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Spinal Cord Injury
Paraplegia
Deana M. Autry
East Carolina University
Part 1: Description of Diagnosis/Condition
Spinal Cord Injury (SCI) is best defined as an injury to the spinal cord itself resulting from trauma, disease, or disorder. SCI’s are classified according to the level and type of injury to which they occur. As the spinal cord is typically referenced by its five nerve parts; cervical (C1-C8), thoracic (T1-T12), lumbar (L1-L5), sacral (S1-S5) and coccygeal (5 fused bones). (Porter, Kaplan, ; Homeier, 2009) These different parts along with whether the injury was complete or incomplete, allow one to know what type/level of injury has occurred as well as the extent of the possible damage. SCI’s are mainly divided into two types; quadriplegia/tetraplegia and paraplegia. The focus of this paper will primarily be paraplegia.
Paraplegia is referred to as a complete or incomplete injury to the spinal cord at T1-S5. This type of SCI usually encompasses paralysis of the legs and lower body. To determine the type and level of injury an individual may encounter many tests. Some of these tests include blood tests, lumbar punctures, CT scans, MRIs, and myelography X-rays. One would also undergo neurological exams to determine the damage, these include the light touch and pinprick test. (Porter, Kaplan, & Homeier, 2009)
The cause of paraplegia resides in either the spinal cord or the brain. The types of causes of paraplegia typically fall into two categories; focal and systematic lesions. Focal lesions can include damage to the vertebrae, disc herniation, tumors, Pott’s Disease, etc. Systematic lesions entail hereditary or genetic factors. Some examples of systematic lesions include Hereditary Spastic Paraplegia, Pellagra, motor neuron diseases, cerebral causes, etc. (Thomas, 2018) The leading causes of spinal cord injuries that can result in paraplegia include motor accidents, falls, violence, sport, and recreational activities, and medical and surgical injuries. Some other common causes include strokes, genetic disorders, oxygen deprivation at or during birth, autoimmune disorders, infections of the brain or spinal cord, tumors/lesions/cancer of the brain or spinal cord, and spinal cord disorders. (SpinalCord.com)
In reference to the prevalence of spinal cord injuries, both quadriplegia, and paraplegia, quadriplegia has more studies researched. However, one can conclude that the portion unstated would be paraplegic. As far as SCI’s in general, approximately 270,000 individuals were reported living with SCI in 2012, with 12,000 new cases each year. (Porter, Kaplan, & Homeier, 2009) Another article stated that one-third of reported cases is that of quadriplegia. Specifically, for hereditary cerebellar ataxias (HCA) and hereditary spastic paraplegias (HSP), it has been estimated that one in every ten thousand people are affected. (Ruano, Melo, Silvia, & Coutinho, 2014) All across the charts, however, men are more likely to acquire a spinal cord injury. A combination of the above reports states that the onset of such injuries typically occurs between the ages of 33 and 41.
As far as the action of treatment for SCI (paraplegia), many factors must play a role. The approach can essentially be broken down into three phases; initial medical treatment, rehabilitation, and outpatient therapy. The initial medical treatment should entail treatment of injury, reduction of further treatment and discussion of potential home and life modifications. The rehabilitation phase focuses primarily on helping the individual gain functional independence. Lastly, the outpatient therapy includes successful home return and community integration. (Porter, Kaplan, & Homeier, 2009)
Specifically, treatment of such injury will include surgery to address the site of the injury as well as secondary surgeries needed to realign or address other problems. Medications should then be given to reduce the risk of infection, blood clots, and other issues that may arise. The next course of treatment will include a whole team approach. This approach includes all teams such as physical therapist, occupational therapist, recreational therapists, etc. coming together to help regain function and build new coping skills. Education about the injury, advocacy and support should be included in all of these steps of treatment. (SpinalCord.com)
For Recreational Therapists, the latter two phases of treatment are where much of the work will be done. During the rehabilitation phase, one should introduce functional and educational skills. Some of these skills should include wheelchair mobility, stress management, and problem-solving. As for the final phase, community reintegration, it should entail not only the patient but their family or support system as well. In this phase, the patients should be able to put to test the skills they have previously learned. In the best outcome, the patient can successfully find programs and activities that they find leisurely to them as well as successful access and participate in them.

Prognosis of individuals with paraplegia depends heavily on whether the injury is complete or incomplete. However, treatments are available to aid in both situations. Treatment in the earlier stages will be more beneficial. Some of these treatments include therapy to strengthen the muscles, surgery to treat the spinal cord or affected areas, and steroid injections to reduce the inflammation. A newly studied research has also found that stem cells can be used as treatment due to their ability to regenerate damaged tissues. (SpinalCord.com) The prognosis also depends highly on the client themselves. The overall outlook on life thereafter and attitude towards treatment can affect the treatment itself as well as life after treatment. Another beneficial aspect to the prognosis of clients is their supports system Therefore if all the above-listed aspects are present and beneficial, the prognosis of individuals with paraplegia can be a positive one.
Part 2: Effect of Condition and Related Limitations on Functioning
Paraplegia can affect an individual physically, cognitively, socially and emotionally. According to the level and type of injury, the physical effects can vary. Some of these physical effects can include loss of sensation below the site of injury, phantom sensations, bladder dysfunctions, bowel dysfunctions, sexual dysfunctions, spasticity, and neurogenic pain. (SpinalCord.com) Spasticity is best defined as “continuous resistance to stretching by a muscle to due abnormally increased tension” (Spasticity). Neurogenic pain can be best defined as pain that is caused by the nervous system. This pain can be neuropathic or central; due to nerve damage or from the lesion of the central nervous system. (Garcia) Also, due to the immobility an individual may have, pressure sores and weakening of the bones and muscles must be considered. Some other secondary physical impairments may include autonomic dysreflexia, respiratory complications, temperature regulations, heterotopic ossification, and postural hypotension. (Porter, 2018)
Most cognitive impairments have been researched in hereditary spastic paraplegia specifically. In one study, researchers were looking at several domains; dementia, intellectual disability, language disorders, information processing speed, attention deficit, and executive impairment. It was concluded that the only significant cognitive impairment was seen in attention deficit and executive impairment. In addition, there were also some signs of social cognition impairment. (Chamard, et al., 2016)
Due to the impact that the physical effects may have on an individual, this can in themselves lead to cause the social and emotional affects one may experience. Individuals who acquire this injury suddenly, with an abrupt change to their lifestyle, may have more of a negative impact on their social life. This is due to the fact that the individual now has to adapt to their new sudden lifestyle changes. Some of these changes that can affect their social life are wheelchair adaptation, social stigmas, and social interactions. If one struggles with this adaptation, this may lead to their emotional affects. The social stigmas in themselves, present an emotional barrier one must try to overcome. Also, the way one acquired the injury can itself pose a negative impact on the patient’s emotional health.

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This type of injury can also have an effect on an individual’s independence in their everyday life. This can be seen in areas such as work or school, community involvement, and leisure participation. As far as work and school, the wheelchair accessibility (or lack thereof) can have a severe negative impact on one’s independence. Also, depending on the job, the individual may no longer meet the physical requirements that the job holds. As for community involvement and leisure participation, it may be based on the level of education and resources the patient has access to. With the many adaptations available in the community and leisure activities, it is possible for individuals to continue to reintegrate into the community successfully. However, if not educated well enough or given enough resources, this may be the most difficult aspect of the patient’s treatment.
Although paraplegia itself is a life-long condition once acquired, its effects can be reduced or maintained. The physical effects can be maintained and occurrence of other secondary physical effects can be reduced. In specific cases, like the ones stated above, some cognitive effects may also be life-long. As for the emotional/social effects, they can only limit the client for a portion of time if treated correctly.
Sample Client
Anthony is a thirty-two-year-old male whose hobby is water skiing. On a leisure day out, Anthony caught a bad wake and hit the water extremely hard. After his friends got him in the boat, they heard him saying he couldn’t feel his legs and immediately rushed him to the closest hospital. After many tests, it was concluded that Anthony acquired a T12 spinal cord injury due to his fall. After a long discussion with his doctor, Anthony understood this to mean that he will lose function of his hips and legs as well as bladder and bowel control. Anthony initially became very frustrated and angry. All he could think about was what this means for his family, as he had a wife and two young children. He also wondered what this would mean as far as his job and if he would ever be able to water ski again.

Part 3: Client Needs and RT Service Providers
Although functional independence may be addressed during other forms of therapy during the treatment process, it is still to be addressed during the recreational therapy. It is highly important that the client is given the skills necessary for the highest level of functional independence possible. Community reintegration is one of the most primary focuses for patients with spinal cord injuries in reference to recreational therapy. After acquiring such injury, one must learn to have to adapt to their new lifestyle and be able to successfully implement skills learned into the real-world application in the community. This community integration also includes the transition from the clinical setting to the community setting. Depending on the circumstance, the patient may have been in the clinical setting for quite some time. If so, the transition to the new setting in which they will live could be tough. Also, wheelchair mobility is an important aspect to address during this transition. The patient should acquire adequate skills for wheelchair use as well as make the sufficient accommodations in their everyday life. Following, one should develop leisure skills and adaptive recreation. The client may have had previous hobbies or interests that they wish to continue to pursue. Given the appropriate skills and resources, the client should know what opportunities and adaptations are out there for leisure and recreation activities. Lastly, education/advocacy/accessibility and health promotional education should be provided. It is highly important that the client is informed on the education of their diagnosis as well as the corresponding advocacy and rights that they have. (Porter, 2018)
Goals and Objectives
Goal: Client will learn positive stress management skills
Objective: Upon stress, the client will engage in the three-part breathing exercise and record how they were feeling before and after exercise in a journal.
Goal: Client will re-engage in previous hobby/leisure activities
Objective: Upon scheduled appointment, the client will receive information on the various adaptive water ski resources in the community; ones most interested are to be recorded.
RT Intervention:
Adaptive water skiing is an adaptive sport that can be played with a wide variety of diagnoses. The adaptive equipment used allows individuals to test out varying abilities; from just skimming the water to jumping and other water tricks. Such adaptive equipment includes the sit-ski, outriggers, and boom and triple bars for holding. For individuals with spinal cord injuries, the sit-ski allows them to remain in the seated position. This sit-ski also comes in various levels; beginners, intermediate, and advanced. Before getting out in the water, one must be assessed on a few levels. These levels include strength, mobility, balance, and overall goals. One must be able to pass a ten-second water test before being allowed on the ski. This test is to ensure that if fallen out of the ski, the skier can successfully hold their breath for ten seconds in the water as well as roll themselves from prone position to supination. Individuals will severe mental disabilities, open wounds, or on precautions from their doctor may not be able to participate. It is to be ensured that every participant understands the directions thoroughly (ex. the correct signs for go, stop, release, etc.). Also, for individuals with advanced knowledge of water skiing prior to their condition, it is important for them to start at the basics and progress. This is because adaptive water ski requires skills and knowledge not presented in traditional stand-up skiing. For the recreational therapist on site, it is important to stress the social aspect of the intervention. It will be likely that there will be other individuals will similar diagnoses, one should encourage the clients to interact with each other. The RT should also be aware of the precautions to their specific client before participation and ensure that they are followed. There will likely be other events/clinics discussed at the end, it would be highly beneficial for the RT and client to discuss the interest into the other related events.
References
Chamard, L., Ferreira, S., Pijoff, A., Silvestre, M., Berger, E., ; Magnin, E. (2016). Cognitive Impairment Involving Social Cognition in SPG4 Hereditary Spastic Paraplegia. Behavioral Neurology, 2016, 1-6. doi:10.1155/2016/6423461
Garcia, N. (n.d.). Neurogenic pain. Retrieved from https://www.neuromodulation.com/neurogenic-painPorter, R. S., Kaplan, J. L., ; Homeier, B. P. (2009). The Merck manual home health handbook. Hoboken, NJ: Wiley.

Porter, T. (2018). Musculoskeletal: Spinal Cord Injury online PowerPoint. Retrieved from https://blackboard.ecu.edu/webapps/blackboard/execute/content/file?cmd=view;content_id=_10390242_1;course_id=_451806_1;framesetWrapped=trueQuality of life and traumatic spinal cord injury. (2004, May 25). Retrieved from https://www.sciencedirect.com/science/article/pii/S0003999398902404Ruano, L., Melo, C., Silvia, C., ; Coutinho, P. (2014). The Global Epidemiology of Hereditary Ataxia and Spastic Paraplegia: A Systematic Review of Prevalence Studies. Neuroepidemiology. doi:10.1159/000358801
Spasticity. (n.d.). Retrieved from https://medical-dictionary.thefreedictionary.com/spasticitySpinalCord.com. (n.d.). Paraplegia. Retrieved from https://www.spinalcord.com/paraplegiaThomas, L. (2018, August 23). What Causes Paraplegia? Retrieved from https://www.news-medical.net/health/What-Causes-Paraplegia.aspxWater Skiing. (n.d.). Retrieved from https://www.disabledsportsusa.org/sport/waterskiing/Wyndaele, M., ; Wyndaele, J. (2006, January 03). Incidence, prevalence, and epidemiology of spinal cord injury: What learns a worldwide literature survey? Retrieved from https://www.nature.com/articles/3101893

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