Paraplegia physical therapy


 * Associate Editors-In-Chief: Abhishek Singh, B.P.T [mailto:abhiksin7556@yahoo.co.in]

Overview
Paraplegia is an impairment in motor and/or sensory function of the lower extremities. It is usually the result of spinal cord injury or a congenital condition such as spina bifida which affects the neural elements of the spinal canal. The area of the spinal canal which is affected in paraplegia is either the thoracic, lumbar, or sacral regions. If the arms are also affected by paralysis, quadriplegia is the proper terminology.

Phases Of Rehabilitation

 * Phase1: Immediately after spinal cord injury (SCI),there is loss of movement & function due to neurotrauma & immobilization .The main emphasis of rehabilitation is to lessen adverse effects of immobilization.It includes all therapeutic intervention during the critical & acute care stages of rehabilitation.It may lasts from a few days to several weeks,when the patient begin activities out of bed.Goal- prevention of secondary complications.
 * Phase2:Early rehabilitation phase.Out of bed activities are tolerated for a longer duration & patient begins to work toward specific long term goals & able to participate in therapeutic programs for minimum of 3 hours per day.
 * Phase3:Most active & rewarding period,efforts of weeks & months of work are realized & results can be seen.The patient gains varying level of independence in specific skills.The patient may be taught advance skills in transferring,wheel chair mobility,grooming & various Activities of daily living(ADL).
 * Phase4:Aimed at a smooth transition to home,patient discharged from rehabilitation centre at this stage.
 * Phase5:Comprises of outpatient & other follow-up services,as well as community reintegration.Individuals may return to work.

Positioning

 * Postural Re-education:Two pillows are generally sufficient to extend(to maintain hyper extension of spine) and support fractures of dorsolumbar spine.Pillows are adjusted in such a way that bony prominences are always free from pressure.Flexion & rotation of trunk & lower limbs are specifically avoided.
 * Upper Limbs Positioning
 * Shoulder - slightly flexed;to relieve pressure on shoulder.
 * Elbow - extended.
 * Forearm - supinated & supported by pillow.
 * Upper arm - pillow between arm & chest wall.
 * Lower Limb
 * Hips- extended & slightly abducted.
 * Knees - extended but not hyperextended.
 * Ankles - neutral or mild dorsiflexion.
 * Toes - extended

One or two pillows are kept between the legs to maintain abduction & prevent pressure on the bony points,i.e. medial condyles & malleoli.

Passive Movements

 * Passive movements of paralyzed limbs are essential to stimulate circulation ,preserve 'FROM' (full range of motion) in joints & soft tissues & prevent muscle shortening.
 * Treatment starts usually on first day after injury & during this spinal shock period(approx 6 weeks) treatment should be given twice daily.
 * While the patient is immobilized in bed or turning frame,full ROM(range of motion) exercises should be completed slowly,smoothly & rhythmically(to avoid injury to insensitive,unprotected joints & paralysed structures) daily except in those areas that are contraindicated or needs selective stretching for example Motion of trunk& some motion of hip are contraindicated.Generally,straight leg raise more than 60° & hip flexion beyond 90° should be avoided.This will put strain on lower thoracic & lumbar spine.
 * When spinal activities returns limb should be handled very carefully so as not to elicit spasm & reinforce the spastic pattern.Forced PROM(passive range of movement)against spasticity may cause injury or fracture of the limb.

Muscle Re-education
To establish a satisfactory compensatory mechanism to cope with paralysed limbs all spared muscles need to be as strong as possible.

Mat Activities: Activity on the mat include:


 * Mobilization & strengthening of trunks & limbs.Trunk mobilization must be taken very gradually & with extreme care.Forced flexion must be avoided.


 * Preliminary training for functional activities.Lifting the buttocks effectively by pushing on the arms in sitting is the basis of most ADL.An effective lift depends upon balance & strength & upon knowing exactly where to place shoulders,hands & trunk,which the patient is taught during this period.


 * Stretching of shortened muscles.

Group Mat Activities 


 * Group activity is very useful as patients watch & copy others activities/exercises with similar lesions & may get motivated by seeing them performing all the exercises with ease.

Orthosis


 * Spinal Corset,Ash/Hyper extension brace,crutches,bilateral full length calipers & many more are used according to the level of lesion.A well thought out,carefully designed & properly fitting orthosis enhances therapeutic treatment as a preliminary exercise to gait training.

Gait Training


 * Patients are encouraged to stand & walk where possible.Standing is very important as it will:-


 * Prevent contractures.


 * Minimizes development of osteoporosis of long bones,hence reduces the danger of recurrent fracture.


 * Reduce spasticity.


 * Stimulate circulation.


 * Improve gait expectations of patients with complete paraplegia.


 * To aid renal function.

Functional Outcome
All patient should be totally independent with all transfers & wheelchair manoeuvres both indoors as well as outdoor.The functional grade of a patient depends upon his age,stature,amount & control of spasticity,any per-existing medical condition & individual's motivation.Patients with lesion at T6-9 will probably walk with the help of crutches or calipers.Ultimately,patients with lesions at level T10 & below can achieve a better functional gait.

Description Of Gait Pattern Possible

- Level of Injury<->Gait Used

- D1-8 ->Swing to with calipers & rollator;may use crutches if spasticity is controlled.

D8-10 ->Swing through or swing to gait with full length calipers & crutches. D10-L2->Swing through or 4 point gait with calipers & crutches.

L2-4 ->Below knee calipers with crutches or sticks-4 or 2 point gait pattern.

L4-5 ->Many requires sticks or other walking aids/may or may not require calipers.

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Mobility Skills
Instruction for safe & appropriate use of wheel chair begins before patient is out of the bed.The patients is oriented about the wheelchairs & its parts.The patient is instructed what to do & not to do during the orientation period.

Do's

i-Lift in the chair every 10 minutes.

ii-Regular Use mirror for the detection of abrasions,blisters,marks & redness on buttocks,back of legs & malleoli.

iii-Lift the paralysed limb while transferring.

iv-Protect the limb against excessive cold or hot.

v-Watch for marks on the penis from condom catheter.

Don'ts

i-Have a hot water bottle/bag in bed.

ii-Knock the limbs against hard objects.

iii-Expose body to strong sunlight or any hot objects like fire or hot drinks on the lap.