Spinal Cord Injury

Definition

According to the Jack Orchard ALS Foundation Glossary, the Spinal Cord is defined as, “Part of the central nervous system extending from the base of the skull through the vertebrae of the spinal column. It is continuous with the brain stem, and like the brain it is encased in a triple sheath of membranes. Thirty-one pairs of spinal nerves arise from the sides of the spinal cord. The spinal cord carries information from the body's nerves to the brain and signals from the brain to the body.” (www.jackorchard.org/2_glossary.asp)

Spinal Cord Injury (SCI) occurs when a traumatic event results in damage to cells within the spinal cord or severs the nerve tracts that relay signals up and down the spinal cord. (www.spinal-cord.org)

In order to begin to understand the complexities of Spinal Cord Injuries, several additional definitions are warranted. To begin with, two terms commonly associated with Spinal Cord Injury include complete versus incomplete injury. Complete spinal cord injury means having no voluntary motor or conscious sensory function below the injury site, whereas incomplete injury means having some voluntary or conscious sensory function below the injury site.

Several other terms requiring definition include paralysis, paraplegia and quadriplegia or tetraplegia:

 Paralysis means a partial or complete loss of function, especially when involving the motion or sensation in a part of the body.  Paraplegia - A condition in which a person's lower extremities and part of the torso are paralyzed as a result of injury or disease of the spinal cord. spot.pcc.edu/osd/glossary.htm  Tetrapalegia - Tetraplegia literally means paralysis in all 4 limbs. It results from injury to the spinal cord within the neck region of the vertebral column. There is loss of sensation and movement in the arms, legs and trunk, as well as loss of bladder and bowel function. http://home4.pacific.net.sg/~wtyoung/sci2.html In summary, Paraplegia refers to paralysis from approximately the waist down and quadriplegia refers to paralysis from approximately the shoulders down.

Statistics

The following statistics were gathered from the Spinal Cord Injury Information Network which can be accessed at http://www.spinalcord.uab.edu/show.asp?durki=21446

 Incidence: in the U. S. or approximately 11,000 new cases each year.  Prevalence: approximately 247,000 persons in the US live with SCI  Age at injury: From 1973 to 1979, the average age at injury was 28.6 years, and most injuries occurred between the ages of 16 and 30. Since 2000, the average age at injury is 38.0 years.  Gender: Since 2000, 78.2% of spinal cord injuries reported to the national database have occurred among males.  Ethnic groups: 67.5% are Caucasian, 19% are African American, 10.4% are Hispanic, and 3.1% are from other racial/ethnic groups.

Causes

Since 2000, the causes of SCI in the US have been:  Vehicular crashes 50.4%  Violence 11.2%.  Falls 23.8%.  Other causes equal 5.6%  Sports' injuries equal 9.0%.

Since 2000, the breakdown of types of SCI at discharge was:

 incomplete tetraplegia (34.3%),  complete paraplegia (25.1%),  complete tetraplegia (22.1%),  incomplete paraplegia (17.5%).  One percent of persons experienced complete neurologic recovery by hospital discharge.

Regarding employment, more than half (63.0%) of those persons with SCI admitted to a Model System (a research and data gathering system related to SCI) reported being employed at the time of their injury. The post-injury employment picture is better among persons with paraplegia than among their tetraplegic counterparts. By post-injury year 10, 31.7% of persons with paraplegia are employed, while 26.4% of those with tetraplegia are employed during the same year.

Types of SCI

The impact of the Spinal Cord Injury is very dependent upon the location of the injury (how far up the spinal cord the injury occurred). Several excellent web sites provide interactive simulations to enable greater understanding and these include Interactive Tutorial available at http://www.nlm.nih.gov/medlineplus/tutorials/spinalcordinjury/nr259101.html

Also excellent photo representation at http://www.makoa.org/sci.htm

The following graph was obtained from This is from http://www.spinalcord.org/spinal-injuries-prognosis.htm and is accompanied by a helpful descriptive graph.

The level of injury is very helpful in predicting what parts of the body might be affected by paralysis and loss of function. Remember that in incomplete injuries there will be some variation in these prognoses.

Neck: Cervical (neck) injuries usually result in quadriplegia.

C-1 to C-4: These very high injuries (C-1, C-2) can result in a loss of many involuntary functions including the ability to breathe, necessitating breathing aids such as mechanical ventilators or diaphragmatic pacemakers.

C-5: C-5 injuries often result in shoulder and biceps control, but no control at the wrist or hand. C-6: C-6 injuries generally yield wrist control, but no hand function.

C-7 and T-1: Individuals with C-7 and T-1 injuries can straighten their arms but still may have dexterity problems with the hand and fingers. Injuries at the thoracic level and below result in paraplegia, with the hands not affected.

T-1 to T-8: At T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control. T-9-T12: Lower T-injuries (T-9 to T-12) allow good truck control and good abdominal muscle control. Sitting balance is very good. Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs.

Besides a loss of sensation or motor functioning, individuals with SCI also experience other changes. For example, they may experience dysfunction of the bowel and bladder. Men with SCI may have their fertility affected, while women's fertility is generally not affected.

Other effects of SCI may include low blood pressure, inability to regulate blood pressure effectively, reduced control of body temperature, inability to sweat below the level of injury, and chronic pain.

Symptoms/Related Physical Issues/ Course of Illness

Spinal Cord Injury most profoundly impacts mobility and the ability to ambulate and, depending on injury site, the ability to have full/any use of the upper limbs. In addition, SCI has a negative impact upon Life Expectancy due often times to secondary related disabilities. Life expectancy for an individual with paraplegia is 90% of an able bodied person and 85% for a person with quadraplegia.

In addition, Crewe and Krause (date) detail the following list of related physically disabling conditions in the chapter on SCI:

 Bowel and Bladder Dysfunction  Sexual Dysfunction  Autonomic Hyperreflexia  Spasticity  Contractures  Pressure Sores  Bone Changes  Respiratory Problems  Cardiac Problems

While the above list details multiples issues, keep in mind that each individual reacts differently to each injury, and not all individuals and injuries will involve all of these related issues. Additionally, Crew and Krause point out the there are multiple Psychosocial Issues also associated with SCI. These include:

 Adjustment issues due to sudden and unexpected nature of disability  Inability to participate in past life activities  Loss of independence  Mobility and accessibility issues  Isolation sometimes secondary to loss of voluntary control of functions  Attitudinal barriers  Depression  Substance Abuse issues

According to the National Institute of Neurological Disorders and Stroke (http://www.ninds.nih.gov/disorders/sci/sci.htm#Is_there_any_treatment) The types of disability associated with SCI vary greatly depending on the severity of the injury, the segment of the spinal cord at which the injury occurs, and which nerve fibers are damaged. Most people with SCI regain some functions between a week and 6 months after injury, but the likelihood of spontaneous recovery diminishes after 6 months. Rehabilitation strategies can minimize long-term disability.

Treatment

Once again, according to the National Institute of Neurological Disorders and Stroke (http://www.ninds.nih.gov/disorders/sci/sci.htm#Is_there_any_treatment), while recent advances in emergency care and rehabilitation allow many SCI patients to survive, methods for reducing the extent of injury and for restoring function are still limited. Immediate treatment for acute SCI includes techniques to relieve cord compression, prompt (within 8 hours of the injury) drug therapy with corticosteroids such as methylprednisolone to minimize cell damage, and stabilization of the vertebrae of the spine to prevent further injury.

Accommodations

Activities of Daily Living:  Allow the person to have a personal attendant at work to assist with toileting, grooming, and eating  Allow periodic rest breaks for repositioning, toileting, or grooming needs  Provide flexible scheduling and allow use of sick leave for medical care  Allow the person to bring a service animal into the workplace

Workstation:  Height adjustable desk or table or a stand-up wheelchair so that a person who uses a wheelchair can work comfortably  Accessible filing system for a person who cannot reach upper and lower file drawers in a vertical file cabinet  Office supplies and frequently used materials on most accessible shelves or drawers for a person who cannot reach upper and lower shelves and drawers  Page turners and book holders for a person who cannot manipulate paper  Writing aids for a person who cannot grip a writing tool  Accessible office machines, such as copiers and faxes, so a person using a wheelchair can access them from a seated position  Voice activated speaker phone, large button phone, automatic dialing system, voice mail system, and/or headset, depending on the person's limitations and preferences  Alternative access for computers such as speech recognition, Morse code entry, trackballs, keyguards, alternative keyboards, and/or mouthsticks, depending on the person's limitations and preferences

Work-site:  Flexible scheduling so a person who cannot drive can access public transportation  Accessible parking for a person who does drive  Accessible route of travel from the parking lot into the building  Accessible restrooms, lunchroom, break room, etc.  Accessible route of travel to the person's workstation  Work from home if transportation to work is not available

Travel:  Accessible transportation  Accessible lodging  Accessible meeting/training site  Medical supplies/wheelchair repair at travel destination  Personal attendant care at travel destination Wheel Chair Etiquette

Below are several suggestions from the Job Accommodations Network in order to enhance professional and individual communication and rapport when working with someone who uses a wheelchair. While these are basic suggestions, it certainly doesn’t hurt to have a reminder of such material for any of us.

1. When addressing a person who uses a wheelchair, do not lean on the wheelchair unless you have permission to do so. A wheelchair is part of an individual’s personal space.

2. Do not assume a person using a wheelchair needs assistance. Always ask before providing assistance. If your offer of assistance is accepted, ask for instructions and follow the instructions given.

3. When talking to a person who uses a wheelchair, look at and speak directly to that person, rather than through a companion.

4. Relax and speak naturally. Do not be embarrassed if you happen to use accepted common expressions such as "got to be running along" that seem to relate to the person's disability.

5. When talking with a person in a wheelchair for more than a few minutes, use a chair, whenever possible. This can facilitate conversation.

6. When giving directions to a person in a wheelchair, consider distance, weather conditions, and physical obstacles such as stairs, curbs, and steep hills.

7. Use proper terminology when referring to a person who uses a wheelchair. Terms such as "wheelchair bound" or "confined to a wheelchair" are inappropriate. Using a wheelchair does not mean confinement.

8. Do not assume that all people who use wheelchairs have the same limitations. People use wheelchairs for a variety of reasons and have different limitations and abilities.

9. If a person who uses a wheelchair has a service animal, do not pet or try to play with it. A service animal is working and should not be interrupted.

10. When greeting a person who uses a wheelchair, it is appropriate to offer to shake hands with that person even if he/she has upper extremity limitations.

Recommended Readings http://www.spinal-cord.org/ This website was created to help Spinal Cord Injury patients and their families and friends with up-to-date information about spinal cord injuries (SCI). The site offers a summary of the type of injury, and its classification and prognosis based on the severity of the injury. http://www.spinalcord.org/

The National Spinal Cord Injury Association – NSCIA educates and empowers survivors of spinal cord injury and disease to achieve and maintain the highest levels of independence, health and personal fulfillment. http://www.spinalcord.uab.edu/show.asp?durki=19769

The Spinal Cord Injury Information Network - The Model SCI Systems conducts research to improve upon and maintain a cost-effective comprehensive service delivery system from the moment of injury across the lifespan of persons who sustain spinal cord injury. Emphasis is on collaborative clinical research to solve the medical management and acute rehabilitation problems of individuals with SCI. http://www.nlm.nih.gov/medlineplus/spinalcordinjuries.html

MedLine Plus – MedLine Plus offers good health information from the world's largest medical library, the National Library of Medicine. http://www.makoa.org/sci.htm

Spinal Cord Injury and Disease Resources – an extensive list of online resources pertaining to Spinal Cord Injury.

 Job Accommodations Network (JAN) -

The Job Accommodation Network (JAN) is a free consulting service that provides information about job accommodations, the Americans with Disabilities Act (ADA), and the employability of people with disabilities. http://www.jan.wvu.edu/links/

Research Article

Crewe, N. M. (2000). A 20-year longitudinal perspective on the vocational experiences of persons with spinal cord injury. Rehabilitation Counseling Bulletin. Vol 43(3), 122- 133.