Critical Rehabilitation of the Patient With Spinal Cord Injury

8/11/2019 Critical Rehabilitation of the Patient With Spinal Cord Injury

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Crit Care Nurs QVol. 28, No. 2, pp. 179187

c 2005 Lippincott Williams & Wilkins, Inc.

Critical Rehabilitation of the

Patient With Spinal Cord InjuryJoyce M. Fries, MS, OTR/L

Most healthcare practitioners have worked with patients with spinal cord injury at some point intheir career, for some it is a specialty. The critical care area usually only has patient with spinalcord injury for a brief time before they are transferred. More recently, there are longer intensivecare unit stays due to multiple trauma and lack of insurance. Nurses must be cognizant of in-dications, contraindications, and best practice interventions to contribute positively to patientslong-term outcomes. As part of the multispecialty team, nurses can be pivotal in preventing sec-ondary complications, especially pressure ulcers. Rehabilitation team members can be consulted

early to provide expertise in managing this complex diagnostic group. Key words: early referral,occupational therapy,positioning,pressure relief,spinal cord injury

THIS article will discuss the advantages ofcritical rehabilitation of the patient withspinal cord injury (SCI). According to the SCINetwork, a resource provided by the NationalSpinal Cord Injury Association (NSCIA), theincidence of SCI is 40 cases per million pop-

ulation in the United States; however, therehave been no studies regarding incidencesince the 1970s. Most new SCI cases (40.9%)are caused by motor vehicle crashes, followedby falls (22.4%) and violence (21.6%). While itis hoped that the presence of air bags in cars

will decrease the incidence of SCI, this wouldnot impact the number of violent acts or fallscausing SCI.1

The yearly lifetime costs for healthcare and

living expenses per year for higher-level in-juries (C1-C4) are $626, 588 for the first yearand $112, 237 for each subsequent year.1 Al-though sums are lower for incomplete SCIs,the expense combined with lost earnings andproductivity create a multimillion-dollar effecton the US economy. Mortality rates are high-est during the first year after injury than in

From the Scripps Mercy Hospital, San Diego, Calif.

Corresponding author: Joyce M. Fries, MS, OTR/L,Scripps Mercy Hospital, 4077 Fifth Ave, San Diego, CA

92103 (e-mail: [email protected]).

subsequent years,1 and complications or sec-ondary injuries can lead to long critical carestays. Another contributing factor is whetherthe patient was insured at the time of in-

jury. The absence of insurance coverage couldextend the critical care and acute hospital

stay as much as 3 months. Therefore, nurs-ing staff needs to familiarize themselves withbest practice methods for the patient withSCI.1

In an effort to minimize the costs relatedto SCI, healthcare practitioners must strive toprevent secondary complications from SCI,including decubitus ulcers, pulmonary em-boli, and joint contracture. The absence ofnormal sensation, combined with the absence

or weakness of normal motor ability, createsa very high risk for the development of pres-sure ulcers. Prolonged bed rest and abnormalrespiratory function can lead to pulmonaryemboli. Finally, abnormal muscle tone andabsence of active range of motion (AROM)can produce joint contractures. All of thesecomplications can increase length of stay, addmore expense, and limit the patients abilityto participate in acute rehabilitation after dis-charge. The involvement of the acute rehabil-itation team is essential in minimizing theserisks.2,3

Once a patient has been diagnosed with anSCI, the first priority is to protect the skin.

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180 CRITICALCARENURSINGQUARTERLY/APRILJUNE2005

This should be a concern whether the spinehas been stabilized or not. Commonly, health-care practitioners are fearful of moving pa-tients who have not yet undergone stabiliza-

tion surgery. There are many times, however,that surgery is delayed because of sepsis orother life-threatening issues, but diligent posi-tion changes and proper equipment must beutilized. Staff can physically stabilize the spineduring position changes by keeping the spinein anatomical alignment: zero rotation. This

will require the aid of at least 3 staff mem-bers with no lifting restrictions. One personmust stabilize the neck while the other 2 turn

the patients trunk slowly and carefully. Flex-ing the hips, knees, and ankles and holdingthe feet flat on the bed surface will allow forbetter control of the lower body. A staff mem-ber can control the knees toward the direc-tion of the turn (which will lead the torso inthe same direction) while the third staff mem-ber controls the shoulder girdle. Care must betaken to prevent spine rotation when usingthis technique. Changes in position must oc-

cur every 2 hours at a minimum whether ornot stabilization has been completed.24

Foam wedges, pillows, or air-filled rolls areuseful in maintaining alignment once the de-sired position has been achieved. Care shouldbe taken to protect all bony prominences.One of the most common areas for a decu-bitus ulcer is the sacral spine. This is causedfrom the natural curvature of the back apply-ing pressure against a flat surface. A patient

with normal sensation will make tiny postu-ral adjustments to relieve pressure where apatient with SCI will be unable to feel thepressure or move to relieve it. This area isalso in the center of the mattress where air isless likely to provide for evaporation of sweatand skin quickly becomes moist or macerated.

When sheets are used to lift the patient to-ward the head of the bed shearing occurs di-rectly over the sacrum. Once the skin is dam-aged, the prevention of an ulcer is even moredifficult and unlikely.

Another common area for pressure in SCIis the posterior thigh, which is caused frompressure through the ischial tuberosities. Thishappens when patients are in bed on their

back and the bed is inclined, or when theyare sitting upright in a wheelchair (for a pro-longed period of time without pressure re-lief and an adequate cushion). The weight of

the upper-body rests on the upper thigh andpushes the ischial tuberosities posteriorly to-

ward the thigh. These ulcers are of great con-cern because they commonly develop out-

ward from the inside, with little evidence onthe skin. It is not uncommon for these ulcersto require debridement down to the bone.

Heels are also a high-risk area for pres-sure ulcers. The bony protrusion of the cal-caneous, also with a natural curvature, rests

against a flat bed surface. The bone pushestoward the skin. Circulation is compromisedand the dermis begins to necros. Sometimes,blisters will form or skin will break open intoa circular pattern. Heels should be protectedfrom the first day after admission. Boots canbe used to keep heels suspended by provid-ing support to the lower leg and foot. Theseorthotics are typically lined with sheepskinmaterial, which adds comfort and allows for

evaporation of perspiration.In addition to orthotics, many differenttypes of beds are available that reduce pres-sure via rotation. These are used mostly tobenefit respiratory function, but are also veryeffective in reducing the pressure over bonyprominences. The Roto-Rest bed is oftenused for patients who have not yet under-gone stabilization. This system can keep thespine aligned with antirotation segments for

the head. The Roto-Rest should never be usedto apply cervical traction but it can maintainneutral spine position (zero rotation) while ro-tating the body up to 62 on each side (to-tal arc of 124).5 This bed has pressure re-duction foam and gel-packed surfaces to helpminimize the risk for skin breakdown over thesacrum. It is imperative that critical care staffare trained in the proper operation of thesebeds since the foam padding is firm (to pro-

vide enough support to immobilize) and willcause pressure if not continually rotating.

There are several other specialty mattressesdesigned for pressure relief. The Triadyne

and Kinair systems have air-filled nylonsections that relieve pressure and decrease


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Critical Rehabilitation of the Patient 181

shearing. The Triadyne bed has a proning op-tion and rotation of the upper-body portionto improve respiratory functioning.6,7 Thesefeatures are effective in reducing the risk for

pressure ulcers but the rotation can only beutilized after stabilization of the spine hasbeen completed. Often, these systems come

with air-filled positioning devices that can im-prove alignment of the spine and extremities.Despite the effectiveness of these mattressesin pressure relief, they are unable to preventpressure and position changes must be com-pleted every 2 hours. Healthcare practitionersshould be cautioned not to assume the mat-

tress is addressing the issue of pressure relief.When specialty beds are not available, the

patient should have some type of mattressoverlay. There are gel overlays, compressorair-filled overlays, and air mattress overlays as

well. At the very minimum, a patient with SCIshould be provided with an air mattress andregular repositioning when resources are lack-ing. The most important rule of pressure re-lief is that a change in position is the best po-

sition. Healthcare practitioners must supportthe spine and turn the patient every 2 hours,regardless of the surface. This can be challeng-ing and time-consuming but should be priori-tized because once a pressure ulcer is present,the length of stay, cost, and psychosocial ef-fect will increase exponentially.24,8 If diligentrepositioning can prevent a decubitus, the pa-tient can rapidly progress and participate fullyin an active rehabilitation program.

Once the patient with SCI has been re-ferred to rehabilitation service, including oc-cupational and physical therapy, he or she

will undergo a comprehensive initial evalua-tion. A baseline level will be documented, in-cluding motor ability and sensory awareness.The patient and therapist will identify client-centered goals on which therapeutic inter-

ventions will be based. Interventions includeremediation of performance components as

well as adaptation for those components thatare not likely to improve.9 In an effort to en-courage active patient participation, he or she

will be instructed by the rehabilitation staffto guide his or her own care as much aspossible.2 Since early motor function is lim-

ited because of spinal shock and edema, pa-tients may only be able to contribute to theteam by directing their care. Patients may gaincontrol over certain issues by taking respon-

sibility for daily tasks. They can direct posi-tion changes by reminding staff when its timeto be turned and can be given choices abouthow and when bathing and hygiene tasks willbe completed. It is necessary to have a clearlydefined method of communication to maxi-mize the patients level of autonomy.

It may be necessary to provide the patientwith an adapted call system to ensure his orher needs are known. These adaptive devices

should be based on current motor functionand allow the patient to operate the call sys-tem with little effort. Some adaptive switchesare low-pressure (less than 2 oz of pressure),use voice control, use a sip-and-puff straw likeswitch, or use chin movement to control thecall system. The type of device prescribed bythe therapist will be dependent on how muchmotor function is present. High-level cervicalSCIs often cause patients to limit volitional

movement to the head and neck. Lever-typetoggle switches can be positioned under thechin and opening the mouth will depress thelever, which will in turn activate the switchand control (turn on or off) the device to

which it is attached. Since the position of thehead will change every 2 hours, these devicescan be difficult to keep within reach of thepatient.

Another option is the sip-and-puff switch.

This is also designed for a one-way (on/off)toggle switch and is operated by a sip (suckingthrough a straw) and puff (blowing throughthe straw). The straws can be placed at theedge of the mouth to allow the patient easy ac-cess to the switch. Sip-and-puff switches canalso be challenging to continually reposition.

The low-pressure switch has many differ-ent sizes and shapes. Often, they are roundand flat and contain wire that can be utilized

within the existing call system with an adap-tive plug. These switches take less than 2 oz ofpressure to activate. They can be operated byturning the head, shrugging the shoulder, orany other slight motion the patient may pos-sess. They are easier to position since they are


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simply placed within the range of the patientsavailable motion.

Finally, there are voice-activated switchesthat utilize infrared technology. These can op-

erate any device that accepts infrared signals,such as TV, VCR, and similar electronic de-

vices. Most hospital call systems are hardwiredand cannot be used with infrared tech-nology as yet. Eventually, devices similar tothese will allow the patient to control almostall electronic devices in the home. They mayalso be used to operate an electric wheelchair.

The rehabilitation team can assist health-care practitioners in turning patients and pro-

vide proper positioning protocols.9

Not onlymust the patient be rolled into alternatingpositions, but these positions should alsomaximize range of motion and assist in pre-

venting joint contracture. A patient with acomplete SCI at or above C4 will have noupper-extremity AROM; however, compen-satory movements of the upper trapeziousmuscles can provide the patient with an abil-ity to support himself or herself in a sitting

position. This can only be achieved with ex-ternal rotation beyond normal ranges. Oneway to accomplish this is to position patientswith their shoulders abducted to 90, elbowsflexed to 90, and shoulders fully externallyrotated. The forearms and hands will be nextto the patients head on either side. It is op-timal to have a pillow under the head butnot under the forearms since this will facil-itate more external rotation at the shoulder

and can only be done while the patient issupine. The head of the bed must be as low astolerated (measured by pulmonary function)to increase the surface area of the body andprevent pressure over the ischial tuberosities.Patients with injuries at or above C4 may com-plain that they feel they are unable to breathebecause of the weight of the denervated chestand abdominal musculature upon their trunk.It should be explained that these positions arecrucial in preventing skin ulcers and that thefeeling will subside, or that they will acclimateafter a few hours.

When side lying, the patient should havemost of the upper-body weight over the

scapula that rests on the bed. The hips andknees should be f lexed, which will allow thepatient to remain on his or her side with-out much support. Pillows or foam cushions

should be placed between the knees and be-hind the back to maintain accurate position-ing. Shoulders can be flexed to 90, or at theside (neutral), but elbows should be extended(0 elbow flexion). This will allow for alter-nating flexion and extension of the elbowsand shoulders when supine versus side lying.

Again, the head of the bed should be as low aspossible to increase surface area and decreasepressure over bony prominences. In the pro-

cess of turning, all staff should be cognizantof the spine and should always avoid rotationin any area.

Hand positioning will vary depending onthe level of injury. In higher-level SCI, C6 andabove, the hands should be kept flexed at alltimes. Rehabilitation staff will provide ten-odesis stretches. These stretches are carefulpassive range of motion (PROM) of the wristand hand keeping the fingers flexed during

wrist extension to end range, and allowing thefingers to extend with wrist flexion to endrange. This will lead to intentional shorteningof the soft tissue of the forearm and create agrasp type position of the hand. If this oc-curs, the patient may eventually have grossgrasp and release and perhaps allow for ahigher level of independence.9Ankle positionshould always be maintained in neutral. Heelboots should be provided within a few days of

admission to ensure that this is attained. Manydifferent types of boots are available from therehabilitation department or an Orthotics andProthestics Vendor. The therapy staff will of-ten provide on/off schedules for the boots toallow for hygiene and skin checks and to en-sure additional pressure is not added to theskin by the boot itself.

Range of motion should also begin early andcontinue throughout the patients length ofstay. The motor impairments caused by SCIlimit AROM and when combined with abnor-mal muscle tone, the potential for joint con-tracture is high. Joint range of motion mayalso assist in preventing the development of


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heterotrophic ossifications, which limit ROMand are difficult to remove once present.Therapists will provide PROM through the fullavailability of the joint. Hips and shoulders

must be flexed and extended to the very endsof the arc to allow adapted sitting positionsonce the patient has reached full rehabilita-tion potential.

In the case of incomplete SCI, therapistswill also utilize active assisted range of motionto facilitate the return of normal muscle func-tion and AROM. It is critical that rehabilitationstaff provide ROM with an awareness of thesoft tissue and bony structures of each joint

they move. For instance, a patient in a hospi-tal bed in a supine position will tend to haveabducted scapulas. This is due to the weightof the upper body on the bed and the mobil-ity of the scapula. The therapist completingROM must palpate the scapula to ensure thebone is moving with the rhythm of the shoul-der girdle. This will ensure that all soft tissuestructures remain intact and uninjured. If thescapula was not mobilized with the shoulder,

the potential for a torn tendon or impingednerve is high. Family members may be edu-cated on how to provide ROM if they feel com-fortable and demonstrate proper techniques.

Family members can be involved early inthe rehabilitation of their loved one. Reha-bilitation staff can instruct family memberin ROM techniques and provide educationon the common rehabilitation continuum ofcare. Resources about support groups, inpa-

tient rehabilitation facilities, and the nature ofSCI may be beneficial to family members. Of-ten, family members are concerned about theappearance of the patient but do not feel com-fortable or know what questions to ask. Oncethe aspects of SCI are described, they may feelmore at ease. Much of the progress in SCI oc-curs after the acute stay when the swellingaround the spinal cord is relieved and trueoutcomes can be measured. There have beenmany occasions when patients have improved

well beyond all medical expectations. It maybe helpful to have other people with SCI ofthe same level to visit the patient and familyto provide support and answer questions.

When patients are stabilized, hopefullywithin the first week of admission, moreactive rehabilitation can occur. There isevidence that suggests early surgical mobiliza-

tion can improve functional outcomes andpatients can begin the rehabilitation processsooner.10 This has benefits on the physicalfunctioning as well as respiratory and cir-culatory systems alike. There is less risk ofsecondary complications like deep veinthrombosis (DVT), pulmonary embolus, andpneumonia. While it may be necessary forthe patient to remain on many medicationsor a ventilator, once surgical stabilization has

occurred, activity levels should be increased.Stabilization can occur surgically without

the need for additional braces or in conjunc-tion with orthotic devices. The most cumber-some of all devices is the Halo Vest. Whileit has clear advantages in ensuring cervicalspine immobilization, it imparts many limi-tations on patient independence. The metalcomponents are screwed into the skull andattached via rods to a sheepskin-lined plastic

vest secured on the torso. Many patients re-port they feel their head is floating and nevertruly supported (especially enough to sleep

well).11 There are many precautions, whichinclude not using soap on the skin under the

vest12 (to prevent irritation of the skin) andnot placing pillows behind the posterior sup-port bars. This can add force to the pins sitesand cause misalignment of the halo. Some pa-tients report increased comfort when a small

towel or pillowcase is rolled up behind theneck to take space and reduce the sensationof floating. Extra sheepskin vests are nor-mally issued to ensure that a clean vest isalways available but they should not be re-placed without the assistance of an orthotictechnician. The vests can be washed withmild soap, well rinsed, and air-dried.

The Minerva Brace provides the patientwith cervical and thoracic immobilizationwith a brace made of plastic and metal. Thereare 2 padded sections around the cervicalarea, one that supports the chin and anotherthat supports the back of the head. Each ofthese supports is attached to the thoracic


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section via flat metal rods. These are rivetedon top of the thoracic section but can be ad-

justed for length with the proper tools. Thethoracic section has several Velcro straps: 2

connecting the front and back, and one overeach shoulder, and chinstraps connect thechin support to the posterior head supports.The anterior metal supports allow for endotra-cheal tube access to the neck. These devicescan be removed while the patient is in bed andare less cumbersome, but also less immobiliz-ing than the Halo vest.

When a lesser degree of cervical immobi-lization is indicated, surgeons may prescribe

cervical collars. At times, they may have a tho-racic component as well. The vest section issimilar to the Halo vest but attaches to thecervical collar with plastic tabs. These aremuch less restrictive and can usually be re-moved for bathing and dressing. Sometimes,the patient may be issued and cervical collarindependently of attachments. The Aspen

and Miami J cervical collars come in sizesrelative to neck length and width. They also

come with extra pads to allow for cleaning.Philadelphia cervical collars are light orangefoam and come in only one size. They are ef-fective for mobile patients but may cause pres-sure ulcers on the posterior head when used

with patients on bed rest.When fractures are more inferior, or lower

in the spine, it may be necessary to use athoraco-lumbar-sacral orthosis (TLSO). Thesecan be large and bulky because they must

immobilize a large section of the spine. Of-ten, they are made of a white plastic material(Kydex) and have 2 sections (anterior andposterior) that meet on the sides of the pa-tient and are fastened with 6 Velcro strapsacross the front. The patient must be cus-tom measured for this orthosis (while they aresupine) by an orthotic technician and deliv-ery takes at least 24 hours depending on the

vendor.They can be donned while supine in bed

or sometimes the surgeon will allow the pa-tient to sit and donn the brace. Donning thebrace in supine can be challenging since pa-tients will always need help to place the rear

section (placing it without help would ro-tate the spine). Fitting the TLSO properly isdependent on the placement of the curvedlower portion over the pelvis and the flat-

tened upper portion on the sternum. It shouldfit snugly enough to prevent flexion, hyperex-tension, or rotation of the spine. Patients mayreport feeling pressure under the top or bot-tom but it may be necessary to ensure immo-bilization of the vertebra.

When only lumbar-sacral immobilization orsupport is indicated, there are many types ofbraces available. Aspen makes a lumbar-sacralorthosis (LSO) that can be adjusted for size

and has 3 Velcro straps in the front that manypatients are able to adjust independently. An-other orthotic called the chair back brace hashard plastic components attached to a corset-type fabric section. These are secured withmetal clips but also have laces that provide forcustom sizing. Hard plastic LSOs are also avail-able when custom fitting and increased im-mobilization is desired. These are fabricatedout of the same plastic as the Kydex TLSO but

do not extend up to the sternum. Once thebrace has been identified and provided (bythe Orthotics Vendor), the rehabilitation staffcan assist the patient and/or train the family inthe correct procedure for donning and doff-ing the device.

Once the spine has been stabilized, immo-bilized, and supported as determined by thesurgeon, rehabilitation staff can begin to mo-bilize the patient out of bed. Considerations

for mobilization are dependent on the levelof injury. Levels are based on the most caudalsegment with normal function and are mea-sured by the Standard Neurological Classifi-cation of Spinal Cord Injury.10 This scale eval-uates the motor and sensory function at eachspinal level. Sensory function is tested by ap-plying light touch or pinprick to each der-matome from C2 through S4-5 bilaterally andscoring as absent, impaired, or present. Eachmyotome muscle groups from C5-T1 and L1-S1 are tested for muscle response and gradedfrom 0 to 5, 0 is no contraction and 5 is normal

AROM against gravity. The area between T1-L1is tested for sensation only because there is no


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way to accurately complete a muscle test onpostural muscles.10

Therapists anticipate what functional levelthe patient can achieve based on the findings

of the initial evaluation. Those with high le-sions (C3 and above) will likely require me-chanical ventilation. Therefore, these patients

will always need physical assistance from oth-ers to live in the community. Despite this fact,many people with high-level injuries can usean electric wheelchair, control most of theirenvironment with specialized adaptive con-trol units, and direct the care that is providedto them. There is no limit to the technology

now available to patients with very little mo-tor function.

The lower down the spinal cord, the morefunctions a patient will have. Patients with C3-4 injuries will have some neck motion andscapular function. They may not need me-chanical ventilation but will be a full-time

wheelchair user. These patients will requirefull-time assistance from another. When the le-sion is in the C5 area, the patient will have

shoulder movements and can achieve inde-pendence with upper-body self-care skills in-cluding self-feeding, oral hygiene, shaving,and handwriting with adaptive devices andset-up. When the lesion is near the C6 level,patient will have some forearm and wristmovement, increasing the complexity of tasksand decreasing the need for adaptive equip-ment or assistance.9

People with SCI at the C7-8 level may

achieve fully independent living. They will beable to transfer to all surfaces using their up-per extremities. They can drive an adapted

vehicle, and can return to the workforce ifproper retraining has been provided. Eachof the lower segments provides the patient

with more motor ability and sensation and ahigher-level of independence. Some patients

with initial paraplegia may gain full gait abil-ity later in their course of treatment. In ad-dition, it is not uncommon for patients todemonstrate differences in motor ability onone side versus the other. For example, a pa-tient with a C5-6 SCI may have wrist exten-sors in the right upper extremity (RUE) but

only elbow flexion in the left upper extrem-ity (LUE). This would allow the patients todevelop a grasp-and-release ability with onearm. Therefore, they will be able to feed them-

selves, dress themselves, and go to the toiletthemselves with little or no help from anotherperson.9

Since patients with high-level injuries canbecome high functioning after an acute reha-bilitation program, it is imperative to begin ac-tive rehabilitation as soon as possible. The firststep in an active rehabilitation process is mo-bilization. Mobilization begins with movingin bed, rolling side-to-side, transitioning from

side lying to sitting, or supine to sitting, andfinally sitting at the edge of the bed. Even pa-tients with high-level injuries (C4) can learn tosit by lockingthe elbows into extension andbalancing the upper extremities and trunk

with a biomechanical technique. Therefore,one of the first interventions includes teach-ing patients and their family members how tomove properly in bed. It is crucial to keep cor-rect spinal alignment, with no rotation. Ro-

tation on the spine can cause torque, whichcan in turn cause further soft-tissue damage,edema, or additional spinal cord trauma. Theshoulders, spine, and pelvis create a basic Hshape and this should be maintained through-out the roll from supine to one side. Initially,the patient will need assistance but should beable to roll correctly without assistance aftertraining.

Mobilization for higher-level injuries will in-

clude dependent transfers to a wheelchair.Some hospitals have Medi-Chairs, which re-cline to a completely flat position, and thenincline to upright sitting. These are helpful

when grading the task of sitting from fullysupine to fully upright since these chairs canstop at any point in between. Patients withSCI will require lower extremity compression(with compression stockings, sequential com-pression devices, or ace wraps) and an abdom-inal binder to prevent orhtostatic hypoten-sion. When orhtostatic hypotension occurs,the chair can remain partially reclined until vi-tal signs return to normal and then incremen-tally inclined. Usually, orhtostatic hypotension


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will diminish with ongoing sitting activitieswhen time is taken to slowly incline and re-cline the chair and avoid sudden changes inposture.

Once the patient can tolerate sitting in achair, a proper cushion must be issued. Thereare many wheelchair cushions available andsome are specially designed for use with SCI.The Roho cushion has been found to be ef-fective in reducing the risk for pressure ulcer,and recurrence when used as a wheelchaircushion and as a mattress section.13,14 Cush-ions must be of the correct size for the patientand the chair in which they are seated. If the

lateral thighs are sliding off the cushion, therewill not be adequate pressure relief over theischial tuberosities and increased pressure onthe trochanter. In addition, if the cushion istoo large for the chair, it will push upwardonto the patients thighs and or the patient

will not be properly centered on the cushion.Despite the presence of a cushion, pressurerelief techniques must be completed every 15minutes and for at least 15 seconds.24 The

patient should be instructed to monitor thetime and remind staff to assist in this effort.With higher-level injuries the staff may haveto recline the chair for the patient whereas pa-tients with lower-level injuries will be able tomove themselves enough to relieve pressurefor the required time.

Ideally, an electric wheelchair with a tiltin spaceoption, alternative operating devices(joystick, chin lever, or sip-and-puff) and a

pressure-relieving cushion would benefit amajority of the patients with SCI. The tiltin space allows for the entire seat back andseat bottom to recline while keeping the pa-tients trunk and lower extremities supported.There is little concern for shearing effectson the skin because the entire chair reclinesrather than only the seat back. With adap-tive controls, as above, the patient can con-trol his or her pressure relief without assis-tance from staff. Many hospitals do not havethe resources to purchase chairs such as theseand alternative equipment may be necessary.The rehabilitation department may have re-lationships with vendors in the community

that will loan equipment to patients until long-term needs have been identified.

When patients are independent in bed mo-bility, they may begin to work on the transi-

tion from side lying to sitting. This normallyinvolves the use of the upper extremities topush the shoulder girdle over the pelvis andinto a sitting position. Patients with lower-level lesions will be able to use the elbowextension, and stabilization of the shouldercomplex, to assist. Higher-level injuries willrequire manual assist to assume a seated po-sition (usually with a recliner chair). It is nec-essary to train the patient with these tech-

niques from both sides whenever capablesince each environment is unique and the pa-tient may have to get up from either side ofthe bed. Sitting balance and sitting toleranceare the next steps in demonstrating improve-ment. This process may take several weeksto attain but offers the patient great benefit.They will enjoy a vertical world in which theycan interact with others, participate in activ-ities of daily living (ADLs), and continue to

strengthen postural muscle groups.Patients that can sit with fair balance may betaught to use a slide board to transfer to a chairor wheelchair. Eventually they may developthe strength and skill to transfer without us-ing the slide board. A patient with paraplegiashould be independent with wheelchair mo-bility at the end of the rehabilitation stay andmay begin to work toward ambulation withassistive devices (long leg braces) if additional

motor function has returned.Patients with SCI have many issues thatmust be closely monitored and carefully man-aged to ensure a minimum of secondary prob-lems and complications. It is rare that an SCIoccurs without other injuries. More commonis SCI combined with fractures, which addsto immobilization of extremities and oftenleads to joint contractures. Commonly, thereare wounds that limit positioning alternativesand add to the risk for pressure ulcers overother bony prominences. Head injuries arefrequently found in patients with an SCI,15

and add cognitive deficits including memoryloss, poor insight, and poor judgment, making


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it difficult for the patient to recall and adhereto the many precautions for an SCI. When allof these impairments are combined there aremany other issues to consider in addition to

the SCI.Tremendous effort must be put forth to pre-

vent secondary complication such as decu-bitus ulcers. This can be accomplished withthe provision of adequate equipment as wellas a multispecialty team.16 Literature suggests

that early surgical stabilization and early trans-fer to the rehabilitation setting can improvelong-term outcomes. It is the goal of all re-habilitation professionals to facilitate the pa-

tients return to their previous environment(home), occupation (job), and leisure inter-ests. It is our responsibility to ensure that thisprocess occurs swiftly and without incident,

while fostering the highest possible level ofindependence.

REFERENCES

1. Spinal Cord Injury Information Network. Spinal cordinjury: facts and figures at a glanceDecember

2003. Available at: http://www.spinalcord.uab.edu.

Accessed August 4, 2004.

2. Mitcho K, Yanko J. Acute care management of spinal

cord injuries.Crit Care Nurs Q. 1999;22(2):6079.

3. Kierney PC, Engrav LH, Isik FF, Esselman PC, Car-

denas DD, Rand RP. Results of 268 pressure sores

in 158 patients managed jointly by plastic surgery

and rehabilitation medicine.Plast Reconstruct Surg.

1997;102:765771.

4. Eldar R. Prevention of pressure sores: a topic

for quality of care improvement. Croat Med J.2002;42(3):361363.

5. Kinetic Concepts, Inc: KCI The Clinical Advantage.

RotoRest Delta. Available at: http://www.kci1.

com/products/pulmonary/rotorestdelta/index.asp.



Triadyne II with Proning Accessory. Available at:

http://www.kci1.com/products/pulmonary/triadyne

2/index.asp. Accessed August 4, 2004.


Kinair IV. Available at: http://www.kci1.com/pro

ducts/surfaces/framedtherapies/kinair4/index.asp.


8. Fife C, Otto G, Capsuto EG, et al. Incidence of pres-sure ulcers in a neurologic intensive care unit. Crit

Care Med. 2001;29:283290.

9. Pedretti LW. Occupational Therapy for Physical Dys-

function.St. Louis: Mosby-Year Book; 1996.

10. Young WF, Shea M. Acute management of spine and

spinal cord injury. Trauma Q. 1998;14(1):2142.

11. Halo Zone. Halo vest tips and halo suggestions.

Avaialable at: http://www.halozone.com/broken

neck/halo tips menu.shtml. Accessed August 4,

2004.

12. Bremer Halo Vest Guide. Your Guide to Wearing

Your Halo Vest.Jacksonville, Fla: Reid; 1993.13. Kato H, Inoue T, Torii S. A new postoperative man-

agement scheme for preventing sacral pressure sores

in patients with spinal cord injuries.Ann Plast Surg.

1998;40(1):3943.

14. Yuen HK, Garrett D. Comparison of three wheelchair

cushions for effectiveness of pressure relief.Am J Oc-

cup Ther. 2000;55(4):470475.

15. Dominique DA, Jallo J. Complications of brain and

spinal cord injuries.Trauma Q.1998;14(1):4359.

16. Goodman CM, Cohen V, Armenta A, Thornby J,

Netscher DT. Evaluation of results and treatment vari-

ables for pressure ulcers in 48 veteran spinal cord-injured patients. Ann Plast Surg. 1999;42(6):665

672.

Documents

Critical Rehabilitation of the Patient With Spinal Cord Injury