Anatomy of a Spinal Cord Injury

Defining, Assessing & Helping Clients Look to the Future

Spinal cord injuries (SCI) are often as complex as the human body itself. Usually the result of physical trauma, a spinal cord injury inflicts sudden, dramatic shifts on a client's body and mind.

Apart from immediate signs of change, such as losing the ability to walk or breathe independently, spinal cord injuries can also present significant, although not immediately apparent, physical and emotional hurdles for a client, and you, to deal with.

The nature of a spinal cord injury—swift, traumatic—makes this kind of client inherently different from others. Unlike a client with multiple sclerosis, severe arthritis, or mobility impairments due to aging, a person with a spinal cord injury usually becomes a patient overnight, with no warning signs or time for mental preparation.

For example, an active, fit mountain climber falls and finds himself unable to move his lower body. By the same token, an otherwise healthy 45-year-old woman gets into her car to run errands, crashes, and suddenly faces life as a wheelchair user.

Spinal cord injuries are always possible, but rarely do people go through life thinking about them before they occur. As a result, when you see a spinal cord client for the first time, you are often faced with a person whose body worked perfectly fine a matter of days ago.

Not only are these clients different emotionally and physically, but also there are equipment challenges with this group. Is it harder to assess a person for mobility equipment who, merely a few weeks prior, was running five miles a day or using her hands to type 65 words per minute?

Breaking It Down
It's important to know what happens when the spinal cord sustains an injury.

The spinal cord is composed of four major nerve regions, going from top to bottom: cervical, thoracic, lumbar and sacral. In the simplest terms, cervical injuries usually result in quadriplegia, thoracic injuries result in paraplegia, and lumbar-sacral injuries affect function in the hips and legs.

Spinal cord injuries are classified according to where they occur along the spinal cord, which is why cervical injuries are called "C-5" or "C-6", thoracic injuries "T-1" or "T-12," etc.

While diseases such as spina bifida and polio can cause spinal cord injuries, the majority of SCI cases in the United States are brought about by trauma. Of the 250,000-400,000 people living with SCI in the United States, the National Spinal Cord Industry Association Resource Center has found that 44 percent sustained SCI from motor vehicle accidents, 24 percent from violence, 22 percent from falls, and 8 percent from sports.

According to the Spinal Cord Injury Resource Center, there are about 10,000 new SCI cases every year in the United States. The most common patients, says the SCIRC, are males between the ages of 16 and 30 years.

Quick Adjustments
Tina Roesler, MSPT/ABDA, the director of training & education for The ROHO Group, says SCI cases are challenging at the onset due to the initial shock. "First and foremost, the client is dealing with a traumatic, life-changing event, and we are asking them to help make a decision about equipment that doesn't yet seem a reality to them. They have typically had little or no exposure to disability, are overwhelmed by the sudden loss of function, and are often still counting on recovery."

In addition, clients who sustain spinal cord injuries today experience a much shorter hospitalization period than in previous years. As these clients are essentially pushed out of hospitals and into re/hab faster, your challenge is assessing a person who is more than likely still dealing with the harsh realities of disability.

"[Spinal cord injuries] come to us earlier because acute-care hospitals are moving people out in less time," says Lilli Thompson of Rancho Los Amigos' Rehabilitation, Research and Training Center in Downey, Calif. "So they come to us a little less stable sometimes, but medically cleared for rehab. But medically cleared for rehab is different than psychologically ready for rehab. Some people are not necessarily ready yet -- they're still trying to identify what has happened to them, much less figure out how they're going to live the rest of their lives ... They don't have as much adjustment time."

Rapid Re/hab
With shorter hospital stays, re/hab also gets pushed through quicker, says Roesler "As rehabilitation stays continue to diminish, we are making decisions about final mobility equipment far earlier than we should. While in Denmark, a client with a thoracic-level SCI may stay in rehabilitation for up to a year, the length of stay for a paraplegic in the United States may only be three to four weeks. This means that we have not begun to see the physiological changes that will happen, and it may be difficult to predict their optimal level of function."

Roesler finds that the rapidity of modern-day re/hab often forces seating specialists and RTS's to make "educated guesses about where the client will be functionally and physiologically in the coming months or years."

Roesler lists four essential questions that often get asked in this early stage:

  1. How much muscle mass do we expect the client to lose?
  2. Are there external fixation devices in place (such as a HALO or TLSO) that will impact seated balance and center of gravity when they are removed?
  3. What is the client's potential for function long-term, based on clinical models and actual observations of the client?
  4. Is the discharge environment going to impact the type of equipment that can be utilized?

"For example," says Roesler, "if a client lives in a three-story walk-up apartment, he may have no option of moving, especially in a short period of time. This may mean that a power chair may not be appropriate, or that we need to minimize weight to maximize independence, success and avoidance of secondary complications such as postural deformities and skin integrity issues."

The Psychology of SCI
Another immediate consideration when treating spinal cord injuries involves the injured client's emotional state. Often, people with SCI go through the same process of grieving we normally associate with death. The weight of losing sensation and/or the ability to walk or perform daily tasks independently can make recovery even more difficult to achieve, and many SCI clients fall into depression and unhealthy coping mechanisms.

In fact, according to a recent Mayo Clinic study, people with SCI abuse alcohol at more than twice the rate of the general population. Another study conducted by the Arkansas Spinal Cord Commission surveyed 650 people with SCI -- and 62.9 percent cited depression as a secondary condition of their injury. To put that into perspective, it was the third most commonly reported condition after changes in sexual functioning (86.9 percent) and spasms (83.7 percent).

Furthermore, a client's family and friends are not immune to the same feelings of loss and depression a person with SCI experiences. Keep in mind that spinal cord injuries' effects are far-reaching, and can easily affect a client's well-being and social support environment.

Pain and Assessment
Depending on the level of spinal cord injury, many clients also experience chronic pain following their injury and well after re/hab. While the nature of a spinal cord injury rarely worsens or changes over time, it is important to recognize pain as a component of an SCI patient's future condition.

"Generally (with SCI), we are dealing with clients who have relatively stable conditions and desire to return to an active lifestyle," says Roesler. "You do not need to focus on possible progression or worsening of the disorder; more often the focus of mobility tends to be on durability, weight and performance. With all of this, configuration is key, especially with manual wheelchair users."

Says Roesler, "Many of these clients are very young when they are injured (18-32 years old, on average), and will be utilizing manual mobility for many years. Chair size, configuration and weight will have a significant impact on accessibility, functional mobility, and the incidence of upper-extremity pain and dysfunction. Getting it right the first time (wheel position, for example) may decrease a client's risk for injury and further complications such as pressure ulcers."

Looking Forward
While SCI clients can indeed seem overwhelming, some early homework and educated decisions can help avoid future complications. Roesler explains, "Altogether, the focus should be on making wise decisions from the beginning so you can impact the quality of life of these clients for years to come... The clinician and RTS need to be willing to take the risk in order to maximize the client's success post-discharge. Getting it right the first time will be critical for the client's long-term success."

This article originally appeared in the October 2004 issue of Mobility Management.

In Support of Upper-Extremity Positioning