Best practice guidance Providing effective support following spinal

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Sponsored by: devastation caused by , including spinal cord caused by road crashes. Brake thanks Hyphen Law, a specialist deputyship services and personal injury trusts firm, and Novum Law, a national firm specialising in injury and serious injury compensation, for sponsoring this report.

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Providing effective support following spinal injury Contents

Spinal cord injuries can have a devastating impact on Classification of traumatic spinal cord injury 3 individuals and their families. Injury severity 3 The effects of spinal cord injury (SCI) vary widely Models and scales used for classification 3 depending on the location and severity of the injury; however, in the most severe cases, it can result in total paralysis and acute respiratory problems. Spinal injury can also cause issues with bladder, bowel and circulatory Effects of spinal cord injury 4 control, and problems relating to sexual function. Secondary injury 4 In terms of life expectancy, the risk of premature death for individuals with SCI is around three times higher than for the general population. 1 Common symptoms of spinal cord injury 4-7 In the UK, around 40,000 people are currently living with Paralysis and loss of movement 4 a spinal injury 2 and every eight hours one new person injures their spine. 3 The World Health Organization Pain, sensation and control of body temperature 5 reports that the risk of spinal injury is far higher among Concurrent (TBI) 5-6 males than females. 4 Bladder control 6

The causes of SCI are categorised as either traumatic Bowel control 6 (e.g. due to accidents, falls, sports injuries, violent Respiratory problems and related conditions 6-7 assaults, etc.) or non-traumatic (medical conditions that Cardiovascular difficulties 7 put pressure on the spinal cord). Common non-traumatic causes of SCI include , tumours and conditions Mental health issues 7 such as motor neurone disease and multiple sclerosis. 5 Speech and language 7 Trauma accounts for around 90% of all spinal injuries. 6 Road crashes are one of the main traumatic causes of SCI and are responsible for more than 35% of newly acquired SCIs. 7 Diagnosis, treatment and care recommendations 8-10 Initial diagnosis of spinal cord injury 8 In more than 40% of traumatic SCI cases, the individual Treatment for spinal cord injury 8 usually sustains another serious injury as a result of the incident. In 14% of cases, the injuries involve serious head Rehabilitation 8 or facial trauma. 8 Treatment for mobility symptoms 8 Treatment for bladder problems 9 This guidance will focus solely on symptoms, effects and best practice advice for supporting people following a Treatment for bowel problems 9 traumatic SCI. Treatment for speech and language issues 9 Treatment for depression and anxiety 9 Treatment for respiratory health problems 10 Use of technology 10

Conclusions and recommendations for care after an SCI 10

References 11-12

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Classification of traumatic spinal The American Spinal Injury Association cord injury impairment scale Another method used by medical professionals to assess Injury severity the severity of an injury is the American Spinal Injury Association (ASIA) impairment scale, which grades an Spinal cord injury (SCI) occurs when nerves that connect injury (A–E) using the following criteria: the brain to the rest of the body are damaged. A number of methods can be used to assess and classify a A. Complete. The patient is completely unable to contract traumatic SCI. In addition to the severity of the injury, muscles and has no sensory function. its location can also have a major impact. B. Sensory incomplete. There will be some sensory function below the level of the injury; however, there Injuries higher up the spine, particularly around the neck, will be no motor function. are likely to lead to ‘’, which can result in complete paralysis of all four limbs, and cause breathing C. Motor incomplete. Motor function will be restored issues. 9 If the lower spine area is affected, ‘’ below the level of the injury, but muscle strength will (lower limb paralysis) is likely to occur and this can also still be limited. Over half of the key muscles will cause issues with abdominal muscles. function at grades 0 to 2 (see below).

D. Motor incomplete. Individuals have functioning motor Models and scales used for classification ability beyond the level of the injury, with at least half of their key muscles assessed at grade 3 or above. Classification through vertebrae E. Normal . This category applies to any SCI patient who Spinal injury can be classified according to the affected has previously had a deficit in their sensory or motor vertebrae. The spine is made up of a total of 33 vertebrae: capabilities, who is now assessed as having normal • seven cervical vertebrae (C1–C7), located at the top strength and has redeveloped abilities. An individual of the spine, immediately below the ; who has not suffered an SCI would not be classified under the ASIA Impairment Scale. 12 • twelve in the thoracic spine (T1–T12), from below the neck to the lower ribs; Muscle function The ASIA scale is also used to assess muscle function • five in the lumbar spine (L1–L5) or lower back; and gives a rating between 0 and 5, where 0 indicates • five in the sacral region (pelvis); and a complete inability to contract the muscle or total paralysis and 5 indicates normal, functioning muscle • four in the coccygeal region (coccyx). 10 strength. 13

Medical professionals usually refer to spinal injuries using the location followed by the vertebra(e) number affected. For example, an injury to the neck could be described as Assessing muscle function using the ASIA scale ‘C3’, which means there is damage to the third cervical vertebra. 0 = total paralysis 1 = flickers of muscle contraction Complete and incomplete An SCI can also be defined as complete or incomplete. 2 = active movement, full range of motion A complete injury means that the ability of the spinal cord with no gravity to send messages to and from the brain is completely lost. Patients with a complete SCI will have a total lack 3 = active movement, full range of motion of movement or sensation below the level of injury. against gravity In contrast, those with an incomplete SCI may have 4 = active movement, full range of motion some motor ability and the spinal cord has not totally lost against gravity when moderate resistance the ability to send messages to and from the brain. is included A patient with an incomplete SCI may have some sensation below the level of the injury, although this may 5 = normal muscle strength and full range be very faint. 11 of motion

Thanks to developments in medical capabilities and enhanced response time to injury, complete SCI is now rarer than incomplete spinal injury.

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Effects of spinal cord injury Common symptoms of traumatic spinal cord injury Injury location There are a number of common symptoms associated The effects and symptoms of SCI vary greatly according with an SCI. to the location of the injury. Nerves in the spine provide a variety of functions, including helping to control and initiate limb movement. Paralysis and loss of movement

Cervical spine Depending on the severity and location of the trauma, the Trauma to the neck can cause injury affecting nerves in injury may lead to partial or complete paralysis. The two the cervical spine (C1–C7). Nerves in the upper section of forms of paralysis are tetraplegia and paraplegia. the spine are responsible for controlling movement in the neck, shoulders, arms and hands. 14 Tetraplegia Tetraplegia (also known as quadriplegia) results from Thoracic spine injury affecting nerves in the cervical spine (C1–C7). 19 Injuries in the thoracic spine (T1–T12) often lead to issues with breathing. This is because nerves located in this Tetraplegia is likely to result in paralysis of all four limbs. section control the intercostal muscles, which expand and The severity of the injury and symptoms experienced will contract when we breathe and help to control the size of generally depend on how high up the spine the damage the chest cavity. Damage to nerves in the thoracic spine has occurred. 20 Alongside loss of mobility, patients will will also affect the function of abdominal muscles and also experience loss of muscle function and tone, and loss other muscles within the trunk. 15 of sensation.

Lumbar spine Injury to the upper vertebrae in the neck (C1–C4) is most Lumbosacral nerves, located in the lower back, control likely to cause severe problems with motor function. 21 muscles in the lower limbs. Damage to the lumbar spine Patients with an SCI in this area tend to be unable to move can lead to problems with hip mobility. their limbs or contract muscles in their chest and trunk. Sacral spine This may result in the patient relying on a ventilator to Sacral nerve damage can result in problems with bowel breathe. Depending on injury severity, a ventilator may only be needed during the initial period of rehabilitation, control and sexual function. 16 or it may be needed for an extended length of time. 22

Secondary injury In contrast, injuries affecting C7 may be less extensive, and patients may retain some level of movement in their After the initial trauma that caused the injury, secondary fingers. They may also be able to extend their elbows after injury can occur. Secondary injury can be caused by rehabilitation. 23 ‘Low tetraplegia’ refers to paralysis inflammation, bleeding, cellular changes and bone following injury affecting vertebrae C5–C7. Patients instability. It can intensify the severity of the initial injury with an injury affecting C7–C8 will generally be able and requires careful management. Immediate treatment to maintain independence in many day-to-day tasks. may be necessary to prevent further damage. Those with an injury at C5 or C6 may require more assistance. 24 Complications that can develop include neurogenic , which results in hypotension (low blood pressure), and bradycardia (low heartbeat, often under 60bpm). 17 Paraplegia Injury to the lower spine may result in paraplegia. should not be confused with spinal Symptoms include lower limb paralysis and potential shock , where symptoms are less severe and consist of issues with stomach muscles 25 and will depend upon loss of reflex activity below the level of injury; the return of which area of the spine is injured. reflex activity can cause conditions such as . Injury to the thoracic spine (T1–T12), lumbar region Restriction to the blood supply of the spinal cord ( cord (L1–L5) or sacral spine (S1–S5) are all likely to lead to ischaemia ) can extend to vertebrae above and below the paraplegia and paralysis of the hips and legs. Other affected level, and can result in a patient’s symptoms common symptoms include issues around physical significantly deteriorating. 18 sensation, bowel and bladder movement and sexual function. 26

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Spasticity SCI patients can experience problems caused by spasticity.

After an SCI, muscle spasms are particularly common in the flexor and extensor muscles, which control movement in the elbow and leg, respectively. Nociceptive pain is most common following SCI, with Symptoms of spasticity will depend on the severity of symptoms relating to the trauma that caused the injury injury, but can include tightening of muscles, sharp, and muscle or joint strain beyond the acute stage. 38 jerking movements and increased muscle tone. Shoulder pain can present a particular challenge if the In some cases, spasticity causes severe pain. 27 patient relies on their arms and shoulders for mobility. Studies have found that over two-thirds of SCI patients may experience some level of shoulder pain after their Flaccidity injury. 39 Flaccid paralysis leads to muscle weakness. 28 Whereas an individual with spasticity may see their muscle tone increase, flaccid paralysis can result in loss of muscle Temperature control Nerve damage can also cause difficulty in controlling tone and atrophy. 29 temperature. This is particularly challenging in cases of complete SCI. 40 Patients may be unresponsive to changes Pain, sensation and control of body in temperature, or to extreme heat or cold. In severe temperature cases, if the body temperature drops below 35°C, it can result in hypothermia. 41 Loss of sensation Patients with a complete SCI will have a total loss of Concurrent traumatic brain injury (TBI) sensation below the level of injury, but nerve damage and sensation vary in patients with incomplete injury. 30 Injury It is common for SCI patients to sustain damage to their above C3 in the cervical spine will generally lead to a brain at the same time as injury to their spine. This is complete loss of sensation in all four limbs. 31 particularly the case following road crashes. Instances of ‘dual diagnosis’ are increasing: in the USA in 2008, 12.5% One side-effect of loss of sensation is that patients may of patients admitted with a TBI were also diagnosed with be more likely to experience pressure sores due to the a concurrent spinal injury (up from 3.7% in 1988); and brain not receiving signals that skin is being damaged. 15.9% of spinal injury patients also had a TBI (up from Regularly relieving pressure in the affected area can help 9.1% in 1988). 42 prevent sores from developing. 32 Some studies have suggested that the risk of dual A patient with SCI may have difficulty detecting heat and diagnosis may be up to 60% higher in incidents where cold. Those who do retain some level of sensation may injury is the result of a road crash. 43 However, research also experience a tingling experience or substantial has also highlighted that TBI is often overlooked in SCI levels of pain. 33 cases, although misdiagnosis is less common in cases where SCI results from a road crash. 44

Pain Symptoms of TBI vary depending on injury severity, but Chronic pain can be a major challenge after SCI and even mild TBI can cause significant problems. up to two-thirds of patients may suffer from pain. 34 Even patients with a complete injury may experience pain. 35 • TBI can affect and concentration, and can cause issues with language and communication. 45 Pain can significantly reduce quality of life. The location and severity of pain varies from patient to patient. Some • Cognitive problems may lead to personality changes, individuals may experience continual, dull discomfort, and also mental illness such as anxiety or depression. while others may have sharp, shooting pains. Around a • Other symptoms include fatigue and mood swings, third of SCI patients suffer from severe and debilitating feelings of irritation and aggression. 46 A patient may pain. 36 lose their inhibitions or behave inappropriately.

Pain can be categorised as ‘neuropathic’ or ‘nociceptive’ • Physical difficulties include muscle weakness, issues (musculoskeletal) and both types can be experienced with balance and problems with walking and simultaneously. Neuropathic pain results from damage coordination. A TBI can severely limit an individual’s to the nervous system and often results in sharp pain. 37 ability to carry out day-to-day tasks. 47 5 Brake Providing effective support following spinal cord injury the road safety charity

• Senses such as eyesight and touch may be impaired, Respiratory problems and related conditions and speech may be affected. Headaches and tremors are also common. 48 SCI can cause significant respiratory problems. Complications arising from respiratory issues and related Studies have indicated that isolated SCI can cause brain illnesses are the leading cause of death following SCI, and inflammation, resulting in damage to nerve cells and are a particular challenge during the first 12 months after resulting neurological problems. 49 the injury. 55

Damage to the cervical and thoracic spine is associated Brake’s report ‘ Providing effective with the development of illnesses such as pneumonia. 56 support following a brain injury ’ Injury to the cervical spine generally results in more provides further information on challenging respiratory complications, such as ventilation

Best pra the effects of a traumatic brain ctice guidance failure, and the rate of mortality related to respiration is Pr oviding effectiv follow e support injury and advice on best practice ing brain injury higher among patients with tetraplegia. Paraplegia is

in support and rehabilitation. Produced by: more closely associated with mortality related to Ab Brake out this report the road sa This repo fety charity rt is produced b an y Brake, the roa Sp d aims d safety onsored by: to sprea charity, To download or order a copy of d awareness an 57 devasta d understan cardiovascular diseases. tion caused ding of the by brain injury, caused by r including brain oad crashes. Br injuries spe ake thanks Hyp cialist Deputysh hen Law, a ip services and firm and N Personal Injur ovum Law, a na y Trusts inj tional firm spe this report, visit shop.brake.org.uk . ury and serious cialising in brai inju n ry, for sponsor ing this report.

1 The extent of respiratory issues will vary with injury location. Symptoms may be worsened by organ damage and rib fractures. 58 can also result in Bladder control respiratory problems. 59

Bladder control issues are very common following spinal Damage to the higher cervical spine (C1–C3) can cause injury and may affect as many as 80% of patients. 50 total paralysis of respiratory muscles. Patients with Bladder problems cause discomfort and can lead to other injuries in this area may have to rely on ventilation for medical issues, such as urinary tract and respiration. Although effects may be less severe following bladder stones. injury to the lower cervical spine, it is likely that mechanical ventilation will be necessary for respiration Damage to the lower end of the sacral spine (S2–S4) during the acute stage of injury. can cause particular bladder control problems. Following injury, the bladder will continue to store urine, Damage to the lowest point of the cervical spine (C6–C8) but challenges arise when damage to the spinal cord is not likely to affect the diaphragm, but may cause prevents the delivery of messages from the brain paralysis of the abdominal muscles. However, this will managing bladder control. 51 This can result in urinary not generally result in respiratory failure and mechanical incontinence. ventilation will not be required. 60

Bowel control Injury to the lower back in the thoracic spine will generally not result in reliance on a ventilator, although injury to the Bowel control issues are also common, and 75% of SCI upper level, to around T7, can cause other difficulties, such as an inability to cough adequately. 61 This can be patients are believed to suffer from faecal incontinence. 52 As with bladder control problems, the challenges are particularly challenging if an infection occurs, as caused by damage to the spine preventing messages secretions may be retained. 62 Patients with injury below T12 are unlikely to lose control of the muscles needed being passed from the brain to the bowel. 53 Symptoms vary depending on the location of the injury. ‘Neurological for respiration. 63 bowel disorder’ causes colon dysfunction and can result in a lack of motor or sensory control (or both). 54 Atelectasis Atelectasis is the most common respiratory issue that follows SCI and is caused by decreased ventilation or issues relating to retention of secretions. In patients with atelectasis, a section of the lung collapses, and this can lead to other respiratory issues, including pneumonia. 64 Symptoms of atelectasis include difficulty with breathing, shortness of breath, coughing and increased heart rate. 65

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Sleep apnoea Deep vein and pulmonary Sleep-disordered breathing is common in spinal injury At the acute stage of an SCI, patients are at risk of patients, 66 due to muscular weakness, and SCI patients developing deep vein thrombosis (DVT). The combination are at risk of developing sleep apnoea. Symptoms of sleep of inactivity during medical treatment, cell damage and apnoea include nocturnal choking and daytime fatigue. 67 issues relating to blood clotting are the major factors that lead to DVT. 74 DVT is most commonly associated with Cardiovascular difficulties blood clots that form in the leg, which can be potentially fatal if they break away from the vein and move to the SCI is linked to a number of cardiovascular problems. lungs, causing a pulmonary embolism. 75 Damage to the autonomic nervous system caused by an SCI can result in disruption to cardiovascular control, the Pulmonary embolism is a potentially fatal condition that effects of which vary according to the location of the injury. affects around 5% of SCI patients. 76 Pulmonary embolism In addition, the potential for SCI to result in either is closely linked with DVT and results from a blockage paralysis or reduced mobility, increases the likelihood in the pulmonary artery, caused by a blood clot. of a patient developing coronary artery disease. 68 The blockage prevents blood from reaching the patient’s lungs, which in turn prevents the lungs from passing oxygen to the rest of the body. 77 Symptoms include sharp Autonomic dysreflexia chest pains, shortness of breath and it can also lead This condition can be life-threatening and affects patients to fainting. 78 with an SCI above T6, particularly those with tetraplegia. Symptoms include headaches, sweating and a slow pulse. 69 Autonomic dysreflexia is associated with a rise in blood Mental health issues pressure, and, if left untreated, can cause and cerebral haemorrhage. 70 Mental health issues are common following SCI due to the significant life changes, pain and frustration Low blood pressure and slow pulse associated with the injury. SCI patients may be at risk of developing low blood pressure due to reduced nervous system activity in the Studies show that nearly half (48.5%) 79 of patients with area below the injury. 71 Orthostatic hypotension, which can an SCI may experience mental health problems – a rate be caused by standing up after a long sedentary period, around double that of the general population in the UK. 80 can also affect SCI patients who have mobility issues, 72 Research has also highlighted that up to a third of SCI and can lead to dizziness, blurred vision and fainting. patients may suffer from depression. 81 It is common for patients to experience anxiety. 82 Disruption to the autonomic pathway can also result in serious disturbances to heart rhythm. Injury in the SCI patients are also at risk of developing post-traumatic cervical spine increases the risk of bradycardia (very slow stress disorder (PTSD) due to the potentially distressing heart rate), which can cause patients to feel dizzy, short way they were injured; studies find that between 7% and of breath and fatigued. Patients may also experience 25% of patients may develop PTSD. 83 palpitations, and bradycardia is linked to cardiac arrest. 73 Speech and language

SCI can affect a patient’s ability to communicate. Speech impairment may be particularly profound if a patient has both an SCI and brain damage. Further information on the impact of brain injury on speech and language can be found in our report ‘Providing effective support following a brain injury’. To download or order a copy of this report, visit shop.brake.org.uk .

Injury in the cervical spine may lead to difficulty with swallowing, known as dysphagia. 84 Speech may also be affected by issues relating to the patient's airways, particularly if mechanical aids for respiration are required. 85 After an SCI, patients may have difficulty with projecting volume and articulation. Speech and language therapists will be able to provide support and rehabilitation. 86

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Diagnosis, treatment and care A range of professionals may be involved in the recommendations rehabilitation process, 92 including: • physical therapists; Initial diagnosis of SCI • occupational therapists; • speech-language pathologists; A number of different symptoms may indicate that an individual has injured their spinal cord. Commonly • ; and observed symptoms include: • physiotherapists.

• low blood pressure (hypotension); Treatment for mobility problems • reduced level of consciousness; • loss of sensation below the level of injury; SCI patients may experience severe physical symptoms and challenges. In cases of complete spinal injury, • impaired or deep breathing; patients may have no independent mobility. One of the • pain in the back, head or neck; first major challenges that rehabilitation will seek to

• balance issues; 87 and address is shortening of the joints (joint ) and stiffness – up to two-thirds of SCI patients suffer from • priapism (long-lasting, painful erection). 88 this in the first year after injury. During this stage, passive range of motion (ROM) exercises are advised, to prevent Immediate medical evaluation and treatment should be contractures developing. 93 sought for any individual who is suffering from these symptoms and may have injured their spinal cord. The level of treatment and rehabilitation available will depend on the extent of the injury. For patients with severe lower limb paralysis, treatment may focus on developing Treatment for SCI strategies to help them transfer into a . The treatment and rehabilitation process for an SCI Ongoing support may include exercises to strengthen patient will be broken down into two stages: immediate upper body muscles and a treatment plan to ensure that treatment at the acute stage , which may include lack of mobility does not adversely affect the patient’s emergency , and further rehabilitation following health. An occupational therapist may be required to discharge from hospital, at the sub-acute stage . modify the patient’s home and improve accessibility. Exercise regimes that may be provided through Acute stage treatment physiotherapy include: Treatment at the acute stage will focus on immediate issues such as stabilising and managing respiration, • strength training for non-paralysed muscles; and preventing any additional damage to the spinal cord. Medical staff will also address musculoskeletal problems • gait training, including the use of treadmills, overhead and any issues with bowel and bladder control, blood gait training or robot-assisted gait training; pressure and circulation. 89 Immediate treatment could • task-specific hand training; also include surgery to realign vertebrae, remove bone • passive movement and stretching; 94 and fractures or fuse broken bones. 90 • task-specific balance training. 95 Further treatment will aim to prevent the development of secondary injury (see page 4). Patients may be transferred to the (ICU), to enable their condition to be monitored by medical staff. 91

Rehabilitation The process of rehabilitation will generally begin once a patient has been stabilised. Treatment will depend on the severity of the injury, and will aim to restore quality of life for the patient. Depending on the nature of the injury, rehabilitation may focus on helping to regain some level of mobility, bowel and bladder function, as well as other skills such as communication.

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Treating spasticity Treatment for speech and language issues and are generally used for treatment of spasticity, but in some cases surgery may Communication issues may be particularly challenging be required. Physical treatment, including exercises to for patients with both TBI and SCI. Information on stretch affected muscles and ROM routines, can also help managing and treating issues with speech and language resulting from a brain injury can be found in our report: to reduce the severity of symptoms. 96 Medicines such as diazepam or baclofen, or injections of Botulinum toxin ‘Providing effective support following a brain injury’. (Botox) are sometimes used to relieve pain in SCI patients. To download or order a copy of this report, visit In severe cases, surgery to release or lengthen tendons shop.brake.org.uk . may be required, but pharmaceutical or physical Treatment sessions will be led by a speech and language therapies are more commonly used. 97 therapist, and aim to address issues relating to neck muscles, and respiratory problems that are affecting Treatment for bladder problems: speech. Rehabilitation for bladder problems is important after spinal injury – without proper treatment, complications Treatment for depression and anxiety such as bladder stones, kidney damage or infections are Providing treatment for mental health problems such likely to develop. Following SCI, bladder problems are as depression, anxiety and PTSD is essential. generally categorised as either reflex bladder (affecting patients with an injury above T12), or flaccid bladder Treatment will generally fall under two categories: (when injury is below T12). and the use of medication. It is likely that a combination of both will be used. Many of the drugs used Symptoms of flaccid bladder result from weakness in to treat depression can have negative side-effects for muscle tone, which prevents the bladder from contracting SCI patients. Tricyclic anti-depressants can cause and emptying. One option for treatment is catheterisation. 98 constipation, which can be particularly challenging in Other treatments include medication to relax the urinary patients with a neurogenic bowel (bowel issues resulting sphincter, or surgery (sphincterotomy) to reduce pressure from nerve damage). The use of SSRIs (selective on the sphincter and improve urine flow from the bladder. 99 serotonin reuptake inhibitors) has been linked to spasticity. 105 One symptom of a reflex bladder is that the patient cannot fully empty their bladder, due to issues with the Counselling and the use of psychotherapy, including muscle tone of the urinary sphincter. Treatment for men cognitive behavioural therapy (CBT), 106 have been found with SCI may include the use of urinary sheaths to to be effective methods of treating depression in SCI manage incontinence. Medication to increase bladder patients. CBT can also be used to help treat symptoms capacity may also be used. 100 of PTSD.

Treatment for bowel problems CBT aims to make problems more manageable and to prevent negative patterns from developing. 107 It can also It is essential that support is provided for bowel problems, help SCI patients to develop strategies to cope with and SCI patients may need advice on how to manage lifestyle changes their injury has caused. bowel movement. Non-surgical treatment for bowel problems includes the use of laxatives and enemas. Abdominal massage and transanal irrigation are also used to stimulate bowel movement. 101 A healthy diet and regular exercise help maintain bowel health, and consumption of warm food or drink is recommended 20-30 minutes before bowel evacuation. 102

Surgical treatment may also be provided, if bowel management methods have been unsuccessful. Options include sacral nerve stimulation 103 and colostomy. 104

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Treatment for respiratory health problems Conclusions and recommendations for care after an SCI Respiratory infections and complications are a major health challenge following an SCI. It is important that • Early intervention and immediate treatment are patients are treated appropriately to prevent further essential after an SCI. Damage caused by the initial complications from developing. Treatments to prevent trauma can be exacerbated through secondary injury. complications include: • It is crucial that spinal injury patients are encouraged • Exercise, or, in cases of severe paralysis, breathing to remain as active as possible after their injury. exercises. Patients with tetraplegia may use inspiratory A number of complications can result from inactivity resistive training, to help increase lung function. 108 caused by paralysis, including obesity and Exercise is also important to help prevent cardiovascular problems. cardiovascular problems. 109 • Many SCI patients develop mental health problems. • Stopping smoking and avoiding people who smoke. The use of medication to treat depression and anxiety Smoking can increase congestion in the trachea should be considered carefully, as some (windpipe) and chest, which increases the risk of have negative side-effects. Psychotherapy techniques respiratory infections developing. 110 such as CBT can be very beneficial.

• Assisted coughing can help clear airways and helps • It is important to recognise that those supporting a to prevent infections. 111 family member or loved one with an SCI face particular challenges. SCI can alter family relationships. Use of technology • Patients should be helped to come to terms with their Technology and computerised aids are increasingly used injury, recognising that symptoms may continue for rehabilitation after an SCI. As well as advanced, despite rehabilitation and care. Patience is essential. specialised , there are a number of other uses for technology to aid mobility and improve muscle • Anyone who has suffered concurrent brain damage function. and SCI may have particularly challenging issues. Further information on the impact of TBI can be found Electrical stimulation devices use electrodes to stimulate in Brake’s report, ‘Providing effective support following nerves and help control muscles after an SCI. 112 brain injury’. To download or order a copy of this report, Electrical stimulation may help restore muscle function visit shop.brake.org.uk . that is crucial for tasks such as standing or walking. 113 Robot-assisted gait training is also used to assist with physical rehabilitation and mobility. 114

Electronic aids to daily living (EADLs) can help patients gain more independence with day-to-day tasks, for example by monitoring lights and heating, opening doors and accessing computers and other devices. They can be linked to voice-recognition software. 115

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References

1 Grassner, L. et al. 2016. Non-Traumatic Spinal Cord Injury at the Neurological Intensive Care Unit: Spectrum, causes of Admission and Predictors of Mortality. 51 Mayo Clinic. 2017. Spinal Cord Injury: Complications. [Online]. [Accessed 06/10/17]. Available from: http://www.mayoclinic.org/diseases-conditions/spinal-cord- Therapeutic Advances in Neurological Disorders. [Online]. 9 (2), pp. 85-94. [Accessed 06/10/2017]. Available from: injury/basics/complications/con-20023837 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784250/ 52 Multidisciplinary Association of Spinal Cord Injured Professionals. 2012. Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central 2 Back Up Trust. 2017. About Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: http://www.backuptrust.org.uk/about-spinal-cord-injury Neurological Conditions. [Online]. [Accessed 06/10/17]. Available from: https://www.rnoh.nhs.uk/sites/default/files/sia-mascip-bowelguidenew2012.pdf 3 Ibid 53 NSW State Spinal Cord Injury Service. 2014. Management of the Neurogenic Bowel for Adults with Spinal Cord Injuries. [Online]. [Accessed 06/10/17]. Available 4 World Health Organisation. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: http://www.who.int/mediacentre/factsheets/fs384/en/ from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155215/Management-Neurogenic-Bowel.pdf 5 New, P. 2002. Non-Traumatic Spinal Cord Injury: Demographic Characteristics and Complications. Archives of Physical Medicine and Rehabilitation. [Online]. 83 (7) 54 Multidisciplinary Association of Spinal Cord Injured Professionals. 2012. Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central pp. 996-1001. [Accessed 19/01/17]. Available from: http://www.archives-pmr.org/article/S0003-9993(02)00017-5/abstract Neurological Conditions. [Online]. [Accessed 06/10/17]. Available from: https://www.rnoh.nhs.uk/sites/default/files/sia-mascip-bowelguidenew2012.pdf 6 World Health Organisation. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: http://www.who.int/mediacentre/factsheets/fs384/en/ 55 Berlowitz, D. et al. 2016. Respiratory Problems and Management in People with Spinal Cord Injury. Breathe. [Online]. 12 (4), pp. 328-340. [Accessed 06/10/2017]. 7 Mayo Clinic. 2017. Diseases and Conditions: Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: http://www.mayoclinic.org/diseases- Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5335574/ conditions/spinal-cord-injury/basics/causes/con-20023837 56 Mayo Clinic. 2017. Spinal Cord Injury. [Online]. [Accessed 24/09/2017]. Available from: http://www.mayoclinic.org/diseases-conditions/spinal-cord- 8 Peitzman, A. et al. 2012. The Trauma Manual: Trauma and Acute Care Surgery. Amsterdam: Wolters Kluwer. injury/basics/complications/con-20023837 9 Spinal Injuries Association. 2017. Understanding Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: https://www.spinal.co.uk/living-with-sci/ 57 Thietje, R. et al. 2011. Mortality in Patients with Traumatic Spinal Cord Injury: Descriptive Analysis of 62 Deceased Subjects. Journal of Spinal Cord Medicine. [Online]. understanding-sci/ 34 (5), pp. 482-487. [Accessed 06/10/2017]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184485/ 10 NHS. 2014. Paralysis: Symptoms. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/Conditions/paralysis/Pages/Symptoms.aspx 58 Berlowitz, D. et al. 2016. Respiratory Problems and Management in People with Spinal Cord Injury. Breathe. [Online]. 12 (4), pp. 328-340. [Accessed 06/10/2017]. 11 Christopher and Dana Reeve Foundation. 2017. What is a Complete vs Incomplete Spinal Injury? [Online]. [Accessed 06/10/2017]. Available from: Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5335574/ https://www.christopherreeve.org/living-with-paralysis/newly-paralyzed/how-is-an-sci-defined-and-what-is-a-complete-vs-incomplete-injury 59 Michael D. et al. 1989. Coincidence of Head and Cervical Spine Injury. Journal of Neurotrauma. [Online]. 6 (3), pp. 177–189. [Accessed 06/10/2017]. Available from: 12 Kirshblum, S. et al. 2011. International Standards for Neurological Classification of Spinal Cord Injury (Revised 2011). Journal of Spinal Cord Medicine. [Online]. 34 (6), http://online.liebertpub.com/doi/pdfplus/10.1089/neu.1989.6.177 pp. 535-546. [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232636/ 60 Denton, M. and McKinlay, J. 2009. Cervical Cord Injury and Critical Care. Continuing Education in Anaesthesia, Critical Care & Pain. [Online]. 9 (3), pp. 82-86. 13 Harvey, L. 2008. Management of Spinal Cord Injuries: A Guide for Physiotherapists. London: Elsevier. [Accessed 06/10/2017]. Available from: https://academic.oup.com/bjaed/article/9/3/82/388828/Cervical-cord-injury-and-critical-care 14 Hopkins Medicine Library. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/17]. Available from: http://www.hopkinsmedicine.org/healthlibrary/conditions/ 61 Vazquez, R. et al. 2013. Respiratory Management in the Patient with Spinal Cord Injury. BioMed Research International. [Online]. 2013, pp. 1-12. physical_medicine_and_rehabilitation/spinal_cord_injury_85,P01180 [Accessed 06/10/2017]. Available from: https://www.hindawi.com/journals/bmri/2013/168757/ 15 Cotton, B. et al. 2005. Respiratory Complications and Mortality Risk Associated with Thoracic Spine Injury. Journal of Trauma-Injury Infection & Critical Care. 62 Brown, R. et al. 2006. Respiratory Dysfunction and Management in Spinal Cord Injury. Respiratory Care. [Online]. 51 (8), pp. 853–870. [Online]. 59 (6), pp. 1400-1409. [Accessed 06/10/17]. Available from: http://journals.lww.com/jtrauma/Abstract/2005/12000/Respiratory_Complications_and_ [Accessed 06/10/2017]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495152/ Mortality_Risk.16.aspx 63 University of Alabama. 2007. Understanding and Managing Respiratory Complications after SCI. [Online]. [Accessed 06/10/2017]. 16 Christopher Reeve Foundation. 2017. Spinal Cord Injury - Lumbar and Sacral Regions. [Online]. [Accessed 06/10/17]. Available from: http://sci.washington.edu/exercise/respiratory%20factsheet.pdf Available from: https://www.christopherreeve.org/living-with-paralysis/health/causes-of-paralysis/spinal-cord-injury 64 NHS Royal National Orthopaedic Hospital. 2017. Respiratory Complications. [Online]. [Accessed 06/10/2017]. 17 Guly, H. et al. The Incidence of Neurogenic Shock in Patients with Isolated Spinal Cord Injury in the Emergency Department. Resuscitation. [Online]. 76 (1), pp. 57-62. Available from: https://www.rnoh.nhs.uk/our-services/spinal-cord-injury-centre/medical-management-advice/respiratory-complications [Accessed 06/10/17]. Available from: http://www.sciencedirect.com/science/article/pii/S0300957207003127 65 Mayo Clinic. 2017. Atelectasis: Symptoms. [Online]. [Accessed 06/10/2017]. Available from: http://www.mayoclinic.org/diseases-conditions/atelectasis/basics/ 18 Bonner, S. and Smith, C. 2013. Initial Management of Acute Spinal Cord Injury. Continuing Education in Anaesthesia Critical Care & Pain. [Online]. 13 (6), pp. symptoms/con-20034847 224-231. [Accessed 06/10/17]. Available from: https://academic.oup.com/bjaed/article/13/6/224/246947/Initial-management-of-acute-spinal-cord-injury 66 Bascom, A. et al. 2015. Sleep Onset Hypoventilation in Chronic Spinal Cord Injury. Physiological Reports. [Online]. 3 (8), pp. 1-10. [Accessed 06/10/2017]. 19 American Association of Neurological Surgeons. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: http://www.aans.org/Patients/ Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562576/ Neurosurgical-Conditions-and-Treatments/Spinal-Cord-Injury 67 Mayo Clinic. 2017. Sleep Apnoea. [Online]. [Accessed 06/10/2017]. Available from: http://www.mayoclinic.org/diseases-conditions/sleep-apnea/basics/ 20 University of Rochester Medical Center. 2017. What is an Acute Spinal Cord Injury? [Online]. [Accessed 06/10/17]. Available from: definition/con-20020286 https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P01180 68 Myers, J. et al. 2007. Cardiovascular Disease in Spinal Cord Injury: an Overview of Prevalence, Risk, Evaluation, and Management. American Journal of Physical 21 NHS. 2017. Paralysis – Symptoms. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/Conditions/paralysis/Pages/Symptoms.aspx Medicine & Rehabilitation. [Online]. 86 (2), pp. 142-152. [Accessed 06/10/2017]. Available from: https://insights.ovid.com/pubmed?pmid=17251696 22 Chiodo, A. et al. 2008. Predictors of Ventilator Weaning in Individuals with High Cervical Spinal Cord Injury. Journal of Spinal Cord Medicine. [Online]. 31 (1), pp. 72-77. 69 Hagen, E. et al. 2012. Cardiovascular Complications of Spinal Cord Injury. Tidsskrift for Den Norske Laegeforening. [Online]. 132 (9), pp. 1115-20. [Accessed 06/10/2017]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2435030/ [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22614315 23 Nas, K. et al. 2015. Rehabilitation of Spinal Cord Injuries. World Journal of Orthopedics. [Online]. 6 (1), pp. 8-16. [Accessed 06/10/17]. Available from: 70 Christopher Reeve Foundation. 2017. Autonomic Dysreflexia. [Online]. [Accessed 06/10/2017]. Available from: https://www.christopherreeve.org/living-with- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303793/ paralysis/health/secondary-conditions/autonomic-dysreflexia 24 Ibid 71 Myers, J. et al. 2007. Cardiovascular Disease in Spinal Cord Injury: an Overview of Prevalence, Risk, Evaluation, and Management. American Journal of Physical 25 NHS. 2017. Paralysis – Symptoms. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/Conditions/paralysis/Pages/Symptoms.aspx Medicine & Rehabilitation. [Online]. 86 (2), pp. 142-152. [Accessed 06/10/2017]. Available from: https://insights.ovid.com/pubmed?pmid=17251696 26 Christopher Reeve Foundation. 2017. Understanding Your Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: https://www.christopherreeve.org/ 72 Mayo Clinic. 2017. Orthostatic Hypotension (Postural Hypotension). [Online]. [Accessed 06/10/2017]. Available from: http://www.mayoclinic.org/diseases- living-with-paralysis/newly-paralyzed/how-is-an-sci-defined-and-what-is-a-complete-vs-incomplete-injury conditions/orthostatic-hypotension/symptoms-causes/dxc-20324950 27 Christopher Reeve Foundation. 2017. Spasticity. [Online]. [Accessed 06/10/17]. Available from: https://www.christopherreeve.org/living-with-paralysis/health/ 73 Kim, S. et al. 2017. Cardiac Arrest Attributable to Dysfunction of the Autonomic Nervous System after Traumatic Cervical Spinal Cord Injury. Chinese Journal of secondary-conditions/spasticity Traumatology. [Online]. 20 (2), pp. 118-121. [Accessed 06/10/2017]. Available from: https://doi.org/10.1016/j.cjtee.2016.11.004 28 NHS. 2014. Paralysis – Symptoms. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/Conditions/paralysis/Pages/Symptoms.aspx 74 Aito, S. et al. 2002. Primary Prevention of Deep Venous Thrombosis and Pulmonary Embolism in Acute Spinal Cord Injured Patients. Spinal Cord. [Online]. 40 (6), pp. 29 British Medical Journal. 2017. Chronic Spinal Cord Injury. [Online]. [Accessed 06/10/17]. Available from: http://bestpractice.bmj.com/ 300-3. [Accessed 06/10/2017]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12037712 best-practice/monograph/1176/diagnosis/step-by-step.html 75 Christopher Reeve Foundation. 2017. What is Deep Vein Thrombosis? [Online]. [Accessed 06/10/17]. Available from: https://www.christopherreeve.org/living- 30 Mayo Clinic. 2017. Spinal Cord Injury: Symptoms. [Online]. [Accessed 06/10/17]. Available from: http://www.mayoclinic.org/diseases-conditions/ with-paralysis/health/secondary-conditions/deep-vein-thrombosis spinal-cord-injury/basics/symptoms/con-20023837 76 Alabed, S. et al. 2015. Incidence of Pulmonary Embolism after the First 3 Months of Spinal Cord Injury. Spinal Cord. [Online]. 53 (Nov), pp. 835-837. 31 Christopher Reeve Foundation. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/17]. Available from: https://www.christopherreeve.org/living-with- [Accessed 06/10/17]. Available from: http://www.nature.com/sc/journal/v53/n11/index.html paralysis/health/causes-of-paralysis/spinal-cord-injury 77 Mayo Clinic. 2017. Pulmonary Embolism. [Online]. [Accessed 06/10/17]. Available from: http://www.mayoclinic.org/diseases-conditions/pulmonary- 32 MSKTC. 2017. Skin Care & Pressure Sores - Preventing Pressure Sores. [Online]. [Accessed 07/10/17]. Available from: http://www.msktc.org/sci/factsheets/ embolism/symptoms-causes/dxc-20234744 skincare/Preventing-Pressure-Sores 78 NHS. 2015. Pulmonary Embolism. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/conditions/pulmonary-embolism/Pages/Introduction.aspx 33 American Association of Neurosurgeons. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/17]. Available from: http://www.aans.org/Patients/Neurosurgical- 79 Migliorini, C. et al. 2008. Spinal Cord Injury and Mental Health. Australian and New Zealand Journal of Psychiatry. [Online]. 42 (4), pp. 309-314. [Accessed 06/10/17]. Conditions-and-Treatments/Spinal-Cord-Injury Available from: http://journals.sagepub.com/doi/abs/10.1080/00048670801886080?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed 34 Van Gorp, S. et al. 2015. Pain Prevalence and its Determinants after Spinal Cord Injury: A Systematic Review. European Journal of Pain. [Online]. 19, pp. 5-14. 80 Mind. 2017. Mental Health Facts and Statistics. [Online]. [Accessed 06/10/2017]. Available from: https://www.mind.org.uk/information-support/types-of-mental- [Accessed 06/10/17]. Available from: http://onlinelibrary.wiley.com/doi/10.1002/ejp.522/epdf health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/#.WZ2bTz6GOUl 35 Defrin, R. et al. 2002. Pain Following Spinal Cord Injury. Spinal Cord. [Online]. 40 (2), pp. 96-97. [Accessed 06/10/17]. Available from: http://www.nature.com/sc/ 81 Fann, J. et al. 2011. Depression after Spinal Cord Injury: Comorbidities, Mental Health Service Use, and Adequacy of Treatment. Archives of Physical Medicine and journal/v40/n2/full/3101245a.html Rehabilitation. [Online]. 92 (3), pp. 352-360. [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21255766 36 Masri, R. and Keller, A. 2012. Chronic Pain Following Spinal Cord Injury. Advances in Experimental Medicine and . [Online]. 760, pp. 74-88. 82 Al-Owesie, R. 2012. Anxiety and Depression among Traumatic Spinal Cord Injured Patients. . [Online]. 17 (2), pp. 145-150. [Accessed 06/10/17]. [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560294/ Available from: https://www.ncbi.nlm.nih.gov/pubmed/22465889 37 Hagen, E. and Rekand, T. 2015. Management of Neuropathic Pain Associated with Spinal Cord Injury. Pain and Therapy. [Online]. 4 (1), pp. 51-65. 83 Post, M. and van Leeuwen, C. 2012. Psychosocial Issues in Spinal Cord Injury: a Review. Spinal Cord. [Online]. 50, pp. 382-389. [Accessed 06/10/2017]. [Accessed 06/10/17]. Available from: https://link.springer.com/article/10.1007/s40122-015-0033-y Available from: http://www.nature.com/sc/journal/v50/n5/full/sc2011182a.html?foxtrotcallback=true 38 Hadjipavlou, G. et al. 2016. Spinal Cord Injury and Chronic Pain. BJA Education. [Online]. 16 (8), pp. 264-268. [Accessed 06/10/17]. Available from: 84 NHS. 2015. Dysphagia (Swallowing Problems) – Treatment. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/Conditions/Dysphagia/Pages/ https://academic.oup.com/bjaed/article/16/8/264/2364840/Spinal-cord-injury-and-chronic-pain Treatment.aspx 39 Eriks-Hoogland, I. et al. 2014. Trajectories of Musculoskeletal Shoulder Pain after Spinal Cord Injury: Identification and Predictors. The Journal of Spinal Cord 85 Brougham, R. et al. 2011. Speech-Language Pathology Treatment Time during Inpatient Spinal Cord Injury Rehabilitation: the SCIRehab Project. Medicine. [Online]. 37 (3), pp. 288-298. [Accessed 07/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4064578/ The Journal of Spinal Cord Medicine. [Online]. 34 (2), pp. 186-195. [Accessed 06/10/17]. Available from: https://www.researchgate.net/publication/43453361_ 40 Song, Y.G. et al. 2015. Changes in Body Temperature in Incomplete Spinal Cord Injury by Digital Infrared Thermographic Imaging. Annals of Rehabilitation Medicine. Characteristics_of_speech_following_cervical_spinal_cord_injury [Online]. 39 (5), pp. 696–704. [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654076/ 86 Ward, C. et al. 2016. Impact of Voice and Communication Deficits for Individuals with Cervical Spinal Cord Injury Living in the Community. International Journal of 41 Khan, S. et al. 2007. Hypothermia in Patients with Chronic Spinal Cord Injury. Journal of Spinal Cord Injury. [Online]. 30, pp. 27-30. [Accessed 06/10/17]. Language & Communication Disorders. [Online]. 51 (5), pp. 568-580. [Accessed 06/10/17]. Available from: http://onlinelibrary.wiley.com/wol1/doi/10.1111/ Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2032005/pdf/i1079-0268-30-1-27.pdf 1460-6984.12232/abstract 42 Ghobrial, G. et al. 2014. Longitudinal Incidence and Concurrence Rates for Traumatic Brain Injury and Spine Injury – A Twenty Year Analysis. Clinical and 87 American Association of Neurological Surgeons. 2017. Spinal Cord Injury. [Online]. [Accessed 06/10/2017]. Available from: http://www.aans.org/Patients/ [Online]. 123, pp. 174-180. [Accessed 06/10/17]. Available from: http://www.sciencedirect.com/science/article/pii/S0303846714001875 Neurosurgical-Conditions-and-Treatments/Spinal-Cord-Injury 43 Kushner, D. and Alvarez, G. 2014. Dual Diagnosis: Traumatic Brain Injury with Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America 88 NHS. 2015. Priapism – Causes. [Online]. [Accessed 06/10/17]. Available from: http://www.nhs.uk/Conditions/Priapism/Pages/Causes.aspx [Online]. 25 (3), pp. 681-696. [Accessed 06/10/17]. Available from: http://www.sciencedirect.com/science/article/pii/S1047965114000424 89 Harvey, L. 2016. Physiotherapy Rehabilitation for People with Spinal Cord Injuries. Journal of Physiotherapy. [Online]. 62 (1), pp. 4-11. [Accessed 06/10/17]. 44 Bhanu, S. et al. 2014. Missed Diagnosis of Traumatic Brain Injury in Patients with Traumatic Spinal Cord Injury. Journal of Rehabilitation Medicine. [Online]. 46 (4), pp. Available from: http://www.sciencedirect.com/science/article/pii/S1836955315001307 370-373. [Accessed 06/10/17]. Available from: http://www.ingentaconnect.com/content/mjl/sreh/2014/00000046/00000004/art00012 90 New York Time. 2014. Spinal Cord Trauma. [Online]. [Accessed 06/10/17]. Available from: http://www.nytimes.com/health/guides/disease/spinal-cord- 45 Headway. 2017. Cognitive Communication Difficulties. [Online]. [Accessed 06/10/17]. Available from: https://www.headway.org.uk/about-brain-injury/individuals/ trauma/overview.html?mcubz=1 effects-of-brain-injury/communication-problems/cognitive-communication-difficulties/ 91 Ahuja, S. et al. 2016. Recent Advances in Managing a Spinal Cord Injury Secondary to Trauma. 2016. F1000 Research. [Online]. 5, pp. 1-12. [Accessed 06/10/17]. 46 Headway. 2017. Emotional Effects of Brain Injury. [Online]. [Accessed 06/10/17]. Available from: https://www.headway.org.uk/about-brain-injury/individuals/ Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890313/ effects-of-brain-injury/emotional-effects/ 92 Mayo Clinic. 2017. The Rehabilitation Team. [Online]. [Accessed 06/10/17]. Available from: http://www.mayoclinic.org/departments-centers/physical-medicine- 47 Mayo Clinic. 2017. Traumatic Brain Injury. [Online]. [Accessed 06/10/17]. Available from: http://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/ rehabilitation/minnesota/doctors/team basics/symptoms/con-20029302 93 Diong, J. et al. Incidence and Predictors of after Spinal Cord Injury--a Prospective Cohort Study. Spinal Cord. [Online]. 50 (8), pp. 579–584. 48 Headway. 2017. Physical Effects of Brain Injury. [Online]. [Accessed 06/10/17]. Available from: https://www.headway.org.uk/about-brain-injury/individuals/effects- [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/labs/articles/22450888/ of-brain-injury/physical-effects/ 94 Harvey, L. 2016. Physiotherapy Rehabilitation for People with Spinal Cord Injuries. Journal of Physiotherapy. [Online]. 62, pp. 4-11. [Accessed 07/10/17]. 49 Science Daily. 2014. Do Spinal Cord Injuries Cause Subsequent Brain Damage? [Online]. [Accessed 06/10/17]. Available from: https://www.sciencedaily.com/ Available from: http://www.sciencedirect.com/science/article/pii/S1836955315001307 releases/2014/11/141114131058.htm 95 Tamburella, F. et al. 2013. Balance Training Improves Static Stability and Gait in Chronic Incomplete Spinal Cord Injury Subjects: a Pilot Study. European Journal 50 Al Taweel, W. and Seyam, R. 2015. Neurogenic Bladder in Spinal Cord Injury Patients. Research and Reports in Urology. [Online]. 7, pp. 85-99. [Accessed 06/10/17]. of Physical and Rehabilitation Medicine. [Online]. 49 (3), pp. 353-364. [Accessed 07/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23486301 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4467746/ 11 Brake Providing effective support following spinal cord injury the road safety charity

96 Christopher Reeve Foundation. 2017. Spasticity. [Online]. [Accessed 06/10/17]. Available from: https://www.christopherreeve.org/living-with-paralysis/health/ 107 NHS. 2016. Cognitive Behavioural Therapy (CBT). [Online]. [Accessed 07/10/17]. Available from: http://www.nhs.uk/Conditions/Cognitive-behavioural- secondary-conditions/spasticity therapy/Pages/Introduction.aspx 97 Adams, M. and Hicks, L. 2005. Spasticity after Spinal Cord Injury. Spinal Cord. [Online]. 43, pp. 577-586. [Accessed 06/10/17]. 108 NHS Royal Nation Orthopaedic Hospital. 2017. Respiratory Complications. [Online]. [Accessed 07/10/17]. Available from: https://www.rnoh.nhs.uk/ Available from: http://www.nature.com/sc/journal/v43/n10/full/3101757a.html?foxtrotcallback=true our-services/spinal-cord-injury-centre/medical-management-advice/respiratory-complications 98 NHS. 2015. Intermittent Self-Catheterisation/Catheterisation. [Online]. [Accessed 06/10/17]. Available from: http://www.nlg.nhs.uk/content/uploads/2014/04/ 109 Sheel, A. et al. 2008. Effects of Exercise Training and Inspiratory Muscle Training in Spinal Cord Injury: A Systematic Review. The Journal of Spinal Cord Medicine. IFP-0683.pdf [Online]. 31 (5), pp. 500-508. [Accessed 07/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607122/ 99 Christopher Reeve Foundation. 2017. Bladder Management. [Online]. [Accessed 06/10/17]. Available from: https://www.christopherreeve.org/living- 110 Christopher Reeve Foundation. 2017. Respiratory Health. [Online]. [Accessed 07/10/17]. Available from: https://www.christopherreeve.org/living-with- with-paralysis/health/secondary-conditions/bladder-management#flaccid-non-reflex-bladder paralysis/health/secondary-conditions/respiratory-health 100 Spinal Injuries Association. 2017. Bladder Management. [Online]. [Accessed 06/10/17]. Available from: https://www.spinal.co.uk/wp-content/uploads/2017/05/ 111 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2964024/ Bladder-Management.pdf 112 Chester, H. et al. 2015. Functional Electrical Stimulation and Spinal Cord Injury. Physical Medicine & Rehabilitation Clinics of North America. [Online]. 25 (3), 101 Hughes, M. 2014. Bowel Management in Spinal Cord Injury Patients. Clinics in Colon and Rectal Surgery. [Online]. 27 (3), pp. 113-115. [Accessed 22/02/2018]. pp. 631-639. [Accessed 07/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519233/ Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174229/ 113 Mayo Clinic. 2014. Treatments and Drugs – New Technologies. [Online]. [Accessed 07/10/17]. Available from: http://www.mayoclinic.org/diseases-conditions/ 102 NHS Royal Orthopaedic Hospital. 2017. Neurogenic Bowel. [Online]. [Accessed 07/10/17]. Available from: https://www.rnoh.nhs.uk/our-services/spinal-cord- spinal-cord-injury/basics/treatment/con-20023837 injury-centre/medical-management-advice/neurogenic-bowel 114 Yeun Nam, K. et al. 2017. Robot-Assisted Gait Training (Lokomat) Improves Walking Function and Activity in People with Spinal Cord Injury: a Systematic Review. Journal of 103 NICE. 2004. Sacral Nerve Stimulation for Faecal Incontinence. [Online]. [Accessed 22/02/2018]. Available from: https://www.nice.org.uk/guidance/ipg99 NeuroEngineering and Rehabilitation. [Online]. 14 (24), pp. 1-13. [Accessed 07/10/17]. Available from: https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-017-0232- 104 NHS. 2017. Colostomy. [Online]. [Accessed 22/02/2018]. Available from: https://www.nhs.uk/conditions/colostomy/ 3 105 Stolp-Smith, K. and Wainberg, M. 1999. Antidepressant Exacerbation of Spasticity. Archives of Physical Medicine and Rehabilitation. [Online]. 80 (3), pp. 339-342. 115 Verdonck, M. et al. 2011. Electronic Aids to Daily Living: Be Able to Do What You Want. and Rehabilitation: Assistive Technology. [Online]. 6 (3), pp. 268-281. [Accessed 06/10/17]. Available from: http://www.sciencedirect.com/science/article/pii/S000399939990148X#! [Accessed 07/10/17]. Available from: http://dx.doi.org/10.3109/17483107.2010.525291 106 Mehta, S. et al. 2011. An Evidence-Based Review of the Effectiveness of Cognitive Behavioural Therapy for Psychosocial Issues Post-Spinal Cord Injury. Rehabilitation Psychology. [Online]. 56 (1), pp. 15-25. [Accessed 06/10/17]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21401282

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