Consequences of an injury
Around 500 new cases of spinal cord injury occur annually in Finland. A spinal cord injury can occur either as a result of an accident or illness, and the injury can also be congenital.
Physical disability is usually the most prominent problem resulting from a spinal cord injury; three out of four patients need to use a wheelchair. However, other problems in the body and organs may cause more severe symptoms than a physical disability.
The ability to function depends on two essential things: where in the spinal cord the injury is located, and whether the spinal cord is completely or only partially damaged. The situation cannot be reliably assessed immediately after the accident, and it can take days or weeks to confirm the prognosis. A manual assessment by a doctor of the skin’s sense of touch and muscle function is still the best way to assess the situation. Over the years, you will become the best judge of your own situation.
Most of us with spinal cord injuries believe muscle paralysis to be the most difficult consequence of our injury, while an injury in the spinal cord tends to cause symptoms other than physical disability. Sensory loss, as well as bladder, bowel and sexual dysfunction, may pose big problems. Such conditions are also caused by damage to the nervous system, the assessment of which is explained in this document.
The extent of a spinal cord injury can be roughly assessed using the ASIA exam. The exam is based on neurological responses, touch and pinprick sensations tested in each dermatome, and the strength of several muscles in the upper and lower limbs is evaluated. The motor or sensory function in the area around the anus can be used to determine whether the injury is complete or incomplete. Sensation and muscle strength are given a score that describes the neurological level of the injury.
The level of neurological damage is determined by the ASIA exam; in practice, it is the most rostral segment with normal muscle and sensory functions. The cervical vertebrae are marked with the letter C (8 segments), the thoracic vertebrae with a T (12 segments), the lumbar vertebrae with an L (5 segments) and the sacral vertebrae with an S (5 segments). The nerve injury can be at a different point (upper or lower) to that of the fracture, so the diagnosis of the fracture does not necessarily determine the level of injury.
A complete injury means that the spinal cord is fully compressed or severed at some point. This means a total lack of sensory and motor function below the level of the injury. In this case, you will be given the highest score, a Grade ‘A’ on the ASIA impairment scale.
An incomplete injury means that at least some nerve fibres function at the point of the injury. An incomplete spinal cord injury can be very mild, walking is smooth, and bladder function is normal, though muscles may be somewhat stiff. However, people with an incomplete spinal cord injury may only have some functional nerve fibres, in which case the condition is very similar to a complete injury. Of course, the more incomplete the injury is, the better. Grade ‘B’ on the ASIA impairment scale means that there is some sensory function below the injury, Grade ‘C’ means that there is some muscle strength, and Grade ‘D’ that there is moderate muscle function.
Spinal cord injuries can be divided into upper (usually cervical or thoracic injuries) and lower nerve cell injuries (usually lumbar and sacral injuries).
In general, a physical disability is the most severe – and, at least, the most obvious – consequence of a spinal cord injury. Assistive devices can help people overcome problems, and it is important that the environment is accessible. Still, there will be things that you cannot do yourself.
If the spinal cord injury is complete, the overall picture will emerge within a matter of months, and the condition is permanent. If it is a case of an incomplete injury, the condition may take a few years to settle. During this time, any nerve paths that have not been functioning will have regained function. Depending on the situation, rehabilitation can significantly improve mobility, though people usually need to practice walking after the trauma. Learning to use a wheelchair is similar to children learning to walk. However, if the injury is not very severe, the injured person may be able to walk as well as before the trauma.
The more incomplete the injury is and the lower on the spinal cord, the better the injured person’s mobility usually is. Ten percent of people with spinal cord injuries walk without assistive devices, 20 percent with assistive devices, 60 percent use a standard wheelchair and ten percent use a powered wheelchair.
The level of functional damage is indicative of muscle mass and strength, and it can be assessed using the ASIA exam. It is advisable that every person with a spinal cord injury knows this individual feature in both theory and practice. The ability to function physically is, however, determined by a number of other injury-related and individual features such as spasticity, physique and age. For this reason, people cannot be compared even if the level of their injury is the same.
There are assistive devices to help people to enhance their mobility. It is worth learning to use them as efficiently as possible. Depending on the level of injury, a wheelchair can enable a person with a spinal cord injury to be active in many ways. Moving onto a bed requires not only strength but also the correct technique, which can be practiced. It is easier to move around if you can pack your wheelchair into your car by yourself. It may be possible to walk downstairs without aid, and, with an appropriate handrail, it may even be possible to climb up them. A wide range of wheelchairs, such as rigid frame and folding wheelchairs, are available. It is a good idea to test different models. A wheelchair is always a compromise between moving around and sitting.
Assistive devices are also often needed for walking. It is always useful to be able to stand up or walk, so these should be practiced with diligently. It may be better to use a wheelchair when moving for longer distances.
Despite the various assistive devices, many people with disabilities have to rely on the help of other people in their daily activities. If the need for assistance is high, this is best carried out by a personal assistant.
Being able to drive a car without assistance makes life a lot easier. New technologies ensure that it is possible to drive a car even if the muscles are not very strong. A quad bike or a snowmobile can also be used to broaden horizons, though the best way to get close to nature is to use a canoe, skimobile or monoski.
Improving and maintaining mobility requires rehabilitation, which can include tough physical exercise as well as a variety of activities for every aspect of life. This is, of course, essential in the months following the trauma, but rehabilitation is often necessary even at later stages. Rehabilitation is approved by KELA, the insurance company or the municipal heath care system.
Other disabilities associated with spinal cord injuries may impair the ability to function over the years. This is, naturally, partly explained by ageing, but arthrosis and different problems with ligaments may also hinder moving about. Exercising to keep fit and strong is also important as a preventive measure.
Spasticity refers to involuntary muscle spasms. A muscle that is completely “paralysed” can contract on its own, while a muscle that is only partially functional can be stiff. Spasticity is caused by independent reflex activity in the spinal cord below the level of injury, the so-called higher-level injury. If the injury is in the lumbar area or lower, the paralysis is usually flaccid. Not everyone experiences spasms.
Appropriate basic care and observation are the best prevention and treatment of spasticity. Muscle stretching, done either independently or in physiotherapy, relieves spasticity, and some people find that heat relaxes their muscles. It is useful to discuss the treatment of spasticity with a physiotherapist, though treatment with medication is often required.
Pain is usually a sign that there is something wrong in your body. You should react to pain in order to remove its cause or to avoid causing more pain, though this is not always possible. In the case of neuropathic pain, the cause cannot always be identified and therefore the pain, which cannot therefore be eliminated, becomes continuous. Pain is a complex matter, and it is possible to learn to live with it. This is easier with pain management and pain management groups.
A spinal cord injury does not, in itself, involve musculoskeletal pain, but the injury always causes abnormal stress on the body. Using a wheelchair strains the shoulders and upper limbs, while muscle imbalance or lack of muscle strength can put a strain on joints when walking. Aches and pains are thus common, and it is important for people with spinal cord injuries to look after themselves and to try to prevent conditions such as arthrosis and problems with ligaments. Muscle maintenance as well as stretching and gym programmes are important for those who use a wheelchair.
Neuropathic pain often manifests itself as a sensation of pins and needles or burning below the level of injury, where there is reduced or absent feeling. The pain is caused by false information sent by the nervous system, and there is often nothing “wrong” in the area of pain. The condition must still be assessed to ensure that a possible problem is not left untreated. Managing neuropathic pain is usually difficult, but a treatment is almost always available. Even an ordinary pain can become neuropathic in nature if it becomes chronic. It is quite typical of people with spinal cord injuries to experience this type of mixed pain.
Due to impaired sensation, some people may be unable to perceive pain at all. A fracture can cause increased spasticity or abnormal sweating, and the only symptoms of appendicitis may by spasms in the stomach muscles, feeling unwell and having a temperature. It is important for people to learn to observe their body and to remember to tell their doctor about any lack of pain.
When an individual with a spinal cord injury experiences joint or muscle pain, its cause must be carefully assessed and treated since the ability to function can deteriorate quickly as a result of a minor pain in the shoulder, for example, which would not be a problem for someone who is able to walk.
A spinal cord injury almost always adversely affects bladder function. The nerves that control urination are located at the base of the spinal cord, and this means that even lower injuries cause bladder dysfunction. Even those with incomplete injuries often suffer from this condition as only around ten percent of the injured say that their bladder function is completely normal. The problems depend on the bladder type and include a loss of feeling that the bladder is full, incontinence, urine leakage and the bladder may empty incompletely. Other problems include complications such as urinary tract infections and symptoms of autonomic dysreflexia.
The kidneys remove waste from the body, and they also regulate fluid and mineral balance. People usually have two kidneys. A ureter carries urine from each of the kidneys to the bladder, which is a muscular sac that stores urine. The normal daily urine output is around 1.5 litres. The bladder empties through the urethra. When the bladder is full (usually about 0.5 litres) and the individual wants to urinate, the detrusor muscle contracts and the sphincter muscles relax. Normally, the bladder empties without thinking, without pressure and completely. The emptying is controlled in the sacral micturition centre, located at the S2-S4 levels. The brain’s role is to give permission when the time is right.
Types of bladder dysfunction can be classified in several ways, usually based on a urodynamic test. The most common types are spastic bladder: a spastic detrusor and sphincter muscle (usually with T12 level injuries or above), and flaccid bladder, a flaccid detrusor and sphincter muscle (usually with injuries below T12).
People with incomplete injuries usually feel the urge to urinate almost normally, while those with complete injuries can usually learn to determine the urge indirectly. People with injuries at the T6 level or above may experience chills or sweating, while those with injuries at the T10 level and below may feel pressure or cramps in the stomach. People with injuries at the T6-T10 levels may not notice when their bladder is full. It is possible to learn to feel when the bladder is full by running one’s fingers on the lower stomach.
The best means to empty the bladder must always be assessed individually, and it may be necessary to change the technique over the years. A urodynamic test assesses the function of the bladder and sphincters, and it is used as the basis for the selection of a safe technique. The ability to function, especially that of the upper limbs, determines the treatment options. The individual’s lifestyle and personal habits are naturally also taken into account.
People with an incomplete injury may be able to empty the bladder “in a normal way” even though there may be problems caused by the rush due to a spastic bladder or a bladder that does not empty completely. Some people may also have to press on their lower stomach with their hands or contract their stomach muscles to empty their bladder.
Intermittent catheterisation is now a common bladder emptying technique, at least after the trauma. Many people with spinal cord injuries also use it permanently, either as the only method or as one method among others. The advantage of catheterisation is that the bladder empties completely without excess pressure.
An old but still a wide-spread technique is to start the emptying reflex by tapping the lower stomach. It is often necessary to intensify the tapping by pressing the bladder. Some people need a catheter through a hole in the abdomen (Cystofix) or a permanent catheter through the urethra, or it may be necessary to have a stoma.
Incontinence may cause urine leakage, and regular emptying of the bladder may help in this case. However, people with a spastic bladder, which only holds 150 ml of urine, need assistive devices; the devices work for men, but not always for women, and sometimes it is advisable to reduce one’s fluid intake. Another type of problem can be caused by functional stomach muscles and a flaccid sphincter muscle. Fortunately, there are ways to improve the condition; these are described in more detail below. It is always a good idea to consult a urologist.
Autonomic dysreflexia is a syndrome that can be triggered by bladder dysfunction in individuals with T6 level injuries or above. Common symptoms are excessive sweating or a pounding headache.
Normally there are no bacteria in the urine. A spinal cord injury predisposes individuals to infections in many ways. Bladder dysfunction weakens the defence system of the bladder mucosa and urethral walls. Bacteria almost always enter through the urethra. Any residual urine remaining in the bladder is an excellent culture medium for the growth of bacteria, which is why it is important to empty the bladder regularly and completely.
Typical bladder infection symptoms, e.g. a burning sensation during urination, may not always be present. Symptoms usually include changes in the bladder, e.g. increased leakage and a frequent need to empty the bladder, or spasticity and pain. If an individual has a temperature and other general symptoms, it is advisable to see if it is a bladder infection. A symptomatic infection is treated with antibiotics, and the course of antibiotics should last at least ten days. Drinking lots of liquids is useful at least for those who empty their bladder by tapping. Drinking more liquids may not be helpful if the bladder is emptied by intermittent catheterisation, though the frequency of catheterisation could be increased. If there are bacteria in the urine but the individual has no symptoms, it is best to monitor the condition. If infections occur often, it is possible to take preventive medication, though this does not always work.
Renal insufficiency may be caused by bacterial infections as well as pressure in the bladder. It has no symptoms in the early stage, and it cannot be diagnosed with a blood test. For this reason, the condition must be monitored by ultrasound scan, for example, so that any changes can be assessed early (e.g. expansion of a ureter due to pressure). Regular monitoring is particularly important if infections are frequent or if bladder pressure increases.
Urinary tract stones form more commonly in the acute stage when calcium is released from the bones. At later stages stones may be caused by infections, for example. Symptoms include bladder dysfunction or persistent bladder infection; a urinary track stone causes intense pain. A bladder stone can usually be detected in an ultrasound scan.
There are numerous assistive devices for the care of the bladder. The catheters used in Finland are self-lubricated with water and thus easy to use. There are several types of urinal condoms and sachets, and patients just have to try them out to find a suitable one. This also applies to incontinence pads.
A spinal cord injury causes two types of changes in bowel function: it slows down, and control of the sphincter muscles weakens or is lost. Slow bowel movement often causes constipation, and it is often necessary to empty the bowel on certain days, while being unable to stop the urge to defecate may be a problem especially when the individual has diarrhoea.
Using a wheelchair – or rather the lack of normal walking and exercising – slows down the frequency of bowel movements. In practice this means that it may take food two or three times longer than usual to move from mouth to rectum, causing the stools to build up and become dry, leading to constipation. A diet rich in fibre helps to prevent the stools from becoming dry and add bulk to the stools, thus helping them to pass more quickly through the intestines. Many medicinal products can be taken to improve the condition. Practising standing and walking is thought to normalise bowel movements. It is important to drink sufficiently, though this may cause bladder issues in some cases.
People with an incomplete injury may be able to empty their bowels as before, i.e. when they have the urge, and this may also be the case for some people with a complete injury. Most people with spinal cord injuries learn to sense when they need to defecate. However, being unable to stop the urge to defecate and a build-up of stools resulting from slow bowel movements may become a problem. Many people cannot tell when they need to defecate due to a lack of sensation or because they are unable to stop the urge. In this case, the bowel needs to be emptied on certain days, using certain medicines, enemas and/or digital evacuation of the stools. This may take place every morning or twice a week, for example, depending on the individual’s schedule.
Haemorrhoids often occur over the years and decades; lots of time spent sitting and some methods of emptying the bowel can result in haemorrhoids. Bleeding, autonomic dysreflexia and spasticity may become problems. Suppositories can be used to treat the condition. Surgical treatment may, however, be necessary in the longer term, at least when external haemorrhoids can no longer be pushed back inside.
Other consequences of a spinal cord injury