Research and Education

PAIN

• Often musculoskeletal (muscle and joint injuries due to stress)
• Worsens with movement
• Local swelling, sensitivity, loss of motion, instability

PAIN

• Non-mechanical
• Mass
• Pain referred from radiculopathy or myelopathy

UPPER LIMB PAIN

• 30% - 70% in chronic spinal cord injury (SCI)
• Mainly involves the SHOULDER and WRIST
• ↑ with age and time since SCI

UPPER LIMB PAIN - WEAKNESS - LIMITATIONS IN MOVEMENT

• Overuse syndrome of the shoulder, elbow, wrist, and hand
• Strain on the acromioclavicular joint
• Anterior instability
• Pain in the scapula
• Rotator cuff impingement syndrome
• Tendonopathies/Tendon ruptures
• Subacromial bursitis
• Clavicular osteolysis
• Synovial bursitis

PAIN IN ELBOW, WRIST, HAND

• Carpal tunnel syndrome
• Cubital tunnel neuropathy
• Entrapment of the ulnar nerve in the wrist area
• Radial styloid tenosynovitis
• Medial and lateral epicondylitis
• Wrist instability
• Scapholunate ligament impingement syndrome
• Scapholunate ligament impingement syndrome
• De Quervain's tenosynovitis
• Osteoarthritis
• Fatigue fractures

CAUSES OF UPPER LIMB PAIN

• Transfers
• Promotion of a wheelchair
• Techniques to reduce applied pressure
• Repetitive lifting (displacement of the forearm upward, glenohumeral joint laxity, joint friction, rotator cuff pathology)
• Repetitive overhead activity, trunk flexion/extension, walking with crutches

Mild activity and proper technique protect

• Imaging abnormalities of the shoulder

↔
Biomechanical wheelchair promotion

• Excessive internal rotation and extension: ↑ impingement of the glenohumeral joint from below the acromion

In tetraplegia:
The weakness of the shoulder rotators due to muscle imbalance also contributes

Shoulder pain in individuals with paraplegia:

• Strengthened/tight anterior shoulder muscles
• Weak/relaxed posterior shoulder muscles
• Disorders of shoulder girdle due to impaired trunk control (high-level injuries)

• Postural problems (anterior head tilt, ↑ cervical lordosis, scapulothoracic protraction, kyphosis, scoliosis)

→ Myoperitoneal pain: trigger points radiating pain or tenderness

• Spasticity, heterotopic ossification, excessive vibration due to improper wheelchair posture during propulsion → cervical and lumbar pain
• Delayed muscle weakness or sensory loss (20% chronic SCI)
• New weakness → peripheral nerve damage (age-dependent loss of anterior horn cells and loss of posterior column fibers), entrapment of the ulnar or median nerve, cervical stenosis (long-term excessive extension or rotation of the neck in the sitting position, gait deviation compensation) or radiculopathy
• Electromyography (EMG) and imaging findings: useful

Rapid progressive delayed: weakness, pain, separate sensory loss (mainly pain/temperature sensation), loss of reflexes, changes in spasticity, dysreflexia, flaccidity, Horner syndrome, functional decline

→

NEED FOR SPINAL CORD COMPRESSION (Risk of upper path and respiratory center and brainstem involvement)

5% Traumatic Spinal Cord Injury (TSCI) within the first 5-10 years

Diagnosis: MRI

Treatment: Surgery

Prevention: Assessment of mechanical cervical spine disorders, transportation, functional requirements at home and work

Treatment:

• Pain management (injections, physical modalities, acupuncture)
• Rehabilitation (maintaining range of motion, balanced strengthening, endurance exercise, posture retraining, joint protection techniques, adaptive equipment, and activity modification)

CHRONIC PAIN (94%)

DISABILITY

REDUCED MOBILITY

PSYCHOLOGICAL STRESS

CHRONIC NEUROPATHIC PAIN: GABAPENTIN

ACTIVITY MODIFICATIONS:

• Avoid wrist extension (lifting weights - transfers)
• Decompression through lateral and anterior translations
• Braces (temporary)
• Overhead reachers - slide boards (preventing impingement)
• A/A: Flex rims, gel-padded gloves
• Vertical alignment in A/A
• Pillow, upper limb support, backrest
• Satisfactory cushion pressure, wheelchair alignment
• Energy conservation techniques
• Encourage weight loss
• Individualized exercise (not overhead)
• Stretching of internal rotators, biceps, chest muscles
• Strengthening of external rotators, abductors, scapular stabilizers (rowing, reverse fly in A/A)
• Avoid excessive shoulder extension
• Gentle pushes while propelling the wheelchair to avoid ulnar nerve injury instead of using finger flexors

Persistent pain and weakness

Electric wheelchair or mixed type

• Vehicle for transportation
• Specialized wheelchair transportation equipment, cranes
• Surgical interventions (TSCI: percutaneous endoscopic approach)

Caregiver support

• Useful for energy conservation
• Increased need with age
• Psychological support for caregivers
• Ergonomic advice for caregivers as they age

CHANGES IN THE RESPIRATORY SYSTEM

TSCI ONSET:

• Paralysis of respiratory muscles
• High level of injury
• Complete injury

EARLY:

• Kyphosis
• Scoliosis ---> Additional strain
• Spasticity
• Decreased pulmonary and thoracic wall compliance
• Atelectasis
• DEATH

Ineffective cough: Pneumonia Inability to take deep breaths

AGE: Risk factor

SMOKING: ↓ FVC (Forced Vital Capacity)

Upper airway damage at level C7: Bronchial hyperresponsiveness

(due to loss of sympathetic innervation, reduced airway lumen, changes in lung mechanical properties)

→ Constriction of the airway and obstruction of air passages

Increased incidence of Sleep Apnea Syndrome in tetraplegia:

• Large neck circumference
• Many years post-TSCI
• Supine sleeping position
• Use of antihypertensive and antiarrhythmic drugs

Increased monitoring of functional changes needed (especially high tetraplegia)

Tachypnea Dyspnea Daytime hypersomnia Fluctuating mental alertness Erythrocytosis without other cause Change in respiratory ability depending on the position Fatigue of respiratory muscles Forced Vital Capacity <2L: Maximum risk of delayed respiratory failure Need for oxygen therapy and assisted ventilation High level of injury Home prevention program with: spirometry, positioning, assisted coughing, breathing exercises Regular inspiratory muscle resistance exercises → Reduces dyspnea and DFC restrictions Strengthening of major chest muscles and magnetic stimulation → Improves cough capacity and expiratory function Immunization: significant Pneumococcal vaccine: every 5 years Influenza vaccine: every year Smoking cessation: reduces respiratory complications

• Counseling
• Nicotine gum
• Transdermal patches
• Bupropion

Neurogenic Intestine and Aging

Aging:

• Decreased secretion of digestive fluids - hard stools

• Slow stomach emptying - cracks

• Slow propulsion of intestinal content - hemorrhoids

• Increased water reabsorption in the colon - diverticula

• 50%: constipation, incomplete emptying, abdominal distension

• 33%: gastrointestinal pain, incontinence

• Alternating diarrhea - constipation: fecal impaction (due to decreased activity, diet, inadequate fluid intake, ineffective bowel routine, stress, medications)

  33%: Neurogenic intestine: a limitation for life - social isolation (incontinence)

Goals:

• Expected, complete emptying
• Prevention of incontinence, chronic constipation, hemorrhoids, cracks, rectal prolapse

Influenced by, among others:

• Age-related functional decline

• Availability of caregiver assistance

• Need for and use of adaptive equipment

• Home accessibility

• Cultural, social, and professional factors

• Lower intestinal neuron dysfunction:

  • Need for regular digital stimulation and emptying

• Upper intestinal neuron dysfunction:

  • Oral stool softeners
  • Laxatives
  • Mechanical or pharmacological stimulation for emptying

• High-fiber diet: does not improve intestinal function in the elderly

• Position changes, transfers, pressure relief: promote peristalsis

• Abdominal zone: facilitates emptying

• Ineffective bowel program → one factor changed at a time and maintained for 3-5 bowel cycles

• Selective colostomy: possible ↑ quality of life in:

  • Long-term daily bowel program
  • Frequent bowel losses

• Need to avoid long-term use of enemas and laxatives due to:

  • Atonic intestine
  • Electrolyte imbalances
  • For frequent use: osmotic laxatives (e.g., lactulose)

• Hemorrhoids (commonly used for underpads and suppositories):

  • Prevention with minimal trauma and cushions (gel or air)
  • Treatment with sclerotherapy, hemorrhoidectomy
  • Complications: bleeding, autonomous dysreflexia

Gastroesophageal Reflux (delayed diagnosis in injuries >T7 due to lack of symptoms)

Treatment:

• ↓ consumption of chocolate, caffeine, mint, alcohol
• Smoking cessation
• Avoid lying down after meals
• Avoid meals before bedtime
• H2 antagonists, PPIs

The need for an annual upper abdomen U/S due to an increased risk of cholelithiasis

After laparoscopic cholecystectomy:

• Independent transfers after 3 to 6 weeks

EXPECTED SURVIVAL

The survival of patients with Spinal Cord Injury (SCI) has significantly improved over the last few decades, but it still remains below normal. The mortality rate for SCI patients is 6.3% in the first year after the injury, 1.7% in the second year, with a subsequent annual decline to 1.2%. Significant risk factors for mortality after injury include advanced age, male gender, violence as the cause of injury, the completeness of the injury, respiratory dependence, and indirect insurance.

MORTALITY AND EXPECTATION

Complications of the urinary system: only 2.3% of deaths 2000% increase in life expectancy, only 30% in the general population (last 50 years) 85-90% of normal (excluding the level and severity of the injury) Leading causes of death: respiratory complications (tetra)/cardiovascular diseases, cancer (more).

PROGNOSIS OF NEUROLOGICAL RECOVERY - FUNCTIONAL OUTCOME

The determination of the functional abilities of individuals with SCI is particularly important for the patient, their family, medical and therapeutic staff, and insurance agencies. The functional abilities in complete SCI depend on the neurological level of injury. Individuals with A3-A4 injuries are fully dependent on activities of daily living (eating, dressing, clothing care, personal hygiene), transfers, and the use of a manual wheelchair. They are also independent in the use of a power wheelchair and unable to drive.

Individuals with A5 injuries are fully dependent on lower limb dressing and personal hygiene activities, while they are independent in the other aforementioned activities with adaptive equipment or partial assistance from others.

Individuals with A6 injuries are independent in upper limb dressing and weight transfers but require adaptive equipment or some assistance in the previously mentioned activities.

Individuals with A7 injuries are independent in feeding, upper limb dressing, and weight transfers, but they may require adaptations or minimal assistance in the activities mentioned above.

Individuals with A8-Θ1 injuries are independent in all activities of daily living except for personal hygiene, which may require adaptive equipment. They are also independent in transfers, weight transfers, and the use of a wheelchair, while they can drive a car with adaptations.

Individuals with T2-Θ10 injuries are independent in all activities of daily living, transfers, weight transfers, and the use of a wheelchair. They can also drive a car with adaptations but do not have functional walking ability using orthoses.

Individuals with Θ11-O2 injuries are independent in all activities of daily living, transfers, weight transfers, and wheelchair use. They can drive a car with adaptations and have functional walking ability using orthoses both indoors and outdoors.

PAIN IN SPINAL CORD INJURY

Pain following a spinal cord injury is particularly common, with recent studies reporting its prevalence ranging from 77% to 81%. In many patients, this pain is severe and significantly impacts their daily functioning, quality of life, and may lead to depression. Some studies suggest that the consequences of pain on quality of life may be greater than the injury itself. Pain tends to remain stable over time, and in cases where it changes, it often worsens. It presents in various forms depending on its location, qualitative description, and assumed etiology, which explains its wide-ranging effects on functionality and the difficulty in its management.

Most pain classification systems associated with spinal cord injuries categorize it into two major groups: musculoskeletal/algopathic and neuropathic/neurological pain. Neuropathic pain, as a category, has a prevalence of 30-40% among individuals with spinal cord injuries five or more years post-injury. Musculoskeletal pain appears to be more common, occurring in 50-60% of individuals with spinal cord injuries five or more years post-injury, and it is generally milder compared to neuropathic pain. Musculoskeletal pain refers to pain originating from areas where some sensory function is preserved, with the pain starting from pain receptors within musculoskeletal structures (muscles, tendons, ligaments, joints, bones). Immediately after the injury, the source of pain may obviously be related to bone, joint, or muscle trauma.

Pain can also result from vertebral fractures and ligament ruptures stabilizing the spinal column. This pain is influenced by the trunk's position and activity. Pain resulting from muscular spasm may begin a significant time after the injury. Pain stemming from overuse syndromes occurs in areas with normal sensation and high levels of activity, such as the shoulder. Shoulder pain is the most common in this category and is caused by deltoid tendonitis, subacromial impingement syndrome, supraspinatus tendinitis, and osteoarthritis. Shoulder pain in individuals with chronic paralysis has a prevalence ranging from 40% to 60%. Shoulder pain following tetraplegia is often due to shoulder instability resulting from the paralysis of shoulder stabilizing muscles, as well as scapular impingement due to a lack of passive and active range of motion and underlying spasticity. Elbow pain in individuals with paralysis is also common (15%-35%) and is primarily due to lateral epicondylitis.

Neuropathic pain is defined as pain arising from an injury or disease affecting the somatosensory pathway. Pain following spinal cord injury becomes perceivable below the level of the injury, in areas with impaired or absent normal sensation. Transition zone pain presents at the injury level and may be caused by entrapment of nerves. Radicular pain is neuropathic pain that appears at the injury level and is caused by injury to the nerve roots associated with the initial injury or subsequent irritation. Splanchnic pain appears in the abdominal region, typically following a spinal cord injury, and is considered neurological/neuropathic pain according to certain classification systems. Because the causes of splanchnic pain may include rectal obstruction, urinary tract obstruction, nephrolithiasis, or other intra-abdominal pathological conditions, in these cases, splanchnic pain is classified as algopathic pain.

SOCIAL REINTEGRATION

Social reintegration, as defined by Stiens and colleagues, "extends beyond the individual: it promotes the full integration and participation of the individual in the physical and psychosocial environment." For individuals with disabilities, such as Spinal Cord Injury (SCI), reintegration involves regaining previous roles and relationships and developing new ones. Even if a person who has recently undergone rehabilitation returns to their adapted home or the same workplace or career, the use of different resources and services or even different "spheres of influence" may necessitate unexpected adjustments to what appears to be a "new" community. On the other hand, individuals may, in practice, move geographically. Finding a more suitable place to live may mean moving from a familiar neighborhood to a new, different, or unfamiliar one in the same city or relocating to an entirely new area of the country. Such a move brings about a change in the physical as well as the emotional and social environment.

The support systems and available resources may vary. Regardless of how the physical environment and geography have changed or not, the social reintegration of an individual with a recently acquired disability depends on both their ability and willingness to participate in a new society and the ability and willingness of the citizens and institutions of the new society to support such reintegration. Special interventions to maximize social participation are limited. Thus, the potential for full social reintegration of an individual is often used to assess broader populations of individuals with disabilities.

The International Classification of Functioning, Disability, and Health (ICF) identifies several areas that explain the nature and role of participation: learning and applying knowledge, general tasks and demands, communication, mobility, self-care, family life, interpersonal interactions and relationships, social and political life. In the ICF, activity is defined as "the execution of tasks or actions by an individual," while participation is defined as "involvement in a life situation." The influence of personal factors, such as individual interests and lifestyle, has been recognized but not classified. Social reintegration is a similar construct to participation as defined by the ICF.

According to Dijkers, "social reintegration after physical injury or disability is the acquisition or regaining of appropriate roles or activities that are age, gender, and culture-related, including independence or interdependence in decision-making and productive behaviors performed as part of the multifaceted relationships with family, friends, and others in the settings of a community." The goal of rehabilitation is to promote the assumption or regaining of culturally and developmentally appropriate social roles after injury or illness and should promote the full integration and participation of individuals with disabilities in the physical and psychosocial environment. Despite the fact that participation in community activities is strongly associated with subjective quality of life, rehabilitation after SCI today usually aims to minimize functional limitations.

QUALITY OF LIFE

A spinal cord injury (SCI) involves not only a range of dysfunctions in movement, sensation, and the autonomic nervous system but often leads to changes in physical functions such as mobility, cardiovascular functions, hand use, etc., affecting the quality of life.

On the other hand, individuals with SCI face significant challenges when it comes to adapting to their new physical abilities after the injury, as well as the potential changes in lifestyle, social relationships, and social integration that may result. These challenges initially appear during the rehabilitation phase but continue when individuals reintegrate into society and may reappear as individuals with SCI age. In recent decades, advancements in medical care have allowed people with SCI to survive the initial injury and extend their life expectancy after SCI.

Rehabilitation focuses on addressing the consequences of the injury with the goal of enabling individuals with SCI to become active and productive members of society, fully integrated and satisfied with their quality of life. Recovery of optimal functional capacity and participation by individuals with SCI, as well as an improvement in their quality of life, are primary goals of the rehabilitation program. Recently, quality of life has been recognized as a significant measure of the success of rehabilitation programs for individuals with disabilities.

The concept of quality of life, as proposed by the World Health Organization (WHO), is defined as 'individuals' perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.' As emphasized by Glass et al., quality of life can be described as an evaluation of happiness or satisfaction in the objective and subjective aspects of life, which are important to an individual.

Premature Aging

Factors that affect the speed and extent of aging:

1. Age of injury
2. Weight
3. Comorbidity
4. Gender
5. Ethnicity
6. Success of rehabilitation program
7. Socioeconomic resources
8. Goals: Maintaining health, maximum functionality, Quality of Life (QoL)
9. Cumulative stress from repetitive daily activities
10. In individuals with Spinal Cord Injury (SCI), the effects of minor changes have a significant impact on independence throughout life.
11. Fatigue, pain, weakness, joint damage → burden on mobility, transfers, lifting, activities of daily living (ADL)
12. Timely intervention in the causes of reduced functionality is crucial for improving functionality.
13. Fatigue (caused by prolonged immobilization) 61%
14. New pain 36%
15. New weakness 31%
16. Early decline in functionality + assistance needs:

• Age at SCI
• Level of SCI
• Time since SCI

17. Preservation of neurological function: More injuries from overuse
18. Incomplete injuries:

• More fatigue
• Pain
• New muscle weakness
• Reduced endurance