Spinal cord injury programme

The two facts that determine everything are the level of injury and whether it is complete or incomplete. They set what is realistic, and a programme that does not start from them is guessing.

For incomplete injuries the emphasis is on recovering function below the level. For complete injuries it is on maximising independence with what remains, which is a different programme, not a lesser one.

Strengthening of preserved muscle groups, transfer training, wheelchair skills, standing and where appropriate robotic or body-weight-supported gait work, and upper limb work in cervical injuries where hand function determines almost everything.

Alongside that: bladder and bowel management, skin and pressure care, spasticity management, respiratory function in higher injuries, and autonomic dysreflexia recognition — which is taught to the patient and family because it is a medical emergency they will need to identify themselves.

Pressure injuries, urinary infection, contracture, deep vein thrombosis, respiratory infection and autonomic dysreflexia cause more readmissions after spinal cord injury than the injury itself does.

Education on each is part of the programme rather than a leaflet at discharge, and the family is trained alongside the patient. In our experience this is what most determines the first year after discharge.

Patients and families ask about walking first, and they are entitled to a clear answer rather than an encouraging one. In complete injuries above a certain level, functional walking is not a realistic goal, and supported standing and stepping are for the health benefits of upright time rather than for mobility.

In incomplete injuries the picture varies enormously and we assess before saying anything. What we will not do is leave an expectation in place because correcting it is uncomfortable.

These three determine independence, readmission and life expectancy more than walking does, and they occupy a substantial part of the timetable. Catheter technique, bowel routine and pressure relief are trained until they are reliable rather than demonstrated once.

The family is trained alongside, because these are the areas where a gap in knowledge produces an emergency months later.

Wheelchair setup, cushion selection and transfer technique are matched to the person rather than issued from stock, and a chair that is wrong can lead to shoulder injury and pressure damage.

Where possible we plan against the actual home: door widths, bathroom, steps. A discharge plan built for an idealised home fails in the first week of the real one.

In a study that followed 951 people after rehabilitation for a new traumatic spinal cord injury, 36.2% were readmitted to hospital at least once within a year of injury, and 12.5% at least twice 2. The commonest reasons were urinary problems such as infection, chest problems such as pneumonia, and skin problems such as pressure ulcers 2.

People who had received more intensive physical therapy during rehabilitation had lower odds of readmission, although an observational study of this kind cannot prove cause and effect 2. It does show where the risk lies: in the same areas that training in bladder management, chest care and pressure relief is aimed at.