Paraplegia is a spinal cord injury that paralyzes the lower limbs, caused by damage to the spinal cord and nervous system. It affects movement in the trunk, legs, and pelvic region. Causes include spinal fractures, tumors, infections, and trauma. Paraplegia is categorized as complete or incomplete based on the extent of movement loss. Complications include pressure sores, urinary issues, muscle tightness, osteoporosis, and respiratory problems. Physiotherapy focuses on prevention of complications, strengthening, stretching, mobility training, and achieving independence through exercise and assistive devices.

1. SPINAL CORD INJURY : PARAPLEGIA
DR SURAJ B.KANASE
Associate Professor
Krishna College Of Physiotherapy
Kimsdu Karad

3. Definition
Paraplegia is a spinal cord injury that paralyses the lower limbs.
It is a result of severe damage to the spinal cord and the nervous
system. Paraplegia mainly affects the trunk, legs, and the pelvic
region, resulting in loss of movement.

4. Causes of paraplegia
1. Upper motor neuron lesions
A. Intracranial causes
• Tumors of the falx cerebri
• Thrombosis of superior sagittal sinus
• Thrombosis of unpaired anterior cerebral artery affecting both leg
area.

5. 2. Spinal causes
• Subacute combined degeneration of the cord
• Multiple sclerosis
• Acute transverse myelitis
• Motor neuron disease
• Fracture dislocation of thoracic and lumbar vertebra
• Epidural abscess
• Vascular causes like hemorrhage, thrombosis, arteriovenous
malformation
• Compression of the cord by space occupting lesion.
• Radiation myelopathy
• Potts paraplegia
• Hereditary spastic paraperesis
• Trauma.

6. 3. Lower motor neuron lesion:
• Anterior horn cells lesion in conditions like poliomyelitis , spinal
muscular atrophy, motor neuron disease.
• Root lesion like cauda equina syndrome.
• Peripheral nerve lesion such as neuropathies, polyneuritis
• Mysthania gravis
• Muscular conditions like muscular dystrophies,polymyositis
• Spina bifida with myelomeningocele.

7. Categorization :
• There are two main categories - complete and incomplete. Complete
paraplegia is witnessed when the injury affects the patient at the
neurological level and it hinders the movement of limbs, whereas in
case of incomplete paraplegia, some of the limbs are still moving.

8. Clinical presentation:
1. Stage of shock:
• Tone is reduced (flaccid/hypotonicity)
• Reflexes are absent.
• Atonic or flaccid bladder
• Patient is totally dependent on others for his activities.

9. 2. After the stage of shock:
• The lower limb will present with either upper motor neuron or lower
motor neuron type of paralysis.
• It depends upon the level of lesion.
• Lesion to cauda equina will present as typical LMN type of paralysis.
• Thoracic or higher lumbar lesion will show LMN type of picture at
the level of lesion and UMN type of paralysis below the level of
lesion.

10. Paraplegia in flexion Paraplegia in extension
1. The Lower limbs of the body will adapt an
extensor attitude.
1. The lower limbs of the body will adapt a
flexion attitude.
2. Only pyramidal tracts are involved in action. 2. Both pyramidal and extrapyramidal tracts
are involved in action.
3. It has an early evolution rate. 3. It has a late evolution rate.

11. Complications Of Paraplegia
Complications resulting from paraplegia may include:
• Pressure sores (decubitus)
• Depression
• Urinary complications
• Tightness and contractures.
• Osteoporosis
• Imapirment in tone
• Pain
• Pneumonia and other respiratory complication

12. Pressure sores
• Pressure sores can be defined as lesions caused by unrelieved
pressure resulting in damage of the underlying tissue. They represent
a common problem in the pathology of paraplegic patients.
• Pressure sores occur over bony prominences and so, they are most
commonly seen at the sacrum and trochanters in paralyzed patients
and at ischium for the patients who sit in a wheelchair for a long time.

13. Depression
• SCI patients have a high risk of anxiety or depression post-discharge,
especially among the younger tSCI patients (age <50 years),
compared with the other health conditions group.
• As patient is no longer a contributing member in the family, he
develops complexity about himself and hence goes into state of
depression.

14. Urinary complications
1. Urinary retention : it increases the chances of infection in urinary
tract.
2. Renal / bladder calculi : as patient is bedridden the absorption of
calcium by the bone is reduced. This causes accumulation of calcium
in blood that eventually gets deposited in kidney causing renal
calculi.

15. Tightness and contractures
• Contracture is the shortening or tightening of tissues that reduces
movement in an area. It can affect skin, muscles, or connective tissues
and often causes pain in addition to decreased range of motion.
• Improper positioning due to altered tone causes tightness and
contractures.
• There is loss of ROM.

16. Osteoporosis
In the SCI population, osteoporosis is likely due to many different
factors.
• Disuse: lack of mechanical loading on the bone inhibits the
stimulation of bone-building cells.
• Disordered vasoregulation: sluggish blood flow to limbs may
contribute to a decrease in bone mass.
• Poor nutritional status: inadequate consumption of a healthy, well
balanced diet.
• Hormonal alterations (testosterone, PTH, glucocorticoids,
calcitonin) that happen as a result of SCI and play a role in the
maintenance of bony formation and reabsorption.
• Metabolic disturbances in metabolites and acidity of the blood can
influence the balance of bony formation and reabsorption.
• Autonomic nervous system disregulation caused by the injury leads
to poor circulation and altered gas and nutrient exchange at the bone.

17. Impairment of tone
• It depends upon level of lesion.
• Flaccidity is seen in LMN type lesion
• Spasticity is seen in UMN type of lesion.
• It largely affects gait patterns and ambulation.

18. Pain
• Chronic pain is one of the most reported health problems in patients
suffering from spinal cord injuries and is described by the patients as
one of the most burdensome sequelae of paraplegia.
• Various types of pain, such as nociceptive, neuropathic and other
types of pain can occur

19. Respiratory complications
• Higher thoracic level injury – paralysis of respirator muscles like
intercostalis and abdominal will cause gross reduction in vital capacity
of the patient.
• This will cause ineffective coughing and secondary infections.

20. Physiotherapy treatment
Aims
1. Prevention of secondary complications
2. Functional independency
3. Psychological counselling
4. Social rehabilitation
5. Family education and home adaptation.

21. General management
• Frequent change of the patient’s posture to guard against bedsores.
• Care of the skin by frequent washing with alcohol followed by talc
powder. In case of urinary incontinence, frequent change of bed-
sheets.
• Care of the bladder: If there is retention, use parasympathomimetic
drugs. If this fails, use a catheter to evacuate the bladder.

22. Stretching/Flexibility Exercises
• slow, sustained lengthening of the muscle
• Stretching is the most important exercise you can do.
• Stretching improves flexibility – the ability to move the parts of your
body through their full range of motion.
• Stretching also can reduce muscle spasticity and cramps and may also
reduce problems such as tendonitis and bursitis.
• To be effective, stretching routines must be done regularly, usually
once or twice a day.

23. • Stretch as far as you can and hold the stretch for 10 seconds and then
ease back.
• Each stretch should be performed slowly, with no sudden jerking or
bouncing.
• Stretching also should be done before and after other exercises to
prevent muscle strain and soreness and to help avoid injuries.

24. Strengthening Exercises:
• Repeated muscle contractions until the muscle becomes tired.
• Strengthening exercises help increase muscle tone and improve the quality
of muscles. This enhances mobility and provides energy and a positive sense
of well-being.
• Strong hip and leg muscles are needed to lift the legs to walk, and strong
arm muscles are needed to carry out daily functions. Strong abdominal and
back muscles help maintain correct posture and can counter pain resulting
from poor gait, poor posture or the use of mobility aids.

25. Physical agents:
• Thermotherapy: are used to decrease the pain and spasticity. They are
(i) Superficial heat:IRR, wax bath, etc. (ii) Deep heat: SWD, MWD,
etc.
• Electrical therapy: is used to increase muscle power and to decrease
the pain. e.g, TENS, EST, IFT.

26. Therapeutic exercises:
• Mat exercise.
• PNF exercise.
• Active and passive ROM exercise.
• Strengthening exercise.
• Stretching exercise.
• Endurance exercise
• Co-ordination exercise.
• Pelvic tilting exercise.
• Hamstring muscle stretching.
• Spinal rotation.
• Calf muscle stretching.
• Neck raising exercise
• Knee rolling exercise.
• Lying in extension.
• Extension exercise.
• Back and gluteal exercise.

27. Orthosis:
• Various orthosis are used to assist patient with paraplegia.
• These are: crutch, walker, cane, brace and wheelchair.

28. Gait training:
• It is the important part of rehabilitation program balance can be achieved by
proper gait training. Gait training can be done by following methods:
• Pre ambulation MAT program:
• Rolling, prone on elbow, prone on hand, quadruped, pelvic tilting, setting
and standing balance.
• Parallel bar progression
• Advanced parallel bar activities.
• Assistive device: E.g, Cane, crutches, walker

29. Home program and Ergonomics:
• Patient is advised to use the lumbosacral orthosis to support the back
during traveling.
• Patient is advice for hot fomentation at home.
• Patient is advised to lying in prone position for at least 15 minutes duration
twice in a day.
• Patient is explained about the proper sitting, standing, lying and lying to
standing , doing the household activity in a proper way.
• patient is advised to take rest and to avoid the forward bending as much as
the patient can avoid.

30. Aerobic Exercises:
• Aerobic exercise strengthens your heart and lungs and improves your
body’s ability to use oxygen. It also reduces fatigue, increases energy
levels and helps you sleep better, control your weight, and lift your
spirits.
• It is generally recommended to gradually work up to three or four
sessions per week, each lasting 15 to 60 minutes. Include a 5-minute
warm-up (including stretching) before the activity and 5 to 10 minutes
of a cool down (stretching and slower activity) afterwards.
• Walking, stationary bicycling, water exercises and chair exercises are
excellent choices.

31. THANK YOU