This document provides an overview of spinal cord injury (SCI), including its definition, epidemiology, clinical presentation, diagnosis, management, and physical therapy approaches. Some key points: - SCI results from traumatic damage to the spinal cord or nerves and affects sensory and motor function below the site of injury. Injuries can be complete or incomplete. - Over 12,500 new SCI cases occur annually in North America, primarily in young adults and older adults. Common causes include vehicle accidents, falls, and sports injuries. - Physical therapy management depends on the level and completeness of injury, and may include respiratory training, strength exercises, and gait training with braces or walkers. The goal is to

1. Spinal Cord Injury
Physiocare Training Course
By : Awad Hassan

2. Introduction
• Spinal cord injury (SCI) is a debilitating neurological condition
with tremendous socioeconomic impact on affected individuals
and the health care system. Today, the estimated lifetime cost of
an SCI patient is $2.35 million per patient.
• According to the National Spinal Cord Injury Statistical Center,
there are 12,500 new cases of SCI each year in North America.
• More than 90% of SCI cases are traumatic and caused by
incidences such as traffic accidents, violence, sports, or falls.
The Male-to-female ratio of 2:1 for SCI, which happens more
frequently in adults compared to children.

3. • Demographically, men are mostly affected during their early and
late adulthood (3rd and 8th decades of life) while women are at
higher risk during their adolescence (15–19 years) and 7th
decade of their lives i.e. age distribution is bimodal, with a first
peak involving young adults and a second peak involving adults
over the age of 60.
• Those over 60 years of age who suffer SCI have considerably
worse outcomes than younger patients their injuries usually
resulting from falls and age-related bony changes.

5. Definition/Description
• Spinal cord injury is defined as traumatic damage to the spinal
cord or nerves at the end of the spinal canal.
• This affects the conduction of sensory and motor signals across
the site of the lesion.
There are two types: incomplete and complete injury.
• Incomplete Lesion: not all the nerves are severed or the
nerves are only slightly damaged. Recovery is possible, but
never to the pre-injury level.
• Complete lesion: the nerves are severed and there is no motor
or sensory function preserved of this point.

6. Clinically Relevant Anatomy
• The spinal cord is the major conduit through which motor and
sensory information travel between brain and body. The spinal
cord contains longitudinally oriented spinal tracts (white matter)
surrounding central areas (gray matter) where most spinal
neuronal cell bodies are located.
• The grey matter is organized into segments comprising sensory
and motor neurons.Axons from spinal sensory neurons enter
and axons from motor neurons leave the spinal cord via
segmental nerves or roots. The roots are numbered and named
according to the foramina through which they enter/exit the
vertebral column. Each root receives sensory information from
skin areas called dermatomes. Similarly, each root innervates a
group of muscles called a myotome.

7. • The spinal column is divided into four regions:
1. Cervical (7 vertebrae).
2. Thoracic (12 vertebrae).
3. Lumbar (5 vertebrae).
4. Sacral (5 vertebrae).

8. Epidemiology/Etiology
• A recent systematic review found the prevalence of Spinal Cord
Injury to be dependent on the region the studies were
conducted in, ranging from 906 per million in the USA.
• Annual incidence rates also varied significantly between
regions, ranging from 49.1 per million in New Zealand to 8.0 per
million in Spain.
• These results indicate that the incidence, prevalence, and
causation of Spinal Cord Injury can differ significantly between
developing and developed countries (high in developed
countries).

9. the most frequent causes of Spinal
Cord Injury reported are :
1. Motor Vehicle Accidents
2. Falls
3. Sport Injuries
4. Violence
5. Self-harm
6. Work-related Accidents.

10. • Data from the National Spinal Cord Injury Statistical Center
(USA) 2010 - 2014 provided the following statistics for etiology
(illustration). Other interesting statistics from this report
include:
• Males account for 80% of new cases
• The average age at injury has gone up from 29 years old (1970) to
42 years old currently.
• Only about 12% of patients are employed 1 year after trauma, rising
to 34.4% 20 years post-injury
• Life expectancy decreases for all individuals with Spinal Cord Injury,
compared to those without a spinal cord injury.

11. Characteristics / Clinical Presentation
:
• As spinal cord injuries are by definition caused by traumas, the
primary examination and presentation will be done in an
emergency response setting. Initial evaluation includes a
pulmonary evaluation to determine loss of ventilatory function
and/or lung injury.
• Signs of hemorrhage and neurogenic shock are also checked in
this initial evaluation.
• Finally, and most relevant to physical therapy, neurologic
assessment is done which includes checking motor function,
sensory evaluation, deep tendon reflexes, and perineal
evaluation.

12. • The ASIA (American Spinal Injury Association) has established
an international standard neurological which can be used to
classify the lesion according to a specific cord syndrome. This
includes motor and sensory evaluation.
• This also includes an impairment scale which indicates the
severity of the lesion.
• The clinical outcomes of SCI depend on the severity and
location of the lesion and may include partial or complete loss of
sensory and/or motor function below the level of injury.

13. • Lower thoracic lesions can cause paraplegia (Traumatic
Paraplegia)
• Cervical level lesions are associated with quadriplegia.
• SCI typically affects:
• The Cervical level of the spinal cord (50%) with the single
most common level affected being C5.
• Thoracic level (35%).
• Lumbar region (11%).
• The life expectancy of SCI patients highly depends on the level
of injury and preserved functions eg ASIA Impairment Scale
(AIS) grade D, requiring a wheelchair for daily activities have
an estimated 75% of a normal life expectancy; patients not
requiring wheelchair and catheterization can have a higher life
expectancy up to 90% of a normal individual.

14. Differential Diagnosis
1. Aortic Artery Dissection
2. Epidural and Subdural Infections
3. Spinal Cord Infections
4. Syphilis (is a bacterial infection usually spread by sexual contact)
5. Vertebral Fracture
6. Transverse Myelitis
7. Acute Intervertebral Disk Herniation
8. Spinal Abscess

15. Medical Management
• The ideal management of acute spinal cord injury is a
combination of pharmacological therapy, early surgery,
aggressive volume resuscitation, and blood pressure
elevation to maximize spinal cord perfusion, early
rehabilitation, and cellular therapies.

16. Pharmacological Intervention
• There is still no commonly accepted pharmacological agent.
• The most important candidates are
• Glucocorticoid (Methylprednisolone), which suppress many of
the ‘secondary’ events of spinal cord injury.
• Thyrotropin-releasing Hormone (TRH) shows antagonistic
effects against the secondary injury mediators.
• Polyunsaturated Fatty Acids (PUFA) such as
Docosahexaenoic Acid (DHA) have recently been explored for
spinal cord injury management.

17. Surgical Intervention
• Early surgical decompression results in a better neurological
outcome.

18. Cellular Therapy Interventions
• Traumatic SCI represents heterogeneous and complex
pathophysiology.
• The aim of cellular therapies is to provide functional recovery of
the deficit through axonal regeneration and restoration.
• Schwann Cell is one of the most widely used cell types for
the repair of the spinal cord.
• Cells are capable of promoting axonal regeneration and
remyelination after injury.

19. Diagnostic Procedures
• Imaging technology is an important part of the diagnostic
process of acute or chronic spinal cord injuries. Spinal cord
injuries can be detected using different types of imaging which
depends on the type of underlying pathology.
• MRI Scans have become the golden standard for imaging
neurological tissues such as the spinal cord, ligaments, discs,
and other soft tissues. Only MRI sequences of sagittal T2 were
found to be useful for prognosticative purposes.
• Spinal fractures and bony lesions are better characterized by
computed tomography (CT) and vascular injuries can be
detected by using an MR angiography or by a CT scan.

20. Examination
• A diagnosis can be made through a thorough history and
examination.
• By performing a neurological examination, if possible to participate in
a reliable physical neurological examination, for the sensory and
motoric functions of the body in the corresponding area of
complaints. After the examination, we can make a judgment of the
severity and the location of the injury.
• If the place of injury is diagnosed we can perform some extra
examinations as described on the following :
• Cervical Examination
• Lumbar Examination
• Thoracic Examination

21. PHYSICAL THERAPY MANAGEMENT
• The rehabilitation of patients who had a spinal cord injury
depends on which level of the spine the injury occurred. Also,
the therapy depends on whether it was a complete or
incomplete spinal cord injury. In case of an incomplete spinal
cord injury, 25% do not become independent ambulators. The
therapies differ according to where the lesion happened,
cervical, thoracic, or lumbar. The rehabilitation of SCI is
a multidisciplinary approach!

22. Possible Upper Incomplete SCI
Therapy:
• When the cervical spine is injured, the consequences for the
patient are life-changing. Patients need therapy for movement
and strength recovery of the upper body and probable
respiratory training.
• Respiratory muscle training consists of inspiratory, expiratory,
or both improvements in muscle strength and endurance.
• Normocapnic hyperpnoea is a method of respiratory muscle
endurance training that simultaneously trains the inspiratory and
expiratory muscles.
• This device consists of a re-breathing bag that works at 30 to
40% of the patient’s vital capacity and is connected to a tube
system and mouthpiece.

24. Possible Lower Incomplete SCI
Therapy:
• The main limitations with lower incomplete SCI patients are that they
have reduced coordination, leg paresis, and impaired balance.
• These limitations can be worked on with the use of braces and tilt
tables.
• If the leg strength improves, therapists can use braces, parallel bars,
and other walking aids to work on the balance weight-bearing of the
patient. In combination with those instruments, the therapist needs to
train the patient using the repetitive and intensive practice of gait.
• The use of a treadmill with an overhead harness is applied to certain
SCI cases and only by choice of the therapist.
• In addition to this therapy, the use of functional ES &
Bobath principles is needed to optimize the rehabilitation of the
patient.

25. Resources
• ASIA - International Standards for Neurological Classification of
SCI (ISNCSCI) Exam
http://www.asia-
spinalinjury.org/elearning/isncsci_worksheet_2015_web.pdf
• Article Exploring additional pharmacological options
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303789/pdf/WJO
-6-42.pdf
• Website of National Spinal Cord Injury Statistical Center
(NSCISC) - Accessed 18/11/2015
https://www.nscisc.uab.edu/Public/Facts%202015%20Aug.pdf

26. THANKS