CAUSES

    The Spinal Cord is like a great telephone communication system. It is made up of nerves, which carry messages between the brain and all other parts of the body. The spinal cord is an extension of the brain. It is enclosed within the spinal column, which is made up of irregularly shaped rings of bone called vertebrae.

    Many nerves lead from the brain through the spinal cord to the skin, muscles, and organs of the body, such as the lungs, bladder, and stomach. They are called peripheral nerves because they travel to the skin, muscles, and organs and cause motion in these body parts. Other nerves lead in the opposite direction, from the surface of the body and organs inside, through the spinal cord, to the brain. These nerves are called sensory nerves because they "sense" and relay information to the brain about heat, cold, pressure, pain, and position.

    There are a total of 31 pairs of spinal nerves that branch out to all parts of the body. Each pair has a motor and sensory nerve. All spinal nerves branch out and divide into peripheral nerves, which reach every inch of your skin, every muscle, every blood vessel, every bone - every part of your body from head to toe - in a type of web.

    All nerves operate along a pathway. When the pathway is broken, messages from and to the brain are not delivered. This is what happens when there is an injury to or disease of the spinal cord. An injured spinal cord is like a broken telephone cable. The telephone on each end of the cable is OK -- just like the brain and body parts on each end of the nerves that run through the spinal column are OK -- but the connection is broken. The result is paralysis and a lack of sensation. SCI affects each person differently because the spinal cord is usually not damaged in exactly the same way in any two individuals.

    Following is an illustration of the different sections of the spinal cord: neck, chest, lower back, and tailbone. The vertebrae, or rings of bone, are used to name the different sections. Also shown are the spinal nerves in each section of the spinal cord that cause motion in all body parts and relay sensation information to the brain from all body parts.

Spinal Cord Sections, Vertebrae, and Spinal Nerves

   Depending on where the spinal cord is injured, a person will either have weakness or paralysis to some degree in the lower body and legs (paraplegia), or, weakness or paralysis to some degree in all legs and arms (quadriplegia). An injury at a particular vertebra will affect all the nerves below the injury. For example, if you are injured at the C5 or C6 level -- at the level of the 5th or 6th cervical vertebrae in the area of the neck -- the nerves in the spinal cord below those vertebrae will be affected, and the injury will involve weakness in shoulder and arm muscles, as well as body and leg muscles (quadriplegia). If you are injured at the T10 level -- i.e. at the level of the 10th thoracic vertebra near the lower back -- the injury will not affect your arms and shoulders, but it will affect your body, abdomen, and leg muscles (paraplegia).

     Doctor's refer to your injury based on where the bones and nervous system were damaged. The nerve tissue of the spinal cord in an adult is shorter than the bony spinal column. Below the neck region, the bony level (e.g. T9) would actually correspond to a lower neurological level (T10). Your diagnosis is based on the two things: the level of the injury to the spinal cord and the level of the fracture in the spinal column. The numbers of the two levels may be slightly different. The level of the injury to the spinal cord refers to the spinal nerves that still have function. SCI can be "complete" or "incomplete". In complete SCI, there is no voluntary movement or sensation below the level of injury. In incomplete SCI, there is some sparing of sensation or voluntary movement. Following is information from the "Sharp Functional Outcome Scale" which provides a framework for long-term functions after spinal cord injury.

SHARP FUNCTIONAL OUTCOME SCALE

RANGE OF MOTION (ROM) EXERCISES

   Range of motion (ROM) is the term that is used to describe the amount of movement you have at each joint, such as your knee. Every joint in the body has a "normal" range of motion. Joints maintain their normal range of motion by being moved. It is therefore very important to move all your joints every day. Stiff joints can cause pain and permanent deformities and can make it hard for you to do your normal daily activities.

   In SCI, you may have difficulty moving your arms and legs, and your joints can easily become stiff and hard to bend. If your knees and hips become stiff, e.g., it will be hard for you to dress yourself and sit in a wheelchair. To prevent joint stiffness and enable you to achieve your highest level of independence, your therapists will teach you range of motion (ROM) exercises. Some patients may need splints to keep the muscles around their joints stretched.
 

*See also Self Stretching and Passive Stretching (Lower and Upper Extremity)

SELF STRETCHING

Important points to remember:

• Never use force while stretching. All that is required is enough force to allow the muscle to stretch.

• Hold the position still, instead of bouncing, especially if you have spasms. This allows your muscle to relax and stretch.

• A good time to do your stretching program is in the morning, or in the evening, as you do your skin inspection.

Self ROM Exercises for Quadriplegics

     Do these exercises while you are leaning against the headboard of the bed, leaning against a piece of furniture that will not move, or sitting in your wheelchair.

• Hook your left wrist under your left knee. Pull your left knee toward the chest. Hold for a count of 10. Repeat 5 times.

• Sit with your left knee bent toward your chest. Use your left wrist and forearm to push the outside of your left knee toward your right leg. Do not force. Hold for a count of 10. Repeat 5 times.

• Sit with your left knee bent up. Slowly lower it out to the side toward the bed or wheelchair. Use your left wrist and forearm to push gently down against the inside of the left knee. Do not force. Hold for a count of 10. Repeat 5 times.

• Facing a bed or chair, place one of your legs straight out on the bed or chair and hold the knee straight. Do not lean forward as this will stretch you too much. Hold for 3-5 minutes on each leg.

• Sit with your legs stretched out in front. Lean forward. You may use your elbows or hands to keep your knees straight. Loop a strap around the bottom of your foot. Pull the strap toward you to stretch your foot, without turning to either side. Hold for a count of 5. Repeat 10 times.

PASSIVE STRETCHING (LOWER EXTREMITY)

Lower Extremity Passive ROM Exercises

     Lower extremity passive exercises are for someone else to stretch your hips, legs, and knees if you are unable to do this yourself. These exercises should be done slowly and gently while you are lying on your back. Each exercise should be done ten times on each leg each day.

Hip and Knee Flexion and Extension

     Cradle the leg by placing one hand under the bent knee. With the other hand, grasp the hip (or place it under the heel) for stabilization. Lift the knee and bend it toward the chest, with the kneecap pointed toward the ceiling. Do not allow the hip to twist during this movement. The foot should stay in a straight line with the hip and not swing in or out. The leg is then lowered to the starting position.

Hamstring Stretching (Straight Leg Raises)

    Method # 1 - Kneel between the legs and support the ankle with your arm or shoulder. The knee will be straight. Place one or both hands just above your knee, stabilizing the hip joint. If one hand is used, the other hand will be placed on the thigh of the other leg to keep it on the bed. If both hands are used, the person's knee may rest lightly on your other thigh. Raise the leg straight up to approximately 90 degrees.

    Method #2 - Place one hand under the knee and the other hand under the heel. With the knee straight and the kneecap pointed toward the ceiling, raise the whole leg toward the ceiling. When the raised knee begins to bend slightly, the hand under your knee should be moved to the top of your knee.

Hip Internal and External Rotation

    Place one hand on top of the knee and the other hand under the heel. Bend the knee halfway to the chest so that there is a 90 degree angle at the hip and knee. Pull the foot toward you and then push it away.

OR:

    Place one hand on the thigh and other hand below the knee. Roll the leg inward until the kneecap faces the other leg. Then roll the leg outward in the opposite direction. The leg always stays straight in alignment and rolls like a log.

Hip Abduction and Adduction

Cradle the leg by placing your hand under your knee and holding it. Place the other hand under the heel, or on the hip, to stabilize the hip joint. Keeping your knee straight, move the leg along the surface of the bed, toward you and away from the other leg, to approximately 45 degrees. Then bring the leg back to the other leg.

Heel-Cord Stretching

     Place one hand on the knee to prevent it from bending. Your other hand cups or cradles the heel and your forearm is placed against the ball of the foot. Push the ball of the foot forward, bending the foot toward the knee and stretching the muscles in the back of the leg.

Ankle Dorsification

Place one hand under the heel, with the foot against the forearm, and push the heel downward with this hand.

     To stretch one muscle (the gastrocnemius), extend the knee, place the other hand on top of the ankle, and push in the opposite direction

     To stretch the second muscle (the soleus), flex the knee, place the other hand under the calf, and push in the opposite direction.

Foot Inversion and Eversion

     With one hand, hold the foot near the heel. With the other hand, hold the lower leg near the ankle. The foot is moved from side to side or in a circle (up, in, down, out).

Toe Flexion and Extension

    With one hand, stabilize the foot just below the toes. With the other hand, gently move each or all of the toes forward and backward.

Hip Extension

     Place the person on his or her side and stand behind them. Place one hand under the knee with the lower leg resting on your forearm. With the other hand, hold your pelvis in place. Pull the leg backward and toward you.

PASSIVE STRETCHING (UPPER EXTREMITY)

Upper Extremity Passive ROM Exercises

     Upper extremity, passive ROM exercises teach someone else how to stretch your arms if you are unable to move your arms by yourself. These exercises should be done slowly and gently, and can be done with the person sitting in a chair or lying down. Do each exercise ten times.

Shoulder Flexion and Extension

    Hold the forearm with one hand. With the other hand, grasp the top of the shoulder joint to stabilize it. Turn the palm inward, facing the body, and keep the elbow relatively straight. Move the arm from the side of the body over the head.

Shoulder Abduction and Adduction

    Place one hand on the shoulder, stabilizing the shoulder joint. With the other hand holding the elbow, support the forearm and turn the palm outward. Bring the arm out to the side, away from the body, as far as it will go.

Shoulder Internal and External Rotation

    Place one hand on the shoulder. With your other hand, hold the forearm. Bring arm out to the side to shoulder level. Turn arm so that the hand points to the ceiling. Then turn arm back down so that hand points to floor and the upper arm is twisting in the shoulder joint.

Elbow Flexion and Extension

     Hold the upper arm with one hand and forearm with the other hand. Bend the arm at the elbow so that the hand touches the shoulder. Then straighten the arm all the way out.

Forearm Supination and Pronation

     Hold under the elbow with one hand and the wrist with the other hand. Turn the palm of the hand so it faces up to the ceiling, and then down to the floor, twisting the forearm.

Wrist Flexion and Extension

     Hold the forearm above the wrist with one hand. Place the thumb and fingers of your other hand on opposite sides of the palm. Holding the hand in this way, bend it up at the wrist, then down at the wrist, about 90 degrees. The fingers will straighten naturally.

Finger Flexion and Extension

     Place the hand palm down. While raising the wrist, bend the fingers up. Then straighten out the fingers as you bend the wrist down.

Thumb

     Bend and straighten the thumb. Stretch the thumb out to the side to stretch the "web space"

TRANSFER PROCEDURES

TRANSFERRING THE PATIENT

     Once Range of Motion exercises have begun and you are able to balance yourself and assume a sitting position, with or without a brace, you are ready for transfer from one place to another, e.g. from the bed to the wheelchair. There are various transfer procedures and devices. Your degree of mobility and the strength and number of people available to help you will determine which method is best for you. There are manual and mechanical transfer procedures and devices.

Two-person lift

     At least two individuals physically lift you in order to transfer you from one place to another.

Pivot

     In the pivot transfer, one person grasps you around your body and the other person grasps your pants or skirt. Using a rocking motion, they lift you and pivot your feet in the direction of the surface to which you are being transferred.

Slide board

     A slide board is a smooth, rectangular board, usually made of wood with beveled edges, approximately 8 inches wide and two feet long. The slide board is positioned between the edges of the surfaces that you want to transfer out of and into. For example, the board is positioned between the edge of the bed and the edge of wheelchair to transfer you from the bed to the wheelchair. One person grasps you around the body. The other person grasps your pants or skirt. Together, they slide you from one surface to the other. You may be able, but need not assist with this method of transfer.

Gait belt

     A gait belt is usually made of nylon, is approximately 2 inches wide, varies in length, and has an adjustable, belt-like loop buckle closure. The gait belt is placed around your waist and grasped by the people who are doing the transfer.

Mechanical Lifts

     To use a mechanical lift to transfer you, a sling must first be placed under you. This is done by rolling you from side to side. Once the sling is positioned under you, it is attached to the lift using hooks, straps, or other devices.

     There are several types of mechanical lifts. To use a direct drive lift, the person must crank the handle in large circular motions to raise and lower you. To use a hydraulic lift, the person most pump the handle up and down to raise and lower you. Depending on the type of hydraulic lift, the person may also have to pull you while you are in the sling to position you properly.

ADAPTIVE EQUIPMENT

     Adaptive equipment, such as remote control devices and electric can openers, are used more and more by all people to more easily accomplish everyday activities. You may need more adaptive equipment that the able-bodied person, because you may not be able to do things as you did before. For you, adaptive equipment are special tools that are made to help you be independent. Adaptive equipment can be used for mobility, eating, writing, dressing, grooming, cooking, and other daily activities. Following is an introduction to the types and uses of adaptive equipment used by people with SCI. Your physical and/or occupational therapist will help you decide which equipment you need or desire. Detailed information about specific products can be found in ABLEDATA, a database of information about more than 20,000 products for people with disabilities of all types, and in support groups, from other people with disabilities.

BRACES, CRUTCHES AND WALKERS

     Some people with SCI are able to walk with the assistance of braces, crutches, and/or walkers. There are two basic styles of crutches: traditional under-arm crutches and forearm, or Canadian-style crutches. The style that is best for you depends on the level of your SCI and your degree of mobility. Walkers are metal frames designed to provide support and stability while walking. Walkers may be folding or fixed; height-adjustable or non-height-adjustable; equipped with wheels on the front, all four, or none of the legs; suited for stairs; and/or equipped with seats.

*See also Wheelchairs and Scooters, and Driving and Transportation

WHEELCHAIRS AND SCOOTERS

Wheelchairs and Scooters

     Wheelchairs come is various types, sizes, styles, weights, costs, and options for seating, brakes, footrests, armrests, and wheels or tires. Most people with SCI use a wheelchair at some point in their lives and should select one based on their level of injury, where and how the wheelchair will be used, and its cost.

Manual Wheelchairs

     Some people with SCI may need, or may choose to use, a manual wheelchair. The most commonly used everyday wheelchair for active SCI users is the lightweight manual wheelchair. All manual wheelchairs require good upper body strength and mobility. They range from lightweight wheelchairs, which can weigh as little as 5 pounds and are easier to operate, to standard wheelchairs, which can weight as much as 45 pounds and require considerable strength to operate. Lightweight wheelchairs were originally designed for wheelchair sports; some are now also used for everyday wheelchairs as well. Some manual wheelchairs, with power packs that allow them to be converted to powered chairs, are very heavy.

Powered Wheelchairs and Scooters

     Other people with SCI may require or prefer a powered mobility device, such as a powered wheelchair or a scooter. People who use a powered wheelchair or scooter usually have limited strength in their arms. Powered wheelchairs use batteries, which must be re-charged on a regular basis, and are usually heavier than manual wheelchairs because of the weight of the batteries and additional adaptive equipment, such as body supports and respiratory equipment.

     Scooters, which are three- or four-wheeled carts, do not look like wheelchairs. They are usually less expensive and more maneuverable because they have a narrower wheelbase. Scooters are propelled by a steering mechanism, located in front of the user, and therefore operate much like a bicycle.

Wheelchairs for Children

     In addition to the wheelchair considerations above, children with SCI have special needs in wheelchair size and appearance. Small child wheelchairs are usually designed for children under six years of age, or with a similar height and weight. Small child chairs are available with options, such as a forward-tilting seat to enable the child to practice certain movements, such as stretching back without loss of balance. Child/junior/growing chairs are designed for children six years and older and come with kits that allow adjustments to the chair to accommodate the growing child. The wheelchair appearance is very important to children and can help them fit into their environment and social situations. There are also scooters for children and strollers for very young children who are not yet ready to propel themselves.

*See also Braces, Crutches, and Walkers and Driving and Transportation

DRIVING AND TRANSPORTATION

Driving and Transportation

     People with limited or no use of their lower limbs can use hand controls to accelerate, brake, and shift gears while driving. Hand controls are available for a variety of needs. There are also many accessories available for cars and vans to make driving or riding safer and more comfortable for people with SCI. Accessories include wheelchair and transfer lifts, handles to assist in transfers from a wheelchair to a car or van, door openers, swivel seats, ramps, raised ceilings, lowered floors, and wheelchair carriers attached to the outside of the car or van.

*See also Braces, Crutches, and Walkers and Wheelchairs and Scooters

EATING AND WRITING

     Following are some of the adaptive equipment suitable to help people with SCI eat and write:

• Spoons, forks, knives with special handles.
• Plate guards to help you scoop.
• Special cups which you can hold yourself.
• Long straws if you cannot reach the table.
• Special cuffs you wear to hold spoons, forks, or knives.
• Special holders for pens, pencils.
• Special pointing tools to type on a keyboard.

DRESSING AND GROOMING

• Dressing sticks so you can reach to your feet.
• Sock aid to pull on your socks.
• Button hooker to open and close buttons.
• Dressing ladder to make it easier for you to move around in bed.
• Velcro fasteners when you cannot tie your shoestrings.
• Loops in your clothes if you cannot grab onto your clothes.
• Long handle sponges and bath mitts if you cannot reach where you need to Special handles for toothbrushes, combs, razors and hairbrushes.
• Long handled mirrors to see parts of your body which you can't bend over to see.

COOKING AND OTHER ADAPTIVE EQUIPMENT

• Mirror over stove so you can see into pots from your wheelchair.

• Special tools to open jars.

• Special reaching tools (called "reachers") to help you pick up things that are too far away.

• Tenodesis splint to help you pick up tiny objects when you don't have a strong pinch.

• Prism glasses so you can look straight down if you can't bend your neck forward.

• Mouthsticks if you cannot use your hands at all.

• Telephone holders or a speaker phone if you cannot hold the phone by yourself.

• Special electronic devices to turn on radios, TVs, lamps, etc., without having to get out of your chair or bed.

     There is much more adaptive equipment available besides the equipment described here. Talk with an occupational therapist or rehab engineer about your needs. The therapist can help you decide what adaptive equipment might be helpful to you.