Spinal Cord Injury Information

I sincerely hope the information presented will be useful and help you and yours cope with this devastating injury.

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SCI INFORMATION, Changes

This important section is devoted to the changes that take place in the SCI body, and includes important information on the circulatory system, the respiratory system, the psychology and psychosocial adjustment of the SCI, even sexuality, sex after SCI.

Bones, Muscles and Nerves

  A number of different conditions can affect your nerves, muscles, and bones after spinal cord injury. This page will address the four: Spasticity, Atrophy and Contractures, Neurogenic Heterotopic Ossification (NHO), Osteoporosis or Weak Bones, with a description of each, advantages and disadvantages, and what you can do about the condition.

Spasticity

  When some spinal cord nerve cells are disconnected from your brain, they gradually develop exaggerated activity due to increased reflexes. Even simple things like touching or irritation to your skin, stretching muscles, or stretching your bladder may cause a reflex contraction of your muscles that you cannot control. One common type of reflex muscle contraction seen after spinal cord injury is a rigid straightening of the knees and pointing of the toes (extensor spasms). Another type is a bending of the hip and of the knee (flexor spasms).

Advantages of Spasticity

• Increases in spasticity can warn you of any pain or problem in those areas where you cannot feel (e.g., a urinary tract infection, a pressure sore).

• Spasticity helps maintain your muscle size and bone strength.

• Spasticity helps promote circulation of your blood.

• You may learn to use your spasticity functionally; for example, using extensor spasms to help transfer or to walk with braces.

Disadvantages of Spasticity

• It may interfere with sleep, driving, sex, walking with braces, etc.

• It may cause scraping of your skin and result in skin breakdown.

• It may cause limited joint movement. (See "Contractures.")

What to Do

  Most spasticity can be tolerated to enable you to benefit from its advantages. Some ways to control spasticity and prevent complications include:

• Performing daily range-of-motion exercises to help reduce spasticity.

• Avoiding stimulation that you find aggravates the spasticity (such as fast movements or certain body positions).

• Asking your therapists about the use of padded straps and splints that can help control spasticity.

• Protecting your feet and legs from striking sharp or hard objects due to a spasm (such as against your wheelchair during transfers).

• Taking a warm (not hot!!) bath or shower.

• Trying to relax or reduce your level of stress.

  If spasticity is interfering with sleep, driving, or other functioning, you should discuss treatment options with your local doctor or health care provider.

Treatment alternatives include:

• Medications, although all have side-effects and none will eliminate spasticity.

• Injections of specific medications into muscle or nerve to reduce spasticity.

• Surgery to nerve roots or the spinal cord.

  Remember that significant increases in spasticity may be a sign that something is wrong in a part of your body where you do not have sensation. Such increases in spasticity might be a warning of a urinary tract infection, a pressure sore, kidney stone, appendicitis, an ingrown toenail, or almost any problem. Notify your local doctor or health care provider if you notice a significant increase or decrease in spasticity.   (top)

Atrophy and Contractures

  Atrophy is the shrinking of muscle size when it cannot be used. Some cord injuries result in more, some in less, atrophy. A contracture is the tightness of tissues around joints and in muscle that limits movements and function.

• Contractures can be a serious problem, but they are preventable. If range-of-motion exercises are neglected, then contractures can permanently limit joint movements. Contractures can interfere with transfers or daily activities. They can also change your posture, which can lead to pressure sores. In some individuals, tightness of some muscles of the hand is actually planned to improve the grip (Tenodesis).

• Atrophy generally is not a medical problem.

Treatment

  Contractures can be prevented by moving joints through their full range of motion regularly. Joints in body areas where the muscles do not work must be moved manually by yourself or by an attendant. Your therapists will instruct you in the range-of-motion exercises most important for you and how they should be performed. Shoulders, elbows, hips, knees, and ankles are the joints that usually are most important in preventing contractures. If you have severe spasticity, then range-of-motion exercises may be particularly important, and you may need to do them several times a day.

  Atrophy is generally not treated directly. Instead, you will learn to avoid any long-term pressure on bony areas (such as buttocks or shoulders) to prevent pressure sores. Atrophy can usually be prevented by electrical stimulation performed two or three times per day. However, each muscle that is to be increased in size must be stimulated, and this can become very time consuming and costly. Unless some functional movement returns or unless this electrical stimulation is medically necessary, this strengthening is not generally done with SCI patients.   (top)

Neurogenic Heterotopic Ossification (NHO)

  Neurogenic Heterotopic Ossification, or NHO, is the growth of a knot-like piece of bone in the soft tissues of your body below the level of your spinal cord injury. This bone is formed in between your muscles, often near a joint. It can affect all joint areas below the level of your spinal cord injury, It most commonly affects the areas of your hips, knees, and elbows.

  Ultimately the bone growth stops on its own. It usually will appear on an X-ray about 4 to 10 weeks after the process begins. The whole process ends in about 18 to 30 months, leaving behind a chunk of complete, honest-to-goodness bone. It is just like any other bone in your body except that it serves no particular function, and it can often cause problems in joint movement.

The Cause

  Unfortunately, the cause of this condition is unknown. It does not occur in all people with SCI. No one knows why some patients get it and others do not. For some reason, young bone cells show up in soft tissue, where they mature and harden.

  Some things that may contribute to and start this process are probably related to changes in your body due to your injury. It may have something to do specifically with changes in blood flow, hormones, or the chemistry in the area where the NHO starts. Some people feel that overly vigorous range-of-motion exercises can tear the tissues and cause the problem. Other theories are that local bleeding in the area caused by an injury or tearing leads to the deposits of bone cells.

Symptoms

• Decreased joint range of motion — this may develop slowly or quickly

• Swelling

• Redness

• Increased skin temperature over this swollen region

Other Cause of These Symptoms

  These other conditions can have the same types of symptoms and must be evaluated:

• An infection in the area

• A broken bone

• Bleeding into the muscle

• A bone tumor

• Deep vein thrombosis (DVT)

  Your doctor may do different tests to find out which condition is actually causing the symptoms. DVT must be ruled out by your doctor immediately, as this is a life-threatening situation and must be treated promptly.

Effects

  The worst complications are severely decreased range of motion and contractures. These greatly interfere with your self-care and mobility. It could cause problems with sitting, lower extremity dressing, transfers, bathing, and walking.

Testing for NHO

Three tests are used to evaluate and follow Neurogenic Heterotopic Ossification (NHO):

  Alkaline phosphatase - The level of alkaline phosphatase in your blood stays high throughout the period of active bone formation. It eventually drops back to normal values when the NHO stops growing.

  X-rays - X-rays are used to confirm the location of the NHO and to estimate how mature the new bone is. An X-ray cannot tell how long it has been there.

  Bone scan - A bone scan is the best test for diagnosing NHO. It can detect NHO about four weeks before an X-ray can.

Treatment

  There is no one, successful treatment of NHO. A medication called Didronal is sometimes prescribed to try to prevent the NHO from starting or continuing.

  Your doctor will know that the NHO has fully matured when your alkaline phosphatase returns to normal again and a bone scan shows no more actively growing bone. The bone may then be removed surgically to improve your joint movement, If the bone does not cause you any movement problems, your doctor may decide to just leave it there.

Help through Range of Motion

  A regimen of full, gentle passive or active assisted range-of-motion exercises helps rather than hurts. You should try to maintain the range that you have.   (top)

Osteoporosis

  Osteoporosis is loss of calcium and phosphorus from bone. It is common following spinal cord injury. Bones that usually are kept strong through muscle activity and walking can no longer get what they need. Osteoporosis weakens the bone and makes it easier to break and slower to heal.

Osteoporosis in People with SCI

  There are no proven treatments for reversing or preventing osteoporosis, although some experimental treatments are being tested. The primary treatment is to prevent fractures. So extra precaution should be used to prevent falls or striking your leg against an object during transfers. Follow the range-of-motion guidelines from your therapists to avoid putting excessive stress or pressure on bones. Walking with braces may help to limit the amount of osteoporosis that develops in the legs.

  Your upper extremities such as your shoulder, elbows, wrists, and hands are important. Using a wheelchair, especially a manual wheelchair, requires more work with your arms than they were used to when you walked. Over-use injuries can occur but are less likely if you follow some simple advice:

• Gloves: Wheelchair push gloves can be worn to protect your hands. They are essential if you have paraplegia, but if you cannot feel all or part of your hands, a protective glove is a good idea.

• Carpal Tunnel Syndrome: An inflammation of the tendons leading into the hand that can cause pressure on the nerve entering the hand, which will result in a painful or numb hand, This is over-use syndrome and prevention is the best cure—avoid repetitive motion of the wrist, especially flexion (bending of your wrist down).

• Ulnar Nerve Compression: The ulnar nerve courses very close to the surface at the elbow. (This is your "funny bone"—not so funny when you bang it.)

• Tennis Elbow (Lateral Epicondylitis): An inflammation of the extensor tendons of the wrist and fingers. (Straightening your fingers and raising your wrist.) Avoid excessive repetitive motion.

• Shoulders: Primary issues at the shoulders are biceps tendinitis and impingement syndrome. Biceps tendinitis is caused by overuse of the muscle—often from overhead reaching activities. Impingement syndrome is more complex. Both problems relate to muscle imbalance and often poor habits in transfers.

  Shoulder protection programs should include anterior stretching of the shoulder, posterior shoulder and rotator cuff strengthening, and avoidance of impingement patterns. Impingement pattern means weight bearing with the hand at or above the height of the shoulders. All transfers should be done with hands down—as low as possible—with a forward bent posture, allowing counterbalance with your head and upper body to decrease the weight bearing on your shoulders. Never use an overhead trapeze or overhead grab bar. See your physical therapist for a simple exercise that should be part of your daily routine if you push a manual wheelchair and do independent transfers.

  Pain is an early indicator. If you have pain in one of your joints or part of your shoulder or arm and you didn’t do something obvious to cause it. you should contact a therapist to help you troubleshoot and solve the problem. Early intervention is best.

Other Upper Extremity Issues

• Edema: Especially for people with high quadriplegia swelling of the hands can be a problem. This makes your hands more vulnerable to skin breakdown. Elevation and compression are the best management combined with daily range of motion. Consult your O.T. for more advice on management. Chronic edema can be a symptom of other problems. When elevation and compression fail to reduce the swelling, contact your doctor.

• Shoulder Subluxation: Again, an issue primarily for people with high quadriplegia without normal shoulder musculature. The problem here is gravity; the weight of the arm pulls the shoulder out of the socket—the results can be pain. The best prevention and management is to support the arm, do not allow your arm to dangle, and do not allow anyone to pull your body weight with your arms.

• Support your arm, not your body, through your elbows. Consult your O.T. for proper positioning.   (top)