Functional Outcomes in Spinal Cord Injuries

The biggest question often posed is whether or not the patient will walk again.  In general, the level of spinal cord injury and the ASIA impairment scale predict functional outcomes.  Factors like other illnesses often affect the functional outcome of the patient. 

Shortened length of stays in the hospital and rehab facility have impacted rehabilitation medicine.  The average length of stay in the acute hospital has decreased from 25 days in 1973 to 19 days in 2002.  In the same time, the length of stay in a rehab facility has decreased from 122 days to only 46 days. 

Functional improvement is much better with incomplete injuries when compared to complete injuries.  For those with incomplete injuries, about half to two thirds of the one year motor recovery occurs within the first 2 months after the injury with a slowing of recovery after 3-6 months. 

In those who initially have trace to fair muscle strength after the injury, about 90 percent will achieve the ability to lift the muscle against gravity.  Of those with zero muscle strength initially, about 64 percent will achieve anti-gravity strength after two years. 

Because of shorter lengths of stays, often rehabilitation must continue after discharge in places like skilled nursing facilities, at home, or in outpatient rehabilitation centers. Efforts should be made to educate patients and families to ensure that rehabilitation continues after discharge from the rehabilitation facility. 

Examples of Functional Outcomes in Spinal Cord Injuries

  • C1-C4 Quadriplegia.  These patients have paralysis of the upper and lower extremities, inability to cough, low endurance, and respiratory compromise due to paralysis of respiratory muscles.  These people are dependent on caregivers for almost all cares.  Some will need mechanical ventilation.  Those with injuries at C4 often don’t need a ventilator but need CPAP at night to help with hypoventilation.  These people often can drink on their own with a straw and power wheelchair independence is possible with the use of controls activated by the mouth, voice, breath, or infrared devices. 
  • C5 Quadriplegia. There is paralysis of the trunk, lower extremities and some of the upper extremities.  It is essential to watch out for elbow contractures in these patients.  They don’t have the upper body strength to do independent transfers but can operate motorized wheelchairs using their upper extremities.  Self-feeding and grooming is usually possible.  This is the highest level of spinal cord injury in which the patient can have the ability to drive with special adaptations. 
  • C6 Quadriplegia. These patients have paralysis of the trunk and lower extremities and loss of some aspects of upper extremity function.  They still have respiratory dysfunction due to paralysis of the intercostal muscles.  They may need assistance in clearing respiratory secretions.  Finger pinching is possible.  Independence with feeding and grooming is usually possible as well.  They can usually dress the upper body but not the lower body.  Transfers are possible with a lot of training using things like sliding boards.  Independent manual wheelchair use is possible but the wheelchair may require the use of special knobs for turning the wheels. 
  • C7 to C8 Quadriplegia. There is paralysis of the lower extremities and trunk with limited grasp and dexterity.  Finger and thumb movements are possible.  The respiratory system is still impaired because of loss of respiratory muscles and they need assistance in clearing secretions.  Eating, grooming and bathing are usually possible independently.  Men will be able to self-catheterize.  With training, independent transfers are possible.  Manual wheelchair use can be undertaken at this level of injury.  A wheelchair accessible van can be purchased and used by these individuals independently. 
  • T1 through T9 Paraplegia. There is paralysis of the lower trunk and lower extremities in these lesions.  The respiratory system is unaffected the lower down the lesion is.  Independence in self-care is greatly improved because upper extremity strength is preserved.  They will require about 1-2 hours per day of attendant care to assist in homemaking tasks. 
  • T10 to L1 Paraplegia. These patients have full respiratory function but paralysis of the lower extremities.  There is good trunk stability and improved potential for ambulation with orthoses.  Bowel and bladder function can be maintained independently.  They need about 1-2 hours of attendant care for homemaking activities. 
  • L2 to S5 paraplegia. There will be partial paralysis of lower extremities.  Bowel and bladder function can be managed independently.  A four point can be used for ambulation. 

Additional Therapeutic Considerations

Things that are important include the ability to ambulate and the ability to manage bowel and bladder function.  There is decreased depression with the ability to ambulate.  Standing is usually possible with the use of a standing frame or tilt table.  Tilt tables are helpful in the early stages to monitor and reposition the patient if their blood pressure decreases upon standing. 

Recreation and Sports Activities

Many people with spinal cord injuries are young and grieve the loss of the ability to do leisure activities.  For this reason, there are a number of organizations focusing on leisure and sports activities for those with spinal cord injuries. 

In the long term, most spinal cord injured patients develop a sedentary lifestyle.  They are at risk for repetitive motion trauma, joint trauma, joint contractures, and pain.  This can lead to depression and other psychosocial consequences. 

For those with spinal cord injuries, exercise is effective in improving endurance and strengthening muscles.  Flexibility, improved bone density, improved posture, and better cardiovascular function are also enhanced with exercise.  The type of exercise a person with spinal cord injury uses must be balanced against the risk of injury. 

I’m Ed Smith, a Sacramento Spinal Cord Injury lawyer. Call on me anytime for free, Friendly advice at 916.921.6400.

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