Rehabilitation and Recovery After Spinal Cord Injury

The International Standards for Neurological Classification of Spinal Cord Injury

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), commonly referred to as the ASIA (American Spinal Injury Association) examination, is the gold standard for clinical or research documentation of sensory and motor impairment to describe the level and severity of SCI. Most recently updated in 2019, it is reliable and valid for injury classification when performed by a trained examiner and when confounding factors (i.e., mechanical ventilation, intoxication, closed head injury, sedation, psychiatric illness, language barrier, severe pain, and cerebral palsy) are absent. The examination is designed to be completed with minimal equipment in the supine patient with minimal repositioning, allowing assessment even in a trauma or ICU setting. An accurate early ISNCSCI evaluation can be invaluable in determining functional and neurorecovery prognosis, which can guide the goals of care. We provide a brief overview here, but the International Standards Training e-Learning Program is encouraged for any clinicians who will be performing or interpreting the examination ( https://asia-spinalinjury.org/learning ).

Sensory Examination

The sensory examination is completed by testing each of 28 dermatomes (C2 to S4/5) bilaterally, as well as deep anal pressure ( Fig. 169.1 ). Two modalities are tested: light touch and sharp-dull discrimination (pinprick), representing the dorsal column and spinothalamic tracts, respectively. Sensation is scored on a three-point scale: 2 is normal, 1 is abnormal, and 0 is absent. Deep anal pressure assessed during digital rectal examination represents somatosensory components of the pudendal nerve from S4‒S5 and is marked by consistently perceived pressure by the patient. The “sensory level” is the most caudal dermatome where bilateral light touch and pinprick are intact, with all cephalad levels also intact.

International Standards to Document Remaining Autonomic Function After Spinal Cord Injury

In 2009, an international expert committee developed the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI). It remains a work in progress, with evidence suggesting good reliability for sacral assessments but only moderate reliability for general autonomic function. To improve the accuracy of performance of this examination, there is a web-based training course available ( https://asia-spinalinjury.org/learning)10 ( Fig. 169.2 ).

The ISAFSCI currently addresses the following autonomic functions: control of the heart (bradycardia, tachycardia, other dysrhythmias), blood pressure (presence of autonomic dysreflexia or orthostatic hypotension), sweating, temperature regulation, and respiration (need for ventilator support). These are graded as normal, abnormal, unknown, or unable to assess. Evaluation of sacral function includes lower urinary tract, bowel, and sexual function.

Restoration of autonomic function is of primary importance for individuals with SCI. Experts anticipate that use of ISAFSCI data in research will elucidate mechanisms of autonomic dysfunction in SCI and improve clinical management and recognition of autonomic complications with significant morbidity and mortality.

Prognosis and Outcome Measures

Neural recovery occurs through several physiological mechanisms with distinct chronologies after injury. Early on, expectations should remain fluid and be frequently reevaluated. Most recovery is seen in the first 6 months and progressively diminishes over time, with further functional gains being unlikely after 2 years. After that time, gross stability should be expected until aging or other comorbidities potentially lead to progressive and/or episodic decline.

Functional potential can be anticipated by neurological level and completeness of injury derived from the ISNCSCI (see Table 169.1 ). It is known, for instance, that conversion from complete to incomplete injuries is infrequent, and that neurological recovery of more than one to two myotomal levels after such injuries is unusual. However, regaining function in even a single myotome can have a significant impact on future function and prognosis (e.g., C5 vs. C6 tetraplegia). When comparing strength of muscles near the NLI, more than 90% of those with at least trace motor function initially achieve antigravity strength at 1 year, while less than half of muscles with no initial movement reach the same milestone. ^, Based on the degree of motor and sensory impairment at the outset of injury, as well as trends in motor recovery, it is possible to predict the short- and long-term potential of patients. Ambulation specifically has been shown to correlated with initial ASIA impairment scale, such that 3% to 6% of patients with A-type, 50% with B-type, 75% with C-type, and 95% with D-type injuries eventually achieve ambulation, as described by various studies.

Although often requested, discussions on the specific percentages of certain outcomes is not advised because they provide a false sense of concreteness and finality. Even results from well-designed studies with homogenous populations can be difficult to apply to individual patients, and the absolute percentages of various outcomes often vary from study to study. Overall, providing trends and principles may be more appropriate. The focus of prognosis conversations should be placed on larger goals such as quality of life and functional independence rather than physiological milestones such as ambulation.

Prognosis discussions with newly injured persons are intimidating for everyone involved. When delivered inappropriately, prognostication can delay or derail the rehabilitation process by causing problems such as mistrust or apathy. Early discussions should aim to promote hope, trust, and shared decision making. Clinicians must assess the emotions, education, and medical literacy of their patients on an individual basis to determine the scope, extent, and timing of information to be presented with each conversation. Repeated explanation should be expected and offered for patients to achieve true understanding. In the rehabilitation setting, patients benefit from an inter- and intradisciplinary approach to learning that should be emphasized with every therapeutic interaction. Formal patient education curricula and referral to consumer resources for self-education are also beneficial adjunctive resources. ^, As patients progress through rehabilitation and cope, and their functional trajectories become clearer, additional information and opportunities for further discussion should be offered.

It is important to recognize that neurorecovery and functional prognosis both change as technology and medical understanding progresses. As a result, long-term potential should be taken into consideration in acute care clinical decision-making. In risk-benefit analyses, it is often tempting to pursue conservative management in the most severe neurologica injuries. Joint contractures, fracture deformities, or instability are often tolerated in a nonfunctional limb. Nerve transfers, tendon transfers, exoskeletons, and epidural stimulators, however, are only a few contemporary examples of interventions potentially denied to patients because of management decisions made years earlier. To maximize an individual’s future potential, an accurate and up-to-date understanding of an individual’s capacity for recovery in the context of medical advances is required by the entire medical team.

Outcome Measures

SCI is not uniform, which makes planning research assessments challenging. Early after injury, measures such as ISNCSCI may detect neurological recovery, while later improvement would be unlikely. Some measures attempt to isolate compensatory benefits, while others focus on physiological recovery. Issues of ceiling and floor effects, reliability, reproducibility, and practicality are among other study-specific factors to consider. Other than the ISNCSCI, there is no robust, universally applicable assessment of functional recovery. This further limits comparison and pooling of study data to improve power and validity of results in this relatively small and difficult-to-recruit population. Clinicians may benefit from using the framework laid out by the International Classification of Functioning, Disability and Health. This language for health and disability is useful for setting reasonable goals and expectations.

Specific scales are reviewed in Table 169.5 . The ISNCSCI examination remains the gold standard for classification and is included (in full or in part) in almost all SCI research. The Spinal Cord Independence Measure III has also gained momentum, with several guidelines suggesting it as the preferred measure for SCI-specific function. In future, use of international datasets may improve future comparison and consolidation of data. Community participation and quality of life may be the hardest factors to predictably impact by medical interventions but should be considered.

Pressure Injuries

A pressure injury is defined as “localized damage to skin and underlying soft tissue, usually overlying a bony prominence or caused by contact with a medical device or another object, which develops because of intense and/or prolonged pressure or pressure combined with shearing.” In 2016, the name for a pressure, or decubitus, ulcer was changed to pressure injury (PrIs) by the National Pressure Injury Advisory Panel to better reflect that pressure-related skin damage includes both deep tissue PrIs and stage 1 PrIs, which are not ulcerations.

Maintaining skin integrity after SCI is critically important for future rehabilitation and quality of life. Of those with new SCI, 20% to 50% develop at least one hospital-acquired PrI before initial rehabilitation, and between 3% and 25% of these PrI are suspected to occur during the early acute period. ^, PrIs are most commonly found at the sacrum/coccyx (37%–43%), heels (16%–19%), and ischia (9%–15%) during the acute hospitalization. Those with complete injuries are more prone to stage 3 or worse PrIs. Those who sustain PrI acutely after SCI show decreased functional outcomes in the first 6 months postinjury, and 8% will die as a result of PrI-related complications. Incidence of prior PrI increases risk of future PrI development; thus, prevention of PrI during the acute phase is important for preventing rehospitalizations because of PrI in the years after SCI. ^,

Preventing and detecting PrIs can be especially difficult in the ICU setting, particularly when respiratory needs require upright positioning. In these cases, careful attention to customizing the PrI prevention plan is needed. Appropriate staging and detection of PrIs within 5 days of onset may lead to decreased severity of PrI, appropriate treatment selection, improved tracking of PrI, and better prognosis for recovery. Use of common risk assessment scales, such as the Norton or Braden, may not have strong validity with acute SCI compared with other trauma patients. For example, anyone with tetraplegia will have a maximum Braden score of 15, which is already a high risk. Use of SCI-specific scales should be considered, such as the Spinal Cord Injury Pressure Ulcer Scale, which can predict PrI occurrence within 2 to 3 days.

There are more than 200 risk factors contributing to PrI development in people with SCI. These can be further classified as extrinsic or intrinsic factors. ^, In the acute setting, extrinsic factors are the primary modifiable risk factors, ^, although some intrinsic factors, such as low blood pressure because of neurogenic shock and nicotine use, may be modifiable as well. The tolerance of skin and muscle tissue to shear and pressure is affected by the microclimate, nutrition, perfusion, comorbidities, and prior soft tissue health. Tissue compression–related ischemia is likely to be compounded by physiological changes, including reduced blood pressure. Sacral skin blood flow of patients with acute SCI is relatively decreased, with earlier reactive hyperemia suggesting microvascular dysfunction. Warm and moist microclimates are also believed to contribute to increased metabolic load and impaired tissue strength. Prevention of PrI, therefore, hinges upon maintaining bowel and bladder continence, providing appropriate nutritional support, performing regular skin inspections, and providing adequate pressure redistribution using position changes and appropriate support surfaces.

Unfortunately, some PrIs may be difficult to avoid. During immobilization on a backboard or gurney for spinal stabilization, pressure relief at the sacrum is difficult, if not impossible. However, spine stabilization boards with sacral pressure–relieving features hold promise for reducing the incidence of PrI during emergency transport. ^, Minimizing the duration of immobilization before transition to a pressure-redistributing surface can help reduce early onset PrIs.

Standard foam mattresses and donut pillows are not appropriate for patients with SCI ; however, there is no one optimal mattress support surface or body position that can alleviate and redistribute pressure away from all bony prominences to pressure-tolerant body areas. ^, Sacral pressure may be increased with elevated head of bed, and trochanteric pressures are increased in 90 degrees of side-lying. Reactive and powered active support surfaces are not appropriate for users with unstable spines.

The lowest interface pressures are associated with fully supine and prone positions, whereas lowest pressure and shear forces are found in air-fluidized beds. Devices such as pillows, wedges, and pressure-relieving heel protectors should also be used to minimize pressure on bony prominences.