delivering outcomes that are purposeful and have value and meaning to the patient and his family. The treatment of patients within a spinal injuries centre, where staff have learnt from a large number of patients, has enabled the development of expertise, skills and knowledge, contributing to the reduction of avoidable complications (Carvell & Grundy 1989) and improved outcome (Smith 1999). Such an environment provides the patient with visible evidence of what can be achieved by others in the same situation, but at a different stage of the rehabilitation process, or who are living at home. These positive characteristics seen in
34
others who are well adjusted can be benecial to successful adjustment (Cushman & Dijkers 1991).
PERCEIVED PERSONAL CONTROL

Perceptions of control have been shown to be important in terms of management of healthcare and disability: Perceived control is dened as the belief that one can determine ones own internal states and behaviours, inuence ones environment and/or bring about desired outcomes (Wallston et al 1987). Rotter (1966) described people who believe that they have a high degree of personal control of events in their lives as having an internal locus of control. These are people who want more information and are hopeful of, and persevere in, attaining goals. He described those who believe they have little or no control over what happens to them as having an external locus of control. Outcomes are seen as random occurrences controlled by fate, chance or powerful others. This may lead to the belief that their own efforts in rehabilitation will not be successful. It is not the actual reality of the extent of control that has been shown to be important, but rather the persons belief about his control over events (Whalley Hammell 1995). Even though a person may have a high lesion and little physical control over his immediate circumstances, this does not necessarily change his perception of the extent of the control he has over his life (Treischmann 1988). This belief is associated with the ability to inuence others in order to achieve ones own ends (Johnson et al 1970). The background to the concept of perceived personal control initially came from social learning theory research and has received a signicant amount of attention in behavioural research (Wallston et al 1987), and more recently in the healthcare eld. It is a complex subject and is mentioned because the patients perceptions and beliefs are an integral part of his learning in rehabilitation, and health professionals need to take account of them in planning rehabilitation programmes (Whalley Hammell 1995). Patient compliance with externally imposed routines is highly rated by professionals but does not facilitate independence and problem-solving skills (Tucker 1984). Independence encompasses thinking and acting for oneself as well as the performance of physical skills. Those patients who believe that they are as physically independent as possible have more positive self-concepts than those who perceive themselves as less independent than they are capable of being (Green et al 1984). Rehabilitation is an intensive process with a great deal for the patient to learn. If learning is to be effective, patients need to dene their own problems, decide on the actions to be taken and evaluate the consequences of their decisions (Whalley Hammell 1995). Banja (1990) offers the idea of empowerment as a key concept. Patients will differ in their desire for personal control and in the extent to which they believe they have
35
it. The concept of perceived personal control forms the basis for psychological interventions that are used within many rehabilitation programmes. Here the focus is on identifying and recognizing fears, distress and loss and challenging an individuals beliefs and attitudes to their situation, so that the person with spinal cord injury can acquire the knowledge, skills and strategies for optimal physical, psychological and social functioning (Duff & Kennedy 2003).
ADJUSTMENT MODEL FOLLOWING SPINAL CORD INJURY

Previous psychological theories proposed that following a spinal cord injury individuals underwent a staged process that required them to sequentially experience depression, anger, confusion and withdrawal before acceptance of the situation could be achieved. Little evidence existed to support these views (Treischmann 1980), although it is acknowledged that these emotional responses may occur at any time as a normal response to the stress encountered (Duff & Kennedy 2003). Current research proposes models of adjustment based on individuals response to stress and the coping strategies that are subsequently utilized. Duff & Kennedy (2003) provide a comprehensive review of the development of these theories encompassing the area of perceived personal control. The principles of an adjustment model post-injury are particularly useful in that they are concerned with the recognition of strategies that facilitate coping and also those that lead to distress and dysfunction. These can lead to easier identication of interventions that can support the individual in managing his situation. It can also clarify the direction of the rehabilitation team in understanding the changing needs of the patient. The components of a model such as that proposed by Duff & Kennedy (2003) are developed from the cognitive model of stress and coping (Folkman et al 1991). This model identies relevant pre-injury factors pertinent to an individual such as:

emotional history and previous vulnerabilities beliefs about self, world and coping beliefs about disability environmental factors biological factors social support.
On encountering the challenge and stress of the spinal cord injury, the individual conceptualizes the impact of its consequences and the perceived threat he faces, along with his perceived ability to cope. A subsequent appraisal assesses the effectiveness of resources the patient has available to cope with the challenge, along with a perception of his potential to manage or accommodate the situation.
36
If the patient regards the challenge as being manageable, positive coping skills can be engaged, based on his perception of his inuence and control. This is described by Duff & Kennedy (2003) as approachfocused coping and includes thinking about the injury, acceptance, planning and problem-solving. This can result in new goals and opportunities, a sense of mastery and self-efcacy, post-traumatic growth, personal development, life satisfaction, development of coping beliefs and the ability to face further challenges. However, if the stress of the injury is perceived as being unmanageable, avoidance coping strategies are employed. These have an emotional impact and can lead to anxiety, depression, a sense of helplessness and hopelessness, accompanied by withdrawal and disengagement. Further appraisal may serve to reinforce the perception of an unmanageable situation, leading to an escalating downward spiral of dysfunction and secondary complications arising from the emotional impact. These may include self-neglect, severe stress reaction, long-term emotional difculties, anxiety and depression, and potential alcohol and drug abuse. An adjustment model of coping is not time limited and can be utilized across the lifespan of the individual as new challenges and situations are encountered, as well as dealing with specic elements such as mobility, relationships etc. This model represents a dynamic and evolving concept of adjustment and provides a useful reference for staff to consider both in the acute and the rehabilitation setting, as well as over the lifespan. It can identify relevant points for intervention at any time post-injury. Adjustment to spinal cord injury is a lifelong process in which constant changes occur both in the patient and in his circumstances. It may be that a minimum of 2 years is needed to achieve some stability in life, although this will vary from person to person (Craig et al 1994). It must also be acknowledged that social networks and relationships that offer support and reassurance of worth will enhance adjustment and self-esteem (Elliott et al 1992). A variety of responses and coping strategies utilized by individuals when learning to live with a spinal cord injury have been mentioned, but some patients have a pre-existing psychological or psychiatric history. A spinal cord injury can result from a suicide attempt. This group of patients has particular problems and require special care and psychological support. Cognitive dysfunction arising from concomitant head injury, alcohol and substance abuse, or other causes of cerebral damage has been reported by various authors to be present in 1060% of patients with acute traumatic spinal cord injury. Resultant problems with inattention, poor memory, reduced concentration, inappropriate social behaviour and poor problem-solving skills all complicate adjustment. Assessment of cognitive dysfunction is recommended to identify appropriate strategies to be utilized within the rehabilitation programme.
37
REHABILITATION AND GOAL PLANNING

Goal planning provides a systematic framework for incorporating behavioural change principles into the rehabilitation process, that is, positive coping strategies that encourage the adjustment-focused coping described earlier (Duff & Kennedy 2003). It aims to place the patient at the centre of his rehabilitation programme and in a situation to optimize his perceived personal control, whilst increasing his engagement in rehabilitation activities (Kennedy et al 1991). Goal planning is based on patient involvement as an active participant in patient and not therapist-led practice, with the recognition and the utilization of the patients strengths to meet identied needs signicant to the patient in regard to his perception of his spinal cord injury. Goals are then set within the rehabilitation team with specic, measurable and realistic targets to be achieved in an agreed time. Regular review and monitoring success can become an empowering process. Areas of unmet need can be recognized and addressed and the roles and contribution of the various healthcare professionals claried. Goal planning provides a strategy for approach-focused coping as highlighted in the adjustment model following spinal cord injury in which the targets set will be directed to behaviour that has relevance to the patients perception of the needs that have arisen from his injury. Collaborative working and the opportunity to learn what is signicant to the patient is important to each member of the interdisciplinary team and has been shown to be of positive benet (MacLeod & MacLeod 1996). The need to address all areas affected by the spinal cord injury throughout rehabilitation is essential if the process is to be considered one of learning and developing new skills and knowledge. The opportunity to discuss any topics should be encouraged and facilitated. This should be an integral part of every interaction with each healthcare professional. The use of specic educational programmes also has been found to be successful. These can take various forms depending on the organization and patient group. The learning style should be considered. Appropriate individual sessions, group lectures or focus groups along with supporting material are in frequent use within spinal injury centres in the United Kingdom. Information is also readily available on a variety of appropriate websites. Lifelong learning programmes have been developed by individuals with spinal cord injury and have been proved to be of benet in continued information sharing long after the initial rehabilitation has been completed (Spinal Injuries Association 2004). The opportunity to discuss issues of sexual dysfunction might need to be specically raised by the healthcare professional in a timely and personal manner along with appropriate evaluation of function and information pertinent to each individual. Relatives and friends also need educational programmes and individual teaching about the consequences of the injury to meet their own need for information and to enable them to give appropriate support to the patient.
38
RETURNING HOME
Returning to the community, whether for the rst weekend home or for discharge from hospital, is a challenging time for the patient. The security of the hospital environment with the reassurances of healthcare professionals knowledge and skills to manage physical concerns and the familiarity of other wheelchair users is replaced by a world where disability and the needs of a wheelchair user may be unfamiliar. Anxieties about home and family life, relationships, access, employment, care provision, nance, attitudes and isolation are all real threats. The patient should be prepared for the transition from the hospital to the community as a continuation of their rehabilitation goals. Review of access in the home environment, frequent community visits, continued social networking, links with local peer groups and community services, awareness and preparation of social support systems and provision of written material and information may be of benet (Whalley Hammell 1995).
CONCLUSION
Successful rehabilitation is hard to dene. This chapter has tried to emphasize that rehabilitation must be patient centred. The psychological impact of and responses to spinal cord injury need to be considered throughout rehabilitation and lifespan by all members of the interdisciplinary team. The aims of the rehabilitation team should not only focus upon the acquisition of skills to enable a person to get out of bed in the morning, but to assist him in nding a reason for so doing (Treischmann 1988).
References
Banja J D 1990 Rehabilitation and empowerment (commentary). Archives of Physical Medicine and Rehabilitation 71:614615 Bodenhamer E, Achterberg-Lawlis J, Kevorkian G et al 1983 Staff and patient perceptions of the psychosocial concerns of spinal cord injured persons. American Journal of Physical Medicine 62:182193 Carvell J, Grundy D 1989 Patients with spinal injuries. Early transfer to a specialized centre is vital. British Medical Journal 299:13531354 Craig A R, Hancock K M, Dickson H G 1994 A longitudinal investigation into anxiety and depression in the rst 2 years following a spinal cord injury. Paraplegia 32:675679 Cushman L A, Dijkers P 1991 Depressed mood during rehabilitation of persons with spinal cord injury. Journal of Rehabilitation 57:3538. Duff J, Kennedy P 2003 Spinal cord injury. In: Llewelyn S, Kennedy P (eds) Handbook of clinical health psychology. Wiley and Sons, Chichester, p 259262 Elliott T, Herrick S, Witty T et al 1992 Social support and depression following spinal cord injury. Rehabilitation Psychology 37(1):3748
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Folkman S, Chesney M, McKusick L et al 1991 Translating coping theory into an intervention. In: Eckenrode J (ed) The social context of coping. Plenum Press, New York Green B C, Pratt C C, Grisby T E 1984 Self-concept among persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation 65:751754 Guttmann L 1976 Spinal cord injuries. Comprehensive management and research, 2nd edn. Blackwell Scientic, Oxford Horn S 1989 Coping with bereavement. Thorsons, Wellingborough, p 104 Johnson J E, Dabbs J M, Leventhal H 1970 Psychosocial factors in the welfare of surgical patients. Nursing Research 19:1819 Kennedy P, Walker L, White D 1991 Ecological evaluation of goal planning and advocacy in a rehabilitation environment for spinal cord injured people. Paraplegia 29:197202 Krishnan K L R, Glass C A, Turner S M et al . 1992 Perceptual deprivation in the acute phase of spinal injury rehabilitation. Journal of the American Paraplegia Society 15(2):6065 MacLeod G M, MacLeod L 1996 Evaluation of client and staff satisfaction with a Goal Planning project implemented with people with spinal cord injuries. Spinal Cord 34:525530 Nordholm L, Westbrook M 1986 Effects of depression, self blame and dependency on health professionals evaluation of paraplegic patients. Australian Occupational Therapy Journal 33(2):5970 Oliver M, Zarb G, Silver J, Moore M, Salisbury V 1991 Walking into darkness. The experience of spinal cord injury. Macmillan, Basingstoke Pellatt G C 2003 Perceptions of the nursing role in spinal cord injury rehabilitation. British Journal of Nursing 12(5):292299 Rotter J B 1966 Generalized expectations for internal control of reinforcement. Psychological Monographs 80(1):609 Smith M 1999 Making a difference. Spinal Injuries Association, Milton Keynes Spinal Injuries Association 2004 Living options. Forward 64:18 Treischmann R B 1980 Spinal cord injuries: psychological, social and vocational adjustment. Pergamon, Oxford, p xii Treischmann R B 1988 Spinal cord injuries: psychological, social and vocational rehabilitation, 2nd edn. Demos, New York Tucker S J 1984 Patientstaff interaction with the spinal cord patient. In: Kruger D W (ed) Rehabilitation psychology. Aspen, Rockville MD, p 262 Wallston K A, Wallston B S, Smith S, Dobbins C J 1987 Perceived control and health. Current Psychological Research and Reviews 6(1):515 Whalley Hammell K 1995 Spinal cord injury rehabilitation. Chapman and Hall, London
Websites with educational information for people with spinal cord injuries
http://www.craig-hospital.org http://www.metrohealth.org http://www.spinal.co.uk http://www.spinalcordinjury.co.uk http://www.spinalnet.co.uk http://www.tbi-sci.org
The acute lesion
CHAPTER
4
Examination of the patient 41 Physiotherapy programme 42 TREATMENT OF THE PATIENT IN BED 42 Correct positioning of the patient 42 The hand 44 Physiotherapy 46 Passive/active movements 46 Active movements 50 Functional electrical stimulation 51
EXAMINATION OF THE PATIENT

For the therapist to gain maximum information regarding the patient, she should be present at the initial neurological examination carried out by the doctor in charge of the case. In this way she will gain information regarding:

the patients injury general condition the site and condition of the fracture, if any the presence of associated fractures or injuries, including any skin lesions condition of the chest, including the results of lung function tests motor function sensory function presence or absence of reexes previous medical history and current medical conditions, e.g. ankylosing spondylitis, rheumatoid arthritis, diabetes occupation family history diagnosis of the level of the lesion immediate medical treatment.
The therapist will subsequently wish to make her own examination, adding to the above information her assessment of:

respiratory function (see Ch. 5) the range of motion of all joints involved and the presence of contractures the strength of innervated muscles with particular regard to completely paralysed muscles unopposed innervated muscle groups imbalance of muscle groups the degree of spasticity, if present the presence of oedema. 41
42
When the doctor and therapist discuss the treatment required, factors such as the following will be given special attention:

respiratory therapy, especially in relation to the treatment of patients on ventilators the danger of muscle shortening due to unopposed muscle action and the required positioning of the joints involved severe spasticity and the positioning required to reduce tone the necessity for splinting.
After her own initial assessment, the physiotherapist will need to discuss treatment with the other members of the multidisciplinary team.
Physiotherapy programme
On the basis of the physiotherapists examination and assessment, the patient and therapist together set short- and long-term goals and plan the treatment schedule to achieve the initial short-term goals (Ch. 3). Detailed records are kept of the initial assessment, treatment and progress of the patient. Everyday incidents are also noted, such as the occurrence of bladder infections, slight injury or pressure marks, the rst outing and the rst weekend home.
TREATMENT OF THE PATIENT IN BED

From the outset, the combined efforts of everyone are concentrated on assisting the patient to achieve maximum independence. When the patient cannot do something for himself, he must learn how to teach others to do it for him. Gaining knowledge and accepting responsibility both start whilst the patient is in bed. He must know where others can nd his belongings in the locker and when, for example, he needs more soap or toothpaste. The patient with a spinal fracture will be in bed from 6 to 8 weeks. Those paralysed from other causes or who have had surgery will spend considerably less time in bed and may even be up in a few days.
Correct positioning of the patient

Correct positioning in bed is vitally important not only to maintain the correct alignment of the fracture, but also to prevent pressure ulcers (Ch. 6) and contractures, and to inhibit the onset of extreme spasticity.
The supine position (Fig. 4.1A)

When supine, the patient is positioned in the following way.
THE ACUTE LESION
43
Figure 4.1 A: Supine position of a patient with a cervical fracture (right arm pillow was removed for clarity). The patient is lying on an Egerton Stoke Mandeville electric turning bed. B: Lateral position of a patient with a low thoracic fracture.
Lower limbs

Hips extended and slightly abducted Knees extended but not hyperextended Ankles dorsiexed Toes extended.
One or two pillows are kept between the legs to maintain abduction and prevent pressure on the bony points, i.e. medial condyles and malleoli.
Upper limbs (for patients with tetraplegia)
Shoulders adducted and in mid-position or protracted, but not retracted
44
Elbows extended; this is particularly important when the biceps is innervated and the triceps paralysed. If the biceps is overactive, extension can be maintained by wrapping a pillow round the forearm, or by using a vacuum splint or making an individual splint of suitable material. Wrists dorsiexed to approximately 45 Fingers slightly exed Thumb opposed to prevent the development of a monkey hand, which is functionally useless.
The arms are placed on pillows at the sides. The pillows should be high enough under the shoulders to ensure that the shoulders are not retracted, when damage to the anterior capsule can occur. If the shoulders are painful and protraction is required, a small sorbo wedge can be placed behind the joint on either or both sides. If necessary, two pillows should be used under the forearms and hands, as it is important that the hands are kept higher than the shoulders to prevent gravitational swelling in the static limbs.
The side-lying or lateral position (Fig. 4.1B)

When lying on the side, the patient is positioned in the following manner.
Lower limbs
Hips and knees exed sufciently to obtain stability with two pillows between the legs and with the upper leg lying slightly behind the lower one Ankles dorsiexed Toes extended.
Upper limbs
Lower arm shoulder exed and lying in the trough between the pillows supporting the head and thorax to relieve pressure on the shoulder Elbow extended Forearm supinated and supported either on the arm board attached to the more sophisticated beds or on a pillow on a table Upper arm as in the supine position, but with a pillow between the arm and the chest wall. For the hipick position see page 75.
The hand
If the hand is to be functional even when paralysed, the maintenance of a good position in the acute phase is essential. The hand must
THE ACUTE LESION
45
remain mobile as subsequently it will be used in different positions and also should surgery be contemplated later on, a supple hand is a prerequisite (Forner-Cordero et al 2003). Gravitational swelling must be avoided. If it is allowed to occur unchecked, contractures easily develop. If length can be maintained by stretching the soft tissues during the acute phase, deformity can be prevented; otherwise the deposited collagen becomes converted into strong brous tissue and a xed deformity results (Cheshire & Rowe 1971). Swelling can be prevented if the collateral ligaments of the metacarpophalangeal joints are kept at their maximum tension, i.e. when the joint is kept in 90 exion. In order to maintain a good functional position Cheshire developed the boxing glove splint. It consists of a light, well-padded, cock-up splint (Fig. 4.2) and a palmar roll. The wrist is maintained at 45 dorsiexion, the metacarpophalangeal joints at 90 exion, the interphalangeal joints at 30 exion and the abductor web of the thumb in full stretch with opposition of the thumb. A layer of wool is placed over the dorsum of the hand and ngers and the whole is bandaged as for an amputation. The splint is removed several times a day for washing, physiotherapy and occupational therapy, and the skin is checked for pressure marks. It is used constantly until the patient is using his hands and then is applied at night only. If the boxing glove splint is not employed, the hand can be kept in a useful functional position with a small palmar roll. Light straps keep the ngers in exion and the thumb in opposition around the
Figure 4.2 Unpadded wrist support for the boxing glove splint.
46
roll. A wrist splint with a suitably padded cover for the dorsum of the hand with tapes to hold the ngers in exion can also be used. A palmar resting (paddle) splint may be useful for patients with ultrahigh lesions depending on the presenting problem and the level of the lesion. These splints are usually worn at night.
PHYSIOTHERAPY
During the period in bed, the following treatment is given:
respiratory therapy to maintain good ventilation (as the need for respiratory care may extend throughout life, this is dealt with separately in Ch. 5) passive movements to assist the circulation and to ensure full mobility of all paralysed structures active movements to maintain or regain muscle strength.
Passive/active movements
Animal studies point to the remarkable ability of the damaged central nervous system to undergo plastic changes (Dunlop & Steeves 2003). Neuronal plasticity, described as simply as possible, is said to be the neurons capacity to reduce the effects of lesions through structural functional changes (Pascual-Castroviejo 1996). It would appear that plasticity can occur in other parts of the central nervous system as well as the brain, including the spinal cord and possibly the isolated spinal cord. As the damaged nervous system has an innate capacity to undergo changes the question arises as to whether plasticity can be harnessed to improve function (see Ch. 14). In view of this and of the fact that movements are planned before they are produced and there is a slight delay period between the two events (Dunlop & Steeves 2003), movements to the paralysed limbs should be given in such as way as to promote active movement. Passive/active movements of the paralysed limbs are essential to preserve full range of movement in joints and soft tissues and to encourage active movements to return. During these movements it is important that the patient is involved, concentrates on the movement and tries to perform it as the physiotherapist moves the limb. Verbal instructions are given to ensure that the patient knows what is happening and can think about the movement even if he cannot see his limbs. Treatment is commenced the rst day after injury or when anticoagulant therapy has started and the prothrombin times are within the therapeutic range (El Masry & Silver 1981). During the period of spinal areexia, i.e. for approximately 6 weeks, treatment is given twice daily. Movements are continued once a day until the patient is mobile and capable of ensuring full mobility through his own activities.
THE ACUTE LESION
47
In addition to movements of the whole limb, each joint starting proximally and working distally and including the metatarsal and metacarpal joints and those between radius and ulna is moved several times through its full range, and appropriate movements are given to prevent muscle shortening. The patella should be mobilized before moving the knee. The movements are performed slowly, smoothly and rhythmically to avoid injury to the insensitive, unprotected joints and paralysed structures. Any limitations imposed by previous medical history and/or age must be taken into consideration. When reex activity returns, the limb must be handled with extreme care, so as not to elicit spasm and reinforce the spastic pattern. A pinch grip or any sudden brisk movement must be avoided. If a spasm occurs during a movement, the therapist holds the limb rmly and waits for the spasm to relax before completing the movement. Forced passive movements against spasticity may cause injury or even fracture of a limb. Sometimes, however, the only way to overcome ankle clonus is to completely dorsiex the ankle, against the spasm, and hold it until the foot relaxes. The movement must be performed rmly but gently. Before moving any limb when tone is increased, the other limbs should be placed in positions which oppose their spastic pattern. For example, the lower limbs can be placed in the frog position where the hips are abducted, laterally rotated and exed to 40 before moving the upper limbs. The importance of detail when giving passive movements cannot be overemphasized if the functional range in all structures is to be maintained. If the patient has not had any passive movements for a week or more since being injured, the movements should be commenced extremely cautiously, avoiding full range for a few days. It is possible that minor contractures are present which, if torn, may give rise to heterotopic ossication (Silver 1996) or the patient may have a deep venous thrombosis.
Cautions
1. Extreme range of movement must be avoided, particularly at the hip or knee, as the tearing of any structures may be a predisposing factor in the formation of heterotopic ossication. 2. Only 45 abduction is given, to avoid tearing any structures on the medial side of the thigh. The medial side of the knee must always be supported to prevent stretching the medial ligament. 3. Flexion of the hip with the knee exed is cautiously carried out where there is a fracture of the lower thoracic or lumbar spine to ensure that movement does not occur around the fracture site. If pain occurs on movement, exion is limited to the painfree range. The movement is gradually increased as the pain diminishes. When the patient is supine, full exion of the knee can only be obtained by combining knee exion with lateral rotation of the hip.
48
4. Straight leg raising is carried out with extreme caution because of the danger of putting a stretch on the dura mater. Hamstring extensibility varies with the individual. Harvey et al (2003) suggest that some physiotherapists apply stretch torques well in excess of those tolerated by individuals with normal sensation. In this study the stretch applied by different physiotherapists to any one subject varied by as much as 40 fold. Further work is needed to determine optimal stretch torques. In the meantime physiotherapists should be guided by the subjective feel of tautness in the patients hamstring muscles and their own interpretation of what constitutes a reasonable stretch. 5. Combined exion of the wrist and ngers is never given. This movement can cause trauma of the extensor tendons, resulting in loss of mobility and function.
Maintenance of muscle length

Gross contractures occur when a paralysed limb is not moved, but contractures can also occur in individual muscles or muscle groups in a limb that is receiving daily treatment. For example, contractures readily occur in the following situations:

where the muscle on one side of a joint is innervated and the opposing muscle is paralysed where a paralysed muscle passes over more than one joint in this case, individual joint movements are insufcient to maintain the muscle length when the patient lies with the spine in hyperextension to heal a fracture, the degree of hyperextension necessary to correct fracture dislocations of the lower thoracic and lumbar spine inevitably produces slight exion of the hip joints where the cervical spine is fractured, the shoulders are held in elevation and retraction due to gravity and unopposed muscle pull.
For these reasons, the following movements should be given in addition to the full range of passive movements.
The shoulder girdle

Particular attention needs to be given to the shoulder girdle. It is so freely movable that its habitual position depends upon the relative tension in the following six muscles which act indirectly on the shoulder girdle through the arms:

trapezius cranial 11, C3, C4 levator scapulae C3, C4, C5 rhomboids C5 serratus anterior C5, C6, C7 pectoralis minor C8, T1 subclavius C5, C6
THE ACUTE LESION
49
together with the tension produced by:

pectoralis major C5, C6 latissimus dorsi C6, C7, C8.
The mobility of the shoulder girdle is largely maintained through adequate unilateral and bilateral passive movements to the arms, which will prevent shortening of these muscles.
The scapula
Mobility of the scapula must be maintained. Movements are performed passively in lying or side-lying with the elbow well supported by the therapist. Passive depression is particularly important where the muscles of elevation are innervated and unopposed. In situations where passive movements of the limbs are impractical, accessory gliding techniques should be applied locally to the joints involved to maintain mobility.
To prevent shortening of the following

Rhomboids. With the arms in horizontal exion, adduct both shoulders at the same time. Both elbows are exed and each hand moves towards the opposite shoulder. Long head of triceps. With the arm held in elevation, ex the elbow. Pectoral muscles. With the opposite shoulder lying in abduction to 90 outward rotation and extension and supported on a padded board, abduct and extend the shoulder with the elbow and wrist extended and with the forearm supinated. The arms can be placed in the cruciform position whilst giving passive movements to the lower limbs but care must be taken not to traumatize the shoulder joints. Biceps. Pronate and supinate the forearm with the elbow exed and with the elbow extended. (Pronation is particularly important for patients with lesions at C5, since biceps pulls the forearm into supination, which is not a functional position.) Flexor tendons of the ngers. Extend the wrist and ngers together. Flexor muscles of the arm. Elevate and laterally rotate the arm with the forearm supinated and the elbow, wrist and ngers extended and with the arm held close to the side of the head. Hip exors, quadriceps and anterior fascia of the thigh. In side-lying, extend the hip through the last 15 of movement, keeping the knee exed. The posterior aspect of the hip must be well supported to prevent movement occurring in the spine. Tensor fascia lata. Adduct and medially rotate the leg beyond the midline. Tendo Achillis. Dorsiex the ankle with the knee extended.
50
Flexor muscles of the toes. Extend the toes, dorsiex the ankle and extend the knee. Clawing of the toes occurs easily and not only hinders walking and increases spasticity but may lead to pressure sores on the dorsal and/or plantar aspect of the toes. Careful attention must also be given to movements involving rotation and exion of the limb. For example, exion and lateral rotation of the hip with exion of the knee are important for self-dressing.
Inspection of the lower limbs

Before commencing treatment, the therapist examines the legs for signs of swelling or pressure. Deep vein thrombosis is a common complication during the early weeks after injury, and the possibility of pressure ulcers is an ever present danger. If a deep vein thrombosis is diagnosed, movements to both lower limbs are discontinued because of the possibility of causing a pulmonary embolus. Movements are recommenced when the anticoagulation therapy is successful.
Active movements
Cervical cord lesions
Gentle, assisted, active movements are given to all innervated muscles from the rst day after injury. Progression is made to unassisted active exercises and the patient is encouraged to move his arms independently and functionally. Where possible, the following movements are taught. Extension of the elbow without triceps. The patient laterally rotates and protracts his shoulder, relaxes biceps and allows gravity to extend the elbow. Independence in this movement should be achieved as soon as possible to prevent shortening of the biceps tendon. Flexion of the shoulder without exion of the elbow. The patient is encouraged to lift the arm off the bed, allowing gravity to keep the elbow extended. Lateral rotation of the shoulder may be necessary initially. Grip without nger movements wrist extension grip or tenodesis grip (see Ch. 8). The grip is obtained by rst allowing gravity to ex the wrist when the ngers and thumb fall into extension. The hands or the rst nger and thumb are placed over the object to be lifted. Extension of the wrist by extensor carpi radialis places passive tension on the exors and enables a light object to be held in position. If the object is heavier, the pull of gravity can be partially overcome by supinating the forearm. Although the efcacy of the wrist extension grip can be augmented by allowing some shortening of the nger exor muscles, not all
THE ACUTE LESION
51
therapists agree with this approach. Of those who do, some advocate that this shortening should be allowed to develop from the outset, while others believe that it should be allowed to occur only when there is no further hope of functional recovery. To prepare the hand for future function one needs to bear in mind what the future might hold. If the lesion is to remain complete the patient will need slight tension in the nger exors to give him a stronger wrist extension grip. If the lesion is to become incomplete the need is to maintain full range of movement in the nger extensors and not allow the tenodesis grip to become too strong (see Ch. 15). The lesions of many of the patients in spinal units are, or become, incomplete. A middle way is to give full range movements, including wrist and nger extension together, for the rst 6 weeks unless the lesion becomes incomplete before then. For the patient with a complete lesion the degree of shortening (or contracture) needs to be carefully controlled. Only a small loss of range of the nger exor muscles is required to provide slight curve of the ngers. Too great a contracture will prevent the patient from putting his hand around a large object, such as a glass or placing his hand at when transferring.
Resisted movements
Gentle resisted movements can be gradually introduced as indicated. Strong unilateral exercise for the whole arm involves head movement and is therefore completely avoided until the fracture is healed. All movements must be given with carefully graded resistance, avoiding any neck movements.
Neck exercises
Gentle static neck exercises are given 6 weeks post-injury if there are no contraindications.
Thoracic cord lesions

Patients with thoracic cord lesions are given frequent resisted arm exercises, manually or by using a chest expander of suitable strength, hand weights or other equipment. All movements are given bilaterally and in a controlled manner when the patient is supine, so that resistance is constant and there is no unequal pull on the unstable spine.
Functional electrical stimulation

As functional electrical stimulation is known to increase muscle bulk (Scremin et al 1999), it is used by some physiotherapists in the hope of contributing to the recovery of muscle strength. Weak muscles with strength 1 or 2 on the Oxford scale are treated daily for 6 weeks or in bursts of 2 weeks at a time.
52
References
Cheshire D J E, Rowe G 1971 The prevention of deformity in the severely paralysed hand. Paraplegia 8:4856 Dunlop S A, Steeves J D 2003 Neural activity and facilitated recovery by training after CNS injury: implications for rehabilitation. Topics in Spinal Cord Injury Rehabilitation 8:92103 El Masry W S, Silver J R 1981 Prophylactic anti-coagulant therapy in patients with spinal cord injury. Paraplegia 19:334342 Forner-Cordero I, Mudarra-Garcia J, Forner-Valero J V, Vilar-de-la-Pena R 2003 The role of upper limb surgery in tetraplegia. Spinal Cord 41:9096 Harvey L A, McQuada L, Hawthorne S, Byak A 2003 Quantifying the magnitude of torque physiotherapists apply when stretching the hamstrings of people with spinal cord injury. Archives of Physical Medicine and Rehabilitation 84:10721075 Pascual-Castroviejo I 1996 Neuronal plasticity. Revista de Neurologia 24:13611366 Scremin A M E, Kurta L, Gentili A et al 1999 Increasing muscle mass in spinal cord injured persons with a functional electrical stimulation exercise programme. Archives of Physical Medicine and Rehabilitation 80:15311536 Silver J R 1996 Association between muscle trauma and heterotopic ossication in spinal cord injured patients. Spinal Cord 34:499500
Respiratory therapy
Ida Bromley, Sarah Brownlee, Lone Rose
When the spinal cord is damaged, the respiratory muscles innervated below the level of the lesion become paralysed. This interferes with the power and integration of the remaining muscles and reduces their ability to drive the chest wall efciently. Patients with injuries to the cervical spine have serious problems, whilst those with lower thoracic and lumbar lesions have very little impairment of lung function. All acute lesions need prophylactic respiratory therapy as all are subject to hypostatic pneumonia. The patient with partial or complete paralysis of any of the muscles of respiration will need special care.
CHAPTER
5
Function of the chest wall and respiratory muscles 53 Diaphragm innervation C3, C4, C5 53 Intercostal muscles innervation T1T7 54 Accessory muscles innervation C1C8 54 Abdominal muscles innervation T6T12 55 Effect of posture on respiration 56 General principles of respiratory physiotherapy 56 Prophylactic treatment 57 Physiotherapy for respiratory complications 64 Respiratory physiotherapy in ventilated patients 66 Long-term ventilation 68 Other conditions affecting respiratory function in the spinal patient 69
FUNCTION OF THE CHEST WALL AND RESPIRATORY MUSCLES

The current view of the action of the respiratory muscles on the chest wall is that an integrated activity of many muscles is probably required to expand the ribcage in the most efcient way. The respiratory muscles comprise three main groups: the diaphragm, the intercostal/accessory muscles and the abdominal muscles. These muscles act upon the chest wall either as prime movers or to strengthen the ribcage and facilitate the action of the others.
Diaphragm innervation C3, C4, C5

The diaphragm is the main muscle of inspiration. As the diaphragm contracts, the central tendon is pulled downwards and forwards, pushing before it the abdominal viscera. It expands the ribcage, using the abdominal viscera as a fulcrum. The efciency of the diaphragm depends on this balance of both ribcage and abdominal compliance. In patients with spinal cord lesions above C5, the diaphragm may be partially or completely paralysed. Its function can be assessed by inspecting or palpating the upper abdomen during inspiration. When the diaphragms function is impaired, the negative intrathoracic pressure during inspiration sucks the diaphragm up into the chest 53
54
and the upper abdomen will move inwards. The ndings of Sinderby et al (1992), who investigated eight tetraplegic patients, imply that the diaphragm acts as a trunk extensor in addition to its respiratory function in these patients.
Intercostal muscles innervation T1T7

The internal and external intercostal muscles have both inspiratory and expiratory action. At lower lung volumes, their function is inspiratory and at higher volumes it is expiratory. When breathing is stressed, the intercostals may alternate with other inspiratory muscles; for example, when the diaphragm becomes fatigued, the intercostals may take over as the main inspiratory muscle until the diaphragm recovers. The reduction in respiratory muscle reserve makes fatigue and failure more likely. The intercostal muscles also stabilize the chest wall; in full inspiration they contract to prevent the intercostal spaces being sucked inwards by the negative intrathoracic pressure generated by contraction of the diaphragm. When the intercostal muscles are paralysed, paradoxical movement of the intercostal spaces on inspiration may occur.
Accessory muscles innervation C1C8

Scaleni
The scaleni muscles are now considered to be primary respiratory muscles. They lift, expand and stabilize the ribcage from their insertion on its upper part.
Sternomastoid and trapezius

The sternomastoid and trapezius are inspiratory muscles and contribute to inspiration only during exercise or stress. Usually they are incapable of providing long-term ventilation. In complete lesions above C3 where there is paralysis of the diaphragm, the accessory muscles become the main inspiratory muscles and can produce a vital capacity of 700 ml, particularly the sternomastoid and trapezius (Danon et al 1979). Diaphragmatic pacing may be considered if indicated in these situations (Glenn et al 1986). Clinical observation of the hypertrophy of the accessory muscles demonstrates their inspiratory role in tetraplegic patients (Short et al 1991). De Troyer & Estenne (1991) attribute an expiratory function to the clavicular portion of pectoralis major in patients with lesions between C5 and C8. With the arms xed, contraction of the clavicular portion on both sides of the chest pulls the clavicle and manubrium sterni downwards, taking with them the upper part of the ribcage. The anteroposterior diameter of the upper ribcage is thus
RESPIRATORY THERAPY
55
reduced. This action was associated with a rise in intrathoracic pressure, which was transmitted through the diaphragm to the abdominal cavity. The anteroposterior diameter of the abdomen increased. It is suggested that latissimus dorsi and teres major (C5, C6, C7) x the humerus and prevent pectoralis major from shortening excessively. Thereby, they facilitate the action of pectoralis major in pulling down the manubrium sterni. It is also suggested that cough is active and not passive in patients with lesions at this level.
Abdominal muscles innervation T6T12

The internal and external recti, oblique and transversus abdominal muscles are the most important muscles of expiration (De Troyer et al 1983). In quiet breathing, expiration is usually a passive process achieved by relaxation of inspiratory muscles. In forced expiration, e.g. coughing or sneezing, the abdominal muscles contract strongly. The action of the abdominal muscles is also important in maintaining the position of the diaphragm and hence its efciency. In the erect posture, the abdominal muscles contract to maintain the diaphragm in the dome-shaped position above the lower ribs by pressing on the abdominal contents and raising intra-abdominal pressure (De Troyer et al 1983). Paralysis of the abdominals, as in high thoracic or cervical cord injuries, results in severe impairment of forced expiration. Sputum retention may occur, causing microatelectasis, major segmental, lobar or lung collapse and an increased susceptibility to infection. Microatelectasis may result in ventilation and perfusion mismatching, causing hypoxia (usually with a normal or low CO2). This can cause additional damage to the spinal cord. During the period of spinal shock, when there is an absence of tone in all muscles below the level of the lesion, the distensibility of the ribcage and abdominal wall prevents the diaphragm from inating the lungs in the most effective way. When the period of spinal areexia is over, the reexes return and the degree of tone in the intercostal muscles will, in general, improve the stability of the ribcage. It also provides some resistance in the abdominal muscles, thus rendering the action of the diaphragm more effective (Guttmann & Silver 1965, Silver & Moulton 1970). The fall in vital capacity below the value that would be expected from the loss of motor power alone, and the rise which often occurs even in the absence of neuromuscular activity reect the distortion of the ribcage and its later improvement as tone returns to the intercostal muscles and the ribcage joints stiffen (De Troyer et al 1983, Morgan & De Troyer 1984). As a result of the paralysis of the respiratory muscles:

The patient is unable to perform active, expulsive expiration. Total ribcage and lung ination is impossible.
56
The partial loss of inspiratory muscle function allows the pleural pressure generated by the diaphragm to distort the ribcage, which results in paradoxical motion. This can be seen in the absence of tone when the intercostal spaces are indrawn during inspiration. This increases the work of breathing and reduces the effectiveness of the action of the diaphragm. Without active abdominal muscles, the patient is unable to cough. The inability to inate parts of the lung and to clear secretions tends to produce microatelectasis with subsequent brosis of lung tissue. Immediately after injury, small areas of collapse interfere with ventilation and may result in transient hypoxaemia. The reduction in available muscle power and the increased load placed on the remaining muscles of respiration increase the likelihood of respiratory muscle fatigue and failure (Morgan et al 1984).
EFFECT OF POSTURE ON RESPIRATION

In the supine position, the action of the diaphragm is aided by the weight of the abdominal viscera displacing the diaphragm cranially and assisting inspiration. Paralysed abdominal muscles allow the abdominal viscera to fall downwards and forwards when the patient is erect. The diaphragm then descends lower into the abdominal cavity and may lie below the lower ribs at the start of inspiration. When the diaphragm contracts, the lower ribs are pulled inwards, reducing the lateral diameter of the lower chest instead of, as is usual, lifting the lower ribs and increasing the lateral diameter. Research has shown that the vital capacity of the tetraplegic patient improves by 6% when the patient is tipped 15 head down from the supine position, and falls by approximately the same amount when the head is tipped up 15. The vital capacity may fall by as much as 45% when the patient is tilted towards the standing position. The use of abdominal binders can lessen the change of vital capacity in the upright position. Care must be taken that they do not restrict the movements of the ribcage (Goldman et al 1986).
GENERAL PRINCIPLES OF RESPIRATORY PHYSIOTHERAPY

Respiratory physiotherapy plays a signicant role in the care of patients with spinal cord injury and physiotherapists need to be aware that patients with high lesions and respiratory insufciency have varying degrees of dysphagia (Wolf & Mainers 2003). When
RESPIRATORY THERAPY
57
there is respiratory muscle paralysis, the inspiratory force and volume are reduced and the ability to produce a forced expiration with raised intrathoracic pressure may be absent. The vital capacity can be as low as 30% after injury and may fall further after the rst few days, largely due to ascending oedema within the spinal canal (Ledsome & Sharp 1981). It then improves quite rapidly for the rst 35 weeks, with further slow improvement up to 5 months. The improvement is due to resolving oedema, increased spasticity of the intercostal muscles reducing paradoxical movement, and possibly some reinnervation. Patients may also become hypoxic due to the reduced respiratory function and sputum retention. Respiratory muscle fatigue may occur. The vital capacity of tetraplegic patients decreases with age and also with years post-injury, declining more rapidly after 20 years as a paralysed person (Tow et al 2001). The principle of respiratory treatment is to replace the function of the paralysed respiratory muscles, and the aim is to maintain respiratory function by:

promoting sputum mobilization and expectoration reducing airway obstruction improving ventilation and gas exchange.
It is important to maintain continuity with the patient by having one physiotherapist in charge of his care and, where possible, to educate and support helpers, medical and nursing staff and family in the patients respiratory care.
Prophylactic treatment
Frequent respiratory assessment is essential for an effective treatment programme, which needs to be constantly modied. The assessment will include:

history of present and relevant associated injuries past medical history, in particular respiratory or cardiovascular problems inspection of movement, using vision or palpation to assess paradoxical movement and diaphragmatic function strength and efciency of cough auscultation, in particular listening for uniform air entry, crackles or wheezes in all lung areas vital capacity measurements (care should be taken not to tire the patient) blood gases chest X-rays.
Breathing exercises
Breathing exercises can be useful in maintaining lung expansion in all areas. Treatment should begin as soon as possible to minimize
58
respiratory muscle wasting. Apical, basal, lateral and diaphragmatic breathing exercises are usually taught twice daily. The emphasis is on relaxed comfortable breathing without excessive effort. The aim is to improve strength and endurance and to postpone fatigue and enable the patient to deal more effectively with respiratory problems. Training programmes for the respiratory muscles using various methods of resistance, e.g. incentive spirometry, are given in some spinal units. Biofeedback can also be used. After inspiratory muscle training using functional magnetic stimulation with tetraplegic patients with lesions from C3 to C7, Uijl et al (1999) found that endurance was increased but there was no measurable increase in strength. Three of the nine patients had complete lesions and the rest were incomplete A non-invasive technique using functional magnetic stimulation to train expiratory muscles of respiration was found by Lin & Hsiao (2001) to improve strength in the eight patients in the study. The strength decreased sharply to baseline 2 weeks after conclusion of the programme. This subject continues to be investigated.
Positioning and postural drainage

The frequent repositioning to prevent prolonged pressure is also benecial for respiratory care. Postural drainage, using gravity to free secretions from the peripheral airways, can be used if the patients condition is stable, and where necessary the traction can be maintained. Padded head supports can be used when turning the patient from side to side to maintain alignment of the cervical spine.
Forced expiration
Patients with paralysis of their abdominal muscles are unable to cough, and assistance to do so is required to prevent sputum retention and lung collapse.
Normal cough
A single cough consists of a rapid maximal inspiration with a closed glottis followed by contraction of the intercostal and abdominal muscles with sudden opening of the glottis producing forced expiration. The effectiveness of the cough depends on the linear velocity of the gas in the airways. At high lung volumes, the cough is effective in clearing secretions from the large airways. At low lung volumes, it becomes more effective in the small airways (Macklem 1974). Spinal patients are unable to achieve high lung volumes. They are able, provided the vital capacity is not too severely affected, to bring sputum from the small to the large airways and they then need assistance with coughing to expectorate (Cheshire & Flack 1979). The forces generated in a cough are not due to active contraction of
RESPIRATORY THERAPY
59
muscle but are the result of elastic recoil of the lung and thoracic tissue generated by the previous breath.
Assisted coughing
The patient with partial or complete paralysis of the abdominal muscles is unable to cough effectively. The therapist can replace the function of the paralysed abdominal muscles by creating increased pressure underneath the working diaphragm (Linder 1993).
Methods of assisting the patient to cough

When the patient is supine, there are two main methods by which one therapist can assist the patient to cough: Method 1. One forearm is placed across the upper abdomen of the patient with the hand curved around the opposite side of the chest. The other hand is placed on the near side of the chest. As the patient attempts to cough, the therapist simultaneously pushes inwards and upwards with the forearm, stabilizing and squeezing with the other hand (Fig. 5.1). Method 2. The hands are spread anteriorly around the lower ribcage and upper abdomen, and with elbows extended the therapist pushes inwards and upwards evenly through both arms as the patient attempts to cough (Fig. 5.2A, B). As it is essential for the effectiveness of method 2 that the therapists arms are kept extended, this method may prove impractical when the patient is on a high bed. With the patient in the lateral position, method 1 may be preferable.
Figure 5.1 Assisted coughing. Method 1 using one therapist.
60
Figure 5.2 Assisted coughing. A, B: Method 2 using one therapist. C: Method A using two therapists. D: Method B using two therapists.
One therapist may not be able to give the necessary pressure to produce a cough, if, for example, the sputum is tenacious or the patient has a large thorax or is easily exhausted. In this case, two therapists working together are usually effective, using one of the following methods:
RESPIRATORY THERAPY
61
Method A. Standing on either side of the bed, the therapists place their forearms across the chest with the hands curved around the opposite side of the chest wall. The arms are placed alternately with the lowest arm across the diaphragm. When the patient attempts to cough, the therapists simultaneously squeeze the chest (Fig. 5.2C). Method B. Standing on either side of the bed, each therapist spreads their hands over the upper and lower ribs of the same side with the ngers pointing towards the sternum. When the patient attempts to cough, the therapists simultaneously push on the chest wall (Fig. 5.2D). Whichever method is used, the pressure must be even and rm with the weight of the therapists body behind the push. The effectiveness of the cough depends on the simultaneous effort of the patient and therapist(s). For maximum effect, the pressure behind the push should be held until the very end of expiration and the force applied should be sufcient to deliver the sputum to the mouth. The sound of the cough produced is usually a good guide to the force needed. Both functional electrical stimulation to the abdominal muscles and manually assisted coughing increase maximum expiratory pressure and therefore enhance the cough (Linder 1993, Zupan et al 1997). By increasing the maximum expiratory pressure, functional electrical stimulation to the abdominal muscles can enhance the cough in tetraplegic patients (see p. 260). It is essential to teach the techniques of assisted coughing to medical and nursing staff involved in the care of the patient, as well as to relatives, since the same techniques can be used if the patient is choking. Once up in his chair, the patient will need to be shown how to cough by himself or be assisted by another person.
Caution
Great care must be taken to avoid causing any movement or pain at the fracture site. Pressure on the abdominal wall alone must be avoided, as a patient with an acute lesion may have a paralytic ileus, internal damage or a bleeding gastric ulcer. Extreme care must be taken when assisting the patient to cough in the presence of any of these complications. The methods described above involving two therapists may be preferable under these circumstances.
Coughing in a wheelchair
To cough unaided, the patient himself must produce the pressure usually provided by the abdominal muscles. This can be done in the following ways:
Hold one armrest or wheel rim, press the other arm against the abdomen and lean well over it.
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Flex one elbow behind the chair back or chair handle; those with wrist exors can hold the wheel. Press the other arm against the abdomen and lean over it (Fig. 5.3). Hold both armrests or ex the elbows behind the chair handles and lean over until the chest is pressing against the thighs (Linder 1993).
To assist a patient to cough in a wheelchair

The therapist stands behind the chair and, linking her hands in front of the patient, pulls back against the upper abdominal wall and lower ribs (Figs 5.4 and 5.5). Should a second therapist be required, she stands in front of the patient and pushes on the upper thorax. If it is not possible to assist the patient from behind, the methods described on pages 59 and 60 may also be used with the therapist standing in front of the patient.
Caution
When using these methods with the patient sitting, it is essential to stabilize the wheelchair either by anchoring the rear wheels against a wall or with an assistant holding the chair from behind.
Frequency of treatment
It is important that the patient coughs several times a day to clear the throat even though the chest appears to be free from secretions. Patients with high lesions cannot clear the nose or throat unaided, and the normal amount of debris delivered daily from the lungs collects in the upper trachea. Although this will not cause distress for
Figure 5.3 Independent coughing. Patient with a complete lesion below C7.
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63
Figure 5.4 Assisted coughing in a wheelchair.
Figure 5.5 Assisted coughing in a wheelchair.
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the rst 2 or 3 days, towards the end of a week the patient will begin to experience some difculty in breathing. Inspiration becomes slightly laboured and nally the debris is pushed down into the bronchial tree. At the end of the week, a patient with a previously clear chest may suddenly develop a high temperature and be found to have pneumonia or collapse of a lung. This can be prevented by prophylactic treatment given three or four times a day for the rst 2 weeks at least. Treatment is subsequently given once a day until the patient is up in a wheelchair and able to clear his secretions unaided. Tetraplegic patients also need prophylactic postural drainage at least once a day. If a mobile cervical patient with a lesion at or above C5 gets a heavy cold, he should return to bed for 24 hours. This prevents the nasal secretions dropping down into the chest and causing congestion. He will need assistance to blow his nose and clear his throat.
Physiotherapy for respiratory complications

Respiratory complications, such as retained secretions, collapse of lobe or segment, and infections, require careful and more frequent treatment. The frequency of treatment depends upon the severity of the chest infection. Little and often is a good maxim. If the patient tires quickly and has copious sputum, it may be necessary to treat him every hour, day and night for 24 hours. For less severe cases, treatment at each turn will be sufcient.
Assessment
Treatment is directed at the particular area affected. Regular assessments are important to initiate or change treatment.
Oxygen therapy
If the blood gases are abnormal, e.g. low Po2 , oxygen may be required, which can be given via mask, nasal spectacles, minitrac or tracheostomy.
Humidication
Secretions may be thick and difcult to expectorate, and in addition there may be some difculty with blocked nasal passages. Humidication can be given via ultrasonic or jet nebulizers with saline. It may be necessary to warm the saline.
Drug therapy
The effect of these complications can be reduced where appropriate by the use of drugs, e.g. bronchodilators, antibiotics or steroids for
RESPIRATORY THERAPY
65
asthma and chest infections. Coordinating the time of treatment with therapy produces the best results.
Sputum mobilization
Chest mobilization
Shaking and vibration on expiration may assist in loosening secretions in peripheral airways to allow drainage to the main bronchus, provided the movement does not compromise the stability of the fracture.
Postural drainage
Gravity can also assist in the removal of secretions. Unless contraindicated, postural drainage may be given to any lesion. Care is taken to gain the correct drainage position for the area affected within the limits imposed by the hyperextended position and the type of bed in use. It is important to give postural drainage before as well as after the turn, and essential when treating high lesions. If both lungs are congested and the uppermost lung is not cleared before the turn, as the patient is moved secretions may drain into the trachea, completely blocking it and choking the patient. This can be prevented if the uppermost lung is cleared before the patient is moved. The therapist should wait whilst the patient is turned and treat him immediately in the new position, before the sputum has a chance to settle.
Continuous positive airway pressure (CPAP) and positive expiration pressure (PEP)
CPAP may be useful in the prevention of alveolar collapse (Harvey & Ellis 1993). PEP may also be used.
Intermittent positive pressure breathing (IPPB)

IPPB can also be used, the objectives being to open small airways, reduce airway collapse and improve ventilation and perfusion. Although improvements in lung volume during IPPB seem to be of sufcient magnitude to be of clinical value, the vital capacity changes immediately post-treatment are of such small magnitude that their clinical value would be less certain (Stiller et al 1992). This area is yet to be evaluated. If, as the evidence from this study suggests, IPPB does not have a clinically signicant sustained effect on lung volume, it may have to be given at frequent intervals to have any benecial effect on respiratory function. Furthermore, if the inspiratory breath can be increased by using IPPB then the elastic recoil of the lung is increased and this can improve expiratory ow, assisting in the clearance of secretions (Jackson 1983). In stable tetraplegic patients, lung volume expansion alone has no major effect on lung function, and
66
Rose et al (1987) suggest that it may be more useful in combination with respiratory muscle training. If the expansion of the ribcage is achieved by mechanical means, then full range of movement may be maintained by the remaining inspiratory muscle action. Loaded expiration or incentive spirometry may be useful in increasing the strength of the inspiratory muscles. IPPB should be used with care due to the potential hazards. Positive intrathoracic pressure can reduce venous return to the heart and can therefore reduce cardiac output. IPPB can generate high intra-alveolar pressure, which can result in damage to the lung and may cause an increase of bronchospasm in patients with asthma or similar conditions. Therefore, it should be used with care in patients with unstable cardiovascular systems and asthmatics and is contraindicated in patients with a pneumothorax (Webber & Pryor 1995). In view of this, treatment should not exceed 10 minutes in duration, including rest periods, but should be repeated several times a day. Severely ill patients may tire very easily and clear instructions to the patient and patience on the part of the therapist are vital for the success of this treatment. Various machines are available which assist the clearance of secretions from the lungs. The Cough Assist is one of these. It inates the lungs and subsequently sucks the air out again, thus aiding the movement of sputum. As with all these respiratory machines it should be used with care and in compliance with the instructions for use.
Respiratory physiotherapy in ventilated patients

Despite efforts, some patients may require ventilation because of deterioration in their condition. The criteria for this are determined by the medical staff. Respiratory failure occurs especially in patients with high spinal injury who may become fatigued, have extensive secretions which may be difcult to remove, and have fractured ribs with ail segments. These patients will have blood gas and chest X-ray changes and their general condition will have deteriorated.
Assessment
It is important to establish whether or not the patients cardiovascular system is stable.
Caution
Physiotherapy may be contraindicated when the cardiovascular system is unstable.
Bagging
Bagging is manually inating the patient via a 2 L water bag, or, if the patient is on peak end-expiratory pressure (PEEP) whilst on the
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67
ventilator, an Ambu bag with an Ambu PEEP valve can be used. Bagging is used to stimulate a cough and to mobilize secretions by increasing the expiratory ow and lung expansion. Treatment should not exceed 1520 minutes. The following techniques should be used to avoid precipitating bronchospasm: following a slow inspiration, given via the bag, the breath is held for a few seconds to allow the poorly ventilated parts of the lung to be aerated, and then the bag is released quickly and expiration occurs, producing a high expiratory ow rate which will help to move the secretions. Chest mobilizations are used on expiration to further assist in draining secretions.
Drug therapy
It may be necessary for the patient to be sedated so that an effective treatment can be tolerated. Adequate pain control may also be required. If there is evidence of bronchospasm, bronchodilators or other drugs can be given prior to treatment.
Suctioning
To prevent bradycardia occurring during suction, it is best to preoxygenate the patient, to use catheters whose size should be no more than half the diameter of the endotracheal tube, and to be as quick as possible. Whilst suctioning the patient, the physiotherapist can use the assisted coughing technique to help mobilize the secretions by increasing expiratory ow.
Caution
Pharyngeal suction can excite parasympathetic nerves, e.g. the vagus nerve, and as this cannot be compensated for by increased sympathetic activity, a profound bradycardia and even cardiac arrest may result. Atropine should be available by the patients bed, to be given intravenously by the nursing staff or doctor. Atropine may cause secretions to become thicker and therefore more difcult to remove.
Tracheostomy
It may be necessary to perform a tracheostomy to maintain a clear airway. A tracheostomy reduces the respiratory dead space by approximately one-half. In consequence, each breath becomes more effective in oxygenating the blood and removing carbon dioxide. It facilitates the removal of secretions from the lungs and the control of oxygen administration. Initially a cuffed tracheal tube is used, as this provides an effective seal for the lungs against secretions or inhaled substances and will readily connect with the tube from the ventilator. Overination of the cuff for long periods can cause excessive pressure on the tracheal mucosa and lead to necrosis, sloughing
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and in due course stricture. This is prevented by inating the cuff just enough to make the seal and by deating the cuff at regular intervals for a short time. The tube should be changed frequently as the lumen can become blocked by encrusted, dried secretions. Speaking tubes can be used prior to complete weaning off the ventilator. If the removal of secretions is the only problem and the patient does not require ventilation a mini-tracheostomy may be useful. A small bore tube is inserted into the trachea through the cricothyroid membrane, facilitating the removal of secretions (Gupta et al 1989).
Weaning
Once the patients respiratory condition has stabilized or improved, weaning may be considered. Sedation is usually stopped, and the patient is disconnected from the ventilator for short periods several times a day. A spirometer can be used to measure tidal volume and vital capacity, and a graph to show time off the ventilator can be a useful incentive. During the weaning period, which may take several weeks, the patient will need a great deal of encouragement. As patients on ventilators cannot talk and communicate, all feel insecure. Anxiety and/or fear, sometimes amounting to panic, is experienced during treatment (Bergborn-Engberg & Haljamae 1989). These anxieties are exacerbated when the ventilator is being removed. The patient should be told exactly what to expect and be warned against being too disappointed when improvement is slow, or when there appears to be no improvement at all for a time. The ventilator should be replaced whenever the patient asks for it, otherwise he may become afraid of having it disconnected again. During these periods off the ventilator, the therapist encourages the use of the diaphragm and the accessory muscles of respiration. Initially, 1, 2 or 3 minutes only may be tolerated, but as the diaphragm becomes stronger, longer periods are gradually achieved. Sleeping without the ventilator is usually very difcult, a problem that can sometimes be due to fear alone, but this can gradually be overcome. CPAP and nasal intermittent positive pressure ventilation (NIPPV) can offer useful respiratory support during this period.
Long-term ventilation
Patients with high cervical lesions, e.g. lesions above C4, may require long-term ventilation. For the patient to have some mobility and independence, all the necessary equipment, such as ventilator unit with a back-up system, mobile suction equipment, manual hyperination bag, suction catheters, gloves etc., must be attached to the chair and easily available at all times. Close liaison with those providing care in the community is essential if these patients are to be safely discharged to the home (see Ch. 14).
RESPIRATORY THERAPY
69
Diaphragmatic pacing
The development of the phrenic nerve stimulator has given some patients, who would otherwise be totally dependent on a life support system, a new independence (Collier & Wakeling 1982). A paralysed diaphragm may be electrically stimulated if the lower motoneurones in the phrenic nerve are intact and the cell bodies in the C3, C4 and C5 segments are viable. Some or all of the phrenic nerve cell bodies or lower motoneurones may have been destroyed. The viability is rst established by percutaneous stimulation of the phrenic nerve. Contraction of the diaphragm is estimated by X-ray screening, ultrasound or palpation. Surface electrodes in the lower intercostal spaces may be used to measure the phrenic nerve conduction time. If the results are satisfactory, electrodes are placed on the phrenic nerve, in either the neck or the thorax, and connected to a receiver embedded in the skin of the anterior chest wall. A radio transmitter is placed on the skin surface over the receiver and the phrenic nerve is stimulated (Glenn et al 1984). The aim is to enable the patient to breathe via the stimulator initially during the day, and eventually, for 24 hours if possible. Patients with diaphragmatic pacers are discharged from hospital earlier, are able to communicate more naturally and are better at manipulating the power drive wheelchair than are patients on mechanical ventilation (Esclarin et al 1994). Where diaphragmatic pacing is not a viable option (the phrenic nerves are not intact or the patient does not want the necessary surgery), Di Marco (2001) suggests that intramuscular diaphragmatic stimulation may be a useful alternative. Electrodes are implanted laparoscopically directly into the diaphragm and activate the phrenic nerve. In a retrospective review of 107 patients with high tetraplegia, Oo et al (1999) found that seven patients were able to be weaned off the ventilator between 96 and 430 days after injury, suggesting that phrenic nerve recovery can take place and that the nerve should be tested at 3-monthly intervals for the rst year post-injury. Fewer than 5% recover after the rst year.
OTHER CONDITIONS AFFECTING RESPIRATORY FUNCTION IN THE SPINAL PATIENT

Patients with spinal cord injury may have associated injuries or conditions and treatment must be adapted accordingly.
Paralytic ileus and gastric dilation

The initial signs of this complication, often rst noticed by the physiotherapist, are distension of the abdomen and/or complaints by the patient of difculty in breathing. This can be particularly dangerous
70
for the tetraplegic patient with his already compromised respiration. Assisted coughing must be given with great care to avoid regurgitation, vomiting or aspiration. If such a patient is likely to vomit, he is turned from side to side only until the danger is past.
Head injuries
Physiotherapy may have to be adapted to prevent a further increase in intracranial pressure in patients with head injuries, e.g. turning, tipping, bagging, coughing and suctioning. Priorities in treatment must be discussed with the medical staff. The failure of the patient to understand or cooperate with treatment may cause problems. Sedation may depress respiration.
Fractured ribs
Special care must be taken when treating patients with fractured ribs to avoid further damage to the chest, including pneumothorax. A ail segment of rib may cause paradoxical movement of part of the chest wall.
Fat embolus
A fat embolus can follow a long limb fracture and is diagnosed by increased confusion, altered blood gases, petechial rash and retinal haemorrhages. Oxygen therapy and steroids are used in treatment.
Adult respiratory distress syndrome

Spinal patients can develop adult respiratory distress syndrome. Careful consideration is required as to whether physiotherapy should be given in such cases because of the pulmonary oedema.
Other respiratory complications

Underlying respiratory pathology may be present in patients who receive a spinal cord injury. Such problems may increase with a cervical injury, e.g. the symptoms of asthma. Prophylactic management may be required.
Cardiovascular conditions
Any circulatory problem can be complicated further by a spinal cord injury and treatment should be altered accordingly.
References
Bergborn-Engberg I, Haljamae H 1989 Assessment of patients experience of discomforts during respirator therapy. Critical Care Medicine 17(10):10681071
RESPIRATORY THERAPY
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Cheshire J E, Flack W J 1979 The use of operant physiotherapy techniques in respiratory rehabilitation of the tetraplegic. Paraplegia 16:162 Collier P S, Wakeling L M 1982 Diaphragmatic pacing: a new procedure for high spinal cord lesions. Physiotherapy 68(2):47 Danon J, Dauz I S S, Goldberg N B, Sharpe J T 1979 Function of the isolated paced diaphragm and the cervical accessory muscles in CI quadriplegia. American Review of Respiratory Diseases 119:909 De Troyer A, Estenne M 1991 The expiratory muscles in tetraplegia. Paraplegia 29:359363 De Troyer A, Kelly S, Zin Wa 1983 Mechanical action of the intercostal muscles on the ribs. Science 220:8788 Di Marco A F 2001 Neural prostheses in the respiratory system. Journal of Rehabilitation Research and Development 38:601607 Esclarin A, Bravo P, Arroyo O et al 1994 Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury. Paraplegia 32:687693 Glenn W L, Phelps M L, Elefteriades J A et al 1986 Twenty years of experience in nerve stimulation to pace the diaphragm. Pace 9(1):780784 Glenn W L, Hogan J F, Loke J S O et al 1984 Ventilatory support by pacing of the conditioned diaphragm in quadriplegia. New England Journal of Medicine 310(18):11501155 Goldman J M, Rose L S, Williams S J et al 1986 The effect of abdominal binders on breathing in tetraplegic patients. Thorax 41(12):940945 Gupta A, McClelland M R, Evans A, El Masry W S 1989 Mini-tracheostomy in the early respiratory management of patients with spinal injury. Paraplegia 27:269277 Guttmann L, Sir, Silver J R 1965 Electromyographic studies on reex activity of the intercostal and abdominal muscles in the cervical cord lesion. Paraplegia 3:122 Harvey L A, Ellis E R 1993 The effect of continuous positive airway pressures on lung volumes in tetraplegic patients. Paraplegia 34:5458 Jackson S E 1983 IPPB. In: Downie P A (ed) Cashs textbook of chest, heart and vascular disorders for physiotherapists, 3rd edn. Faber and Faber, London Ledsome J R, Sharp J M 1981 Pulmonary function in an acute cervical cord injury. American Review of Respiratory Diseases 124:41 Lin V W, Hsiao I N 2001 Functional magnetic stimulation for conditioning of expiratory muscles in patients with spinal cord injury. Archives of Physical Medicine and Rehabilitation 82:162168 Linder S H 1993 Functional electrical stimulation to enhance cough in quadriplegia. Chest 103:166169. Macklem P 1974 Physiology of cough. Transactions of American Bronchooesophalogical Association, 150 Morgan M D L, De Troyer A 1984 The individuality of chest wall motion in tetraplegia. Thorax 39:237 Morgan M D L, Gourlay A R, Denison D M 1984 An optical method of studying shape and movement of the chest wall in recumbent patients. Thorax 101:235 Oo T, Watt J W H, Soni B M, Sett P K 1999 Delayed diaphragm recovery in 12 patients after high cervical cord injuries : A retrospective review of the diaphragm status of 107 patients ventilated after acute spinal cord injury. Spinal Cord 37:117122
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Rose L, Geary M, Jackson J, Morgan M 1987 The effect of lung volume expansion in tetraplegia. Physiotherapy Practice 3:163167 Short D I, Silver J R, Lehr R P 1991 Electromagnetic study of sternomastoid and scalene muscles in tetraplegic subjects. International Disability Studies 13:4649 Silver J R, Moulton A 1970 The physiological sequelae of paralysis of the intercostal and abdominal muscles in tetraplegic patients. Paraplegia 7:131141 Sinderby C, Ingvarsson P, Sullivan L 1992 The role of the diaphragm in trunk extension in tetraplegia. Paraplegia 30:389395 Stiller K, Simionato R, Rice K, Hall B 1992 The effect of intermittent positive pressure breathing on lung volume in acute quadriparesis. Paraplegia 30:121126 Tow A M P-E, Graves D E, Carter R E 2001 Vital capacity in tetraplegics twenty years and beyond. Spinal Cord 39:139144 Uijl S G, Houtman S, Folgering H T M, Hopman M T E 1999 Training of the respiratory muscles in individuals with tetraplegia. Spinal Cord 37:575579 Webber B A, Pryor J A 1995 Physiotherapy for respiratory and cardiac problems. Churchill Livingstone, Edinburgh Wolf C, Mainers T H 2003 Dysphagia in patients with acute cervical spinal cord injury. Spinal Cord 41:347393 Zupan A, Savrin R, Erjovic T et al 1997 Effects of respiration muscle training and electrical stimulation of abdominal muscles on respiratory capabilities in tetraplegic patients. Spinal Cord 35:540545
Pressure effects and prevention

Lone Rose
CHAPTER
6
Contributory factors in patients with spinal cord injury 73 Pathology 74 Prevention of pressure ulcers 75 Turning the patient 75 Care of the skin 77 Posture and seating 77 Posture 78 Assessment of posture 80 Assessment of bodyseat interface pressure 85 Cushions 86 Posture and seating clinics 88 Pressure consciousness: re-education in self-care of the desensitized areas 89 Pressure relief 89 Turning at night 90 Inspection of the skin 92 The paralysed limbs 92 Dos and donts 92
There are many factors that contribute to the development of a pressure ulcer (Graham 1997) but pressure remains the main and most direct cause of tissue breakdown. It cannot be overemphasized that pressure ulcers are caused in bed or in the chair through prolonged pressure, which prevents adequate circulation to the area. Despite the development of increasingly sophisticated pressure relief devices, pressure ulcers continue to feature as a common complication in both acute and chronic spinal cord injury (Yarkony & Heinemann 1995). Ulcers develop mainly over bony prominences which are exposed to unrelieved pressure in the lying or sitting position. The most vulnerable areas are the sacrum, trochanters, ischial tuberosities, knees, bulae, malleoli, heels and fth metatarsals. The occiput, scapulae and elbows are also at risk in patients with cervical cord lesions. If the patient is placed in a plaster cast, ulcers may develop over the ribs, spinous processes, and anterior and posterior superior iliac spines. Pressure ulcers readily occur under splints, plasters, calipers and braces applied over anaesthetic areas.
Contributory factors in patients with spinal cord injury

The individual with spinal cord injury is at particularly high risk of developing pressure ulcers due to the following contributory factors.
Loss of sensation and voluntary movement

The bodys normal response to prolonged pressure is a feeling of discomfort or pain. The reaction to this warning signal is an automatic change of position. Not only will the loss of sensation prevent the patient with a spinal cord injury from receiving these warning signals but the paralysis will make it harder or impossible for him to shift his position to relieve it.
Loss of vasomotor control

The impairment of the circulation produces a lowered tissue resistance to pressure. Ischaemia due to local pressure therefore occurs 73
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more readily. The vasomotor paralysis is most extreme immediately after injury, and severe ulcers can be produced very rapidly. Although the vasomotor system is never subsequently normal, some improvement does occur when reex activity returns to the isolated cord.
Pathology
There are currently in excess of 30 pressure ulcer grading tools to help classify the degree of tissue damage. The Stirling scale is the one used at the National Spinal Injuries Centre, Stoke Mandeville Hospital (Reid & Morrison 1994). It describes four stages of pressure ulcer development, which may be summarized as follows.
Stage 0 (pre-ulcer stage)

Normal intact skin, healed skin with scarring or an area of erythema and slight oedema caused by transient circulatory disturbance. When pressure is relieved, this inammation disappears within 48 hours. This is not classied as a pressure ulcer.
Stage 1
There is permanent damage to the supercial layers of the cutaneous tissues. Vascular stasis occurs, and reddening and congestion of the area do not disappear on digital pressure. The skin is discoloured blue/purple/black.
Stage 2
There is abrasion of the skin or formation of blisters. This may be followed by supercial necrosis and the formation of a shallow ulcer without undermining adjacent tissues.
Stage 3
There is full thickness skin loss involving damage or necrosis of subcutaneous tissue but not extending to underlying bone, tendon or joint capsule.
Stage 4
There is full thickness skin loss with extensive destruction and tissue necrosis extending to underlying bone, tendon and capsule. If the infection extends to the bone, periostitis and osteomyelitis will develop, which may result in the destruction of joints and the formation of ectopic bone. If unchecked, these major lesions may lead to general septicaemia and death.
PRESSURE EFFECTS AND PREVENTION
75
Development of bursae
A bursa can develop, frequently over the ischial tuberosity, due to prolonged sitting. The surrounding tissues are rapidly involved if infection occurs, and a very small skin opening may be the only visible sign of a deep cavity reaching down to the infected bursa, and usually to the bone.
PREVENTION OF PRESSURE ULCERS

As Sir Ludwig Guttmann used to say, Where there is no pressure, there will be no sore. Prevention therefore depends primarily upon the frequent relief of pressure in conjunction with the correct positioning of the patient (see Ch. 4). In order to establish the most appropriate routine of pressure relief and positioning for each patient, it is essential that an assessment of risk is carried out on admission by an experienced nurse and at regular intervals throughout the rehabilitation. The degree of risk of developing a skin problem will vary from individual to individual and will largely depend on age, sex, body build, level and completeness of injury, degree of incontinence and general health. Other factors such as smoking, anaemia and diabetes will further increase the risk. There are several scales that can be used to document and monitor the level of risk of developing a skin problem. One example is the Waterlow scale (Waterlow 1991).
Turning the patient

Newly injured patients are turned every 3 hours, day and night, 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. For patients who are unable to tolerate the traditional side-lying position (e.g. because of shoulder pain or halo traction), the hipick position can be used. In this position only the lower half of the trunk is rotated to the side together with the lower limbs, exed at the hips and knees. A small pillow or rolled up towel should be placed in the lower back to ensure that the sacrum stays free of pressure. A pillow is placed between the knees to prevent pressure areas developing on the medial sides of the knees. The exed knees should be supported on a pillow if full rotation cannot be achieved. Feet should be placed on pillows as necessary to prevent pressure areas on the malleoli and borders of the feet. The hipick position should not be used where there is a risk of causing movement at the site of the fracture (low thoracic and lumbar fractures). Special attention should be given to inspection and protection of potential pressure areas on the occiput and shoulders if the hipick position only is being used.
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The most susceptible areas, i.e. where bony points are close to the skin, must be kept free of any pressure by adjusting the pillows accordingly. At each turn, all such areas are inspected, the skin is checked and all wrinkles and debris are removed from the bed linen. Any evidence of local pressure, however minor, is an urgent warning. Redness that does not fade on pressure, septic spots, bruising, swelling, induration or grazing indicates an impending pressure ulcer. All pressure must be relieved from any area thus affected until it is healed. For example, if the sacrum shows signs of redness, the left and right lateral positions only should be used until the mark has completely disappeared. An electrical turning and tilting bed can be used to facilitate the 3-hourly turning of patients (Huntleigh Healthcare Ltd, UK; Pegasus Ltd, UK). This type of bed is divided longitudinally into three sections. On pressing a button, two of these sections elevate to 70. The remaining third can be slightly raised to maintain the patient in position. The head and foot of the bed will tilt down to 15. A head traction unit can be attached when skull traction is required. This unit enables constant cervical traction to be maintained when turning the patient. A face-piece supports the head in the lateral position. A detachable armrest enables the upper limb to be positioned with the elbow fully extended and the shoulder abducted. All turns should be supervised by an experienced nurse who organizes each turn and ensures that correct spinal alignment is maintained whilst the patient is moved. If a turning/tilting bed is not available, the patient can be positioned on a bed with sorbo rubber packs. The space between the packs is altered to suit the position and stature of the patient, so that the bony prominences are free from pressure. The prone position is particularly useful for the non-acute lesion if the sores are on the sacrum, trochanters or ischii, or on all three sites. In this position, care must be taken to ensure that the toes, knees, iliac crests and genital areas are clear of pressure (Fig. 6.1). Support to the back is given by sandbags or rm pillows when in the side-lying position. If sorbo packs are not available, pillow packs can be used. These are made by tying ve or six pillows tightly together. For the non-acute patient the intervals between turns can gradually be increased but will always be guided by the individuals specic needs at any one time. It is important to remember that an individuals tolerance to pressure can alter due to simple factors such as body temperature and general well-being. There is a large variety of mattresses and mattress overlays available designed to help in the prevention of pressure ulcers. Body support systems are constantly being developed to facilitate the healing of pressure ulcers. Ultimately the type of bed and mattress used has to meet the needs of the individual patient as identied by the risk assessment at that time.
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Figure 6.1 Prone position of patient on a pack bed.
Care of the skin

The emphasis is on cleanliness and dryness. Intact skin is kept clean by the normal use of soap and water. No local applications of methyl alcohol etc. are used. Dead epithelium tends to collect, through disuse, on the soles of the feet and palms of the hand. It can be prevented and removed by thoroughly washing and towelling these areas and then massaging an emollient into the skin.
POSTURE AND SEATING

Any wheelchair user needs a well-tting wheelchair with an effective cushion if the dangers of prolonged pressure and poor posture are to be minimized. Even the most sophisticated cushion cannot work optimally if it is not adequately supported by the wheelchair. It is therefore essential when assessing a wheelchair user that the wheelchair and cushion are considered as one unit. On completion of the assessment and prescription, the seating must be tted properly to the individual as otherwise it may itself become the cause of tissue trauma (Batavia & Batavia 1999). The purpose of the seating is to offer the user a stable and comfortable base from which he can function at his full potential with maximum efciency and minimum effort. It should also promote a symmetrical posture and provide adequate skin protection. If the position of the patient is not stable on the seat, the patient will tend to slide on the seat, causing friction, which is more damaging to the
78
skin than pure pressure. Regular friction may be indicated by the reduction in hair growth in patches over the ischii. The seating system should be supportive but not restrictive. Normal posture is dynamic the patient recently out of bed should be encouraged to change his posture frequently in the chair but also know how to return to a symmetrical upright posture.
Posture
Most patients with a recent spinal cord injury will need some encouragement and support to adopt the correct position in the wheelchair. Due to the lack of, or altered, sensation below the level of the lesion, the patient will not receive the normal sensory input to tell him when he is adopting a normal posture in the chair. He needs time to learn to recognize when he is positioned correctly by using the sensory input from the unaffected parts of the body. To achieve this, it is crucial that this sensory stimulus is that of normal postural alignment from the rst day out of bed, and this should be carried on throughout the 24 hour period, not just when the patient is up in the wheelchair. Attention to detail and a consistent approach to positioning in the early days of rehabilitation will soon show the benet. The therapist needs to take a very active role in guiding and supporting not only the patient but also all other professionals involved with positioning the patient, whether in the wheelchair or in bed. This is particularly the case with patients who have high tone, asymmetrical neurological decit or incomplete lesions. The patients position in bed needs to address the postural problems observed in sitting without compromising the skin integrity of the patient. A commonly used and very effective position in bed for patients with a scoliosis or increased kyphosis is the hip icked position as described earlier. This position is very effective in breaking up high tone patterns, stretching the side exors of the trunk, and it encourages trunk extension if positioned well. After the prolonged period of bedrest, the postural muscles unaffected by the spinal cord injury will inevitably be weak. It is benecial if static neck and back extension exercises can be initiated during the last 2 weeks prior to getting up and carried on during the initial rehabilitation phase. When the patient is positioned in the wheelchair he should sit with the bottom right to the back of the seat, the trunk and head symmetrical, all four limbs resting in normal alignment, the weight distributed evenly over as wide an area as possible and the anatomical curves of the spine maintained. In order to achieve this it is essential that the wheelchair used when mobilizing the patient is a good t. Seat width it should be possible to just slide a hand between the widest point of the hips and side of the chair. Recent weight gain or weight loss must be considered.
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If the seat is: 1. Too narrow there is danger of excessive pressure on the hips (trochanters). If the trunk cannot be accommodated comfortably within the back uprights the user will tend to rotate with one side comfortably within the backrest and the other on top of the backrest upright. 2. Too wide this is likely to lead to asymmetrical pelvic posture as the patient tends to place the hips to one side or the other for stability. This in turn will lead to pelvic obliquity and scoliosis with increased risk of developing a pressure area on the lower ischium and possibly also on the side of thorax resting against the side support of the backrest. Seat depth the whole length of the thighs should be supported to within 5 cm (2 inches) (maximum) of the popliteal fossa. If the seat is: 1. Too long the patient will not be able to get to the back of the seat and will slump and gradually slide forwards. This will create excessive pressure and friction on the sacrum. 2. Too short the area over which the weight can be distributed will be decreased, thereby increasing overall pressure on the remaining contact area. Footplates must be adjustable to allow the thighs to be in contact with the full length of the cushion. If the footplates are: 1. Too high the area over which the weight is distributed is reduced and the pressure will be increased over the remaining contact area. 2. Too low increased pressure on the distal part of the thigh will reduce venous return and increase the risk of oedema to the lower legs and feet. The downward drag of the feet will make it harder for the patient to lift fully back onto the seat. Backrest height should be high enough to give adequate support without interfering with the shoulder girdle and upper limb function when propelling the wheelchair. For patients with levels above T6 the backrest should be no higher than the inferior angle of the scapulae. For paraplegic patients with levels below T6 the backrest should be no lower than the level of sensation. If the backrest is: 1. Too high the patient will feel as if he is being pushed forward and will frequently ask to have his hips pulled forwards to compensate, resulting in a slumped position. This will encourage the body to gradually slide further forwards on the seat with ever increasing trauma to the sacrum. Furthermore the loss of lumbar lordosis will lead to gradually increasing thoracic kyphosis and increased cervical lordosis often associated with neck pain.
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2. Too low if the backrest does not offer sufcient support the newly injured patient will typically tend to arch over the backrest with an anteriorly tilted pelvis. In order to compensate and gain increased trunk support they will lower themselves in the chair by bringing their hips forward. This results in posterior tilt of the pelvis and increased thoracic kyphosis. A temporary back extension may help until the patients balance and postural control have improved. Backrest angle should be as close to vertical as the patient can tolerate. If the patient needs to be tilted back it is important to maintain a minimum of 90 hip exion to prevent sliding forward and losing the lumbar curve. This may be achieved either through independent adjustment of back/seat angle or by reclining the backrest with simultaneous ramping of the cushion at the front by inserting a wedge under the rst third of the cushion. If the wedge goes further under the cushion, the patient tends to be raised overall in the seat and the effect is lost. Maintaining the normal curves of the spine can be very difcult to achieve in a standard slingback style backrest. A tension adjustable backrest (see Fig. 11.3) provides the most effective and comfortable way of sculpting the backrest to the contours of the individual. Most newly injured patients tend to be very stiff in the lumbar spine when rst mobilizing out of bed. The tension adjustable backrest can be altered regularly as the spine becomes more exible. Armrests will assist newly injured patients to maintain their balance in the chair. Being able to rest on armrests occasionally will help to alleviate fatigue of the postural muscles of the trunk. As they make it easier for patients to alter their position in the chair, armrests also encourage a more dynamic posture. Armrests should ideally be height adjustable for optimum support. If the armrests are 1. Too high the shoulders will be elevated and may lead to shoulder/neck pain. 2. Too low the patient will have to stoop to rest on them, which will encourage kyphotic trunk posture. There may also be drag on the shoulder joint leading to shoulder pain. For more detailed description of wheelchair options and adjustments, see Chapter 11.
Assessment of posture
For posture to be functional it must be dynamic. Even tetraplegic patients with very high lesions can develop the ability to shift their posture by shrugging their shoulders or moving their head. It is important that the therapist takes time during the assessment process
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to observe these movements, which are often automatic rather than conscious, as they may have a bearing on how to interpret the assessment ndings. These habits develop over time and are more pronounced in patients in the nal stage of rehabilitation or readmission and outpatients. The posture is usually assessed rst in the habitual sitting position in the users present seating system, then in supine to check joint ranges and if any tightness can be corrected with gravity eliminated and nally in a corrected sitting position. The order in which the assessment is carried out can vary from therapist to therapist but the postural assessment usually starts with the orientation of the pelvis as this determines the position of the legs, trunk and head.
Assessment in the habitual sitting position frontal view

With the therapist looking at the patient from the front the pelvis is checked for obliquity (i.e. level horizontally), rotation and tilt (anterior/posterior).
Pelvic obliquity
This is assessed by palpating the anterior superior iliac spines (ASIS) and observing whether one is lower than the other. If there is a pelvic obliquity, the main area at risk of pressure will be the ischial tuberosity on the lower side of the pelvis. Where an obliquity can be observed clinically, a more objective way of measuring it may be required to monitor any future deterioration. An anthropometer or slide rule can be used to measure the distance from the oor to the top of the iliac crest on right and left sides. The difference between the two sides will give the absolute obliquity in any given posture or seating system.
Pelvic rotation
The rotation of the pelvis is determined by palpating both ASIS and observing whether one is forward in relation to the other. Provided there is no history of orthopaedic problems with the hips and thighs, the alignment of the knees may assist in determining whether the pelvis is rotated. The rotation can either be described according to the side it is rotated towards (e.g. pelvis rotated to the left) or according to its orientation on the down side if an obliquity is present (e.g. pelvis down and rotated back on the left). As in the case of the obliquity, an anthropometer or slide rule can be used to monitor more accurately the rotation by measuring the distance from the ASIS to the backpost of the chair on both sides. The difference between left and right denotes the measure of rotation.
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Pelvic tilt
The normal tilt for the pelvis in the seated position is neutral, i.e. when the anterior superior iliac spines (ASIS) are level with the posterior superior iliac spines (PSIS). The pelvis is said to be in posterior tilt if the ASIS is higher than the PSIS and in anterior tilt when the ASIS is lower than the PSIS. For the pelvis to be in neutral, the femora need to be at true 90 in the hip joint. This is not usually achieved on a at seating surface. The thigh is thicker proximally than distally and therefore the femur will effectively slope downwards and not be parallel to the surface, making the angle at the hip joint < 90. Any seating system with a ramped effect, e.g. a posteriorly inclined seat or a cushion which is thicker at the front, will promote a neutral pelvic position. A quick guide is to imagine the patient sitting with a tray on his lap. It should neither slope away from him nor towards him. As it can be very difcult to palpate both ASIS and PSIS simultaneously helpful clues may be picked up from other parts of the body. Posterior tilt of the pelvis is characterized by a attened lumbar spine with a characteristic long C kyphosis and compensatory increased cervical lordosis in order to maintain horizontal vision (poking chin posture). Main areas at risk of pressure are the sacrum and coccyx and the spinous processes of the spine. The legs will typically be abducted and externally rotated. Anterior tilt of the pelvis is usually associated with adduction and internal rotation of the legs. The lumbar spine will be hyperlordotic with compensatory thoracic and cervical curves. If severe, pressure areas may appear in the perineal area as well as on the coccyx where it comes into contact with the back of the chair. Frequently the patient with anteriorly tilted pelvis does not use the backrest for support or has to extend back to be able to reach it. With either posterior or anterior tilt of the pelvis, the range of rotation in the trunk will be restricted and therefore function will be affected.
Lower limbs
The greater trochanters are palpated to ensure that the whole of the pelvic/hip girdle is supported within the perimeter of the cushion. When palpating the hips it is important to be alert to the possibility of a dislocated or subluxed hip in sitting. The hips, knees and feet should be in line with one another. If the knees are adducted and the feet placed far apart there is the potential for medial knee strain. If the knees are abducted and the feet are placed close together, the lateral side of the lower leg is likely to be in touch with the frame of the wheelchair with the subsequent risk of pressure problems. The thighs should be in contact with the full length of the cushion and the feet should be weight-bearing on the soles of the feet. There is no standard formula for the correct angle of the hips, knees and
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ankles in sitting. This should be determined by careful examination of the free range of movement in each joint, which should be carried out in supine.
Trunk, upper limbs and head

Working up from the pelvis the shoulders should be level and the head in the middle. The trunk should be central in the wheelchair with an equal amount of backrest showing on each side. Pelvic obliquity inevitably leads to a compensatory scoliosis as the spine curves to enable the head to align itself for upright posture. Often the head will be tilted to one side with one shoulder higher than the other. If the scoliosis is severe, upper limb function may be affected as one or both hands may need to be used in order to maintain balance and upright posture. If armrests are used for support, the upper limbs should rest comfortably on them without elevating the shoulders or having to stoop to rest on them.
Assessment in the habitual sitting position lateral view

Looking at the patient from the side, the lumbar, thoracic and cervical curves are described as well as the head position. In normal upright posture the shoulder is vertically above the hips with the head between the shoulders. This can be difcult to achieve when the patient rst gets up but should always be the ultimate aim. As the head will always try to stay above the pelvis, the further back the trunk is tilted, the further forward the head will ex. This posture will eventually lead to neck and shoulder pain. In order to achieve sufcient stability while using their arms, tetraplegic and high paraplegic individuals will often sit with the shoulders slightly behind the hips. The normal curves of the spine should still be maintained by using a well-adjusted back canvas.
Assessment in the habitual sitting position posterior view

Standing behind and with the patient leant slightly forward the spine is palpated for any sign of scoliosis. The prole of the trunk and skin creases will often give away any tendency to scoliosis. When assessing for scoliosis it is important that clothes are removed and that the patient is sitting as close to upright as possible to get the maximum effect of gravity in the usual sitting position. It is important that the patient is assessed for scoliosis in his habitual posture to get an impression of the effect of the seating on the posture. Rotation of the trunk can most clearly be assessed by observing the patient from above.
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Assessment in supine on a rm surface

After assessing the position of the pelvis, trunk, head, upper and lower limbs in the habitual sitting position, it is essential to establish whether any abnormal posture identied is xed or correctable as this will determine the appropriate intervention. This can most effectively be done by assessing the patient in supine, where the effect of gravity can be eliminated. This part of the assessment can be difcult to carry out for the therapist, especially with heavy individuals or those with high tone. Proper attention must be paid to back care at all times.
Pelvis/trunk
It is helpful to observe the posture that the individual adopts when rst positioned in supine before correcting the alignment. Trunk extension should be observed with only the minimum of support under the head. With the knees and hips exed to allow the pelvis to move freely, the therapist checks the range of movement in the pelvis in terms of obliquity, rotation and tilt. This will also test the correction of any scoliosis. It may be necessary to have assistance to stabilize the shoulders or help to take the weight of the legs.
Lower limbs
Passive hip exion is tested whilst xing the pelvis with one hand. The degree of hip exion achieved before the pelvis starts to roll posteriorly will determine the maximum seat/back angle of the wheelchair. If the seat/back angle of the seating system places the user in more exion at the hips than is freely obtainable, a posteriorly tilted pelvis will result. With the hip exed the lower leg is then raised to test the range of knee extension. Tight hamstrings is one of the most common causes of posterior tilt of the pelvis so it is important that the legrests of the wheelchair place the leg in sufcient knee exion to release tension in the hamstrings and allow free upright position of the pelvis. Passive range of movement in the foot and ankle is also checked for any restrictions which may affect the position of the feet on the footplates.
Head and upper limbs

It may be necessary to check the range of movement in the neck and shoulder girdle if problems have been observed in the upright posture. Finally the patient may need to be assessed in short-sitting on a rm surface to assess the potential for correction of any abnormal posture against gravity. The procedure is the same as for habitual upright posture.
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Following the assessment, changes are made to the seating system according to the ndings. Frequent reviews and adjustments to the seating are recommended as the posture usually changes as the patient progresses through the rehabilitation. If the patient is struggling to maintain an upright and symmetrical posture, a body brace may be used (see Fig. 7.1). This is usually only necessary in the short term for patients undergoing initial rehabilitation. For some patients with established postural problems, it may be an effective long-term solution. Similarly foot orthoses may be required to ensure a good position on the footplates/footbar.
Assessment of bodyseat interface pressure

Poor posture in the wheelchair will not only affect the patients function and comfort, it will also affect the distribution of pressure and thereby increase the risk of pressure problems. Apart from meeting the patients need for postural support, the cushion must also be able to distribute the pressure over as wide an area as possible. The more the cushion can conform to the bodys contours, the better it will achieve this. Measurements of the pressure between the patients body and the seating surface in sitting can be taken by using either simple hand-held pressure transducer systems as described by Rothery (1989) and Dover et al (1992) or more sophisticated (and more accurate) computerized systems as described by Bar (1991), Henderson et al (1994) and Bogie et al (1995). Single cell transducers can help to identify peak pressures. However, interface pressure monitors which are able to map the entire seating area via a series of interconnected cells will give a more complete impression of the distribution of pressure. The cushion should distribute the pressure evenly throughout the contact area with no peaks and troughs. The pattern of distribution is of primary interest, not merely the absolute value of pressure measured at a certain point. Capillary closure pressure of 32 mmHg is frequently quoted as a threshold for tissue viability and hence interface pressures above this level are thought to produce ischaemia (Kosiak 1961, Daniel et al 1982). However, the length of time that an individual can withstand a certain pressure over bony prominences varies greatly from person to person. A guideline is given by Reswick & Rogers (1983). If shearing forces, e.g. through bad posture or transferring, as well as vertical pressure are applied to the tissue, the process of tissue necrosis will be accelerated. More recent studies show that deeper tissue such as muscle is more susceptible to pressure and that deep ulcers, e.g. as a result of bruising after a bad transfer or a fall, can develop very fast without signicant supercial signs of tissue breakdown (Bouten et al 2003). Whatever system is used, it is important that the therapist takes into consideration the degree to which the pad used to measure the pressure may interfere with the pressure-distributing properties of the cushion being assessed. Interface pressure measurements are an
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extremely useful adjunct to a full clinical assessment, but as most only demonstrate the pressure distribution at the moment of use, they should never be used as the sole indicator of a cushions suitability.
Cushions
A wide variety of cushions is available worldwide ranging from simple easy-to-use cushions to highly sophisticated ones. No one cushion will be appropriate for every patient, but all wheelchair users must have at least a foam cushion. Where there is a choice of cushions other than foam, the therapist will need to examine and assess not only the patients posture and skin care needs, but also comfort, the method of transfer, the patients balance and stability in sitting and his degree of independence. Some cushions, for example, may cause difculties when transferring, may be too heavy for the patient or relatives to handle, or may not be available in the appropriate size. The climate in which the cushion is used can also affect the durability of the cushion. A hot, humid climate will make certain types of foam deteriorate faster. The patient and anybody involved in his care after discharge need to understand how the cushion works and how to look after it. Where the patient has more than one wheelchair, it may be necessary for the cushion to be used in both. This also applies to any special back supports which may be used. Trial periods with more than one cushion may be necessary. Cushions are made from different substances, including foam and gel emulsion. Some are a combination of a contoured, rm base with a uid- lled pad on top, such as the Jay (Fig. 6.2) and Flo-tech ranges. Some are air- lled, e.g. the Roho dry otation cushion (Fig. 6.3) and
Figure 6.2 Jay 2 base and Flolite pad separated.
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Figure 6.3 (left) Roho Quadtro cushion. It has four intercommunicating compartments, allowing for greater stability and postural control. Figure 6.4 (right) Range of Vicair cushions.
Vicair (Fig. 6.4), or a combination of air and foam, e.g. Varilite. Many cushions are now contoured and designed to lower the ischial tuberosities into the cushion while lifting the distal end of the femur, promoting a more upright position of the pelvis (Green & Nelham 1991). This design of cushion also helps to reduce the interface pressures under the ischial tuberosities (Gilsdorf et al 1990). Cushions that are in sections (right/left, front/back) tend to offer greater stability and postural control. The Jay range of cushions has several options for modications (Fig. 6.5) which can be employed either for assessment or for permanent use. Depending on the material of the cushion and the way it is used, it may last for anything from 6 months to several years. The patient must know the likely lifespan of the cushion, how to assess the wear and how to organize a replacement. Most cushions come supplied with an outside cover. Although the cover needs to be well-tting, it must not detract from the conforming properties of the cushion, as the patient will then be supported by the cover rather than the cushion itself. This is a common problem with PVC-type covers. The best material for a cover is a two-way stretchy cotton based material, e.g. terry towelling. Where access to a range of cushions is limited, the use of what is available and some imagination can go a long way to make a relatively simple cushion more effective. A foam cushion with ischial cut-outs lled with bags of air or water will offer a far greater degree of pressure relief than the foam on its own. A cushion made from
88
Figure 6.5 Jay box of modications.
bicycle inner tubes and plastic balls has been described as being more effective than a foam cushion (Guimaraes & Mann 2003). Whatever the sophistication of the cushion used, the need for regular pressure relief and checking of skin must never be forgotten.
Posture and seating clinics

The value of using posture and seating clinics as an integral part of the rehabilitation programme is well documented (Noble 1981, Rothery 1989, Dover et al 1992). They serve not only to facilitate early identication of problems through continual assessment of the individual seating needs of the patient, but also to create an important focus for education on matters relating to skin care and posture for patients as well as carers and staff. This type of assessment is
89
valuable not only for newly injured patients but also for readmission and outpatients. Patients usually attend for an initial assessment for wheelchair and cushion, and advice on posture and pressure prevention, as soon as they are out of bed. The patients continue to be seen regularly whilst in hospital and after discharge at follow-up outpatient attendances. Attempts are made to evaluate the quality of life of each patient, as social and psychological factors inuencing behaviour inevitably have an effect on the incidence of pressure ulcers (MacLeod 1988, Rothery 1989). The long-term effects of ill-tting seating should not be underestimated. It will reduce the patients function and increase pain and discomfort. The function of the inner organs may be compromised. The risk of contractures and deformities will increase as will the risk of pressure ulcers. If an ulcer develops, the cost to the patient can be catastrophic in terms of social isolation, poor psychological wellbeing and nancial hardship, as prolonged enforced bedrest may put employment at risk.
PRESSURE CONSCIOUSNESS: RE-EDUCATION IN SELF-CARE OF THE DESENSITIZED AREAS

Whilst the patient is in bed, the prevention of pressure ulcers is the responsibility of the multidisciplinary team. As soon as he is mobile, this responsibility must be transferred to the patient if he is to remain free from pressure ulcers in the future.
Pressure relief
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. In the upright sitting position, maximum weight is taken on the ischial tuberosities. Therefore as soon as the patient sits in the wheelchair, the therapist must teach him the most practical method of pressure relief by leaning side to side, leaning forward or tilting the chair. Traditionally patients have been instructed to relieve pressure by lifting every 10 minutes for 1015 seconds. However, studies of transcutaneous oxygen ow carried out at the National Spinal Injuries Centre, Stoke Mandeville Hospital, indicate that the oxygen levels take a lot longer to recover than 1015 seconds. By placing an oxygen sensor over the ischial tuberosity with the patient in sidelying, a baseline reading of transcutaneous oxygen is established, as described by Bogie et al (1995). The sensor stays in place while the patient is transferred to the wheelchair and cushion currently being used and adopts his usual posture. As the ischial tuberosity is now weight-bearing, the effect of loading on the transcutaneous oxygen levels can be monitored. As the level of oxygen displayed on the
90
monitor is visible to the patient, the educational benet of this procedure is considerable (Kennedy et al 2003). Inevitably the oxygen level will drop during loading. While carrying out pressure relief, the patient is encouraged to time how long it takes for the oxygen to return to unloaded levels. Usually this takes between 1.5 and 2 minutes. Few patients at the early stages of rehabilitation will have the strength or stamina to perform the traditional lift on the wheels or armrests for that length of time. An increasing body of evidence shows that upper limb pain is a fact of life for many long-term manual wheelchair users (see Chs 17 and 18). This evidence combined with the ndings relating to oxygen recovery has prompted the search for alternative methods of pressure relief which are less stressful on the upper limb but equally effective (Coggrave & Rose 2003). For most patients, leaning forward is the most practical, either onto the elbows (Fig. 6.6A) or completely forward with the chest resting on the knees (Fig. 6.6B). For those patients unable to relieve pressure independently, leaning forwards may be the most suitable method, as a helper can easily provide the necessary assistance (Fig. 6.6C). The helper can stand either by the side or in front of the patient. If the patient is unable to tolerate leaning forwards or is anxious in this position, leaning sideways may be an alternative. None of these methods may be practical for patients who have a lot of pain or who are ventilated. An alternative may be to tilt the chair backwards as long as the tilt is sufcient (65), although this is not as effective as leaning forwards (Henderson et al 1994). To minimize the strain on the person assisting in this method, the assistant should be seated behind the patient with the wheelchair tilted back, resting against the knees. At each assessment, the method of pressure relief is reviewed. To give the patient more choice in adopting the most appropriate method in any given situation, he will be taught several methods if possible. All patients are instructed to relieve pressure for 1.52 minutes once every half-hour, including during mealtimes and when out socially, e.g. visits to the cinema. In many cases the interval will gradually extend to once every hour. Pressure relief will eventually become second nature and the patient will do it automatically. Until that time, he will need to be frequently reminded and encouraged. If required, various pressure gauges with alarm systems are available to assist the patient to remember to lift.
Turning at night
The patient must also become responsible for the prevention of pressure occurring during the night. He must learn to turn himself regularly in bed, to reposition the pillows between the legs and to ensure as far as possible that he is not lying on any creases in the bed linen. The interval between turns will depend on the condition of the skin and the type of mattress used.
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C Figure 6.6 A: Forward lean onto elbows. B: Full forward lean. C: Assisted forward lean.
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Inspection of the skin

Care of the desensitized and paralysed areas of the body must form an integral part of the patients daily life. He must learn to inspect his skin night and morning for pressure marks, abrasions and septic spots. It is important to recognize that the night inspection will show problems related to activities during the day, usually associated with sitting in the wheelchair. The morning inspection will alert the individual to problems which may have arisen during the night. Special attention should be given to the most vulnerable areas, i.e. the sacral, ischial and trochanteric areas, plus the knees, malleoli and toes. A mirror is used to inspect any areas the patient cannot view directly. A long-handled mirror can be adapted for tetraplegic patients or those with restricted mobility. Those patients who are unable to inspect their own skin must be responsible for requesting that this is done. If a mark is discovered, the cause of it must be determined in order to prevent it happening again. The length of time that it takes for the mark to disappear provides important information regarding the severity of the trauma.
The paralysed limbs

Great care must be taken in lifting the limbs whenever the patient transfers. A bruise sustained by knocking the malleolus against the footplate, for example, can become a deep sore and take weeks and even months to heal. Bruises devitalize the overlying skin and should be treated as pressure marks. 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.
Dos and donts

The patient is taught the following list of simple dos and donts when he rst gets out of bed:

Do relieve pressure in the chair for 1.52 minutes every half-hour. Do lift the paralysed limbs when transferring. Do little lifts when using a transfer board or use a sliding sheet to reduce friction. Do cover the tyre of the rear wheel when transferring whilst undressed. Do use a mirror to detect marks, abrasions, blisters and redness on buttocks, back of legs and malleoli. Do watch for marks on the penis if using a sheath. Do protect the limbs against excessive cold. Do have the bath water ready and not too hot.
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Dont force the transfer board under the bottom, lean over to the side before placing it. Dont allow the clothes to be pulled to be repositioned. Dont open the hot tap when having a bath in case hot water drips on the toes. Dont have a hot water bottle in bed. Dont expose the body to strong sunlight; tetraplegic patients must wear a hat. Dont knock the limbs against any hard object. Dont carry hot drinks on the lap. Dont rest the paralysed limbs on hot water pipes or radiators. Dont sit too close to the re. Dont leave the legs, particularly the feet, unprotected against car heaters.
References
Bar C A 1991 Evaluation of cushions using dynamic pressure measurement. Prosthetics and Orthotics International 15:232240 Batavia M, Batavia A I 1999 Pressure ulcer in a man with tetraplegia and a poorly tting wheelchair: a case report with clinical and policy implications. Spinal Cord 37:140141 Bogie K M, Nuseibeh I, Bader D L 1995 Progressive changes in tissue viability in the seated spinal cord injured subject. Paraplegia 33:141147 Bouten C V, Oomens C W, Baaijens F P, Bader D L 2003 The etiology of pressure ulcers: Skin deep or muscle bound? Archives of Physical Medicine and Rehabilitation 84:616619 Coggrave M J, Rose L S 2003 A specialist seating assessment clinic: changing pressure relief practice. Spinal Cord 41:692695 Daniel R K, Priest D L, Wheatley D C 1982 Etiological factors in pressure sores: an experimental model. Archives of Physical Medicine and Rehabilitation 62:492498 Dover H, Pickard W, Swain I, Grundy D 1992 The effectiveness of a pressure clinic in preventing pressure sores. Paraplegia 30:267272 Gilsdorf P, Patterson R, Fischer S, Appel N 1990 Sitting forces and wheelchair mechanics. Journal of Rehabilitation and Research Development 27:239246 Graham A 1997 The development of pressure sores in patients with spinal cord injury. Journal of Wound Care 6:393395 Green E M, Nelham R L 1991 Development of sitting ability, assessment of children with a motor handicap and prescription of appropriate seating systems. Prosthetica and Orthotics International 15:203216 Guimaraes E, Mann W C 2003 Evaluation of pressure and durability of a lowcost wheelchair cushion designed for developing countries. International Journal of Rehabilitation Research 26(2):141143 Henderson J L, Price S H, Brandstater M E, Mandac B R 1994 Efcacy of three measures to relieve pressure in seated persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation 75:535539 Kennedy P, Berry C, Coggrave M et al 2003 The effect of a specialist seating assessment clinic on the skin management of individuals with spinal cord injury. Journal of Tissue Viability 13(3):122125
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Kosiak M 1961 Etiology of decubitus ulcers. Archives of Physical Medicine and Rehabilitation 42:1929 MacLeod A D 1988 Self-neglect of spinal injured patients. Paraplegia 26:340349 Noble P C 1981 The prevention of pressure sores in persons with spinal cord injury. Monograph 11, International Exchange of Information in Rehabilitation. World Rehabilitation Fund, Inc., New York Reid J, Morrison M 1994 Towards a consensus: classication of pressure sores. Journal of Wound Care 3(3):157160 Reswick J B, Rogers J E 1983 Maximum suggested pressure/time application over bony prominences. In: Barbenel J C, Forbes C D, Lowe G D O (eds) Pressure sores . Macmillan, London, 1983 Rothery F A 1989 Preliminary evaluation of a pressure clinic in a new spinal injuries unit. Paraplegia 27:3640 Waterlow J 1991 A policy that protects. The Waterlow Pressure Sore Prevention/Treatment Policy. Professional Nurse February: 258264 Yarkony G M, Heinemann A W 1995 Pressure ulcers. In: Stover S L, DeLisa J L, Whiteneck G G (eds) Spinal cord injury: clinical outcomes from the model systems. Aspen: Baltimore
Initial physical re-education
CHAPTER
7
Programme for patients activities 95 Important physical factors inuencing the restoration of independence 95 Motor function 96 Physical proportions of the patient 96 Spasticity 99 Aims of treatment 100 Vasomotor disturbance 100 Fainting 103 Postural sensibility 103 Balance exercises in the sitting position 104 Balance in the wheelchair 107 Posture 107 Sport 107 Muscle re-education 108 Progression 108
As soon as the spine has consolidated for those treated conservatively, or when the surgeon permits, the patient is allowed to sit up in bed prior to sitting in a wheelchair. A support is usually worn for 2 or 3 weeks to prevent acute exion until the spinal musculature becomes stronger. A padded, metal-framed brace with three-point support on the pelvis, the sternum and the midpoint of these two at the back is used for patients with thoracic lesions (Fig. 7.1). If a rmer support is required, a corset can be supplied by several rms. Those with cervical lesions use an anterior collar, which holds the neck in the anatomical position. Both thoracic and cervical supports can be made to measure or obtained commercially.
Programme for patients activities

Once out of bed the patient, relevant members of the rehabilitation team and especially the nurse in charge liaise to work out a programme of increasing activity according to the patients individual needs. For rehabilitation, the patient needs to wear loose clothing that is comfortable and easy to clean, and at, lace-up shoes. Initially the patient will attend the physiotherapy and occupational therapy departments for only a short period, approximately 1 hour in each department. Gradually, as the patient is able to stay up for longer, the programme is increased. As always, this will depend upon the patients age, general state of health and previous medical history. Assessment for a suitable wheelchair and cushion is undertaken as soon as possible.
IMPORTANT PHYSICAL FACTORS INFLUENCING THE RESTORATION OF INDEPENDENCE

As with all patients, age, sex, medical history, current associated problems and previous lifestyle play a part in successful rehabilitation. The majority of patients incurring injuries to the spinal cord are young males, for whom expectations for the achievement of independence should be high. 95
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Previous employment and leisure activities inevitably affect the existing strength of shoulder and shoulder girdle muscles. A coal miner will have greater strength in the shoulders and be more used to using his muscles than an ofce worker. Similarly, a trained athlete, horseman or squash player has greater coordination and visuospatial appreciation than a patient who has never used his body in these ways. The degree of motor function, the amount of spasticity present and the height and weight of the patient inevitably inuence the restoration of independence. Physiotherapists generally think that the length of the arms in relation to the length of the trunk is also a factor, although this was not found to be the case by Bergstrm et al (1985).
Motor function
The degree of motor function, which depends upon the level of the lesion, is obviously a crucial factor in determining the independence nally achieved: Very considerable variations exist in the segmental supply of muscles which may inuence the clinical presentation (Grays Anatomy Williams et al 1995). An easy reference guide to the major segmental innervation of the most important muscles of the upper and lower limbs is provided in Appendices 4 and 5. A chart of progressive attainment in the four broad areas of daily living activities personal independence, wheelchair manoeuvres, transfers and gait is given in Appendix 6. Each activity is listed at the highest segmental level at which it is currently attainable.
Figure 7.1 Three-point brace.
Physical proportions of the patient

The physical proportions of the patient inuence the ease and speed with which independence can be achieved. Height, weight and the length of the arms in relation to the length of the trunk appear to affect the rehabilitation of all patients with spinal cord injury, but particularly those with lesions complete below C6. The most intrepid patients having led the way, therapists have gradually come to expect a greater degree of independence for these patients (Yarkony et al 1988). Achieving it, however, is expensive in effort and time for both the patient and the therapist and may incur extended hospitalization. In order to identify those patients most likely to benet from extended rehabilitation, it is necessary to determine the factors that differentiate between the successful and unsuccessful groups.
Physical ability in relation to anthropometric measurements in persons with lesions at C6

A study was undertaken at the National Spinal Injuries Centre, Stoke Mandeville Hospital, in the UK in 1985 (Bergstrm et al 1985) to assess which anatomical and anthropometric characteristics of the
INITIAL PHYSICAL RE-EDUCATION
97
patient with tetraplegia complete below C6 could be of value in predicting which patients would learn to transfer independently. The 36 chronic patients were restricted to those with a transverse spinal cord syndrome complete below C6 where extensor carpi radialis was present and the triceps muscle was absent or graded 2 or less on the Oxford scale. There were 33 males and 3 females and the ages ranged from 18 to 52 years. 23 anatomical and anthropometric variables were selected in order to give as complete a picture of the patient as possible. Spasticity, although difcult to quantify, was included, as it was felt that, if severe, it could prevent patients from transferring independently. Two groups of patients were dened: those who could transfer independently from a wheelchair to a surface of similar height (T) and those who could not (NT). Table 7.1 shows the results for the total group of 36 patients, and for the subgroups representing transfer and non-transfer ability. It is interesting that the data does not show the monkey syndrome (long arms and a short trunk) to be statistically signicant for the ability to lift, although this is the subjective impression of therapists working in this eld. Although not signicant, functional arm length was greater in the T group. The largest signicant difference between the two groups was in the base triangular measurement. This measurement was devised to obtain an impression of how much the subject leans forward in sitting and lifting (Fig. 7.2). The triangle was formed from:
Anterior aspect of head of humerus Length of arm
Triangular base
Figure 7.2 Triangular base
Table 7.1 Means and standard deviations of all the measured and predictor variables for the total group and the subgroups (T, NT). The Students t-value and its level of signicance for the difference between NT and T groups are also shown
Variables Units Total group (n = 36) Mean Age Weight Stature Sitting height Cervicale to datum a Right shoulder ex Left shoulder ex Biacromial width Bitrochanteric width Functional arm lengthb Acromion to oor static Acromion to oor lifting Triangular base static Triangular base lifting Head circumference Spasticity 4-skinfolds Fat (% of body weight) Fat mass Fat free mass Functional arm length/ stature Functional arm length/ sitting height Functional arm length/ cervicale to datum years kg cm cm cm cm cm cm cm cm cm cm cm cm cm Grade mm % kg kg Ratio 28.4 65.7 176.1 93.1 66.3 10.6 9.9 38.5 34.4 60.6 59.0 59.0 12.5 13.0 57.9 4.6 44.1 17.9 12.3 53.4 0.3 SD 7.9 14.3 9.2 4.5 3.6 1.8 1.7 2.5 2.4 3.8 4.2 3.9 5.6 5.4 1.8 0.6 23.4 6.6 6.5 9.4 0.01 NT group (n = 25) Mean 29.1 68.4 176.3 93.4 66.6 10.3 9.7 38.4 38.8 60.3 59.1 59.2 11.6 11.0 57.8 4.5 50.3 20.1 14.2 54.2 0.3 SD 9.0 15.0 9.3 4.3 3.3 1.6 1.5 2.5 2.1 3.4 3.5 3.4 4.0 4.3 1.8 0.7 25.1 6.3 6.7 10.0 0.01 T group (n = 11) Mean 26.7 59.6 175.5 92.2 65.8 11.1 10.5 38.9 33.5 61.1 58.8 58.4 14.4 17.1 58.1 4.7 30.0 12.9 8.0 51.6 0.3 SD 4.8 11.0 9.4 5.0 4.2 2.1 1.9 2.6 2.7 4.5 5.7 4.9 8.1 5.4 1.8 0.4 9.3 4.1 3.5 8.2 0.01 1.0 2.0 0.2 0.7 0.5 1.1 1.3 0.6 1.4 0.5 0.2 0.5 1.1 3.3 0.4 1.3 3.5 4.1 3.6 0.8 1.3 1.4 -1.3 ns ns ns ns ns ns ns ns ns ns ns ns ns P < 0.005 ns ns P < 0.001 P < 0.001 P < 0.001 ns ns t-value Level of signicance
Ratio
0.7
0.03
0.6
0.03
0.7
0.04
ns
Ratio
0.9
0.05
0.9
0.05
0.9
0.05
ns
ns = not signicant. a C7 to ischium. b Anterior aspect of head of humerus to base of palm.
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the perpendicular from the anterior aspect of the head of the humerus the distance along the oor to the hand the length of the arm. The subjects with transfer ability leaned further forwards when lifting. This gives greater mechanical advantage as it balances the body more accurately over the acromial point which is the fulcrum for the lift. There was a signicant difference between the two groups in the data on total body fat. This indicates that additional weight as fat is detrimental when attempting to lift and transfer. The NT group had considerably broader hips. This forces the subject to place the arms further away from the sides, which effectively reduces arm length and minimizes any mechanical advantage. Morphologically, females have narrower shoulders and broader hips than males. This data con rms the clinical impression that tetraplegic women do not lift as well as men and that fewer can transfer. As 23 variables were considered to be too many for practical use, an analysis was carried out on these variables to assess the extent to which a smaller number of anatomical and anthropometric data could predict the nal ability to transfer. Nine variables were nally selected:

biacromial width body weight cervicale to datum fat percentage head circumference shoulder exibility sitting height spasticity triangular base lifting.
Using these variables, it is possible to predict into which group (T or NT) a patient will fall with an accuracy of 90%. However, this result is tentative due to the small size of the sample. Data needs to be collected from a further sample of patients, and the present results used to classify patients into the T or NT group, in order to assess the validity of the process. (Bergstrm et al 1985)
Spasticity
There is no doubt that severe spasticity is one of the most incapacitating complications of spinal cord injury and can seriously curb rehabilitation, in some cases preventing even a minimal degree of self-care. Early positioning of acute lesions has a great inuence on the development of reex patterns of spasticity in both complete and
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incomplete lesions. With adequate early treatment, the majority of patients are left with a degree of spasticity which is useful to them in many ways and which does not inhibit daily life. Some patients, however, develop incapacitating spasticity in spite of treatment. The problems arising from severe spasticity are dealt with in the relevant sections of subsequent chapters.
AIMS OF TREATMENT
The ultimate aim of rehabilitation is to achieve the highest degree of tness, independence, balance and control that the patients lesion permits. This is to be achieved by re-education and the fullest possible use of each muscle over which the patient has voluntary control. The immediate aims of treatment therefore are:

readjustment of vasomotor control re-education of postural sensibility the re-education and hyperdevelopment of the normal parts of the body to compensate for the paralysed muscles; the fullment of these aims is the foundation for restoring independence (Guttmann 1946) (Figs 7.3 and 7.4) the education of the patient in self-care of the desensitized areas (see Ch. 6).
Those patients who have had some form of surgical intervention and spend less time in bed will follow the same overall programme of rehabilitation. Certain elements may have to be curtailed initially and progression will vary depending upon the procedure undertaken.
VASOMOTOR DISTURBANCE
Postural hypotension is particularly common in patients with cervical or high thoracic lesions. This is due primarily to loss of vasomotor control in the splanchnic area. The blood vessels in the viscera are unable to constrict when the body is raised from the horizontal to the vertical position. The vasomotor control that is lost cannot be regained, but the patient can overcome this by developing other vascular reexes which are still intact. The reexes are trained in a variety of ways, by means of deep breathing exercises, tilting exercises in bed, frequent changes of position and graduated balance exercises in the sitting and standing positions. Before sitting out in the wheelchair, the patient is tilted in the bed. Gradual progression is made from the initial 30 until the patient can sit at 90 without feeling faint. Houtman et al (2000) found that, compared with able-bodied people, a greater fall in arterial pressure and stroke volume occurs in patients with lesions above T4 when the patient is tilted head-up.
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Re-education of balance
Instruction
Resisted exercises Mat work Sport Pressure consciousness Muscle strength
Early rehabilitation
Self care
Initial transfers
Dressing Washing Feeding Bladder and bowel care
Chair to plinth Chair to plinth Chair to bed Chair to car Chair to toilet
Tetraplegia
Paraplegia
Basic wheelchair manoeuvres Basic movements in wheelchair

Figure 7.3 Early physical rehabilitation.
The alterations in cerebral oxygenation, however, were the same in both groups. The mechanism by which this is achieved remains obscure. Deep breathing exercises are given in each position. The time in the tilted position is lengthened gradually from 10 to 15 minutes to 3 hours over approximately a week. The skin over the ischia and coccyx is not accustomed to weight-bearing. Constant inspection is necessary as a pressure ulcer can easily develop. Whilst sitting, the paraplegic patient should practise lifting his body weight on his hands. He can either push down on the bed or use wooden lifting blocks if available. This exercise helps to establish the vascular reexes, increases the strength of latissimus dorsi and relieves some pressure on the buttocks.
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C5 T5 Stand in standing frame C4 and above Stand on tilt table
Swing-to in bars 4 Point in bars
T6 T9
All 3 gaits on crutches Car Crutches Floor Crutches Stairs Gait training
T10 and below
Rehabilitation after balance reflex is trained
Further activities of daily living
Final wheelchair manoeuvres
Final transfers
Chair Bed with sliding board Flicking up and down small kerb Up and down kerbs Rearwheel balance Chair Chair Chair Chair Chair
C5/6
C7/8
Car Toilet Easy chair Bath Floor
C7/8 and below
T1 and below
T1 and below
Figure 7.4 Independence expected according to the level of the lesion.
When vasomotor control is established in the bed, training is commenced in the wheelchair, initially for a few moments at a time. The process of gradually and regularly extending the time is repeated. Functional electrical stimulation to the leg muscles increases blood pressure and may prove useful in treating orthostatic hypotension if this remains a problem (Sampson et al 2000). A xed dose up to a certain stimulation can be given and controlled by the patient. Active rehabilitation in the various departments begins when the patient can tolerate 1.5 hours in the wheelchair. At rst the patient will need to be pushed to the departments. As he has not experienced motion of any kind for several weeks, even relatively slow speeds will
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seem alarmingly fast. As soon as possible, the patient should push himself and be responsible for keeping his own appointments.
Fainting
As fainting can occur, it is advisable not to leave the patient alone during the early days of vasomotor training in the wheelchair. If the patient complains of feeling faint or dizzy, has blurred vision or appears white and sweaty, the legs must be elevated immediately and the chair tipped onto its rear wheels. Deep breathing is encouraged by giving pressure during expiration over the lower ribs and upper abdomen. Should loss of consciousness occur with no signs of recovery within a minute, the patient should be placed at. The vasomotor problem must be explained to the patient. Instructions should be given on how to aid the circulation when feeling faint by brisk movements of the arms and deep breathing. Encouragement is essential, as once a patient has fainted, fear of a recurrence may inhibit his activity.
POSTURAL SENSIBILIT Y
The patient with a complete spinal cord lesion has lost not only sensibility to touch, pain and temperature, and motor power of the trunk and limbs, but also his postural or kinaesthetic sense, below the level of the lesion. Kinaesthesia is the perception of the position and movement of ones body parts in space. It also includes perception of the internal and external tensions and forces tending to move or stabilize a joint (Rasch & Burke 1971). In complete lesions above T12 where postural sensibility in the hip joints is abolished, the patient has difculty in keeping his balance in the unsupported upright position. The development of a new postural sense is a major objective in the rehabilitation of these patients. It is the foundation for all daily living activities. Postural control is achieved largely through those muscles that have a high innervation and low distal attachment. These muscles form a bridge between the normal parts of the body, including of course the brain, and the paralysed areas. The most important of these muscles is the latissimus dorsi. It has a high segmental supply (C6, C7, C8) and an extensive attachment to the spine and pelvis. Therefore, in all lesions below C7, it bridges the paralysed and nonparalysed parts of the body and allows patients with high thoracic and low cervical cord lesions to regain a high degree of balance and control. Proprioceptive impulses arising from any movement of the pelvis are transmitted centrally along the afferent nerve bres of these
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normally innervated muscles and thus reconnect the insensitive part of the body with the cerebral and cerebellar centres promoting appropriate efferent postural responses to the paralysed area . . . Eventually a new pattern of postural sensibility develops along the nerve supply of the trunk muscles. (Guttmann 1976, p. 582) Latissimus dorsi is important both in the restoration of the paraplegic patients upright position and in future gait training. The function of this muscle is greatly assisted by other trunk and shoulder girdle muscles, particularly trapezius, because of its dorsal attachment as low as T12, and the abdominal muscles with their insertion on the pelvis. The patient develops his new postural sense primarily by visual control. He performs exercises sitting in front of a mirror where he can see the position of his body and limbs. This visual-motor feedback helps him gradually to develop more acute sensory impressions, i.e. interpreting the muscle stretch sensations of the latissimus dorsi and other trunk muscles, and a new sensorial pattern becomes established. He will then perform movements without the aid of a mirror, and eventually functional activity without conscious effort to balance.
Balance exercises in the sitting position

These exercises are primarily carried out sitting on the plinth in front of the mirror, though some patients may need to begin their exercises sitting in the wheelchair (see p. 264).
Position of the patient

The patient sits on a low plinth in front of a long mirror. A pillow is placed under the buttocks to guard against excessive pressure. The thighs and feet are well supported so that a right-angle is formed at the hips, knees and ankles.
Role of the therapist
The therapist stands behind the patient so that she can watch his movements in the mirror and have control should he lose balance. Her hands initially support the patient either over the shoulders or around the thorax. Her hands should be visible to the patient. Should she put them where he cannot feel, he will be unaware of the support and lose condence. Assurance is given that the therapist will not move away. The fear of falling, especially backwards, is very marked. The therapist should never leave her position unless the patient has some form of support, as he can easily overbalance and fall off
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the plinth. The position is obviously more dangerous for those with severe spasticity. The therapist can, to a large extent, control the speed of the patients activity by her voice and her general handling of the situation. Her voice should be quiet and condent and, most important of all, unhurried since all exercise involving balance must be performed slowly. She should give constant direction and encouragement. When the patient overbalances, the therapist should allow a gross movement to occur before restraining him, otherwise he may not be aware of the movement that has taken place.
Progression of exercises
Self-supported sitting
Watching himself in the mirror, the patient learns to support himself in as upright a position as possible, with his hands rst on the plinth at his sides and then on his knees. If the lesion is high and the arms are short in relation to the trunk, it may help to have a pillow at each side of the patient to support the hands. Time and trouble should be taken to teach the patient to hold the correct sitting position before commencing exercises involving motion.
Single arm exercises

Always watching himself closely in the mirror, the patient raises one arm rst sideways, then forwards and lastly upwards whilst supporting himself with the other hand on his knee. A small degree of movement of the head and trunk to the side of the supporting hand will be necessary to compensate for the weight of the moving arm. Single arm exercises are not found to be helpful for patients with lesions at C6 or above, since without triceps the supporting arm is ineffective.
Bilateral arm exercises

Larger compensatory movements of the head and trunk will be necessary when moving both arms in the unsupported sitting position. The patient rst tries to lift the hands from the knees to the arms bend position and then progresses to raising both arms sideways, forwards and upwards (Fig. 7.5). The sideways stretch position presents little difculty since the centre of gravity is barely altered. In the forwards stretch position, the patient must lean his head and body backwards to counteract the line of gravity which would otherwise fall in front of the hip joints. The upwards stretch position is particularly difcult for patients with high lesions, since the centre of gravity is raised and the patient has no abdominal muscles to help him to maintain his equilibrium.
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Bilateral arm exercises without the mirror

When the patient has mastered the basic positions and exercises, bilateral exercises are performed without the mirror and with the eyes closed.
Other exercises
Balance can be further improved by, for example, asymmetrical work, altering the rate of movement, resisted trunk exercises, stabilizations and ball throwing.
Duration and frequency of treatment

These exercises are physically and mentally exhausting. Treatment is given daily for only 510 minutes initially, progressing gradually to half an hour. Frequent rests should be given during treatment by allowing the patient to lean back against the therapist for a few moments. Tetraplegic patients need to rest the head to allow the neck extensors to relax. Balance training requires constant practice and it is valuable to treat patients with thoracic lesions twice daily.
Mirror
Figure 7.5 Balance position of a patient with a complete lesion below T6.
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Balance in the wheelchair

Balance exercises are commenced in the wheelchair for the following reasons:
Poor posture when sitting on the plinth. This occurs: with high cervical lesions, C5 or above, where the head pokes forward and the patient is unable to extend the neck with some thoracic lesions where the trunk is exed due to weak extensor muscles. It may be necessary for such patients to concentrate on back extension exercises for a week, balancing only in the wheelchair. When the general muscle tone has improved the patient can return to balance exercises on the plinth. General debility. The patient may not be t to be moved in and out of the chair. Recently healed ulcers. The scar tissue may be delicate. Movement in and out of the wheelchair may constitute a potential danger until the scar tissue becomes stronger.
Exercises in the wheelchair are carried out in front of the mirror as described above, rst leaning against the back of the chair and progressing to sitting away from the backrest. As soon as possible, balance on the plinth should be commenced or resumed.
Posture
Although the aim is to achieve as upright a position as possible, this will vary according to the level of the lesion. The low thoracic lesion (with abdominal muscles) should have a straight back. The upper thoracic lesion (without abdominal muscles) has a typical posture with increased kyphosis and lordosis. The low cervical lesion usually has a good, straight posture providing trapezius is strong and the patient has not been allowed to sit on his sacrum for several weeks or months, producing a long kyphosis. The high cervical lesion may have a poor posture with poking head and exed spine or, where the neurological decit is asymmetrical, a scoliosis.
Sport
Archery and table tennis are useful activities in training postural control.
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MUSCLE RE-EDUCATION
To establish a satisfactory compensatory mechanism to cope with the paralysed limbs, all innervated muscles need to be as strong as possible (Guttmann 1976, p. 577). For patients with complete lesions, it is particularly important where possible to hypertrophy the following:

latissimus dorsi shoulder and shoulder girdle muscles, particularly adductors arm muscles abdominal muscles.
The choice of technique for strengthening these muscles belongs to the individual patient and therapist. Methods currently used include:

manual resistance, including proprioceptive neuromuscular facilitation (PNF) techniques (Knott & Voss 1968) spring and sling suspension therapy weights tetraplegic patients can use weighted cuffs round the wrists weights and pulleys all types of multi-gym (Nash et al 2002) sport.
PNF is particularly useful for:

patients with incomplete lesions with very little spasticity strengthening the trunk muscles strengthening the arms of patients with cervical lesions.
In the absence of more sophisticated systems, bilateral strengthening exercises for latissimus dorsi and the pectoral muscles can be carried out by paraplegic patients using a simple system of weights and pulleys (Fig. 7.6). With the pulley handles at shoulder level, the patient pulls down to the chair wheels keeping the elbows straight. If the elbows are allowed to ex, triceps will be strengthened and not latissimus dorsi as desired. Body weight is useful as resistance in free exercises such as pressups and lifting up on blocks.
Progression
In all exercise programmes, progression must be carefully graded both for strength and endurance and for the effect on cardiorespiratory function. It is often helpful for patients to watch in a mirror when performing exercises so as to have some visuospatial feedback. Biofeedback can be useful in muscle re-education. It assists the patient to strive for maximum effort and enables him to measure his achievement.
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Figure 7.6 Weights and pulleys used to strengthen latissimus dorsi.
References
Bergstrm E M K, Frankel H L, Galer I A R et al 1985 Physical ability in relation to anthropometric measurements in persons with complete spinal cord lesions below the sixth cervical segment. International Rehabilitation Medicine 7(2):5155 Guttmann L 1946 Rehabilitation after injury to spinal cord and cauda equina. British Journal of Physical Medicine 9:130160 Guttmann L, Sir 1976 Spinal cord injuries. Comprehensive management and research, 2nd edn. Blackwell Scientic, Oxford Houtman S, Colier W N J M, Oeseburg B, Hopman M T E 2000 Systemic circulation and cerebral oxygenation during head-up tilt in spinal cord injured individuals. Spinal Cord 38:158163 Knott M, Voss D E 1968 Proprioceptive neuromuscular facilitation. Baillire Tindall and Cassel, London Nash M S, Jacobs P L, Woods J M et al 2002 A comparison of two exercise training techniques for eliciting matched metabolic responses in persons with paraplegia. Archives of Physical Medicine and Rehabilitation 83:201209 Rasch P J, Burke R K 1971 Kinesiology and applied anatomy. Febiger, Philadelphia
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Sampson E E, Burnham R S, Andrews B J 2000 FES effect on orthostatic hypotension. Archives of Physical Medicine and Rehabilitation 81:139143 Williams P L, Bannister L H, Berry M M et al (eds) 1995 Grays anatomy, 38th edn. Churchill Livingstone, Edinburgh Yarkony G M, Roth E J, Heinemann A W 1988 Rehabilitation outcomes in C6 tetraplegia. Paraplegia 26:177185
Personal independence
CHAPTER
8
Patients with lesions at C1C4 111 Patients with lesions at C5 112 Patients with lesions at C6 112 Wrist or tenodesis grip 112 Procedures to augment arm and hand function 115 Splinting 117 Activities for patients with lesions at C6 118 Dressing for all patients with lesions at C6 and below 119 Dressing techniques 121 Dressing in the wheelchair 121 Dressing on the bed 124 Accommodation 125 Adaptations 125 Equipment 126 Employment 126 Canine Partners for Independence 127
Close cooperation between the occupational therapist and the physiotherapist is essential in planning the patients rehabilitation programme. The work of the two disciplines complement one another and in many areas overlap. All but those with the highest lesions need to learn to dress, and in addition tetraplegic patients must learn to eat and drink, brush their hair, clean their teeth, and wash and shave. All need to be able to instruct others how to undertake those tasks they cannot do for themselves.
PATIENTS WITH LESIONS AT C1C4

Patients with lesions between C1 and C3 have varying degrees of head control and no other movement and will need assistance with respiration. In addition to head movement those with lesions at C4, have an innervated trapezius which allows them to shrug the shoulders and thereby learn to move their upper body very slightly in the wheelchair (see p. 264). The range of equipment to enable patients with disabilities, including those with ultra-high spinal cord lesions, to access computers and control their environment is constantly increasing. The environmental control systems are adapted to meet the needs of the individual and usually include at least the operation of the computer, television and video, lights, front door and curtains. Patients can use breath, eye blinks, voice, head movements or equipment mounted on the head or held in the mouth to operate the controls. Many systems are now available to facilitate computer control. For example operation can be achieved through:

a wire-free light device mounted on the head and controlled by head movements in two axes head-mounted laser pointer voice control with the words dictated at a normal speaking rate a switching device which recognizes the increase in alpha waves as the eye closes (Craig et al 2002) head-mounted or mouth-held stick with a rubber capped tip. 111
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The light-sensitive or touch screen monitors can have overlays which allow the individual to create his own keyboard on screen. Words or pictures can be used if required. For those with lesions at C4 who can, and choose to, use a mouthstick, various adaptations to the keyboard can be made. There are keyboards with large letters, or with guards around the whole, or on one side of each letter, light touch and left hand keyboards. The mouth stick can also be used to turn pages, paint and play board games with suitably adapted pieces. For patients with incomplete lesions there are various adaptations in mouse design, for example larger than normal rollerball, joystick, touch mouse and an ergonomic mouse which can be held in the hand. These can be used with a variety of wrist rests. Scanners are available which turn documents into speech.
PATIENTS WITH LESIONS AT C5

These patients have good functioning deltoids and biceps but no muscle control at the wrist. A light cock-up splint is used to stabilize the wrist joint. This contains a slot in the palmar surface to hold simple gadgets such as a spoon, fork or typing stick (Fig. 8.2e). With practice, most patients with lesions at this level learn to eat, type, move papers and operate a computer using a stick with a rubber cap, and to play games such as draughts, chess and dominoes with specially adapted pieces. Mobile arm supports may be of use to patients with weak shoulder and/or elbow muscles. The Handmaster is a device for improving hand function (Uzerman et al 1996). It may be useful for patients with lesions at C5 who have shoulder and elbow movement. It uses non-invasive functional electrical stimulation with wrist and forearm support to restore some function to the hand by providing a key grip and release, palmar grasp and release, and a static open hand position. It can also be used to exercise relevant muscles (Allen & McBride 2003).
PATIENTS WITH LESIONS AT C6

These patients have an active brachioradialis and extensor carpi radialis. Patients with lesions at C7 without nger movement can be included in this group, although the active elbow extension and wrist exion give greater dexterity in all activities.
Wrist or tenodesis grip

The non-paralysed hand is a multifaceted tool for independence. For example, it can hold a pen with thumb and two ngers or use all
PERSONAL INDEPENDENCE
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ngers splayed to pick up a circular object such as a jar lid. It can pick up objects as small as money or as big as a plate, hold a tumbler and use instruments of various sizes. In the paralysed hand key pinch grip has been described as the primary hand function to restore to people with tetraplegia (Moberg 1975). This is known as the wrist or tenodesis grip (see p. 50) where the wrist posture determines the position of the ngers and thumb allowing the thumb to come into contact with the nger(s) (Fig. 8.1A, B). The grip is achieved through the combined control of the unaffected muscles with the passive tension in the nger and thumb muscles. To produce an effective grip in this way the strength in the wrist extensors must be able to overcome the wrist exor tension imposed by the weight of the hand and the structures crossing the wrist (Johanson & Murray 2002). Due to the forces present in the
B Figure 8.1 The tenodesis grasp used for hand closing (A) and hand opening (B). In the absence of active forces from muscles under voluntary control, wrist posture determines the position of the ngers and the thumb. (From Johanson & Murray 2002. Courtesy of V.R. Hentz MD, Palo Alto, CA.)
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hand the grip tightens as wrist extension is increased. With practice the patient is able to pick up light objects and, using small straps, learn how to use small gadgets to eat, write, clean the teeth, use an electric shaver etc. (Fig. 8.2). Patients develop compensatory strategies to maximize the use of their hands and use the effect of gravity to augment the grasp. For example, if the object to be lifted is too heavy for the grip, supination allows the patient to cradle the object in the hand. Most patients with lesions at C6 and C7 attain a high level of hand function in the long term and many no longer use any gadgets (Harvey & Bally 2001). A number of wrist/hand orthoses are available to increase the function of weak wrist muscles and produce grip. The exor hinge splint, which utilizes extensor carpi radialis to produce a pincer grip, can be a useful asset to some patients, especially those who return to work. Modular kits are available which enable the splint to be tted and in use within a few days.
b e
a h
g f
Figure 8.2 a: Finger splint to hold pen. b: Rubber tipped nger splints for using computer. c: Strap with slot for holding gadgets. d: Strap with slot and toothbrush. e: Wrist support with strap for fork. f: Pushing glove. g: Hairbrush. h: Mouthsticks, with dental bite and without.
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Procedures to augment arm and hand function

If surgery is to be considered the hand needs to be supple. Patients with stiffness, severe spasticity or pain in their hands may be excluded from consideration (Forner-Cordero et al 2003). Surgery to produce a grip and improve hand function in tetraplegic patients began over 30 years ago (Zancolli 2002). The goal of any surgery is to make the patient more independent and various procedures have been employed. The early emphasis was on stabilizing joints and transferring tendons (Bryden et al 2004). More recently attention has been focused on neuroprostheses often combining tendon transfers with functional electrical stimulation of appropriate muscles. Surgical procedures are not normally considered until 12 to 18 months after injury. The process is usually long and independence is curtailed as one arm is immobilized during this period. The assessment of the patient, both physical and psychological, must be comprehensive and detailed. The patient must be well informed and have a precise and realistic need for the reconstruction, such as greater independence in relation to bladder management, or more dexterity for work. Unsatisfactory results can come from inappropriate patient selection.
Elbow extension
The inability to extend the elbow actively hinders many of the tasks of daily living, as the patient has to rely solely on the weight of the forearm for stability. Transferring some bres from the posterior deltoid muscle to triceps on the same side provides the patient with stable elbow extension (Moberg 1975). The strength of the other shoulder muscles needs to be considered in addition to the strength of deltoid, as other weakness may affect the outcome of surgery. Independence is increased as the patient can reach an object from a high shelf, use his hand in the supine position and nds it easier to steer the wheelchair and drive a car. Other procedures are also used and some combine elbow surgery with the provision of a tenodesis grip or even with nger movements. Wuolle et al (2003) in a study of 67 patients (involving 107 arms) found that 70% of the patients were generally satised with the results and 66% had improved independence. In a separate study Rothwell et al (2003) found that the levels of improved function after surgery were generally maintained 10 years later.
Freehand system
The neurocontrol Freehand system is an upper extremity neuroprosthesis using functional electrical stimulation to increase hand function for patients with spinal cord injury at C5. It was designed at Case Western Reserve University, Cleveland, Ohio in 1987 (Keith et al 1989). A programme was started in 1995 at the Salisbury
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District Hospital, in England, which is the European Training Centre for Neurological Control (Kilgore et al 1997). The system is designed to provide the patient with two hand grasps: the palmar or power grasp, where the ngers ex towards the abducted thumb, used for holding a glass and picking up large objects; and a lateral prehension grip, where the thumb adducts to the exed ngers, used for small objects such as a key. The ability to open and close the hand allows the patient to have more control over everyday tasks such as eating, writing, using a telephone and inserting a computer disk. A pacemaker-type stimulator is implanted in the upper chest on the side of the hand to be controlled, and from it electrodes control eight muscles in the hand, enabling the ngers to ex and extend and the thumb to abduct and adduct with the ngers in exion. An external transmitter is placed over the chest implant and connected to a microprocessor which can be attached to the wheelchair. A small, light metal stick with a ball-bearing joint at one end and a disc at the other (a joystick) is xed to the upper sternum. The disc end is located on the shoulder on the opposite side to the hand to be controlled. Signals pass from the joystick via the microprocessor to the external transmitter over the implant site. Small movements of elevation, depression, protraction and retraction of the shoulder then control the opening and closing of the hand. The grasp can be locked and unlocked by a strong, quick movement into elevation at the shoulder so that the grasp can be maintained as long as required. To enhance the usefulness of the implanted system, the patient may also have the posterior bres of deltoid transplanted into triceps to provide elbow extension and extend the range of movement of the arm. Both surgical procedures, implanting the neuroprosthesis and transplanting the muscle, can be carried out at the same time. As with the implantation of all functional electrical stimulation systems, the team approach is essential and the surgeon, clinical engineer and occupational therapist need to be involved from the outset. A comprehensive assessment of the patient, including both physical and psychological aspects, is also essential if the patient is to be successful. It is important that the patient identies his goals for having the system implanted and these can be used subsequently to judge its success. A training programme involving surface stimulation for the muscles to be used is undertaken by the patient prior to operation. Postoperatively the patient has his arm in plaster for 24 weeks, and after that a phased programme to use the system is started. The system provides an active grasp with strength which increases independence and quality of life (Peckham et al 2001, Taylor et al 2002). Marketing the Freehand neuroprosthesis was halted in September 2001 after 300 devices had been implanted. A second generation of neuroprostheses which benet from the outcomes of the rst group may be produced (Keith & Hoyen 2002).
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In order to determine if further independence has been achieved through the surgery a classication system for hand function which is sensitive to small changes is required. The ASIA scale (Appendices 1 and 2) is not sufciently detailed. Two different measures have been developed. It is hoped that the Southampton Hand Assessment Procedure (SHAP) will enable clinicians to compare and monitor hand function (Light et al 2002); the Canadian Occupational Performance Measure (COPM) is a tool primarily designed to measure the patients satisfaction in achieving the goals he had set himself (Law et al 1998, Samuelsson et al 2004).
Splinting
Each patient is assessed individually and a hand regimen instituted. When a patient requires a splint the occupational therapist and the physiotherapist treating the patient should discuss the case so that the patient benets from the expertise of both. To be effective a splint needs to be appropriate for the purpose and applied correctly. All splints should be worn for short periods initially so that the skin can be checked for excessive pressure. Patients do not wear their splints for a variety of reasons: because the splint does not solve the problem, cannot be put on easily, is uncomfortable, ugly or impractical, or they do not understand why they need it (Taylor et al 2003). If the splinting is to be successful close cooperation between ward staff and therapists is essential. Splints are usually required to maintain position, correct a contracture or to encourage function, and can be made from several materials, e.g. plaster of Paris, synthetic plaster materials, thermoplastics or neoprene. Some patients require two splints: one may need to be worn at night to maintain hand position and another during the day to aid independence. Some examples of the ways in which splints may be used:
Long paddle splint (from forearm to nger tips with the ngers slightly exed) for a patient with a lesion at C4 or above to maintain the hand in a good position and give some control over the arm. Wrist extension splint for a patient with a lesion at C5 to inhibit lengthening of the extensor tendons and allow the hand to be used with simple gadgets. A patient with a lesion at C6 with wrist extensors less than grade 3, as for C5 above but may also need tapes over the ngers to hold them in exion to encourage the tenodesis position. A knuckle duster splint to inhibit metacarpophalangeal hyperextension for a patient with a lesion at C7. A splint to encourage opposition of the thumb may be needed by a patient with an incomplete lesion or one at C7.
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Activities for patients with lesions at C6

Feeding
Patients start to eat by using a strap which has a slot in the palmar surface to hold the fork (Fig. 8.2c) or spoon and then by extending and relaxing the wrist. After some practice the strap is usually discarded and the fork held by balancing it over the thumb and against the palm of the hand or over the little nger. A plate guard may be helpful initially.
Drinking
A cup or mug with a large handle is held by hooking the thumb through the handle and extending the wrist. A glass without a handle can be lifted by sliding the ngers and thumb around the glass with the wrist extensor relaxed and then extending the wrist to produce the necessary grip. As the hands are insensitive and the movements slow and clumsy, insulated mugs are preferred whilst training. Standard cups are used later by most dextrous patients.
Cleaning the teeth

The toothbrush is used in the strap (Fig. 8.2d) or laced between the ngers. To unscrew the cap from the toothpaste tube, the cap can be held by the teeth whilst both hands rotate the tube. The teeth can also be used to squeeze out the paste. Toothpaste dispensers can be obtained from companies specializing in products for disabled people.
Brushing the hair

Most patients nd a shampoo brush with a wide handle easy to use (Fig. 8.2g).
Shaving
To enable the patient to shave unaided, a soft leather jacket can be sewn around the electric shaver and a strap attached to t over the dorsum of the hand. Many patients learn to use the razor without the jacket. The patient manoeuvres the razor into position between the ngers and palm of the right hand, with the head of the razor projecting between the thumb and rst nger. He then places his left hand round the other to strengthen the grip. By pressing the two hands together the grip is maintained.
Bladder, bowel and skin care

The care of the bladder and bowels is dealt with in Chapter 2 and re-education in self-care of desensitized areas in Chapter 6.
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Computers
Computers and word processors can be used for both work and leisure activities. Most patients use a small, rubber-tipped stick on an extension splint on the rst or second nger (Fig. 8.2b). Where possible, both hands are used.
Using the telephone

A telephone can be adapted to allow the patient with an ultra-high lesion to make independent calls. If these adaptations are not available the receiver can be mounted on a retort stand and a simple wooden bar with a rm handle placed across the receiver rest. A mouth stick can be used to dial and to remove and replace the wooden bar. Some environmental control systems have the facility to use a phone.
Writing
Several gadgets are available for use with a pen or pencil. Small splints supporting nger and thumb can easily be made for the individual patient (Fig. 8.2a). Some tetraplegic patients give up the gadget in time and either lace the pen through their ngers or hold it in one hand, putting the other hand on top to reinforce the grip.
Housework
Both low tetraplegic and paraplegic patients prepare for their return to housekeeping in the occupational therapy department kitchen and in the ward. They dust, cook, wash up, make their beds and do their laundry, as appropriate to their home surroundings. They have the opportunity to discuss ways and means to overcome individual problems in the home and in this way gain the necessary condence to return to their family responsibilities.
DRESSING FOR ALL PATIENTS WITH LESIONS AT C6 AND BELOW

Dressing begins as soon as the spine is stable. Upper extremity dressing refers to the ability to put on and remove clothing over the upper limbs. Lower extremity dressing refers to the ability to put on and remove clothing over the lower limbs. Total dressing refers to the ability to achieve both the foregoing. Although most paraplegic patients will nally achieve total dressing both on the bed and in the wheelchair, they are initially taught to dress on the bed. Tetraplegic patients need to gain some sitting balance before attempting to dress, and it is usual to begin with upper extremity dressing in the wheelchair. Each patient, having learnt the
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basic methods, will nd an individual way which best suits his requirements and daily schedule. Dressing techniques are described later.
Caution
Training is delayed where there is:

instability of the spine at the site of the injury a need to avoid rotation after surgical intervention delicate scar tissue which might easily break down during rolling or through friction.
Clothing
All clothing should be loose-tting. The trousers need to be at least a size larger than normally worn to accommodate the urinal and avoid trauma due to friction. Zips in a side seam of the trouser leg are also helpful if wearing a urinal or calipers. A wrap-over skirt and protective pants with a front fastening may be helpful for female patients who nd difculty in removing clothing for toilet purposes. Shoes that are one size larger than those worn prior to the paralysis are usually required to avoid pressure and accommodate for any oedema or spasticity. They should have smooth inside seams, must remain in position when the legs are lifted and should be selected according to the patients needs. For tetraplegic patients, zips or Velcro fastenings are the most easily managed. Since the thumb is used as a hook on many occasions, loops or split rings on the zipper pulls may be helpful. Brassires should have stretch straps and should not be boned, because of the danger of pressure marks. Loose woollen socks are easier to put on initially. Progression can be made to synthetic socks later if desired. Clip-on ties may be useful for some patients with cervical lesions.
Level of lesion in relation to dressing

Total dressing should be achieved by patients with lesions as high as C7, i.e. patients with active exion and extension of elbows and wrists. Total dressing may be achieved by patients with lesions at C6 both with or without triceps, but lower extremity dressing for these patients, though useful in emergency, is usually so costly in time that it is not practical. Upper extremity dressing should be achieved by patients with lesions at C5C6 except for the following activities:

putting on a brassire tucking the shirt tails into the trouser band fastening buttons on cuffs and shirt fronts.
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Patients without nger movement cannot usually manage to put on the urinal. As always, these objectives are only possible within the limits imposed by the previous medical history, age and physical proportions of the patient.
Dressing techniques
In most movements, two actions are involved:

moving the garment moving the body, i.e. wriggling into or out of the garment.
Balance
Those tetraplegic patients who can lift in the chair during dressing should put the stronger hand towards the back of the armrest, with the forearm braced against the backrest support and the weaker hand towards the front of the armrest. This arrangement gives more stability anteroposteriorly and allows wriggling movements forwards and backwards as well as from side to side. Patients who have difculty in maintaining balance whilst using both arms are more stable if the buttocks are brought a few inches forward in the chair.
Spasticity
Increased tone may be an advantage in exing and extending the lower limbs. Uncontrollable muscle spasm in the lower limbs may render independent dressing impossible. Sitting cross-legged for 1520 minutes may help to reduce severe extensor spasticity before attempting to dress. As it is easier to achieve, the tetraplegic patient is taught to undress rst. However, for clarity, in the following section the method for putting the garment on is described rst. This procedure is usually reversed when taking it off.
Dressing in the wheelchair

Upper extremity dressing in the wheelchair
As upper extremity dressing provides no problem for low lesions, i.e. those with abdominal muscles, reference in this section is to patients with cervical and high thoracic lesions.
Putting on a garment of soft material with or without a front fastening

This method can be used for blouses, vests, sweaters, skirts and dresses that open down the front. If it is found easier and the garment
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is large enough, the buttons can be left fastened. Many tetraplegic patients without a grip can learn to fasten buttons by using a button hook. 1. Position the garment on the thighs, with the neckline towards the knees. 2. Put both arms under the back of the garment and through the armholes. 3. Push the garment past the elbows. 4. Using the wrist extension grip, hook the thumbs under the garment and gather the material up from the neck to hem. 5. Using adduction and lateral rotation of the shoulders and exion of the elbows and neck, pass the garment over the head. 6. Relax the shoulders and wrists and remove the hands from the back of the garment. Most of the material will be gathered up at the back of the neck and under the arms. 7. There are several ways in which the garment can be worked down into place: a. shrug the shoulders and/or elevate and laterally rotate the shoulders with the elbows extended to get the material down across the shoulders b. hook the wrists into the sleeves and pull the material free at the axilla c. using two hands pull down on each side of the front d. hook one hand in the material at the neck, lean on the opposite forearm on the armrest and pull the garment down.
Taking the garment off

1. Hook the thumb in the back of the neckline, extend the wrist and pull the garment over the head, turning the head towards the side of the raised arm. Maintain balance by either: a. leaning on the opposite forearm b. pushing on the thigh with the extended arm. 2. Hook the thumb in the opposite armhole and push the sleeve down the arm. Pull the arm out of the garment.
Putting on a jacket
1. Put the weaker arm in the armhole and push the sleeve up the arm. 2. Maintain balance by leaning on and over the forearm resting on the armrest. 3. Put the other arm in the armhole behind the back. 4. Elevate the arms and shrug the shoulders to get the jacket over the shoulders.
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Removing a jacket.
Reverse the above procedure.
Putting on a brassire with fastening at the back

1. Powder under the breasts and round the chest wall, especially if subject to sweating attacks. 2. Place the bra on the knees, inside out and upside down, i.e. with the lower edge of the bra towards the knees. 3. Balance on the weaker elbow. Hold the middle of the bra with the strong hand, take behind the back and bring the fastening to the front. 4. Fasten the hooks or Velcro at the front. It may help to lift slightly on the forearms. 5. Wriggle the bra round to the back. Powder again if necessary. 6. With the thumbs in the strap pull up over breasts. 7. Place one arm at a time in the appropriate shoulder strap. Hook the thumb under the bra strap, lean to the opposite side and put the strap over the shoulder. Repeat for the other arm. 8. Look in the mirror to see that the bra is not wrinkled. (Note: adjust the length of the straps when the bra is off)
Taking off the brassire

1. Hook the thumb under the opposite strap, and push down whilst elevating the shoulder. 2. Pull the arm out of the strap. 3. Repeat on the other side. 4. Push the bra down and turn it round to bring the fastening to the front. 5. Undo the fastening.
Lower extremity dressing in the wheelchair

When dressing the lower extremity, the socks should be put on before the trousers to avoid catching the toes and causing trauma.
Putting on and removing socks and shoes

Whether in the chair or on the bed, maximum control is achieved when putting on and taking off socks and shoes by crossing one ankle over the opposite knee. The tetraplegic patient uses the wrist extension grip and the palm of the hands in a patting movement to pull on the socks.
Putting on trousers
1. Lift the right leg with the right wrist behind the knee and the forearm on the armrest. Put the trouser leg over the foot. Repeat with the left leg.
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Alternatively, cross the right ankle over the left knee, put the trousers over the foot and pull up to knee height. Replace the right foot on the footplate. Repeat with the left leg. 2. Pull the trousers well up over the knees and under the thighs, lean on the left forearm and lift the right knee with the left wrist to pull the trousers up the thigh. 3. Hook the right ngers or thumb inside the back of the waistband, lean over to the left and lift on the left hand and forearm. Repeat from side to side. At each lift, wriggle forwards and backwards whilst the buttocks are in the air. Alternative method to pull the trousers over the buttocks for paraplegic patients: 1. Lean forward on the forearms on the armrests, depressing the shoulders and lifting the buttocks, and pull the trousers up. 2. Lean well back taking the weight on the top of the backrest, wriggle the buttocks forward and at the same time pull up the trousers.
Dressing on the bed

Upper extremity dressing on the bed
This presents no real problems for paraplegic patients. Tetraplegic patients have more stability for upper extremity dressing in the wheelchair and rarely do it on the bed.
Lower extremity dressing on the bed

Putting on trousers
1. Put the trouser legs over the feet as for the socks. 2. Flex the knee with the hand, wrist or forearm and pull the trousers up over the thighs. Lean on the elbows if necessary. 3. Repeat for the other leg. 4. Lean to the right on the right elbow, and pull the trousers over the left buttock. 5. Lean to the left and pull the trousers over the right buttock. Repeat this as often as necessary. A monkey pole may be necessary for patients with high thoracic lesions to lift onto the side at the commencement of training. The trousers may be removed by reversing the procedure. Alternative method for putting on trousers for tetraplegic patients: 1. Sit up, hook the right hand under the right knee and pull the knee into exion. 2. Put the trousers over the right foot.
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3. Repeat for the left foot. It may help to have both legs slightly exed and laterally rotated at the hips. 4. Work the trousers up the legs by alternately exing the knees and using a patting sliding motion with the palms of the hands. 5. Lie down and pull the right knee onto the chest. 6. Stay supine and hold the right knee with the left forearm or roll into left side-lying. Throw the right arm behind the back, hook the thumb in the waistband or belt loops, or the hand in the trouser pocket, and pull the trousers over the right buttock. 7. Repeat for the other side. These steps may need to be repeated several times until the trousers are in place over the hips. 8. Fasten the trouser placket by hooking the thumb in a loop on the zipper pull. If the patient cannot cross one ankle over the other, the trousers, socks and shoes have to be put over the feet in long-sitting. This is more difcult since the heels are resting on the bed.
ACCOMMODATION
The two major practical problems in resettlement are obtaining suitable accommodation and employment. Paraplegic patients, except for those handicapped by age or other illness, are usually able to return to live independently in the community. The majority of tetraplegic patients do return to their own homes, although often with maximum support from the social services and the family. Over the last decade organizations and governments have placed increasing emphasis on housing for people with disabilities. The home may need to be adapted or to have an extension, or it may be totally unsuitable, in which case the only solution is for the patient to be rehoused in a at or bungalow. Accommodation for patients who are unable to return home may be found in units for young disabled people, voluntary institutions or hostels with sheltered workshops.
Adaptations
The need for adaptation to the home varies considerably in relation to the level of the patients lesion and to his age and sex. Those adaptations most frequently necessary are to the bathroom facilities, which are usually too small, and to the kitchen. Access for the wheelchair to the toilet and bath or shower is necessary for those patients capable of independent transfer. To cook without unnecessary danger may necessitate adaptations to cupboards, cooker and working surfaces in the kitchen. Free access to the house from outside is essential and those able to drive will need a garage wide enough to accommodate the wheelchair beside the car for independent transfer.
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Although adaptations are necessary to enable access to, and independence within the home, a number of problems have been noted during the adaptation process. These include restriction of choice in the selection of adaptations, the length of the process and the appearance of the home subsequently. The value and meaning that the individual and his family attach to their home can be affected and these issues need to be dealt with sensitively (Hawkins & Stewart 2002).
Equipment
Some patients will need very little, if any, special equipment in the home; others may need a great deal. A bed, special mattress, hoist, and home nursing equipment, as well as a telephone and environmental control system, may all be necessary for a patient with a high cervical lesion.
EMPLOYMENT
Future employment is discussed with the patient as early as possible. Many patients are unable to return to their former employment as most are manual workers. Unemployment rates amongst registered disabled persons are higher than in the working population as a whole. Krause et al (1999) found that 50% of people with spinal cord injury were unemployed one year post-injury. Assessment at an industrial rehabilitation unit may be necessary, followed by retraining at a day or residential training establishment for disabled people. Some patients undertake new studies and embark on a second career and others, already in professions or business, return to all types of work. The internet is proving an asset to many who nd travelling to work difcult. Countries will differ in their ability to provide the necessary equipment and facilities to enable people to be re-employed and also in the way people with spinal cord injury receive nancial support after their injury. Noreau et al (1999) in a Canadian study with 418 subjects con rm the signicance of education and transportation in the ability of people to return to work or to enjoy leisure pursuits or contribute to community organizations. In a recent study of 236 people with spinal cord injury in Denmark (193 men and 43 women, 126 with paraplegia and 110 with tetraplegia) over 86% had a passenger van or another car (Biering-Sorensen et al 2004). Tomassen et al (2000) in the Netherlands found that only 37% of the 234 people with spinal cord injury in their study were gainfully employed and suggest that long-term support to nd jobs is necessary if more people are to return to work.
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CANINE PARTNERS FOR INDEPENDENCE

In Australia and the UK in recent years the Canine Partners for Independence have placed many dogs with disabled people including those with spinal cord injury. The dogs are trained to assist the owner with everyday tasks such as picking things up from the oor, assisting with the washing machine and dressing. These dogs not only provide functional assistance and relieve carers but are also great companions.
References
Allen G, McBride K 2003 Persons with C5 or C6 tetraplegia achieve selected goals using a neuroprosthesis. Archives of Physical Medicine and Rehabilitation 84:119124 Biering-Sorensen F, Hansen R B, Biering-Sorensen J 2004 Mobility aids and transport possibilities 1045 years after spinal cord injury. Spinal Cord 42:699706 Bryden A M, Wuolle K S, Murray P K, Peckham P H 2004 Perceived outcomes and utilisation of upper extremity surgical reconstruction in individuals with tetraplegia at model spinal cord injury systems. Spinal Cord 42:169176 Craig A, Moses P, Tran Y et al 2002 The effectiveness of a hands-free environmental control system for the profoundly disabled. Archives of Physical Medicine and Rehabilitation 83:14551458 Forner-Cordero I, Mudarra-Garcia J, Forner-Valero J V, Vilar-de-la-Pena R 2003 The role of upper limb surgery in tetraplegia. Spinal Cord 41:9096 Harvey L A, Bally J 2001 Hand function of C6 and C7 tetraplegics 116 years following injury. Spinal Cord 39:3743 Hawkins R, Stewart S 2002 Changing Rooms: The impact of adaptations on the meaning of home for a disabled person and the role of occupational therapists in the process. British Journal of Occupational Therapy 65(2):8186 Johanson M E, Murray W M, 2002 The unoperated hand: The role of passive forces in hand function after tetraplegia. In: The tetraplegic upper limb. Hand Clinics 18:391398 Keith M W, Peckham H P, Thrope G B et al 1989 Implantable functional neuromuscular stimulation in the tetraplegic hand. Journal of Hand Surgery (American volume) 14A:524530 Keith M W, Hoyen H 2002 Indications and future direction for upper limb neuroprostheses in tetraplegic patients: a review. In: The tetraplegic upper limb. Hand Clinics 18:519528 Kilgore K L, Hunter Peckham P, Keith M W et al 1997 An implanted upper extremity neuroprosthesis: follow-up of 5 patients. Journal of Bone and Joint Surgery 79-A(4):533541 Krause J S, Kewman D, De Vivo M J 1999 Employment after spinal cord injury: an analysis of cases from the Model Spinal Cord Injury Systems. Archives of Physical Medicine and Rehabilitation 80:14921500 Law M, Baptiste S, Carswell A et al 1998 Canadian Occupational Performance Measure, 3rd edn. CAOT Publications, Ottawa, Canada
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Light C M, Chappell P H, Kyberd P J 2002 Establishing a standardised clinical assessment tool of pathologic and prosthetic hand function: Nominative data, reliability and validity. Archives of Physical Medicine and Rehabilitation 83:776783 Moberg E A 1975 Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Journal of Bone and Joint Surgery (Am) 57:196206 Noreau L, Dion S-A, Vachon J et al 1999 Productivity outcomes of individuals with spinal cord injury. Spinal Cord 37:730736 Peckham P H, Keith M W, Kilgore K L et al 2001 Efcacy of an implanted neuroprosthesis for restoring hand grasp in tetraplegia: a multi-centre study Archives of Physical Medicine and Rehabilitation 82:13801388 Rothwell A G, Sinnott K A, Mohammed K D et al 2003 Upper limb surgery for tetraplegia: A 10-year re-review of hand function. Journal of Hand Surgery 28A:489495 Samuelsson K A M, Tropp H, Gerdle B 2004 Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users. Spinal Cord 42:4146 Taylor P, Esnouf J, Hobby J 2002 The functional impact of the Freehand System on tetraplegic hand function. Clinical results. Spinal Cord 40:560566 Taylor E, Hanna J, Belcher H J C R 2003 Splinting of the hand and wrist. Current Orthopaedics 17:465473 Tomassen P C D, Post M W M, van Asbeck F W A 2000 Return to work after spinal cord injury. Spinal Cord 38:5155 Uzerman M J, Stoffers T, Groen F et al 1996 The NESS Handmaster orthosis: restoration of hand function in C5 and stroke patients by means of electrical stimulation. Journal of Rehabilitation Sciences 9(3):208 Wuolle K S, Bryden A M, Peckham P H et al 2003 Satisfaction with upper extremity surgery in individuals with tetraplegia. Archives of Physical Medicine and Rehabilitation 84:11451149 Zancolli E A 2002 History of surgery in the rehabilitation of the tetraplegic upper limb. In: The tetraplegic upper limb. Hand Clinics 18:369376
The biomechanical principles used in transferring

Roger Ellis
Most people who suffer from a spinal cord injury will in time devise their own technique for transferring. Transfers need to be modied to the environment by the individual using all the knowledge and skill that the physiotherapist can impart. Once the basic principles have been established, the physiotherapist should allow the patient to solve his own problems. The correct training for transfers is essential because they are a large proportion of the skills that are needed to develop independence. Therefore the mechanics of transferring need to be understood by the physiotherapist who, in turn, will teach them to the patient. To be successful at transferring requires appropriate training in strength and skill until a safe technique is established. It has been shown in stroke patients who did exercises to increase strength that they were more independent at one month than those who only received functional training (Inaba 1973). This principle also applies to patients with spinal cord injury, where the physiotherapist is responsible for combining appropriate exercise with functional training to achieve a result. The following section is intended to assist the physiotherapist to understand the theory behind preparing a patient to transfer independently. It is a useful exercise for the therapist to identify the changing order of levers during the various stages of each transfer as they rarely remain the same throughout the manoeuvre.
CHAPTER
9
Elements of safe, efcient transfers 129 Levers 130 Factors that make transferring easier 133
Elements of safe, efcient transfers

Three elements are basic for efcient and safe transfers: 1. Mobility. Before starting to teach transfers the patient should develop the ranges of movement necessary to achieve a triangular base as shown in Figure 7.2. The position is known as the the vital triangle. 2. Balance. As soon as possible the physiotherapist has to work with the patient to develop balance and stability commensurate with injury level. 3. Strength. The level of neurological trauma will decide the pattern of muscle strength available to successfully clear the surface from 129
130
which transfers are being made. Paraplegic patients with normal upper limb power would be expected to perform all transfers, depending on their age, weight and sex. Tetraplegic patients with selective power will rely on their remaining strength distribution as described in Chapter 12. Therefore: Mobility Balance + Technique = Safe efcient transfers Strength Skin safety and the prevention of sores is the overriding message that all patients should understand when transferring. Poor transfers performed regularly result in eventual skin breakdown with more time spent on bedrest.
Levers
The physiotherapist must have a clear understanding of the mechanical principles involved when teaching transfer techniques. A lever is a rigid bar; capable of moving around a xed point called a fulcrum (F). Work is done when force or effort (E) applied at one point on the lever, acts upon another force or weight (W), acting at a second point on the lever. The perpendicular distance from the fulcrum (F) to the effort (E) may be called the efforts arm. And that from the fulcrum to the weight (W) as the weights arm. (Gardiner 1963) There are three orders or classes of levers, which are determined by the relative positions of the fulcrum, effort and weight. Each of these can be relevant at some point during the transfer.
First order
The fulcrum is situated between the effort and the weight (Fig. 9.1).
Example
The use of this class of lever can be found during the initial stages of some transfers. The patient rst assumes a stable sitting position by leaning back in the wheelchair before lifting one leg to place it into the bath, onto a plinth/bed or into a car. The sacrum is acting as the fulcrum (F); the arm is the effort (E), lifting the leg the weight (W). This order can be found at certain points when legs are being lifted and the effort from the arms is behind the fulcrum. However, the type of lever may change throughout this transfer.
THE BIOMECHANICAL PRINCIPLES USED IN TRANSFERRING
131
Second order
The weight is situated between the fulcrum and the effort (Fig. 9.2). This class of lever is found during reverse transfers (patient moving backwards). The patient is in the long sitting position with the arms behind the trunk The effort (E) is through both arms. Legs and truncal mass are the weight (W). Once the lift has started the heels become the fulcrum (F).
Examples

Reverse transfers from bed to chair, plinth or bath Tetraplegic person lifting backwards in a wheelchair to reposition himself using the wheels of the wheelchair to gain lift.
W F
Figure 9.1 First-order fulcrum.
W F
B Figure 9.2 Second-order fulcrum.
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Third order
The effort is between the fulcrum and the weight (Fig. 9.3). This is the most common lever used during transfers. For it to be successful the vital triangle must be achieved before the techniques can be taught.
Examples

Surface transfers Bed-to-chair transfers Transferring into a car, from chair to toilet, or chair to bath through 180.
During most transfers the order of leverage changes and will depend on the body mass of the patient, position of the effort arm and the transfer technique to which the patient is most suited.
E F
B Figure 9.3 Third-order fulcrum.
THE BIOMECHANICAL PRINCIPLES USED IN TRANSFERRING
133
Factors that make transferring easier

Low body weight Upper limb strength commensurate to injury level Joint exibility and full forward mobility to achieve at least the vital triangle position Good balance Buttock clearance Patient ability to solve problems Daily practice A longer arm to trunk length ratio (monkey syndrome). Thought to be a factor by physiotherapists although not proved to be so in Bergstrms research see p. 97) Use of the extended wrist, which adds 5 to 7 cm (2 to 3 inches) to the height of the lift Placing one leg on the wheelchair footplate, which can offer greater trunk mobility for the transfer Knowledgeable teaching by the physiotherapist.
References
Gardiner M D 1963 The principles of exercise therapy, 3rd edn. G Bell & Sons, p 1011 Inaba M, Edberg E, Montgomery J, Gilis M K 1973 Effectiveness of functional training, active exercise, and resistive exercise for patients with hemiplegia. Physical Therapy 53(1): 2835
Basic functional movements
CHAPTER
10
Mobilization and strengthening of the trunk and limbs 135 Preliminary training for functional activities 135 Basic principles 136 Lifting 136 To lift and move sideways 137 To lift and move forwards 138 Moving the paralysed limbs 138 Sitting and lying 140 To sit from the supine position without using a monkey pole 140 To lie down from the sitting position 142 To sit from the supine position using a monkey pole 142 To roll prone from the supine position 144 To turn onto the side 144 To turn in bed 146
MOBILIZATION AND STRENGTHENING OF THE TRUNK AND LIMBS

Some degree of stiffness in the trunk will result from the weeks of immobility in bed. In addition, there will be some shortening of the hamstring muscles. If the activities of daily living are to be mastered, good mobility is essential. Therefore, mobilization of the trunk in all directions and stretching of any tight muscle groups form an essential part of early rehabilitation. Active assisted, active and resisted work are given as indicated for trunk, shoulders, shoulder girdle and head. The use of the head and shoulder girdle in exion and rotation is essential in many functional activities, especially for patients with cervical or high thoracic lesions.
Caution
As the fracture is recently healed, mobilization of the trunk must be undertaken very gradually and with extreme care. Forced movements, particularly forced exion, must be completely avoided. Initially only free active exion is given.
PRELIMINARY TRAINING FOR FUNCTIONAL ACTIVITIES

To give the patient condence, these activities need to be undertaken on a wide plinth. Lifting the buttocks by pushing on the arms is the basis of most of the activities of daily living. An effective lift depends upon balance and strength and upon knowing exactly where to place the hands and how to hold the head, shoulders and trunk. The following comments apply primarily to patients with cervical and high thoracic lesions. Where the abdominal muscles are innervated, trunk control will be adequate and all lifts will be relatively easy. 135
136
Basic principles (see also Ch. 9)

In order to maintain balance whilst moving, the rst principle of body mechanics must be observed, i.e. the line of gravity must remain inside the base of support. To achieve this in the sitting position with no muscle power around the hips, the head and shoulders must be kept forward of the hip joints. When lifting the trunk with the hands just in front of the hip joints, the head, trunk and hips must be exed as much as possible. This position gives a mechanical advantage so that the same strength achieves a higher lift. An optimum degree of exion will be reached beyond which the lift becomes impractical for those without triceps, because the elbows will be exed. All patients start lifting themselves with extended elbows. Many patients with triceps later progress to lifting with the elbows exed, when the mechanical advantage increases as the degree of hip exion increases. In all movements the head acts as a weight to assist or resist any movement. When the arms are short or when there is extra weight around the hips, lifting is more difcult (see Ch. 8). The following manoeuvres provide the basis for functional activities such as dressing, turning in bed and transfers:

lifting and moving moving the paralysed limbs sitting up and lying down rolling prone and turning onto the side.
The therapist is behind, at the side of or in front of the patient as required to assist or resist each component of the movements involved. Clear instructions should be given at every step. Initially assistance will be necessary to maintain sufcient exion of the head and trunk as patients generally feel that they need to extend the trunk in order to lift. The therapist should never try to assist the patient in functional activities by lifting under the axillae. This action entirely negates any effort by the patient to lift by depressing the shoulders.
LIFTING
The therapist. The therapist is behind the patient and, as well as
maintaining the necessary exion, may need to aid the lift with her hands under the buttocks. Later, where possible, stabilizations are given in the lifted position.
Action of the patient

1. To balance in long-sitting, ex the head, shoulders and trunk so that the line of gravity is kept in front of the hip joints. With the arms close to the sides, place the hands on the plinth slightly forward of the hips and preferably with the palms at and ngers
BASIC FUNCTIONAL MOVEMENTS
137
extended. If the arms are short in relation to the trunk a higher lift may be obtained by lifting on the clenched st. Where triceps is paralysed, lateral rotation of the arms assists stability at the elbows. 2. Lean forward with the head and shoulders bent over the knees. A greater degree of exion is needed by tetraplegic patients. When innervated, the abdominal muscles will ex the trunk and the movement of the head and shoulders becomes less important. 3. With the elbows extended, push down on the hands. 4. Depress the shoulders and lift the buttocks off the plinth. At the moment of lift, raise the head. This will prevent the trunk collapsing forward.
To lift and move sideways

The therapist. In addition to the factors already mentioned, the therapist may need to encourage rotation. Action of the patient
1. Place the right hand on the plinth close to and slightly in front of the hip. 2. Place the left hand at the same level but approximately a foot away from the body. This distance will depend on the length of the arm in relation to that of the trunk. The elbows are extended and the forearms supinated, or in mid-position (Fig. 10.1A). 3. Flex further forward over the knees and lift the buttocks. At the same time twist the head and shoulders to the right, bringing the left shoulder forward and the right shoulder back (Fig. 10.1B). Where latissimus dorsi is innervated, it will pull the pelvis forward towards the arm which is away from the side.
Figure 10.1 Lifting sideways. Patient with a complete lesion below C6 without triceps and with the clavicular portion of pectoralis major only.
138
To lift and move forwards

Action of the patient. The legs need to be in lateral rotation and free
to ex at the knee: 1. Lean well forward, with the head over the knees (Fig. 10.2A). 2. Place the hands on the plinth a little in front of the hip joints and close in to the sides. The elbows are extended and forearms supinated. 3. Lift the buttocks (Fig. 10.2B). 4. Keep the head exed and the buttocks will move forward. Once beyond the point of balance, the patient will collapse forward (Fig. 10.2C).
MOVING THE PARALYSED LIMBS

In order to perform the activities of daily living, the patient will need to lift and move his paralysed limbs. The paraplegic patient will accomplish this quickly and easily, almost automatically. The tetraplegic patient will need intensive training and practice, and must not be disheartened if success is delayed. It is necessary to be able to:

move the legs along the plinth cross one ankle over the other cross one ankle over the opposite knee ex the leg in sitting and side-lying.
A method for tetraplegic patients to ex and lift the leg is described on page 146. Balance can be maintained whilst moving the legs by leaning forward on one or both elbows. This position leaves the hands free to lift, push or pull the leg. The pelvis must be straight and the patient leans a little to one side, as well as forward, to keep the body weight over the static leg.
139
Figure 10.2 Lifting forwards. Patient with a complete lesion below C6 without triceps and with the clavicular portion of pectoralis major only.
140
SIT TING AND LYING

These movements can be achieved without any equipment or using a monkey pole.
To sit from the supine position without using a monkey pole

1. In one brisk movement throw the right arm over to the left, ex the head and shoulders and twist them to the left. This will rotate the upper part of the trunk (Fig. 10.3A, B). 2. Balance on both elbows (Fig. 10.3C). 3. Take the weight on the right elbow and bring the left elbow closer to the trunk. 4. Balance on the left elbow and, holding the head forwards and protracting the shoulders, transfer the right arm to the right side of the body and balance on both elbows (Fig. 10.3D). 5. Lean over on the left elbow, outwardly rotate the right arm and extend it behind the body (Fig. 10.3E). 6. Adjust the position until the weight can be taken on the right arm and extend the left arm in a similar manner (Fig. 10.3F). 7. Slowly bring the hands forward alternately, a few inches at a time, until the weight is over the legs (Fig. 10.3G). Where possible, step 4 can be omitted.
Alternative method for steps 14

1. With the arms in pronation by the sides put the wrists under the buttocks. 2. With the elbows on the plinth strongly extend the wrists. 3. Flex the head, protract the shoulders, and with the elbows as the pivot-point pull the weight of the head and upper trunk onto the elbows. 4. Move each elbow backwards a few inches at a time. Continue as in the previous method, steps 5, 6 and 7. If the patient nds difculty with the hands under the hips, the thumbs can be hooked in the trouser pockets initially to enable him to get the feel of the movement.
Alternative method from step 2

From the position where the weight is on both elbows (Fig. 10.3C), the patient can walk on his forearms along the plinth to achieve the sitting position (see Fig. 16.14).
141
Figure 10.3 AG: Sitting up. H, I: Lying down. Patient with a complete lesion below C6 without triceps and with the clavicular portion of pectoralis major only.
142
To lie down from the sitting position

1. Keeping the head exed and shoulders protracted, lean over to the right and drop the weight onto the right elbow (Fig. 10.3H). 2. Balance on the right elbow. 3. Flex the left arm and transfer half the weight onto the left elbow. 4. Still keeping the head and shoulders forward (Fig. 10.3I), straighten one arm at a time until lying at.
To sit from the supine position using a monkey pole

Position of the monkey pole
The point of suspension for the monkey pole is over the midline of the body or slightly beyond midline towards the side of the supporting arm and approximately level with the xiphisternum. The handle should be just within the reach of the patients extended wrist.
Action of the patient.To lift onto one elbow:

1. Extend the right arm and hook the extended wrist over the monkey pole (Fig. 10.4A). 2. Pull the body towards the monkey pole and lean on the left elbow (Fig. 10.4B). 3. Flex the right elbow over the monkey pole and hold the body weight whilst bringing the left elbow closer to the trunk. 4. Support the body weight on the left elbow (Fig. 10.4C). To get up on two extended arms, proceed with either of the following methods.
Method 1
5. Lean on the left elbow. 6. With the elbow exed ick the right arm into lateral rotation and hold the wrist against the monkey pole chain (Fig. 10.4D). 7. Hold the body weight with the right arm, outwardly rotate the left shoulder and extend the arm behind the body (Fig. 10.4E). 8. Lean well over the left arm, release the monkey pole and extend the right arm behind the body. 9. Move the hands forward alternately, a few inches at a time, until the weight is over the legs (Fig. 10.4F).
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Figure 10.4 Sitting up using a monkey pole. Patient with a complete lesion below C6 without triceps and with the clavicular portion of pectoralis major only.
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Method 2
5. Lean well over to the left and balance on the left elbow. 6. Take the right arm out of the monkey pole, outwardly rotate the shoulder, and extend the arm behind the body. 7. Transfer most of the weight onto the right arm and push the left arm straight. 8. Move the hands forward alternately, a few inches at a time until the weight is over the legs. Patients without pectoral muscles, or with the clavicular head of pectoralis major only, may nd method 1 to be the easier of the two. Patients with good hand function grasp the monkey pole with one hand and lift onto the opposite elbow. From there, the procedure is the same as method 2. Occasionally a paraplegic patient may need to use a monkey pole for one of the following reasons: age, overweight, ossication around the hip joints or a previous medical history of heart or lung disease.
To roll prone from the supine position

Action of the patient. To roll to the right:
1. Flex the head and shoulders and ing the arms over to the left, so that the necessary momentum can be gained in step 2 (Fig. 10.5A). 2. In one brisk movement, ex the head and shoulders and ing the arms from left to right. As this movement is completed, the right shoulder is pulled back as far as possible (Fig. 10.5B). 3. The momentum of the arms is transferred to the trunk and legs and the lower half of the body will roll prone (Fig. 10.5C). 4. Place the left forearm on the plinth and take the weight on it. 5. Pull the right shoulder back and take the weight on both forearms (Fig. 10.5D). 6. Lie at and put the arms by the sides.
To turn onto the side

1. Sit up with or without the monkey pole as described. 2. Lean on the left extended arm. 3. Hook the extended right wrist under the right knee and ex the leg. 4. Facing the left, lean down on the left elbow and at the same time pull the right leg into further exion and cross the right knee over the left leg. 5. Place the right forearm on the plinth and take the weight on it. 6. Lower the trunk into side-lying.
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Figure 10.5 Rolling. Patient with a complete lesion below C6 without triceps and with the clavicular portion of pectoralis major only.
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To turn in bed
When the patient is able to turn on the mat and to move and position his legs, progression is made to turning in bed.
Action of the patient. To turn from supine to right side-lying:

To sit up, either of the two ways already described can be used, or the patient can sit up using a bed loop. The loop is attached to the end of the bed and is just long enough to hook on the forearm: 1. Put the left forearm through the loop and ex the right elbow, extending the wrist to grip the edge of the mattress (Fig. 10.6A). 2. Pull on the loop with the left arm and transfer the weight onto the right elbow (Fig. 10.6B). 3. Release the strap (Fig. 10.6C). 4. Extend the left arm behind the body and take the weight on it (Fig. 10.6D). 5. Extending the right arm take the weight on both arms. Move the hands forward until the weight is over the legs (Fig. 10.6E). To position the pillow: 6. Flex the left knee with the extended left wrist and push the pillow under the knee (Fig. 10.6F). 7. Keeping the weight well over the right hip, lift the lower leg onto the pillow with the right arm (Fig. 10.6G). Adjust the position of the pillow and legs. 8. Turn the upper trunk to the right and take the weight rstly on the right and then on both elbows. 9. Lean forward and take the maximum weight on the left elbow and forearm. Rock onto the left elbow and pivot the buttocks backwards across the bed (Fig. 10.6H). 10. When adequate movement backwards has been achieved, adjust the head pillow for individual comfort. 11. Take the weight onto the left elbow and lower the weight onto the right shoulder, lying down on the side (Fig. 10.6J).
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Figure 10.6 Turning in bed. Patient with a complete lesion below C7 with wrist control only.
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Figure 10.6 contd
Initially the therapist may need to assist the patient to achieve the rocking movement by pressing down over the patients left shoulder girdle with one hand and lifting under the right buttock with the other (Fig. 10.6I). When the patient can turn himself in bed and position the pillows correctly he will be encouraged to take responsibility for turning himself at night with supervision from ward staff.
Wheelchairs and wheelchair management

Ida Bromley, Lone Rose
Guide to wheelchair selection
With advances in technology has come a revolution in wheelchair design, both manual and powered. In many parts of the world the range of wheelchairs is now vast. This increase in choice has made selection more complex both for the professional and for the user. With the number of options and the continuing development of these chairs, expert advice is required to select an appropriate chair for each individual. The following considerations may assist in shortening the list of potentially suitable wheelchairs to be tried.
CHAPTER
11
Guide to wheelchair selection 149 Types of wheelchair manual 150 Adjusting the manual wheelchair to suit the user 155 Types of wheelchair powerdrive 157 Other types of wheelchair 159 Hybrid power/manual chairs 159 Reclining/tilting manual wheelchairs 160 The stand-up chair 160 Sports chair 160 Paediatric wheelchairs 160 Latest trends 161 Wheelchair accessories 162 WHEELCHAIR MANOEUVRES 165 Basic movements within the wheelchair 166 Initial and advanced wheelchair manoeuvres 168 Initial manoeuvres 169 Advanced manoeuvres: tetraplegic patients 171 Advanced manoeuvres: paraplegic patients 171 Transport 182
Use of wheelchair
The environment in which the wheelchair will be used most of the time will particularly have a bearing on the durability and types of wheels selected. If mainly used indoors, the wheelchair needs slimmer tyres to reduce friction, whereas if used mainly outdoors, a strong frame and thicker tyres with better grip would be preferable. For some users a manual self-propelling chair may be adequate for use indoors whereas a powered chair may be required for outdoor use. The type of use whether general purpose or specic such as sport, work or leisure. If the wheelchair is not going to be controlled by the user, special attention must be paid to how the user will be assisted. If the wheelchair is not going to be used full-time, storage needs to be considered.
Mode of transfer

Transfers through standing require the footplates to be able to ip-up and/or swing safely out of the way. Sideways transfers with or without a transfer board require sufcient space to clear the large rear wheel or other obstacles to avoid tissue trauma. Where hoisting is required, sufcient access for the caregiver to place and remove the hoist sling must be taken into 149
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consideration. The style of front end of a wheelchair and height off the oor of footplates can affect access with a hoist.
Transport
If the wheelchair has to be lifted in/out of a vehicle the overall weight of the wheelchair as well as the weight distribution (balance when lifted) becomes particularly important. The room available in a particular vehicle may determine the type of wheelchair in terms of compactness when folded. If the user stays in the wheelchair whilst travelling, the wheelchair must be compatible with adequate clamping systems to rmly secure it to the oor of the vehicle. The user will need separate seatbelt and headrest systems.
The user
Although most wheelchair manufacturers offer a wide range of sizes (width and depth), individuals of exceptional stature (either very tall or very short) may have a limited range of wheelchairs to choose from. All manufacturers state maximum user weight for each type of wheelchair. An increasing number of wheelchairs are becoming available for larger individuals. Special back support and cushions may be required for the wheelchair due to the special postural needs of the user.
Rehabilitation is wasted if appropriate equipment is not provided at the end of it, i.e. equipment that will enable the individual to continue to use and progress the skills learnt during rehabilitation.
T YPES OF WHEELCHAIR MANUAL

The drive behind the revolution in manual wheelchair design over the last 20 years has been the desire to develop a lighter and more manoeuvrable wheelchair, which would enable the wheelchair to be tted to the needs of the user rather than the other way round. Postural stability, efciency of propulsion and manoeuvrability are all improved, facilitating the use of the chair, e.g. in rear wheel balance, which is the key to wider mobility in the environment. The key features in this new design are the use of lighter materials and greater adjustability in the wheelchair itself.
Weight
The terms lightweight and ultra light are used freely in the context of manual wheelchair design today. The weight of any
WHEELCHAIRS AND WHEELCHAIR MANAGEMENT
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wheelchair is largely dependent on the materials used and the number of individual parts. Traditionally wheelchairs were made from steel and weighed 25 kg (55 lb) Steel is still used in some wheelchairs, but most wheelchairs are now made from aluminium, titanium, carbon bre or a combination of these materials. All wheelchairs today are therefore much lighter than the traditional wheelchair used 20 years ago. For the same size of wheelchair the weight can vary from 7 to 15 kg (15.4 to 33 lb) depending on style of chair. Custom-made wheelchairs with minimal adjustability are lightest of all. Frame style. The traditional design with a vertically folding frame (Fig. 11.1) tends to be heavier as the cross frame design requires more metal to achieve the required strength. The rigid, horizontally folding frame design (Fig. 11.2) is stronger as well as lighter as there are fewer movable parts in it. The rigid frame design also tends to be more efcient as no energy is lost in the movement of individual frame parts. Some users nd that the slight movement of the frame in a folding frame design is more comfortable. Some wheelchair manufacturers offer a rigid frame chair with an ergonomic seat unit for optimal positioning (see p. 156). Most manufacturers offer a wide choice in both seat widths and depths, usually in 2 cm (0.8 in) increments. For correct sizing of the seat, see Chapter 6. Most wheelchairs now have detachable rear wheels, which not only reduces the weight when stowing the chair in a car but also makes the package to be lifted much more manageable.
Backrest

Many manual wheelchairs have adjustable backrest height as standard. Rigid frame wheelchairs have the facility to independently adjust the backrest angle in relation to the seat. Some folding frame wheelchairs offer this as an optional extra. Sling back canvasses tend to offer very poor postural support. Most manufacturers offer a tension adjustable backrest as an optional extra. This consists of adjustable bands between the two upright struts. These are adjusted by means of Velcro so that the spine can be supported wherever the support is needed (Fig. 11.3) (see Ch. 6). Some manufacturers of custom-made chairs are beginning to recognize the difference in the male and female body shape and have started to offer female backrests. Frequently women have the dilemma of requiring a wider chair at the hips than at chest level, which leads to the backrest interfering with the pushing action. The female back is the same width as the seat at the base but tapers in above the pelvis.
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Chair handle
Back rest
Arm rest
Calf strap
Tipping lever
Wheel rim Brake lever Heel strap
Figure 11.1 Example of standard folding frame wheelchair.
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Figure 11.2 Example of high performance rigid frame wheelchair.
Figure 11.3 Tension adjustable backrest.
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Rear wheels
Standard size for a self-propelling wheelchair is 24 in (60 cm) but wheel sizes from 20 to 26 in (50 to 65 cm) are available. If attendant controlled, some manufacturers offer rear wheel sizes of 10 to 12 in (25 to 30 cm), known as transit wheels. The larger the rear wheel, the less effort is involved in pushing the chair whether by the occupant or the assistant. The tyres can be pneumatic with pressures from 60 psi to 100 psi or solid. Some manufacturers offer an extensive choice of tyres from smooth, slim, low prole racing bike styles to very high prole, chunky mountain bike style tyres. The type of tyre used will affect friction when pushing a softer, broader pneumatic tyre will increase friction but gives a softer ride. A slim, high pressure or solid tyre will reduce friction, but gives a harder ride. Puncture proof inserts are available for most pneumatic tyres. For optimal performance pneumatic tyres must be kept at the recommended pressure.
Front castors
Sizes range from a few inches in diameter to the traditional 8 in (19.8 cm) castor. A larger castor will make it easier to roll over rough ground but makes it heavier to turn the wheelchair. Large castors are more likely to interfere with the feet on the footplates when turning the chair. Small castors require greater skill from the user when pushing outdoors as the weight has to come off the castors when pushing over soft or rough ground to prevent getting stuck. Castor tyres can be solid or pneumatic, slim or chunky. The same principles for comfort and rolling resistance apply as for the rear wheel. Some wheelchairs can have quick-release castors.
Legrests and footplates
The angle of the legrests (sometimes described as foothangers) affects the overall length of the wheelchair and therefore the turning radius. The traditional standard wheelchair had legrests at 60 knee exion. This is now rare in modern design. The most common legrest angle is 70 or 80 and some manual wheelchairs have 90 front ends. The range of movement in the hamstrings and degree of knee exion determine the limitation of the angle of the legrests (see Ch. 6). Leg length will also affect choice of angle as people with long legs will have to be higher off the ground if wanting 90 front end to their chair, which in turn may affect their ability to get under tables. Legrests can either be swing-away detachable or integral to the frame of the chair. Folding frame chairs tend to have swing-away
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detachable legrests whereas the rigid frame manual wheelchairs tend to have integral ones. Some legrests are tapered to make them narrower at the bottom. This feature helps to reduce the turning circle of the chair. Footplates can be ip-up style which can be adjusted independently for right and left leg or can be a single ip-up footplate. Integral legrests can have a footbar or a single xed footplate. Some footplates are angle adjustable. Footplates can be tted with heel loops to prevent the feet slipping back off the footplate. Some heel loop designs are quite short and users with large feet will tend to have only the middle of the foot supported on the footplate. A calf strap can be used as an alternative. For some users with excessive spasticity both may be necessary.
Adjusting the manual wheelchair to suit the user

The correct position of the patient in his wheelchair is important if pressure ulcers and deformities are to be avoided and if the patient is to have maximum stability for independent activity (see Ch. 6). The majority of patients are apprehensive and unstable when rst sitting up in a wheelchair. Their primary need is to feel safe in their wheelchair. Having a wheelchair with minor but essential adjustability available makes it possible to adjust the wheelchair to give the user the benet of a more manoeuvrable chair and still reect the greater need of stability over mobility. The seating system needs to support the user in a good posture whilst at the same time allowing him to be dynamic. The following section describes the advantages and disadvantages to the user of the adjustments, which will affect the biomechanics of the wheelchair. For more detailed description of wheelchair ergonomics, see Engstrm (2003).
Rear wheel position forward/backward

Pushing efciency is directly linked to the axle position of the rear wheel the further forward the rear wheel is placed under the user, the more manoeuvrable the chair becomes as more weight is placed over the rear wheel (Boninger et al 2000). Wheelchairs with several forward position options are often referred to as high performance wheelchairs. Advantage to function is that it improves manoeuvrability and pushing efciency, shortens the turning radius and makes backwheel balance easier. Disadvantage to the user may be that it makes the chair tip backwards more easily and may interfere with sideways transfers. When adjusting the chair to the user the balance is between stability and mobility. The optimal rear wheel position will vary according to the progress of the individuals skill (at a given point in time) as well as from individual to individual. At the beginning of rehabilitation the rst time user will primarily need stability
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in order to be able to learn new skills. As condence and skills grow greater mobility becomes more important. For the more timid individual with limited potential for advanced wheelchair skills the rear wheel may only be moved safely forwards in small increments up to a maximum of 45 cm (2 in) whereas the more skilled user over time may choose to have the rear wheel forward by 10 cm (4 in) or more. Conversely the rear wheel may be positioned rearwards if the user needs greater stability due to partial or full amputation of one or both lower limbs.
A
Rear wheel position up/down

This alters the seat angle in relation to the rear wheel and will determine how deep the user sits between the wheels. Combining adjustment of the seat angle with the backrest angle will create three basic seat unit positions: standard, tilted and reclined (Fig. 11.4). A hybrid position of the standard and the tilted is referred to as the bucket position, i.e. seat tilted but backrest vertical. The optimal position is considered to be when the user can reach the centre of the hub of the wheel with the tips of the middle ngers when sitting in an upright position. If the correct arm position in relation to the wheel is reached without achieving the desired seat angle, further raising of the front end of the seat can be achieved by either ramping the cushion or extending the castor forks. As the seat slopes down towards the back of the chair, gravity will assist the user in achieving and maintaining his position towards the back of the seat. However, a sloping seat may affect transfers as it necessitates moving uphill in preparation for a transfer out of the chair. Most users who are able to transfer independently or with minimal assistance are able to cope with a difference in oor to seat height of 5 cm (2 in) from front to back. A severely sloping seat will also increase subischial pressures and can interfere with urinary drainage if leg bags are used as the urine has to drain uphill.
Rear wheel position camber

D Figure 11.4 A: Ergonomic seat frame. B: Standard seat unit seat horizontal, backrest vertical. C: Tilted seat unit seat/back angle = 90. D: Reclined seat unit seat/ back angle > 90.
Cambering angling the rear wheels in relation to the frame of the chair greatly improves directional stability, making it easier to maintain a straight line on uneven ground and facilitating turning the chair. It brings the wheels closer to the body, improving pushing efciency. It does, however, make the wheelbase wider, which may affect access through doorways.
Front castors
By moving the rear wheel forward the wheelbase is shortened, which may result in making the wheelchair unstable forwards, if the user reaches forward. To counteract this, the castors usually have the
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facility to be moved forwards by one or two positions. Having a very short wheelbase also requires greater skill when mounting a kerb. If the angle of the seat is altered through moving the rear wheel up or down on the frame, the castor housing needs to be adjusted accordingly. The castor housing should always be perpendicular to the oor to avoid castor utter.
Footplates
Footplates should be adjusted to take the weight of the leg and offer support throughout the length of the thigh (see Ch. 6). The feet should be supported in plantargrade or slight dorsiexion.
Backrest
The height of the backrest should be sufcient to fully support the posture without interfering with function. Backrest angle should be as close to vertical as the user can tolerate without losing balance. The tension adjustable backrest should be adjusted according to the principles for posture laid out in Chapter 6.
Seat canvas
Some wheelchairs tend to have a sag in the seat canvas. As most cushions are designed to be supported on a at surface it is important to eliminate the sag by using a solid seat insert made of wood, solid plastic or shaped foam.
T YPES OF WHEELCHAIR POWER-DRIVE

For users who are unable to self-propel or who nd it difcult to use a manual chair all the time, the power-drive chair provides the ideal solution. Most power-drive users will have a manual wheelchair for back-up. As for the manual wheelchair, the range of power-drive chairs has greatly increased in recent years and they too are available in a wide range of sizes. The power-drive chair is classied as indoor, indoor/outdoor, outdoor/indoor or outdoor. This classication is largely dependent on the power of the motor and the combination of front and rear wheels.

The indoor power-drive chair tends to have four solid tyres. The indoor/outdoor power-drive chair has pneumatic rear tyres with solid front tyres. The outdoor/indoor and outdoor power-drive chairs tend to have pneumatic tyres on all four wheels to be able to cope with rugged terrain.
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Power-drive chairs can be either front- or rear-wheel drive. The front-wheel drive has the advantage of being able to turn on its own axis.
Control unit
This determines the power sent from the battery to the motor. The control unit can be adjusted for speed and sensitivity to suit the individuals need. Controlling the chair can be by hand via a joystick which can be individualized depending on hand function. Other types of controls are chin or head controls, i.e. sip/puff, head switches, or the chair can be attendant controlled.
Seat unit
The style of seat unit varies from a standard sling-seat/back to wellupholstered, contoured seats and backrests, reminiscent of a car seat. However, it is possible to use independent back systems and cushions with most chairs. It is usual and indeed recommended that users with spinal cord injury will use their own pressure-relieving cushion. Backrests tend to be taller than in manual chairs for added stability, particularly in the chairs intended for outdoor use. Some power-drive chairs have the facility to recline or tiltin-space (whole seat unit tilts without altering back/seat angle). This function offers the user the opportunity to change position in the chair and can be controlled either manually or electrically. The degree of tilt offered by most manufacturers will not be sufcient for adequate pressure relief (see Ch. 6) but will still provide increased comfort to the user through a change in position. Tilting the seat unit is usually preferable to reclining as the pelvic/hip posture remains unaltered. When using the recline facility, shear forces on the back are greatly increased when bringing the backrest back to upright. This can be reduced by leaning the user forward (Gilsdorf et al 1990).
Headrest
All power-drive chairs that are being transported with the user in them must be tted with headrests for safety purposes. Headrests are essential in chairs that recline or tilt. They should be adjustable in all directions for maximum comfort and may have to be altered for different seat positions.
Caution
Where the users head extends to rest on the headrest, care must be taken when feeding as this position opens the airways and food may go into the respiratory tract.
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Leg support
Legrests tend to be swing-away with ip-up footplates, which in some cases are angle-adjustable. Elevating legrests can be raised or lowered either manually or electrically.
Kerbclimber
This device enables kerbs of up to 13 cm (5 in) to be mounted in a power-drive chair. The action of the kerbclimber lifts the chair over the kerb and it is not advisable to use this with any head control system. The kerbclimber needs to be positioned relatively close to the ground to be effective, which may cause it to activate whilst going over small obstacles on the ground when the user does not expect it. Careful training of the user is required.
Armrests
All are detachable or swing-away and in most cases also height adjustable. Special contoured arm supports are frequently used on top of the armrest.
Batteries
Most power-drive chairs have gel batteries, which are maintenance free apart from charging. They are safer to transport than wet batteries, especially on planes, are more expensive, tend to have a shorter lifespan (2 years +) and may take longer to charge. Although still heavy, batteries have reduced in weight as well as in size over the years. Most power-drive chairs can be tted with systems that can be used with environmental control units as well as computer systems, giving the user greater independence once up in the chair. More sophisticated power-drive chairs have got stand-up modes and/or variable seat height. In some chairs it is possible to continue to manoeuvre the chair whilst using these functions.
OTHER T YPES OF WHEELCHAIR Hybrid power/manual chairs

Several systems are available whereby a manual wheelchair with quick release rear wheels can be converted to a power-drive chair or power-assisted manual propulsion. Manual propulsion can also be assisted by adding a fth central rear wheel. The power-assist systems have been shown to be effective in reducing the strain of manual
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wheelchair propulsion and are ideally suited to the person with or at risk of upper limb joint degeneration, or with reduced exercise capacity or who has marginal strength and endurance for manual wheelchair propulsion (Cooper et al 2001, Levy et al 2004). These systems are heavy and would make independent car mobility very difcult. Some systems add considerable extra width to the wheelchair and may make some access difcult. A growing number of systems are available, e.g. the E-Fix and F16 (power-drive), the E-motion and i-Glide (power-assist) and the Samson Jockey (fth wheel power-assist).
Reclining/tilting manual wheelchairs

Some chairs only allow the backrest to recline; others have both a reclining and a tilt facility. The effect of both these functions on posture is described in Chapter 6. This style of chair is intended for the user who is unable to maintain upright posture against gravity and is unable to control the wheelchair himself. In order to maintain stability through the full range of adjustments of this style of chair, the wheelbase has to be longer. This can make the chair difcult to manoeuvre in a conned space. Traditionally these chairs have had small rear wheels but newer models can be supplied with large rear drive wheels which will make it easier for the attendant to push, especially up and down kerbs or on sloping surfaces. Separate seat and back systems can be used with most chairs and some chairs can also accommodate ventilators.
The stand-up chair

This chair (Fig. 11.5) enables the patient to raise himself to the standing position to perform an activity and to sit down again independently. The seat of the chair is raised slowly to the required height either manually or electrically. The movement can be interrupted or reversed at will. Several models and mechanisms are available.
Sports chair
Highly specialized wheelchairs are now designed for specic sports, e.g. basketball, tennis, wheelchair rugby and racing. Hand bike attachments can be used with a range of manual wheelchairs.
Paediatric wheelchairs
The range of wheelchairs both manual and power-drive for children has experienced the same expansion and technological advances as for the adult user. The biomechanical principles applied to adults
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regarding pushing efciency can equally be applied to children as children essentially propel their wheelchairs in the same manner as adults (Bednarczyk & Sanderson 1994). Some special points need to be considered when selecting a wheelchair for a child.
Larger rear wheels on a manual wheelchair will be very efcient but may place a young child much higher than its peer group for play and education. Postural management of the spinal cord injured child is of paramount importance (see Ch. 16) but the natural instinct of most children to be active must also be considered. A balance between dynamic activity and postural control must be found for the full 24-hour period. Normal developmental milestones must be respected and the disabled child needs equipment that will enable him to reach these. This has implications for the age at which a child can be provided with a wheelchair that he himself can control to explore his wider environment. Very young children (12 months+) can learn to propel a manual wheelchair safely. If a power-drive chair is required the childs cognitive skills must be assessed carefully for obvious safety reasons. With paediatric power-drive chairs an adult should always have a remote cut-out switch, which can instantly immobilize the chair (similar to a car key fob). All children want to feel part of a peer group. The colour, speed and cosmetics of their wheelchair are probably the most important criteria for them. It is essential to involve the child actively in the selection of the chair.
Figure 11.5 Example of stand-up chair.
LATEST TRENDS
New technologies are being developed all the time. Recent designs have seen the development of highly sophisticated chairs like the iBOT Mobility System, which is able to climb kerbs and stairs and manage very rough terrain. Through a system of gyroscopes it is able to balance on two wheels and still be fully mobile (http://www.independencenow.com). The quest to reduce the weight of manual wheelchairs continues as does the drive to nd new ways of collapsing wheelchairs into ever smaller, more compact and more transportable packages. Development of power-drive chairs and cars that can be controlled by voice continues. Keeping up with new development can be difcult for the busy clinician but in this technological age the internet offers quick access to all the main manufacturers websites. Attending equipment exhibitions is preferable whenever possible as it gives the opportunity to try new equipment and discuss with the manufacturers and agents. It is important for clinicians and users to feed back their experiences if future advances are to reect the clinical and not merely commercial need.
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WHEELCHAIR ACCESSORIES
There are various accessories which can be obtained with most models when necessary.
Anti-tipping levers
These levers are designed to prevent the chair and patient overbalancing backwards. They can be adjustable and are removable, and it is possible to mount small kerbs with them in situ, thus increasing independence for children and patients with cervical lesions.
Armrests
There are several models, all detachable:

standard desk arms the front upper quarter is cut away to allow the chair to be wheeled closer to a desk or table height adjustable lift-up swing-away tubular.
Most detachable armrests have automatic locking devices.
Backrests
These are available in a number of sizes to provide sufcient support without impeding mobility. The angle of the backrest is adjustable, which permits patients, particularly those without abdominal muscles, to recline a few degrees from the vertical, allowing greater freedom to use the arms. Some have xed or swing-away lateral supports for increased postural control.
Brakes
These can be push/pull or scissor type, which can be mounted high or low on the frame of the chair. Some push/pull brakes are designed to swivel away underneath the seat like the scissor style brake. Some manufacturers are bringing out brake designs that are located in the hub of the wheel.
Brake extensions
These are sometimes necessary to enable patients with cervical lesions to reach the brakes without falling forward. For patients with weak grip the brake extensions give added leverage.
Caddy
These are small levers which attach to the legrests of the wheelchair. When folded down they are perfect for carrying a briefcase. When not in use they simply fold up parallel to the legrest.
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Capstans and pushrims

Capstans are rubber-capped projections spaced at regular intervals around the rim of the wheel. These help some patients with high cervical lesions to get a purchase on the wheels when pushing the chair. Friction-coated or specially designed hand rims increase the effectiveness of the push for weaker users.
Carrying bag
This hangs under the seat of the chair to hold personal belongings. Bags should not be carried on the backrest of a manual wheelchair as it alters the balance point of the wheelchair and will eventually ruin the back canvas.
Castor locks
Castor locks contribute to sideways stability of the chair for transfers.
Crutch or walking stick holder

This consists of a small platform attached to the tipping lever and a strap on the upper part of the backrest to carry the crutches.
Cushions
See Chapter 6.
Elevating legrests
These increase the overall length of the chair by 10 cm (45 in) and its weight by approximately 1 kg (2.2 lb) They are useful for:

patients with high lesions with vasomotor problems any patient with a leg injury.
Frogslegs
Suspension in the front castor fork makes it easier to push over small lips and ridges.
Guards
Side guards
The intrinsic stability of the chair is high, so that even patients with cervical lesions may not need armrests. In this case, side guards may be required to protect the clothes.
Spoke guards
Guards on the outside of the wheels protect the ngers, especially of patients with cervical lesions.
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Mobile arm support

A splint supports the weight of the arm and on a pivot, allowing maximum performance from minimum motor power.
Push handles
These can be integral to the backrest or detachable. Some are height adjustable, which is particularly relevant for users who require regular assistance from a tall person or from a range of people of varying heights. Some wheelchairs can be supplied with stroller handles which angle away from the back of the chair and make it more comfortable for the person pushing.
Restraining or safety strap

This is attached to the supports for the backrest on each side and fastens with Velcro or a buckle across the abdomen. All patients with cervical lesions use them when rst mobile and those with lesions at C4C5 and above may continue to use them.
Stepper tube
This is a small metal lever that assists an attendant when tipping the chair back to go up and down kerbs.
Suspension
Several manufacturers offer suspension on both manual and powerdrive chairs.
Tetra clip
This helps people with restricted or weak hand function to release the hub of a quick release wheel.
Tray
The tray clips on to the armrests and provides a useful surface for many activities. It is also useful, when well padded, as a support for the arms for patients with high cervical lesions.
Tyres
High pressure, pneumatic and solid tyres are available.
Wheels
There is a range of sizes from approximately 12 to 26 in (30 to 65 cm) in diameter.
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Zipper backrest
This can be tted to permit entry and exit from the rear of the chair. Following assessment it is essential that the user is given the opportunity to try the wheelchair in circumstances he will encounter in daily life. It may be necessary to try more than one before being able to decide which is the most suitable. Rarely does one wheelchair meet all the requirements of the user just as one pair of shoes does not meet all the needs of an able-bodied person. However with the ability to congure very easily it is now possible to have one wheelchair with different sets of rear wheels for different purposes, e.g. slim, low prole tyres for easy pushing indoors and pneumatic, puncture proof, high pro le ones for outdoors. Evidence from a survey of wheelchair provision to people with spinal cord injury (Rose & Ferguson-Pell 2002) indicates that it takes time for people to adjust to life after discharge from the spinal unit. As the person settles into a new routine, so the requirements of the wheelchair become clearer. The benets to the user of being provided with a wheelchair that can be adjusted to the change in skills and condence over time cannot be stressed enough. The wheelchair system needs to be exible enough to allow the user access to frequent reviews, advice and change of wheelchair if wheelchair provision is to meet the needs of the user over time. Mobility needs continue to change. The special needs of the person growing old with spinal cord injury are described in Chapter 17. Problems with pain from degenerative changes and repetitive strain in upper limbs are not conned to the older person in terms of chronological age but can also be seen in the person who has lived with spinal cord injury for 20+ years. For example, a person injured at the age of 17 will still only be 37 years old at 20 years post-injury, so he will be old in spinal cord injury terms, but most people would still consider themselves young at the age of 37! Provision needs to reect the requirements of the individual who has lived for a long time with disability but still has the expectation of living the active and ful lling life of his peers. Whereas many people used to subscribe to the motto of use it or lose it more recent evidence promotes conserve it to preserve it.
WHEELCHAIR MANOEUVRES
In recent years several manual wheelchair training guides and wheelchair skills programmes have been published (Axelson et al 1998, Kirby 2005). The Spinal Injuries Association in the UK has produced a wheelchair skills video called Turning the corner (Spinal Injuries Association 2003). All recognize the need amongst professionals as well as users for practical advice on how to become a procient
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wheelchair user. The value of a specically targeted wheelchair skills programme as part of a rehabilitation programme has been documented by MacPhee et al (2004). The basic movements of the patient within the wheelchair and the initial wheelchair manoeuvres described below are written for tetraplegic patients without a grip. The basic safety measures, such as holding on with one elbow or wrist, become progressively unnecessary as the level of the lesion descends. The advanced wheelchair manoeuvres are divided into sections, since some activities are unsuitable for patients with cervical lesions. Adaptations in technique may have to be made for chairs of a different design.
BASIC MOVEMENTS WITHIN THE WHEELCHAIR

To To To To
manipulate the brakes remove the armrest pick up objects from the oor reach down to the footplates.
Whenever the patient prepares to move within the wheelchair or to move into or out of it, he must rst position the wheelchair itself. To give maximum stability, the small front wheels must point forward, as this prevents the chair tipping onto the footplates, and the brakes must be applied. If the patient is going to lean out of the chair in any direction, the buttocks must be well back in the seat.
To manipulate the brakes

To reach the right brake: 1. Hook the left elbow behind the left chair handle. 2. Lean forward and to the right, allowing the left biceps to lengthen as the trunk movement occurs. To release the brake, use exion of the elbow and shoulder to push the lever forward with the palm of the hand or the lower part of the supinated forearm (Fig. 11.6A, B). To apply the brake, pull the lever back using the right biceps and either the extended wrist or the supinated forearm (Fig.11.6C, D).
To remove the armrest

Most armrests now tend to be either ip-up or swing-away as well as detachable. The technique for swinging them out of the way varies greatly depending on type but all tend to be easier to manipulate than the traditional detachable style. For tetraplegic patients strong wrist extension is essential if they are to manipulate the armrest independently.
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Figure 11.6 A, B: Brake off. C, D Brake on. Patient with a complete lesion below C6 without triceps.
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To pick up objects from the oor

Objects are picked up by leaning sideways out of the chair, and not by leaning forward over the footplates; the forward position is unstable and therefore dangerous.
To lean to the left

Position the chair sideways in relation to the object. Hook the right elbow behind the right chair handle and lean over the left armrest. To avoid excessive pressure on the ribcage, maintain this position for only a few seconds at a time. The armrest can be removed to allow shorter patients the necessary reach. To regain the upright position, pull up with the right elbow. When triceps is innervated, the extended wrist can be used under the outer rim of the armrest to maintain balance and regain the upright position.
To reach down to the footplates

This position will be necessary to adjust the footplates, to empty the urinal or for adjustments when dressing: 1. Lean forward on the elbows on the armrests. 2. Change the position of the arms one by one and lean on the forearms on the thighs. 3. Put one hand at a time down to the feet, leaning the chest on the thighs. To regain the upright position, patients without triceps must (1) throw the stronger arm back over the backrest and hook the extended wrist behind the chair handle, and (2) pull the trunk upright by strongly extending the wrist and exing the elbow. Patients with good functioning triceps pull the trunk upright by hooking one or both extended wrists underneath the upper, outer edge of the armrest(s).
INITIAL AND ADVANCED WHEELCHAIR MANOEUVRES

When putting the wheelchair in motion in any direction, the position of the head and shoulders is important. They are used to reinforce the action of the arms, whether to gain greater momentum or to act as a brake. Patients start moving the chair by pushing on the tyres. Paraplegic patients may progress to using the wheel rims, particularly outside, but many patients with tetraplegia continue to use the tyres because they nd the purchase easier and the push more effective. Pushing gloves (see Fig. 8.2f) are used by tetraplegic patients to protect the skin from callus formation and abrasions due to friction or injury.
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Those designed with the thumb portion set in opposition may assist in encouraging the tenodesis grip. Specially designed pushrims, temporary capstans or using rope or rubber tubing wrapped around the wheel may help older patients and tetraplegic patients to learn to push the chair. Many of the initial wheelchair manoeuvres can be taught in a group where patients learn from and encourage each other. Competition over slalom courses where the obstacles include ramps and turns in narrow connes is also useful. Penalties are given for touching as well as moving any of the marker buoys.
Initial manoeuvres

To push on the at To use the chair on sloping ground To turn the chair.
To push on the at
When wheeling on the at, the push forward with the arms is reinforced if accompanied by strong exion of the head and shoulder girdle. Momentum is gained because there is a general thrust forward with the upper part of the body. Signicant differences were observed by Boninger et al (2002) between the ways in which patients pushed their manual wheelchairs, and the stroke pattern was not always the same on both sides. It is suggested that a semicircular motion where the hand falls below the pushrim during the recovery phase produces the most work for the least effort. With this motion more time was spent in the push phase at a given speed.
To reverse on the at
1. Put both arms over the backrest between the chair handles. 2. Place the hands on the wheels with the elbows extended and shoulders elevated. 3. Leaning backwards, depress the shoulders and thrust downwards, with as much weight as possible over the arms. Slopes can be ascended in reverse in this way if the patient is unable to push up forwards.
To use the chair on sloping ground

To push up a slope
1. Leaning forward, place the hands towards the back of the top of the tyre (Fig. 11.7). 2. Push forward using exion of the elbows and exion and adduction of the shoulders. The chair can be held on a slope by turning the wheels across the incline.
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Figure 11.7 (left) Pushing up a slope. Patient with a lesion at C6. Figure 11.8 (right) Turning. Patient with a lesion at C6.
To slow down when going down a slope

Extend the head and shoulders and brake either with both hands towards the front of the tyres or with the rst metacarpals under the wheel rims and the wrists extended.
To turn the chair to the left

1. Place the left hand towards the back of the tyre with the arm over the backrest, behind the chair handle. 2. Laterally rotate the left arm and with the body weight over the hand push backwards on the inner side of the wheel (Fig. 11.8). 3. Push forward with the right hand.
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Advanced manoeuvres: tetraplegic patients

To push the chair over a 5 cm (2 in) step
This manoeuvre can be accomplished by patients with lesions at C6 without triceps, and may be necessary to get over a draught excluder or similar obstacle: 1. Place the palms on top and to the outer side of the tyre with the ngers down over the rim and the thumb between the rim and the tyre. 2. Push the chair backwards. 3. Then push briskly forward, leaning the body weight forward at the same time.
Advanced manoeuvres: paraplegic patients

To balance on the rear wheels To mount and descend a kerb To jump the chair sideways To mount and descend a ight of stairs in a high performance wheelchair To transfer a wheelchair into a car.
To balance on the rear wheels

Balance and movement on the rear wheels are useful to facilitate independent travel over rough ground, e.g. over grass, sand or shale, and also in negotiating kerbs or a step. This technique is safe only for patients with a good grip, i.e. for patients with lesions at T1 and below. In a well-adjusted lightweight wheelchair patients with lesions at C6 may also manage it. Anti-tipping levers are used initially. There are three manoeuvres involved:

To tilt the chair onto the rear wheels To balance the chair on the rear wheels To move and turn the chair on the rear wheels.
Action of the therapist

The therapist always stands behind the patient in step-standing, with the thigh of the forward leg ready to support the chair if control is lost. She holds the chair handles loosely (Fig. 11.9d). Assistance is given to tilt the chair by pressing down on the chair handles, and to nd the balance point by giving pressure in each direction as necessary. The therapists hands must be very sensitive to the movement of the chair, correcting it only when the patient is out of control. She must allow enough scope for the patient to be really aware of each movement that occurs, so that the patient can become familiar with the feel of the chair in the balance position.
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Caution
The therapists hands must remain on the chair handles until the patient has complete control, as it is all too easy for the patient to overbalance backwards and injure himself. Much practice will be needed. Not until the therapist is entirely satised that the patient is completely competent should he be allowed to balance without her behind him as a safeguard.
Action of the patient To tilt the chair onto the rear wheels
1. Place the hands on the wheels approximately in the 10 oclock position, holding the tyre and the rim or the tyre only, whichever is most comfortable. 2. Slightly extend the head, and put pressure on the wheels as though moving backwards (Fig. 11.9A). 3. Push forward quickly and forcefully, and the front wheels will lift off the oor (Fig. 11.9B). The height of the lift depends upon the force of the push.
To balance on the rear wheels

The balance point is much further back than most patients realize. It is found by playing the wheels forwards and backwards and using the head and shoulders as a counterweight. When overbalancing forwards, push the wheels forwards. When overbalancing backwards, push the wheels backwards. Control may be easier when holding the rims or the wheel and rim (Fig. 11.9C).
To move and turn on the rear wheels

Once balance is achieved, it is not difcult to move on the rear wheels. The technique is the same as with the front wheels down.
To mount and descend a kerb

This activity can be accomplished by patients with a normal grip, i.e. those with lesions at T1 and below.
To push up a kerb
1. Tilt the chair onto the rear wheels. 2. Push forward until the front wheels hang over the kerb (Fig. 11.10A) and lower them gently. 3. Leaning forward, push forward forcefully to bring the rear wheels onto the pavement. If the patient is unable to tilt the chair onto the rear wheels, he should ick the front wheels high enough to mount the kerb. The ick up
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is achieved in the same way as the tilt but requires less strength and balance. Patients with lesions at C7C8 with good hand function may mount low kerbs in this way and some patients with lesions at C6 in a high performance wheelchair may also be able to do it.
Figure 11.9 Rear wheel balance.
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Figure 11.10 A: Pushing up a kerb. B: Descending a kerb. Patient with a lesion at T6.
To descend a kerb
With the back to the kerb, lean well forward and push slowly backwards until the rear and then the front wheels roll down the kerb (Fig. 11.10B).
To jump the chair sideways

This manoeuvre can be useful when turning into a doorway from a narrow passage: 1. 2. 3. 4. 5. Apply the brakes. Lean away from the back of the chair. Grip the highest point of the wheel rims. Lift the buttocks off the chair. Quickly lift the wheels up and sideways before the buttocks descend again to the seat.
To mount and descend a ight of stairs in a high performance wheelchair

To go up and down a ight of stairs, each step must be deep enough to accommodate the weight-bearing section of the wheel. Within normal limits, the height of the step is not a limiting factor. This manoeuvre is only taught to patients who have already mastered all other activities in the wheelchair and who are willing to undertake the risks involved in learning the procedure.
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To go up a ight of stairs with the rail on the right
Action of the therapist. The therapist can assist using either of two
methods:
Stand behind the patient, holding the chair handle with one hand and grasping the stair rail with the other to anchor both herself and the patient (Fig. 11.11A). For wheelchairs without handles, a strap secured to the back-strengthening bar can be used. Stand on one side of the patient and control the twist of the chair by holding the wheel on the step whilst the patient alters the position of his arms to pull up to the next step (Fig. 11.11B). Should assistance continue to be required this method can be taught to relatives or friends to enhance mobility in the community.

1. With the chair close to the rail and the rear wheels against the step, stretch the right arm back and grasp the stair rail (Fig. 11.12A). 2. Lean back and balance on the rear wheels. 3. Grasp the right wheel rim with the left hand as far down the wheel as the patient can reach.
Figure 11.11 A: Ascending a ight of steps with assistance from behind. Patient with a complete lesion below T11. B: Ascending a ight of steps with assistance from below. Patient with a complete lesion below T12.
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4. Pull the arms towards each other and ascend the step (Fig. 11.12B). 5. Hold the right wheel rmly against the next step with the left hand and slide the right hand up the rail. 6. Move the left hand down the wheel. Repeat steps 46 to ascend each subsequent step.
To go down a ight of stairs

The steps are descended backwards. Method 1 (using a rail on the left): 1. Position the chair close to the rail. 2. With the left hand, grasp the rail approximately level with the shoulders. 3. With the right hand, grasp the top of the right wheel and/or wheel rim. 4. Lean forwards and allow the chair to move backwards down the step, controlling it with the right hand (Fig. 11.13). 5. As the wheel descends onto the step, sit a little more upright and stabilize the chair. Lower the left hand on the rail and
Figure 11.12 Ascending a ight of steps. Patient with a complete lesion below T12.
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Figure 11.13 Descending a ight of steps holding rail and wheel. Patient with a complete lesion below T10.
repeat 4 to go down the next step. (The footplates may bump onto the upper step as the chair descends.) 6. The left arm moves gradually down the rail with the chair. There is a tendency for the chair to twist as it descends. Method 2 (using a rail on the right): Those patients who are both exceptionally skilled and strong may descend steeper steps in the following way: 1. With the left forearm held close to the chest, grasp the rail with the left hand. 2. Rotate the upper trunk and grasp the rail approximately midway between the top and next step with the right hand (Fig. 11.14A). 3. Lean on the rail to take some of the body weight; great care must be taken not to pull the body out of the wheelchair. 4. In quick succession, let rst one wheel and then the other descend the step. The chair twists during this manoeuvre and it is difcult to hold it with only one wheel on the step (Fig. 11.14B, C). The safest and easiest way to descend a ight of stairs backwards is to use two rails if both can be reached comfortably. The wheelchair is lowered one step at a time as in method 1.
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Figure 11.14 Descending a ight of steps holding only the rail. Patient with a complete lesion below T12.
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In either method, the therapist stands behind the chair, controlling its descent as necessary.
To descend shallow steps in a high performance wheelchair

Tip the chair onto the rear wheels and lower the chair onto the next step as in going down a kerb. Stop on each step to ensure continued control (Fig. 11.15).
To transfer the high performance wheelchair into the car

1. Move the drivers seat as far back as possible and recline the back of the seat. 2. With the rear wheels towards the driver, tip the chair onto the front wheels (Fig. 11.16A). 3. Rest the top of the backrest against the open door. 4. Remove the left wheel (Fig. 11.16B). 5. Pull the chair towards the car and remove the right wheel (Fig. 11.16C). 6. Turn the chair until the seat faces the driver. 7. Grasp the front of the seat with the right hand and hold the top of the backrest with the left hand (Fig. 11.16D).
Figure 11.15 Descending shallow steps without a rail in a high performance wheelchair.
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C D Figure 11.16 Transfer of a high performance wheelchair into a car. Patient with a complete lesion below T12.
8. Lean against the back of the car seat and lift the chair across the body and into the back of the car (Fig. 11.6E, F). Reverse the procedure to take the chair out of the car.
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Figure 11.16 contd
To transfer wheelchairs without removable wheels into a car

Patients can transfer the wheelchair into the car through the front passenger door. The chair is accommodated either in front of or behind the seat, which is adjusted accordingly.
Method 1
1. 2. 3. 4. 5. Transfer into the car through the passenger door. Fold the wheelchair, leaving the brakes off. Lift the front wheels of the chair into the car. Transfer to the drivers seat. Pull the chair into the car.
Method 2
Alternatively, after step 2 of method 1: 3. Transfer to the drivers seat. 4. Lean across the passenger seat and tip the chair onto its rear wheels. 5. Pull the chair, rear wheels rst, into the car.
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The efciency of either method depends largely upon the physical proportions of the patient, and the best way should be found by trial and error. To get the chair out of the car, the procedure is reversed. It is easier to push the chair out when the rear wheels are adjacent to the door, i.e. using method 1. Some cars can be adapted with a sliding door in place of the passenger door, and a hoist for loading the wheelchair.
TRANSPORT
Both paraplegic and tetraplegic patients can have their own cars converted to hand controls. A patient with a lesion as high as C5 can drive a car providing it has automatic transmission. Adaptations for patients with special needs, e.g. those with incomplete lesions, are developed on an individual basis. Patients with paralysis of both lower and one upper limb can drive (Dollfus et al 1983). Many spinal units have facilities for driving assessment. Most patients learn to drive through national organizations. Some makes of cars and vans can be adapted with a ramp or hoist to give access to the driving position for the patient in his wheelchair. This is particularly useful for those who are able to drive but unable to transfer, e.g. those in electrically powered chairs. Some car rental rms have adapted vehicles for disabled users. Automatic rented cars can be quickly adapted to accommodate a paraplegic driver, enhancing the possibilities of independent travel (Dollfus et al 1983).
References
Axelson P, Chesney D Y, Minkel J, Perr A 1998 The manual wheelchair training guide. PAX Press, Minden, NV Bednarczyk J H, Sanderson D J 1994 Kinematics of wheelchair propulsion in adults and children with spinal cord injury. Archives of Physical Medicine and Rehabilitation 75:13271334 Boninger M L, Baldwin M, Cooper R A et al 2000 Manual wheelchair pushrim biomechanics and axle position. Archives of Physical Medicine and Rehabilitation 81:608613 Boninger M L, Souza A L, Cooper R A, Fitzgerald S G 2002 Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion. Archives of Physical Medicine and Rehabilitation 83:718723 Cooper R A, Fitzgerald S G, Boninger M L et al 2001 Evaluation of a pushrim-activated, power-assisted wheelchair. Archives of Physical Medicine and Rehabilitation 82:702708 Dollfus P, Ball J M, Zimmerman M D R, Claudron J 1983 A driving adaptation for tetraplegic persons and a travelling adaptation device for paraplegic persons. Paraplegia 21:127130 Engstrm B 2003 Ergonomic seating a true challenge. Posturalis Books, Stockholm
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Gilsdorf P, Patterson R, Fischer S, Appel N 1990 Sitting forces and wheelchair mechanics. Journal of Rehabilitation Research and Development 27:239246 Kirby R L 2005 Wheelchair skills training programme manual and skills test, version 3.2. Available from: http://www.wheelchairskillsprogram.ca select link Manual Levy C E, Chow J W, Tillman M D et al 2004 Variable-ratio pushrim-activated power-assist wheelchair eases wheeling over a variety of terrains for elders. Archives of Physical Medicine and Rehabilitation 85:104112 MacPhee A H, Kirby R L, Coolen A L et al 2004 Wheelchair skills training program: a randomized clinical trial of wheelchair users undergoing initial rehabilitation. Archives of Physical Medicine and Rehabilitation 85:4150 Rose L S, Ferguson-Pell M 2002 Wheelchair provision to people with spinal cord injury part 1. British Journal of Therapy and Rehabilitation 9(10):392400; part 2: British Journal of Therapy and Rehabilitation 9(11):S9-S14 Spinal Injuries Association 2003 Turning the corner developing manual wheelchair skills. Available from The Spinal Injuries Association, Suite J, 3rd Floor, Acorn House, 387391 Midsummer Blvd, Central Milton Keynes, MK9 3HP
Transfers
CHAPTER
12
Technique 186 The chair 186 Transfers by the therapist 187 To transfer from chair to plinth with the patient moving to his right 187 The cervical lift using two therapists 188 Independent transfers 190 To transfer to the plinth (moving to the right) 190 Removal of the footplates 194 To transfer to the car (moving to the left) 198 To transfer to the toilet (moving to the right) 200 To transfer to the toilet through the back of the chair 202 To transfer into an easy chair 202 To transfer to the bath 202 To transfer to the oor 208 To lift back into the chair 210 To transfer forward onto the bed 210 Transfers from a high performance wheelchair 212 To transfer to the oor 212 To transfer from the oor to the chair 212
For patients with spinal cord injury, transfers fall broadly into three groups: 1. those in which the feet are lifted and the trunk moves horizontally, e.g. transfer to plinth or bed 2. those in which the feet are at oor level and the trunk moves horizontally, e.g. transfer to toilet or easy chair 3. those in which the feet remain on the oor and the trunk moves vertically, e.g. transfer to bath or oor. The rst group is the most stable. The second requires skilled balance. The third requires considerable strength. These factors explain the division of the transfers into initial and advanced for both tetraplegic and paraplegic patients. All patients commence with the transfers in group 1. Tetraplegic patients without triceps progress only to the easiest of those in group 2. To lift without triceps, the patient must have a strong deltoid to hold the shoulder joint in three planes, an elbow joint capable of being locked in hyperextension, and sufcient mobility in the wrist joint to allow weight to go through the arm with the palm on a at surface. As can be seen in the following list, advanced transfers for the most active tetraplegic patient with triceps and wrist control only reach group 3 with the bath transfer, whereas advanced transfers for paraplegic patients are in group 3 exclusively.
For patients with tetraplegia
Initial transfers chair to plinth removal of footplates Advanced transfers chair to bed chair to car chair to toilet chair to easy chair chair to bath.
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For patients with paraplegia
Initial transfers chair to plinth or bed, sideways and forwards chair to car chair to toilet, sideways and backwards chair to easy chair Advanced transfers chair to bath chair to oor.
TECHNIQUE
The techniques described are those most commonly used for the various transfers. Slight variations will occur depending upon the individual height, weight, agility and age of the patient, and the level of the lesion. All transfers, except for that from the chair to the oor, are described for the tetraplegic patient. It is a simple matter to adapt the transfer for a patient with a lower lesion. The patient is always to lift, and not drag, his body to avoid knocking his limbs on the furniture or his buttocks on the wheel. Whilst transferring the buttocks, the head, shoulders and trunk must be exed with the head well forward over the knees. It is essential that the plinth be the same height as the wheelchair for transfer training, and, ideally, all surfaces should be at the correct height. Tetraplegic patients will achieve a transfer only under these conditions, but after training, most paraplegic patients will transfer to any surface without difculty. The mechanics of transferring weight are covered in Chapter 9. To prevent damage through shear forces, a shield of a malleable synthetic substance can be made to t over the upper quadrant of the wheel during transfers. This can be useful for patients, particularly those with cervical lesions, who nd difculty in learning to transfer.
The chair
In all cases, the chair must be in the position of maximum stability. It may slip during the transfer if the tyres are worn or the oor is slippery, or if the patient pushes horizontally instead of vertically. If possible, the footplates are removed but this will depend upon their design. This is not necessary for independent transfer to the plinth or bed. It is dangerous to pull up the footplates without swinging them out, since they may catch on the malleoli and cause bruising or damage to the skin.
TRANSFERS
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TRANSFERS BY THE THERAPIST

When one therapist transfers a patient who can give little or no assistance, the therapist must take great care to position herself and the patient correctly in order to avoid undue strain.
A
To transfer from chair to plinth with the patient moving to his right
Position of the chair
The chair is angled at approximately 30 to the side of the bed.

1. Bring the buttocks forward in the chair until the feet are on the oor. 2. Flex the trunk and hips until the patient is lying over the therapists right shoulder (Fig. 12.1A). The therapist always has her head turned in the direction of the movement (Fig. 12.1B).

1. Brace the feet and knees against the outside of the patients feet and knees. 2. Flex the hips, keep the back straight and hold the patient under the buttocks. 3. Rock the patient against the knees and move him across to the plinth (Fig. 12.1C, D). If preferred, a transfer belt can be used instead of holding the patient under the buttocks. The belt is made of reinforced strong webbing. It has three or four loops or holding straps along its length. The belt is fastened securely round the patients waist. The therapist grasps either one of the loops or the bottom of the belt on each side. A sliding board can also be used to assist in the transfer. Boards are available in a variety of shapes, e.g. straight when the board has to be placed in front of the rear wheel, or horseshoe-shaped when the board ts around the wheel.
Figure 12.1 Transferring a patient with a lesion above C5.
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The cervical lift using two therapists

Where other methods of transferring the patient are not possible and mechanical equipment is not available, this method is considered the safest for both patient and therapists. The lift can be used to transfer a patient to and from the bed, a second chair or from the oor in an emergency.
Transfer from bed to chair

The chair is angled at approximately 30 to the side of the bed.

The patient is in long-sitting with the head and trunk exed and the arms folded across the lower ribs.
Position of the therapists to transfer the patient to the left

Operator 1 stands behind the patient with one leg on each side of the right rear wheel. She holds the patient around the thorax, grasping the patients folded arms. The therapist must grip the lower thorax with her forearms to prevent the upper spine from elongating as the patient is lifted. Operator 2 is in step-standing facing the bed. She grasps the legs with one arm high up under the thighs and the other under the lower legs. The heavier the patient, the higher up the legs the grasp needs to be (Fig. 12.2A). On a prearranged signal, both operators lift together, operator 1 taking a step sideways and operator 2 a step backwards. The patient must be lifted high enough to avoid knocking the buttocks against the rear wheel or the spine against the chair handle or backrest support (Fig. 12.2B).
TRANSFERS
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Figure 12.2 Transfer using two therapists.
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INDEPENDENT TRANSFERS
Various methods of lifting the buttocks for patients with lesions at different levels are shown in Figure 12.3). The position of the hands and trunk and the use of the head will vary considerably in patients with cervical lesions. The simplest lift is achieved by pushing down on the armrests or the top of the rear wheel, straightening the elbows and depressing the shoulders (Fig. 12.3AD). Lifting and repositioning should be done slowly and carefully. Patients with cervical lesions may only be able to lift one side at a time (Fig. 12.3E, F), and those without triceps need to hyperextend the elbows.
To transfer to the plinth (moving to the right)

This transfer consists of three manoeuvres:

to bring the buttocks forward in the chair to lift the legs onto the plinth to transfer the trunk onto the plinth.
Figure 12.3 Various methods of lifting in the wheelchair.
TRANSFERS
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Figure 12.3 contd
192

Line the chair up with the plinth at an approximate angle of 20. With the buttocks forward in the chair, this small angle allows the transfer to occur in front of the rear wheel. A shield or a pillow is placed over the rear wheel to prevent injury should the buttocks knock against it during training.
The therapist. The therapist stands in front of the patient, ready to encourage exion of the head and trunk and to assist or resist the individual movements as necessary. Action of the patient To bring the buttocks forward in the chair
1. Extend the right wrist and ex the forearm under the right armrest. 2. Using the right arm, pull the trunk a little to the right and insert the left wrist behind the left hip. If wrist extension is strong, the forearm is pronated; if it is weak, the forearm is supinated (Fig. 12.4A). 3. Push on the right elbow on the back of the armrest. Flex the left elbow and push the left hip forward and at the same time extend the head and lean backwards. The cushion will slide forward with the leg (Fig. 12.4B). Repeat to bring the right hip forward. Figure 12.4C shows an alternative method for bringing the hips forward by pushing with both hands behind the hips at the same time. To lean forward over the legs, place both hands on the rear wheels and at the same time ex the head, protract the shoulders and thrust forward on the hands (Fig. 12.4D).
To lift the legs onto the plinth

1. To maintain balance, hook the right forearm round the right chair handle. 2. Put the left wrist under the right knee and lift the leg by exing the elbow (Fig. 12.4E). Pull the knee up to the chest by pulling the trunk upright with the right arm and leaning back in the chair. 3. Rest the left wrist on the right armrest and bring the right arm forward onto the plinth (Fig. 12.4F).
TRANSFERS
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Figure 12.4 Transferring to a plinth. Patient with a complete lesion below C6 without triceps.
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4. Change the position of the arms so that the right wrist holds the knee, with the forearm supported on the armrest. The supinated left forearm moves down to support the lower leg (Fig. 12.4G). 5. Push the heel onto the plinth. Remove the right armrest. 6. Lift the left knee as for the right and hold the hip and knee in as much exion as possible. 7. Maintaining balance on the left elbow, lift the lower leg with the right wrist (Fig. 12.4H). 8. Lean over to the right and cross the left leg over the right (Fig. 12.4I).
To transfer the trunk onto the plinth

The basic technique for this activity is the same as for lifting sideways on the mat: 1. Place the right hand on the plinth level with the upper thigh and the left hand on the cushion (Fig. 12.4J), or on the armrest where possible. 2. With the head and trunk exed, lift upwards and then to the right (Fig. 12.4K). 3. Several lifts will be necessary to complete the transfer (Fig. 12.4L).
Removal of the footplates

Depending on the type of chair the footplates may need to be removed.
TRANSFERS
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Figure 12.4 contd
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To remove the right footplate

Action of the patient Transfer the right foot to the left footplate or to the oor
1. Balance is maintained with the left hand on the armrest if the patient has a lesion at C7, or with the left elbow or wrist hooked around the left chair handle if triceps is paralysed. 2. With the right wrist extended under the lower leg (Fig. 12.5A), ex the elbow and lift the foot over to the left footplate (Fig. 12.5B).
Remove the footplate (Fig. 12.5CF)

1. With the wrist extended, release the lever by pushing it forward with the dorsum of the hand (Fig. 12.5D). 2. Swing back the footplate using extension of the wrist (Fig. 12.5E). 3. Lift the footplate off the bracket using the dorsum of the hand and wrist extension (Fig. 12.5F).
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Figure 12.5 Tetraplegic patient removing the footplate.
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To transfer to the car (moving to the left)

Some patients with lesions at C6 without triceps, and those at C7 with no hand function, may nd that a sliding board facilitates this transfer. The most useful dimensions of the sliding board have proved to be 60 cm 20 cm 1.5 cm tapered at both ends. A notch at the end facilitates the handling of the board, and a loop may be necessary for some patients to enable them to remove the board after transfer.

The chair is angled at approximately 30 to the side of the car. Remove both footplates or, if preferred, only one (the left in the case of Fig. 12.6).

1. Lift the feet into the car as for transferring to the plinth. Remove the armrest. 2. Place a sliding board under the left thigh. 3. Lift using the left half of the sliding board and the right armrest or chair seat (Fig. 12.6A), keeping the head and trunk well exed. 4. Repeat the lift as often as necessary, moving the hands a little to the left each time (Fig. 12.6B). The head and trunk must remain exed with the nose almost touching the steering wheel during the later lifts (Fig. 12.6C). 5. Remove the sliding board from the right and adjust the legs in the sitting position (Fig. 12.6D).
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Figure 12.6 Transferring to a car. Patient with a complete lesion below C7 with wrist control only.
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To transfer to the toilet (moving to the right)

Place the chair at an angle of between 50 and 90 to the toilet seat. Many patients nd the lift easier with the chair at right angles, because this position brings the armrest furthest from the toilet closer to the handrail. Remove the footplates if necessary.
The therapist
The therapist stands in front of the patient, bracing the patients knees and feet and holding under the buttocks or in the trouser band. As the patients prociency increases, the therapist gradually withdraws her support.

1. Check the position of the feet to see that they are at on the oor and vertically beneath the knees so that the weight is over them. Remove the right armrest. 2. Keep the head and shoulders exed throughout the transfer. 3. With the left hand on the armrest and the right on the rail, lift to the right (Fig. 12.7A, B). 4. With the left hand on the wheel and the right hand on the rail, lift further back onto the toilet (Fig. 12.7C). To transfer back to the chair reverse the procedure. In the absence of a wall rail, the experienced paraplegic patient can lift with his right hand on the toilet seat.
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Figure 12.7 Transferring to a toilet. Patient with a complete lesion below C7 with wrist control only. (Note back support on toilet.)
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To transfer to the toilet through the back of the chair

This method can be used when spasticity is severe. For example, the patient may be at risk transferring sideways when there is a combination of hip extension and knee exion spasticity. The normal backrest can be replaced by one which opens throughout its length by means of a zipper. The patient lifts backwards as shown in Figure 12.8, with one hand on the rail and the other on the toilet seat. Relaxation of the extensor spasticity may be obtained by exing one or both legs before lifting backwards.
To transfer into an easy chair

This transfer is basically the same as the sideways transfer to the toilet, the arm of the easy chair being used instead of the wall rail. The wheelchair is positioned at right angles to the easy chair, with the front edge of the seat approximately halfway along the seat of the easy chair. This position brings the two lifting points closer together.
To transfer to the bath

The bath is lled with water before entering and drained before leaving. Bath transfer can be accomplished by patients with lesions at C7 and below.
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Figure 12.8 Backwards transfer.
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To transfer over the bath end

1. 2. 3. 4. 5. 6. 7. 8. Position the chair so that the feet almost touch the bath. Lift both legs onto the edge of the bath (Fig. 12.9A). Swing away the footplates (Fig. 12.9B). Wheel forward until the chair is adjacent to the bath (Fig. 12.9C). Lift the buttocks forward in the chair. Continue lifting forward with the right arm on the bath edge and the left arm on the armrest (Fig. 12.9D). Transfer the left hand to the bath and lift onto the edge of the bath with the trunk almost fully exed (Fig. 12.9E). Maintaining the exion, move the hands along the bath sides and lift, lowering the body into the bath as gently as possible (Fig. 12.9F, G).
To get out of the bath, reverse the procedure, exing the legs before commencing to lift. Those patients who are unable to lift the whole depth of the bath can use a low wooden bath seat as an interim step. The edge of the seat must be padded and care taken to ensure that the skin is not damaged during the lift.
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Figure 12.9 Transfer over the bath end. Patient with a complete lesion below C7 with wrist control only.
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Figure 12.9 contd
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To transfer over the bath side

Position the chair either sideways at an angle of 30 to the bath or facing the bath: 1. Lift the legs into the bath. 2. Lift onto the bath edge. 3. With one hand on each side of the bath, turn to face the bath (Fig. 12.10). 4. Lift and lower gently into the bath. Where there is a ledge behind the bath, a combination of these two methods can be used. First, transfer over the side onto the ledge, where the patient is more stable, and from there into the bath, as in Figure 12.9.
Figure 12.10 Transfer over the bath side. Patient with a complete lesion below C8.
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To transfer to the oor

The therapist
The therapist stands in front of the patient, correcting his position and assisting him to maintain balance as necessary.

1. Remove the armrests. 2. Lift with the left elbow on the backrest and the right hand on the wheel, and pull the cushion out with the left hand (Fig. 12.11A).
Figure 12.11 AE: Transfer to the oor. FI: Transfer back into the chair. Patient with a complete lesion below T11.
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Figure 12.11 contd
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3. Remove the footplates and place the cushion between the front wheels for protection when sitting on the oor (Fig. 12.11B). 4. Gripping the front of the seat supports, lift the trunk (Fig. 12.11C) and allow the buttocks to slip forward over the edge of the chair (Fig. 12.11D). 5. Gradually lower the weight to the oor (Fig. 12.11E). Patients without abdominal muscles will need to extend the head and shoulders to tip the buttocks forward off the chair at step 4. The extension is maintained to prevent the patient pitching forward whilst lowering the trunk.
To lift back into the chair

Sitting with the back to the chair: 1. Either place both hands on the front of the seat supports or replace one footplate and place one hand on the top of the footplate tting. 2. Lift strongly, extending the head and neck (Fig. 12.11F). 3. Contract the abdominals, if present, and depress the shoulders to pull the pelvis back onto the seat (Fig. 12.11G). 4. Lift the feet onto the footplates.
To replace the cushion

If the cushion is soft enough double the cushion and place it between the wheel and the hip (Fig. 12.11H). Lift on both wheels and the cushion springs into place under the buttocks (Fig. 12.11I).
Alternative method for patients without abdominals

Replace the armrests. Double the cushion and place it low down between the back and the backrest. Lift on both armrests and the cushion springs into position. In both methods, the position of the cushion may need nal adjustment. If the cushion is heavy and/or solid and the above method cannot be used, the patient will need to rst transfer into his wheelchair, then to another surface, replace the cushion and transfer back into his wheelchair.
To transfer forward onto the bed

The forward transfer may be useful for the very young or for those who are overweight or severely spastic.
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1. Lift the feet onto the bed. 2. Wheel the chair forward until it is touching the bed. 3. Keeping the head and trunk exed, lift forward in the chair. Small children who cannot lift on the armrests may lift by pushing down on the cushion (Fig. 12.12A). Repeated lifts may be necessary (Fig. 12.12B). 4. With the left hand on the bed and the right hand on the cushion, lift the buttocks sideways onto the bed (Fig. 12.12C, D). Repeated lifts will be necessary.
Figure 12.12 Forward transfer to the bed. Child with a complete lesion below T10.
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TRANSFERS FROM A HIGH PERFORMANCE WHEELCHAIR

Some adjustment in technique is required when transferring from the high performance wheelchair, which may have rigid footplates and a more forward position of the rear wheels than on the standard chair. When transferring sideways to, for example, the toilet or bath, the angle between the chair and the toilet may have to be altered and, with non-detachable footrests, forward transfer to the bed or over the bath end may not be possible. Transfers to and from the oor are achievable by patients with complete lesions below C7 using the high performance wheelchair.
To transfer to the oor

Bring the hips forward in the chair as described on page 192. Remove the armrests. Lift the feet onto the oor in front of the footplates. Holding the top of the left footrest support with the left hand, lean forward and to the right until the right hand can take weight on the oor (Fig. 12.13A). 5. Lift towards the right hand, keeping the head and trunk well exed (Fig. 12.13B) and lower the body onto the oor (Fig. 12.13C). 1. 2. 3. 4. The high performance wheelchair will move during this manoeuvre, but this should not affect the patients control of the movement.
To transfer from the oor to the chair

1. Sit close to the right side of the footplates. 2. Hold the top of the left footrest support with the left hand and place the right hand on the oor beside the right hip (supported on the knuckles to give extra height if necessary, as in Fig. 12.14A). 3. Flex head and trunk as far as possible. 4. Push on the right hand and pull with the left hand (Fig. 12.14B). 5. Swing the buttocks into the chair. To ensure minimum effort, the lift needs to be performed as quickly as possible commensurate with safety, avoiding knocking the hips or buttocks on the chair (Fig. 12.14C). 6. As the buttocks reach the chair, hold rmly with the left hand and pull the trunk to the left to regain balance (Fig. 12.14D). The chair will move during the lift but this should not affect the patients control of the movement. The transfer using a hoist is described in Chapter 14.
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Figure 12.13 Transfer to the oor from a high performance wheelchair. Patient with a complete lesion below T12.
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Figure 12.14 Transfer from the oor to a high performance wheelchair. Patient with a complete lesion below T12.
Gait training
CHAPTER
13
Functional gait 217 Appliances 217 Standing a patient with a knee anklefoot orthosis 219 Standing between parallel bars 219 To stand a patient 219 To sit down 222 Exercises in standing 222 GAIT 225 Gait training in the bars 226 Swing-to gait 226 Four-point gait 229 Swing-through gait 230 Gait training on crutches 230 Balance exercises 230 Walking on crutches 231 To transfer from chair to crutches 232 Stairs 239 To get down and up from the oor onto crutches 242 To get out of a car onto crutches 244 Final functional activities on crutches 244 Gait using hipkneeanklefoot orthoses (HKAFOs) 248 Assessment 250 Team 251 Training 251 Gait 251 Gait using functional electrical stimulation (FES) standing systems 254 contd
It is important to put walking into perspective in terms of function in everyday life amongst able-bodied people outside hospital. Although most patients want to learn to walk, the energy cost of walking on crutches is high even for patients with low lesions, and in general only those with lesions at T10 and below, who are not overweight and who demonstrate some athletic ability, are successful and use their walking for functional purposes. Orthoses are expensive. Research has shown that the majority of paraplegic patients use their wheelchairs as their main means of locomotion. Not more than 10% of patients with complete lesions use orthoses for functional activities and a little less than one-third never use them at all (Haln 1970, Hong et al 1990). In view of this and the constantly increasing cost of medical services, fewer patients are being taught to walk. To be procient enough to walk in the environment an extended period of hospitalization is required. In some units a patient keen to walk returns to hospital maybe one year post-injury when strength and balance have improved. In some countries to be able to walk is almost essential if the patient is to function outside his living accommodation. As in all rehabilitation, much depends upon the physical proportions, age, sex and previous medical history of the patient, and even more upon his motivation. Further research on predictive factors is required to identify those patients with complete lesions who will become and remain functional walkers. All patients are encouraged to stand, as the upright posture is believed to have a positive inuence on:

contractures in the lower limbs osteoporosis of the long bones with the danger of recurrent fractures the circulation spasticity renal function.
In a study on children with myelomeningocele, the non-walkers had ve times the number of pressure sores and twice the number of fractures as the walking group (Mazur et al 1989). Most patients with lesions between T1 and T9 are able to walk between parallel bars using a swing-to gait and may progress to
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216
contd Surface stimulation 254 Implanted electrodes 254 Gait using hybrid systems RGO with FES 255
walking with crutches or a rollator for exercise only. Some may prefer to use a hipkneeanklefoot orthosis and use a four-point gait. Where the terrain is difcult for wheelchair use and motivation is high, some patients with lesions from T6 to T9 may learn swingthrough gait on crutches and use it functionally at home, though these are rare exceptions. Patients with lesions from C5 to C8 use a standing frame (Fig. 13.1) or stand between parallel bars, and those with higher lesions use a tilt table. The physiotherapist needs to bear in mind that posture has an effect on respiration (see Ch. 5). As the arterial pressure falls when the patient is tilted head up into standing, the tilt table should be raised gradually and remain at 45, or below if more comfortable for the patient, for the rst session (Houtman et al 2000; see p. 100). The degree of tilt is increased as the patient becomes more accustomed to the position. Standing unassisted between bars aids the retraining of postural sensibility even for those with low cervical lesions, for the patient utilizes all innervated arm and trunk
Figure 13.1 Oswestry standing frame.
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muscles to maintain balance. It is therefore an excellent exercise even for those who will not be able to walk.
Functional gait
The aim is to teach the use of both wheelchair and crutches so that the patient is equipped to use either, as the occasion demands. A widely increased sphere of independence is gained through crutch walking. Independent entrance can be obtained, for example, to buildings with small doorways, hotel accommodation, aircraft and trains. For the active patients, the benets gained in everyday life far outweigh the patience and effort involved in training. Concern is sometimes expressed about the effect that weightbearing has on the shoulder joint. Research to determine the effect of the swing-through crutch walking gait on shoulder degeneration showed that no degenerative changes occurred, and there was an increase in the forearm bone density (Wing & Tedwell 1983). More recent studies have shown that, as most of the activities undertaken by active paralysed people involve the shoulder joints in weightbearing, in older age problems in the shoulders occur at an earlier age than in the rest of the population (see Ch. 17).
Appliances
The basic requirements are to x the knee joints and to hold the feet in dorsiexion. The overdevelopment of the trunk muscles, together with the creation of a new postural sense, may render any additional bracing unnecessary. Patients with low cervical or high thoracic lesions may walk with a hipkneeanklefoot orthosis (HKAFO), which supports the hips and trunk. Research continues to try to improve the function and appearance of these orthoses, and the hybrid system of orthosis plus functional electrical stimulation (FES) or using FES alone. Important advances have been made, but apart from the KAFO it is difcult to use these orthoses functionally.
Kneeanklefoot orthosis (KAFO) (calipers)

Kneeanklefoot orthoses (KAFOs), which allow the legs to bear the weight, are the only essential appliance for many patients. If standing is to minimize the formation of osteoporosis, it is vital that the weight should go through the long bones. Ischial weight-bearing is to be avoided because of the danger of causing pressure ulcers. A buckettype thigh corset is used. The knee supports need to be wide. They encircle the knee to prevent lateral movement and give adequate support to the paralysed joint (Fig. 13.2). Round sockets are used in the shoe with backstops. In a small number of cases with extreme plantarexion spasticity, toe-raising springs may be needed in addition to the backstops.
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These orthoses are made of duralumin as they need to be as light as possible although if necessary they can be made of steel. For selected patients, usually those with accid lesions or who have minimum spasticity, ortholon cosmetic calipers may be prescribed. The lower section is moulded around the calf and heel and under the foot to just below the metatarsophalangeal joints, and the upper section is moulded around the back of the thigh. They are cosmetically more acceptable, but care must be taken to ensure that they do not cause pressure ulcers, particularly around the ankle.
Caution
Ortholon calipers are unsuitable for patients with severe spasticity or oedema of the feet and lower legs. KAFOs are available which have adjustable locked ankle joints (Scott 1971). The correct angle to gain maximum stability is found with the patient standing in the balanced position between the parallel bars, with hips hyperextended and feet dorsiexed beyond 90 (see p. 221). The ankle joint is locked with the patient standing in this position. The shoe is at to take a steel plate and is permanently xed to the orthosis, which is made of steel and is heavier than if made from duralumin. Greater stability is provided and they may be particularly useful for patients with lesions between T6 and T9 (Duffus & Wood 1983).
Figure 13.2 Calipers.
Modular KAFOs and plaster of Paris leg splints

Modular KAFOs can be kept in stock to t on a temporary basis until the made-to-measure orthosis is available. In the absence of modular calipers, posterior shells of plaster of Paris are made for each patient and used to stabilize the knees. The shells extend from 5 cm (2 inches) below the ischial tuberosities to 5 cm above the malleoli. It may be necessary to reinforce the plasters with a strip of steel or wire for patients who are overweight or who have severe spasticity. Temporary toe-raising springs are used with these splints to hold the foot in dorsiexion. They consist of a webbing band round the leg, with adjustable straps, a short spring and a narrow webbing band under the shoe (Fig. 13.3).
Shoes
Shoes for use with any type of orthosis should provide good support for the feet and be made of soft leather without toe caps. To prevent pressure ulcers, all the inside seams, particularly around the heel, must be smooth. Leather soles stitched to the uppers provide the most suitable support for the sockets, back stops, or T-straps if necessary. To accommodate for slight oedema and avoid damage when putting them on, the shoe tting should be at least half a size larger than the size previously worn.
Figure 13.3 Temporary toe-raising spring and plaster of Paris splint.
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STANDING A PATIENT WITH A KNEEANKLEFOOT ORTHOSIS Standing between parallel bars

Because of the loss of all postural and equilibrium reactions below the level of the lesion, a new postural sense must be developed in the erect position. Compensation by sight for the loss of sensation is essential, and a long mirror is used at the end of the bars and another to the side of the patient. Patients without muscle control at the hips lift their legs by the action of latissimus dorsi and the associated action of trapezius and shoulder girdle muscles. Postural sense in standing is developed largely through the action of these bridge muscles. Occasionally, vasomotor disturbances occur on standing patients with higher lesions. If necessary, an abdominal binder can be worn temporarily to assist in preventing pooling of the blood in the splanchnic vessels. Fainting is more likely to occur when the patient is tall and thin (Figoni 1984).
Position of the wheelchair

The chair is positioned with the supporting crossbar of the bars behind the front wheels, if possible. This will prevent the chair from slipping backwards.
Height of the bars

For the efcient use of latissimus dorsi and triceps, the bars must be at the correct height. With the hand on the bar and the shoulders relaxed, the elbow should be slightly exed. This usually brings the wrist approximately level with the greater trochanter, but this depends upon individual physical proportions. For the initial stand, the height of the bars is determined by guesswork. After seeing the patient on his feet, the therapist must make the necessary adjustments. It is a common error to have the bars too high. In this case, elevation of the shoulder renders depression almost impossible and the patient cannot lift the leg effectively. With the bars too low, stability can be gained only when the patient leans forward with his weight on his hands.
To stand a patient
Stand facing the patient, with the feet either side of the patients legs, ready to grip with the knees to prevent the feet from sliding forward. Step-standing may be preferred, as in Figure 13.4A. Hold the patient under the buttocks and pull the hips forward as the patient lifts.
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Figure 13.4 AC: Standing a paraplegic patient. D: Balance exercise in the bars. Patient with a complete lesion below T5.

1. Sitting well back in the chair, lean forward and place the hands at the end of the bars with the elbows vertically above the wrists (Fig. 13.4A). This position allows the patient to stand by pushing down on the bars. The tendency to reach along the bars and pull up must be avoided. 2. Push down on the hands and stretch upwards, not forward (Fig. 13.4B). 3. As the weight comes over the feet, hyperextend the hips and at the same time extend the head and retract the shoulders. 4. Move the hands a short distance forward along the bars (Fig. 13.4C). If the patient is tall or overweight, a second therapist
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may be needed to push the feet back as the patient lifts. This will reduce the effort required by the patient.
To get behind the patient and establish the balanced position

Keeping the hips in extension with the left hand, and the upper trunk extended with the right arm, move behind the patient by passing under his right arm. At the same time, slide the arms around the patients trunk to maintain his position (Fig. 13.5). Brace one hip against the patients sacrum to maintain hyperextension of his hips. Prevent forward or lateral movement of the trunk with the right hand on the upper thorax and the left hand on the pelvis (Fig. 13.4D). Watching in the mirrors, the therapist helps the patient to nd his point of balance and encourages him to hold it without her support. When this has been achieved, resisted exercises can be given to improve balance and coordination. Suitable patients with lesions at C6/7 should be able to stand in this way, but will need the assistance of a second therapist to push the buttocks and hips forward and the shoulders back. If a young and active patient with a lesion at C7 or C8 is anxious to walk, swing-to gait can be taught as for the paraplegic patient.
Posture correction
The standing posture is corrected so that: 1. weight goes through the heels 2. legs are inclined only a few degrees forward of 90 at the ankle 3. hips are slightly extended so that the line of gravity lies behind the hip joints, through the knee joints and slightly in front of the ankle joints to prevent the jack-knife fall forward 4. spine is as upright as possible. Some adjustment must be made in the upper thoracic spine to compensate for the hyperextended hips. Overcorrection must be avoided 5. bars are held with the hands approximately level with the toes 6. shoulders are relaxed. The posture of the patient with useful abdominal muscles should be almost erect except for the slight hyperextension necessary at the hip joints. As the level of the lesion rises, a greater degree of compensation will be necessary at the hip joints. In all cases, overcorrection should be avoided. If the patient is allowed to lean forward with the weight over the toes and with the spine and shoulders extended, he will be unable to lift the weight off his feet. The second mirror placed at the side of the patient may assist him to correct his posture by showing the anteroposterior deviations from the vertical.
Figure 13.5 Moving behind the patient (note abdominal belt).
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There is a ne point between over- and undercorrection. This position provides the basic balance point from which all gait training proceeds.
Duration of the stand

Depending upon the height of the lesion the patient may remain on his feet for only 2 minutes or up to 5 or 10 minutes on the rst day. A gradual increase in the duration of the stand is most important in order to allow the circulation to adapt with the minimum ill effect on the patient. Initially it is more benecial to stand two or three times for a few moments only than to stand once for a longer period. The constant change in posture stimulates the vascular system and promotes a more rapid establishment of vasomotor adjustment.
To sit down
The therapist, holding the patient under the buttocks and controlling his legs with her knees and feet, allows him to sit down gradually.

With the feet approximately a foots length from the chair: 1. Hyperextend the hips and place the hands in their original position on the bars. 2. Take the weight on the arms. 3. Flex the head and trunk, and lower the weight gently until the buttocks reach the chair.
Caution
Care must be taken to ensure that the patient does not knock his hips against the sides of the chair, or drop his weight suddenly onto the buttocks. Bruising, both supercial and in the deeper tissues, can easily occur. When resting in the chair, with splints or calipers on the legs, the heels must be supported on a stool; otherwise the weight of the leg is taken on the upper end of the femur. If preferred, calipers can be unlocked at the knee joints.
Exercises in standing
As control is gained over the upper thorax, the therapist can place both hands around the hips to support only the pelvis. The hands are placed along the iliac crest, with the ngers over the anterior superior iliac spine. With the hands in this position, the therapist
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can pull the pelvis back with her ngers (Fig. 13.6A), push it forward with the heel of her hand (Fig. 13.6B), give pressure downwards (Fig. 13.6c) or lift upwards. In this way, the therapist has complete control of the patient and can assist or resist movement in any direction.
Balance exercises
Watching his position in the mirror, the patient is taught to:

hold, move out of and regain the correct posture maintain balance whilst lifting one hand off the bar (Fig. 13.4D). Progression is made by moving the arm in all directions, and later by repeating this with the eyes closed move both hands forwards and backwards along the bars.
Exercises for strength and control

Before commencing gait training, the patient must learn to tilt his pelvis by using latissimus dorsi, and to become aware of the degree of control he can achieve with this compensatory mechanism.
Pelvic side tilting

To hitch the left leg, place the left hand on the bar only slightly in front of the left hip, and the right hand about half a foot length further forward. Keeping the elbow straight, press rmly down on the left hand and depress the shoulder. The leg must be lifted upwards and not forwards.
To lift both feet off the ground and control the pelvis
Place both hands on the bars slightly in front of the hip joints. Push down on the bars, with the elbows straight, and depress the shoulders. To gain control of the pelvis, the patient should practise holding himself at both full and partial lift, rotating the trunk and tilting the pelvis with the feet lifted off the ground.
Resisted trunk exercises

For greater efciency in balance, strength and control, resisted trunk exercises in the standing and lifting positions and resisted hitching are also given.
Passive stretch in standing

Where strong spasm in the hip exors and abdominal muscles prevents the patient from assuming the erect posture, a passive stretch can be given. The therapist gives rm pressure forwards with her hip
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against the patients sacrum, and with her hands pulls backwards over the front of the shoulder joints. If the position is maintained for a few moments the spasticity usually relaxes and the patient is able to maintain his balance.
Cautions
1. Stretching must always be performed with extreme care. Unskilled passive stretching has resulted in fracture of the neck of the femur. The top of the caliper becomes the fulcrum and the strain is transferred to the femoral neck. 2. Until the spasm relaxes, the patient may experience some difculty in breathing. The spasticity is initially increased by the stretch, and the tightness of the abdominal muscles may prevent adequate movement of the diaphragm. 3. The therapist must make sure that she has no hard objects in her pocket which could cause pressure.
Standing frames
Where walking is impractical, a standing frame may be used (Fig. 13.1). Some standing frames have additional supports at each side so that a strap can be used to control the trunk of the tetraplegic patient, if required. Standing frames are being produced which allow the patient to stand and move on at indoor surfaces. The Dynamic Parapodium and the Grandstand are two such devices. Hand wheels drive the front wheels of the latter and it is adjustable, which enables it to continue to t a child as he grows. The Dynamic Parapodium, which has to be carefully adjusted to each user, enables each foot to move forward a few inches at a time by rocking from side to side (see Appendix 8).
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GAIT
There are three types of gait used:

swing-to gait four-point gait swing-through gait.
Controlled walking is achieved only through perseverance, perfect timing, rhythm and coordination. The patient is taught always: 1. to move the hands rst 2. to walk slowly and place his feet accurately 3. to take the weight through the feet and so ensure that the hands can relax between each step 4. to lift the body upwards and not to drag the legs forwards. An accurate technique must be achieved in bars if crutch walking is to be successful. Where it is anticipated that the patient will become an accomplished walker, it is usual to commence training with the four-point gait. It is easier to learn to use the latissimus dorsi muscles at rst separately and then together than vice versa.
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GAIT TRAINING IN THE BARS Swing-to gait

This is the universal gait because it is both the simplest and the safest. All patients with lesions above T10 are normally taught this gait rst.
The therapist
The therapist stands behind the patient with her hands over the iliac crests. Assistance is given to lift, to control the tilt of the pelvis and to transfer weight as necessary (Fig. 13.6AC).

1. Balance in the hyperextended position. 2. Move the hands, either separately or together, forward along the bars approximately half a foot length in front of the toes. 3. Lean forward, with the head and shoulders over the hands (Fig. 13.6D), and lift the legs, which will swing forward to follow the position of the head and shoulders. The step is short and the feet must drop just behind the level of the hands (Fig. 13.6E). To achieve this, the lift must be released quickly, otherwise the feet will travel too far and land between or in front of the hands. When on crutches, it is unstable and therefore dangerous to have the feet and hands in line. It must therefore be avoided in the bars. The swing-to gait is a staccato gait with no follow through: lift and drop. The patient should also be taught to swing backwards along the bars.
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Figure 13.6 AC: Position of the therapists hands. D, E: Swing-to gait. F: Four-point gait.
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To turn in the bars

The turn is achieved in two movements by turning through 90 each time. To turn to the right: 1. Place the left hand forward about a foot length along the bars and the right hand either level with or a little behind the trunk. 2. Lift and twist the shoulders and upper trunk to the right. The feet land facing the bar to the right (Fig. 13.7A). 3. Balance in this position and move the left hand across to the right bar (Fig. 13.7B). 4. Twisting the upper trunk to the right, place the right hand on the opposite bar. 5. Lift the feet round to a central position between the bars (Fig. 13.7C).
Figure 13.7 Turning in the bars. Patient with a complete lesion below T11.
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Four-point gait
This gait is the slowest and most difcult of all and is only achieved on crutches by accomplished walkers. It facilitates turning and manoeuvring in con ned spaces. It also provides an excellent training exercise in strength, balance and control.
The therapist. The therapist holds the pelvis in the usual way. Both
by instruction and by correction with her hands, the therapist emphasizes each move, ensuring that the patient achieves it correctly. Only when the patient consistently makes a single movement correctly does the therapist stop correcting that component. The patient needs to see and feel the correct posture at each move, and therefore constant repetition is necessary.
Action of the patient To take a step forward with the left leg
1. Place the right hand forward about half a foot length along the bar and the left one just in front of the hip joint. 2. Take the weight on the right leg, so that the hip is over the right foot and the knee and ankle in a vertical line. 3. With the left shoulder slightly protracted, push on the left hand and depress the shoulder (Fig. 13.6F, p. 227). The effort is to lift the leg upwards. 4. As the left leg is lifted, it swings forward to follow the shoulder. The lift is released when a large enough step has been made. (Small steps should be taken initially, but the foot must always land in front of the hand.) 5. Take the weight over the left leg. 6. Move the left hand forward along the bar in preparation for moving the right leg. Pelvic rotation must be avoided. The following are possible reasons for an inadequate lift:

some weight remains on the moving leg the hands are too far forward the weight may be over the toes and not back over the heels, in which case the trunk may be hyperextended and the legs consequently inclined too far forward insufcient depression of the shoulder girdle on the side of the moving leg the bars are too high or too low the lift is not held for sufcient time to allow the leg to swing forward.
To take a step backward with the left leg

1. Place the left hand slightly behind the hip joint. 2. Lift the leg and at the same time lean forward on that side. 3. Bend the elbow and ip the leg backwards.
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Swing-through gait
This gait requires skilled balance, but it is the fastest and most useful.
The therapist
The therapist gives assistance where necessary with her hands controlling the pelvis until the patient can accurately and slowly perform the movements. The forward thrust of the pelvis to push the weight over the feet usually needs to be emphasized.

1. Place the hands forward along the bars as for the swing-to gait. 2. Lean forward and take the weight on the hands. 3. Push down on the bars, depress the shoulder girdle and lift both legs. The lift must be sustained until the legs have swung forward to land the same distance in front of the hands as they were originally behind. Considerably more effort is required than for the swing-to gait. 4. As the weight is lifted and the legs swing forward, hyperextend the hips, extend the head and retract the shoulders. 5. To move the trunk forward over the feet, push on the hands, extending the elbows and adducting the shoulders. When the weight is rmly on the feet, move the hands along the bars for the next step.
GAIT TRAINING ON CRUTCHES

Progression is made to crutch walking only when the technique between the bars is good. The height of the elbow crutches is checked as for the bars. The change from walking in bars to crutch walking is considerable, and all patients are initially unstable and fearful. A high degree of balance skill is essential and this is only achieved with perseverance and much practice.
Balance exercises
Balance on crutches is trained in the same way as when balancing in the bars (Fig. 13.8A). Resisted work is also given to enable the patient to gain adequate control over the trunk and pelvis.
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Walking on crutches
Swing-to and four-point gaits are taught rst and progression is made to swing-through (Fig. 13.8B, C). Until the new postural sense is established training is again carried out in front of a mirror. Progression in the four-point gait may be made by using one bar and one crutch if preferred. Otherwise, progression is directly onto two crutches, as there is less tendency to trunk and pelvic rotation. The technique for each gait is the same as already described for walking in bars. Much greater skill is required and several weeks of practice will be needed to acquire the necessary balance and coordination.
Figure 13.8 A: Balance exercise on crutches. Patient with a complete lesion below T5. B: Four-point gait. C: Swing-through gait. Patient with a complete lesion below T12 (B and C).
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To transfer from chair to crutches

An unaided exit from a chair is essential if crutch walking is to be functional. There are three techniques used to get into and out of the chair with crutches:

forwards technique sideways technique backwards technique.
All three methods are taught where possible, and the patient chooses that which he nds easiest.
Forwards technique
Severe abdominal and/or exor spasticity which prohibits the necessary hyperextension at the hips, or excessive height, may prevent a patient accomplishing this technique. When the patient is well over average height with the extra length primarily in the legs, the elbows are higher than the shoulders with the crutches in position for the lift. Latissimus dorsi and triceps are thus at a mechanical disadvantage and a balanced lift is impossible.
The therapist
The therapist stands in front of the patient astride the legs and ready to give support with her hands around the scapula region (Fig. 13.9AD).
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Figure 13.9 Chair to crutches forwards technique. Patient with a complete lesion below T6.
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1. Check the position of the chair and swing away or remove the footplates. During early training, when the weight distribution may be incorrect, a feeling of stability is given if the chair is backed against a wall. 2. Sit well back in the chair (Fig. 13.10A). 3. Place the crutches midway between the front and rear wheels, level with each other and equidistant from the sides of the chair (Fig. 13.10B). To avoid rotation during the lift, the position of the crutches must be accurate. 4. Lean forward over the crutches and balance. 5. Lift on the crutches, adducting and extending the shoulders. 6. The feet are lifted backwards, and as the weight goes onto them, hyperextend the hips and retract the shoulders (Fig. 13.10C). 7. When balanced, move the crutches forward and assume the correct standing position (Fig. 13.10D). To sit down, reverse the procedure, as in Figures 13.10DA. If the physical proportions of the patient are suitable, an alternative method is shown in Figure 13.10E. The short patient reaches back with his hands, releases the crutch handles and grasps the armrests. Such patients may be able to stand up in the same way. To prevent trauma, which could result in haemorrhage and bursa formation, sitting down should be done slowly without bumping on the chair.
Sideways technique
Some patients of below average height are able to get out of the chair using one crutch and an armrest:
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A
Mirror
Figure 13.10 AD: Chair to crutches forwards technique. Patient with a complete lesion below T9. E: Short patient sitting down.
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1. Put the left arm through the forearm support, position the left crutch and grasp the armrest. 2. Turn through 45 towards the left armrest. 3. Place the right crutch in front and to the left of the midline of the chair. 4. Lift on both arms (Fig. 13.11A, B). 5. With the weight on the feet, balance on the right crutch and grasp the left crutch handgrip. Reverse the procedure to sit down.
Figure 13.11 Chair to crutches sideways technique.
Backwards technique
The therapist stands in front of the patient ready to control the pelvis or legs as necessary. To turn to the left: 1. Cross the right leg over the left (Fig. 13.12A). 2. Lift the buttocks to the right side of the chair (Fig. 13.12B). 3. Turn the trunk to the left, moving the left hand to the right armrest and the right hand to the left armrest (Fig. 13.12C). 4. Push on both armrests to stand (Fig. 13.12D) facing the chair.
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Figure 13.12 Chair to crutches backwards technique. Patient with a complete lesion below T12.
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Figure 13.12 contd
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5. Hitch the feet to the left (Fig. 13.12E). 6. Put each hand through the crutch forearm supports and return to holding the armrests (Fig. 13.12F). 7. Grasp the handgrips in turn. 8. Walk backwards away from the chair (Fig. 13.12G). Reverse the procedure to sit down.
Stairs
Climbing stairs is normally functional for patients with good abdominal muscles. Some young and active patients with lesions between T6 and T10, with or without a spinal brace, may also become efcient and independent. Patients can climb the stairs either forwards or backwards. The forwards technique is usually taught rst because it has the advantage that the patient can see where he is going. Most agile patients with good abdominal muscles will learn both methods and make their own choice. Where there is severe abdominal and/or hip exor spasticity, the degree of hyperextension easily obtainable at the hip joints may be too limited for the forwards technique. Two rails are used initially, progression being made to one rail and one crutch. Finally, the second crutch must be carried, usually in the crutch hand, as illustrated in Figure 13.13.
The therapist. The therapist always stands behind the patient. She holds the trouser band or a therapeutic belt with one hand and grasps the patient round the waist with the other. After the initial attempts, both hands should be placed around the pelvis in the usual position for greater control. Assistance is given, as necessary, until the technique is mastered.
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Forwards technique using one rail and one crutch

To walk upstairs
1. Standing close to the rail, grasp it approximately half a foot length in front of the toes. 2. Place the right crutch on the stair above, level with the hand on the rail (Fig. 13.13A). The hands must be level to avoid trunk rotation when lifting. The tendency to grasp the rail too far forward and pull must be avoided. 3. Lean over the hands and lift as high as possible, keeping the trunk and pelvis in the horizontal plane (Fig. 13.13B). 4. As soon as the feet land on the stair above, hyperextend the hips to nd the balance point (Fig. 13.13C).
To walk downstairs
1. Standing close to the rail and keeping the body in the horizontal plane, place the right crutch close to the edge of the same stair. 2. Place the left hand down the rail on a level with the crutch (Fig. 13.13D). 3. Lift and swing the feet down to the stair below (Fig. 13.13E). 4. Hyperextend the hips and retract the shoulders as soon as the feet touch the ground (Fig. 13.13F). Very short patients may need to put the crutch on the stair below the feet and lift down to the crutch.
Backwards technique using one rail and one crutch

To walk upstairs
1. Balance in hyperextension whilst placing the left hand higher up the rail and the crutch on the stair above, keeping the hands level (Fig. 13.13F). 2. Lift backwards (Fig. 13.13E). 3. Regain the balance (Fig. 13.13D).
To walk downstairs
1. Place the crutch on the edge of the same stair as the feet, with the hands level (Fig. 13.13C). 2. Lift the feet backwards to the edge of the stair. 3. Lean forward on the hands, lift and ick the pelvis backwards (Fig. 13.13B). 4. Drop the feet onto the stair below (Fig. 13.13A).
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Figure 13.13 Climbing and descending stairs. Patient with a complete lesion below T11.
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Kerbs
Kerbs are negotiated by putting the crutches on the kerb rst and then taking a swing-through step onto the pavement. The same technique is used to descend a kerb. A long shallow step can be mounted in the same way. Patients are not taught to ascend ights of narrow steps on two crutches.
To get down and up from the oor onto crutches

Crutches to oor
The therapist stands behind the patient and controls the pelvis, feet and legs, as necessary: 1. From the standing position on the mat (Fig. 13.14A), walk the crutches forward one by one (Fig. 13.14B) until the hips and trunk are sufciently exed for the outstretched hand to reach the oor. 2. Balance on the right crutch, release the left crutch and put the left hand on the oor (Fig. 13.14C). 3. Balance on the left hand, release the right crutch and put the right hand on the oor (Fig. 13.14D). 4. Walk forward on the hands until lying prone (Fig. 13.14E).
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Figure 13.14 AE: Crutches to oor. FK: Floor to crutches. Patient with a complete lesion below T11.
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Floor to crutches
The therapist may need to assist the patient to get the weight over his feet initially: 1. Lying prone, make sure the ankles and toes are dorsiexed so that the feet are vertical (Fig. 13.14F). 2. Position the crutches, tips forward, well in front of the body and put both forearms through the forearm supports. 3. Press up on the hands, and at the same time use the abdominal muscles to pull the pelvis towards the hands and so prevent the legs being pushed backwards. 4. Maintaining the action of the abdominal muscles, walk the hands towards the feet, trailing the crutches (Fig. 13.14G) until the weight is over the feet (Fig. 13.14H). 5. Balance on the left hand, grasp the right crutch handgrip and place the crutch on the oor (Fig. 13.14I). 6. Balance on the right crutch and take hold of the left crutch in a similar manner. Balance on both crutches (Fig. 13.14J). 7. Walk the crutches towards the feet until standing erect (Fig. 13.14K).
To get out of a car onto crutches

1. Turn to face the open door and lift the legs out of the car. 2. Lock the knee joints. 3. With the window open, use the window ledge and the back of the seat, or the seat and a crutch, to lift into standing. 4. Balance with the hips hyperextended and take hold of each crutch in turn.
Final functional activities on crutches

The patient is taught to walk on slopes and over uneven ground such as grass and shale. He must also learn to open and close a door, to sit in and rise from an easy chair, and to sit down at and rise from a table by pushing down on the table with one hand and using the crutch in the other. The Walking Index for Spinal Cord Injury (WISCI) is a complex scale developed to measure walking ability and to be used particularly in clinical trials (Marshall & Nance 2000). It is a more precise scale for documenting change in levels of walking than the Functional Independence Measure, where the main emphasis is on the physical assistance needed for daily living. WISCI was constructed by international experts from spinal cord injury units in eight countries. The inter-rater reliability was shown to be 100% by Ditunno et al (2000) and the Index is being tested through retrospective and prospective studies in the clinical eld (Box 13.1).
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Figure 13.14 contd
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Box 13.1 Walking Index for Spinal Cord Injury (WISCI) From Ditunno et al (2000), with permission
Physical limitation for walking secondary to impairment is dened at the person level and indicates the ability of person to walk after spinal cord injury. The development of this assessment index required a rank ordering along dimension of impairment, from the level of most severe impairment (1) to least severe impairment (19) based on the use of devices, braces and physical assistance of one or more persons. The order of the levels suggests each successive level is a less impaired level than the former. The ranking of severity is based on the severity of the impairment and not on functional independence in the environment. The following denitions standardize the terms used in each item: Physical Physical assistance: assistance of two persons is moderate to maximum assistance Physical assistance of one person is minimal assistance. Braces: Braces means one or two braces, either short or long leg No braces means no braces on either leg. Walker: Walker is a conventional rigid walker without wheels. Crutches: Crutches can be Lofstrand (Canadian) or axillary Cane: Cane is a conventional straight cane.
Level 1
10
11
12
Description Ambulates in parallel bars, with braces and physical assistance of two persons, less than 10 meters. Ambulates in parallel bars, with braces and physical assistance of two persons, 10 meters. Ambulates in parallel bars, with braces and physical assistance of one person, 10 meters. Ambulates in parallel bars, no braces and physical assistance of one person, 10 meters. Ambulates in parallel bars, with braces and no physical assistance, 10 meters. Ambulates with walker, with braces and physical assistance of one person, 10 meters. Ambulates with two crutches, with braces and physical assistance of one person, 10 meters. Ambulates with walker, no braces and physical assistance of one person, 10 meters. Ambulates with walker, with braces and no physical assistance, 10 meters. Ambulates with one cane/ crutch, with braces and physical assistance of one person, 10 meters. Ambulates with two crutches, no braces and physical assistance of one person, 10 meters. Ambulates with two crutches, with braces and no physical assistance, 10 meters.
13
14
15
16
17
18
19
Ambulates with walker, no braces and no physical assistance, 10 meters. Ambulates with one cane/ crutch, no braces and physical assistance of one person, 10 meters. Ambulates with one cane/ crutch, with braces and no physical assistance, 10 meters. Ambulates with two crutches, no braces and no physical assistance, 10 meters. Ambulates with no devices, no braces and physical assistance of one person, 10 meters. Ambulates with one cane/ crutch, no braces and no physical assistance, 10 meters. Ambulates with no devices, no braces and no physical assistance, 10 meters.
WISCI Scoring Sheet Patient Name Date Check descriptors which apply to current walking performance, then assign the highest level of walking performance In scoring a level, one should choose the level at which the patient is safe as judged by the therapist, with patients comfort level described. If devices other than stated in the standard denitions are used, they should be documented as descriptors. If there is a discrepancy between two observers, the higher level should be chosen.
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Descriptors Devices // bars <10 ft // bars 10 ft Walker Standard Rolling platform Crutches Uses 2 Uses 1 Canes Quad Uses 2 Uses 1 No devices No braces No assistance WISCI levels Level 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Devices Parallal bars Parallal bars Parallal bars Parallal bars Parallal bars Walker Two crutches Walker Walker One cane/crutch Two crutches Two crutches Walker One cane/crutch One cane/crutch Two crutches No devices One cane/crutch No devices Braces Braces Braces Braces No braces Braces Braces Braces No braces Braces Braces No braces Braces No braces No braces Braces No braces No braces No braces No braces Assistance 2 persons 2 persons 1 person 1 person No assistance 1 person 1 person 1 person No assistance 1 person 1 person No assistance No assistance 1 person No assistance No assistance 1 person No assistance No assistance Level assigned Distance Less than 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters 10 meters Braces Long leg braces Uses 2 Uses 1 Short leg braces Uses 2 Uses 1 Assistance Max assist 2 people Min/mod assist 2 people Min/mod assist 1 person Patient reported comfort level Very comfortable Slightly comfortable Neither comfortable nor uncomfortable Slightly uncomfortable Very uncomfortable
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GAIT USING HIPKNEEANKLEFOOT ORTHOSES (HKAFOs)

Over the past few years some of the mechanical problems of the early reciprocating walking orthoses (this is a generic term for all the following orthoses) have been eliminated and their popularity has increased. These orthoses enable patients with lesions from C6/7 (with triceps) to T12 to walk with more stability and greater freedom than with kneeanklefoot orthoses (KAFOs) because they offer support to the trunk, pelvis and hips as well as to the knees and feet. Work in the late 1960s produced HKAFOs that linked the hips together to allow reciprocal movement of both hips. In the UK, Scrutton (1971) used Bowden cables in an HKAFO for children with spina bida and Motlock in Canada developed a mechanism based on the use of gears. A renement on the original design by Scrutton produced the reciprocating gait orthosis at the Louisiana State University (Scott 1971). At the present time, four main types of reciprocating walking orthoses are available internationally. The ORLAU (Orthotic Research and Locomotor Assessment Unit) or Parawalker (Hip Guidance Orthosis) was produced in Oswestry, UK, initially for children with spina bida but more recently for adults with spinal cord lesions (Butler & Major 1971, Stallard 1986). The Parawalker is a rigid structure with good lateral stiffness, which prevents adduction of either hip. The control of adduction is important as the swing leg has less ground clearance if the stance leg adducts (Stallard & Major 1995). The hip joints are free to move between 18 of exion and 6 of extension when locked for walking. The swing phase is achieved by a pendulum action using gravity and a low-friction orthotic hip joint. The shoes t onto metal footplates with rocker soles, which adds to the rigidity of the brace but prevents the orthosis being worn under everyday clothing (Fig. 13.15). When the gluteal muscles were stimulated to support hip extension and abduction in an FES hybrid walking project, energy consumption was reduced (Nene & Patrick 1990). The Reciprocating Gait Orthosis (RGO) uses two Bowden cables to link the two sides of the brace (Douglas et al 1983). The front cable assists exion of the hip and the rear one maintains extension of the brace, effectively acting as the absent hip extensor. This orthosis is more exible and lighter than the Parawalker. The foot support is plastic and ts inside the shoe, allowing the orthosis to be worn under normal clothing (Fig. 13.16). Although patients can don and doff the orthosis, it is difcult to stand up or sit down in it without assistance. Modications to the RGO were made by Hugh Steeper Ltd to produce the Advanced Reciprocating Gait Orthosis (ARGO). The piston mechanism of this orthosis assists the action of standing and sitting by enabling the knees to extend and ex. The two Bowden
Figure 13.15 Parawalker.
Figure 13.16 Reciprocating gait orthosis.
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cables are reduced to one, which is encased in a tube, in an effort to prevent the cables breaking and to improve cosmesis. Motlock suggested a modication to the RGO which is known as the Isocentric Reciprocating Gait Orthosis (IRGO). As the cables in the RGO are the least dependable part of the orthosis and are cosmetically unacceptable, they are replaced by a centrally pivoting bar attached around a pelvic jacket (Motlock 1992). Whereas hip extension in the RGO is adjusted by tightening the Bowden cables, in the IRGO it is achieved by turning the screw threads inside a barrel at each hip joint. Although continued exercise is linked in many research articles to improvement in psychological well-being, rejection of the ARGO is common. Scivoletto et al (2000) found it to be 47%. This is an expensive device which still does not provide autonomy and its use is limited. RGOs that are adjustable may be the way forward as the patient could try out the system before a specic orthosis is made for him. This might reduce the number of orthoses that are subsequently rejected (Scivoletto et al 2003).
Walkabout
This orthosis was designed in Australia. It is available in the UK and elsewhere, although it is not as extensively used as the Parawalker and RGO in the UK, where it is mainly prescribed for patients with low thoracic lesions. Plastic shells support the upper and lower legs and pass under the soles of the feet, and the knee joints are hinged. In an attempt to avoid the problems that arise at the hip joints, the KAFOs in this orthosis are joined at the top inside edge by a small bar. This contains the mechanism that allows the swing leg to move forward when the weight on it is released. There are no hip joints, but a exible thoracic band attached to the calipers by loops can provide some trunk support if required. The Walkabout is more easily concealed beneath normal clothing than either the Parawalker or the RGO.
Similarities and differences in HKAFOs

Most braces have a weight tolerance limit. The recommended weight for the Parawalker is 75 kg (165 lb). Above 76.4 kg, the Bowden cables tend to snap on the RGO, and over 80.9 kg (177.9 lb) it becomes a physical struggle for the user to walk. In the two main types of orthoses, Parawalker and RGO, the aim is similar although the orthoses are different in design and appearance. The body is braced from mid-trunk to the feet with knees and ankles immobilized in both orthoses. Flexion and extension are allowed at the hips but adduction is prevented when the leg is lifted off the ground. Both braces work to bring about exion of the swing leg after weight transference (Whittle et al 1991).
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The Parawalker was designed to be used with crutches and the RGO with a specially designed rollator with the restrictive front bar removed to allow for a more normal stride length. In practice, patients using either orthosis can walk with crutches or rollator. After 4 months use, Whittle et al (1991) found no signicant difference between the Parawalker and the RGO in the general gait parameters of cadence, stride length and velocity, and effort expenditure was similar. Banta et al (1991) and Bowker et al (1992) found energy cost less with the Parawalker. Whittle & Cochrane (1989) found that the effort expended through the crutches was less with the Parawalker. The RGO was lighter and therefore easier to transport and its cosmesis was preferred (Whittle & Cochrane 1989). The functional results did not differ between subjects or centres as greatly as expected in a multicentre trial of the Parawalker, RGO and ARGO orthoses in Italy (Lotta et al 1994). The main difference in outcome seemed to depend on the device adopted. For example, patients in the Parawalker cannot climb stairs, but the orthosis never needed repairs, it took the shortest time to don and doff and less time for the patients to learn to use it. Using the IRGO as opposed to the ARGO, energy cost was slightly less and mean velocity slightly greater, although neither was statistically signicant (Winchester 1993).
Assessment
If the patient is to be successful in using a reciprocating walking orthosis, it is essential that an accurate assessment is undertaken before it is prescribed. More important perhaps than the usual physical factors, such as spasticity or exion contracture which might mitigate against continued use of the orthosis, is the patients perception of its functional use and his expectations of the degree of independence it might allow (Sykes et al 1995). Walking with any of these orthoses has many limitations. The gait is slow and the patient can only cover short distances with great physical effort (Whittle et al 1991). Disappointment can only be avoided if the patient appreciates that walking with one of these orthoses is a useful form of exercise. It is not an alternative to wheelchair locomotion (Stallard et al 1989). As well as the physical and psychological assessment, the home and work situation must also be discussed. Stallard et al (1989) suggest that all the following factors should be considered:
independence as well as walking in the orthosis, the patient should be able to don and doff it and be able to get into and out of the wheelchair energy cost cosmesis reliability of the orthosis cost.
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The problem is to identify those patients who will continue to use the orthoses so that optimal benet can be achieved with minimal wastage (Sykes et al 1995). The usual practice in spinal cord injury units in the UK is to reassess the patient who shows an interest in using a reciprocating walking orthosis approximately 1 year after discharge from the initial period of rehabilitation. The orthosis most suited to the needs of the individual patient can then be selected.
Team
An experienced team consisting of an orthotist, doctor, physiotherapist and orthotic technician must be involved in the assessment, prescription and construction of the orthosis. A tailored t is crucial and the team approach is essential if the patient is to succeed. When the patient starts to use the orthosis and is learning to walk, the team continues to monitor progress and adjust the t as necessary.
Training
Before learning to use a reciprocating walking orthosis, the patient completes a training programme to increase muscle strength, aerobic power and cardiovascular efciency.
Gait
To achieve reciprocating gait, three actions must occur:

the swing leg has to clear the ground the swing leg has to move from extension to exion the trunk has to move forward over the stance leg, i.e. the hip has to extend.
Parawalker
The patient transfers to the plinth and the Parawalker is placed in the wheelchair. The patient lifts into it and fastens the straps. The chair is positioned in the bars as described earlier.

1. Lock the knee joints. 2. With the heels on the ground, lie back in the chair and lock the hip joints. (If low in the chair, lift up until the body is at an approximate angle of 45.) 3. Hold onto the bars and pull up into standing. Two therapists usually assist the patient to stand for the rst time, one on each side of the bars. As the patient has been at home for at least a year and has undertaken a strengthening programme before
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being tted with the orthosis, his arms should be strong and little effort should be required of the therapists.
To walk moving the right leg rst

1. Push sideways with right hand using latissimus dorsi to transfer weight to left leg. 2. The right leg swings forward. 3. Take the weight on the right leg and continue to push with right hand to extend right hip. Repeat on left side. Crutch walking is commenced in 2 or 3 days.
To stand up with crutches

1. Lock the knee and hip joints in the wheelchair. 2. Place the tip of the crutches alongside the back of the rear wheels on each side of the chair. 3. Push into standing. 4. Edge crutches forward, one at a time to the balance position with the crutches in front. Walk as described above. To sit down reverse the procedure.
RGO
The chair is positioned between the bars as already described.
To stand up
1. Engage the clips at the hip joints. 2. Push down on the bars and stand up. 3. Extend the hips to complete the locking action at the hips.
To sit down
Disengage the clips and lower gently into the chair. The Bowden cables can be tightened to adjust the degree of extension at the hips or, if the hip exors are tight, the degree of exion. One of the most vital adjustments to the brace is the control of extension of the trunk to enable the patient to maintain his balance. The two upper straps at the front and back of the brace can be adjusted to control the position of the trunk within the brace. Extension is controlled by slackening the Velcro fastening on the back strap and then tightening the front strap. The upper body weight is moved backwards over the heels, achieving the balance position and correct posture for a patient with spinal cord injury. If the back strap is too tight, the patient is pushed forward off balance.
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IRGO
The IRGO has largely replaced the RGO as it is less cumbersome and the pre-selection function of the hip joints of the IRGO enables the patient to stand up and sit down safely.
To stand up
1. In sitting, place the clips at the hip joints (called pre-selection hip joints) in the up position. 2. Push down on the bars and stand up. 3. Forcibly extend the hips; the joints will lock automatically in their pre-selected setting.
To sit down
1. Place the clips at the hip joints in the pre-selected down position. 2. Forcibly extend the hips; the hip joints will unlock. 3. Lower gently into the chair.
To walk moving the right leg

1. Transfer weight onto the left leg. 2. Using latissimus dorsi, lift the right (swing) leg by pushing down on the right hand. 3. The right leg swings forward. 4. Transfer weight onto the right leg. 5. Continue to push with the right arm to extend the right hip. This movement into full extension on the supporting leg is called the tuck phase. Repeat to move the left leg. The patient learns to walk in parallel bars and progresses to rollator or crutches. To create a relatively normal stride using the rollator, the patient pushes the rollator forward between each step. Crutch walking is described on page 231. Follow-up studies on the number of patients who continue to use these orthoses when the training period is over are remarkably similar. Sixty-four per cent continued to use the Parawalker (Moore & Stallard 1991) and 62% continued to use the RGO (Ellis 1995). The effort of walking is the main reason why most patients do not continue to walk after discharge from hospital (Coghlan et al 1980). Using the IRGO as opposed to the ARGO, the energy cost was slightly less and the mean velocity slightly greater, although neither was statistically signicant (Winchester 1993).
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Although construction problems still exist and the energy required to walk in these orthoses is high, they enable patients with high lesions, including those with low cervical lesions, to stand and walk, and as long as patients are interested progress will continue to be made.
GAIT USING FUNCTIONAL ELECTRICAL STIMULATION (FES) STANDING SYSTEMS

For the past 30 years, experiments have been undertaken to enable patients to walk using electrical stimulation of the relevant muscles. Surface, nerve cuff and deep muscle electrodes have been used. FES is applied to the intact lower motoneurone pathways and is therefore only suitable for upper motoneurone paralysis, as with stimulation of the phrenic nerve (Ch. 5). Initially, FES is used to improve the condition and bulk of the paralysed muscles. When the state of the muscles has improved, electronic implants can be used to activate muscles in functional sequence. Interestingly, 50 years ago Sir Ludwig Guttmann showed that muscle bulk could be improved in rabbits (Guttmann & Guttman 1942) and later in humans using galvanic stimulation (Guttmann & Guttman 1944).
Surface stimulation
Root stimulation gives access to the whole motor output, whilst surface stimulation reaches only part of it. Usually the gluteal and hamstring muscles are stimulated for standing, and quadriceps and the exor withdrawal response for walking. To stimulate more muscles is impractical as it is too time-consuming. Surface stimulation is wasteful of current and requires assiduous attention to skin care, and the stimulation varies with movement of the limbs (Rushton et al 1995). As surface stimulation methods are essentially limited to experimental work and for assessment, the electrode system must be implanted to obtain consistent and selective results.
Implanted electrodes
Three types of implanted electrodes are used:
Percutaneous wires are inserted through the skin and focused on a motor point. Any number of wires may be used. Formal surgery is not required and the wires are inserted easily by a practised operator. This procedure has a high risk of electrode failure and a high incidence of infection. Cosmesis is unacceptable (Barr et al 1995). The nerve cuff electrode is placed around peripheral nerves in a formal surgical procedure.
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The epimysial electrode (disc type of electrode) is placed near the motor point of large muscles. Less dissection is required than for the cuff type but multichannel lower limb systems still require extensive surgery and the cabling also has to be implanted in the limb. As cable connectors tend to fracture, further surgery is often required.
A sacral anterior root stimulator implant (SARSI) has been widely used to restore bladder control in male and female patients and erectile function in male patients (Brindley & Rushton 1990). A lumbar anterior root stimulator implant (LARSI) has been used to stimulate lumbar and sacral roots (L2S2) to restore lower limb function in two patients. These systems are now commercially available, as are some surface and upper limb motor locomotor systems. Stringent criteria are necessary for the selection of patients for any FES system, which will include psychological as well as physical assessments. For example, joints must have full range of movement and be free of osteoporosis and the patient must be physically t, as energy consumption is high. Patients gain the usual benets from standing and walking with these systems, and Jaeger et al (1990) found psychological benets also, in that the patients self-esteem and condence appeared to increase. To use a surface system long term is impractical, but surface stimulation as a non-invasive means of assessment and training is necessary for an implant system (Barr et al 1995). Both systems are useful and in many ways complementary (Rushton 1996). FES does not restore functional gait. It is a form of exercise and remains experimental. Whatever the technique used, walking speed is slow and, together with energy consumption, is a limiting factor. Major technical problems continue to be encountered, for example in the selection and control of stimulation, failure of equipment and muscle fatigue. To replace the intricate mechanism of normal gait is an enormous task. It is not surprising that progress is slow. Research continues in many centres worldwide. In a study to examine the safety of FES, Ashley et al (1993) found evidence to suggest that there was a danger of autonomic dysreexia during treatment in patients with lesions above the splanchnic outow, i.e. above T6. Extra caution should therefore be employed with these patients.
GAIT USING HYBRID SYSTEMS RGO WITH FES

The difculties of mimicking the voluntary activity of walking by computer-controlled electrical stimulation, and its potential use to restore function, are well documented by Peckham (1987). With such a large number of sophisticated component parts, computercontrolled gait is open to malfunction and this has given rise to the use of functional electrical stimulation with an orthosis, producing an integrated or hybrid system.
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Interest has developed since 1984 when, in the United States, the Louisiana State University reciprocating gait orthosis was combined with FES to quadriceps and the gluteal muscles (Petrofsky et al 1985). The reciprocating gait orthosis supported the patient as only a few of the muscles used in walking were stimulated and greater use of the trunk and arms was required to maintain balance. In addition, if the electrical system failed, the patient was still supported. Research continues in many countries, but a functional system has not yet been developed. In most studies, the quadriceps and hamstring muscles are stimulated but the user still has to lift his body weight with his arms to swing the stride leg forward. The energy cost of paraplegic walking is intrinsically high (Nene et al 1996). Few patients continue to use the systems after the training programmes are completed (Merati et al 2000). Hip and knee adjustments are required, the electrical connections are fragile and break easily, and other problems occur. This means that the patient needs to be frequently in contact with the rehabilitation team and this is not always practical because of distance. Patients will only use a system if it allows them to walk without too much effort and perform other functions when wearing it. Energy consumption, transportability and the gait pattern all need improving if patients are to continue to use these systems (Nene et al 1996).
References
Ashley E A, Laskin R D, Olenik L M et al 1993 Evidence of autonomic dysreexia during functional electrical stimulation in individuals with spinal cord injuries. Paraplegia 31:593605 Banta J V, Bell K J, Muik E A, Fezio J 1991 Parawalker energy cost of walking. Journal of Pediatric Surgery 1(suppl 11):719 Barr F M D, Harper V J, Rushton D N et al 1995 Screening and assessment for a lumbosacral anterior root stimulation implant programme. In: 5th Vienna International Workshop, August. Department of Biomedical Engineering and Physics, University of Vienna, p 9598 Bowker P, Messenger N, Ogilvie C, Rowley D 1992 The energetics of paraplegic walking. Journal of Biomedical Engineering 14:344350 Brindley G S, Rushton D N 1990 Long-term follow up of patients with sacral anterior root stimulator implants. Paraplegia 28:469475 Butler P B, Major R E 1971 The Para-Walker a rational approach to the provision of reciprocal ambulation for paraplegic patients. Physiotherapy 73:393397 Coghlan J K, Robinson C E, Newmarch B, Jackson G 1980 Lower extremity bracing in paraplegia a follow up study. Paraplegia 188:2532 Ditunno J F, Ditunno PL, Graziano V et al 2000 Walking Index for Spinal Cord Injury (WISCI) Spinal Cord 38:234243 Douglas R, Larsonn P F, DAmbrosia R, McCall R E 1983 The LSU reciprocating gait orthosis. Orthopaedics 6:834839 Duffus A, Wood J 1983 Standing and walking for the paraplegic. Physiotherapy 79(2):4546
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Ellis R 1995 The patients evaluation of reciprocating gait orthoses. Secretariat of 8th World Congress of International Society of Prosthetics and Orthotics, Melbourne, Australia Figoni S F 1984 Cardiovascular and haemodynamic response to tilting and to standing in tetraplegic patients. Paraplegia 22:99109 Guttmann E, Guttmann L 1942 The effect of electrotherapy on denervated muscles in rabbits: muscle bulk increased. Lancet i:169 Guttmann E, Guttmann L 1944 The effect of galvanic exercise on denervated and re-innervated muscles. Journal of Neurology and Neurosurgery 7:7 Haln H R 1970 Lower extremity bracing in paraplegia with usage follow up. Paraplegia 8(3):147153 Hong C, Sna Luis E B, Chung S 1990 Follow up study on the use of leg braces issued to spinal cord injury patients. Paraplegia 28:172177 Houtman S, Colier W N J M, Oeseburg B, Hopman M T E 2000 Systemic circulation and cerebral oxygenation during head-up tilt in spinal cord injured individuals. Spinal Cord 38:158163 Jaeger R J, Yarkony G M, Roth E J, Lovell L 1990 Estimating the population of a simple electrical stimulation system for standing. Paraplegia 28:505511 Lotta S, Fiocchi A, Giovannini R et al 1994 Restoration of gait with orthoses in thoracic paraplegia: a multicentre investigation. Paraplegia 31:608615 Marshall R, Nance P 2000 Walking Index for Spinal Cord Injury (WISCI) and international multicentre validity and reliability study. Spinal Cord 38:234243 Mazur J M, Shurtleff D, Menelaus M, Colliver J 1989 Orthopaedic management of high-level spina bida. Journal of Bone and Joint Surgery 71A:5661 Merati G, Sarchi P, Ferrarin M et al 2000 Paraplegic adaptation to assistedwalking: energy expenditure during wheelchair versus orthosis use Spinal Cord 38:3744 Moore P, Stallard J 1991 A clinical review of adult paraplegia patients with complete lesions using the ORLAU Para Walker. Paraplegia 29:191196 Motlock W M 1992 Principles of orthotic management for child and adult paraplegia and clinical experience with the isocentric RGO. In: Proceedings of the 7th World Congress of the International Society of Prosthetics and Orthotics, Chicago, p 28 Nene A V, Patrick J H 1990 Energy cost of paraplegic locomotion using the parawalker electrical stimulation hybrid orthosis. Archives of Physical Medicine and Rehabilitation 71:116120 Nene A V, Hermens H T, Zilvold G 1996 Paraplegic locomotion: a review. Spinal Cord 34:507524 Peckham P H 1987 FES: current status and future prospects of applications to the neuromuscular system in spinal cord injury. Paraplegia 25:279288 Petrofsky J S, Phillips C A, Larson P, Douglas R 1985 Computer synthesised walking: an application of orthosis and functional electrical stimulation (FES). Journal of Neurological and Orthopaedic Medicine and Surgery 63:219230 Rushton D N 1996 Surface versus implanted electrodes in the daily application of FES. In: Pedotti A, Ferrarin M (eds) Restoration of walking for paraplegics: recent advances and trends. IOS Press, Oxford Rushton D N, Donaldson N D, Barr F M et al 1995 Lumbar root stimulation for restoring leg function: results. In: Paraplegia, 5th Vienna
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International Workshop on FES, August. Department of Biomedical Engineering and Physics, University of Vienna, p 3942 Scivoletto G, Petrelli A, Di Lucente L et al 2000 One year follow up of spinal cord injury patients using a reciprocating gait orthosis: Preliminary Report. Spinal Cord 38:555558 Scivoletto G, Mancini M, Fiorelli E et al 2003 A prototype of an adjustable advanced reciprocating gait orthosis (ARGO) for spinal cord injury (SPI). Spinal Cord 41:187191. Scott B A 1971 Engineering principles and fabrication techniques for the Scott-Craig long leg brace for paraplegics. Orthotics and Prosthetics 25:1419 Scrutton D R 1971 A reciprocating brace with polyplanar hip hinges used on spina bida children. Physiotherapy 57:6166 Stallard J 1986 Reciprocal walking orthoses for paraplegic patients. British Journal of Therapy and Rehabilitation 3(8):420425 Stallard J, Major R E 1995 The inuence of orthosis stiffness on paraplegic ambulation. Prosthetics and Orthotics International 19:108114 Stallard J S, Major R E, Patrick J H 1989 A review of fundamental design problems of providing ambulation for paraplegic patients. Paraplegia 27:7075 Sykes L, Edwards J, Powell E S et al 1995 The reciprocating gait orthosis: long term usage patterns. Archives of Physical Medicine and Rehabilitation 76:779783 Whittle M W, Cochrane G M 1989 A comparative evaluation of the hip guidance orthosis (HGO) and the reciprocating gait orthosis (RGO). Health Equipment Information National Health Service Procurement Directorate, London Whittle M W, Cochrane G M, Chase A P et al 1991 A comparative trial of two walking systems for paralysed people. Paraplegia 29:97102 Winchester P K 1993 A comparison of paraplegic gait performance using two types of reciprocating gait orthoses. Prosthetics and Orthotics International 17:101106 Wing P C, Tedwell S J 1983 The weight bearing shoulder. Paraplegia 21:107113
Ultra-high lesions
CHAPTER
14
Physiotherapy during the acute stage 261 Physical rehabilitation 262 The power-drive chair 262 Physiotherapy 263 Abilities 265 Handling the patient 266 To relieve pressure 266 To turn the patient 266 To transfer a patient with a lesion at C1C3 from bed to chair using a hoist 266 Handling the wheelchair 268 To push up a kerb 268 To push down a kerb 268 To put the chair in the boot of the car 268 Staff education 268 Permanent care 269 Equipment 269
Injuries to the upper cervical spine (C1C3) paralyse the diaphragm as well as the other muscles of respiration and prove fatal at the scene of the accident unless the condition is recognized and articial respiration given immediately. Due to the knowledge and expertise of the emergency services in the UK, many patients with fractures at this level now reach hospital. The most common injury is at C2 when the cranial nerves are intact and there is partial supply to the accessory nerve but the diaphragm is paralysed and the patient will need ventilation. Where the injury occurs at C4, the patient usually manages to reach hospital on a partially functioning diaphragm. Most lesions then ascend a segment when a ventilator becomes necessary. The lesion descends in the majority of cases and the patient nally manages to breathe unaided. The major muscles remaining innervated in the patient with a lesion at C4 are the upper portion of the trapezius and sternomastoid supplied by the accessory nerve, and platysma supplied by the facial nerve. In the United States 52% of spinal cord injuries are in the cervical region. Of these 20% will require mechanical ventilation initially and approximately 5% will always require it (Di Marco 2001). Not only are these patients totally paralysed apart from the head, but if ventilated they have no means of communication and therefore no way of expressing emotions and physical needs. A rudimentary system of communication needs to be established with the patient as soon as possible (Chawla 1993). Eye movements or blinking can be used to indicate yes and no. Later a scanning system can be used, such as selecting alphabet letters, items or words from a chart. The speech and language therapist needs to be involved from the day of admission. All staff need to remember that the patient has no means of initiating conversation. When the patient on a ventilator becomes used to it he will learn to speak on inspiration, when the air ows both towards the lungs and through the larynx. During expiration almost all the air ows towards the ventilator as the impedance of the ventilator pathway is much lower than that of the laryngeal pathway. The speech produced during inspiration is not very satisfactory, the speech phase is short, so speech comes in bursts and there are long pauses which often come
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when in the middle of a sentence. Hoit et al (2003) suggest that speech can be improved by simple changes in the ventilator setting, that is by lengthening inspiratory time, applying end-expiratory pressure and combining these two. The changes give longer time for speech and reduce the length of the pauses by reducing expiration. Each of these interventions improved speech but the most successful was the combination of the two. Although caution should always be used when applying positive end-expiratory pressure to individuals with compromised cardiac function or those with autonomic dysfunction, these interventions were found to be safe and comfortable on a short-term basis.
Verbal independence
Even with so little ability to communicate, the patients wishes should be taken into account. An early priority is to assist the patient to begin to take control of himself and his environment; for example, as soon as possible, the patient is encouraged to know where his belongings are to be found in the locker and when he needs replenishments. The ability to describe all aspects of the care he needs is vital for the patient with an ultra-high cervical lesion. During his rehabilitation the patient must learn, for example:

the settings for the ventilator suction and hyperinationary techniques correct positioning in bed and in the wheelchair turning procedures bladder and bowel care the management of all equipment how to avoid pressure ulcers how to recognize indicators of impending problems.
Not only must he master the details of the care taught to him by the various professionals, he must also show that, in turn, he can teach his carers. Plasticity of the human motor cortex may explain the increase in acuity of sight and hearing which those who treat patients with lesions at C2 observe. Hallett et al (1993) suggested that the relationship between the motor cortex and the muscles supplied may be modied in patients with disability. They used transcranial magnetic stimulation and muscle responses (motor-evoked potentials) to demonstrate the change in cortical mapping which occurs in patients with complete spinal cord lesions. It would appear that cortical representation of intact muscles spreads onto the area previously controlling the now paralysed muscles. Previous studies (Levy et al 1990, Topka et al 1991) support Hallet et als ndings. However, Brouwer & Hopkins-Russeels (1997) study does not and they suggest there is a need for further investigation to determine the association of
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pathology and specic rehabilitation intervention strategies with the occurrence or extent of motor cortical expansion. Patients with lesions between C1 and C4 have no motor power in the arms, trunk or legs. There is complete loss of sensation, bladder, bowel and sexual function, and vasomotor control. As a result of the paralysis of the vasoconstrictors, there is a marked vasodilatation initially. This causes blockage of the nasal air passages which adds to the difculties of respiration without a tracheostomy. This phenomenon, known as Guttmanns sign, is often present in patients with lower cervical lesions also (Guttmann 1976). When the stage of spinal areexia is over, spasticity and rigidity of muscle develop, the limbs becoming predominantly spastic in extension. Physical rehabilitation is limited to training the vasomotor system to enable the patient to lead a wheelchair life and to teaching him control of the power-drive chair and his environment. Special equipment is needed for those patients who return home, and the relatives require expert training. Due to their respiratory problems and limited conversation patients with high lesions need a level of trust in staff and carers beyond that of other patients. Patterson et al (2005) suggest that peer support volunteers, who have had some training in understanding the issues involved, may assist in building trust with a newly injured patient and bridging the gap between patient and staff.
PHYSIOTHERAPY DURING THE ACUTE STAGE

Chest therapy is vital and is described in Chapter 5, including the treatment of a patient on a ventilator. Treatment will be needed every 2 hours if not every hour for the rst 2448 hours. For patients without a tracheostomy, it is advisable to continue daily postural drainage for several months as a prophylactic measure once the acute stage is over. For patients with a tendency to chest infection, this should be continued throughout life. If a patient with a lesion at this level develops a head cold, he should remain in bed for a day or two to prevent secretions dripping down into the chest when the patient is vertical. The ventilated patient will need to gain condence in the physiotherapist and others involved in his care in order to be as relaxed as possible when the respirator is removed for suction or other purposes. Whilst giving the patient encouragement and reassurance, and with his permission, the physiotherapist needs to disconnect the ventilator for very brief periods to acclimatize the patient. If possible, ventilated patients should be taught to breathe using the accessory muscles. Glossopharyngeal breathing is also useful if the staff know how to teach it and if the patient can learn it, but it does prove a difcult task (Pool & Weerden 1973). Later these patients may be assessed for diaphragmatic pacing.
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To minimize the effect of the extensor spasticity, the position of the arms is important. From the rst day, the correct position is adduction of the shoulder, 45 exion or mid-position of the elbow, extension of the wrist and exion of the ngers. When the fracture is healed, training for the vasomotor system must be taken very slowly. An abdominal binder is often a help for the rst few weeks to minimize pooling of the blood in the splanchnic vessels. Some patients may continue to wear them. Taylor et al (2002) employed functional electrical stimulation to the abdominal muscles to control blood pressure and augment cough in a patient with a C2/4 lesion. The patient used a chin-controlled joystick to activate the electrodes placed on either side of his abdomen. After eating, when his blood pressure fell to a low level, stimulation was self-administered every 3 to 5 minutes, gradually increasing the time between groups of bursts to once every hour after 90 minutes. This increased expiratory ow. The user became independent in coughing, has no need of suction and the maintenance of blood pressure has improved the quality of his life (see Ch. 5).
Caution
Functional electrical stimulation is mentioned by Karlsson (1999) as a potential trigger for autonomic dysreexia if applied to the legs or visceral organs. Blood pressure needs to be monitored.
PHYSICAL REHABILITATION The power-drive chair

These patients will require a power-drive chair. The chair will be controlled by pushing a small sensitive lever in the appropriate direction, using the chin, head, mouth or breath. As the power-drive chair is heavy to dismantle and put in a car, the patient will also need a transit chair. The patient on a ventilator will need to carry on his chair the ventilator unit with back-up system, suction equipment and manual hyperination bag. The non-ventilated patient may need to carry a portable ventilator and the patient with a paced diaphragm will have to x the pacer to his chair, usually attached to the armrest (Fig. 14.1). Particular care needs to be taken in choosing a chair and cushion to t the individual requirements of the user (Chs 6 and 11).
Position of the patient in the wheelchair

The patient has no muscles with which to save himself, and therefore his position in the chair must be carefully checked for safety and
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Figure 14.1 A patient with a pacer on the armrest and a ventilator between the rear wheels.
stability and to ensure that there are no factors likely to irritate his spasticity. A semi-reclining backrest assists both stability and respiration, particularly if the patient is ventilated or the diaphragm remains partially paralysed. The arms need to be adequately supported to reduce spasticity and to minimize the strain on the shoulder joints. The forearms and hands can be positioned on a wheelchair tray, cushion on the lap or specic support made for some models of wheelchair (Fig. 14.2). It is suggested by Corfman et al (2003) that patients using electric powered wheelchairs should always use a seatbelt and footrests when driving as falls from the chair only occurred when seatbelts and footrests were not being used. Driving speed was not a factor.
Physiotherapy
Once the patient is up, treatment is directed towards:

hypertrophy of the innervated muscles control of the power-drive chair reducing spasticity educating the patient and relatives/carers in all relevant aspects of care maintaining balance in the chair, for the patient with a lesion at C4.
264
Figure 14.2 Position in the wheelchair of a patient with a lesion at C2.
Patient with a lesion at C1C3

The patient will not be able to move within his wheelchair. The main priority is to mobilize and strengthen the neck muscles to enable the patient to look around, take his head off the head rest, use a computer, drive the power-drive wheelchair and control his environment by electronic means. Hypertrophy of the few remaining muscles can be achieved with surprising results. Free movement and manual resistance are used to mobilize and strengthen. As the neck gets stronger, the head rest is removed for short periods. Passive movements to the arms are continued and, if necessary, to the legs also.
Patient with a lesion at C4

In addition to the above, balance exercises in the chair are carried out in front of the mirror to help the patient (1) become aware of his position in space, and (2) use his head and shoulders to maintain his equilibrium, especially when moving over uneven ground. 1. The therapist sits the patient away from the back of the chair and if necessary reclines the backrest to a greater angle to give more room for the exercise. The therapist nds the balance point and the patient tries to hold the position by moving his head and using trapezius.
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2. The patient sits back in the chair, leaning against the backrest and facing the mirror. By exing the head quickly and then lifting it quickly, the patient can learn to bounce his shoulders away from the backrest. Having bounced the upper trunk away from the chair, the patient side-exes his head, and his upper trunk moves a few inches to one side. Once learnt, this manoeuvre is invaluable as it aids stability when the chair is being moved. This may require a great deal of practice but repays the effort involved.
Reduction of spasticity
Spasticity may be reduced by passive movements, by reex-inhibiting postures on the plinth or bed, by careful positioning in bed at night and by standing. Drugs may be given to control severe spasticity.
Standing
A tilt table is used to stand patients with ultra-high lesions as they have insufcient motor power to assist in maintaining their own standing position. A tilting bed may be used at home. The patient stands for only 2 or 3 minutes on the rst day. This is increased to two periods of the same duration on the second day. Subsequently, the time is increased a few minutes only per day until the patient can stand for about 20 minutes. In time, some patients, even those with lesions at C2, can stand and want to stand for long periods, i.e. 2 hours or more, as they say they enjoy it. It is helpful for the patient to stand daily whilst training the vasomotor response, but afterwards the patient stands two or three times a week. If possible, a relative is taught the technique so that the patient can continue to stand at home.
Abilities
The patient with a lesion at C1C3 can learn to operate a computer using the voice, chin, head, mouth or another muscle with a suitably adapted interface (see Ch. 8). The patient with a lesion at C4 can learn to use various mouth sticks to operate a computer, type, turn pages, paint and play certain games. A platform can be tted at a convenient height so that the patient can pick out and replace the mouth sticks required. Innovative schemes enable some enthusiastic people with lesions at this level to take part in certain sports, for example target shooting. The rie is manipulated by means of a microswitch triggered by the tongue and a weighted lever and pivot allow the gun to be aimed (Owen-Jones 2004).
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Several environmental control systems are available which enable the completely paralysed patient to operate a selection of appliances in his environment. This is done by means of a switch, activated by the lightest touch, for example, of the chin, head or breath, or by the voice. The patient can, for example, control lights, doors, power points, curtains, entertainment systems and use a telephone. Patients with these high lesions may need to employ carers, and if so, will need to be able to advertise, interview, train and arrange for payment for them.
HANDLING THE PATIENT To relieve pressure

This is discussed in Chapter 6.
To turn the patient

1. Cross one ankle over the other in the direction of the turn. 2. Turn the shoulders by putting one arm, e.g. the right, across the chest to hang down on the left side and pull the left shoulder back. 3. The therapist thrusts her arms underneath the buttocks until she can grip the anterior superior iliac spine, if possible. The arms are kept close together the heavier the patient, the closer the arms need to be. 4. Turn the buttocks and at the same time pull them back into the middle of the bed. The bounce of the mattress can be utilized to ip the patient over. When a turn onto the side is not necessary but pressure over the sacrum and buttocks needs to be relieved, steps 3 and 4 alone can be used to turn the buttocks through 30. A pillow should be used to support the buttocks.
To transfer a patient with a lesion at C1C3 from bed to chair using a hoist
Before moving the patient, ensure that the ventilator is appropriately positioned. 1. Sit the patient up and put the sling behind him as low down as possible. 2. Lie the patient down. 3. Lift one leg at a time, to bring the sling under the thighs. Or, a. roll the sling lengthwise b. roll the patient onto one side
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4.
5. 6. 7. 8.
c. place the sling as far as possible under the back d. roll onto the other side and pull the sling through. Attach the sling to the hoist (Fig. 14.3A), which may be freestanding or on a permanent rail in the patients own home, for example. Use the hoist to lift, move and lower the patient into the chair (Fig. 14.3B, C). Lift the thigh to remove the sling on each side. Lean the patient forward and remove the sling from behind his back. Lift buttocks back in the chair (Fig. 14.3D) and correct his sitting position.
Reverse the procedure to move from chair to bed. Occasions will occur when the patient needs to be transferred but the hoist is not available, e.g. when travelling. In this case, manual lifts will be required; these are described in Chapter 12.
Figure 14.3 Transfer using a hoist.
268
HANDLING THE WHEELCHAIR To push up a kerb

1. Tip the chair onto its rear wheels by pressing down on the chair handles and one of the tipping levers. 2. Push the chair on the rear wheels until the front wheels are over the kerb. 3. Lower the chair onto the front wheels and push the rear wheels up the kerb.
To push down a kerb

Tilt the chair onto its rear wheels and push down the kerb on the rear wheels only. If the patient is large and heavy, or excessively nervous, turn the chair around and allow the rear wheels to descend rst.
To put the chair in the boot of the car

Take out the cushion, remove the wheels if applicable, fold the chair and remove the footplates if necessary. Check that the brakes are on. With the side of the chair facing the operator, hold onto the crossbars or the wheels. Tip the chair up onto the thighs and pivot it into the boot. Lightweight wheelchairs are more easily handled. If the wheels are not removable, they are usually placed to the back of the boot. Deep boots entail lifting the chair the depth of the boot before it can be taken out. Therefore, unless two chairs need to be carried, a boot in which the oor is level with the door is more convenient.
STAFF EDUCATION
An increasing number of patients require ventilation during rehabilitation and on a permanent basis. All the staff of a spinal unit need to have the knowledge and condence to manage a ventilatordependent patient, so that he can move safely around the unit and take advantage of all the hospital has to offer. Coggrave (2001) suggests that multidisciplinary study sessions can be a useful way of educating staff. Porters, administrative staff and managers as well as doctors, nurses and therapists can all be included. People who are mobile in hospital are more likely to participate in community activities after discharge (Kennedy et al 1991).
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PERMANENT CARE
It is a tribute to the medical social workers, to the social services and particularly to the relatives that so many of the patients with ultrahigh lesions return to their own homes. Some patients have large families where the strain of caring for the disabled person is spread between several members. In other cases, there is only one relative available. Some depend on maximum social support, while others accept only a little help. Patients with additional problems may need permanent hospital care. Others may have no suitable relative young and t enough to cope with the full-time care needed. Some of these patients may be able to pay for the necessary assistance, while others will need to go into long-term care in homes with heavy nursing wards. Many questions are still to be answered regarding long-term planning for people with high spinal cord lesions (Mathson-Prince 1997). The person who is to care for the patient with a very high lesion at home needs special training which should start as soon as possible. If willing and able, carers are encouraged to assist the staff in suctioning techniques from an early stage. There are many tasks for them to learn and the carer should spend a minimum of a week at the hospital before the patient is discharged. The carer will need to learn how to handle the patient and the wheelchair, how to dress the patient and attend to the bladder and bowels. It is also important for the carer to see what the patient can do for himself and how best to help him achieve even minimum independence. The staff need to assist the patient and carer to nd the most appropriate way of dealing with all the tasks so that in time they will occupy a less prominent role in home life. The presence of a ventilator-dependent person in the home obviously has a profound effect on family life. The most important factors in successful adaptation appear to be the level of communication with the family and the degree of commitment between all family members (Glass 1993). Due to improvements in medical care and rehabilitation, as well as in technology, people with high tetraplegia are living longer. A longitudinal study of people with lesions from C1 to C4, 14 to 24 years post-injury was undertaken by Bushnik & Charlifue (2005). They found that the 63 subjects reported living rich and ful lled lives.
Equipment
Beds
An electronically manipulated bed and/or special mattress is usually required for home use. These aids do not negate the necessity to turn the patient but either lengthen the period between turns or facilitate the turn itself. Beds are available which raise the patient from supine
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to the sitting position and there are also beds that turn the patient. Some relatives may prefer to turn the patient manually. In some cases and with suitable adaptations, the patient may be able to operate the bed himself, thus achieving a small measure of independence. These patients, with or without a pacer, will also require ventilators, suction equipment with all disposable supplies, a manual chair and a power chair at home.
Hoists
The hammock sling supports the head and is completely safe for patients with high cervical lesions. As the support for the lower body is under the thighs, not under the buttocks, it can easily be removed during the day so that the patient does not have to sit on it. Hoists are available to get in and out of the car but are often cumbersome and bulky to use. The patient with a C1C3 lesion will need to travel in a car in his wheelchair. Mechanisms are available which enable the patient in a wheelchair to be lifted either into the area of the passengers seat or into the rear of a hatchback car or van. Safety procedures for patients with a lesion at C1C3 are vital. When at home, someone who knows how to suction the patient and who can cope with any other possible problem should always be able to see, and be seen by, the patient. All equipment needs to be taken with the patient when he travels by car and someone should travel with the patient in addition to the driver.
Technology for the future

Studies on the use of robotics technology in the development of manipulative aids for personal care and control of the environment continue. Further work in this interesting eld is required in order to simplify the devices and make them effective but less expensive, and to establish the rehabilitation potential and acceptability to the user of this approach. Recent advances in the technology of functional electrical stimulation and new systems for the patient to control equipment may allow the control of multiple functions. Research continues on functional electrical stimulation systems which could enable the patient with high tetraplegia to have some arm and even hand function (Bryden et al 2005).
References
Brouwer B, Hopkins-Russeel H 1997 Motor cortical mapping of proximal upper extremity muscles following spinal cord injury. Spinal Cord 35:205212
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Bryden A M, Kilgore K L, Kirsh R F et al 2005 An implanted neuroprosthesis for high tetraplegia. Topics in Spinal Cord Injury Rehabilitation 10:3852 Bushnik T, Charlifue S 2005 Longitudinal study of individuals with high tetraplegia (C1-C4) 14 to 24 years post injury. Topics in Spinal Cord Rehabilitation 10:7993 Chawla J C 1993 Rehabilitation of spinal cord injured patients on long term ventilation. Paraplegia 31:8892 Corfman T A, Cooper R A, Fitzgerald S G, Cooper R 2003 Tips and falls during electric powered wheelchair driving: Effects of seatbelt use and driving speed. Archives of Physical Medicine and Rehabilitation 84:17971802 Coggrave M 2001 Care of the ventilator dependent spinal cord injured patient. British Journal of Therapy and Rehabilitation 8:146149 Di Marco A F 2001 Neural prostheses in the respiratory system. Journal of Rehabilitation, Research and Development 38:601607 Glass C A 1993 The impact of home based ventilator dependence on family life. Paraplegia 31:93101 Guttmann L, Sir 1976 Spinal cord injuries. Comprehensive management and research, 2nd edn. Blackwell Scientic, Oxford, p 261 Hallett M, Cohen L G, Pascual-Leone A et al 1993 Plasticity of human motor cortex spasticity: mechanisms and management. Springer-Verlag, Berlin Hoit J D, Bangett R B, Lohmeier H L et al 2003 Clinical ventilator adjustments that improve speech. Clinical investigations in critical care. Chest 124:15121521 Karlsson A K 1999 Autonomic dysreexia: Scientic review. Spinal Cord 37:383391 Kennedy P, Walker L, White D 1991 Ecological evaluation of goal planning and advocacy in a rehabilitation environment for spinal cord injury people. Paraplegia 29:197202 Levy W J, Amassian V E, Traad M, Cadwell J 1990 Focal magnetic coil stimulation reveals motor cortical systems reorganised after traumatic quadriplegia. Brain Research 501:130134 Mathson-Prince J 1997 A rational approach to long term care: comparing the independent living model with agency-based care for persons with high spinal cord injuries. Spinal Cord 35:326331 Owen-Jones B 2004 Forward (Spinal Injuries Association publication) June, p 19. Patterson R W, Bushnik T, Burdsall D, Wright J 2005 Considerations of peer support for persons with high tetraplegia. Topics in Spinal Cord Rehabilitation 10:3037 Pool G M, Weerden G J V 1973 Experiences with frog breathing tetraplegic polio victims as telephone operators. Paraplegia 11:253 Taylor P N, Tromans A M, Harris K R, Swain I D 2002 Electrical stimulation of abdominal muscles for control of blood pressure and augmentation of cough in a C3/4 level tetraplegic. Spinal Cord 40:3436 Topka H, Cohen L G, Cole R A, Hallet M 1991 Reorganisation of corticospinal pathways following spinal cord injury. Neurology 41:12761283
The incomplete spinal lesion

Susan Edwards
CHAPTER
15
Introduction 273 Classications 274 Central cord syndrome 274 Anterior spinal cord syndrome 278 BrownSquard syndrome 279 Psychological factors 281 Treatment 281 General comments 281 Analysis of movement and implications for treatment following incomplete spinal cord damage 282 Pathophysiology 290 Pathological activity associated with hypertonia 293 The acute lesion in bed 295 The shoulder 299 The pelvis and gait 302 Walking aids 306 Orthoses and splints 307 Gymnastic ball 307 More recent advances in the medical management of increased tone 309 Summary 312
INTRODUCTION
The term incomplete lesion encompasses all patients with some sparing of neural activity below the level of the lesion. The number of patients with incomplete lesions as opposed to complete lesions is increasing and is now reported to be 55% of the total spinal cord injury population (Sekhon & Fehlings 2001) although Paddison & Middleton (2004) put the gure as high as 65%. The reasons for this changing trend towards more incomplete lesions include greater awareness of the importance of immobilization after injury, the use of restraints and airbags in motor vehicles and treatment once in hospital to limit secondary damage (Sekhon & Fehlings 2001). The percentage of incomplete lesions may in fact be even higher as data relating to spinal cord demographics and treatment outcome are usually reported in the spinal cord injury literature and yet many patients with spinal cord lesions are never admitted to a spinal injuries unit. Non-traumatic incomplete spinal cord lesions account for at least 1.2% of all neurology outpatient consultations (Stevenson et al 1996). The outcome for patients with complete lesions, for example a C6 or T12, is more predictable than for those with incomplete lesions. As with all lesions, the pre-morbid status of the patient is of paramount importance in inuencing outcome but, according to a review carried out by Burns & Ditunno (2001), it is now possible to predict with reasonable accuracy the long-term outcome within a week of the initial injury. However, patients with incomplete lesions include not only those who sustain their injury as a result of trauma, but also those with more diverse pathologies, many of which are progressive. Prognosis for patients with progressive pathology is inevitably more difcult to predict. Patients with incomplete spinal cord damage as a result of pathological causes include those with:

vascular accidents or disease tumours cervical myelopathy inammatory disease. 273
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CLASSIFICATIONS
No two lesions will be identical. The pathology will always be different because of the complex nature of the spinal cord. However, certain types of lesions are referred to as syndromes. These include:

central cord syndrome anterior cord syndrome BrownSquard syndrome.
Central cord syndrome

The central cord syndrome (CCS) was initially described by Schneider et al (1954) and it is reported to be the most common type of incomplete spinal cord injury (Bosch et al 1971, Chen et al 1997, Tow & Kong 1998). The American Spinal Injury Association (ASIA) dene this syndrome as: a lesion, occurring almost exclusively in the cervical region that produces sacral sparing and greater weakness in the upper limbs than in the lower limbs (ASIA 2000).
Cause
This type of lesion usually affects older people with pre-existing cervical spondylosis. The mechanism of injury is that of hyperextension with inward bulging of the ligamentum avum squeezing or pinching of the spinal cord (Tow & Kong 1998, Newey et al 2000). Falls or motor vehicle accidents are reported to be the main cause of CCS although men over the age of 40, with predisposing narrow cervical canals and osteoarthritis of the cervical spine, have also been identied to be at risk following body surng accidents (Scher 1995). Although more common in the middle-aged and elderly population, CCS may occur in people of any age and be associated with other aetiologies, injury mechanisms or predisposing factors (Fig. 15.1) (Roth et al 1990). In older age groups, fracture of the cervical spine is less common than in younger subjects (Penrod et al 1990) and in the absence of a fracture, this lesion may be difcult to diagnose. Magnetic resonance imaging will provide con rmation and additional information. The acute CCS is considered to arise from an injury which affects primarily the central part of the spinal cord and is frequently haemorrhagic (Fig. 15.2) (Morse 1982, Maroon et al 1991). However, Quencer et al (1992) found no evidence of haemorrhage into the substance of the cord and concluded that CCS was not primarily a grey matter lesion but that the neurological disability, at least in part, was due to damage to the white matter tracts. They suggested that the most common mechanism of injury may be direct compression
40 36 Age >45 years 31 30 16 Number of patients Age <45 years
20
24
10
20
7 0 Motor vehicle accidents Falls
10 3 Sports and diving 1
Gunshot Assault wounds
Aetiology
Figure 15.1 Aetiology distribution of central cord syndrome patients. (From Roth et al 1990, with permission from American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.)
Posterior columns (position, vibration and proprioception) Lateral corticospinal tract (voluntary movement)
Sa cra l ar Lu Th or ac ic l Ce rvi ca mb
mb Lu Th
Sacral
ar or
Lumbar Thoracic
ac Ce rvi ca l
ic
Cervical
Lateral spinothalmic tract (pain and temperature)
Figure 15.2 Cross-section of cervical spinal cord. Hatched areas represent a zone of central haemorrhage ( ) and surrounding oedema ( ). The impingement on pathways, especially central cervical bres, in part subserving upper extremity function, is readily apparent. (After Morse 1982, with permission from American College of Emergency Physicians.)
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of the cord in an already narrowed spinal canal. This would explain the predominance of axonal injury in the white matter of the lateral columns. These ndings were supported by Collignon et al (2002), who concluded that acute traumatic CCS may be due to the impairment of the corticospinal tract; the results of their study con rming the absence of intramedullary haemorrhage. Roth et al (1990), in a study of 81 traumatic CCS patients, found that more than 90% of patients had neurological recovery of both upper and lower limbs, neurological recovery being dened as an increase in strength of one muscle grade. This recovery generally occurred in the order of lower limbs, bladder function, upper limbs and nally the hands. The extent of recovery is greatest in younger patients, who have a better prognosis for recovery of activities of daily living and in becoming functional walkers (Penrod et al 1990, Roth et al 1990), although Newey et al (2000) noted that the poorer outcome identied in patients over 50 is heavily weighted by a particularly bad outcome in those over 70 years of age. The tendency for older people to have a higher incidence of comorbid medical problems may also contribute to this poor functional outcome (Tow & Kong 1998) and it is possible that arteriosclerosis may compromise blood supply to the cord in older subjects and that the initial damage may be more severe due to cervical spondylosis (Scher 1995).
Clinical picture
The general clinical picture is of:

disproportionately more motor impairment of the upper than lower extremities bladder dysfunction, often with urinary retention varying degrees of sensory loss.
Spasticity, shoulder pain, hand oedema and dysaesthetic pain are noted complications (Roth et al 1990, Maroon et al 1991) and the development of contractures and/or painful joints of the upper limbs remains a very real danger throughout all stages of treatment and management and may progress over time. Roth et al (1990) found the number of patients with shoulder pain and dysaesthetic pain increased, to be greater at discharge than during rehabilitation. Progressive neurological deterioration, characterized by spasticity, has been identied in older patients with CCS, whereby patients who were initially functionally ambulant became wheelchair-dependent (Maroon et al 1991). However, in contrast, Newey et al (2000) found that, although most patients had brisk reexes and some continued to experience spasms, spasticity did not cause signicant functional problems and motor power continued to improve after the patient was discharged from rehabilitation. Tow & Kong (1998) had similar ndings in that, whilst 20% of patients in their study (n = 73) required antispastic medication for lower limb spasticity, neurologi-
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cal recovery, as assessed by the discharge motor score, was not signicantly different between these patients and those without spasticity.
Motor decit
At the level of the lesion, there will be damage to the motoneuronal pool resulting in a accid paralysis of those muscles supplied from this level (Scher 1995). For example, a lesion occurring at the C5 level will give rise to accidity, most notably of deltoid and biceps. The wasting of these muscles gives rise to the fairly typical upper limb picture associated with the central cord lesion. Hand dysfunction is an outstanding feature of cervical myelopathies (Nakajima & Hirayama 1995) but this is variable in CCS. The hands may be relatively uninvolved, but without the background of proximal stability, selective upper limb function will be impaired. In other cases, the hands may be paralysed. The predominant loss of muscle function in distal muscles may be explained by axonal damage. Disruption of axons, particularly in the lateral columns in the region occupied by the corticospinal tracts, reects their importance for hand and nger function (Quencer et al 1992, Collignon et al 2002). Paralysis of the hands may lead to the development of stiff and painful joints or cervical hand syndrome (p. 45) and swelling may occur that is compounded by the effect of gravity. Many patients with CCS will achieve an independent gait with or without the use of walking aids and all too often they walk independently before they have signicant recovery of the upper limbs. In a sense, these patients differ from virtually all other patients with neurological disability, in that use of the arms in gait re-education is recommended. Whilst it cannot be extrapolated that increased use of the upper limbs for balance and support in gait re-education will transfer to more selective functional use of the hands, this might go some way to facilitating neuronal adaptation and cortical reorganization (Puri et al 1998, Smith et al 2000). Once the patient is able to walk independently, there may be little if any opportunity for the arms to be involved in function (Fig. 15.3). Depending on the severity of the lesion, the patient will demonstrate some degree of motor decit in the trunk and lower limbs which is invariably characterized by the presence of hypertonicity.
Sensory decit
This is extremely variable, ranging from severe sensory loss to virtually no impairment. The disability of these patients is often underestimated. Those who are ambulant may appear less disabled and yet, without the use of their upper limbs, they are invariably more impaired than the chairbound paraplegic person.
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Figure 15.3 Standing posture of people with central cord syndrome. The use of the arms for support on a frame or crutches is encouraged.
Anterior spinal cord syndrome

Cause
Traumatic
This syndrome may result from a forced exion, compression injury which may occur in diving or road trafc accidents (Foo et al 1981). The trauma is often associated with anterior spinal artery compression giving rise to ischaemia which may contribute to the clinical presentation (Grundy & Swain 2002).
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Non-traumatic
The anterior cord syndrome may result from infarction secondary to anterior spinal artery thrombosis, spinal cord angioma or rupture of aortic aneurysm. Signicant neurological recovery following spinal cord infarct is unusual unless there is improvement within the rst 24 hours (Geldermacher & Nager 1989, cited in Stevenson et al 1996).
Clinical picture
This syndrome results from damage to the anterior part of the spinal cord. The clinical signs and symptoms are those of:

motor loss loss of pain and temperature sensation preservation of tactile and joint position sense.
The severity of impairment will depend upon the extent and exact site of the damage but continuous pain has been identied as a key feature following spinal cord infarction (Pelser & van Gijn 1993). Patients presenting with motor loss and sensory sparing are classied as Frankel B, or B on the ASIA impairment scale. However, these scales make no distinction between the types of sensory sparing, for example, tactile joint position sense and pain and temperature. A clear distinction has been made between the different types of sensory sparing with those with preserved pin prick being shown to have an excellent prognosis to regain a functional gait. Crozier et al (1991) found that 66% of Frankel B patients with preservation of pin perception recovered to become functional walkers, whereas only 14% with light touch were able to walk (n = 33). Vibration sense, tactile and joint position sense are served by the dorsal columns, whereas pain and temperature sensation are dependent upon the spinothalamic tracts. Preservation of pin prick indicates some integrity of the spinothalamic tracts in the anterolateral aspect of the spinal cord and therefore the possibility of some sparing of the adjacent corticospinal tracts (Foo et al 1981). Body awareness enables patients with anterior cord lesions to respond more quickly to the rehabilitation process, often achieving their treatment goals in a shorter time, but management of these patients is the same as that for Frankel A patients. Although sensory sparing clearly indicates that the lesion is incomplete, a signicant difference in outcome is only possible where there is some motor recovery.
BrownSquard syndrome
This syndrome results from a transverse hemi-section of the spinal cord, whereby half of the spinal cord is damaged laterally (Grundy & Swain 2002, Sullivan 1989).
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Cause
Lateral damage to one side of the cord may be caused by penetration injuries such as stab wounds but may also result from other aetiologies and injury mechanisms such as road trafc accidents and rugby football injuries. Fracture dislocation of a unilateral articular process and acute ruptured intervertebral disc have also been reported to give rise to this syndrome (Sullivan 1989). Although knife injuries may result in the classical picture of BrownSquard syndrome, their incidence is variable. In over 1600 cases of spinal cord injury in the United States, only 1.1% were due to penetrating injuries other than gunshot wounds (Waters et al 1995). However, of 1600 patients in South Africa admitted to a spinal injuries unit, a quarter were the result of stab wounds. Of these, 50% had BrownSquard syndrome (Peacock et al 1977).
Clinical picture
Motor decit
Paralysis or weakness occurs on the same side as the lesion due to destruction of the motor tracts. In addition, there will be a lower motoneurone lesion at the level of spinal cord damage resulting from damage to the motoneuronal pool which is particularly signicant at the cervical or lumbar enlargements.
Sensory decit
Destruction of the posterior column results in loss of position sense, vibration and tactile discrimination below the level of the lesion on the affected side. Destruction of the lateral spinothalamic tract causes loss of sensation of pain and temperature on the side opposite to the lesion. As the bres entering this tract do not cross for several segments, the upper level of this sensory loss is likely to be a few segments below the level of the lesion. Fibres entering the cord at the level of the lesion may be involved before they cross, causing a narrow zone of similar pain and temperature loss on the same side. Typical cases of BrownSquard syndrome are rare. Many patients with incomplete lesions will present with some asymmetry whilst not ful lling the exact criteria of this syndrome. Patients with a total severance of the lateral half of their spinal cord will have little if any recovery, whereas those with contusions or contra-coup injuries are likely to show signicant functional improvement. The majority of these patients will walk independently, with a reciprocal gait, as only one leg has lost or reduced motor power. An orthosis and/or walking aids may be required. Even among these syndromes described above, there is considerable variability in the severity of neurological damage and thus in the
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functional outcome. Incomplete spinal cord damage resulting from other pathologies, such as tumours, inammatory disease, cervical myelopathy and vascular disease, is often more diverse and the outcome even more unpredictable.
Psychological factors
Obviously, with both complete and incomplete lesions, the psychological factors resulting from such a devastating injury have to be taken into account throughout all stages of rehabilitation. The patient with an incomplete lesion may have a particular problem in coming to terms with his disability. Being incomplete, prognosis is ill-dened and it is particularly difcult, even for those with a substantial functional recovery, to accept less than 100% normality (Sullivan 1989). If surrounded by patients with complete lesions, it is easy to consider the patient with an incomplete lesion fortunate because he has some sparing. Although this is true, even those patients making a good recovery may still be unable to return to their normal lifestyle. Understanding the patients psychological response to his condition is crucial for effective rehabilitation. The physiotherapist, because of her close contact with the patient, may be the one chosen as condante by both the patient and his relatives. It is important that she allows him to express his fears and/or frustrations while offering constructive advice. Where more professional counselling is thought to be required, the patient and/or relatives should be encouraged to talk to a clinical psychologist.
TREATMENT General comments

The therapeutic management of a patient with an incomplete lesion may differ signicantly from that of a patient with a complete lesion. Therapists working in spinal injury units develop great skill in maximizing the potential of patients with complete lesions and may be tempted to treat the patient with an incomplete lesion along similar lines. Clearly, it is essential for all persons involved in the rehabilitation of the patient with an incomplete spinal cord injury to assess the activity limitation and participation restriction of each patient as it relates to that individual and not to compare him with other patients, especially those with complete lesions. It has been suggested that patients with incomplete spinal cord lesions, particularly those caused by slowly progressive pathologies, are best managed in a neurological rehabilitation unit as opposed to a spinal injury unit (Stevenson et al 1996) and, given that over 50%
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of all spinal injured patients have incomplete lesions, this statement is of enormous signicance to the future management of this client group. However, a key consideration relates to bladder and bowel management in that the patient with an incomplete spinal cord lesion may have severe disruption of bladder and bowel function, which requires the specic expertise of a spinal injury unit. Greater liaison and transference of skills should be made between therapists and other staff working in spinal injury units and neurological rehabilitation centres. Patients with incomplete spinal cord lesions demonstrate many diverse disabilities depending on the level and extent of the pathology. It is important that both the patient and therapist have realistic expectations in terms of outcome and that appropriate short-term goals are selected to demonstrate progress. Accurate initial and ongoing assessment is essential to set and monitor these mutually agreed goals with appropriate, objective outcome measures to determine the efcacy of treatment. Whilst normal movement is often cited as the ultimate goal of rehabilitation, all too often this is not achievable for patients with extensive neurological damage and compensatory strategies are necessary in order for the patients to overcome their physical limitations. The therapeutic skill lies in determining that compensation which is necessary and even essential for function and that which is unnecessary and potentially detrimental to the patient.
Analysis of movement and implications for treatment following incomplete spinal cord damage
Many authors describe the analysis of movement as the basis for the development of treatment techniques for patients with neurological damage (Bobath 1990, Carr et al 1995, Shumway-Cook & Woollacott 2001, Edwards 2002). However, the emphasis differs with regard to treatment approaches. For example, Bobath (1990) advocated the control of abnormal reex activity and the underlying tone to improve coordination of movement, whereas Carr et al (1995) direct movement training towards improving performance of everyday actions, thereby enabling the patient to learn control of muscle activity and develop strength and endurance during functional motor performance. Over recent years, the emphasis of the Bobath approach has changed signicantly in that the musculoskeletal consequences of neurological damage are now recognized to be of equal importance to the tonal problems. Unfortunately, although this more holistic approach is now widely taught on Bobath adult hemiplegia courses in the UK, there is no current literature to describe this change of emphasis. Normal movement is dependent upon an intact central nervous system (CNS) which can receive, integrate and respond to stimuli. The complexity of this processing is illustrated by Harris-Warwick
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& Sparks (1995), where they refer to motor plans being implemented through networks that determine the order, timing and strength of movement around each joint, which is translated into a choreography of motoneurone activity that drives the individual muscles at the right moment and with the right force. Spinal cord damage will affect this processing; the extent to which it is damaged being determined by the site and severity of the lesion. Key features that inuence movement include:

muscle tone and positioning speed of movement and degree of support sensory feedback and feedforward postural control and balance reactions musculoskeletal viability.
Muscle tone and the inuence of positioning

Normal muscle tone is dependent upon an intact CNS, which enables an individual to maintain an upright posture and adapt to a varying and often changing base of support and which allows selective movement for function. Tone is the resistance offered by muscles to continuous passive stretch (Brooks 1986) and this de nition clearly has implications for both the neural and non-neural components of the movement disorder. Following spinal cord damage, tone may be impaired as a result of overactivity of affected muscle groups and/or the musculoskeletal consequences of impaired mobility. The management of patients with incomplete spinal cord lesions will be determined to a large extent by the alterations in muscle tone. Positioning in bed, particularly during the early stages, passive/active movements, facilitation of transfers, posture in the wheelchair and standing will all be inuenced by the underlying tone. Equally, the manner in which these activities are carried out will in turn inuence the prevailing muscle tone. Facilitation of active movement on a background of impaired tone, particularly low tone, is often more difcult when the patient is fully supported. Bedrest is often essential in the immediate aftermath of traumatic spinal cord injury and therefore alternative positioning is not possible. However, as soon as the medical condition allows, positioning against gravity with appropriate support is recommended to stimulate a more active response (Edwards 2002).
Speed of movement and degree of support

This is of particular relevance to the postural adjustments that precede and accompany movement. Horak et al (1984) examined the activation times for trunk and leg movement while lifting the arm. Activity in these postural muscles preceded the arm displacement, presumably to provide stability for the ensuing movement. The
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sequencing of these postural adjustments was found to be more variable during slower movements. As less stabilization is required during slower movement, the preparatory muscle activity is not programmed as rigidly as with more rapid movement. These early changes in postural muscles were signicantly decreased if the subject was supported at the shoulder or even touched a rail with a single nger (Cordo & Nashner 1982). These two factors, the speed at which the movement is performed and the support provided during movement, are of particular signicance for patients with neurological damage such as may result from spinal cord injury. Many patients will be unable to move as quickly as normal subjects and changes in the postural adjustments may be related to the speed of the movement as much as the pathology. The order and timing of postural adjustments will be inuenced when providing assistance for a patient to stand and walk. Clearly it is important to facilitate a more normal posture or movement, but it may be of equal value to allow the patient to correct his own posture. If the therapist constantly supports the patient, the postural adjustments will always be dependent upon this support.
Sensory feedback and feedforward

Postures and movements are guided by a mixture of motor programmes and sensory feedback because calculations made ahead of time in the CNS are always corrected after central and peripheral reports about reality (Brooks 1986). Rothwell (1994) describes the production of voluntary movement as being sequential in terms of the idea or reason to move, the motor plan which is constantly updated to t the requirements of the muscles involved in the movement and the execution of the movement. This interaction between central and peripheral systems may be considered a cyclical event whereby movement skills are constantly reinforced and re ned by repetition. If the patient is unable to move due to signicant paralysis, he will be unable to reinforce his movement skills. Hallett et al (1993) demonstrated the change in cortical mapping of a patient with a complete cervical spinal cord lesion using transcranial magnetic stimulation (TMS). The cortical representation of deltoid expanded to encroach on the territory previously subserving the paralysed muscles innervated below the neurological level of the lesion. Patients who develop abnormal tone and movement may create new motor programmes that are dictated by the stereotyped activity. Movements attempted on a background of increased neural activity will involve effort and produce an abnormal sensory input to the CNS. The aim of physiotherapy is to modify this often stereotypical response by facilitation of more normal movement patterns. Prolonged use of a limited repertoire of pathological movement patterns creates a dominant abnormal response which becomes increasingly difcult to reverse. Once established, re-education of more purpose-
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ful movement can sometimes only be achieved with outside intervention such as localized injections of botulinum toxin to weaken the overactive muscles (p. 309). The direct effect of sensory loss is more difcult to quantify. Patients who have full muscle power but who have no appreciation of movement can be as disabled as those without motor control. Clearly any specic sensory loss will have implications for the initiation, guidance and control of movement.
Postural control and balance reactions

Postural control, which provides stability and orientation, requires:

the integration of sensory information to assess the position and motion of the body in space the ability to generate forces for controlling body position (Shumway-Cook & Woollacott 2001).
Postural adjustments occur throughout the body and are effective only on a background of normal muscle tone. They occur during any movement and any alteration in the position of the bodys centre of gravity requires modication of tone throughout the body musculature. For example, during quiet stance, the muscles of the feet and lower limbs are constantly making minute adjustments to maintain equilibrium with the bodys centre of gravity over the base of support. Shumway-Cook & Woollacott (2001) refer to this response as the ankle strategy, in that the body is maintained or restored to a position of stability through movement centred primarily about the ankle joints. If this proves to be inadequate, movements to regain balance or maintain equilibrium over a compliant or small surface area may then occur at the hip, this being referred to as the hip strategy; and if this fails, the natural response is to take a step, the stepping strategy. For patients with incomplete spinal cord lesions, the hip strategy will be called into play if there is inadequate control at the ankles, which may result from weakness and/or muscle imbalance. A typical example of this is in patients with a positive support reaction whereby the foot is unable to adapt to and accept the base of the support. The patient is unable to transfer weight over the full surface of the foot and the ankle remains in a degree of plantarexion. The compensatory response is exion at the hip to maintain the body weight over the base of support (Bobath 1990, Edwards 2002). Postural adjustments also refer to the alignment of body segments, the head, trunk and limbs, with each other and with the environment. They are observed in virtually all sequences of movement, such as rolling, sitting up and lying down, and are dependent upon the interaction between exion and extension which allows for rotation. Any traumatic injury to the spine will interfere with these responses in that there is invariably a reduced range of movement following any acute injury.
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This is particularly noticeable following immobilization of the cervical spine using a halo jacket. It has been observed in clinical practice that even those patients who have full neurological function have severe difculties in attaining correct body alignment following prolonged immobilization in this type of support. Although a valuable means of stabilization, it would appear that the rigidity of the device virtually negates muscle activity between the points of contact. It is therefore not unusual to see an anterior tilt of the pelvis and poking chin, with little if any neck and trunk rotation, on removal of the support. Patients with impaired movement control are often apprehensive, realizing that their response to sudden and unexpected perturbations may be inadequate to maintain balance. Movements are consequently slower and the background postural tone higher, particularly when standing and walking, in anticipation of potential falls.
Musculoskeletal viability
The different types of skeletal muscle are referred to as slow oxidative (SO), fast glycolytic (FG) and fast oxidative glycolytic (FOG). Their characteristics are summarized in Table 15.1 (Rothwell 1994). The SO muscles are those which participate in long-lasting but relatively weak contractions, such as in the control of posture, whereas the FG muscles generate large forces but are readily fatigued. The recruitment order of a motor unit is dependent upon the size of its motoneurone (Henneman et al 1956, cited in Rothwell 1994) and is in the order of SO, FOG, FG. From a functional perspective, the SO muscles provide postural control to allow for the FG to perform the more selective movements. Muscles alter their characteristics in response to function, that is to say it is the activity of the muscle which determines the muscle bre type (Pette & Staron 1997). Following spinal cord injury, the disturbance of spinal cord circuitry leads to disordered muscular activation patterns which will alter the muscle characteristics (Fung et al 1990). Damage to motoneuronal cells at the level of the lesion gives rise to accid paralysis or weakness of the affected muscle groups. This is well illustrated in patients with central cord syndrome at the level
Table 15.1 The characteristics of different types of skeletal muscles (from Rothwell 1994, Table 3.1, with permission)
Fibre type I SO Slow (S) IIA FOG Fast fatigue resistant (FR) Mediumsmall IIB FG Fast fatiguable (FF) Large
Motor unit type
Fibre diameter
Small
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of C5 where the shoulder muscles are often signicantly wasted, exhibiting rapid and extensive atrophy in response to the deprivation of normal activity patterns (Goldspink & Williams 1990, Given et al 1995). Pathological movement patterns may emerge due to damage to the descending tracts and these will impose different activity patterns on muscle due to the stereotyped movements. Phenotype expression is dependent upon both neural activity and mechanical factors and all muscles stay fast unless they are subjected to stretch and force generation (Goldspink 1999). Therefore, in the absence of dynamic muscular activity against gravity, the SO muscles atrophy more readily than the FG (Given et al 1995). However, a relative increase in both SO and FG bre types has been reported in the literature. Dattola et al (1993) and Edstrom (1970) found an increase in SO bre type in patients following stroke and Goldspink et al (1992) and Vrbova et al 1995 reported a change in bre type from slow to fast in patients with neurological disability that interfered with their ability to maintain postural control against gravity. From a therapy perspective, people who, following spinal cord injury, are unable to sustain muscle activity against gravity will be unable to maintain the SO muscle characteristics associated with postural control. Re-education of postural control may then be dependent upon the activity of FG muscle bres, which are not suited to this task as they are unable to sustain force (Edwards 2002). In both scenarios, atrophy will be a notable feature due to denervation as a result of damage to the motoneuronal cells and/or disuse as a result of disruption to the descending tracts as occurs in upper motoneurone lesions (Gordon & Mao 1994). The mechanical properties of muscle, particularly the length and stiffness, are also key determinants for normal functional use. The length-associated changes of muscle will affect patients with paralysis and/or hypertonus in that, in both instances, full-range active movement is impaired and normal motor function is not possible (Ada & Canning 1990, Goldspink & Williams 1990, Edwards 2002). Muscle imbalance occurs when relative changes in muscle length and recruitment patterns take place between agonist/antagonist and synergic muscle groups (Fitzgerald & Stokes 2004). Imposed length changes have been shown to alter the mechanical properties and structure of muscle. Immobilization in a shortened position produces short, stiff muscles with fewer sarcomeres and an increase in connective tissue. These length changes and sarcomere loss are accelerated when the muscle shortening is induced by electrical stimulation or tetanus toxin and it is suggested that these results provide a model for the rapid length changes seen in spastic muscle (Herbert 1988). The main remit of the physiotherapist is to maintain the range of movement in all affected muscle groups. This is of particular signicance for patients with incomplete spinal cord lesions in that the majority of patients will have some degree of neurological recovery.
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As recovery occurs in a specic muscle, if the antagonist muscle has become shortened, it will be more difcult, if not impossible, to maximize this recovery. An understanding of these key features of movement is essential for the development of treatment techniques for the patient with incomplete spinal cord injury. Of all patients with neurological damage, the patient with an incomplete spinal cord injury often presents with the most diverse functional problems, which will depend upon the site and extent of the lesion. In order to develop appropriate treatment strategies, it is important to distinguish between the primary decit and the secondary compensation. Analysis of positions and movement sequences in normal subjects is useful to draw comparison with the postural and movement decits which may result from incomplete spinal cord damage. In this way, the distinction between the primary cause and secondary compensation can be more readily made.
Analysis of specic positions

Although few individuals demonstrate identical characteristics when assuming any one position, certain features are remarkably similar. A detailed description of the normal characteristics of supine-lying, prone-lying, side-lying, sitting and standing is to be found in Edwards (2002). Table 15.2 provides a summary of the identied features when assuming each of these positions. This table is by no means conclusive. Its purpose is to allow comparisons to be drawn between normal subjects and patients with movement disorders. Analysis of these positions in this way provides a structure for the assessment of patients with physical disability and for the selection of the most appropriate position in which to treat the patient. For example, patients with accidity should be stimulated by treatment in positions requiring anti-gravity activity. Those with hypertonus should be mobilized in an appropriate position to inhibit the hypertonia in order to prepare them to accept the base of support.
Key points of control

Key points of control are described as areas of the body from which movement can be most effectively controlled and from where movement may be centralized. The proximal key points are the trunk, shoulder girdles and pelvis, and the distal key points are the hands and feet (Bobath 1990). Trunk mobilization is recognized as an important treatment modality and in the majority of cases is a prerequisite for the facilitation of movement of the limbs (Davies 1990, Edwards 2002). If the trunk is unable to make the required postural adjustments to movement of the limbs, then these distal movements will inevitably be abnormal.
Table 15.2 Characteristics of supported positions and positions requiring anti-gravity activity
Supported positions Supine Midline Backwards of CKP Backwards of CKP (posterior tilt) Extension, abduction, lateral rotation Extension, abduction, lateral rotation Extension Flexion Flexion, adduction, medial rotation Flexion, adduction, medial rotation Forwards of CKP (posterior tilt) Backwards of CKP (anterior tilt) Flexion, adduction, medial rotation Flexion, abduction, lateral rotation Flexion Forwards of CKP Forwards of CKP Midline Midline Supported sitting Sitting Standing Midline
Positions requiring anti-gravity activity
Prone
Head
To side
Shoulders
Forwards of CKP
Forwards of CKP Backwards of CKP (posterior tilt) Flexion, adduction, medial rotation Extension, lateral rotation Extension inuence
Pelvis
Forwards of CKP (anterior tilt)
Upper limbs
Flexion, adduction, medial rotation
Lower limbs
Adduction, medial rotation
Overall
Flexion
CKP = central key point.
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Posture and movement within the trunk may be effectively controlled by manual guidance from a central point between the xiphisternum and the T8 vertebra. This is called the central key point. The relationship of the central key point with the proximal key points provides a basis for the analysis of abnormal patterns of posture and movement. In the normal subject, although asymmetrical postures may be adopted, the relationship between the central key point, the head and the proximal key points is generally symmetrical. Although asymmetry may be seen, as in cross-legged sitting, it is in no way comparable to that of a patient with neurological dysfunction. As a basis for the analysis of neurological damage and the resultant impaired movement, it is helpful to assess the patient in terms of the midline deviation. This may be considered in three planes of movement:

the sagittal plane the coronal plane the horizontal plane.
The relationship of the key points to the midline will vary in different positions depending upon the ability of the individual to:

support himself in anti-gravity situations accept the base of support in supported positions.
A key point from which to inuence movement is determined by the ability of the individual to respond to facilitation of movement. For example, care must be taken when facilitating from a distal key point, such as the hand, to ensure that there is appropriate activity within the trunk and at the shoulder. If the patient is unable to make the required adjustments, the shoulder may be traumatized. This analysis demonstrates that there can be no stereotyped picture of what is normal. Individuals have different levels of postural tone in accepting the base of support and reacting to the effects of gravity. Similarly, movements from one position to another will show similarities but may vary quite considerably whilst still being accepted as being within a normal range.
Pathophysiology
The movement dysfunction of patients with incomplete spinal cord lesions may originate from:

impairment of supraspinal control through damage to descending tracts (Dimitrijevic et al 1983) disturbance of spinal cord circuitry which leads to disordered muscular activation patterns and abnormal reex activity (Fung et al 1990) weakness/atrophy due to damage to the motoneuronal pool at the level of the lesion and/or as a consequence of damage to the descending tracts (Gordon & Mao 1994)
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change in the mechanical properties of muscle (Given et al 1995) muscle imbalance, as a result of changes in muscle length and recruitment patterns taking place between agonist/antagonist and synergic muscle groups (Fitzgerald & Stokes 2004).
The activity limitation and participation restriction following incomplete spinal cord injury therefore arises primarily as a result of hypertonia and/or weakness, through both neural and mechanical mechanisms.
Neural components of hypertonia

Spasticity is a common consequence of spinal cord injury and is often more severe in patients with incomplete lesions, particularly those classied as Frankel B and C (Maynard et al 1990, Heckman 1994). However, there is some controversy with regard to terminology and the de nition of spasticity (Sheean 2001). The classical de nition of spasticity is that it is a motor disorder characterized by a velocity-dependent increase in tonic stretch reexes with exaggerated tendon jerks resulting from hyperexcitability of the stretch reex as one component of the upper motoneuron (UMN) syndrome (Lance 1980). However, whilst patients with incomplete spinal cord injury may demonstrate spasticity, this is rarely the primary disabling feature. The upper motoneurone (UMN) syndrome is a more general term used to describe patients with abnormal motor function following cerebral or spinal cord lesions (Katz & Rymer 1989). The clinical features are broadly divided into negative and positive phenomena. The negative features include weakness and loss of dexterity whereas the positive features are characterized by excessive or inappropriate motor activity. Spasticity, as dened by Lance (1980), is but one component of this syndrome. Whereas spasticity is velocity dependent and is therefore afferent mediated, many patients present with continuous muscle contraction that continues in the absence of movement. This is referred to as spastic dystonia, which is thought to arise as a result of continuous supraspinal drive to the spinal motoneurones and is therefore efferent mediated (Burke 1988, Young 1994, Sheean 2001). The supraspinal control of muscle tone is primarily dependent upon the balanced interaction between parapyramidal tracts which arise in the brainstem. The key tracts are the dorsal reticulospinal tract, which has an inhibitory inuence, and the medial reticulospinal and vestibular-spinal tracts, which have a facilitatory effect on extensor tone. All three systems are thought to inhibit exor reex afferents (Brown 1994, Sheean 2001). The main clinical difference between complete and incomplete spinal cord lesions is that incomplete lesions often have more dominant extensor tone as opposed to the complete lesion, which is strongly exor (Brown 1994). Where the facilitatory tracts in the ventral part of the cord are spared, this incomplete lesion will give rise to paraplegia in extension; with a
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complete lesion, the exor reex afferents are disinhibited resulting in paraplegia in exion (Sheean 2001). A characteristic feature of spasticity is impaired reciprocal inhibition (Boorman et al 1996), frequently termed reciprocal innervation by physiotherapists (Edwards 2002). This is associated with an increase in the degree of antagonist muscle contraction seen during alternating muscle actions. It has been suggested that muscle relaxation is accomplished, not simply by inhibition of the active motoneurone pool, but also by active, possibly presynaptic, processes which speed de-recruitment of the motoneurones. These active processes are impaired in patients with incomplete spinal cord lesions with spasticity (Boorman et al 1996). Dietz et al (1995) proposed that reduced modulation of electromyographic (EMG) patterns observed during locomotion a longer lasting tonic gastrocnemius EMG activity and co-activation of antagonist leg muscles may be due to impaired function of polysynaptic spinal reexes. Neural hypertonia may be considered as a dynamic phenomenon and reects the age, site and size of the lesion responsible for its genesis. The reorganization of neural pathways following spinal cord injury occurs as a result of the sprouting of new neuronal connections and through unmasking of existing but functionally inactive pathways. Whereas sprouting occurs over time, unmasking is evident within hours (Topka et al 1991). In the uninjured spinal cord, the efciency of synaptic function and the pattern of synaptic connections within the neural circuitry responsible for learning have been shown to be activity-dependent. This dispels the concept that the spinal cord is relatively non-plastic and serves simply to relay supraspinal commands. There is evidence supporting both activity-dependent and injury-induced plasticity after spinal cord trauma (Muir & Steeves 1997).
Non-neural components of hypertonia

Neural hypertonia will invariably give rise to muscle imbalance with one muscle group being dominant over the antagonist group. This in turn will lead to changes in the biomechanical properties of muscle and reduced tendon compliance (Dietz 1992). The increased mechanical resistance of the musculoskeletal system including reduced tendon compliance and physiological and histochemical changes in muscle bres is an inevitable consequence of paralysis and/or stereotyped pathological movement patterns. It is these mechanical factors that are considered by many to be the major cause of residual disability (Dietz 1992, Given et al 1995, ODwyer et al 1996). However, in spite of the importance of mechanical factors to the genesis of hypertonia, the mechanical contribution to hypertonia would not arise without the damage to the CNS producing the reduced activity and/or stereotypical postures associated with spinal cord injury (Edwards 2002).
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Pathological activity associated with hypertonia

Positive support reaction
This term is used primarily by physiotherapists to describe a pathological extensor response in the lower limb evoked by a stimulus of pressure on the ball of the foot (Bobath 1990, Sheean 2001, Edwards 2002). This reaction, which is considered to be of distal origin, prevents transference of weight over the full surface of the foot. The patient, with increased extensor tone of the lower limb and plantarexion and inversion of the foot, is unable to accommodate to the supporting surface. This extensor response prevents hip extension during stance phase of gait, the patient having to ex forward at the hip to maintain balance. Although the knee is held in extension, this position is not maintained with normal quadriceps activity and it is not uncommon to observe wasting of this muscle group. The knee becomes hyperextended due to the inability to attain normal alignment of the pelvis over the foot, impaired interaction between the hamstrings and quadriceps muscle groups and shortening of gastrocnemius (Edwards 2002). Patients with a positive support reaction are in danger of developing contractures of all muscle groups held in a shortened position. Those most notably affected are:

soleus and gastrocnemius tibialis posterior intrinsic foot musculature and plantar fascia iliopsoas rectus femoris hip adductors.
The clinical picture of the positive support reaction is most apparent during gait. The increased extensor tone prevents release of the knee and the patient has to hitch the leg forward during the swing phase of gait. It may also affect the patients ability to stand up or sit down, the extensor tone preventing mobility at the knee. Inhibition of this pathological response must incorporate desensitization by mobilization of the foot itself. Physiotherapists are often advised to avoid contact with the ball of the foot. However, in this instance, mobilization of the foot, the posterior crural muscle group and the Achilles tendon is recommended to desensitize against both the intrinsic and extrinsic stimuli (Edwards 2002). This distal intervention should be used in conjunction with facilitation of more normal alignment of the pelvis over the weight-bearing foot. Botulinum toxin is increasingly being used to weaken the dominant muscle groups responsible for the positive support reaction (Dunne et al 1995, Richardson et al 2000). Used in conjunction with physiotherapy and in some cases splinting, this has shown promising results (Edwards 2002) (see p. 309).
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Flexor withdrawal response

This response occurs as a protective mechanism in normal subjects and may be observed as an individual withdraws the hand from a hot stove, or the foot when stepping on a nail. It is determined by the direction of the noxious stimulus and therefore may not necessarily be into exion (Rothwell 1994). Patients with incomplete spinal cord lesions may demonstrate this response, but in a more stereotyped and consistent pattern and in response to a fairly innocuous stimulus such as removal of the bedclothes. The withdrawal response in the lower limbs is that of exion and lateral rotation at the hip, exion at the knee and dorsiexion or plantarexion at the ankle. The foot may be everted or inverted, often being everted with dorsiexion or inverted with plantarexion at the ankle. Noxious stimulus on a background of abnormal tone may give rise to this response. For example, a pressure ulcer, pain or an ingrowing toenail may cause an increase in hypertonia with exion of the limb (Schomburg 1990, Thompson 2002). It is essential to determine if there is an external cause and to treat this prior to undertaking more radical intervention. The short-term inuence of such a stimulus may be readily reversible, but prolonged exposure may have more residual effects such as the development of contractures (Edwards 2002). The clinical picture of the exor withdrawal response is most apparent during the swing phase of gait where there is exaggerated exor activity. Weight-bearing through the affected limb(s) was previously recommended but this should be carried out with caution. Attempts to stand the patient on a leg which is contracted into exion may further aggravate the situation, not least by imposing an additional painful stimulus (Edwards 2002).
Paralysis/weakness
Weakness may result from damage to the motoneuronal pool producing peripheral denervation or as a consequence of damage to the corticospinal tract. With a complete spinal cord lesion, there is total ablation of the anterior horn cells at the level of the lesion and therefore no nal common pathway to the muscle. This produces a accid paralysis of muscles innervated from that level of the spinal cord. In incomplete lesions, the extent of this destruction will be variable depending on the site and severity of the lesion. The lesion may affect virtually all efferent and afferent neurons at a certain level but not causing complete interruption of their function. Alternatively, there may be lesions where there are distinct parts of the spinal cord which are completely damaged but others that are preserved intact (Bajd et al 1989).
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In many instances, the strength of the muscle will be reduced, but some control may remain, producing weakness as opposed to a complete paralysis. EMG investigations have revealed that the active units could be divided into those under normal control, spontaneous active units which could not be activated by the subject, and units which could only be slowly and weakly activated (Stein et al 1990).
The acute lesion in bed

One of the main aims of physiotherapy is to minimize the effects of hypertonia and to prevent length-associated changes in the musculoskeletal system to enable more appropriate function. Changes in cortical representation of body parts due to loss of function have been shown to occur within minutes (Hallet et al 1993) and therefore early treatment is essential to minimize these adverse effects. The spinal cord damage gives rise to the presenting signs and symptoms with regard to impaired muscle tone, but it is how the patient copes with this pathological movement that will determine the outcome in terms of muscle, neural and soft tissue changes. Although this section relates to the early management of these patients, it is of relevance throughout all stages of rehabilitation.
Positioning
In the early stages of traumatic spinal cord injury, the positioning of the patient is determined by the management of the fracture site. The position of the incomplete lesion is, therefore, the same as that for the complete lesion. Where severe hypertonia is a complicating factor, it may be necessary to avoid the supine position and to use pillows and sandbags to support the fracture site and keep the patient in side-lying. If the extensor aspect of the patients body is in contact with the bed, as is the case even when on his side on the EgertonStoke Mandeville electric turning bed, a stimulus is provided for him to push against which may exacerbate his hypertonus and might therefore be contraindicated.
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The frog position, where the hips are abducted, laterally rotated and exed to approximately 40, can be used to break up severe extensor hypertonus (Fig. 15.4). Patients positioned in this way to control extensor tone should be closely monitored for any increase in exor tone, as it is possible to reverse the pattern of hypertonus completely. Alternate positioning of the arms is also recommended in certain spinal injury units. The crucix position and positioning of the arms in lateral rotation (Fig. 15.5A, B) should be used with caution as they are at the extreme end of range. Any shortening of, for example, the pectoral muscles or medial rotators of the shoulder may place undue stress on an already vulnerable joint. The neural structures may also become shortened and specic tension tests are recommended to maintain or restore adaptive lengthening of the nervous system (Davies 1994, Panturin 2004).
Figure 15.4 Frog position.
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B Figure 15.5 Positioning of arms. A: The arms in lateral rotation. B: Crucix.
Clearly the aim is to prevent this shortening occurring in the rst place, but even with the most rigorous intervention with regard to positioning and movement in the early stages, it is very difcult to replicate the full repertoire of normal movement. Any normal subject lying in the crucix position will appreciate the discomfort felt over a relatively short period of time.
Passive/active movement
Assisted movements should be carried out with the patients full awareness and participation. Regenerating axons in the adult CNS are capable of forming synapses with both appropriate and inappropriate target neurons. Facilitation of appropriate patterns of activity will assist in establishing functional connections between regenerating supraspinal axons and spinal neurons (Muir & Steeves 1997).
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Motor learning is an active process and can only occur as a result of relatively permanent changes in the capability for skilled movement (Schmidt 1991). Passive movement, while of value in maintaining muscle and joint range, does little to effect functional change unless there is some participation on the part of the patient. As such, the term passive is inappropriate in that the patient should always be involved in the activity. In the early stages following spinal cord injury, no active movement may be possible. However, given that there is often signicant anatomical continuity across the injury site, even in patients with minimal function below the lesion (Dimitrijevic et al 1983), it is imperative to ensure that the patient is aware of, and contributes to, the desired movement. The physiotherapist must appreciate changes in tone and, by her handling, modify this tone before taking the limb through normal joint range. If movements are performed in this way, with close communication between patient and therapist, there will be less danger of trauma and of the joints becoming painful and contracted. Effort during movement should be avoided where hypertonus is present. The physiotherapist gives sufcient guidance and assistance to the patient to reduce to a minimum the effort required to perform the movement. This is particularly important where pathological movements may jeopardize stability at the fracture site. Some patients may be particularly sensitive to any stimulus, even removal of the bedclothes prior to doing the movements and, with cervical lesions it may be necessary for another person to support the shoulders to eliminate excessive movement around the fracture site. In the majority of patients, extensor hypertonus is the dominant pattern in the lower limbs (Bajd et al 1989) and this posturing may also be in evidence in the arms and trunk of a patient with a high cervical lesion. A combination of both exor and extensor hypertonus frequently occurs and movement initially may be from one total pattern to the other. In those cases where there is severe extensor hypertonus, it may be necessary initially to move the limbs into the total exor pattern in order to have any effect on the predominant extension. After breaking up the total extensor synergy, it is important to work recovering muscles out of any stereotyped pattern. For example, with the leg exed, the patient is encouraged to use any active hip exion with adduction and medial rotation and, when moving into extension, this should incorporate abduction and lateral rotation, always maintaining control to avoid an extensor thrust. Partial preservation of brain inuences contribute to the central excitatory state of segmental reexes and hypertonia and, as control of movement improves, there is often a notable reduction in the level of hypertonicity (Maynard et al 1990).
Compensatory movements
Teaching compensatory movement patterns may be considered to be inappropriate in the early stages, but this is dependent upon the
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functional outcome. For example, for patients with a complete C6 lesion, in the absence of triceps, extension of the elbow can only be accomplished by means of lateral rotation at the shoulder with distal support at the hand. Although the resultant movement is compensatory, it in no way precludes recovery of triceps. Clinical experience suggests that the reverse is true, in that with extension of the elbow and using this movement in functional activities, activity in triceps is stimulated. It has been shown that the cortical representation of extensor carpi radialis varies according to the function. Some parts of its cortical representation are concerned with this muscle as a prime mover, for example when used in the tenodesis grip, while others are concerned with its role as a stabilizer of the wrist during movements of the hand (Turton et al 1993). The early use of the tenodesis grip is therefore more difcult to substantiate. Patients with no nger movement but with wrist extension will readily use a tenodesis grip to maximize function. However, if nger movements then recover at a later date, it is often difcult for the patient to cease to rely on this grip, thereby impeding functional use of the ngers. Compensatory movement must therefore be viewed on merit in the light of the presenting signs and symptoms and the expected prognosis, always assuming a positive outcome.
The shoulder
Patients with cervical cord damage, particularly those with central cord lesions, will invariably have abnormal movement at the shoulder due to the imbalance of muscle activity (Roth et al 1990). The shoulder joint is the most mobile joint of the body, sacricing stability for this mobility. With paralysis or weakness of the muscles around the shoulder, functional activities are severely compromised. It is essential to understand the components of normal activity at the shoulder in order to prevent trauma and possible contracture through inappropriate handling and movement. The shoulder joint cannot be viewed in isolation. Movements of the shoulder joint are dependent upon the integrity and responsiveness of the shoulder girdle, trunk, pelvis and lower limbs. For example, full elevation of the arms is dependent upon adequate extension within the thoracic spine (Crawford & Jull 1993). The normal shoulder mechanism is dependent upon the structure and relationship of seven articulations (Fig. 15.6). The scapula lies in a slightly laterally rotated position, there being a ratio of approximately 2 : 3 in the distance between the medial edge of the spine of the scapula and the vertebral column, and the inferior angle and the vertebral column (Fig. 15.7A). The glenoid fossa faces anteriorly, laterally and superiorly in its articulation with the head of the humerus. This relationship between the head of the humerus and the glenoid fossa provides a degree of stability described as the locking mechanism of the shoulder (Basmajian 1978).
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7 3 2 1 4 5 6
Figure 15.6 Composite drawing of the shoulder girdle. 1, Glenohumoral; 2, suprahumeral; 3, acromioclavicular; 4, scapulocostal; 5, sternoclavicular; 6, costosternal; 7, costovertebral. (From Cailliet 1987.)
Figure 15.7 Relationship of the shoulder girdle and vertebral column. A: Normal relationship. B: Abnormal relationship.
Functional movement of the upper limb requires coordination of movement between the glenohumeral joint and the scapula on a background of dynamic co-contraction and stability in the trunk. This interaction is dependent upon normal muscle activity. In patients with cervical cord damage, this muscle activity will be impaired.
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The patient with accidity/low tone, on assessment in the sitting position, demonstrates the following:
The scapula adopts a more vertical position (Fig. 15.7B), the inferior angle lying the same distance from the vertebral column as the spine of the scapula. Winging of the scapula is apparent. The glenoid fossa lies vertically in its articulation with the head of humerus, thereby creating a position of abduction at the glenohumeral joint. This nullies the locking mechanism and the support of the arm now depends primarily on the capsule and the coracohumeral ligament. Subluxation frequently occurs. The upper bres of trapezius become hyperactive in an attempt to counteract the weight of the upper limb.
The patient with neural hypertonia presents with similar malalignment, but the situation is exacerbated by the increased tone:
The scapula will be pulled medially towards the vertebral column under the inuence of the rhomboids. In extreme cases, the position of the inferior angle of the scapula will be closer to the vertebral column than that of the medial aspect of the spine of the scapula. Winging of the scapula is often pronounced. The degree of abduction at the glenohumeral joint may be increased. Hypertonia of the medial rotators of the upper limb will cause further malalignment of the glenohumeral joint and may give rise to anterior subluxation. In some cases, the medial rotators of the upper limb may become shortened.
Movements of the arm away from the body will, in this situation, create a hypermobile scapula. The inferior angle will rotate laterally around the chest wall and there will be little or no isolated movement at the glenohumeral joint. Because of the variability in injuries sustained, it is not possible to describe in detail the particular problems that any one patient with cervical cord damage will have. It is important to recognize that although contractures are more likely to occur in the presence of hypertonia (Yarkony & Sahgal 1987), profound disability has been reported as a result of reduced joint mobility in patients with GuillainBarr syndrome, a peripheral CNS disorder (Soryal et al 1992). This analysis describes a basic concept of normal movement, to enable the therapist to identify the patients individual problem(s) and select appropriate treatment techniques. In every case, treatment must attempt to restore a more correct alignment of the upper limb, shoulder girdle and trunk. Movements of the upper limb, be they passive or active, must be performed with a full understanding of the normal shoulder mechanism and an accurate analysis of the patients problem.
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The pelvis and gait

Extensive work has been carried out in the eld of gait analysis taking into consideration:

kinematics monitoring the gait pattern electromyography monitoring muscle activity kinetics monitoring forces that produce change/motion efciency of gait measuring energy expenditure, speed and endurance.
An understanding of these aspects of normal gait is invaluable when assessing patients with incomplete spinal cord damage. This detailed analysis using highly sophisticated equipment allows the primary errors in walking to be distinguished from compensatory changes, which is essential in planning effective treatment (Sutherland 1992). The different problems that may arise as a result of incomplete spinal cord damage are too numerous and diverse to enable a standardized treatment approach. However, there are certain aspects of gait which must be considered with observational analysis and in planning treatment:

the quality of postural tone, both the neural and mechanical components the speed and efciency of gait the midline orientation of the central key point and the proximal key points of the shoulder girdles and the pelvis in terms of the sagittal, coronal and transverse planes the ability of the feet to accept the base of support.
In addition, each patient must have a full neurological assessment to determine the motor and sensory decit. Special attention must be paid to aspects such as skeletal deformity or surgical intervention in the form of vertebral fusion or the insertion of, for example, a Harrington rod. Normal walking is dependent upon a continual interchange between mobility and stability, which requires free passive mobility and appropriate muscle action (Perry 1992). Box 15.1 provides a summary of normal muscle activity and function during gait. This box illustrates the complexity of gait. The muscles identied do not have one single action but may work concentrically, eccentrically or isometrically at different stages of the gait cycle. This is of particular relevance when considering the use of muscle or nerve blocks. For example, the role of the plantarexors during gait is to contribute to knee stability, provide ankle stability, restrain the forward movement of the tibia on the talus during stance phase, and minimize the vertical oscillation of the whole-body centre of mass (Sutherland et al 1980). Therefore, whilst muscle or nerve blocks will reduce undesirable hyperactivity such as may occur with hypertonia, they may also lead to knee and ankle instability and increased energy expenditure.
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Box 15.1 A summary of normal muscle activity and function during gait (after adaptation by Gage 1991, after Perry 1989, with permission from Cambridge University Press)
Terminal swing Muscle function. Ends swing and prepares limb for stance.

Hip exors these muscles are usually not active at this time Hamstrings eccentric action decelerates the forward swing of the thigh and leg Quadriceps concentric action to extend knee for stance Tibialis anterior ankle dorsiexion supports the ankle at neutral to prevent foot drop
weight line which results in knee exion Quadriceps eccentric contraction to decelerate knee exion and absorb shock of oor contact Gluteus maximus concentric action to extend hip and accelerate trunk over femur. Its action through the iliotibial band contributes to knee extension Adductor magnus concentric action to advance and internally rotate pelvis on stance limb Gluteus medius eccentric action to abduct hip and stabilize pelvis to minimize contralateral pelvic drop
Peroneals stabilize the foot against inversion forces Long toe exors stabilizes metatarsophalangeal (MTP) joints to augment forefoot support
Pre-swing Muscle function. Muscle control ends stance and prepares limb for swing.

Midstance Muscle function. Acts to allow smooth progression over a stationary foot while controlling position of the GRF referable to hip and knee.
Gastrocnemius may unlock the knee so that it may resume exion Adductor longus concentric action advances the thigh Rectus femoris eccentric action at knee to decelerate the inertia of the shank. Concentric action at hip to augment hip exion
Initial contact Muscle function. Acts to allow smooth progression and stabilizes joints while simultaneously decelerating the bodys inertia.
Initial swing Muscle function. Provides ability to vary cadence and maintain foot clearance.
Gluteus maximus controls exor moment produced by ground reaction forces (GRFs) Hamstrings inhibit knee hyperextension and assist in controlling exion moment at hip Tibialis anterior initiates the heel rocker
Soleus eccentric action to decelerate ankle dorsiexion over the planted foot during the period of the second rocker Quadriceps stabilizes exed knee. Action ceases when GRF vector passes in front of knee Gluteus maximus ceases action when GRF becomes posterior to hip
Terminal stance Muscle function. Acts to provide acceleration and adequate step length.
Loading response Muscle function. Acts to allow smooth progression and stabilizes joints while simultaneously decelerating the bodys inertia.

Hamstrings concentric action unlocks the knee Tibialis anterior decelerates foot fall by eccentric contraction and pulls the tibia anterior to the bodys
Soleus intensity of action increases to limit dorsiexion. Also acts as invertor of subtalar joint to provide stability Gastrocnemius concentric action to stop forward motion of tibia and begin plantarexion of ankle Tibialis posterior stabilizes the foot against eversion forces
Hip exor group (iliacus, adductor longus, sartorius, gracilis) concentric action to advance thigh and works in conjunction with shank inertia to create knee exion Biceps femoris (short head) augments knee exion during slow gait when inertial forces are inadequate Tibialis anterior concentric action to dorsiex foot Long toe extensors concentric action with tibialis anterior to dorsiex foot
Midswing Muscle function. Little muscle action necessary because inertial forces are propelling the limb.
Tibialis anterior concentric action to prevent foot drop
Normal gait has four major attributes which are frequently lost in abnormal gait. These are:

stability in stance sufcient foot clearance during swing appropriate swing-phase pre-positioning of the foot an adequate step length (Gage 1992).
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For example, with predominant extensor tone, both legs are used for weight-bearing, preventing adequate exion of the moving leg. The most obvious features are:
extensor hypertonus of the lower limbs with adduction and medial rotation at the hips and plantarexion and inversion at the ankle and foot a posterior tilt of the pelvis compensation of the trunk and upper limbs, which is dependent upon whether or not the arms are used for support or balance.
The compensatory mechanisms often used to overcome this pathological activity include the following:
The patient rises higher on his toes, throwing his trunk backwards to propel the moving leg forward with a minimum of exion at the hips and knees. The patient walks with a scissor gait with gross overactivity of the upper limbs to preserve balance. With the increased extensor activity in the trunk, the tilt of the pelvis may be altered, the resulting anterior tilt reversing the pattern of hypertonia in the legs to one of exion. Use of crutches or a frame may result in overuse and xation into exion of the upper limbs and trunk.
The positive support reaction is invariably present. Treatment must therefore combine desensitization of the feet with appropriate reeducation and facilitation of more normal standing balance and gait. Treatment will be determined by the compensatory mechanism used by the patient. It is important to realize that in many patients it is possible to completely reverse the pattern of hypertonia. There is inadequate normal extensor activity in the supporting limb, and facilitation of exion of the moving limb may produce a reciprocal inhibitory effect in the supporting limb, causing the patient to collapse. It must be appreciated that some patients depend upon their extensor hypertonus to allow them to walk. Whilst it is important to inhibit this pathological synergy in order to facilitate more normal extensor activity, over-inhibition may prevent the patient maintaining himself upright against gravity. There is a very ne line between a functional gait, albeit abnormal, and the wheelchair-bound patient. The essential requirement for normal walking is a comprehensive feedback system affording balance, stability and selective movement. This can only exist on a background of normal postural tone and full range of movement of muscles and joints. Although the lower limbs provide the dynamic movement component of gait, postural stability within the trunk and contralateral arm swing are equally important. The importance of the pelvis in providing dynamic stability throughout the gait cycle cannot be overemphasized. It provides the
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integration of all phases of the gait cycle, allowing for movement at the swing phase and stability during the weight-bearing stance phase, with reciprocal interchange of action. For example, exor hypertonia of the lower limbs is associated with an anterior pelvic tilt with compensatory hyperextension of the lumbar spine and overuse of the upper limbs for balance. Treatment in this instance would initially be in standing, to encourage normal extensor activity in the legs (Brown 1994) while mobilizing the pelvis to prevent the often unnecessary degree of compensation (Edwards 2002). Basic principles of treatment which should be observed in all cases include:

Standing balanced with the body in correct alignment and with the weight taken throughout the entire surface of the feet. Standing without using the arms. If this is impossible the patient is encouraged to use his arms for balance only, rather than for weight-bearing. If the patient learns to push down with the hands in front, the weight is brought forward over the ball of the foot. This will tend to elicit the positive support reaction in those patients with hypertonia and predisposes to exor contractures of the hips. Pelvic control. Pelvic alignment and stability are essential to ensure dynamic control of the lower limbs. Weakness or paralysis of the hip abductors and extensors, producing instability at the pelvis, may well give rise to hyperextension of the knee. Treatment must be directed at improving control at the pelvis rather than correction of the more apparent problem at the knee (Edwards 2002). Weight transference in both the sagittal and coronal planes with appropriate release of the non-weight-bearing leg. Selective movement of the lower limb without excessive use of the trunk.
The use of splints or orthoses must be carefully assessed. In normal gait, foot clearance is only 0.87 cm (third of an inch) in midswing, leaving very little room for error (Gage 1992). Weakness of the dorsiexors or excessive tone or shortening of plantarexors will compromise a normal gait pattern and lead to compensatory mechanisms such as a high stepping gait or hip hitching. The therapist must determine the benets or otherwise of anklefoot orthoses, or indeed kneeanklefoot orthoses (KAFOs), depending on the degree of paralysis, abnormal tone and changes in muscle length. For detailed information regarding the use of splints and orthoses see Edwards & Charlton (2002). Functional electrical stimulation (FES) has been reported to be effective in the treatment of incomplete spinal cord injured patients (Biss & Fox 1988, Granat et al 1993, Stein et al 1993) and has been recommended as an orthotic approach in the management of patients with incomplete spinal cord injury (Bajd et al 1989). Stimulation of the common peroneal nerve stimulates the exor withdrawal
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response, thereby aiding the swing-through phase of gait (Granat et al 1993). It has been suggested that FES may be of assistance in the prevention of pressure ulcers, contractures, muscle atrophy and bone demineralization (Bajd et al 1989). More recent advances in gait training for these patients include the use of a treadmill with the body weight supported (Fung et al 1990, Dobkin et al 2003, Dietz et al 1995, Muir & Steeves 1997). Barbeau (2003) highlighted the importance of task specicity with regard to the use of treadmill training with supported body weight for patients with incomplete spinal cord injury. Rehabilitation approaches that focus on reducing hypertonia or are non-specic, such as passive stretching or general home exercises, are unlikely to have any benecial effect on functional locomotion. It is suggested that by supporting the body weight with treadmill training, the activation of hypertonia and some of the functional consequences of disordered motor control may be reduced (Dobkin 1994). The spinal cord has the capacity not only to generate a locomotor pattern, but also to learn (Dietz 2003). This method of enhancing lower limb movement may prove useful in guiding and strengthening functional synapses of regenerating axons to maximize their contribution towards restoring function (Muir & Steeves 1997, Dietz 2003).
Walking aids
Although it has been suggested that the use of assistive devices such as parallel bars may lead to overcompensation (Barbeau 2003), in many instances some form of walking aid is necessary to enable patients with incomplete spinal cord injury to attain an independent gait. Where possible, the aid should be used to assist balance rather than as a means of support but inevitably this will depend on the degree of impairment. Crutches, a rollator or the patients own wheelchair are preferred to a frame, as they enable the patient to obtain a greater degree of hip and trunk extension and in consequence a more normal walking pattern. With the frame in the forward position, prior to the patient taking a step, exion and retraction occur at the hips, thereby increasing the danger of hyperextension of the knees. If either one or two sticks are required, they should be slightly higher than is usually prescribed (to the height of the greater trochanter). This prevents the patient using them for excessive support and initiating walking by means of trunk exion and trunk side-exion.
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Orthoses and splints

The choice of orthosis will depend upon the degree of paralysis and the severity of hypertonia. Not only the rehabilitation staff but also the patient must be involved in this choice. Unless the patient believes that the orthosis will benet him and is prepared to use it, there is no value in supplying one. There has been considerable improvement in the orthoses available, with particular emphasis on their cosmetic appearance. The lightweight, moulded orthoses or the toe-off orthoses are often appropriate for patients with accid paralysis and may also be used for some patients with hypertonus (Edwards & Charlton 2002). To assess the benet of a below-knee orthosis, a bandage can be used to maintain the foot in dorsiexion. Where hypertonus is present, the bandage must hold the foot in eversion as well as dorsiexion to inhibit the overactivity in the invertors (Fig. 15.8). Not only does this allow the physiotherapist to assess the patients gait with the appropriate correction, but it also indicates if the patient is likely to develop proximal hypertonia in response to the corrective device on his foot. The main disadvantage of this bandage is that it may restrict the blood ow to the lower leg and can therefore only be used for short periods of time. Splinting materials may also be used as an adjunct to treatment and/or as a means of evaluating the effect of a more permanent orthosis. A combination of Softcast and Scotchcast splinting materials is increasingly being used in clinical practice to support or maintain range of movement of a limb. Softcast is impregnated with a polyurethane resin, which sets on exposure to water or the air (Schuren 1994). Once set, this material has a rubberized texture which provides only semi-rigid immobilization. Reinforcement with Scotchcast enables specic control across a joint as the clinical presentation dictates. Details of the use of these materials are to be found in Edwards & Charlton (2002). Patients with incomplete spinal cord injury show varied problems necessitating different orthoses or casts which can range from KAFOs or back slabs to a single below-knee splint. Splints may also be required to maintain range of movement in the upper limb or to provide stability at one joint to facilitate movement at another. They are frequently used as an adjunct to treatment following treatment with botulinum toxin. Great care is taken with selection and the patient must be assessed at regular intervals following discharge from hospital to ensure that the orthosis remains appropriate to his needs.
Gymnastic ball
Treatment using the gymnastic ball was originally devised by KleinVogelbach (1980) and was adapted for use in neurological conditions
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Figure 15.8 Application of bandage to hold the foot in dorsiexion and eversion. Note the small band of foam (A) to protect the skin from the pressure of the bandage.
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by Hasler (1981); a comprehensive description of the use of the ball is to be found in Carriere (1999). The ball, which is made of resilient hard plastic, comes in various sizes and may be used with good effect in the treatment of some patients with incomplete spinal cord injuries (Silva & Luginbuhl 1981). The choice of size depends upon the reason for which the ball is being used and the physical proportions of the patient. The ball is useful:

as a means of inhibition and proximal mobilization where there is excessive hypertonia in retraining balance reactions and coordination, thereby improving body awareness in giving controlled strengthening exercises where weakness of specic muscle groups is apparent.
It is essential that the patient is totally condent and unafraid. If the patient is frightened, not only will the treatment be ineffective, but it may cause a signicant increase in hypertonicity and therefore prove to be detrimental (Lewis 1989). It is also important to appreciate that, although the ball is widely used in many areas of neurological rehabilitation, there is no evidence to date to support the effectiveness of this intervention (Jackson 2004).
More recent advances in the medical management of increased tone

Botulinum toxin for the management of focal hypertonia and intrathecal baclofen for the treatment of more global hypertonia are increasingly being used in the management of patients with neurological disability.
Botulinum toxin
Botulinum toxin is a potent neurotoxin which produces temporary muscle weakness by presynaptic inhibition of acetylcholine release at the neuromuscular junction (Hambleton & Moore 1995). This weakness does not occur immediately but usually takes between 10 and 14 days, depending on the size of the muscle injected and the dosage. Recovery occurs over a period of approximately 10 to 12 weeks through terminal sprouting. Botulinum toxin is widely accepted as an effective treatment for focal dystonias and it is licensed for use in the treatment of blepharospasm, hemifacial spasm, cervical dystonia, the upper limb following stroke and the lower limb in children with cerebral palsy. It is only more recently that the use of botulinum toxin in the treatment of hypertonia has become more established, although there is still considerable variation between studies (Thompson 2002).
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Where specic localized muscles are considered to be a major inuence in the production and maintenance of hypertonia, botulinum toxin may be a useful adjunct to rehabilitation. The main reasons for its use in the treatment of spasticity are to:

redress problems created by muscle imbalance enable improved hygiene evaluate the effects of surgery, primarily for children with cerebral palsy (Cosgrove et al 1984).
The purpose of intervention with botulinum toxin is to weaken the dominant overactive muscle or muscles to enable clearly identied treatment goals to be accomplished. For example, patients with a positive support reaction are unable to transfer their weight over the full surface of the foot during stance phase of gait due to hypertonia of the posterior crural muscles. The compensatory strategies which may be adopted by the patient in response to this reaction are described above (p. 293). Treatment of the overactive muscles with botulinum toxin weakens the calf muscles, enabling an improved gait pattern for the duration of the toxins effect. It is hypothesized that during this period, the improved gait pattern will become established as a more normal motor programme, thereby enabling carryover in the longer term (Scrutton et al 1996, Richardson et al 2000). However, the adverse effects that this weakness may have on gait have been discussed (p. 302) and the toxin should be used with caution. Patients with incomplete spinal cord lesions may also have muscle imbalance which is due to dominant muscle activity precluding recovery of the weaker antagonists. Botulinum toxin has been used successfully in the treatment of a patient with an incomplete C6 lesion. Recovery of the nger extensors was impeded by the dominance of nger and thumb exion and reliance on a tenodesis grip. Using a combination of botulinum toxin to weaken the dominant exor muscles and a removable cast to control the position of the wrist in a neutral position, this prevented the use of the tenodesis grip. Over the course of 12 weeks the patient developed sufcient control to enable functional use of his nger extensors (Richardson et al 1997). The use of botulinum toxin in the treatment of hypertonia differs from that in the treatment of focal dystonia. Patients with focal dystonia usually attend at 3-monthly intervals for reinjection. For patients with hypertonia, the treatment may be only a single event which should always be used in conjunction with therapy. Splinting is often of value to supplement the effects of the toxin. If splinting is to be incorporated as part of the therapy programme, application of the cast should be delayed until the effects of the toxin are apparent, 5 to 7 days after injection. It is essential to determine that the cause of the movement impairment is due to overactivity and not to mechanical changes of muscle and soft tissue. Botulinum toxin weakens muscle and it is therefore of no use whatsoever for patients who no longer demon-
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strate increased muscle activity, characteristic of neural hypertonia. Assessment with electromyography (EMG) is therefore recommended (Thompson 2002). It is possible to identify the more supercial muscles with surface EMG electrodes, but the more deeply sited muscles require needle EMG to ensure accurate administration of the toxin. Criteria for effective use of what is an expensive treatment are:

identication of the clinical problem the use of EMG to con rm increased muscle activity as the cause of the movement disorder an ongoing therapy programme to re-educate movement for the duration of the toxins effect.
Botulinum toxin is suitable only for more focal hypertonia, as the dose that can be administered is limited. Patients with more widespread stereotyped pathological patterns of the lower limbs may be more effectively managed with intrathecal baclofen.
Intrathecal baclofen
Baclofen is a gamma-aminobutyric acid (GABA) receptor agonist. GABA is the major inhibitory neurotransmitter of the central nervous system. Baclofen binds to GABA receptors and has a presynaptic effect on the release of excitatory neurotransmitters. It also acts postsynaptically, directly decreasing the ring of motor units (Losseff & Thompson 1995). Oral baclofen does not readily cross the bloodbrain barrier but is equally distributed to the brain and spinal cord. This may lead to centrally mediated effects such as drowsiness, dizziness and confusion without adequate relief of spasticity. Intrathecal administration permits direct access of the drug to the receptor sites in the dorsal horn of the spinal cord, thereby minimizing these central effects (Porter 1997). Doses of less than one-hundredth of those required orally have been shown to be effective in the management of hypertonia (Thompson 2002).
Indications for usage

Uncontrolled hypertonus may be so severe as to cause pain, interrupt sleep and interfere with function. Although more widely used in the treatment of patients with complete spinal lesions and multiple sclerosis with severe exor hypertonia, intrathecal baclofen is also effective in regulating increased tone in patients with incomplete cord lesions. Severe hypertonus may mask underlying active movement and reduction of this may enable the patient to utilize this potential function. In spite of the potential side effects of oral baclofen, this would always be the method of choice. It is only those patients who are refractory to oral administration, or who have intolerable side effects, who may be considered suitable for intrathecal baclofen.
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The patient must be free of noxious stimuli such as pressure ulcers, infection or constipation as these may prevent an accurate assessment of the patient (Porter 1997).
Delivery system
The delivery system consists of a pump which lies subcutaneously in the abdomen with a reservoir of baclofen which is connected to the intrathecal space by means of a catheter. The dose can be titrated to the individuals need, delivering bolus or continuous infusion at a predetermined rate (Losseff & Thompson 1995). The pump needs to be re lled every 412 weeks and the dose adjusted as required (Gianino 1993). The patients response to intrathecal administration of baclofen is assessed by means of a bolus injection given via a lumbar puncture before proceeding to permanent infusion (Thompson 2002). Potential complications include respiratory distress and infection, and technical problems such as pump malfunction or problems with the catheter have been reported (Losseff & Thompson 1995). It is recommended that this procedure is carried out in a specialist centre where there are standardized protocols and patients are regularly monitored. Depending on the severity and possible functional use of the spasticity, the dose may be a simple continuous cycle or less during the day to enable function and more at night to allow sleep (Gianino 1993). Intrathecal baclofen may be contraindicated in patients who depend on their hypertonus for function. For example, patients who are ambulant, albeit with a grossly pathological gait pattern, may no longer be able to walk following this intervention. The majority of patients in this situation will opt to keep mobile for as long as possible unless the purpose of the intervention is management of pain.
SUMMARY
Patients with incomplete spinal cord lesions demonstrate many different and diverse movement disorders necessitating thorough assessment and individualized treatment programmes. The prognosis is less predictable than for patients with complete lesions and the therapeutic management must reect the variability of the presenting signs and symptoms. This chapter provides a basis for a problem-solving approach to treatment. Improved understanding and awareness of movement enable the therapist to identify how a posture or movement differs from the normal and thereby to select appropriate treatment strategies. For those patients with non-progressive pathology, throughout all stages of rehabilitation, treatment is aimed at improving functional abilities without the use of unnecessary compensation. However, patients with progressive pathology, for example those with carci-
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noma, may benet from the use of early compensation to allow them to return home as soon as possible to give them the maximum time in their familiar environment. The restoration of function is the ultimate goal of rehabilitation, but all too often this is not achievable for patients with extensive neurological damage. There must be a balance between re-education of more normal movement patterns and acceptance and indeed promotion of necessary and desirable compensation (Edwards 2002). As previously stated, the therapeutic skill lies in determining that compensation which is necessary, and even essential, for function and that which is unnecessary and potentially detrimental to the patient.
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Sutherland D H 1992 Gait analysis in neuromuscular diseases. In: Perry J (ed) Gait analysis: normal and pathological function. Slack Inc, New Jersey Sutherland D H, Cooper L, Daniel D 1980 The role of the ankle plantar exors in normal walking. Journal of Bone and Joint Surgery 62A:354363 Thompson A J 2002 Drug treatment of neurological disability. In: Edwards S (ed) Neurological physiotherapy: a problem-solving approach, 2nd edn. Churchill Livingstone, London Topka H, Cohen L G, Cole R A, Hallet M 1991 Reorganisation of corticospinal pathways following spinal cord injury. Neurology 41:12761283 Tow A, Kong K 1998 Central cord syndrome: functional outcome after rehabilitation. Spinal Cord 36:156160 Turton A, Fraser C, Flament D et al 1993 Organisation of corticomotorneural projections from the primary motor cortex: evidence for task-related function in monkey and in man. In: Thilmamm A F, Burke D J, Rymer W Z (eds) Spasticity: mechanisms and management. Springer-Verlag, London Vrbova G, Gordon T, Jones R 1995 Nerve-muscle interaction. Chapman and Hall, London Waters R L, Sie I, Adkins R H, YaKura J S 1995 Motor recovery following spinal cord injury caused by stab wounds: a multicenter study. Paraplegia 33:98101 Yarkony G M, Sahgal V 1987 Contractures: a major complication of craniocerebral trauma. Clinical Orthopaedics and Related Research 219:9396 Young W 1994 Neurorehabilitation of spinal cord injury. Journal of Neurorehabilitation 8:39
Spinal cord injury in children

Ebba Bergstrm
INTRODUCTION
Children with spinal cord injury (SCI) who are under the age of 16, and particularly before they have reached maturity, have special rehabilitation needs because of the ongoing physical, intellectual, psychological and social development (Vogel & Betz 1996). Although the rehabilitation is largely the same as for adults with SCI, there are many aspects that are specic to young children. This chapter will principally deal with those aspects of management specic to children with SCI. Growth and maturity inuences all aspects of the care and management. The development of the skeleton is affected by a neurological injury such as SCI. It predisposes the child to joint contractures and spinal deformity. Spinal deformity in particular is then in turn exacerbated by growth. It is the most common and severe complication for a child following SCI. The rehabilitation process should continue until skeletal development is completed and the child is sufciently mature to care for him/herself. Close links with parents, carers, school and local healthcare agencies must be established. Teaching, of all those involved with the child, in the consequences and complications of childhood SCI is also an important part of the rehabilitation. The incidence of SCI in children under 13 years is much less than in teenagers and adults (510% of the adult incidence) (Vogel & De Vivo 1996). The cause of accidents is similar to the adult population and always reects the surrounding society. In the industrialized world, road trafc accidents are the most common cause of injury (including a larger proportion of pedestrian injuries among children), followed by falls from heights, sporting injuries and assault. In some urban areas, gunshot wounds are reported to equal the number of road accidents (Haffner & Hoffer 1993, Montes 1996) and in some reports they are higher. The immature spine has anatomical and structural characteristics. The head is proportionally larger, the cervical spine proportionally longer and the facet joints are more horizontal. Children are therefore vulnerable to certain traumas. They have a higher frequency of upper cervical cord injuries than teenagers and adults. Spinal cord injury
CHAPTER
16
Introduction 319 Spinal deformity 320 Growth 321 Spinal column 321 Contractures 326 Tone 329 Sleeping posture 329 Management 329 Modications necessary to adult rehabilitation programme 334 Postural sensibility 334 Mat work 334 Muscle strength 336 Dressing and self-care 336 Transfers 336 Wheelchair 336 Involvement of parents 337 Involvement of the school 337 Follow-up 338 Research ndings 340
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without radiographic abnormalities (SCIWORA) (Osenbach & Menezes 1989, Pang & Pollack 1989) is common among the young. It has been suggested that, through its elasticity and cartilaginous properties, the spine of a young child can withstand gross distortion, especially in exion and rotation, without fracturing bones. The spinal cord cannot stand the same degree of stretch; consequently, traction results in cord damage. However, with modern radiological diagnostic tools, such as magnetic resonance imaging, it is now possible to detect changes to the spinal cord and the term SCIWORA should therefore be used with care. An approximately equal number of spinal cord lesions in children as in adults result from non-traumatic lesions caused by transverse myelitis, vascular accidents and cysts or tumours. The aim of rehabilitation is the same for the child with SCI as for the adult, namely to:

maximize potential in order to reach as high a degree of independence as possible teach the individual and their carer how to prevent and manage complications.
A childs rehabilitation potential depends on age (developmental stage) and size as well as on the extent of the neurological damage. The childs normal chronological development will have an inuence on the timing and progression of rehabilitation. Some skills may have to be postponed until the child is mature enough to tackle them. For example, it is inappropriate to teach a 2-year-old to dress or a 5-yearold to catheterize himself. The size of the child may also mean that some transfer techniques need to be modied. All these factors need to be taken into account when planning rehabilitation and management of the spinal cord injured child. Rehabilitation is a continuous process throughout childhood and adolescence till physical, psychological and general maturity is reached. Regular assessments are essential to identify the need for and timing of rehabilitation periods. Specic aspects of the management during these rehabilitation periods will be addressed (e.g. transfers, dressing, bladder and bowel management). During the acute phase, physiotherapy for the child is the same as for the adult patient. Some modication to therapy is required in certain aspects of rehabilitation (as will be discussed later) but the major difference in the treatment of children is in the approach to the management and monitoring of contractures and the development of the spine in the presence of neurological decit.
SPINAL DEFORMIT Y
The most serious and common complication following paediatric SCI is spinal deformity and contractures (Lancourt et al 1981, Mayeld et al 1981), which are strongly correlated to age at onset of
SPINAL CORD INJURY IN CHILDREN
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paralysis and level of lesion (Bergstrm et al 1999). Those injured in early childhood and those with paraplegia develop more severe curves but virtually all children are likely to develop some degree of deformity. The sequence of events and the reasons for the development of spinal deformity are not completely understood but many factors play a part in this development. Continual growth and an immature skeleton are obviously what sets children apart from adults and exaggerate the development and speed of the processes below:

the posture collapses due to paralysis under the inuence of gravity asymmetrical neurological lesions causes asymmetrical pull on the skeleton contracted joints will pull the spine out of its normal alignment muscles lengthen on the convex side of the curve and shorten on the concave side bones that are not supported by a normal neuromuscular system change shape.
Other important factors are spasticity and sleeping postures.
Growth
Growth is mainly determined by genetic factors and growth hormones. The functional use and loading of the skeleton are other factors inuencing growth. The use of the skeleton is severely altered after a spinal cord injury. Any bone tissue in the body that has an excessive repetitive force applied to it will form itself accordingly. The immature skeleton is particularly susceptible to such stress and reshaping. The growth will also exacerbate this process by laying down the bone growth according to the stresses exerted upon it. For children with SCI it is therefore very important that a correctly aligned posture is maintained at all times, except when engaged in sport, play or other specic tasks that are part of a normal movement pattern.
Spinal column
Collapsing spine
The collapsed posture, so commonly seen following SCI, is caused by the paralysis itself. The muscles that kept the body upright before paralysis can no longer do this; therefore gravity will pull the body down. The spinal column, with its multitude of bones and joints, is particularly susceptible to this lack of support and will collapse (Figs 16.1, 16.2, 16.3). The de nitive shape that the spine adopts will
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Figure 16.1 (left) Forward exion. Patient aged 9 years (injured at 2 years) with a complete lesion below T5. Figure 16.2 (right) Side exion. Patient aged 11 years (injured at 5 years) with a complete lesion below T6.
vary and develop individually with each child, depending on the particular distribution of paralysis and spasticity as well as their habits of moving, sitting and sleeping. The spine may collapse into exion, giving rise to a long kyphotic C curve which results in weight-bearing on the sacrum and total obliteration of the lumbar lordosis (Fig. 16.1). In most cases, this posture will be accompanied by external rotation of the femur and, in time, extension contracture of the hip which makes correction of the posture difcult. The spine may collapse into side exion with rotation of the vertebral bodies, causing a long C-shaped scoliosis with an oblique pelvis or a lumbar scoliosis with a compensatory curve above it (Fig. 16.2). The collapsing spine is readily correctable with traction (or, as in Fig. 16.4, self traction by lifting) but in time develops severe structural change.
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Figure 16.3 (left) Correction of spinal deformity with traction. Patient aged 10 years (injured at 4 years) with a complete lesion below C7. Figure 16.4 (right) As Figure 16.3.
Scoliosis (due to uneven muscle activity)

Unilateral muscle pull due to asymmetrical neurological decit or spasticity of the thoracic and lumbar spine induces side exion or rotation of the trunk. This often means that the individual has to position himself further into the asymmetry in order to balance during two-handed activity, thus further increasing the risk of spinal deformity. Unilateral innervation of hip exors will pull the pelvis out of normal alignment and inuence the alignment of the spinal column.
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Reversal of the lumbar lordosis and thoracic kyphosis

Flattening of the lumbar lordosis, usually caused by poor sitting posture or extensor spasticity, will lead to compensatory extension of the spine higher up and attening of the thoracic kyphosis (Fig. 16.5). In severe cases, these curves are reversed to lumbar kyphosis and thoracic lordosis.
Hyperlordosis of the lumbar spine

This is associated with hip exion contractures that if allowed to develop, will make it difcult to stand and to t any standing orthosis (Fig. 16.6). This may be caused by active hip exor muscles, which
Figure 16.5 (left) Flattening of lumbar lordosis. Patient aged 11 years (injured at 8 years) with a complete lesion below C8. Figure 16.6 (right) Hyperlordosis of the lumbar spine. Patient aged 18 years (injured at 8 years) with a complete lesion below C7.
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tilt the pelvis forwards, or it may be secondary to an accentuated thoracic kyphosis due to a displaced fracture as well as postural collapse.
Secondary deformity of the ribcage

All scolioses will give rise to rotation of the spinal column. The rotation will cause a posterior rib hump on the convex side of the scoliosis (see Fig. 16.3). The ribs on the convex side will be more horizontal than normal, whilst those on the concave side will be more vertical (Fig. 16.7).
Summary
Any spinal deformity will add to the problems of paraplegia and tetraplegia. It will diminish the chest cavity and further decrease lung function. Pelvic obliquity causing uneven pressure will heighten the risk of pressure sores. Poor posture will inuence balance and general function. All spinal deformities will alter the position of the neck and may in future years cause musculoskeletal changes and give rise to
Figure 16.7 Postero-anterior X-ray of ribcage. The ribs on the convex side are more horizontal than normal, while those on the concave side are more vertical. The left lung volume is decreased.
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pain and impaired movement of the neck, shoulders and arms. A severe spinal deformity is also aesthetically unacceptable to most people and gives a negative self-image and reduces self-esteem.
Contractures
All joint contractures inuence the position of the adjoining joints. Limb contractures, particularly the hip joints, will determine the position of the pelvic and thus the spinal column. In many cases this is what initiates the development of the spinal deformity.
Hip joint
The angle between the neck of femur and the shaft is 150 in the newborn and reduces to 125 in the adult. The more erect angle of the femur contributes to poor development of the hip joint in those paralysed in early childhood. For the acetabulum and the head of the femur to form a stable joint with well-rounded surfaces, the hip joint has to be held and loaded in normal alignment (extension, neutral rotation and slight, 5, abduction). Internal rotation and adduction of the femur (whether by the femur exing on the pelvis or through pelvic obliquity and rotation on the femur) will give little or no surface contact in the joint. Poor development of the joint (Fig. 16.8) and a predisposition to subluxation or dislocation will follow.
Figure 16.8 Antero-posterior X-ray of pelvis. The left acetabulum is relatively at and the head of the left femur is grossly abnormal. (The apparent pelvic deformity is mainly projectional.)
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Contracture of the hip exor and shortening of the iliotibial tract and tensor facia lata mean that full extension of the hip joint may only be obtained in abduction it cannot be obtained with the limb in midline. In truth this masks a hip exion contracture; therefore, when passive movements are performed, correct alignment of the limb must always be maintained.
Knee joint
The knee joint of the toddler is in a varus position and develops into valgus after 4 years of age and continues to develop into a straight adult knee. During this time the head and neck of femur changes alignment. The anterior torsion of the neck of femur reduces from 40 in the newborn to 12 in the adult and the angle between the neck of femur and the shaft reduces from 150 to 125. This explains the change in alignment of the knee joint. However, the change is also dependent on normal neuromuscular development. Valgus deformity of the knee joint (Fig. 16.9) is commonly seen in children with SCI and is caused by a combination of the anterior
Figure 16.9 Valgus deformity of knee joints.
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torsion of the neck of femur and contracture of tensor facia lata and the iliotibial tract. It will be exacerbated by collapse of the medial arch of the foot when standing (Fig. 16.10A). The knee appears to have full extension and increased valgus deformity, but in reality it is primarily a knee exion contracture. This is demonstrated by extending the leg while ensuring correct alignment at hip, knee and ankle, allowing no internal rotation of femur or tibia/bula. This valgus deformity should not be compensated for in the tting of a kneeanklefoot orthosis (KAFO) as this will exacerbate the problem. The caliper should be made as straight as possible (seen in the sagittal plane), allowing the knee to remain in the degree of exion necessary for the limb to be in correct alignment. Weight-bearing with the knee in the valgus position may result in an altered angle between the tibial plateau and the shaft of the tibia.
Figure 16.10 A: Valgus deformity of the left knee with collapse of the medial longitudinal arch of the foot. Patient aged 5 years (injured at 1 year) with a complete lesion below T12/L1. B: Medial longitudinal arch supported.
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This in turn may cause torsion of the tibia, pulling the foot into external rotation. If this deformity is corrected in the caliper by positioning the foot in neutral, it increases the internal rotation of the leg. The foot should be allowed to remain in external rotation in the caliper. However, the degree of rotation of the tibia varies in normal children so that sometimes the foot is naturally externally rotated. In this case also, where no other deformity is present, the design of the caliper should allow the foot to remain in its natural position. The action of the KAFO should be augmented by passive stretching of the knee into extension, maintaining the limb in midline.
Foot
Collapse of the medial arch will cause eversion of the foot, and if the foot is allowed to remain in this position, the tendo Achillis will shorten on the lateral side. When passively stretching the tendo Achillis, rst the heel must be pulled towards midline and only then should the foot be dorsiexed. Footwear must be tted with a medial longitudinal arch support (Fig. 16.10B), which will also help to reduce valgus deformity of the knee.
Tone
Increased tone and spasticity usually develop in a specic pattern for each individual. It acts as an unopposed muscle pull and will repetitively pull the affected part of the body in the same direction. When there is no counter-pull it will contribute to the development of contractures and deformity of both spine and limbs.
Sleeping postures
The postures and positions that are adopted during sleep are also very important in the general management of the body. After all, a considerable proportion of time is spent sleeping. It is therefore important to ensure that positions of optimum correction are encouraged. (The correct position is identied for each individual according to his or her posture and tone.) All the factors described here will inuence one another and become part of a perpetual cycle.
Management
As virtually all children with SCI will develop some degree of spinal deformity it is important to implement management strategies to
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avoid this and to try to incorporate them into the daily routines of the child, family and school.
Spinal posture
Lack of sensation following SCI causes a reduced postural awareness. This can easily lead to poor posture (see Ch. 6). Observation in front of a mirror, with minimal clothing, is useful to help establish a well-aligned posture. Constant vigilance is needed to ensure a good posture in the future; it is a useful routine to continue to check the posture in the mirror from time to time. The posture is also corrected and maintained by wearing a madeto-measure external spinal support. As soon as possible after the acute bed phase, a cast is made for a body jacket. Very young or anxious children need to become familiar with the procedure and the people involved in the making of the orthosis to ensure cooperation during the casting of the brace. The brace should be as near to normal in alignment as possible, with special care taken to maintain a lordosis so that the child remains upright with minimal force applied at the top and bottom of the brace. For maximum support of the spinal column and stabilization of the pelvis, the brace needs to be as long as possible whilst allowing for shoulder depression in order that the child can lift during functional activities. It is important that a brace is worn as early as possible, while the spine is still straight or at least correctable. This is to ensure that as much growth as possible takes place under the most favourable conditions. The thoracic support is either a moulded leather or plastic jacket or in some cases a corset. The material chosen will depend on the need of the individual child. Moulded leather and plastic will give good support; however, leather will allow itself to yield slightly to the wearer and therefore offers better protection against skin breakdown. This becomes more apparent the heavier the person is and the more deformed the spine. For the high tetraplegic person it is important to be aware of respiratory function. A rm plastic back shell with a fabric or elastic front may be a suitable compromise. Fabric corsets may provide enough support and reminder for those with a clinically straight back and who have a thoracolumbar lesion. The spinal support should be worn at all times when the child is up and about. Children with a very low or incomplete lesion, with no neurological decit of the trunk, may not need a brace. In these cases, the development of the spine will still need to be closely monitored as hip contractures may develop and pull the spine out of alignment.
Standing for the complete lesion

Normal bone growth and development is inuenced by weightbearing as well as the forces of compression and traction produced
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in normal walking, running and playing. Standing is the only position where the spine adopts all its normal curves: cervical and lumbar lordosis and thoracic kyphosis. It also maintains the hip joints in their anatomical position and assists them to develop correctly. This is particularly important for those injured at an early age before the joint is fully developed. Standing also stretches the knees and ankles. Walking is a physical stimulation for the skeleton, which if done regularly may decrease the risk of osteoporosis and fractures. To avoid malalignment of the skeleton it is important that this is done with the legs and spine fully supported by the spinal brace and calipers for the legs, to avoid malalignment of the skeleton. Well-aligned standing is best maintained by the use of a thoracolumbar sacral hipkneeanklefoot orthosis (TLSHKAFO) (Fig. 16.11A) These are made from the age of 18 months (i.e. when standing would normally start). The KAFO part is made with overlapping steels above and below the knee to allow for growth. Knee joints will be included as soon as practical, i.e. as soon as the childs leg is long
Figure 16.11 A: Hipkneeanklefoot orthosis. B: T-straps.
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enough to allow the joints to be incorporated in the length of the orthosis. For stability of the knee in the median plane and for some control of rotation of the leg (either from the hip or from the foot), a wrap-around knee extension strap is used (see Fig. 16.11A). This can be reversed to offer a different directional pull on the leg. In most cases, the KAFOs will be attachable to the brace to achieve stability of the hips and make ambulation easier (Fig. 16.11A). If the thoracolumbar support from the TLSHKAFO is to be worn on its own, the hip joints must be part of the KAFOs and not the brace. Alternatively a separate brace for sitting only can be provided. Footwear should provide a stable support and include the ankle and an extensive opening to provide easy access to check size and the position of the toes. T-straps (Fig. 16.11B) may be added to give extra support to the ankle joint in the sagittal plane. In order to stand for several hours it may be necessary to use a standing frame or a mobile stander (see Fig. 16.13). Standing frames on their own do not give sufcient support when the skeleton is still growing as they do not support each joint specically as a bespoke set of caliper and brace does. The rotational forces in particular are very difcult to control and they will produce subtle changes in the alignment that are easily missed until a contracture has been established.
Ambulating for the complete lesion

Back slabs made from plaster of Paris, Soft/Scotchcast or thermoplastic materials may be used initially to achieve the upright position while waiting for the completion of the orthosis. Gait training with crutches or rollator is commenced at the age when able-bodied children would start to walk or slightly later, i.e. 1824 months old. Where possible, all three gaits are taught. When the child is wearing the TLSHKAFO, it is only possible to teach swing-to and swing-through gaits (see Ch. 13). Crutches are the most versatile walking aid, allowing faster walking and greatest access. Slightly longer crutches will be necessary since trunk exion is not possible when lifting, due to the restriction of the brace. A rollator may be preferred to crutches, especially in crowded environments such as school where the risk of being inadvertently knocked over is high. Walking with a rollator is slower than with crutches and some adjustment to techniques for getting from the wheelchair to standing may be required depending on the height of the child and the size of the wheelchair. To enable the child to stand and move around throughout the day, it may be necessary to use the TLSHKAFO together with a swivel walker (Fig. 16.12), mobile stander (Fig. 16.13) or standing frame. The swivel walker allows the child mobility without using his hands for support, thus freeing them for other activities, and a child with a very high lesion (C3C4) can use it. If used without the orthosis, donning and dofng is easier, which is appreciated by busy school staff. However, it does not provide such a good support for the limbs
Figure 16.12 Swivel walker.
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(as discussed under Standing for the complete lesion) and walking is slow. The mobile stander (see Fig. 16.13) is a self-propelling device that the child stands in, preferably wearing the orthosis. This offers independent mobility for the child with a higher lesion (from C6 to the upper thoracic lesions) and freedom to use the hands when stationary.
Contractures
Apart from standing and ambulating, another way to ensure good movement of all the joints is regular passive movements of all or particular joints that may be inuenced by spasticity or other unopposed muscle activity. For some children, the joints will have to continue to be stretched daily and for others it may be enough to do it three to four times a week. Established contractures will always require specic stretches. Overall stretches, such as standing and prone-lying, will only stretch the most mobile segments, usually the spinal column. Some children will require an anklefoot orthosis (AFO) to maintain the ankles at neutral (90), either as night splints or for use during the day or both. Corrective devices such as below knee (BK) irons with corrective T-straps are sometimes used. Elbow and hand splints as well as leg gaiters are also used.
Figure 16.13 Mobile stander.
Sleeping habits
A large part of our lives is spent in bed sleeping. It is important that this period is recognized as a potential force for inuencing posture. The lying position should be assessed carefully to ensure that the sleeping positions used will enhance the posture and that habits (typically one-handed habits dictated by the position of the bed in the room) are not allowed to become the driving force behind the development of deformity. If it becomes more comfortable to sleep on one side rather than the other, it may be an early indicator that the structures adjacent to the spine are becoming more mobile and stretched on one side and shortened on the other. Changing the position or correcting it with wedges or pillows could counter this. This time can also be used for gentle stretches. Sleeping prone is a useful way to stretch hips, knees and the back. It also gives the skin, which during the day time is the weight-bearing area, a prolonged rest, without taking up extra time. This routine should be instigated before any contractures have developed, as those with shortened hip exors may overstretch the lumbar lordosis instead of stretching the hips. For those with high lesions, a special sleep system that allows careful positioning will be of great help. This consists of foam wedges and blocks that are designed to be easily positioned and secured, to keep limbs and/or torso in optimum position.
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Spasticity
The management of increased muscle tone (as a result of spasm) is usually the same as for contractures. Passive movements, orthoses and standing may help some people considerably. If this is not sufcient it may be necessary to resort to drug treatment (see Ch. 18). At times the management has to be a compromise in order to t in with the life of the child, family, school and educational commitments. Therefore it is particularly important to reassess the situation frequently.
MODIFICATIONS NECESSARY TO ADULT REHABILITATION PROGRAMME

Most treatment and techniques to move, transfer, dress and perform general self-care tasks are the same as those for the adult. Some general adjustments will have to be made when treating children. Children, depending on their age, have a short attention span and require shorter treatment sessions. Games and play are useful ways to get children to work for general balance, coordination, strength and tness as well as specic tasks. Most activities will be taught at the age-appropriate time, but as well as being too young the child may simply be too small for some transfers. Therefore, if the child with SCI is very young, short periods of rehabilitation related to specic tasks will be required over many years. Wearing a rigid trunk support will change the biomechanical basis for rehabilitation and some alteration in the methods may be required.
Postural sensibility
Children aged 3 years and over are given short periods of training, sitting on the plinth in front of the mirror in the usual way. This is augmented for small children by play therapy on the mat. Games and activities involving the use of rst one and then both hands are encouraged whilst the unassisted sitting position is maintained. Children under 3 years are usually treated daily on the mat only, but where possible a mirror is used to give the child the necessary visual feedback.
Mat work
The ability of the young child to sit up from lying down is very important, as it releases the mother from going to the child early in the morning to sit him up in his cot to play. Where this activity has
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not been taught, the mother may continue to lift the child even when he is 5, 6 or 7 years of age. To sit up from lying down on the mat: 1. Turn the upper trunk and left arm to the right (Fig. 16.14A). 2. Push up onto both elbows and then hands (Fig. 16.14B). 3. Walk on the hands to the sitting position (Fig. 16.14C, D). The child is also taught to turn over, to roll into the prone position and to move himself and his legs around on the mat.
Figure 16.14 Sitting up. Child with a complete lesion below T10.
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Muscle strength
In order to prevent spinal deformity, particularly if the child is wearing a brace, it is important to hypertrophy the back muscles and latissimus dorsi and to continue these exercises throughout growth.
Dressing and self-care

The child with SCI is taught to dress and wash at the same age as the able-bodied child. He is also taught as early as possible to look at his own legs for pressure marks, to put pillows between the legs when turning in bed, and to lift and move with care. If the child plays on the oor, crawling and turning, he needs to be made aware of positions that the lower limbs may adopt. When dragging legs that have no sensation, they may become trapped in awkward positions, which in some cases can cause them to fracture.
Transfers
Some of the techniques of transferring may have to be altered due to the size of the child. The brace will also inuence the transfer technique. For example, it gives stability to a collapsing spine and in this case becomes a helpful aid. It is important that the transfers are taught wearing the brace since different postures will alter the biomechanical relationships of the body and thereby necessitate a different technique. (It can be difcult to motivate a child to learn the same task twice, with and without the brace.) It is easier and safer for the young child to get onto the bed forwards (see Fig. 12.12). When transferring onto the toilet, the child will need to keep his feet on the footplates or have them propped on a solid stool of suitable height until the feet reach the oor. The lifts involved are usually too great for a child to transfer onto the oor or into the bath without assistance. Stools of varying height can be used as stepping stones for the child to get from his chair to the oor and back. A bath seat may be used in a similar way. To transfer into a car, a sliding board may be necessary if the gap is too wide for the small child.
Wheelchair
The chair should offer the child a good posture and mobility with minimum energy expenditure. Since children are not scaled down adults, it is not sufcient to have a scaled down adult chair. A childs wheelchair should be adjustable to allow for growth. Seat height from the oor needs to be considered. Small children mainly play on the oor and have their environment, such as school
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and infant school, furnished to their size. In this environment the paralysed child needs a chair that will bring him into contact with his peer group. The adult carer needs push handles that are extended above and are situated away from the backrest, in order not to impede the childs mobility (see Ch. 11). To give maximum ergonomic advantage for the carer, the push handles need to be angled away from the backrest. Various sizes of wheels, castors and supports for the castors are available. These allow the seat to be raised to accommodate the growing child. The backrest can be adjusted in height and, on some models, the seat and back canvasses are provided in several sizes (see Ch. 11).
INVOLVEMENT OF PARENTS
The responsibility for any childs physical well-being and care falls to the parent, as does the responsibility for the majority of decisions regarding his life. The parents should therefore be involved in all aspects of rehabilitation and great care needs to be taken to make sure that they have a clear understanding of all the special tasks and techniques as well as the reasoning behind them. It is essential that parents learn in detail the care of the bladder, bowels and skin, and see how the child walks and how to give any necessary assistance. It is also important for parents to see what the child can accomplish by himself, e.g. in dressing and transfers, and be taught how important it is that the child should continue his independence when home, even if he is slow at rst. Parents should also be made aware that, as the child grows and becomes heavier they (the parents) are at increased risk of damaging their own back if they continue to give physical help in the same manner as when the child is toddler age. The parents must have enough knowledge to feel condent to encourage the child to further independence, and be made to feel welcome to come back for further advice, and help. The treatment outlined in this chapter is very demanding for the child, but perhaps more so for the parents. It can be very difcult to allow the child maximum independence when it means very slow progress through the days tasks. To motivate a child to stand and walk in the knowledge that he is quicker, gets less tired and can participate in more social activities if he uses a wheelchair is hard for any parent, and even more so if it causes conict with the child and threatens to undermine their relationship. Therapists and medical staff must face these realities, take their share of responsibility and assist the parents and child to arrive at a working compromise.
INVOLVEMENT OF THE SCHOOL

The education of the physically disabled child is of paramount importance. He must be encouraged and assisted to make the best use of his intellectual resources since so many manual occupations will be
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inaccessible to him. The Education Act 1981 has introduced in Britain the principles of the integration of children with special educational needs with able-bodied children and the development of facilities to meet the special needs of disabled children. It is desirable that, after spinal cord injury, children should return to mainstream schools and playgroups when their initial period of rehabilitation is concluded. They will then integrate at an early age with able-bodied children and will also have the same chance to achieve the necessary qualications for higher education. It is encouraging that more schools are welcoming the child back to school after becoming disabled, and are making the necessary alterations to school buildings. As a large part of the childs day is spent at school, it will be necessary for the school to be involved in the special routines incorporated in the childs care. Special provision for standing may be necessary, such as a standing frame or a high table in the classroom. The child may have to don and doff the orthosis for toileting or rest, and the skills needed have to be passed to the appropriate person(s) at the school. Access to the school will have to be considered as for the home or the workplace for an adult, and any necessary adaptations undertaken.
FOLLOW-UP
Due to the childs continued physical and general maturity, a regular and frequent follow-up system is necessary, usually taking place every 69 months. The most important aspect of the follow-up for the therapist is to monitor the development of the spine and contractures and to check the t of orthoses and other equipment. This needs to be done as objectively as possible. A simple method to record the development of the spine is to photograph the children in a standardized manner. With the spinal column and the posterior superior iliac spine marked, posterior and lateral views are taken with the convex side of the spine furthermost when the child is seated unsupported (to see the maximum deformity) and suspended either by lifting himself or by being lifted under the axilla, to see the spontaneous correction. A skyline (contour) view at the angle of maximum deformity is also taken. When the camera is kept at a constant distance from the child and at a constant height in relation to the seat, some comparison between the pictures can be made and a trend in development can be seen. However, it needs to be augmented with radiographs every 2 years, and yearly if deformity is evident, as this is more revealing than inspection only (Fig. 16.15A, B). This will enable a more realistic assessment of the development of the spinal deformity to be made and intervention of a more vigorous form such as internal xation to be considered if and when necessary. Children with SCI will succumb to the complications of spinal deformity and contractures much more readily than adult patients.
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Figure 16.15 A: Photograph of back (neurological level T9) seated. Spinous processes and posterior superior iliac spines are marked. B: Radiograph taken seated of the same back as in part A.
All concerned should work to reduce and minimize this process so that the child reaches adulthood with as near normal a posture as possible. The spine needs to be kept mobile, not only to prevent deformity and possible consequent damage to internal organs, but also to ensure maximum success should surgical stabilization of the spine be considered when the child gets older. As the children mature intellectually, they need to take on more of their own care and further intensive periods of rehabilitation may be required. The children should be given every opportunity to achieve their potential so that they can gain their maximal social and intellectual as well as physical independence.
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RESEARCH FINDINGS
A study was undertaken at the National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital (Bergstrm 1994), to assess the impact of childhood SCI on spinal deformity and growth in the now adult individual. The 80 subjects taking part in the study came from 189 patients who had an acute onset SCI before their 16th birthday and were treated at the NSIC from within 1 year of onset. Seventy-six of the subjects had radiographs of their whole thoracic and lumbar spine taken in their habitual upright position (56 seated and 20 standing) in a standardized manner. The statistical analysis was primarily based on two-way subdivisions of the subjects (due to the small sample) as follows:

level of lesion tetraplegic/paraplegic severity of lesion complete/incomplete lesion age at injury <11 years, >11 years.
Scoliosis, lordosis and kyphosis were measured from the radiographs according to Cobb (1948). For the purpose of crosstabulation, these three parameters were divided into three groups:

scoliosis mild (< 20), moderate (2059), severe (>59) lordosis hypolordosis (<35), normal (3564), hyperlordosis (>64) kyphosis hypokyphosis (< 25), normal (2549), hyperkyphosis (> 49).
Of the 76 subjects analysed, 78% had a scoliosis of more than 10 and 53% had one of moderate to severe magnitude; 42% had a hyperlordosis and 41% a lordosis that was too at; 45% were hyperkyphotic, while 14% had a thoracic spine that was too at. Only one subject had a normal spine. Both level and severity of paralysis as well as age at onset have a strong inuence on the magnitude of the scoliosis, as illustrated in Table 16.1. The level of lesion, expressed simply as tetraplegia and paraplegia, has a clear inverse relationship with the degree of scoliosis. The paraplegic subjects have a greater scoliosis than the tetraplegic subjects and also appear in proportionally larger numbers in the increasingly more severe scoliosis group. The severity of lesion, when only divided two ways into complete and incomplete lesions, shows a positive relationship with the magnitude of scoliosis. The complete lesions have more severe scoliosis than the incomplete lesions. The proportion of complete lesions also increases as the magnitude of the scoliosis increases. Age at onset is closely related to the occurrence and magnitude of scoliosis. The very young at onset have a more severe scoliosis and are proportionally more numerous in the increasingly more severe scoliosis group.
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Table 16.1 The distribution of scoliosis (Cobb angle) by level of injury, severity of injury, age at onset, duration of injury and range of hip movement in 76 childhood SCI subjects
Level of injury Tet Par Severity of injury Comp Incomp < 11 Number Mean Cobb angle Level of signicance Scoliosis 019 2059 60 Level of signicance Missing cases Tet = tetraplegia; Par = paraplegia; Comp = complete lesion; Incomp = incomplete lesion. *, P < 0.05; **, P < 0.01; ***, P < 0.001. 26 17 50 33 42 36 34 18 17 38 >11 59 24 < 20 38 22 > 20 38 33 < 15 42 21 15 32 37 Onset age (years) Duration (years) Flexion contracture
**
***
**
18 8 0 **
18 23 9
12 23 7 **
24 8 2
4 8 5 *
32 23 4
20 16 2
16 15 7
25 15 2 *
9 16 7
When analysing the lordosis angle separately for the seated and standing subjects, those seated show a signicantly greater lordosis in the paraplegic subsection than in the tetraplegic (50 and 28, respectively) and also among those with severe (15) hip exion contracture compared with those with no or mild (<15) hip exion contracture (56 and 27, respectively) (Table 16.2). Among the 20 standing subjects, there was a signicant difference of lordosis angle when subdivided according to level of lesion only. The lordosis was signicantly larger in the paraplegic group (78 compared to 62 in the tetraplegic group). Of the 20 individuals the majority (15) had hyperlordosis, and 13 of those had no or mild contracture of the hips (Table 16.3). These subjects illustrate the connection between hyperlordosis and hip exion contractures when constantly seated. However, this is not the case for those who predominantly walk. Measurements of body segments were carried out in accordance with Weiner & Laurie (1969). In order to examine the effect of SCI on growth, the length of the humerus and the tibia were compared. The humerus was chosen as the single bone least likely to be affected by the paralysis and the tibia as the bone most likely to be affected. Table 16.4 shows the mean tibial length to be longer than the mean humeral
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Table 16.2 The distribution of lordosis angle in 56 seated childhood SCI subjects by level of injury, severity of injury, age at onset, duration of injury and range of hip movement Level of injury Tet Par Severity of injury Comp Incomp < 11 Number Mean lordosis angle Level of signicance Lordosis 034 3564 65 Level of signicance Missing cases Tet = tetraplegia; Par = paraplegia; Comp = complete lesion; Incomp = incomplete lesion. *, P < 0.05; **, P < 0.01. 17 28 39 50 42 40 14 51 14 51 >11 42 41 < 20 27 38 > 20 29 48 < 15 25 27 15 30 56 Onset age (years) Duration (years) Flexion contracture
**
12 3 2
18 6 15
24 7 11
6 2 6
6 2 6
24 7 11
15 5 7
15 4 10
20 3 2 **
10 6 14
Table 16.3 The distribution of lordosis angle in 20 standing childhood SCI subjects by level of injury, severity of injury, age at onset, duration of injury and range of hip movement
Level of injury Tet Number Mean lordosis angle Level of signicance Lordosis 034 3564 65 Level of signicance Missing cases Tet = tetraplegia; Par = paraplegia; Comp = complete lesion; Incomp = incomplete lesion. *, P < 0.05. 1 9 62 * Par 11 78 Severity of injury Comp Incomp 20 71 Onset age (years) < 11 3 69 >11 17 71 Duration (years) < 20 11 66 > 20 9 78 Flexion contracture < 15 17 71 15 2 71
1 2 6
0 2 9
1 4 15
0 2 1
1 2 14
1 3 7
0 1 8
1 3 13
0 1 1
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Table 16.4 Mean humeral length and tibial length for female and male subjects by level and severity of lesion and age at onset
Female Humerus (mm) All Level of injury Tetraplegic Paraplegic Severity of injury Complete Incomplete Onset age <11 years >11 years 338 Tibia (mm) 350 n Humerus (mm) 363 Male Tibia (mm) 366 n
34
41
347 333
369 340
12 22
358 366
379 359
14 27
340 336
345 355
17 17
363 364
359 376
25 16
334 339
331 354
6 28
370 360
357 370
13 28
Table 16.5 Mean humeral length and tibial length for female and male subjects with neurological damage at and below L1 by severity of lesion and age at onset
Female Humerus (mm) All Severity of injury Complete Incomplete Onset age <11 years >11 years 333 Tibia (mm) 345 n Humerus (mm) 338 Male Tibia (mm) 342 n
342 327
335 351
4 5
360 327
351 338
1 2
326 334
305 349
1 8
360 327
351 338
1 2
length among both female and male subjects. In the female subjects, the mean tibial length is shorter in those injured before age 11. The male subjects show a shorter tibia in the paraplegic, incomplete and injured before 11 years groups than their respective counterparts. In order to examine the effect of a lower motoneurone injury on growth, the humeral/tibial relationship was re-examined in the same manner, separately for those nine subjects with neurological damage at L1 and below (Table 16.5). The lower motoneurone lesion is thought to have greater retarding inuence on growth than upper motoneurone lesions, as the upper motoneurone lesion has an intact
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neural arc. This allows involuntary motor function below the lesion level which ensures better circulation and some muscular stresses on the bones. Both are important factors in stimulating growth. The relationship between the two bones now shows a similar picture for females and males. The mean length of the tibia is longer for both sexes, but when subdivided as previously, the complete lesions and those injured before the age of 11 have a shorter mean tibial length than mean humeral length. These results indicate that SCI does affect the growth of a child, but the many factors potentially inuencing growth are confounding one another in this small sample.
References
Bergstrm E M K 1994 Childhood spinal cord lesion: its effect on skeletal development, growth and lung function a retrospective study. A Masters thesis, Loughborough University of Technology Bergstrm E M K, Short D J, Frankel H L et al 1999 The effect of childhood spinal cord injury on skeletal development: a retrospective study. Spinal Cord 37: 838846 Cobb J R 1948 Outline for the study of scoliosis. American Academy of Orthopaedic Surgeons Instructional Course Lectures 5:261275 Haffner D L, Hoffer M M 1993 Etiology of childrens spinal injuries at Rancho Los Amigos. Spine 18:679684 Lancourt J E, Dickson J H, Carter R E 1981 Paralytic spinal deformity following traumatic spinal-cord injury in children and adolescents. Journal of Bone and Joint Surgery 63A:4753 Mayeld J K, Erkkila J C, Winter R B 1981 Spine deformity subsequent to acquired childhood spinal cord injury. Journal of Bone and Joint Surgery 63A:14011411 Montes L 1996 Demographics, management and prevention. In: Betz R R, Mulcahey M J (eds) The child with a spinal cord injury. American Academy of Orthopaedic Surgeons, Rosemont, IL, p 179185 Osenbach R K, Menezes A H 1989 Spinal cord without radiographic abnormality in children. Pediatric Neuroscience 15:168175 Pang D, Pollack I F 1989 Spinal cord injury without radiographic abnormality in children the SCIWORA syndrome. Journal of Trauma 29:654664 Vogel L C, Betz R R 1996 Introduction. In: Betz R R, Mulcahey M J (eds) The child with a spinal cord injury. American Academy of Orthopaedic Surgeons, Rosemont, IL, p xxixxiv Vogel L C, De Vivo M J 1996 Etiology and demographics. In: Betz R R, Mulcahey M J (eds) The child with a spinal cord injury. American Academy of Orthopaedic Surgeons, Rosemont, IL, p 312 Weiner J S, Laurie J A 1969 Human biology: A guide to eld methods. International biological programme handbook. No. 9. Blackwell Scientic Publications, Oxford
Ageing with spinal cord injury

Ebba Bergstrm
CHAPTER
17
Introduction 345 Long-term survival 345 Causes of death 346 Changes in functional ability with age 346 Pain in the shoulders 347 Postural changes 348 Tissue viability 349 Weight 349 The role of the patient in accepting change in function 349 The role of the caregiver in assisting change in function 350 The role of the professional in facilitating change in function 350
INTRODUCTION
Over the last few decades, it has been acknowledged that spinal cord injury is not a static unchanging state, and studies have been undertaken on the problems associated with ageing in patients with longstanding spinal cord injury. Survival following spinal cord injury was relatively rare prior to World War II. Medical advances since 1945 have greatly enhanced both the initial and long-term survival of this group of people with permanent disability. Efforts have inevitably concentrated on improving initial care, emergency medical services, rehabilitation and social integration through the establishment of spinal cord injury centres but increased awareness of long-term outcomes has inuenced the way initial rehabilitation is currently carried out.
LONG-TERM SURVIVAL
Mortality, morbidity, health, function and psychosocial outcomes were examined in an extensive study with 834 individuals who had their spinal cord injury at least 20 years previously (Whiteneck et al 1992). The study was carried out on patients treated at two spinal cord injury centres in the UK. As expected, morbidity was inuenced by the decade in which the injury occurred and therefore the initial care given. The mean survival rate for those injured in the 1940s was 26 years, whilst the rate for those injured in the 1960s was 33 years. Patients with incomplete lesions and those with lower lesions lived longer. Recent studies show survival times based on standard mortality ratio (SMR) (De Vivo & Stover 1995). This is used to calculate the life expectancy at different ages of injury. According to Yeo et al (1998) the life expectancy was 92% compared to the general population for those with incomplete lesions (Frankel D regardless of level), 84% for those with complete paraplegia and 70% for those with complete tetraplegia. These gures are similar to those presented by Frankel et al (1998) and De Vivo et al (1999). In addition to level of injury and completeness, survival time is also
345
346
dependent on age at injury, gender, ventilator status and aetiology of injury.
CAUSES OF DEATH
The study by Whiteneck et al (1992) showed that renal failure is no longer the primary cause of death in patients with spinal cord injury and, as death from renal failure decreased, the causes of death more closely resembled those of the general population. Frankel et al (1998) reviewed the medical notes of 3179 individuals including the 834 reported by Whiteneck et al (1992) in a long-term survival study of spinal cord injury. The study spanned nearly 50 years (1943 to 1990) and con rms the changes in ranking of causes of death that has occurred. The urinary system is no longer the primary cause of death in patients with spinal cord injury as it was in the early decades of this study. Respiratory diseases are the main cause of death in the latter decades. It should, however, be noted that pneumonia is often cited as cause of death when no autopsy had been carried out or there was no de nitive cause of death. Heart disease was the second and injuries and suicide the third most common cause of death in the last two decades of the study. These ndings are also con rmed in US studies (De Vivo et al 1999, Soden et al 2000).
CHANGES IN FUNCTIONAL ABILIT Y WITH AGE

The 282 survivors in the study carried out by Whiteneck et al (1992) were medically examined, revealing signicant changes in functional abilities associated with the ageing process. Problems were related to pressure ulcers, kyphosis or scoliosis, restricted neck exion, loss of range of movement at the shoulders and hip exion contractures. Changes in functional ability, in the same study involving 279 individuals with long term spinal cord injury, were examined by Gerhart et al (1993). Almost one-quarter reported that their need for physical assistance had increased over the years. The majority reported general good health and rated their quality of life as either good or excellent. Quality of life increased with length of time postinjury, apart from those who needed more assistance and felt their quality of life had declined. Ages at which physical decline appeared, late 40s for those with tetraplegia and early 50s for those with paraplegia, are considerably younger than would be expected in nondisabled individuals. Factors identied as contributing to the need for more assistance were fatigue/weakness, specic medical problems, pain and stiffness, weight gain and postural changes. Pain in the shoulder was signicantly more frequent in the group that needed more assistance. These ndings are corroborated by others and illustrate that individuals with spinal cord injury have much narrower margins of
AGEING WITH SPINAL CORD INJURY
347
tness, strength and function than the general public. For many functional tasks, such as lifting a leg, transferring and pushing the wheelchair, maximal strength and tness and optimal mobility, tone and weight are required. Minimal changes in only one of these variables can totally jeopardize the ability to function independently.
Pain in the shoulders

The shoulders are key weight-bearing joints for individuals who use a wheelchair or ambulation device (Bagley et al 1987). When a patient transfers, the intra-articular pressure in the shoulder joint rises dramatically and the bones, joints and soft tissues of the upper body are subjected to considerable stress while supporting the body weight (Jansen et al 1994). The same study showed that the level of physical strain is not uniform for patients with the same level of lesion performing the same activities of daily living. A Wheelchair Users Shoulder Pain Index (WUSPI) has been developed by physiotherapists in the United States to measure shoulder pain causing limitation of function in individuals who use wheelchairs (Curtis et al 1995a,b). It can be used as a tool for research purposes and for clinicians to document baseline dysfunction. Subjects in this study experienced most pain when performing activities requiring extreme range of shoulder movement or high level of upper limb strength, or when performing movements with the arm above the head. Activities such as wheeling up an incline or on outdoor surfaces, lifting an object from an overhead shelf, transferring from bath to wheelchair or washing the back caused most pain. An Australian study (Pentland &Twomey 1994) identied the same tasks as being most painful and also included driving. Individuals who have joint pain induced by activity will eventually limit the activities to minimize the pain. The reduced activity level will then lead to reduced strength that in turn will exacerbate the pain as the biomechanics of the joint is further altered. Exercise regimens are necessary, to restore the muscle balance around the joint. Curtis et al (1999) demonstrated the effects of such an exercise protocol on shoulder pain, which interferes with functional activities in wheelchair users. Individuals who underwent the treatment showed an improvement compared to the control group. An assessment of the daily activities will identify areas where reduction in activities, without reducing independence or level of socialization, should be undertaken and discussed with the spinal cord injured person and the caregiver. The caregiver is particularly important if he or she is a spouse who is also experiencing the ageing process. The use of a sliding board and/or a sliding sheet will reduce the level of strain and muscle activity of the shoulder joints. A shower unit will reduce or cut out the split-level bath transfers that require maximal strength to perform. A shower wheelchair may also reduce the number of
348
toilet transfers considerably. Russell & Shamley (2003) showed a reduction of electromyographic (EMG) activity, in the pectoralis major and infraspinatus muscles, in both leading and trailing arm during transfers using a sliding board compared with no sliding board. Advice should be given to patients about warming up before stressing limbs, checking the environment and avoiding over-reaching and sudden unusual stresses, e.g. long distance pushes or transfers to toilets where access is difcult. Although not every individual with spinal cord injury will experience upper limb joint pain, it has now been comprehensively demonstrated that it is a common occurrence and with severe consequences for those affected. Therefore these changes of daily activities should be discussed as soon as upper limb pain/weakness is experienced. If some of these changes can be accepted sooner, rather than later, maybe the level of pain and discomfort can be reduced. Those who underwent their rehabilitation in the 1960s and 1970s or earlier were often made to feel that the level of independence and skill they had achieved was expected to remain for all but their last few years of life. Anything less is often experienced as a failure.
Postural changes
Postural changes through development of spinal deformity, either kyphosis/lordosis or scoliosis and the position of the neck need careful assessment. Other common but more peripheral postural changes are limb contractures. The hip joint is commonly affected by contractures or poor alignment. These changes often lead to pain and discomfort that gets worse with prolonged sitting. In other words it is the posture itself that causes the pain. Long-term misalignment develops into xed deformity as in contractures of joint capsules, ligaments and muscles. Some improvement can possibly be had with intensive stretching. For long-term correction of position, specialized seating systems and lower limb orthoses can be used. Increased thoracic kyphosis, which leads to excessive forward exion, increases the amount of neck extension required to maintain horizontal vision (see Ch. 6). This often leads to unacceptable neck pain towards the end of the day. With the range of backrests on the market now, it is possible to accommodate such posture or have a chair that can vary the posture during the day. In some instances a corset or a rmer brace may alleviate the discomfort by the support it gives. Some cushions will not only improve the pelvic alignment when seated but will also enhance the position of the lower limbs with wedges and centre pommels. Sidepieces can help to align the femur. Good supportive footwear and ankle foot orthoses will also correct the position of the lower limb. These are often used when the position of the feet causes all the pressure to be distributed to one point on the foot instead of evenly over the whole sole of the foot.
349
Tissue viability
The ageing skin becomes more vulnerable and after a few decades with spinal cord injury even those who have never experienced problems with pressure ulcers may nd that they are more prone to develop red marks and even ulcers. Liem et al (2004) found that pressure ulcers were the second most common reason for the need to increase help with activities of daily living. For those who learned to relieve pressure in the old way, by lifting and holding for 1015 seconds, the lift may no longer be efcient for those with painful upper limbs. Pressure-relieving techniques have changed since research has shown that considerably longer periods of pressure relief are needed for oxygen levels to recover (Coggrave & Rose 2003). Different techniques, such as leaning forward or sideways are now advocated. After the treatment of a pressure ulcer, careful assessment of cushion and pressure distribution, wheelchair, posture and transfer techniques is imperative to identify the most suitable equipment and technique, thus minimizing the risk of it reoccurring. The skin covering the area of a healed pressure ulcer is not as viable as undamaged skin, so extra vigilance is necessary. The pressure mapping is particularly effective as a feedback tool to assess pressure relief. For further reading refer to Chapter 6.
Weight
Weight gain is normal in the later years of life in the general population. For the spinal cord injured it decreases functional skills, particularly for those who are functioning at the margin of their ability in terms of strength and mobility. It reduces the ability to transfer and do many activities of daily living that require good or optimal mobility, such as reaching the feet, picking up and moving the legs. Weight has been associated with median nerve injury in this group (Boninger et al 1999). The opportunity to keep a check on the weight is limited for most wheelchair users as access to suitable scales is scarce. It is also more difcult to lose weight when paralysed as the general ability to exercise has been restricted. Weight should be part of the general health check to ensure intervention as soon as possible.
THE ROLE OF THE PATIENT IN ACCEPTING CHANGE IN FUNCTION

Individuals with spinal cord injury need to realize the importance of respecting and protecting their upper limbs, to expect that their equipment needs will change and acknowledge that accepting assistance or using equipment does not signify failure (Whiteneck et al 1993). The professional who recommends the change of equipment
350
considers this as an easier and labour-saving way of achieving the goal. Although this is true in theory all new techniques and equipment need considerable training and familiarization just as they did during the original rehabilitation. This must be allowed for, to ensure that the patient is able to make full use of the new equipment and skill. There is often a psychological barrier having to learn the same task in several ways even in the early stages of rehabilitation. Having overcome all difculties and lived independently for several decades, it is difcult to accept that the process has to be repeated with a less independent goal to aim for. It is vital for the professional to give the spinal cord injured the time to accept this fact.
THE ROLE OF THE CAREGIVER IN ASSISTING CHANGE IN FUNCTION

Many caregivers of the older generation of the spinal cord injured are members of the family who are contemporaries with the person, such as spouses, or an older generation as in the case of parents, and are themselves experiencing the ageing process. Spouses of long-term spinal cord injured survivors who full a caregiving role report more symptoms of stress and depression than their partners with disabilities and other spouses who are not caregivers (Weitzenkamp et al 1997). When assessing the changing needs of the patient, the need and capabilities of the caregiver have to be carefully considered. The caregivers may feel that they are letting the spinal cord injured person down if they are no longer able to help as before. They may no longer be able to assist with a lift or keep going all day to full two persons needs. Some changes in need may indeed be on account of the carer as opposed to the spinal cord injured individual. When a spouse or close relative is the main caregiver, the systems funding the care and equipment need to be exible enough to take into account the combined needs of the spinal cord injured individual and the relative. The professional should be aware of the fact that the person with spinal cord injury and his family sometimes nd it difcult to discuss these issues openly, particularly in front of relative strangers. Sometimes each fails to appreciate the others needs. The spinal cord injured person often has very poor insight into the stress experienced by the able-bodied spouse.
THE ROLE OF THE PROFESSIONAL IN FACILITATING CHANGE IN FUNCTION

If problems with posture or in other areas are to be identied early and avoided or delayed, professionals who understand the ageing process and know the patients over a long period need to be involved in their regular check-up. It is also important to have an understand-
351
ing of the state of the rehabilitation services at the particular era when the patient was rst injured and the changes and developments that have happened since then. The choices are greater now compared with 20 years earlier and the patient may not have kept up with developments. It is possible to address problems related to strength, pain and posture by using adaptive equipment, lightweight or power-drive wheelchairs, cars that you can wheel into, customized seating systems and specialized cushions (Gerhart et al 1993). Change in bladder or bowel care may be indicated at this stage. Constipation has been cited as a common cause for increased need of assistance. Changes in equipment, techniques and the amount of assistance needed have a severe effect on the life of the individual with spinal cord injury and his family. Some equipment, such as hoists and special beds for easier access when administering care, are bulky. Bathrooms may need redesigning to create room for a wheel-in shower. This may necessitate architectural changes in the home. A professional carer who comes at set times is an intrusion into the personal space of all family members. These changes often mean an altered life style. For the rst generation of the ageing spinal cord injured this was often not fully appreciated. Technical developments and changing attitudes in society in general, combined with the growing knowledge of the ageing effect on people with spinal cord injury, have led to changes in rehabilitation. In the 1960s and 1970s and before, the alternative to functional independence was dependence on family or living in a care home. With new legislation and attitudes, regardless of level of disability, everybody can live independently and have a choice in how to live their lives. Personal independence in self-care is often willingly sacriced for the opportunity to go out to work. Further research into the functional changes associated with ageing and the need for further assistive devices and assistance will lead to more appropriate and timely educational programmes for this growing population of people with spinal cord injury.
References
Bagley J C, Cochran T P, Sledge C B 1987 The weight-bearing shoulder. The impingement syndrome in paraplegia. Journal of Bone and Joint Surgery 69A:676678 Boninger M L, Cooper R A, Baldwin M A et al 1999 Wheelchair pushrim kinetics: body weight and median nerve function. Archives of Physical Medicine and Rehabilitation 80:910915 Coggrave M J, Rose S L 2003 A specialist seating assessment clinic: changing pressure relief practice. Spinal Cord 41:692695 Curtis K A, Roach K E, Applegate E B et al 1995a Development of the wheelchair users shoulder pain index (WUSPI). Paraplegia 33:290293 Curtis K A, Roach K E, Applegate E Bet al 1995b Reliability and validity of the wheelchair users shoulder pain index (WUSPI). Paraplegia 33:595601
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Curtis K A, Tyner T M, Zachary L et al 1999 Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord 37:421429 De Vivo M J, Stover M D 1995 Long term survival and causes of death. In: Stover S L, DeLisa J A, Whiteneck G G (eds) Spinal cord injury: clinical outcomes from the model systems. Aspen: Gaithensburg, MD, p 289316 De Vivo M J, Krause J S, Lammertse D P 1999 Recent trends in mortality and causes of death among persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation 80:14111419 Frankel H L, Coll J R, Charlifue S W et al 1998 Long-term survival in spinal cord injury: a fty year investigation. Spinal Cord 36:266274 Gerhart K A, Bergstrm E, Charlifue S W et al 1993 Long-term spinal cord injury: functional changes over time. Archives of Physical Medicine and Rehabilitation 74:10301034 Jansen T W J, van Oers C A J M, Veegen H E J et al 1994 Relationship between physical strain during standardised ADL tasks and physical capacity in men with spinal cord injury. Paraplegia 32:844859 Liem N R, McColl K M, King W, Smith K M 2004 Ageing with a spinal cord injury: Factors associated with the need for more help with activities of daily living. Archives of Physical Medicine and Rehabilitation 85:15671577 Pentland W E, Twomey L T 1994 Upper limb function in persons with long term paraplegia and implications for independence: Part 1. Paraplegia 32:211218 Russell B, Shamley D 2003 A study using surface EMG to compare the activity of shoulder muscles used by paraplegics during transfers with and without a transfer board. 42nd ISCoS Annual Scientic Meeting Abstract Book. Beijing, China, October 2003; p 97 Soden R J, Walsh J, Middleton J W et al 2000 Causes of death after spinal cord injury. Spinal Cord 38:604610 Weitzenkamp D A, Gerhart K A, Charlifue S W et al 1997 Spouses of spinal cord injury survivors: the added impact of caring. Archives of Physical Medicine and Rehabilitation 78:822827 Whiteneck G G, Charlifue S W, Frankel H L et al 1992 Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Paraplegia 30:617630 Whiteneck G G, Charlifue S W, Gerhart K A et al 1993 Ageing with spinal cord injury. Demos Publications, New York Yeo J D, Walsh J, Rutkowski S, Soden R et al 1998 Mortality following spinal cord injury. Spinal Cord 36:329336
Complications
CHAPTER
18
Contractures 353 Causes 353 Conservative treatment of established contractures 353 Surgical treatment 355 Heterotopic ossication (HO) or para-articular calcication 355 Current physiotherapy 357 Surgery 357 Oedema 358 Feet and legs 358 Hands 358 Osteoporosis 359 Spontaneous fractures 359 Pain 360 Classication systems 360 Pain syndromes 361 Pressure ulcers 363 The treatment of established pressure ulcers 363 Physiotherapy 364 Shoulderhand syndrome (SHS) 365 Spasticity 366 Treatment of established spasticity 366 Spinal deformity 368 Prevention and treatment 368 Syringomyelia 369
CONTRACTURES
Contractures cause delay in achieving or even prevent the achievement of maximum independence. It is the direct responsibility of the therapy and nursing staff to prevent their occurrence.
Causes
The causes of contractures are:

incorrect positioning in bed or incorrect posture in the wheelchair inadequate physiotherapy spasticity.
It is difcult to separate these three closely linked factors in relation to the formation of a contracture.
Conservative treatment of established contractures

Passive movements, including to the accessory joints Prolonged passive stretching Active exercises Splinting Passive and active exercises in a heated pool Ice therapy and ultrasound.
Passive movements
Passive movements are always given at every treatment in addition to any other methods employed. In conjunction with the passive movements, a passive stretch is also given in the position of maximum correction.
Prolonged passive stretching

Prolonged optimal passive stretching for both the prevention and correction of contractures is an effective means of treatment (Harvey 353
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& Herbert 2002). A prolonged passive stretch can be given for exion 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. For example, for exor contractures of the knee, the legs are kept in extension with a strap over the knees. To avoid pressure, pillows are placed (1) under the lower legs to keep the heels off the bed, (2) between the knees to prevent the apposition of skin surfaces, and (3) over the knees, underneath the strap.
Flexion contracture of the hips

The 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. To avoid pressure, a pillow is placed between the knees, and the toes must be over the end of the plinth (Fig. 18.1). Correction is obtained by strapping the hips down to the plinth. The strap placed over a pillow on the sacrum is tightened gradually. Care must be taken to arrange the two groups of pillows so that the stretch is given to the hip exors. If the space between the pillows is too wide, the stretch merely increases the lumbar lordosis. The ankles can also be tied down with a padded strap if there are exion contractures of the knees. The stretch is normally maintained for 2030 minutes at a time.
Active exercises
Holdrelax techniques are used to obtain relaxation where the muscle groups are innervated and resisted work is always given to the antagonists.
Figure 18.1 Passive stretch for the hip exor muscles.
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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 rstly at the joint principally controlled by the major muscle involved. For example, where the elbow, wrist and ngers are exed, biceps is the major muscle and maximum correction is given at the elbow joint. Air- lled plastic splints are commercially available and can be useful in some cases.
Passive and active exercises in a heated pool

The hot water aids relaxation, and is especially benecial if there is severe spasticity.
Ice therapy and ultrasound

Ice therapy and ultrasound are used as and where suitable. Constant attack is the motto for dealing with contractures. Treatment needs to be carried out several times a day using a variety of methods. For example, contracted biceps tendons have been successfully treated by giving daily passive movements, active exercises, ice therapy, ultrasound and splinting; and hip and knee exion contractures by giving passive movements, passive stretching on the plinth, ice therapy and exercises in a heated pool.
Surgical treatment
When no improvement has occurred for approximately 6 weeks in spite of intensive therapy, surgery may be considered. Release of the iliopsoas by iliopsoas myotomy (Michaelis 1964), elongation of the tendo Achillis, and obturator neurectomy to release the adductor muscles are useful surgical procedures in cases of severe contractures which have not responded to conservative methods (Eltorai & Montroy 1990). If the patient has strong spasticity as well as contractures, other surgical procedures may be recommended (see p. 368).
HETEROTOPIC OSSIFICATION (HO) OR PARAARTICULAR CALCIFICATION

A special form of heterotopic ossication, exclusively of noninfectious or traumatic aetiology, has been repeatedly observed in both complete and incomplete paraplegic and tetraplegic patients below the level of the lesion. The condition is also found in patients
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with non-traumatic lesions (Taly et al 1999). There are numerous publications from many parts of the world on this subject, but the aetiology and pathology of the disease remain obscure. An extensive clinical review of heterotopic ossication has been undertaken by van Kuijk et al (2002) which includes the incidence, clinical signs. risk factors and various therapies. Clinically signicant heterotopic ossication was shown to be present in between 20% and 30% of patients. The development of bone in the connective tissue always occurs below the level of the lesion and rarely after the rst 6 months post-injury. The areas most commonly affected are the hips, knees and elbows, and the medial aspect of the femur. The joints themselves are not affected but the ossication can become massive enough to cause an extra-articular ankylosis. The therapist is often the rst member of the team to notice the onset of the disease. When moving the limb, she becomes aware that the joint involved does not feel quite normal. Although there is no real resistance to movement, the joint does not feel clear and free. It is as though the movement were taking place through sponge. At this very early stage, there will be no radiological evidence and there may not be any visible evidence, just the awareness of a vague abnormality on moving the limb. Swelling, and possibly some erythema, may occur within a few days. Early X-ray evidence shows cloudy patches in the muscles involved but this may not show up for a further 23 weeks, and by this time there will be some joint stiffness. As the disease progresses, X-rays show calcareous deposits in the para-articular tissues and nally dense ossication of the ligaments, fasciae and muscles surrounding the joints. The degree of ossication which occurs before the disease burns itself out varies considerably. Some patients have very little residual loss of joint range, whilst others have severe loss of function and independence. Early diagnosis is of crucial importance. Waiting for late clinical or radiographic symptoms may allow a signicant amount of ectopic bone to be deposited before treatment is initiated. Banovac & Gonzalez (1997) suggest that bone scintigraphy in asymptomatic patients is a sensitive test for early diagnosis of HO. The study showed that epidronate (the most common drug used for HO) therapy, given in higher doses and started in asymptomatic patients, may prevent the development of HO. Various types of medication have been used prophylactically. Banovac et al (2001) suggest that indometacin used prophylactically has an inuence on the development of HO and Banovac et al (2004) suggest COX-2, a selective inhibitor (rofecoxib). Low eld irradiation has been given to minimize or prevent HO and after surgery to prevent recurrence (Van Kuijk et al 2002). Ultrasonography used by an experienced person can detect HO prior to seeing it on X-ray and it is being increasingly used to docu-
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ment clinically suspected HO (Pullicino et al 1993). The sonographic appearance of early HO suggests that it might be due to a partial muscle tear with massive haemorrhage (Snoecx et al 1995). Passive movements on the seven patients in the Snoecx et al (1995) study were started a week after injury. Silver (1996) suggests that contractures could have been already forming in the limbs, tears occurred when passive movements were commenced and HO was the result. If the direction of tear could be determined (longitudinal or transverse), it could be related to the movements performed and the possibility of a link investigated (Silver 1996). Most treatments appear to inhibit the development of HO but as yet there is no satisfactory way of preventing the condition. Its prophylaxis is mainly based on the early identication and adequate treatment of risk factors such as pressure ulcers, urinary tract infections and spasticity (Van Kuijk et al 2002).
Current physiotherapy
In the initial stage when the joint feels spongy and the area may be red and swollen, passive movements to that joint are discontinued until the inammation 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. When the disease becomes less active, after approximately 48 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 HO, all passive movements must be given with extreme care.
Surgery
Gross heterotopic ossication limits joint range and, as a result, independence. It may even interfere with a comfortable sitting position in the wheelchair. To restore some independence, operations are performed to remove the bone, but surgery is only considered after the disease has completely burnt itself out, which is usually 18 months to 2 years after onset. Recurrence of ossication is not uncommon even after this time lapse. In ankylotic heterotopic ossication of the hip where there are mobility, social and hygiene problems, Becker et al (2003) suggest that total hip replacement surgery can be a satisfactory method of treatment. This may supersede the Girdlestone operation which has been used in these circumstances.
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OEDEMA Feet and legs

Due to the poor vasomotor control and loss of muscle tone in the legs, some patients get oedema of the feet, ankles and lower legs when they rst start sitting out of bed. This is, of course, severely aggravated if the patient has had a deep venous thrombosis. Every effort must be made to correct this condition in the early stages so that it does not become chronic. To stimulate the vasomotor system, the legs are elevated several times during the day, and if necessary the bed is elevated at night. Besides being elevated in the physiotherapy department, the patient should be responsible for putting his feet up on a chair at appropriate times during the day, e.g. at meal times, in the occupational therapy department and while watching television. The patient and therapist should work out a suitable programme. Only if this procedure fails to reduce the swelling after 34 weeks are elastic stockings supplied. These are more frequently necessary for patients who have had a deep venous thrombosis. Full-length stockings are given. The patient may need to spend 2448 hours in bed with the foot of the bed elevated to disperse the oedema before measurements for the stockings can be taken.
Hands
Patients with high lesions sometimes develop oedema in the hands. This is again due to impairment of the vasomotor control with consequent loss of vasoconstriction in the blood vessels and poor venous return. This always occurs below the level of the lesion. If the oedema is not dispersed, the collagen deposit is changed into brous tissue and contractures develop (see p. 45).
Elevation
To reduce the oedema, the hands are kept in elevation day and night except during occupational therapy and physiotherapy sessions.
Passive movements
Forced passive movements to oedematous joints can only cause trauma and encourage the formation of contractures. Therefore, movements are given to affected joints with extreme care and full range is obtained only when the swelling is reduced, which may take half an hour or several days. Treatment is given several times a day, taking care to maintain full range of all the non-affected joints. After an initial period of elevation, boxing glove splints or other forms of adequate splinting may be used if desired to keep the swelling down.
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In tetraplegic patients, usually over the age of 30, oedema followed by contractures of the metacarpophalangeal and interphalangeal joints sometimes occurs in spite of regular and intensive treatment. In these cases, the joints often resemble rheumatoid arthritic joints. They are red and shiny as well as swollen. When the disease has ceased to be active, treatment can be given as described for contractures. The aetiology of this complication is still obscure.
OSTEOPOROSIS
Research into the physiology of bone formation and absorption has shown that the mineral metabolism associated with atrophy of the muscular and skeletal systems changes as a result of prolonged bedrest. These changes are emphasized when the bedrest is combined with immobilization. Considering the inevitable immobility of the paralysed limbs, it is not surprising that osteoporosis is present to some degree, below the level of the lesion, in all tetraplegic and paraplegic patients (Frey-Rindova et al 2000). The degree of osteoporosis is considerably increased by chronic infection from any cause. The natural history of the development of the atrophy of the skeleton below the level of the lesion is not well understood (Szollar et al 1997). The change in bone mass in patients with spinal cord lesions is different from that due to other causes, e.g. the menopause or age. Unlike vertebral collapse, in these other forms of osteoporosis there is mineral loss in the hips, no loss in the lumbar spine and, as far as can be detected by densitometry, the most dramatic loss in the femoral region (Szollar et al 1997). Belanger et al (2000) found that after treatment with functional electrical stimulation the bone mineral density of the distal femur and proximal tibia gained 30% of the bone lost in their study of 14 patients. No change occurred in the mid tibia. Treatment was given 5 days a week for 24 weeks. The benet was not sustained after treatment ceased. With the advent of sensitive, non-invasive techniques to measure bone mineral density (Szollar 1998) and sensitive biochemical markers now available, screening for osteoporosis may be advocated. Further research might then be facilitated, and therapeutic strategies identied to reduce the loss of bone density in these patients.
Spontaneous fractures
Osteoporotic bone is rareed and therefore easily fractured (Lazlo et al 2001). Freehafer (1995) reported that fractures of the distal femur and proximal tibia account for 33% of all fractures in spinal cord injured patients and these are related to bone density loss. Fractures can occur as a result of exceptionally minor injuries and are referred to as spontaneous fractures. For example, a patient who has had paraplegia for some time may fracture his femur whilst
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dressing or turning over in bed, or a child may receive a simple knock in school. The therapist can easily fracture an osteoporotic limb through careless handling when giving strong and extensive passive movements, particularly if contractures are present. Due to the lack of sensation, the patient may be unaware that a fracture has occurred until the area becomes swollen, or until he feels unwell or has a fever. The therapy and nursing staff should inspect the legs regularly for any swelling and report abnormal ndings immediately. The fractures are generally treated conservatively using wellpadded splints. The splint is removed daily and the limb inspected for any areas of excessive pressure or skin damage. The padding is renewed before reapplying the splint. Where possible, passive movements are continued to maintain joint range.
PAIN
Pain causes emotional distress in addition to that caused by the spinal cord injury and is a signicant problem for paraplegic and tetraplegic people (Anke et al 1995). Large variations occur in the reported incidence of pain ranging from 18% to 96% in 29 classication systems over the past 50 years (Richards et al 2002). Siddall & Loeser (2001) report the incidence as variable but the average as 60% with a third of these rating the pain as severe. They also suggest that structural plastic changes in the central nervous system may cause changes in receptor function and normal inhibition and produce increased neuronal excitability resulting in pain. There appears to be little consensus on the nature, terminology and de nition of the various types of pain.
Classication systems
Classication systems usually describe the site and quality of pain and its bearing on the activities of daily life. In each system scales are used to describe the type of pain, the site of the pain and, for each site identied, the feel of the pain to the patient. Words such as nerve, visceral, mechanical, overuse, psychogenic are used to describe the type of pain. Scales differ between researchers in descriptive words used and the number included. Donovan et al (1982) use ve, Tunks (1986) nine, and Cardinas et al (2002) seven. Some systems may include other factors about the type of pain, for example its duration or whether there are aggravating or mitigating factors, such as rest or activity. Words such as throbbing, stabbing, cramping, burning, tingling, aching are used to describe the feel of the pain and again the lists of words vary in the different systems. Verbal descriptions are inevi-
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tably used in these classications but the validity of verbal descriptions alone to distinguish between pain types has yet to be established (Putzke et al 2002). All researchers agree the need for some uniformity in classication in order to facilitate research and the comparison of results, so that progress can be made in the search for treatments for this distressing problem (Cardinas et al 2002). Reviews of this subject have been undertaken by Hicken et al (2001) and Siddall & Loeser (2001).
Pain syndromes
The therapist should be familiar with:

pain due to periarticular and muscular contractures central cord pain referred pain. neck pain in association with orthostatic or postural hypotension (Cariga et al 2002). This pain, described as aching or tiring, is present in the neck and across the shoulders in a coat-hanger pattern. It occurs when getting up or late in the day, is increased by exercise and relieved by lying at.
Pain due to periarticular and muscular problems

This pain is always found above the level of the lesion, most frequently 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 contractures around the shoulder and shoulder girdle due to faulty positioning and lack of movement. The number of patients with shoulder pain appears to vary between spinal units (Salisbury et al 2003). In this study the range of movement was limited in exion, extension, and external rotation and abduction and may have been lost during the rst weeks post-injury, possibly before admission to a spinal unit. Further research is needed in relation to risk factors, especially positioning, surgery and physiotherapy. General mobilization is given as for any contracted joint where sensation is unimpaired. It must be borne in mind that the patients general condition and morale at this time are often poor and pain tolerance low. Rough handling or indiscriminate stretching of a joint sets up involuntary protective spasm, and the patient loses condence. Independence is a major goal in rehabilitation but the wheelchair user puts an unnatural load on the muscles and joints of the upper trunk and limbs in almost every daily living task. Not surprisingly musculoskeletal pain is a common complication (Ballinger et al 2000). The posture in the wheelchair, if not carefully controlled, may also play a part. In order to balance and push the wheelchair many
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patients sit in a kyphotic posture when the scapula changes its vertical alignment. The scapula will then rotate in the sagittal plane forward and downward, depressing the acromial process and changing the face of the glenoid fossa (Samuelsson et al 2004). A correct and comfortable sitting position is all important (see Ch. 6). The shoulder is a key weight-bearing joint for individuals who use wheelchairs or devices to aid ambulation (Bagley et al 1987). After the initial period of rehabilitation shoulder pain in paraplegic patients is most frequently associated with wheelchair activities, the most difcult and painful being loading the wheelchair into the car, followed by pushing up inclines (Samuelsson et al 2004). Patients continue their daily life and perform their activities in spite of the pain and Ballinger et al (2000) found that the level of activity did not decrease. In contrast Widerstrom-Noga et al (2002) report decreased activity due to pain. In older patients or those who have had their paralysis for many years, shoulder pain can severely affect their activity (see Ch. 17). Physiotherapists nd the Wheelchair Users Shoulder Pain Index a useful tool. It measures shoulder pain that is limiting daily activities such as transfers and self-care tasks, and could be used to monitor the effects of interventions to prevent shoulder pain and loss of function (Curtis et al 1995).
Central cord pain (neuropathic pain)

Central cord pain remains a problem for patients with spinal cord injury. All who have this pain also have autonomic instability (Bowsher 1996, Bennett 1991) The sensations such as burning, scalding, stabbing are felt at or below the level of the lesion and are more prevalent in patients injured when they are older. No correlation with gender was found (Werhagen et al 2004). 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. 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 (Anke et al 1995). Management of this type of pain is the most difcult. Only mild analgesics are prescribed, as drugs are quickly habit-forming in these cases and they are not usually successful in relieving the pain. To et al (2002) report some initial success with gabapentin. Controlled trials are now required. Anticonvulsant drug therapy (Balazy 1992), antidepressants and transcutaneous nerve stimulation (Hachen 1978) have all been tried. Widerstrom-Noga & Turk (2003) con rm the inadequacy of available modalities to manage chronic pain related to spinal cord injury. Occasionally, due to the severity of the pain, destructive procedures may be undertaken. Although the effect is limited to the pain at the level of the lesion Lammertse & Falci (2001) have shown improvement in the success rate of the dorsal root entry zone procedure.
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Dorsal column stimulation and deep brain stimulation may be tried. Although these procedures have their advocates, no long-term benets have as yet been documented. 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. Patients with complete lesions of the mid-thoracic and thoracolumbar cord sometimes develop a band of hyperpathia around the level of the lesion. The patient complains that there is a tight band around his chest, and occasionally is so hypersensitive that he cannot bear anything to touch his skin.
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 paralysed to the non-paralysed area via the phrenic nerve. For example, a patient with a C4 lesion had a haematemesis due to a perforated ulcer. On looking back at the therapists notes, it was seen that the patient had complained of nausea and pain across the upper part of the shoulders for at least 2 weeks previously. Patients with cervical lesions can suddenly develop severe frontal headache. This may be due to overdistension of the bladder and should be investigated without delay.
PRESSURE ULCERS
The effects of pressure and its prevention are described in Chapter 6. Patients admitted early to a spinal unit have a signicantly lower risk of developing pressure sores (Aung & El Masry 1997). In their study of 60 patients, Rodriguez & Garber (1994) found that the pressure ulcers developed within 2 years post-injury and were more frequent in those with lesions above T6. Of those who smoked, 36% got pressure ulcers, as compared with 26% of the non-smokers.
The treatment of established pressure ulcers

Conservative treatment
Relieve pressure
The rst essential step in treating a pressure ulcer is to relieve the pressure on the ulcer totally and continuously. This means complete bedrest for patients who are already ambulant or wheelchair bound. The patient must be turned every 3 hours, day and night, to prevent further ulcers from developing on unaffected areas, and positioned in such a way that no weight is thrown on the ulcer(s). Rings around the heels to relieve localized pressure are contraindi-
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cated. The area of skin under the ring may receive sufcient pressure to cut off the blood supply to the area in the centre, which is the area most at risk. A low air loss bed facilitates positioning a patient with multiple ulcers, or a sorbo pack bed or pillow packs spaced as for sorbo packs can be used on top of an ordinary mattress. If pressure is not relieved over the ulcer, any other measures taken will prove unsuccessful.
General treatment
Blood transfusions may be required to keep the haemoglobin level in the upper range of normal.
Local treatment
All slough and necrotic tissue is radically excised. This prevents the toxic effects which result from the absorption of dead tissue into the bloodstream. A wide range of lotions is used. The use of topical antibiotics is controversial. The dressing is completely sealed off with a wide porous dressing.
Surgical treatment
Various surgical procedures may be considered in selected cases.
Physiotherapy
Passive movements
Passive movements are given to the paralysed limbs to prevent contractures and are recommenced after surgery when the surgeon considers it advisable. As a general rule, the patients can be divided into those with severe spasticity and those with accid lesions. If the patient has severe spasticity or if any one movement causes violent spasm, all movements are avoided until the ulcer is healed. If the lesion is accid or the patient has minimum spasticity, and the pressure ulcers are around the hips or back, it may be possible to commence moving the knees and feet after a week to 10 days. Initially very gentle movements only are given. Whilst moving the joints involved, the therapist watches the scar to avoid excessive tension. The range of any movement which looks potentially dangerous is increased with extreme caution to avoid breakdown of the wound.
Grease massage
The pliability of the skin is an important factor when excision of the ulcer is considered. The more pliable the surrounding tissues, the
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easier is the approximation of the skin following the excision. When necessary, daily massage with lanolin is given to a wide area surrounding the ulcer. Deep nger kneading increases the circulation and improves the elasticity and mobility of the skin and subcutaneous tissue.
Exercise
The patient is encouraged to pull a chest expander or lift weights of suitable strength several times every hour to maintain strength in the arms and upper trunk.
Chest therapy
Pre- and postoperative therapy is given if a general anaesthetic is used for any surgical procedures.
Pressure consciousness
The patient must be educated, or re-educated, in pressure consciousness and have his posture, cushion and wheelchair checked by the therapist expert in the eld.
Transfers
In spite of any previous rehabilitation, once the patient is mobile all transfers are checked to see that due care is taken when lifting and moving the limbs.
SHOULDERHAND SYNDROME (SHS)

The clinical features of the SHS are shoulder pain, wrist/hand pain, oedema, vasomotor changes, trophic changes and osteoporosis on X-ray. Aisen & Aisen (1994) found that almost one-third of the patients in their study had three or more of these symptoms. Shoulder pain was more common in patients with lesions between C3 and C5 (23/23) whilst hand/wrist pain (15/23) occurred with the same frequency in patients with upper and lower cervical lesions (Aisen & Aisen 1994). Almost all were satisfactorily resolved with conservative treatment after about 4 months. The pathophysiology of this condition is unclear, although sympathetic hyperactivity appears to be important The few studies reported are on SHS after stroke, where it is sometimes treated with corticosteroids and also by stellate block with good effect (Braus & Strobel 1991). Treatment by physiotherapy is conservative, continuing movements without force and elevating the limb to reduce swelling.
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SPASTICIT Y
During the period of spinal areexia following complete transverse section of the cord, there is accid paralysis of all muscles below the level of the lesion. Subsequently, the isolated cord resumes some autonomous function and the motor paralysis becomes spastic. The heightened reex activity of the isolated cord is demonstrated by increased tone in the muscles and brisk tendon reexes. The ensuing degree of spasticity varies. In some cases it may remain mild, while in others the afferent stimuli, uninhibited by higher centres, cause a mass response in the isolated cord, and a mass response of muscle action ensues. This can produce any combination of muscle spasm, e.g. total exor or extensor patterns, or alternating exor and extensor spasticity, or exion of the knees with extension of the hips. The increased muscular tension leads to an uneven distribution of pressure on joint cartilage. This may result in the destruction of cartilage, capsular contractures or partial dislocations of varying degrees. Spasticity is dealt with more extensively in Chapter 15.
Treatment of established spasticity

A combination of the following methods may be used:

physiotherapy chemotherapy surgery.
Certain factors stimulate spasticity and these are excluded before deciding on a course of treatment:

distension of internal organs below the level of the lesion, i.e. bladder and bowels septic conditions, such as urinary tract infections, or infected pressure ulcers contracted tendons and joints, which reduce the threshold of irritability of the stretch reex local skin lesions, ingrowing toe nails, etc.
When considering treatment, the following facts are borne in mind:

fatigue has a depressant effect on spasticity muscle accommodates to prolonged stretch posture inuences reexes spasticity is inuenced by emotional factors.
Physiotherapy
Passive movements. These are always given to maintain mobility in all structures.
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Prolonged passive stretching

The stretch may be given manually, or by utilizing one of the stretch positions as for contractures, or in the standing position.
Hydrotherapy
Passive movements and swimming exercises in a heated pool may provide temporary relief for some patients.
Reex inhibiting postures

These may be useful to reduce spasticity or maintain relaxation during treatment. The position adopted when sleeping can be used to reduce spasticity. For example, sleeping prone for 3 or 4 hours reduces exor spasticity in the lower limbs.
Standing and walking

Weight-bearing reduces spasticity. However, in some severely spastic cases, the standing position may be impossible without rst reducing the spasticity by some other means, e.g. passive movements, a passive stretch or hydrotherapy.
Ice therapy
Ice towels may reduce spasticity when it is associated with contracture, but they have not proved valuable in treating the large muscle groups for spasticity alone.
Chemotherapy
Chemotherapy is used in the following ways.
Drug therapy
Antispasmodic drugs can be used with some effect on certain patients, although their effectiveness in reducing severe spasticity is extremely limited. They are usually prescribed with caution only after a period of physiotherapy has proved insufcient, as the side effects, notably that of sedation, can affect the patients rehabilitation.
Intrathecal injections and local temporary nerve block

(See also Ch. 15.) Intrathecal injections of baclofen have been used with good effect for some years in the treatment of severe spasticity (Penn &Kroin 1987, Azouvi et al 1996). Intrathecal morphine may be useful if the patient is intolerant to baclofen (Soni et al 2003).
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Local temporary nerve blocks using botulinum toxin are also used to relieve spasticity in specic muscle(s) (see p. 309).
Surgery
Surgical procedures on peripheral structures may be required if chemotherapy and nerve blocks fail are preferred to those performed on the cord or roots. Methods used to reduce spasticity include diminishing the contraction potential of the muscle by elongating the tendon, or by severing the nerve supplying a large muscle group, and by tenotomy or capsulotomy (Eltorai & Montroy 1990). In certain patients with complete or incomplete lesions, it appears that one muscle triggers off the spastic pattern. In these cases, a surgical procedure may be performed to block conduction to the trigger muscle. In most instances the result is an overall reduction in spasticity.
SPINAL DEFORMIT Y
Any patient conned to bed for some time is in danger of developing contractures and may also develop a scoliosis. Children and adolescents are in particular danger because of continuing growth and extreme joint mobility (see Ch. 16). When a patient spends a high proportion of time in an abnormal, incorrect posture for functional activities, convenience or comfort, whether in bed or in a wheelchair, deformities develop. Gross scoliosis or pelvic distortion will severely hamper the patients rehabilitation and may prevent him from attaining complete independence or from functional weight-bearing. In assessing the deformity, the exact nature of the problem needs to be identied, especially whether the posture is correctable or has become xed.
Prevention and treatment

Every effort must be made to prevent such deformities by correct positioning in bed and when seated in the wheelchair, re-education of posture and muscle development. The correct choice of cushion, and the posture and t of the patient in his wheelchair are dealt with in Chapter 6. The following methods of treatment can be useful:

strengthening the weaker or less used muscle groups, including the use of functional electrical stimulation. stretching those muscles tending to shorten and maintaining a passive stretch in the overcorrected position. re-education of posture and regular reassessment of efcacy of the wheelchair cushion
COMPLICATIONS
369
corrective sleeping postures bracing.
Corrective sleeping postures

Pillows can be used to support the spine in a corrected position at night. For example, a patient with a long C curve to the left should have sufcient pillows under the thorax when lying on his left side to give maximum correction of the deformity.
Bracing
A spinal brace may be necessary to support the child or adolescent with a bad posture in sitting or standing. Occasionally an adult may also need a brace for this purpose.
Surgery
Surgical procedures may be indicated in selected cases.
SYRINGOMYELIA
The major symptoms of this complication are pain, which may be localized centrally or which may radiate into the arm or trunk, sensory impairment and increasing weakness. It appears to be more common in tetraplegic than in paraplegic patients (Rossier et al 1985). The results of conservative treatment have proved unsatisfactory. With magnetic resonance imaging and the possibility of nontraumatic investigation, it is possible to detect syringomyelia earlier and to drain those cysts producing signicant symptoms or signs. Human embryonic spinal cord tissue has been implanted into humans with post-traumatic progressive syringomyelia with some success. The procedure proved to be safe and to obliterate the cyst (Johnston 2001). Physiotherapy is directed towards re-education after surgery. This is a distressing condition where increasing weakness can rob the patient of his independence.
References
Aisen P S, Aisen M L 1994 Shoulder-hand syndrome in cervical spinal cord injury. Paraplegia 32:588592 Anke A G W, Stenchjem A E, Kvalvik Stanghelle J 1995 Pain and life quality within two years of spinal cord injury. Paraplegia 33:555559 Aung T S, El Masry W S 1997 Audit of a British centre for spinal injury. Spinal Cord 35:147150 Azouvi P, Mare M. Thiebaut J B et al 1996 Intrathecal baclofen administered for control of severe spasticity: functional improvement and long term follow-up. Archives of Physical Medicine and Rehabilitation 77:3539
370
Bagley J C, Cochran T P, Sledge C B 1987 The impingement syndrome in paraplegia. Journal of Bone and Joint Surgery America 69:676678 Balazy E 1992 Clinical management of pain in spinal cord injury. Clinical Journal of Pain 8:102110 Ballinger D A, Rintula D H, Hart K A 2000 The relation of shoulder pain and range of motion problems to functional limitations, disability and perceived health of men with spinal cord injury: a multi-faceted longitudinal study. Archives of Physical Medicine and Rehabilitation 81:15751581 Banovac K, Gonzalez F 1997 Evaluation and management of heterotopic ossication in persons with spinal cord injury. Spinal Cord 35:158162 Banovac K, Williams J M, Patrick L D, Haniff Y M 2001 Prevention of heterotopic ossication after spinal cord injury with indomethacin. Spinal Cord 39:370374 Banovac K, Williams J M, Patrick L D, Levi A 2004 Prevention of heterotopic ossication after spinal cord injury with COX-2 selective inhibitor (rofecoxib). Spinal Cord 42:707710 Becker S W J, Rohl R, Weidt F, 2003 Endoprosthesis in paraplegics with periarticular ossication of the hip. Spinal Cord 41:2938 Belanger M, Stein R B, Wheeler G D et al 2000 Electrical stimulation: can it increase muscle strength and reverse osteopenia in spinal cord injured individuals ? Archives of Physical Medicine and Rehabilitation 81:10901098 Bennett G J 1991 The role of the sympathetic nervous system in painful peripheral neuropathy. Pain 45:221223 Bowsher D 1996 Control pain of spinal origin. Spinal Cord 34:707710 Braus D F, Strobel J 1991 The shoulder hand syndrome after stroke: a prospective study. Annual Neurology 30:278279 Cardinas D A, Turner J A, Warms C A, Marshall H M 2002 Classication of chronic pain associated with spinal cord injuries. Archives of Physical Medicine and Rehabilitation 83:17081714 Cariga P, Ahmed S, Mathias C J, Gardiner B P 2002 The prevalence and association of neck (coat-hanger) pain and orthostatic (postural) hypotension (oh) in human spinal cord injury. Spinal Cord 40:7782 Curtis K A, Roach K E, Brooks Applegate E et al 1995 Development of the wheelchair users pain index (WUSPI). Paraplegia 33:290293 Donovan W H, Dimitrijevic M R, Dahm L, Dimitrijevic M 1982 Neurophysiological approaches to chronic pain following spinal cord injury. Paraplegia 20:135146 Eltorai I, Montroy R 1990 Muscle release in the management of spasticity in spinal cord injury. Paraplegia 28(7):433440 Freehafer A A 1995 Limb fractures in patients with spinal cord injury. Archives of Physical Medicine and Rehabilitation 76:823827 Frey-Rindova P, de Bruin E D, Stussi E et al 2000 Bone mineral density in upper and lower extremities during 12 months after spinal cord injury measured by peripheral quantitative tomography, Spinal Cord 38:2632 Hachen H J 1978 Psychological, neurophysiological and therapeutic aspects of chronic pain. Preliminary results with transcutaneous electrical stimulation. Paraplegia 15:353367 Harvey L A, Herbert R D 2002 Muscle stretching for treatment and prevention of contracture in people with spinal cord injury. Spinal Cord 40:19
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Hicken B L, Putzke J D, Richards J S 2001 Classication of pain following spinal cord injury: literature review and future directions. Pain following spinal cord injury. International Association for the Study of Pain. Johnston L 2001 Human spinal cord injury: new and emerging approaches to treatment. Spinal Cord 39:609613 Lammertse D P, Falci S P 2001 Surgical management of central pain in persons with spinal cord injury: The dorsal root entry zone (DREZ) procedure. Topics in Spinal Cord Rehabilitation (Pain Management) 7(2): Fall Lazlo M G, Shiraji P, San M et al 2001 Osteoporosis and risk of fracture in man with spinal cord injury. Spinal Cord 39:208214 Michaelis L S 1964 Myotomy of iliopsoas and obliquis externus abdominis for severe spastic exion contracture at the hip. Paraplegia 2:287294 Penn R D, Kroin J S 1987 Longterm intrathecal baclofen infusion for treatment of spasticity. Journal of Neurosurgery 66:181185 Pullicino C V N, McClelland M, Badwan D A H et al 1993 Sonographic diagnosis of heterotopic bone formation in spinal cord injury patients. paraplegia. International Journal of the Spinal Cord 31:4050 Putzke J D, Richards J S, Hicken B L et al 2002 Pain classication following spinal cord injury: the use of verbal descriptors. Spinal Cord 40:118127 Richards J S, Hicken M A, Putzke J D et al 2002 Reliability characteristics of the Donovan Spinal Cord Injury Pain Classication System. Archives of Physical Medicine and Rehabilitation 83:12901294 Rodriguez G P, Garber S L 1994 Prospective study of pressure ulcer risk in spinal cord injury patients. Paraplegia 32:150158 Rossier A B, Foo D, Shillito J, Dyro F M 1985 Post traumatic cervical syringomyelia. Brain 108:439461 Salisbury S K, Low Choy N, Nitz J, 2003 Shoulder pain, range of motion and functional motor skills after acute trauma. Archives of Physical Medicine and Rehabilitation 84(10):14801485 Samuelsson K A M, Tropp H, Gerdle B 2004 Shoulder pain and its consequences in paraplegic spinal cord injury wheelchair users. Spinal Cord 42:4146 Siddall P J, Loeser J D 2001 Pain following spinal cord injury: Scientic Review. Spinal Cord 39:6373 Silver J R 1996 Association between muscle trauma and heterotopic ossication in spinal cord injured patients. Spinal Cord 34:499500 Snoecx M, De Muynck M, Van Laere M 1995 Association between muscle trauma and heterotopic ossication in spinal cord injured patients: reections on their causal relationship and the diagnostic value of ultrasonography. Paraplegia 33:464468 Soni B M, Mani R M, Oo T, Vaidyanathan S 2003 Treatment of spasticity in a spinal cord-injured patient with intrathecal morphine due to intrathecal baclofen intolerance a case report and review of literature. Spinal Cord 41:586589 Szollar S M 1998 Bone mineral density and indexes of bone metabolism in spinal cord injury. Archives of Physical Medicine and Rehabilitation 77:2835 Szollar S M, Martin E M E, Parthemore J G et al 1997 Demineralisation in tetraplegic and paraplegic man over time. Spinal Cord 4:223228
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Taly A B, Nair K P S, Kumar V M et al 1999 Heterotopic ossication in non-traumatic myopathies. Spinal Cord 37:4749 To T-P, Lim T C, Hill S T et al 2002 Gabapentin for neuropathic pain following spinal cord injury. Spinal Cord 40:282285 Tunks E 1986 Pain in spinal cord injured patients. In: Bloch R F, Basbaum M (eds) Management of spinal cord injuries. Williams & Wilkins, Baltimore, MD, p 180211 Van Kuijk A A, Geurts A C H, van Huppevelt H J M 2002 Neurogenic heterotopic ossication in spinal cord injury. Spinal Cord 40:313326 Werhagen L, Budh C N, Hultling C, Molander C 2004 Neuropathic pain after traumatic spinal cord injury relations to gender, spinal level, completeness and age at time of injury. Spinal Cord 42:665673 Widerstrom-Noga E G, Turk D C 2003 Types and effectiveness of treatments used by people with chronic pain associated with spinal cord injuries: inuence of pain and psychosocial characteristics. Spinal Cord 41:600609 Widerstrom-Noga E G, Duncan R, Felipe-Cuervo E, Turk D C 2002 Assessment of the impact of pain and impairments associated with spinal cord injury. Archives of Physical Medicine and Rehabilitation 83:395404
Sport in rehabilitation
THE THERAPEUTIC VALUE OF SPORT
Clinical sport has an important contribution to make in the rehabilitation of patients with spinal cord injury. It assists in restoring the patients strength, balance, coordination and endurance. It stimulates activity of mind and encourages self-condence and interaction with others. Some patients were enthusiastic sportsmen before becoming disabled and, once introduced to sport in a wheelchair, will continue when they leave hospital. Neill & Maguire (2004) found that most patients emphasized the importance of sport in rehabilitation. It is suggested by Ditor et al (2003) that participation in sporting activities increases quality of life and decreases stress and pain. Sports clubs provide a useful opportunity for mixing with the local community. Swimming, archery and table tennis are particularly valuable during rehabilitation. Dartchery, snooker and basketball or volleyball are also useful (Guttmann 1976).
CHAPTER
19
The therapeutic value of sport 373 Swimming 373 The pool 373 Therapeutic uses 374 Swimming instruction 375 Instruction for patients with thoracic or lumbar lesions 375 Instruction for patients with cervical lesions 376 Incomplete lesions 377 Archery 377 Therapeutic value 377 Archery for patients with cervical cord lesions 379 Dartchery 379 Darts 380 Table tennis 381 Therapeutic value 381 Basketball 381 Bowls 381 Fencing 382 Snooker 382 Tennis 382 Wheelchair rugby 382 Rules 382 The benet of competitive sport 382
SWIMMING The pool

To enable patients to swim, the pool must be a reasonable length, if possible a minimum of 8 metres. If different depths are required, a sloped oor is preferable to steps. Skin damage can easily occur against the hard edges of steps as the paralysed legs trail in the water. As it is generally found that cold water increases spasticity, the water temperature is kept high: 3236C (9096F). At this temperature, spasticity is reduced in the majority of patients.
Hygiene
The pool should have some form of continuous ow system through a lter plant. The chlorine content is maintained and checked twice 373
374
a day. Samples of the water are cultured regularly. The patient expresses his bladder prior to entering the pool and should have had a satisfactory bowel evacuation.
Entry into the water

Some type of hydraulic lift provides the safest method of entry for all tetraplegic patients and for those patients with lower lesions who are incapable of independent transfer. Active paraplegic patients enter over the side of the pool using a sorbo rubber pad placed over the edge to protect the skin from the hard surface.
Therapeutic uses
Swimming increases exercise tolerance, vital capacity and cardiovascular efciency. Swimming prone increases the activity of the diaphragm and consequently lung volume in patients with cervical cord lesions because of the need to hold the breath in this position.
Increase of muscle strength

Swimming increases the strength of all innervated muscles. Motor power in patients with incomplete lesions can be increased by normal hydrotherapy techniques, using water to eliminate gravity or to assist or resist movement. In addition to swimming, exercises to increase muscle strength in patients with complete lesions can be given using the water to assist or resist movement as required.
Improved coordination
Coordination can be improved by all the strokes used in swimming, in particular the unilateral strokes.
Reduction of spasticity
This is achieved passively through the heated water, passive movements and passive stretching, and actively through swimming.
Reduction of contractures
Passive stretching of contractures is often facilitated by the heated water.
Psychological and social aspects

Mobility in the water is often the only experience of unaided body movement within the environment that most paralysed patients enjoy. Consequently, a new enthusiasm is often noted when pool activities
SPORT IN REHABILITATION
375
are commenced. It also provides a further opportunity to mix with able-bodied people. Many patients enjoy swimming with family and friends.
Swimming instruction
The Halliwick method of teaching independence in the water is largely used in the UK as a recreational activity, but it also has great value in the therapeutic eld (Martin 1981). The objective of this method is water safety leading to independent freedom of movement in water, which is achieved with no help other than a close instructorswimmer relationship. The method suggests that the swimmer should rst adjust to the water and then learn to change his position in the water so that he can always move himself into a position in which he is able to breathe.
Rolling
To roll in the water, the swimmer turns his head to one side, e.g. the left, and moves one arm, e.g. the right, across his body causing him to tip over until he is face down in the water. The same procedure is repeated to continue the roll to bring the swimmer face upwards again. The 360 roll needs to be practised until it can be done with ease. Independence in the water is rst achieved on the back, the prone position being more difcult to maintain without muscle power at the hip joints. Symmetrical strokes are taught initially, as asymmetrical activity causes the paralysed limbs to roll and the patient nds difculty in maintaining a straight course.
Instruction for patients with thoracic or lumbar lesions

When supine in the water, the paralysed portion of the body lies at an angle of 45 from the site of the fracture. To compensate for the paralysed limbs, the head needs to be well extended.
Backstroke
The therapist supports the patient under the neck; the patient, maintaining his head in extension, moves his arms simultaneously away from the sides with the elbows exed. He then extends the elbows and brings the arms back to midline, with the thumbs just breaking the surface of the water. Because the hips are lower in the water, the body will be pushed upwards if the arms are brought back to the sides. Similarly, when the patient relaxes the stroke, his body will sink again. In this way, a vertical as well as a horizontal component
376
to the movement is produced with consequent wasted effort. Once the patient has become accustomed to his position in the water, the sculling stroke is expanded, and the arms are brought out of the water close to the head, as in the Old English backstroke. To prevent his head submerging when the arms are in full elevation, the patient must relax his extended head for a second or two.
Breaststroke
The position of the body when the patient is prone in the water resembles an inverted U, with the head submerged and the buttocks oating to the surface. To counteract this tendency, the patient is initially taught to do the breaststroke with his head constantly out of the water, as strong extension of the head and upper trunk is needed to keep the buttocks submerged. The therapist assists the patient with one hand under his chin and the other pressing down on his buttocks. As the patient becomes aware of his position in the water, the chin support is withdrawn. Later the pressure on the buttocks is gently released and the patient must work hard to maintain the necessary extension. When this is achieved, the patient begins to swim with his head under water for several strokes in the usual way. He must, however, start to extend his head much sooner than the able-bodied breaststroke swimmer. The head of the paraplegic swimmer will be forced under water just before his hands are level with his shoulders.
Unilateral strokes (crawl)

Without the necessary leg movement to prevent it, the lower half of the body will roll during a unilateral stroke. The roll can be prevented during back crawl by making small paddling movements with the non-stroke arm as the stroke arm pulls down.
Buttery stroke
Patients with lesions at C6 and below who have been procient in this stroke prior to their accident can relearn it.
Instruction for patients with cervical lesions

Patients with functional use of latissimus dorsi and triceps swim in the same way as patients with lower lesions. Patients with lesions at C6 can occasionally become independent swimmers, but the majority, although capable of swimming alone, need an attendant in case difculties arise.
Rolling
This is described on page 375.
377
Backstroke
To gain extension at the elbow without triceps, the arm must be kept in lateral rotation and it can be lifted only a few degrees above shoulder level. As the arm returns to the water and pulls down, water pressure will keep the elbow straight.
Swimming prone
Without triceps, the true movements of the breaststroke are impossible. The patient with a lesion at C5C6 pulls his arms through the water towards his body using biceps, deltoid and the clavicular head of pectoralis major. While the patient is swimming face down, it is important that the therapist keeps one hand on the patients shoulder where he has sensation. Initially, most patients will only be able to swim two or three strokes, but within six or seven sessions this can be increased up to an average of 810 metres.
Leaving and returning to the side of the pool

To leave the side, the patient lies parallel with the side of the pool with the head extended and pushes off gently, with the arm just on the surface of the water. To return to the side, the patient swims in parallel with, and as close as possible to, the side of the pool, keeping the nearside arm under the surface of the water. He then rapidly ings the arm into the overow trough and strongly exes his neck. To maintain this position, paddling movements are performed with the free arm by pulling the water towards the body, as in the breaststroke movement.
Incomplete lesions
Patients with incomplete lesions with weak, scattered muscles and patchy sensation can gain strength and coordination from using all the available swimming strokes.
ARCHERY
From both the medical and recreational aspects, archery has proved to be an ideal sport for patients with spinal cord injury.
Therapeutic value
Increase of muscle strength
Archery develops and strengthens the essential muscles of the paraplegic patient, i.e. erector spinae, deltoid, pectorals, rhomboids, trapezius and latissimus dorsi (Fig. 19.1A).
378
Figure 19.1 Archery. A: Patient with a complete lesion below T10. B: Patient with a complete lesion below C6.
Balance, control and coordination

When the bow arm is lifted and the centre of gravity consequently altered, skilled balance is required to maintain the erect posture.
379
Initially patients with high thoracic lesions may need to bring the buttocks slightly forward in the chair and lean heavily against the backrest to achieve sufcient stability. As the balance improves, the upright posture is resumed. Accurate marksmanship requires control, dexterity and judgement, and demands ne coordination of the eye, hand and arm.
Social value
Whether the archer stands or is in a wheelchair, they meet on equal terms. The wheelchair archer can join a club for able-bodied sportsmen, which provides a further opportunity for integration with the local community.
Archery for patients with cervical cord lesions

Special equipment is necessary to enable the tetraplegic patient to shoot.
The release
To release the arrow without nger exion or extension, a hook device is used. A small hook at the end of a metal splint is strapped to the palmar surface of the middle nger extending across the wrist of the drawing hand (Fig. 19.2). To release the string the archer slightly pronates his forearm. Pronation gives greater accuracy, as supination allows gravity to act on the unstable forearm. This causes the elbow to drop and results in inaccurate shooting. With the appropriate training, archers of ability who use the hook release can reach the longest international distance of 90 metres.
The bow arm

The patient without triceps needs a splint to maintain the elbow in extension. If the wrist extensors are weak, a wrist splint is frequently necessary to prevent the wrist being forced into exion by the tension of the bow. The bow needs bandaging into the hand. To gain the necessary stability, all patients with cervical cord lesions need to be tied into the chair. The tie is usually placed around the upper thorax and tied to the chair handle on the side of the drawing arm (Fig. 19.1B).
DARTCHERY
This game, played in pairs, was developed for paraplegic patients. Bow and arrows are used to shoot at a target face which is a replica of a dartboard. The target is set at a distance of 15 metres from the
380
Figure 19.2 Archery hook.
players and the rules are basically the same as those governing dart play.
DARTS
The dart board must be at an appropriate height for wheelchair users. If the player cannot hold conventional darts, blow darts can be used. The rules are the same as for able-bodied players.
381
TABLE TENNIS Therapeutic value

The therapeutic value of table tennis includes:

improved coordination, especially that of eye and hand improved agility in the wheelchair.
The loss of sensation and lack of balance make the patient fearful of falling during his early days in a wheelchair. Consequently, the patient is often rigid, unwilling to move any part of his body except his head. In his desire to hit the ball, this fear is gradually forgotten and the patient comes to realize that he can move about within the chair without either tipping it or falling out. The patient is taught to play with the chair stationary in the centre of the backline. The rules of play are the same as for the able-bodied, with the exception of the alternate shot rule for doubles. This rule is amended so that either partner can return any shot except when receiving service. Patients with cervical cord lesions also enjoy table tennis. Those without nger movement need the bat bandaged or strapped into the hand. To play backhand shots, those without triceps use outward rotation of the shoulder. An adjustable table tennis bat has been developed for tetraplegic sportsmen where the angle of the head of the bat can be changed in relation to the grip. The bat is held rmly in the hand by an elasticated glove. This allows a greater range of shots (Taktak 1997).
BASKETBALL
Wheelchair basketball is a fast and exciting game which calls for teamwork and accurate control of the body, chair and ball. Mobility, strength, endurance and dexterity in wheelchair management are developed. It is a game for those patients with a good functional grip, as accurate and immediate control of the chair is essential. A less active form of this game, volleyball, can be played by patients in their rst period of rehabilitation.
BOWLS
Bowls are played from the wheelchair with the same rules as for able-bodied players. This game can also be played on a carpet with 5 cm bowls for tetraplegic and 10 cm bowls for paraplegic players during their rehabilitation. It can also be played on a snooker table when the 3 cm bowls are bowled down a wooden slide.
382
FENCING
The weapon used for novices is the foil. No wheelchair skills are required as the chair remains static and tactics are all-important.
SNOOKER
This game provides excellent practice in coordination skills, particularly for patients with cervical cord lesions.
TENNIS
The rules are the same as for able-bodied tennis except that the ball is allowed to bounce twice before it must be hit.
WHEELCHAIR RUGBY
This game is for people with tetraplegia. It is similar to basketball, except that the goals are scored by having two wheels over the back line of the key area whilst being in possession of the ball. Some of these games, if not all, are usually available in spinal units as the skills required to play contribute to the rehabilitation of patients with spinal cord injury.
RULES
All sports are conducted, as far as possible, under the rules of the game for the able-bodied; for example, archery under the rules of the Grand National Archery Association and swimming under those of the Amateur Swimming Association. Each sport has its own rulebook with changes for disabled sportsmen where they are required.
THE BENEFIT OF COMPETITIVE SPORT

In one sense, all sport is competitive. The sportsman always competes with his past performance. He also competes, consciously or unconsciously, with others taking part in the same swimming or archery session. A protable physical and psychological stimulus is provided by competitive sport. These activities create a sense of comradeship and help to eliminate any self-consciousness suffered by patients in relation to their disability. They can give a sense of physical adequacy
383
and increase self-esteem (Bedbrook 1981). Competitive sport is also of great value in integrating disabled people with the able-bodied community and the facilities of some sports centres are available for both groups. Some spinal units have a staff member, often a physiotherapist, who liaises with local tness clubs and sports facilities to advise on equipment and access which may then enable people in wheelchairs to participate. Inter-spinal unit games offer a taste of competitive sport to patients still in hospital. They provide the opportunity to mix with people from other units, some of whom will be paralysed and some able-bodied, in a relaxed atmosphere where the social as well as the athletic skills of the recently paralysed patient will be required. Some patients become procient and enter international sporting events. Some wheelchair users are not interested in competitive sport but want to participate in sporting activities with family and friends (Kennedy & Smith 1990). Due to the initiative, enterprise and enthusiasm of disabled individuals, the list of sports open to the paralysed person is continually being extended. One person is now experimenting with aikido from a wheelchair, but he was a keen and able martial/artist prior to his accident (Booton 2003). Wheelchair users can enjoy angling, athletics, badminton, cricket, sailing, canoeing, scuba diving, snorkelling, waterpolo, karting and ying light aircraft with hand controls, parachuting in tandem, basketball, fencing, eld events, swimming, track racing and weight lifting and many winter sports such as mono- and bi-skiing. The majority of sports are unsuitable for open competition with able-bodied people, archery, angling, green bowling, snooker and table tennis being exceptions. Competitive sport for patients with spinal cord injury is organized on a national and international level through the International Wheelchair and Amputee Sports Federation.
References
Bedbrook G 1981 The care and management of spinal cord injuries. SpringerVerlag, New York Booton T 2003 Aikido on wheels. Forward (Spinal Injuries Association publication), June Ditor D S, Latimer A E, Ginis K A M et al 2003 Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain. Spinal Cord 41:446450 Guttmann L, Sir 1976 Spinal cord injuries. Comprehensive management and research, 2nd edn. Blackwell Scientic, Oxford, p 617627 Kennedy D W, Smith R W 1990 A comparison of past and future leisure activity participation between spinal cord injured and non-disabled persons. Paraplegia 28:130136
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Martin J 1981 The Halliwick method. Physiotherapy 67(10):288291 Neill S B, Maguire S 2004 Patient perception of the impact of sporting activity on rehabilitation in a spinal cord injury unit. Spinal Cord 42:627630 Taktak D M 1997 An adjustable table tennis bat and grip system for tetraplegics. Spinal Cord 35:6163
ASIA scale (a): Standard neurological classication of spinal cord injury
APPENDIX
387
Standard neurological classification of spinal cord injury

R
C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-5
Motor Key Muscles

Elbow flexors Wrist flexors Elbow extensors Finger flexors (distal phalanx of middle finger) Finger abductors (little finger)
0 = total paralysis 1 = palpable or visible contraction 2 = active movement, gravity eliminated 3 = active movement, against gravity 4 = active movement, against some resistance 5 = active movement, against full resistance NT = not testable
Hip flexors Knee extensors Ankle dorsiflexors Long toe extensors Ankle plantar flexors Voluntary anal contraction (Yes/No) + = (100) Motor score
Totals
(Maximum) (50) (50)
Neurological level The most caudal segment with normal function Sensory Motor
Maynard F M et al 1997 Figure 4 in International Standards for Neurological and Functional Classication of Spinal Cord Injury. Spinal Cord 35(5): 272 (with permission from American Spinal Injury Association).
Light touch R L
C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S45
Pin prick R L
Sensory Key Sensory Points

0 = absent 1 = impaired 2 = normal NT = not testable
T2 C5 S3
C2
C3
C4
C2 C3 C4 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T2 C5
S4-5
C6 T1
T1 C6
L 2 S2 L 3
L 2 L 3 S2
Palm
L1
L1
Palm
L2 C8 C6 C7 L3 Dorsum
L2 C8 C7
C6 L3 Dorsum
L 4 S1 L5
L 4 S1 L5 L5
L4
L4 L5
Key Sensory Points

S1 S1
Any anal sensation (Yes/No)
= Totals (Maximum) + (56) (56) (56) (56) =
Pin prick score Light touch score
(max: 112) (max: 112)
Complete or incomplete? Incomplete = Any sensory or motor function in S455 ASIA Impairment Scale
Zone of partial preservation Sensory Caudal extent of partially Motor innervated segments
ASIA Scale (b): Functional Independence Measure and impairment scale

Functional Independence Measure (FIM) 7 Complete Independence (Timely, Safely) 6 Modied Independence (Device) L E V E L S Modied Dependence 5 Supervision 4 Minimal Assist (Subject = 75%+) 3 Moderate Assist (Subject = 50%+) Complete Dependence 2 Maximal Assist (Subject = 25%+) 1 Total Assist (Subject = 0%+) ADMIT A. B. C. D. E. F. Self Care Eating Grooming Bathing Dressing-Upper Body Dressing-Lower Body Toileting No Helper
APPENDIX
2
ASIA IMPAIRMENT SCALE
served in the sacral segments S4S5. preserved below the neurological level and includes the sacral segments S4S5. the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
A = Complete: No motor or sensory function is preHelper
B = Incomplete: Sensory but not motor function is
C = Incomplete: Motor function is preserved below

DISCH
D = Incomplete: Motor function is preserved below E = Normal: motor and sensory function is normal
CLINICAL SYNDROMES
the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
Sphincter Control G. Bladder Management H. Bowel Management Mobility Transfer: I. Bed, Chair, Wheelchair J. Toilet K. Tub, Shower Locomotion L. Walk/Wheelchair M. Stairs Communication N. Comprehension O. Expression Social Cognition P. Social Interaction Q. Problem Solving R. Memory Total FIM NOTE: Leave no blanks; enter 1 if patient not testable due to risk.
W C W C
Central Cord BrownSquard Anterior Cord Conus Medullaris Cauda Equina
A V V N
A V V N
Maynard F M et al 1997 Figure 5 in International Standards for Neurological and Functional Classication of Spinal Cord Injury 35(5): 273 (with permission from American Spinal Injury Association).
390
SCIM Spinal Cord Independence Measure
APPENDIX
3
` ` ` ` ` ` `
Loewenstein Rehabilitation Hospital, Department IV (Version 1, May 1996, Raanana, Israel) Patient Name: ID: Examiner Name: (The score attached to the relevant description of each function should be placed in the adjacent square below the relevant data) Self-Care date 1. Feeding (cutting, opening containers, bringing food to mouth, holding cup with uid) 0. Needs parenteral, gastrostomy or fully assisted oral feeding 1. Eats cut food using several adaptive devices for hand and dishes 2. Eats cut food using only one adaptive device for hand; unable to hold cup 3. Eats cut food with one adaptive device; holds cup 4. Eats cut food without adaptive devices; needs a little assistance (e.g., to open containers) 5. Independent in all tasks without any adaptive device 2. Bathing (soaping, manipulating water tap, washing) 0. Requires total assistance 1. Soaps only small part of body with or without adaptive devices 2. Soaps with adaptive devices; cannot reach distant parts of the body or cannot operate a tap 3. Soaps without adaptive devices; needs a little assistance to reach distant parts of body 4. Washes independently with adaptive devices or in specic environmental setting 5. Washes independently without adaptive devices 3. Dressing (preparing clothes, dressing upper and lower body, undressing) 0. Requires total assistance 1. Dresses upper body partially (e.g., without buttoning) in special setting (e.g., back support) 2. Independent in dressing and undressing upper body. Needs much assistance for lower body 3. Requires little assistance in dressing upper or lower body 4. Dresses and undresses independently, but requires adaptive devices and/or special setting 5. Dresses and undresses independently, without adaptive devices 391
392
date 4. Grooming (washing hands and face, brushing teeth, combing hair, shaving, ` ` ` ` ` ` ` applying makeup) 0. Requires total assistance 1. Performs only one task (e.g., washing hands and face) 2. Performs some tasks using adaptive devices; needs help to put on/take off devices 3. Performs some tasks using adaptive devices; puts on/takes off devices independently 4. Performs all tasks with adaptive devices or most tasks without devices 5. Independent in all tasks without adaptive devices Respiration and Sphincter Management 5. Respiration 0. Requires assisted ventilation 2. Requires tracheal tube and partially assisted ventilation 4. Breathes independently but requires much assistance in tracheal tube management 6. Breathes independently and requires little assistance in tracheal tube management 8. Breathes without tracheal tube, but sometimes requires mechanical assistance for breathing 10. Breathes independently without any device 6. Sphincter management Bladder 0. Indwelling catheter 5. Assisted intermittent catheterization or no catheterization, residual urine volume >100 cc 10. Intermittent self-catheterization 15. No catheterization required, residual urine volume <100 cc 7. Sphincter management Bowel 0. Irregularity, improper timing or very low frequency (less than once in 3 days) of bowel movements 5. Regular bowel movements, with proper timing, but with assistance (e.g., for applying suppository) 10. Regular bowel movements, with proper timing, without assistance 8. Use of toilet (perineal hygiene, clothes adjustment before/after, use of napkins or diapers) 0. Requires total assistance 1. Undresses lower body, needs assistance in all the remaining tasks 2. Undresses lower body and partially cleans self (after); needs assistance in adjusting clothes and/or diapers 3. Undresses and cleans self (after); needs assistance in adjusting clothes and/or diapers 4. Independent in all tasks but needs adaptive devices or special setting (e.g., grab-bars) 5. Independent without adaptive devices or special setting
APPENDIX 3
393
Mobility (room and toilet) date 9. Mobility in bed and action to prevent pressure sores 0. Requires total assistance 1. Partial mobility (turns in bed to one side only) 2. Turns to both sides in bed but does not fully release pressure 3. Releases pressure when lying only 4. Turns in bed and sits up without assistance 5. Independent in bed mobility; performs push-ups in sitting position without full body elevation 6. Performs push-ups in sitting position 10. Transfers: bedwheelchair (locking wheelchair, lifting footrests, removing and adjusting arm rests, transferring, lifting feet) 0. Requires total assistance 1. Needs partial assistance and/or supervision 2. Independent 11. Transfers: wheelchairtoilettub (if uses toilet wheelchair transfers to and from; if uses regular wheelchair locking wheelchair, lifting footrests, removing and adjusting arm rests, transferring, lifting feet) 0. Requires total assistance 1. Needs partial assistance and/or supervision, or adaptive device (e.g., grab-bars) 2. Independent Mobility (indoors and outdoors) 12. Mobility indoors (short distances) 0. Requires total assistance 1. Needs electric wheelchair or partial assistance to operate manual wheelchair 2. Moves independently in manual wheelchair 3. Walks with a walking frame 4. Walks with crutches 5. Walks with two canes 6. Walks with one cane 7. Needs leg orthosis only 8. Walks without aids 13. Mobility for moderate distances (10100 meters) 0. Requires total assistance 1. Needs electric wheelchair or partial assistance to operate manual wheelchair 2. Moves independently in manual wheelchair 3. Walks with a walking frame 4. Walks with crutches 5. Walks with two canes 6. Walks with one cane 7. Needs leg orthosis only 8. Walks without aids
` ` ` ` ` ` `
394
date 14. Mobility outdoors (more than 100 meters) 0. Requires total assistance 1. Needs electric wheelchair or partial assistance to operate manual wheelchair 2. Moves independently in manual wheelchair 3. Walks with a walking frame 4. Walks with crutches 5. Walks with two canes 6. Walks with one cane 7. Needs leg orthosis only 8. Walks without aids 15. Stair management 0. Unable to climb or descend stairs 1. Climbs 1 or 2 steps only, in a training setup 2. Climbs and descends at least 3 steps with support or supervision of another person 3. Climbs and descends at least 3 steps with support of handrail and/or crutch and/or cane 4. Climbs and descends at least 3 steps without any support or supervision 16. Transfers: wheelchaircar (approaching car, locking wheelchair, removing arm and foot rests, transferring to and from car, bringing wheelchair into and out of car) 0. Requires total assistance 1. Needs partial assistance and/or supervision, and/or adaptive devices 2. Independent without adaptive devices
` ` ` ` ` ` `
Reproduced with permission from Catz A, Itzkovich M, Agranov E, Ring H, Tami A 1997 SCIM A new SCL disability scale. Spinal Cord 35:850856.
Major segmental innervation of the muscles of the upper limb

C2 + C3 C3 + C4 Trapezius + C5 Levator scapulae Sternomastoid C7
APPENDIX
4
Pronator teres Pectoralis minor Extensor digitorum Extensor digiti minimi Flexor carpi radialis + C8 Triceps Extensor carpi radialis brevis Palmaris longus C8 Extensor carpi ulnaris Flexor carpi ulnaris Extensor indicis Flexor digitorum profundus Flexor digitorum sublimis Abductor pollicis longus Abductor pollicis brevis Opponens pollicis Flexor pollicis longus Extensor pollicis longus Extensor pollicis brevis +T1 Adductor pollicis Flexor pollicis brevis Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi Lumbricales Interossei
C4 C5
Diaphragm Rhomboids Deltoid Teres minor Supraspinatus Infraspinatus Subclavius + C6 Biceps
C6
Brachialis Supinator Brachioradialis Subscapularis Teres major Coracobrachialis + C7 Serratus anterior Latissimus dorsi Extensor carpi radialis longus + C8 Pectoralis major
T1
395
Major segmental innervation of the muscles of the lower limb

L1 Psoas minor +L2 Psoas major Iliacus +L3 Sartorius +L4 Adductors +L4 L4 L5
APPENDIX
5
Gluteus medius Gluteus minimus +S1 Quadratus femoris Semimembranosus Semitendinosus Biceps femoris Peroneus longus Peroneus brevis S1 Obturator internus Gastrocnemius +S2 S2 Gluteus maximus
L2
L3 Quadriceps
Obturator externus +L5 Tensor fascia lata Tibialis posterior +S1 Tibialis anterior Extensor hallucis Extensor digitorum longus Peroneus tertius Popliteus
Flexor hallucis longus Flexor digitorum longus Soleus +S3 Interossei
S3
Abductor hallucis Adductor hallucis Lumbricales Abductor digiti minimi
396
Functional independence
APPENDIX
6
Segmental level Personal independence Type, turn pages, use telephone and computer with mouthstick Type Feed Drink Wash, shave, brush hair Dress upper half Sit up/lie down in bed Write Turn in bed Dress lower half Skin care Manipulate brake Push on the at Remove armrests/footplates Push on sloping ground Turn chair Chair bed Chair car ?with sliding board Wheelchair management Transfers Gait C4 C5 C6
C7
Pick up objects from oor Wheel over uneven ground Bounce over small elevations Negotiate kerbs
Chair toilet Chair chair ?Chair bath
Stand in frame
C8
Bladder and bowel care
Chair bath Chair oor
Stand in frame
T1T5
Balance on rear wheels Pull wheelchair into car
Stand in frame Swing-to in bars
T6T9
Chair crutches
Swing-to on crutches or rollator ?Stairs All three gaits on crutches Stairs Car crutches Floor crutches
T10L1
397
Segmental innervation of the skin
APPENDIX
7
C4 T2 C5
Upper limb C3 C4
C5
T1 C6 T1
C6 C8
C6
C8 C7
C8
C7
C6
Figure A7.1 Upper limb. Reproduced from Grays Anatomy, 35th edn, with permission.
Arrangement of dermatomes on the anterior aspect of the upper limb. The solid black line represents the ventral axial line, and the overlap across it is minimal. Across the interrupted lines, overlap is considerable. 398
Arrangement of dermatomes on the posterior aspect of the upper limb. The solid black line represents the dorsal axial line, and the overlap across it is minimal. Across the interrupted lines, the overlap may be and often is considerable.
APPENDIX 7
399
Lower limb
L1
S4
S3
Ventral axial line L2
S3
L2
L3
Preaxial border L3 Ventral axial line
S2
Dorsal axial line
Postaxial border
Extension forwards from dorsal axial line L5
L4 L4 S2 L5
S1 S1 L5 L4 L5 L4 S1
Figure A7.2 Lower limb. Reproduced from Grays Anatomy, 35th edn with permission.
Segmental distribution of nerves of the lumbar and sacral plexuses to the skin of the anterior aspect of the lower limb.
Segmental distribution of nerves of the lumbar and sacral plexuses to the skin of the posterior aspect of the lower limb.
Useful addresses and equipment suppliers
APPENDIX
8
International Medical Society of Paraplegia (IMSOP) National Spinal Injuries Unit Stoke Mandeville Hospital Aylesbury Bucks HP21 8AL International Spine Research Trust (ISRT) Nicholas House River Front Eneld Middlesex EN1 3TR Mobility Advice Charity National Headquarters Ashwellthorpe Norwich NR16 1EX Motability (Provides Simple Wheelchairs Overseas) Brockley Academy Brockley Lane Backwell Bristol BS48 4AQ www.motivation.org.uk The Pain Relief Foundation University Hospital Aintree Liverpool L9 7AL
LIST OF USEFUL ADDRESSES

Access Travel (Lancs) Ltd Holidays for Disabled Persons 6 The Hillock Astley Lancashire M29 7GW www.access-travel.co.uk The Back-up Trust The Business Village Broomhill Road London SW18 4JQ www.backup.org.uk The British Wheelchair Sports Federation and The International Wheelchair and Amputees Sports Federation Olympic Village Guttmann Road Aylesbury Bucks HP21 9PP www.wsw.org.uk Canine Partners Opening doors to independence (Canine partners for independence) Mill Lane Heyshott Midhurst West Sussex GU29 0ED www.caninepartners.co.uk
Centre for Accessible Environments Nutmeg House 60 Gainsford Street London SE1 2NY Disability Law Service 39 Cavell Street London E1 2BP Disability Sport England Solecast House 1327 Brunswick Place London N1 6DX The Disabled Drivers Association Ashwell Park East Harling Norwich NR16 1EX Disabled Living Foundation (Equipment for Disabled People) 380384 Harrow Road London W9 2HU Equipment for the Disabled (Equipment for Severely Disabled People) Mary Marlborough Lodge Nufeld Orthopaedic Centre Oxford OX3 7LD
400
APPENDIX 8
401 Environment control systems

The Gemini System Scientic and Technical Developments Melbourne Road Wallington Surrey SM6 8SD Possum Ltd Middleton Green Road Langley Slough Berkshire SL3 6DF
Society for Tissue Viability Wessex Rehabilitation Association Odstock Hospital Salisbury Wiltshire SP2 8BJ Spinal Injuries Association Suite J, 3rd Floor Acorn House 387391 Midsummer Boulevard Milton Keynes MK9 3HP www.spinal.co.uk
Cushion suppliers (international)

Sunrise Home Healthcare Group (Jay Cushions and backrests) Mobility Products Division 7477 East Dry Creek Parkway Longmont CO 80503 USA www.sunrisemedical.com RoHo International Inc. (RoHo Cushions and mattresses) 100 N Florida Avenue Belleville IL 622215429 USA www.roho.com Cascade Designs Inc. (Varilite cushions and backrests) 4000 First Avenue South Seattle WA 98134 USA www.varilite.com Vicair BV (Vicair cushions and backrests) Koetserstraat 14 1531 NX Worner The Netherlands www.vicair.com
EQUIPMENT SUPPLIERS Automatic transmissions

Reselco Engineering Ltd 72 Black Lion Lane Hammersmith London W6
Gymnastic ball
Central Medical Equipment Ltd 7 Ascot Park Estate Lenton Street Sandiacre Nottingham NG10 5DL
Chariot
Lomax Thomson Ltd Kingsway East Dundee Scotland DD4 8ED
Highlite Portable Gantry

(Portable hoist) Huntleigh Healthcare Woden Road West Wednesbury West Midlands WS10 7BL UK www.huntleigh-healthcare.com
Countryside buggy suppliers

Able Buggies Ltd Lane End Farm Bare Heath Wareham Dorset BH20 7NS
Electrical turning and tilting bed

Huntleigh Healthcare Ltd 310312 Dallow Road Luton LU1 1TD Pegasus Limited Pegasus House Waterberry Drive Waterlooville PO7 7XX
Keytools
(Computer accessories for severely disabled people) For the Computer Enabled PO Box 700 Southampton SO17 1LQ www.keytools.com
402 Incontinence products

Condom urinals
GU Manufacturing Co Ltd 28a Devonshire Street London W1
Oswestry standing frames

Theo Davies Berwyn Mill Glyn Ceiriog Llangollen Wrexham South Wales LL20 7HN
F16 Sunrise Medical Ltd Sunrise Business Park High Street Wollaston Stourbridge DY8 4PS www.sunrisemedical.com
Conveen penile sheaths

Colloplast Ltd Peterborough Business Park Peterborough PE2 0FX
Wheelchairs
Gerald Simmonds Healthcare Ltd Gerald Simmonds Wheelchairs Stoke Mandeville 9 March Place Gatehouse Way Aylesbury Buckinghamshire HP19 3UG Mobility 2000 Telford Industrial Centre Stafford Park 4 Telford Shropshire TF3 3BA
Sports and other wheelchairs

Cyclone (Sports wheelchairs and off road/rough terrain wheelchairs) Ellesmere Port South Wirral L66 1BR www.chasswheel.com EPC (Equipment for the physically challenged handbikes, scooters etc.) 43 Alexandra Road Farnborough Hants GU14 6BS www.epc-wheelchairs.co.uk
Rear and other access vehicles

Team Traction 130 Sturry Road Canterbury Kent CT1 1DP
Sorbo packs
Vitafoam Ltd Don Mill Middleton Manchester M24 2DB
Hybrid power/manual chairs

E-Fix and E-Motion Ulrich Alber GmbH Vor dem Weissen Stein 21 D-72461 Albstadt-Tailngen Germany Email: [email protected] www.ulrich-alber.de iGlide Independence Technology PO Box 7338 Endicott, NY 13760 USA www.independencenow.com/ iglide/
International wheelchair suppliers

Sunrise Home Healthcare Group (Quickie Wheelchairs) Mobility Products Division 7477 East Dry Creek Parkway Longmont CO 80503 USA www.sunrisemedical.com Etac AB (Etac wheelchairs Swede) PO Box 203 SE 334 24 Anderstorp Sweden www.etac.com < http://www.etac. com >
Standing frames
Grandstand
Prime Engineering (a Division of AXION industries Inc.) UK Agent: Enhancement (Agencies) Ltd IPER Division 23 Kingsland Road Hemel Hempstead Herts HP1 1QD
Dynamic parapodium
Doktor Perner Company Ltd Tymienckiego 22/24 Street 90 349 Lodz Poland www.parapodium.pl
APPENDIX 8
403
Levo stand-up wheelchair Valutec Ltd Steigstrasse 2 Ch-8610 Uster 3/Zurich Switzerland
Otto Bock Reha (Wheelchairs) Max-Nader Strasse 15 D-37115 Duderstadt Germany www.ottobock.com < http:// www.ottobock.com >
Invacare/Kschall UK (Wheelchairs) Invacare UK Ltd South Road Bridgend Industrial Estate Bridgend CF31 3PY www.kuschall.com
Further reading
Department of Transport 1996 Door to door, A guide to transport for disabled people, 5th edn. HMSO, London Edwards S 2002 Neurological physiotherapy: a problem-solving approach, 2nd edn. Churchill Livingstone, Edinburgh Fuller G 2000 Neurological examination made easy, 2nd edn, Harcourt, London Glass C A 1999 Spinal cord injury; impact and coping. British Psychological Society, Anthony Rowe Ltd. Reading, Berks Grundy D, Swain A (eds) 2002 ABC of spinal cord injury, 4th edn. BMJ Publications, London Harrison P. 2000 A & E The rst 48 hours: The initial management of people with actual or suspected Spinal Cord Injury from Scene of Accident to A & E Dept. Spinal Injuries Association Harrison P. HDU/ICU Managing spinal cord injury. Critical care. Spinal Injuries Association (www.spinal.co.uk) Joyeux D (ed) 2002 Moving forward, the guide to living with spinal cord injury. Spinal Injuries Association Le Clercq C (ed) 2002 The tetraplegic upper limb. In: Hand Clinics 18(3) MacIntyre N, Branson R D 2001 Mechanical ventilation. W B Saunders, London Senelick R C, Dougherty K 1998 The spinal cord handbook for patients and their families. Heath South Press, Birmingham, AL Sheean G (ed) 1998 Spasticity rehabilitation. Churchill Communications Europe, London Shumway-Cook A, Woollacott M 2001 Motor control theory and practical applications. Lippincott Williams & Williams, Baltimore, MD Wade D 2003 Measurement in neurological rehabilitation. Oxford University Press, Oxford Whalley Hammell K 1995 Spinal cord injury rehabilitation (Therapy in Practice series). Chapman & Hall, London Whiteneck G G, Charlifue S W, Gerhart K A et al 1993 Ageing with spinal cord injury. Demos Publications, New York
Video
Tussler D, Dalley J. Gaining ground physiotherapy following spinal cord injury. Spinal Injuries Association.
405
Subject Index
Notes page numbers ending in b indicate boxes page numbers ending in f indicate gures page numbers ending in t indicate tables A Abdominal binders 56, 219, 262 Abdominal muscles bladder management 20 paralysis 55, 56 respiration 5556 Accessory muscles, respiration 5455 Accommodation 125126 Active movements 5051 in bed 4650 contractures 354 incomplete lesions 297299 Acute lesions see Spinal lesion(s), acute Adaptations accommodation 125126 bathroom 125, 347348, 351 keyboard/mouse design 112 Addresses 400401 Adductor longus, gait 303b Adductor magnus, gait 303b Adjustment model 3536 Adult respiratory distress syndrome 70 Advanced Reciprocating Gait Orthosis (ARGO) 248249 Ageing 345352 equipment changes and 165, 349350 functional ability 346349 shoulder pain 347348 Air-lled cushions 8687 Ambu bag 67 Ambulation, children 332333 American Spinal Injury Association scale (ASIA scale) 45, 6, 6t, 387389
Analgesics, mild 362 Ankle clonus 47 Anklefoot orthosis (AFO) 333 Ankle positioning 43, 44 Ankle strategy 285 Anterior spinal artery compression 278279 Anterior spinal cord syndrome 278279 Anterior superior iliac spines (ASIS) palpation 81 Anterior vertebral artery 3 Anthropometric measurements 81, 9699 Anticoagulant therapy 14 Antispasmodic drugs 367 Appliances see Equipment Archery 377380, 378f balance 378379 cervical cord lesions 378f, 379 coordination 378379 postural control training 107, 378379 social value 379 stability 378f, 379 therapeutic value 377379 Archery hook 379, 379f Armrests (wheelchair) 162 correct positioning 80, 83 power-drive chairs 159 removal 166 Ashworth scale 7t ASIA scale (American Spinal Injury Association scale) 45, 6, 6t, 387389 Assisted coughing 5961 supine position 5961, 59f, 60f wheelchair 62, 63f Atropine 67 Automatic (reex) bladder 1920 Autonomic dysreexia 2627 functional electrical stimulation 255
Autonomous (non-reex) bladder 20 Avoidance coping strategies 36 B Back extension exercises 78 Backrest (wheelchair) 151, 162 angle 80, 157 female 151 height 7980 positioning 80, 157 power-drive chairs 263 tension adjustable 80, 151, 153f zipper 165 Back shells, children 330 Backstroke, swimming 375376 Baclofen, intrathecal 311312, 367 contraindications 312 delivery system 312 indications 311 Bagging 6667 Balance dressing 121 exercises C4 lesions 264265 on crutches 230, 231f power-drive wheelchair 264265 sitting position 104106 standing 223 treatment duration/ frequency 106 wheelchair 107 paralysed limb moving 138 reactions 285286 transfers 129 Bandages, below-knee orthosis 307, 308f Basketball 381 Bathroom adaptations 125, 204, 347348, 351 Bath seat, wooden 204 Batteries, power-drive wheelchairs 159 Bed loop 146
407
408
Bedpans 22 Beds, electrical turning and tilting 76, 269270 Below-knee (BK) irons 333 Biceps femoris, gait 303b Biceps, length maintenance 49 Biofeedback, muscle re-education 108 Biomechanics, transfers 129133 Bladder automatic (reex) 1920 autonomous (non-reex) 20 management 1823 paralysis 19 substitute lling sensations 19 training 1920 Blood pressure, tilting 216 Blood transfusions 364 Bobath adult hemiplegia courses 282 Body brace 85, 96f Body jackets 330 Body weight ageing 349 lifting 101 wheelchair choice 150 Bone, ectopic formation 74 Botulinum toxin 309311, 368 electromyography assessment 311 incomplete lesions 309311 positive support reaction 293 splints and 307, 310 Bowel management 2324 Bowls 381 Boxing glove splint 45, 45f, 358 Braces body brace 85, 96f children 330 spinal deformity 369 three-point 95, 96f Bradycardia, suctioning 67 Brake extensions 162 Brakes (wheelchair) 162 manipulation 166, 167f Brassires 120 putting on/taking off 123 Breaststroke 376 Breathing exercises 5758 accessory muscle use 261 BrownSquard syndrome 279281 cause 279 motor decit 280 sensory decit 280281 Bruises 92 Bursae development 75 Buttery stroke, swimming 376
SUBJECT INDEX
C Caddy, wheelchair 162 Calf straps, wheelchairs 155 Calipers see Hipkneeanklefoot orthoses (HKAFOs); Knee anklefoot orthosis (KAFO) Cambering 156 Cambridge Stem Cell Institute 8 Canadian Occupational Performance Measure (COPM) 117 Canine Partners for Independence 127, 400 Capstans, wheelchair 163 Capsulotomy, spasticity 368 Cardiovascular conditions 70, 346 Carers ageing patients 350 education programmes 37 ultra-high lesions 266, 269 Carrying bags 163 Cars crutches 244 hand controls 182 transfer of wheelchairs into 179182, 180181f, 268 travel in wheelchairs 270 Castor locks 163 Castors (wheelchair) 154 positioning 156157 Catheterization 19, 20 Central cord pain (neuropathic pain) 362363 Central cord syndrome (CCS) 274277 axonal damage 277 causes 274276, 275f clinical picture 276277 denition 274 gait 277 haemorrhagic 274, 275f motor decit 277 neurological recovery 276 sensory decit 277 standing posture 277, 278f Central key point 290 Central tendon, diaphragm 53 Cervical cord lesions active movements 5051 archery 378f, 379380 C2 lesions 259 C4 lesions 259, 264265 functional independence 397 lifting 190 posture 107 sport 376377, 379380 Cervical fracture, postural reduction 1617 Cervical lift 188, 189f
Cervical nerve roots 4 Charcots joints 26 Chemotherapy 367368 Chest mobilization 65 Chest wall muscles 5356 Children 319344 crutches 332 dressing 336 follow-up 338339 documentation 338, 339f growth 321, 341344, 343t management 329334 parental involvement 337 rehabilitation aims 320 rehabilitation programme modications 334337 research ndings 340344 school involvement 337338 self-care 336 spinal deformity 320334 transfers 211, 211f, 336 traumatic injury 319320 wheelchairs 160161, 336337 Clothing 95, 120 Coat-hanger pattern, pain 361362 Cock-up splint 112, 114f Cognitive dysfunction 36 Cognitive model of stress and coping 3536 Collapsing spine, children 321322, 322f, 323f Collars 95 Communication systems 259 Competitive sport, benets 382383 Compliance, patient 34 Complications 353372 early 1415 respiratory 6466 Computed tomography 16 Computers 111112, 114f, 119, 265 Condom urinal 2122, 21f Constipation 24, 351 Continuous positive airway pressure (CPAP) 65 Contractures 353355 ageing 348 causes 48, 353 central cord syndrome 276 children 326329, 333 nger exors 51 hip see hip contractures hypertonia 301 positive support reaction 293 surgery 355 swimming 374 treatment 353355 Coordination 374 Coping strategies 36
SUBJECT INDEX
409
Exercises balance see under balance breathing 5758, 261 manual resistance 108 neck 51, 78, 264 upper limb 105106, 106f Extensor carpi radialis 50 External locus of control 34 Eye movements, communication systems 259 F Fainting 103, 219 Fast glycolytic (FG) muscle 287, 288 Fast oxidative glycolytic (FOG) muscle 287 Fat embolus 70 Feeding 114f, 118 Feet see Foot Female pads (incontinence) 22 Femoral fractures osteoporosis 359360 passive stretching 224 Fencing 382 Fertility, male patients 25 Finger splints 114f First order fulcrum 130, 131f Flaccid paralysis, post injury 1314 Flexion, children forward, kyphosis 322 side, scoliosis 322, 322f Flexor hinge splint 114 Flexors, length maintenance 49, 50 Flexor withdrawal response 294 Flolite pad 86f Fluid-lled cushions 86 Foam cushions 86 Focal dystonia 309, 310 Foot contractures 328f, 329 mobilization 293 oedema 358 Footplates (wheelchair) 154155 positioning 79, 157 power-drive chairs 263 removal 194196, 197f Forced expiration 55, 58 Forwards stretch position 105 Four-point gait in bars 227f, 229 crutches 23, 231f stepping backwards 229 Fractures BrownSquard syndrome 280 femoral 224, 359360 osteoporotic 359360 rib 70
Corsets, children 330 Corticosteroids 16 Cough Assist 66 Coughing assisted see Assisted coughing normal 5859 in wheelchair 6164, 62f, 63f Crawl, swimming 376 Crucix position 296297, 297f Crush injuries 14 Crutches balance exercises 230, 231f cars, getting in/out of 244 children 332 doors, opening/closing 244 to oor 242244, 243f oor to 243f, 244, 245f gait training 230244 incomplete lesions 306 kerbs 242 slopes 244 stair climbing 239242, 241f backwards technique 240, 241f forwards technique 240, 241f transfer from chair 232239 backwards technique 236239, 237238f forwards technique 232234, 233f, 235f sideways technique 234236, 236f Crutch holder 163 Cushions 8688, 401 D Dartchery 379 Darts 380 Deep brain stimulation 363 Deep venous thrombosis 1415, 50, 358 Deformity, spinal see spinal deformity Dermatomes lower limb 399, 399f upper limb 398, 398f Desk arms, wheelchairs 162 Diaphragm 5354 intramuscular stimulation 69 ultra-high lesions 259 Diaphragmatic pacing 69 Digital evacuation, faeces 24 Dorsal column stimulation 363 Dorsal reticulospinal tract 291 Dressing balance 121 on bed 124125 C6 and below lesions 119125 children 336
garments without front fastening 121122 lower extremity 119, 123125 spasticity 121 techniques 121 total 119, 120 upper extremity 119, 120, 121123, 124 in wheelchair 121124 Drinking 118 Drug therapy acute phase 16 mild analgesics 362 respiratory complications 6465 spasticity 309312, 367368 ventilated patients 67 see also speci c drugs/drug types Dynamic Parapodium 224 E Ectopic bone formation 74 Education pressure consciousness 8993 programmes 37 relatives/friends 37 staff 268 websites 39 Education Act 1981 338 Effort, levers 130 Efforts arm 130 Elastic stockings 358 Elbow(s) extension without triceps 50 side-lying position 44 supine position 44 surgical procedures 115 Electrical turning and tilting bed 76 Electrodes, implanted 254255 Elevating legrests 163 Elevation, hand oedema 358 Embolism, pulmonary 15, 50 Employment 96, 126 Environmental control systems 111, 159, 266 Equipment accommodation and 126 age-related changes in 165, 349350 personal independence 112, 114, 114f suppliers 401403 ultra-high lesions 269270 wheelchairs see Wheelchairs see also specic appliances Erectile stimulation 23 Evacuation, in bed 24
410
spinal 1617 spontaneous 359360 Frame (wheelchairs) folding 151, 152f rigid 151, 153f styles 151, 152f, 153f Frankel scale 5, 6t Freehand system 115117 Friction 7778 Frogslegs 163 Frog position 47, 296, 296f Fulcrum 130 Functional electrical stimulation (FES) 51 autonomic dysreexia 255 incomplete lesions 305306 orthostatic hypotension 102 patient selection criteria 255 reciprocating gait orthosis and 255256 standing systems 254255 surface stimulation 254 technical problems 255 ultra-high lesions 270 vasomotor system 262 Functional independence 397 ageing 346349 basic movements 135148 patients acceptance 349350 see also Personal independence Functional Independence Measure (FIM) 5, 6, 390 Functional magnetic stimulation 58 Functional movements, basic 135148 G Gadget holding appliances 112, 114, 114f Gait 225256 abnormal 303304 analysis, incomplete lesions 302306 anterior spinal cord syndrome 279 BrownSquard syndrome 280 central cord syndrome 277, 278f children 331 compensatory mechanisms 304 exor withdrawal response 294 functional 217 functional electrical stimulation 254255 normal 302, 303b in parallel bars 219 balanced position 221, 221f duration of stand 222 height of bars 219 patients action 220221, 220f
SUBJECT INDEX
posture correction 221222 therapist action 219, 220f wheelchair position 219 positive support reaction 293 sitting down 222 spasticity treatment and 310, 367 splints and 307 standing 219224 balance exercises 223 exercises 222224, 227f training 215258 appliances 217218 in bars 226230 children 332 on crutches 230244 Gastrocnemius 303b Girdlestone operation 357 Glenohumeral joint 301 Glenoid fossa 299, 301 Glossopharyngeal breathing 261 Gloves, pushing 114f, 168169 Gluteus maximus, gait 303b Gluteus medius, gait 303b Glycerine suppositories 24 Goal planning/setting 37 Grafts 8 Grandstand frame 224 Grease massage 364365 Grip 5051, 116 Ground reaction forces (GRFs), gait 303b Guards, wheelchairs 163 GuillainBarr syndrome 301 Guttmanns sign 261 Gymnastic ball 307309, 401 H Haemorrhage, spinal cord 3, 14 Hair brushing 114f, 118 Halliwick teaching method 375 Halo jacket immobilization 286 Hammock slings 270 Hamstrings 84, 303b Hand(s) augmentation of function 115117 central cord syndrome 277 oedema 358359 positioning 4446 surgery 115 Hand controls, vehicles 182 Handmaster 112 Head injuries 14, 70 postural assessment 83, 8485 Headaches, bladder distension 363 Headrest, power-drive wheelchairs 158 Head traction units 76
Healthcare professionals ageing patients 350351 negative attitudes 33 Heart disease 70, 346 Heel loops, wheelchairs 155 Heterotopic ossication (HO) 355357 High performance wheelchairs 155 mounting/descending stairs 174 179, 175f, 176f, 177f, 178f shallow steps 179, 179f transfer into car 179180, 180181f Hip(s) female 99 exion with knee exion 47 exors 49, 303b heterotopic ossication 357 passive exion assessment 84 side-lying position 44 sitting position assessment 82 supine position 43 Hip contractures ageing 348 children 326327, 326f passive stretching 354, 354f Hip ick position 7576 Hip hitching 305 Hipkneeanklefoot orthoses (HKAFOs) 248254 follow-up studies 253 gait 251254 multidisciplinary team 251 patient assessment 250251 similarities/differences 249250 training 251 types 248249 use discontinuation 253 weight tolerance limit 249 Hip strategy 285 Hoists 270, 351 transfer using 149150, 266267, 267f Hold-relax techniques 354 Home, returning 38 Housework 119 Human embryonic spinal cord tissue implantation 369 Humerus head 299 Humidication 64 Hydraulic lifts, swimming 374 Hydrotherapy contracture treatment 355 spasticity 367 swimming 373377 Hygiene swimming pool 373374 urinary 2223
SUBJECT INDEX
411
Lower limb(s) inspection 50 muscle innervation 396 oedema 358 postural assessment sitting position 8283 supine position 84 Lower motoneurone injury, growth and 343, 343t Lumbar anterior root stimulation implants (LARSIs) 255 Lumbar spine fractures, postural reduction 17 hyperlordosis 324325, 324f, 341 lordosis reversal 324, 324f Lying 140148 position assessment, children 333 M Magnetic resonance imaging (MRI) 16 Mattresses, pressure ulcer prevention 76 Mat work, children 334335, 335f Maximum expiratory pressure, coughing 61 Mechanical ventilation 6668, 259 Medial arch collapse 329 Medial reticulospinal tract 291 Menstruation 25 Methylprednisolone 16 Microatelectasis 55, 56 Mini-tracheostomy 68 Mirrors postural sense development 104, 330 skin inspection 92 Mobile arm supports 112, 164 Mobile standers 333, 333f Monkey hand 44 Monkey pole dressing 124 sitting from supine position 142 144, 143f Monkey syndrome 97, 133 Morphine 367 Motor function, independence 96 Motor learning 298 Mouse adaptations 112 Mouthsticks 112, 114f, 265 Movement(s) active see Active movements basic functional 135148 eye, communication systems 259 incomplete lesions compensatory 298299 speed 283284 support 283284
Hypertonia extensor 298 neural components 291292 non-neural components 292 passive/active movement 298 pathological activity 293295 shoulder 301 I iBOT Mobility system 161 Ice therapy contracture treatment 355 spasticity 367 Iliopsoas myotomy 355 Incomplete lesions see Spinal lesion(s), incomplete Incontinence garments 22 Independence crutch walking 217 functional 397 personal see Personal independence restoration 95100, 102f verbal 260261 Indometacin 356357 Indoor power-drive wheelchairs 157 Industrial rehabilitation unit 126 Indwelling catheter 19 Intercostal muscles 54 Interface pressure monitors 85 Intermittent catheterization 19 Intermittent positive pressure breathing (IPPB) 6566 Internal locus of control 34 International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP) 9 International Standards for Neurological and Functional Classication of Spinal Cord Injury 46 International Wheelchair and Amputee Sports Federation 383 Isocentric reciprocating gait orthosis (IRGO) 249 gait 253254 pre-selection hip joint 253 sitting/standing 253 J Jackets, putting on/removal 122 Jay cushions 86, 86f modications 87, 88f Jumping wheelchairs sideways 174
K Kerbclimber 159 Kerbs on crutches 242 in wheelchairs 159, 172174, 174f, 268 Keyboard adaptations 112 Key points of control 289290 Kinaesthesia 103 Kitchen adaptations 125 Knee(s) contractures, children 327329, 327f positioning 43, 44 positive support reaction 293 sitting assessment 82 valgus deformity 327329, 327f, 328f Kneeanklefoot orthosis (KAFO) 217218, 218f adjustable locked ankle joints 218 children 331332 materials 218 modular 218 valgus deformity 327328 Knuckle duster splint 117 Kyphosis, thoracic 324 L Labour 25 Lateral (side-lying) position 43f, 44 Lateral prehension grip 116 Latissimus dorsi postural control 103104 re-education 108, 109f respiration 55 Leaning, forwards assisted 90, 91f pressure relief 90, 91f Legrests (wheelchairs) 154155 angle 154 elevating 163 power-drive chairs 159 Levers 130132 anti-tipping 162 Lifting 101, 136138 feet from oor 223 forwards 138, 139f pressure relief 8990, 91f principles 136 sideways 137, 137f in wheelchair 190191f to wheelchair 188, 190191f Loaded expiration 66 Loading response, gait 303b Locus of control 34 Long paddle splint 117 Lordosis angle, children 341, 342t
412
passive see Passive movements resisted 51 sensory feedback 284285 voluntary 73, 284 Multisystems impairment 1824 Muscle(s) atrophy 287 bridge 219 heterotopic ossication 357 hypertrophy 108 innervation 395396 length maintenance 4850 re-education 108 strength children 336 sports 377 transfers 129130 tone 283 children 329 incomplete lesions 283 normal 283 supraspinal control 291 see also Spasticity trigger 368 types 286287, 286t viability 286287 see also specic muscles Muscle blocks 302 N Neck exercises 51, 78, 264 pain 348, 361 position, children 325326 see also entries beginning Cervical Needs Assessment Checklist (NAC) 67 Nerve blocks 302, 367368 Nerve cuff electrodes 254 Neuronal plasticity 46 Neuropathic pain (central cord pain) 362363 Neuroprostheses 115 Non-reex (autonomous) bladder 20 O Object retrieval, from oor 168 Obturator neurectomy 355 Oedema 14, 1516, 358359 Orthoses incomplete lesions 305, 307 toe off 307 wrist/hand 114 see also individual types Orthotic Research and Locomotor Assessment Unit (ORLAU) orthosis see Parawalker
SUBJECT INDEX
Osteomyelitis 74 Osteoporosis 359360 Oxygen therapy 64 P Pain 360363 classication systems 360361 neuropathic 362363 periarticular causes 361362 referred 363 Pain syndromes 360363 Palmar (power) grip 116 Palmar resting (paddle) splint 46 Palmar roll 45 Para-articular calcication 355357 Paradoxical motion 56 Paralysed limbs, moving 138 Paralytic ileus 6970 Paraplegia, denition 3 Parawalker 248, 248f, 249250 gait 251252 standing with crutches 252 Parents, involvement of 337 Passive movements in bed 4650 C1-C3 lesions 264 contractures 353 hand oedema 358 incomplete lesions 297299 pressure ulcers 364 Passive stretching, prolonged contractures 353354 spasticity 367 Patient activities C6 lesions 118119 programme 95 Patient-centred practice 3139 acute management 32 family/friend involvement 32 history 3132 initial rehabilitation 3334 Pectoralis major, respiration 5455 Peer support volunteers 261 Pelvic control 223 incomplete lesions 305 Pelvic obliquity 81, 325 Pelvic tilt abnormal gait 304 anterior 82 normal 82 posterior 82, 84 side 223 Pelvis incomplete lesions 302306 postural assessment sitting position 81, 82 supine position 84
Perceived control 3435 Periostitis 74 Peripheral nerve transplants 8 Permanent care, ultra-high lesions 269270 Peroneal muscles, gait 303b Peroneal nerve stimulation 305306 Personal independence 111128 C1-C4 lesions 111112 C5 lesions 112 C6 lesions 112119 Phrenic nerve stimulator 69 Physical proportions, patient 9699, 98t chair to crutch transfer 234, 235f transfer into car 182 Physiotherapistpatient relationship 281 Pillows postural reduction 17 pressure ulcer prevention 76 supine position 43 Plaster of Paris leg splints 218, 218f Pneumatic tyres, wheelchairs 154 Poking chin position 82, 286 Positioning analysis 288, 289t in bed 18, 4244, 78, 295297 hand 4446 incomplete lesions 283, 295297 postural drainage 58, 65 power-drive wheelchair 262263, 264f see also individual positions Positive expiration pressure (PEP) 65 Positive support reaction 293, 304 Postural drainage 58, 65, 261 Postural hypotension 100 neck pain 361 Postural reduction 1617 Postural sensibility 103107 children 334 standing between bars 216217 Posture age-related changes 348 assessment sitting position 8085 supine position 8485 children 330 control 103104 incomplete lesions 285286 lesion level 107 normal adjustments 285 pressure ulceration 7789 respiration and 56 Posture and seating clinics 8889 Power-drive wheelchairs 157159, 262263
SUBJECT INDEX
413
Rolling prone to supine position 144, 145f in water 375 S Sacral anterior root stimulation implants (SARSIs) 23, 255 Safety strap, wheelchairs 164 Scaleni muscles 54 Scapula 299 hypermobile 301 mobility maintenance 49 neural hypertonia 301 winging 301 School involvement 337338 Scintigraphy, heterotopic ossication 356 Scissor gait 304 Scoliosis 83, 107, 340 children 323, 340, 341t Scotchcast splinting material 307 Sculling stroke 376 Seat (wheelchairs) angle 156 bucket position 156 canvas 157 depth 79 height 336337 position 156, 156f sloping 156 width 7879 Seatbelts, wheelchairs 263 Seating ill-tting 89 posture and 7789 Second order fulcrum 131, 131f Segmental innervation, skin 398399 Self-care, children 336 Self-catheterization 20 Sensory feedback, movement 284285 Sensory feedforward 284285 Sexual dysfunction 2426, 37 female 2526 male 2425 Shaving 118 Shearing forces 85 Shoes 120 children 329 orthosis use 218 putting on/removing 123 sizing 120, 218 Shooting, targets 265 Shoulder(s) 299300, 300f exion without elbow 50 incomplete lesions 299301 locking mechanism 299 mobility maintenance 4859
classication 157 control unit 158 equipment carried 262, 263f paediatric 161 patient positioning 262263, 264f seat unit 158 Power (palmar) grip 116 Pregnancy 2526 Pressure bodywheelchair seat interface 8586 consciousness 365 effects 7394 measurement 85 prevention measures 7394 relieving techniques 8990, 349, 363364 sores/ulcers due to see Pressure ulcers Pressure transducer systems 85 Pressure ulcers 363365 ageing 349 bursae development 75 pathology 7475 patient education 8993 physiotherapy 364365 predisposing factors 7374 prevention 7577, 349 risk assessment 75 skin care 77 skin inspection 92 stages 74 surgery 364 transcutaneous oxygen ow 8990 treatment 363364 urinary hygiene 22 voluntary movement loss 73 Prone position 289t pressure ulcer prevention 76, 77f in water 375 Proprioceptive neuromuscular facilitation (PNF) 108 Proximal key point 290 Psychological factors 281 ageing 350 swimming 374375 wheelchairs 33 Pulmonary embolism 15, 50 Push handles, wheelchair 164, 337 Pushing gloves 114f, 168169 Pushrims, wheelchair 163 Q Quadriceps gait 303b maintenance of length 49 Quality of life, ageing 346
R Rear wheels 154 balance 171172, 173f camber 156 forward/backward position 155156 tilting onto 172, 173f turning on 172 up/down position 156, 156f Reciprocal innervation 292 Reciprocating gait orthosis (RGO) 248, 248f, 249 functional electrical stimulation and 255256 sitting/standing 252 Reciprocating walking orthoses see Hipkneeanklefoot orthoses (HKAFOs) Record keeping acute lesions 42 follow-up, children 338, 339f Rectus femoris, gait 303b Re-education, initial physical 95110 Referred pain 363 Reex (automatic) bladder 1920 Reex inhibiting postures 367 Reex loss 13 Renal disease 18, 346 Resisted movements 51 Respiration assessment 57 posture and 56 Respiratory disease 346 Respiratory muscles accessory 5455 function 5356 paralysis 5556 training 58, 66 Respiratory physiotherapy 5372 conditions affecting 6970 general principles 5669 prophylactic 5764 for respiratory complications 6466 in ventilated patients 6668 see also specic techniques Rhomboids 49 Ribcage deformity, children 325, 325f Rib fractures 70 Rib hump, posterior 323f, 325 Robotics technology 270 Rocho dry otation cushion 86, 87f Rofecoxib 356 Rollator children 332 incomplete lesions 306
414
pain 347348, 361362 relations 299, 300f sitting position assessment 83 supine position 43 weight-bearing 217 Shoulderhand syndrome (SHS) 365 Side guards, wheelchairs 163 Side-lying position 43f, 44 Sitting 140148 children 335, 335f lying down 141f, 142 position 289t self-supported 105 from supine position with monkey pole 142144, 143f without monkey pole 140, 141f without pectoral muscles 144 supported 289t Skin ageing 349 care 77 innervation 398399 inspection 92 Skirts 120 Skull traction 17 Sleeping children 329, 333 spinal deformity 369 Sleep systems 333 Sliding boards 187, 198, 199f, 347 Slopes crutches 244 wheelchairs 169170, 170f Slow oxidative (SO) muscle 286, 287 Snooker 382 Society attitude 348 Socks 120, 123 Softcast splinting material 307 Soleus, gait 303b Sorbo rubber packs 76, 374 Southampton Hand Assessment Procedure (SHAP) 117 Spastic dystonia 291 Spasticity 99100, 366368 central cord syndrome 276277 children 329, 334 denition 291 dressing 121 drug therapy 309312, 367368 botulinum toxin 310, 368 intrathecal baclofen 312 impaired reciprocal inhibition 292 reduction, ultra-high lesions 265 stimulating factors 366 surgery 368 swimming 374
SUBJECT INDEX
treatment 366367 ultra-high lesions 262 Speaking tubes 68 Spinal areexia 14 bladder paralysis 19 passive/active movements 46 Spinal cord 5f injury see Spinal cord injury oedema 14, 1516 repair 79 segments 34 Spinal Cord Independence Measure (SCIM) 6, 391394 Spinal Cord Independence Measure II (SCIM II) 6 Spinal cord injury 111 adjustment to 3536 ageing and 345352 associated injuries 14 cause of death 346 causes 3 in children see Children clinical effects 1315 complications, early 1415 incidence 1 incomplete lesions 4 lesion level denitions 34 long-term survival 345346 management aims 1527 measurement scales 47 non-traumatic 3 physiological effects 1329 recovery assessment 89 reex loss 13 traumatic 3 see also Spinal lesion(s); individual regions Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) 6 Spinal cord injury without radiographic abnormalities (SCIWORA) 319320 Spinal cord transection 13 Spinal deformity 368369 children 320334 prevention 368369 sleeping postures 369 surgery 369 traction 322, 323f treatment 368369 Spinal lesion(s) acute 4152 bladder management 20 patient examination 4142 physiotherapy programme 42 record keeping 42 treatment in bed 4251
incomplete 273318 classication 274281 complete lesions vs. 291292 incidence 273 movement analysis 282290 muscle weakness 294295 paralysis 294295 pathological causes 273 pathological movement patterns 287 pathophysiology 290292 psychological factors 281 rehabilitation units 281282 swimming 377 treatment 281312 treatment in bed 295299 ultra-high 259271 acute stage physiotherapy 261262 future technology 270 patient abilities 265266 patient handling 266267 physical rehabilitation 262266 wheelchair handling 268 see also specic sites/levels Spinal man 1, 2f Spinal mobility 17 Spinal reduction 1516 Spine, early management of 1518 Splints/splinting 117 botulinum toxin and 307, 310 of contractures 355 incomplete lesions 305, 307 materials 307 osteoporotic fractures 360 see also individual types Spoke guards, wheelchairs 163 Sport 373383 benets of 382383 postural control training 107 rules 382 therapeutic value 373 see also individual activities Sports wheelchair 160 Sputum mobilization 6566 retention 55 see also Coughing Standard mortality ratio (SMR) 345 Standing central cord syndrome 277, 278f children 330332 control exercises 223 incomplete lesions 305 in parallel bars 219 passive stretch 223224 position 289t positive effects 215
SUBJECT INDEX
415
children 336 ease of 133 efcient 129130 to oor 208209f, 208210, 336 oor to chair 209f, 210 cushion replacement 209f, 210 patients without abdominal muscles 210 footplate removal 194196, 197f forward onto bed 210211, 211f high performance wheelchair 212 to oor 212, 213f oor to chair 212, 214f sideways 212 independent 190211 mobility 129 paraplegic patients 186 patient care 92 to plinth 190194, 192, 193f, 195f pressure sores 92, 130, 365 safety 129130 technique 186 tetraplegic patients 185 by therapist 187188, 189f chair to plinth 187, 187f to toilet 200, 201f, 336 though back of chair 202, 203f wheelchair position 186 wheelchair selection 149150 Transit wheels 154 Transport 150, 182 Trapezius hyperactive 301 respiration 5455 Trays, wheelchair 164 Treadmills 306 Treatment aims 100, 101f Triceps, length maintenance 49 Trousers 120, 123125 Trunk mobilization 135, 288 postural assessment sitting position 83 supine position 84 resisted exercises 223 strengthening 135 T-straps 331f, 332 Tuck phase 253 Turning in bars 228, 228f in bed 18, 146148, 147148f night time 90 onto side 14 pressure ulcer prevention 7576, 90, 363 on rear wheels 172
spasticity 265, 367 strengthening exercises 223 Standing frames 216, 216f, 224 children 332 Dynamic Parapodium 224 Grandstand 224 suppliers 402 Stepper tube, wheelchairs 164 Stepping strategy 285 Sternomastoid, respiration 5455 Stirling scale, pressure ulcers 74 Stockings, elastic 358 Straight leg raising 48 Suctioning 67, 261 Suicide 346 Supine position 4244, 43f, 289t assisted coughing 5961, 59f, 60f diaphragm 56 lower limbs 43 posture assessment 8485 sitting from 140144, 141f, 143f upper limbs 4344 Suprapubic bags 2122 Suprapubic catheter 19 Surgery augmentation of hand function 115 contractures 355 elbow 115 pressure ulcers 364 spasticity 368 spinal deformity 369 tendo Achillis elongation 355 Swelling, gravitational 45 Swimming 373377 cervical lesions 376377 entry into water 374 incomplete lesions 377 instruction 375 leaving/returning to poolside 377 prone position 377 psychological/social aspects 374375 therapeutic uses 374375 thoracic/lumbar lesions 375376 Swing-through gait in bars 230 children 332 Swing-to gait in bars 226228, 227f children 332 crutches 231, 231f Swivel walkers 332, 332f Syringomyelia 369 T Table tennis 107, 381 Target shooting 265
Teeth cleaning 114f, 118 Telephones, using 119 Tendo Achillis maintenance of length 49 shortening, children 329 surgical elongation 355 Tennis 382 Tenodesis (wrist extension) grip 50 51, 112114, 113f, 298299 Tenotomy 368 Tension adjustable backrest 80, 151, 153f Tensor fascia lata 49 Teres major 55 Tetra clip, wheelchair 164 Tetraplegia, denition 3 Third order fulcrum 132, 132f Thoracic kyphosis 324 Thoracic spine fractures, postural reduction 17 repair 8 Thoracolumbar sacral hipknee anklefoot orthoses (TLSHKAFO) 331332, 331f Three-point brace 95, 96f Thrombosis, deep venous 1415, 50, 358 Tibialis anterior, gait 303b Tibialis posterior, gait 303b Tibial torsion 329 Tilting in bed 100 wheelchairs 172, 173f pressure relief 90 Tilt tables 216, 265 Toe-raising springs 217 temporary 218, 218f, 307 Toilet training 24 Toothpaste dispensers 118 Total body fat 99 Tracheostomy 6768 Traction, spinal deformity 322, 323f Transcranial magnetic stimulation (TMS) 284 Transfer belt 187 Transfers 185214 balance 129 to bath 202207 children 336 over bath end 204, 205206f over bath side 207, 207f to bed 211, 211f biomechanical principles 129133 to car 198, 199f, 336 chair to crutches 232239, 233f, 235f, 236f, 237238f chair to easy chair 202
416
ultra-high lesions 266, 270 in wheelchair 170, 170f, 172 Tyres, wheelchair 154, 164 U Ultra-high lesions see Spinal lesion(s), ultra-high Ultrasound 355, 356 Upper limb(s) augmentation of function 115117 balance exercises bilateral 105, 106, 106f single 105 muscle innervation 395 position incomplete lesions 296 ultra-high lesions 262 postural assessment sitting position 83 supine position 8485 side-lying position 44 supports mobile 164 power-drive wheelchairs 263 warming up 348 Upper motoneurone injury, growth 343344 Upper motoneurone (UMN) syndrome 291 Urethral catheterization 19 Urinals 2022 Urinary hygiene 2223 Urinary sheath 21, 21f V Valgus deformity, knee 327329, 327f, 328f Vascular reex training 100 Vasomotor system disturbances 100103, 219 oedema 358 pressure ulcers 7374 training 262
SUBJECT INDEX
Velcro fastening 120 Ventilated patients 6668 assessment 6667 speech 259260 weaning 68 Ventilation, long-term 6869 Verbal independence 260261 Vestibular-spinal tract 291 Vicair cushion 87f Visual control, postural sense 104 Vital capacity 55, 56, 57 Vital triangle 97, 97f, 129 Voice controlled systems 111 Volleyball 381 W Walkabout 249 Walking see gait Walking aids 306 Walking Index for Spinal Cord Injury (WISCI) 244, 246247b Walking stick holder 163 Weaning, ventilators 68 Weight, levers 130 Weights and pulley systems 108, 109f Weights arm 130 Weights training 108 Wheelchair rugby 382 Wheelchairs 149183 accessories 162165 adjustments 155157 balance 107, 264265 bodyseat interface pressure 8586 children 160161, 336337 coughing 6164, 62f, 63f dressing in 121124 t 7880 high performance see High performance wheelchairs hybrid power/manual 159160 initial rehabilitation 100103 leaning to side 168
lifting 190191f manoeuvres 165182 manual 150157 mounting/descending kerbs 159, 172174, 174f movements, basic 166168 musculoskeletal pain 361362 patient adjustment to 165 patients position 7880 position of 166, 186 power-drive see Power-drive wheelchairs pushing 155, 168170, 170f, 171 reclining/tilting 160 reversing 169 selection 149150 spinal curvature 80 sports 160 stand-up 160, 161f suppliers 402403 suspension 164 trends in 161 turning 170, 170f weight of 150151 see also individual parts Wheelchair Users Shoulder Pain Index (WUPSI) 347, 362 Wheels 164 chambering 156 rear see Rear wheels Wires, percutaneous 254 Wrist extension (tenodesis) grip 50 51, 112114, 113f, 298299 Wrist extension splint 117 Wrist/hand orthoses 114 Wrist splint 46 Writing 114f, 119 X X-rays, heterotopic ossication 356 Z Zip fastening 120 Zipper backrest 165

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2006, Elsevier Ltd First edition 1976 Second edition 1981 Third edition 1985 Fourth edition 1991

Working together to grow libraries in developing countries

Roger Ellis MCSP

Lone S. Rose MCSP

Dot Tussler MCSP MSc

Spinal cord injury

TETRAPLEGIA AND PARAPLEGIA

Social activities outside the hospital

Home for week-ends for assessment

Toilet Bladder and bowel care

Home Spinal man re-integrated at home, at work and in local community

Figure 1.1 Dependence to independence.

SPINAL CORD INJURY

lower cervical, C5C7 mid-thoracic, T4T7 thoracolumbar, T10L2.

DEFINITION OF THE LEVEL OF LESION

TETRAPLEGIA AND PARAPLEGIA

SPINAL CORD INJURY

Cervical segments 1-8

Thoracic segments 1-12

Lumbar segments 1-5 Sacral segments 1-5

1 2 3 4 5 Sacral roots Lumbar roots

III IV V I II III IV V V II III IV I V

TETRAPLEGIA AND PARAPLEGIA

Table 1.1 The ASIA impairment scale

Table 1.2 The modied Frankel scale

SPINAL CORD INJURY

Table 1.3 The Ashworth scale

REPAIRING THE SPINAL CORD

TETRAPLEGIA AND PARAPLEGIA

SPINAL CORD INJURY

TETRAPLEGIA AND PARAPLEGIA

SPINAL CORD INJURY

Physiological effects and their initial management

TETRAPLEGIA AND PARAPLEGIA

Deep venous thrombosis

PHYSIOLOGICAL EFFECTS AND THEIR INITIAL MANAGEMENT

MANAGEMENT OF THE SPINE

TETRAPLEGIA AND PARAPLEGIA

Fractured cervical spine

PHYSIOLOGICAL EFFECTS AND THEIR INITIAL MANAGEMENT

Fractured thoracic or lumbar spine

TETRAPLEGIA AND PARAPLEGIA

Correct positioning of the patient

Turning the patient

Management of the bladder

The acute lesion

PHYSIOLOGICAL EFFECTS AND THEIR INITIAL MANAGEMENT

urethral catheterization intermittent indwelling suprapubic drainage.

the automatic bladder the autonomous bladder.

The automatic (or reex) bladder

TETRAPLEGIA AND PARAPLEGIA

The autonomous (or non-re ex) bladder

PHYSIOLOGICAL EFFECTS AND THEIR INITIAL MANAGEMENT

Figure 2.1 Urinary sheath.

Figure 2.2 Condom urinal.

TETRAPLEGIA AND PARAPLEGIA

PHYSIOLOGICAL EFFECTS AND THEIR INITIAL MANAGEMENT

Sacral anterior root stimulators

Management of the bowels

TETRAPLEGIA AND PARAPLEGIA