12.45 Rehabilitation of spinal cord injuries

Prior to the Second World War most spinal cord-injured patients died soon after injury. The establishment of systems of comprehensive care, pioneered by the National Spinal Injuries Centre in Stoke Mandeville Hospital, changed this situation.

Spinal cord injury affects every system of the body. Successful rehabilitation depends on the effective management of all aspects. Failure of care in any area results in unnecessary morbidity and mortality. A multidisciplinary approach is essential if the optimum rehabilitation outcome is to be achieved.

The greatest threat to the successful rehabilitation of the patient is fragmentation of care. To avoid this, systems of care were initially developed in the United Kingdom, and later in Australia, New Zealand, the United States of America, and Canada, where all aspects of treatment could be addressed by those with the required training. Those systems where all facets of medical care following the accident and emergency department phase are dealt with in one centre have fewer complications than those that involve acute care in one hospital followed by subacute and chronic care elsewhere.

A spinal cord injury is complete if there is no somatic motor or sensory function below the level of injury. If the arms are spared the patient has paraplegia. If they are involved the patient has tetraplegia. The level of injury is the lowest intact spinal cord segment. If there is residual function several segments below this then the injury is incomplete and the patient has either paraparesis or tetraparesis.

The incidence of traumatic spinal cord injury is between 10 and 50 per million in the population each year. The figure in the United Kingdom is towards the lower end of this range.

The two components relevant to rehabilitation are prevention of the injury, and avoidance of the secondary deleterious effects that are the consequence of poor care.

Spinal cord injury is most commonly caused by motor vehicle accidents. Seat belts, both front and rear, side impact support systems, and inflation bags reduce the incidence and severity of injury.

Sports-related injuries are uncommon. In the United Kingdom the most common are, in order of frequency, diving, rugby, and horse riding.

Diving-related injuries can be partly prevented by good education, appropriate pool design, adequate poolside signs, and appropriate supervision by attendants trained in safe methods of retrieval.

Rugby injuries can be reduced by adherence to the rules of the game, the avoidance of participants playing out of position, and ensuring that players are suitably fit. Where complete tetraplegia is caused by cervical dislocation, relocation within 4h of injury can produce full recovery in two-thirds of cases.

Avoidance of the secondary deleterious effects that are a consequence of poor care is dependent firstly on the recognition that a spinal injury may have occurred, and secondly on knowledge of, and expertise in the correct actions to take. Ten per cent of unstable spinal injuries in the United Kingdom are missed. Of these, circa 50% deteriorate neurologically due predominantly to inappropriate movement at the injury site, compared with less than 5% of those managed appropriately. Common sites where fractures are overlooked include the cervicodorsal junction and spinal fractures below the major fracture. If there are reasonable grounds for believing that there is an unstable spinal injury, appropriate steps must be taken to immobilize the spine until the diagnosis has been confirmed or refuted. The more the spinal cord is damaged the less complete its recovery and the worse the rehabilitation outcome.

Optimum rehabilitation outcome depends on good management of all facets that affect the spinal cord-injured person.

Associated injuries must be well treated to ensure optimum rehabilitation outcome. Amongst the more important are the following.

Successful rehabilitation following spinal cord injury is dependent on the total involvement of the disabled person. Good executive function enables the spinal cord-injured person to lead a safe and well-integrated life. Relatively minor impairments of personality, memory, concentration, and intellect can interact with the other problems associated with spinal cord injury to make safe independent living and successful employment more difficult.

People with spinal cord damage are more dependent on their arms than prior to injury. Joint damage, and to a lesser extent long-bone fractures, can severely impair transfers and wheelchair skills. Contractures are frequently very disabling.

Problems in arm joints commence at an earlier age after spinal cord injury because they are put under stress by the routine activities of wheelchair life. The onset of these difficulties is accelerated by damage sustained at the time of injury.

Peripheral nerve and brachial plexus injuries occasionally occur in association with the spinal cord damage. Paraplegics require both arms for most activities. The affected arm cannot cope so well with transfers and wheelchair control.

Chest and abdominal injuries, though life-threatening at the time of injury, are seldom important in rehabilitation terms.

The level, degree of completeness, and pattern of the spinal cord injury are of central importance in determining rehabilitation outcome and prognosis. There is no level of neurological disability, including ventilator dependency, that is incompatible with life in the community.

Methylprednisolone is seldom given in the United Kingdom as the harmful effects of the very high doses of steroids required outweigh the relatively small rehabilitation benefits.

Preserved sensation below the injury makes the paralysed person aware of complications such as pressure sores, fractures, and intra-abdominal events, thereby improving life expectancy through earlier diagnosis.

The neurological level of injury is the most important determinant of rehabilitation outcome. Each segmental level in the cervical region in particular is of vital importance.

Complete C3 and above patients usually require a greater or lesser degree of ventilatory support.

C4 level patients can almost always breathe independently but are otherwise almost totally dependent. Electric wheelchair mobility and high-technology control of the environment is achievable using retained head and neck control.

C5 level patients have good shoulder control as well as elbow flexion. With aids, such as feeding straps, limited function is possible. Assistance is required with every activity.

C6 level patients have good wrist dorsiflexion. Elbow extension can be achieved by means of trick movements. By locking the elbow, transfers are sometimes possible. Wrist dorsiflexion is associated with passive tenodesis of the fingers and the thumb. Upper-limb reconstructive procedures can be of great benefit at this level of injury. Active elbow extension can be achieved by the Moberg posterior deltoid to triceps transfer operation. Stronger hand key and grasp grips can be achieved by tendon transfers around the wrist, such as insertion of extensor carpi radialis longus into flexor digitorum profundus and brachioradialis into flexor pollucis longus. These procedures do not usually increase transfer capability. They improve upper-limb control and lead to improved quality of life.

C7 and C8 level patients lack fine intrinsic hand muscle control but have sufficient upper-limb function to achieve partial independence in transfers and activities of daily living.

Upper-thoracic (T2–T6) level patients lack the abdominal and lower paraspinal muscle control required for good truncal balance. Wheelchair control and transfers are impaired as a result. Spontaneous spasms can cause problems in transfers. Ambulation is difficult and requires both long-leg orthoses and truncal braces.

Lower-thoracic (T7–T12) patients have greater abdominal and paraspinal muscle control and hence better truncal balance. Higher kerbs can be negotiated because of better wheelchair control.

L1-level patients frequently achieve ambulation using long-leg orthoses though this is seldom of functional benefit.

Mid-lumbar level patients have good quadriceps control. This usually allows functional ambulation in younger patients through using below knee orthoses.

The incidence of tertiary spinal cord change is commoner than had previously been recognized. These changes continue to develop throughout the life of the spinal cord-injured person. The most important is the spinal cord syrinx. The previously quoted incidence of syrinx formation of 2–4% was largely based on clinical diagnosis. It is now clear that the incidence of syrinx is much greater because the majority do not have clinical features. The incidence of syrinx at 5 years postinjury is 9%. In those injured over 20 years it is 20%.

The presence of a syrinx has important consequences for rehabilitation. Lifestyle should be altered to avoid those abrupt stresses, strains, and other events that could cause serious spinal cord deterioration. Falling from the wheelchair in a poorly executed transfer, for example, can be associated with loss of the use of a hand. The aetiology and management of syrinxes remains controversial. Surgery is not usually required. Continued review is essential.

A neurosurgeon with a specialist interest in the spinal cord-injured patient is an essential member of the multidisciplinary team.

Following the acute event, spinal problems are not usually an issue. Degeneration may occur at an earlier stage in the mobile motion segments above and below the injured one. This can give rise to increased spinal pain, stiffness, and altered neurological function. This contributes to the greater dependence that arises with aging. Deformities such as gibbus are seldom functionally important.

Long spinal fixations can be very disabling. A young person with paraplegia and a long fixation is usually totally independent in their younger years but when they are older their loss of truncal mobility cannot be so readily compensated by increased movement in his hips. This brings forward the stage at which dependence increases. Long fixations in the cervical region prevent the tetraplegic person from looking around, making driving a car more difficult.

Around 10% of spinal injured patients have fractures at multiple levels. Those below the level of the main injury are important if they cause neurological damage or deformity. For example, a complete cervical spinal cord-injured person with an L1 fracture must have the latter carefully treated if reflex bladder, bowel, and sexual functions are to be retained.

Progressive skeletal deformity is a particular problem in children. Regular careful review of their spinal position is required until skeletal maturity. Whereas gibbus does not significantly increase disability, scoliosis can be a significant problem. Sitting posture, the pattern of pressure on the ischial areas, cardiorespiratory function and transfers are impaired by scoliosis.

An orthopaedic spinal surgeon with a specialist interest in the spinal cord-injured person is an essential member of the multidisciplinary team.

Musculoskeletal and neurogenic pains are common following spinal cord injury. They can be intractably disabling. Treatment is frequently difficult.

Sometimes the pain makes it necessary for patients to shift from one position to another or to lie down at intervals during the day. Employment can be difficult for this reason and also because of the effect on concentration of the pain itself and its associated medication.

Neurosurgical intervention is rarely required. Behavioural approaches usually offer the best prospect for the patient learning to cope with the pain. An anaesthetist with a specialist interest in the spinal cord-injured person is an essential member of the multidisciplinary team.

Bladder sensation and control are impaired by spinal cord injury. All methods of bladder care are associated with events that can be distressing and inconvenient. With intermittent self-catheterization there is incontinence. Toilets are frequently inaccessible. With automatic drainage the urinary sheath occasionally disconnects causing soaking. Penile problems can prevent application of the sheath forcing bed-rest or an indwelling catheter. High voiding pressures can compromise renal function.

When partial bladder control remains there is often urgency and frequency that seriously impairs quality of life. Journeys depend on accessible toilets. Anticholinergics or intravesical botulinum toxin may help.

Bladder management in females is particularly difficult. There are no satisfactory external collecting appliances. The risk of incontinence and the smell of urine impair self-confidence and femininity.

A variety of urological procedures exist that benefit certain groups of patients. The more commonly used include augmentation cystoplasty, surgical or botulinum toxin distal urethral sphincterotomy, the artificial urinary sphincter, and sacral root stimulators. Many patients elect to have indwelling suprapubic or urethral catheters because their improved quality of life outweighs the increased risks of infection, bladder stones, intravesical bladder change, urethral discharge, catheter blockage and autonomic dysreflexia.

Continued vigilance of the upper urinary tract is required throughout the life of the paralysed person. Asymptomatic upper tract problems such as calculi and dilatation can occur. An annual evaluation will usually suffice to ensure early diagnosis and treatment. Improved urologic techniques, such as lithotripsy, have reduced the morbidity of upper tract stones.

Experienced nurses are important sources of advice and help with incontinence aids and appliances.

A urological surgeon with a specialist interest in the spinal cord-injured person is an essential member of the multidisciplinary team.

Upper gastrointestinal problems are seldom significant.

Faecal evacuation is usually a major problem. Most patients require suppositories or digital stimulation. Some require aperients. A disciplined pattern of bowel control is essential.

Episodes of incontinence can be very distressing. They are minimized by discipline and avoidance of precipitating factors such as hot curries.

Most paraplegics are able to manage their bowels independently by transferring onto the toilet followed by suppository insertion or digital evacuation. The rectum needs to be checked after bowel emptying to ensure that no faeces remain.

Most tetraplegics need assistance. Bowel evacuation whilst seated on a shower chair over the toilet and followed by a shower is usually effective.

Bowel problems are common in chronic spinal cord injury. Faecal evacuation may take a progressively longer time. Aperients become less effective. The life of the paralysed person can be greatly disrupted. Colonic irrigation or colostomy is sometimes required.

Nurses are the key team members advising on bowel care following spinal cord injury.

Wear and tear of upper-limb joints is increased. As paraplegic patients get older, episodes of upper-limb joint pain and stiffness occur with increasing frequency, especially in the shoulder girdle.

Heterotopic ossification can occur in the early stage following injury. Hip mobility can be severely impaired. Transfers and activities of daily living become more difficult. The ossification process eventually becomes quiescent. Surgery is rarely required. It should only be undertaken after ascertaining that there is no residual heterotopic activity. There is a small place for radiotherapy immediately following excision of abnormal tissue.

Contractures interfere with independent living, mobility, and transfers. They give rise to pain and disability. In tetraplegics, contractures of the shoulders, elbows, and wrists are a particular problem. In paraplegics, lower-limb contractures prevent ambulation and interfere with transfers.

Therapy to joints is essential at all stages following spinal cord injury, and especially in the acute phase. Splinting of hands and correct positioning of shoulders and elbows can prevent unnecessary upper-limb joint morbidity. Therapists should establish the treatments that should be continued by the patient, carers, and family.

In the chronic spinal cord-injured person long-bone fractures occur following relatively minor trauma. Internal fixation often fails because of the osteoporotic bones, infection, and the development of pressure sores. Immobilization in casts must be carefully supervised to avoid pressure sores.

Spasms and spasticity usually occur in spinal cord injury. They are sometimes helpful but more usually a problem. They can cause embarrassment, hinder transfers and driving, impair sleep of both paralysed person and partner, and throw the legs and trunk out of position.

Treatment of spasms includes eradication of any precipitating cause, in particular intravesical and bowel-related pathology, good physiotherapy including standing, systemic drugs such as baclofen, tizanidine, and dantrolene, local injections such as botulinum toxin, and, occasionally, operative intervention such as insertion of an intrathecal baclofen infusion system.

Systemic medication for spasticity has adverse effects. Baclofen causes drowsiness and interferes with concentration, affecting both quality of life and employment. The intrathecal drug delivery systems can have complications such as tube dislodgement and kinking.

For the management of spasticity to be effective there must be expertise in the spinal cord injury centre in all relevant physiotherapeutic, medical, and surgical techniques. Intrathecal pump insertions should only be carried out by those with experience.

Permanent ventilator-dependent patients can live safely in the community provided that they have sufficient care. A trained carer must at all times be ‘in-line-of-eye’ of the ventilated person. This carer must be able to carry out tracheal suctioning, tracheostomy replacement, ventilator reconnection, and bagging. Alarms to summon help immediately are required. With a portable ventilator and other suitable devices, good mobility including aircraft travel can be achieved. High tetraplegic ventilated patients value their lives even though these are impoverished in physical terms

Mid- and low-cervical patients have good diaphragmatic control but no intercostal or abdominal muscle function. Their cough is weak.

Respiratory impairment is the most important increased risk to life in tetraplegics. Carers need to be carefully instructed in the relief of choking, the assisted cough, postural drainage of the chest, the cough assist machine, and clearance of secretions.

Mid-thoracic paraplegics lack a good cough because their abdominal muscle control is absent. They require help with chest infections in their older years.

For the management of respiratory problems to be fully effective there must be a chest specialist available who has a special interest in the respiratory problems of the spinal cord-injured. Expert anaesthetic support is required to make domiciliary ventilation as safe as possible.

Postural hypotension is a common problem in the early stage following spinal cord injury. It is seldom disabling thereafter. It can cause muscle neck and shoulder girdle ischaemic muscle pain that is mistaken for spinal column pathology.

Autonomic dysreflexia is a serious potential problem in all patients with injuries at T6 and above. It can be precipitated by any stimulus arising below the level of injury. The most common are those from the bladder and the bowels. Some events, such as rectal electrostimulated semen emission and vibrator-induced ejaculation, are particularly potent stimuli.

During autonomic dysreflexic episodes the arterial blood pressure can rise to dangerously high levels. Cardiac dysrhythmia may occur. Patients may describe their heads bursting open with pain. Sweating may be so profuse that a change of clothes or bedding is necessary.

Because tetraplegics cannot deal with the factors that precipitate autonomic dysreflexia, care must be available to ensure that when such attacks occur they are dealt with promptly and safely. It is essential that staff, patients, family, and carers are fully conversant with the diagnosis and treatment of this unpleasant and dangerous complication.

Despite immobility and leg dependency, deep venous thromboses and pulmonary emboli are uncommon except in the early stage following injury. Anticoagulation is rarely required following the acute stage. In contrast, cardiac and arterial problems are common. Cardiovascular exercise through FES (functional electrical stimulation) cycling or rowing, treatment of dyslipidaemias, cessation of smoking, and attaining an ideal weight are essential.

Peripheral oedema and superficial vascular skin changes are common. Careful attention must be paid to the feet so that cellulitis and other complications are avoided. Chiropody is sometimes helpful. Cardiovascular risk factors need to be regularly reviewed.

Immobility and loss of sensation contribute to the risk of pressure sores. Careful discipline and good care will largely prevent their development. The insensitive skin must be inspected morning and evening. The minor red marks and skin abrasions that occur during transfers are best treated by rest in bed until the skin has returned to normal.

With aging, the skin and its underlying tissues become less resilient and the risk of pressure sores increases. Patients may go many years without a pressure sore and then develop a serious one.

During the acute stage following injury turning every 2h in bed is necessary. In the later stages such frequent turning is rarely required. Prone lying is an excellent way of maintaining the hips, minimizing spasticity, and preventing pressure sores.

Paraplegics are usually able to turn in bed independently in their younger years. They require increasing help as they get older. Various aids such as monkey poles are helpful. Tetraplegics usually require assistance with turns. The required time between turns in bed at night depends on the individual. A risk assessment will indicate if one or two people are required for turns.

Variable height beds make transfers easier. The ability to elevate the head of the bed aids independence. Rotating beds are seldom popular. Most patients prefer double beds that they can share with their partners. Beds that appear normal are preferred to beds with a hospital appearance.

Specialist mattresses increase the time between turns and reduce the burden on carers. They can make turns more difficult.

Different types of cushions are available. The appropriate one for the individual must be selected. A spare cushion is required in case the main one is damaged. Good posture is as important as cushions in the prevention of pressure sores. A Jay Back may be required to correct posture. The Jay Protector enables patients to go up and down steps on their bottoms and to travel more safely in vehicles when other methods for buttock support are not available.

The nursing staff of the centre must be conversant with teaching techniques for lifting and turning to patients, families, and carers. A posture and seating clinic is essential to ensure that the optimum seating system for the patient is defined.

Sexuality is severely impaired following spinal cord injury. Men sometimes feel incomplete because not only is normal sexual intercourse impossible but also they feel they cannot be full husbands, fathers, and breadwinners, or be involved in ‘masculine’ activities.

Women can lose their self-respect. Wearing attractive clothes such as skirts is limited by the leg-bag and the wheelchair. Urinary incontinence reduces self-confidence and produces a smell of urine.

Although many approaches are available to achieve erections, including oral medications, implants, intracavernosal injections, and external aids, the spontaneity, sensation, and orgasm of normal intercourse are lost. Oral phosphodiesterase inhibitors such as sildenafil produce effective erections in approximately 70% of impotent males.

Fertility in spinal cord-injured men is usually severely impaired. Obtaining semen is the first problem. Methods for achieving this include the penile vibrator, rectal electrostimulated semen emission, and microepididymal sperm aspiration. The second and more important problem is oligoasthenospermia.

Fertility centres are usually required for parenthood to be achieved. Their contribution includes preparation of the semen and treatments of the female partner to increase her fertility. Of the current techniques, intracytoplasmic sperm injection has the highest success rate. Men without any motile sperm, such as those who were prepubertal at the time of injury, can now become fathers.

Female intercourse is possible but passive. Orgasm does not occur except in women with lower levels of injury. Fertility is usually unimpaired

Both male and female spinal cord-injured people face limitations in their parental roles. Relationships and marriages are under greater stress following spinal cord injury. The prospects for maintaining and developing lasting relationships are reduced, particularly in young women.

The spinal cord injury service must have doctors, nurses, and therapists who are knowledgeable in the sexual problems that follow spinal cord injury. Sexuality and fertility clinics are important. A gynaecologist with a special interest in the particular problems of the spinal cord paralysed woman is essential. Close liaison with a fertility clinic is mandatory if optimum live birth rates are to be achieved for couples where the male partner is spinal cord-injured.

Wheelchair selection requires expert therapist assessment. Different wheelchairs are necessary for different purposes. A sports wheelchair, a lightweight wheelchair, and an outdoor electric wheelchair may be required by the same person for use at different times.

The pattern of wheelchair requirement varies with the individual. It also changes with age. A young tetraplegic can cope with a lightweight manual wheelchair on level surfaces and up shallow slopes. In their older years they will require an electric wheelchair instead.

The range and type of wheelchairs that are available is enormous and constantly changing. Before the appropriate wheelchair for an individual is selected it must be evaluated in a practical setting. The most sophisticated wheelchairs allow control of the environment through systems built into the wheelchair. These chairs can also take portable ventilators. They can provide stand-up or reclining facilities.

The wheelchair must be integrated with an appropriate car for satisfactory mobility out of doors. The selection of the appropriate vehicle and its controls requires careful assessment in a specialized centre. The individual characteristics of the patient must be considered. Tall tetraplegics are restricted in the vehicle that they can use whilst seated in their electric wheelchair. Swivel seats aid transfers.

In general, tetraplegics at the level of C5 and below are able to drive. Those at C5 usually require a joystick control. Some at C6 and most at C7 and below can cope with vehicles with hand controls, automatic transmission, servo-assisted brakes and power-assisted steering.

Ambulation is seldom a functional form of mobility for paraplegics or tetraplegics but it can be useful as a form of exercise. For those with poor truncal balance, such as low tetraplegics and higher-thoracic paraplegics, orthoses that provide truncal support are necessary. With lower thoracic and upper-lumbar levels of injury, knee–ankle–foot orthoses usually suffice. Those with good quadriceps control usually ambulate with ankle–foot orthoses alone. The majority of spinal cord-injured patients who learn to ambulate soon cease to do so. Few regret having mastered the technique.

Public transport, such as buses and trains, is difficult. Air travel is usually feasible.

Recreational mobility equipment, such as the quadbike for mobility over rough ground, can be helpful.

A portable ramp is useful when visiting places where ramped access is not available.

This refers to the way in which a paralysed person gets from one position to another.

Nearly all paraplegics become independent in level transfers. Most achieve the more difficult split-level transfers such as from easy chair to wheelchair and out of the bath. The most difficult transfers, such as getting from the floor into the wheelchair, are achieved by only the most able.

There is great individual variation between paraplegics in their capability with transfers. Factors associated with reduced ability include increasing age, poor truncal balance, spasticity, spasms, obesity, joint contractures and upper-limb problems such as muscle strains and nerve injury. Those with a low arm to trunk length ratio, for example, achondroplastics, seldom achieve independent transfers.

A few low-level tetraplegics become totally independent in transfers, usually with the aid of a sliding board. Most require help.

The minimum pattern of help required by each individual is best determined by a risk assessment after a course of rehabilitation in a spinal cord injury unit. Hoists are important transfer aids. Portable hoists are versatile but ceiling mounted ones take up less room.

This refers to the normal activities of daily life that the able-bodied take for granted. The occupational therapy department is vital in this area.

Paraplegics are usually independent. Tetraplegics are usually partially dependent, especially in lower-half activities such as washing, dressing, and personal hygiene. Obesity, poor truncal balance, increasing age, upper-limb musculoskeletal problems, spasms, spasticity, and short arms reduce the ability to carry out activities of daily life.

Higher-level tetraplegics benefit substantially from environmental control systems. Provided that a single muscle can be voluntarily moved in an accurate and predictable manner then the environment can be controlled, such as closing curtains and using the telephone. An expert is required to advise which system is appropriate to an individual’s needs.

Most paraplegics and tetraplegics benefit from remote control door-openers.

Paraplegics are usually able to manage wall-mounted shower seats. Higher-level paraplegics and low-level tetraplegics find the shower chair system more helpful.

Most paraplegics can manage a normal bath whilst they are young. This becomes more difficult with aging. A bath-board may then help. Eventually a specialized bath is required.

The effects of sudden paralysis, potential double incontinence, impotence, infertility, loss of personal relationships, and all the other manifestations of spinal cord damage insinuate into every facet of life. The impact can be devastating. Despite this, depression is not a major consequence of spinal cord injury. Most paraplegic and tetraplegic people who have experienced a spinal cord injury unit have learned to minimize the effect of their disability. They seldom concentrate on what they cannot do. Children in particular adapt well. Counselling may be helpful at various stages though it is usually resisted.

The psychologist in the multidisciplinary team has an important role not only in diagnosing and treating patients but also in assisting family and staff in dealing with the psychological and emotional strains that surround spinal cord injury. A psychiatrist with a special interest is essential because first the risk of suicide is increased and second psychiatric conditions such as depression and schizophrenia can result in traumatic spinal cord injury.

The enormous impact of paralysis on the family including parents, siblings, spouses, and children must be considered. Relationships can be destroyed. The old age of parents can be shattered by paralysis in their children. The ability of the spinal cord-injured person to be a complete father, mother, husband, or wife is severely impaired. The adverse effects on the family rebound on the patient who sometimes feels guilty for the suffering caused.

It is no longer widely accepted that family members should look after their spinal cord-injured relative. It is better for normal relationships to be retained. A wife should remain wife, mother, and lover, rather than become nurse and carer.

Family teaching days are essential. Chronic spinal cord-injured patients and their families provide invaluable insights based on experience to the families of those who have recently been injured.

The accommodation in which most spinal cord-injured people live at the time of their injury is seldom suitable for life in a wheelchair. Early housing assessment is required.

Incomplete paraplegics who can ambulate and cope with stairs in their younger years find this increasingly difficult as they grow older. Many eventually become wheelchair dependent. Crutch and rollator walking take up more space that normal ambulation. Doorways and corridors need to be wider to take account of this.

Tetraplegics and complete paraplegics are safer in ground-floor wheelchair accessible accommodation. This is seldom achieved in the United Kingdom because most houses are two-storey, and most spinal cord-injured people like to remain in their own area. Accordingly, through-floor lifts and stair-lifts are usually required.

The precise housing requirements following spinal cord injury depend on the person concerned and the pattern of disability. It is seldom possible in the United Kingdom for all needs to be met by statutory authorities so compromise is almost always required.

There should be a covered way for the car and from the car to the front door together with adequate space for the patient to get in and out of the vehicle under cover. There should be appropriate, usually ramped, access to the house. Doorways and corridors should be of sufficient width to accommodate the wheelchair base and turning circle. Adequate storage space should be available to avoid equipment cluttering up corridors and living space. The main bedroom should be of sufficient size for ready wheelchair mobility and with adequate storage space for catheters, urinary sheaths, and other personal equipment. There should be an en suite toilet and bathroom to the main bedroom. For tetraplegics, and paraplegics in the later years of their lives, carer accommodation is required.

Paraplegic and tetraplegic people are less able to maintain their body temperature. Adequate heating is required. The temperature control of tetraplegics is compromised by their altered sympathetic nervous system, so air conditioning is required.

Recreations possible before injury are seldom practicable afterwards. A home computer system is often helpful. High tetraplegics benefit from page-turners. Although some paraplegics and tetraplegics enjoy wheelchair sports, the majority are no more sporting that the rest of the population. Access to places of public enjoyment such as theatres and cinemas is often difficult.

Regular holidays help to maintain morale and family relationships. They are usually more expensive. Extra help is required.

Occupational therapists, and specialist clubs and societies can provide information. Many recreations such as skiing, scuba diving, piloting aeroplanes, sailing, abseiling, and various sports are possible.

This most important rehabilitation goal is often not achieved. The opportunities for employment following spinal cord injury are greatly reduced.

Many universities have facilities where spinal cord-injured people can study. Most succeed in obtaining good degrees. However, there is a great difference between obtaining a qualification and achieving employment. In general, the wheelchair dependent are disadvantaged when there is competition.

Those who had physical outdoor manual employment prior to injury, and in particular those with poor academic backgrounds, usually remain unemployed.

Academically capable patients and those who succeed in retraining in clerical skills still face many problems. It takes longer for them to get up and get going in the morning. At work the car must be under cover and with access from it to the place of work. The latter must be wheelchair accessible. Getting from one floor to another and from one building to another is usually difficult and sometimes impossible. There must be facilities at work to allow for episodes of incontinence. Employers have to accept that complications such as red marks and urinary tract infections will result in time off work. Drugs such as baclofen interfere with concentration and mental agility.

Although many paraplegics and some tetraplegics achieve some form of employment, it is more likely to be part-time than full-time, and intermittent rather than continuous, and involve early retirement.

In the chronic stage following spinal cord injury, complications such as pressure sores and urinary tract infections can arise. Some can be successfully treated at home. When hospital admission is required, this should be into a spinal cord injury centre. Annual comprehensive review in a spinal cord injury unit is required.

It is essential that the effects of ageing are taken into account when planning a spinal cord injury service. There is no stereotypical pattern for aging. Some people are intrinsically more able than others. Others have the effects of aging brought forward by problems such as contractures.

Low-level paraplegics are usually independent when young apart from domestic activities, shopping, certain obstacles out of doors, gardening, and home maintenance.

Mid-level paraplegics may require assistance with the standing frame, bath and car transfers, and lifting the wheelchair in and out of the car. Spasticity, spasms, intrinsic ability, obesity, truncal balance, and age are important.

Most low-level tetraplegics require some assistance. For example, they can feed themselves but not cut meat. They can drive a car but not transfer into it or lift in the wheelchair. Someone should be on hand to deal with an emergency such as autonomic dysreflexia or choking on food.

Whilst in general it is not appropriate for family members to be involved in the care of their relations, they frequently choose to do so and provide extremely good care.

In general, carers can carry out straightforward physiotherapy activities provided that they are initially trained and subsequently monitored by specialist physiotherapists.

The successful rehabilitation of a spinal cord-injured person is dependent on a full understanding of the particular individual including past history, current situation, and future aspirations. Treatment should be in a spinal cord injury centre that can manage all acute, subacute and chronic aspects.

The clinical service specifications of a modern United Kingdom spinal cord centre have been laid out. They include cooperation in the efficient retrieval and early admission of acute spinal cord-injured patients for specialized care, the provision of all necessary treatment in the acute, subacute, and chronic phases, life-long surveillance, readmission when required, and outreach services at all stages.