RHS 403 Spinal Cord Injury

Sacral Level (S1-S4)

Ambulation is usually possible with little or no equipment. Bowel and bladder function may still be affected to some degree. In most instances, individuals are able to recover most preinjury function.

cervical level (c1-c8)

An injury to the spinal cord at the cervical level (C1 through C8) results in quadriplegia (paralysis of both upper and lower extremities) (see Figure 7-1). Injuries at C1 or C2 can be fatal because the functioning of all muscles, including the muscles of respiration, is lost. Due to weakness or paralysis of muscles of respiration with injuries at the cervical level, especially those involving injury at the C1 through C4 level, respiratory assistance with a mechanical respiratory device or ventilator may be necessary. Individuals with higher-level injuries are more susceptible to respiratory infections and pneumonia due to their inability to expectorate mucus effectively owing to paralysis or weakness of respiratory muscles. Individuals with injuries at the cervical level will likely require assistance from others for self-care. Most individuals with spinal cord injuries at C4 or above use a personal attendant for hygiene care, dressing, and transfers. Wheelchair ambulation may be possible through use of a mouth stick, which individuals can employ to manipulate an electric wheelchair. With an injury at the C5 level, some gross movement of the upper extremities, such as bending the arm at the elbow, is possible. Individuals may be able to hold a light object between the thumb and finger, or may be able to maneuver small objects with the assistance of hand splints. Assistance will still be required for most activities, but individuals may be capable of transfer on their own with the assistance of special equipment. Although total independent living without some assistance may not feasible, independent electric wheelchair ambulation is possible. Individuals with injury at C6 also have gross motor movement of upper extremities and may be able to retain some independence in self-care, such as feeding and dressing with the aid of special orthotic equipment. Propelling a wheelchair manually may be possible, with a modified hand rim, although many individuals continue to operate a motorized chair. With the use of hand splints, individuals may also be able to write. Independent transfer from bed to chair or to a car may also be possible, as is driving with the use of special assistive devices. Individuals with C7 injuries are capable of straightening their arm and are able to sit up in bed, dress themselves, and transfer. With some adaptations in the environment, almost total independence may be achieved. Fine motor movements of the hands are affected, but writing may be possible with the use of a special device that can be strapped to the hand. Likewise, driving is possible with hand controls. With C8 injuries, individuals have some sensation in their hands and may become totally independent with a modified environment and some assistive devices.

vocational issues

Employment rates for individuals with spinal cord injury vary widely. Employment for an individual with spinal cord injury, just as with other health conditions, depends on the person's psychosocial characteristics as well as the physical, social, economic, and political environment. A critical factor in employment after spinal cord injury is the extent to which an individual can return to work in the same occupation in the same position as prior to the injury. The level of injury and the individual's previous occupation determine, to a great extent, the amount and type of activity the person will be able to perform and the assistive device or special accommodations needed. For instance, individuals with injuries at the thoracic level will probably require a wheelchair for mobility but will have full use of the upper extremities. Consequently, an individual who is an accountant, for instance, would be able to continue in his or her profession with only some environmental modifications. In contrast, an individual with a high cervical injury with no upper extremity function who had worked as a construction worker may require change of occupation or retraining for another type of position in the field that does not require the same type of physical mobility and stamina. In all instances, the individual's interest and aptitude should be considered. Environmental barriers such as steps, table heights, and width of doorways will need to be considered in the work environment. Given that many individuals with spinal cord injuries also have difficulty with temperature regulation, the work environment should be climate controlled. Other factors to be considered are the individual's ability to sit for long periods of time, strength, endurance, and transportation available. With a higher level of injury, in which there may be diminished breathing capacity or for which ventilator assistance is required, attention to environmental pollution and cleanliness of the air in the work environment should be considered. Other workplace modifications, such as flexible scheduling including shorter work days or longer rest periods, may also be helpful to attaining or maintaining employment. Unless individuals have an associated brain injury, there should be no cognitive deficits associated with spinal cord injury. Preinjury education, vocational interests and skills, and congruence with level of functional capacity after injury are important considerations in vocational placement. Age and the presence of financial disincentives are other factors that may influence an individual's employment status . Spinal cord injury is a lifetime condition. As natural physiological changes occur with aging, additional interventions or equipment may be needed. Consequently, periodic checkups should be instituted to identify individuals who are experiencing difficulty in the workplace or who encounter new barriers to access so that appropriate accommodations can be instituted.

lumber level (L1-L5)

Many of the muscles of mobility are intact with L1 through L5 injuries. All upper body muscles and many of the leg muscles remain functional. Ambulation with braces or use of a cane or crutches may be possible, especially for short distances. Individuals are able to gain total independence in care, although hand controls may be necessary for operating a motor vehicle. Bowel and bladder function are still affected, however, reflex emptying of bowel and bladder may be possible.

thoracic level (t1-t12)

Spinal cord injuries occurring at T1 or lower result in paraplegia (paralysis of the lower extremities). Upper extremities for the most part are unimpaired, with the exception of T1 injuries, in which there may be slight weakness and some loss of flexibility in the hands. Individuals with an injury between T1 and T3 experience paralysis of the muscles of the trunk even though the upper extremities are functional. Consequently, they may need a brace or other support to maintain posture in an upright position. In most cases, individuals with injuries at T1 through T12 are able to attain total independence in self-care, wheelchair ambulation, and transfer. Although individuals with injuries at T7 to T12 may be able to walk with the use of long leg braces, because of the strenuous nature of the activity, ambulation may be possible for only short distances.

Autonomic Dysreflexia

a complication of spinal cord injury usually above T6. It is caused by loss of coordinated response by the autonomic nervous system, causing an exaggerated response to stimuli below the level of the injury, such as an overextended bladder, pressure sores, or constipation. This atypical reflex condition is characterized by a sudden rise in blood pressure, profuse sweating (diaphoresis), and headache as the result of excessive neural discharge from the autonomic nervous system. Unless immediate management is instituted to decrease the blood pressure, this condition carries a risk of stroke. Identifying and avoiding situations or conditions that trigger autonomic dysreflexia are important in the prevention of this condition.

contractures

(loss of range of motion, or fixed deformity of a joint) may occur in paralyzed limbs if the joints are not moved through their regular range of motion. Contractures of the upper extremities in individuals with quadriplegia can interfere with the use of assistive devices. If individuals with paraplegia or quadriplegia develop contractures of the hip or knee, it may be difficult to assume adequate positioning in a wheelchair. Regular movement of joints through the full range of motions via passive exercise conducted by another person or through use of special equipment can prevent contractures from occurring. In addition, proper wheelchair seating and correct positioning of joints can help reduce the risk of contractures.

sexuality

Attitudes and beliefs of society often reduce human sexuality to the physical components rather than recognizing that the physical aspects of sexual activity are merely one part of sexuality. Sexuality also relates to feelings of sexual attraction, emotional intimacy, and affection. Although physical changes associated with spinal cord injury usually necessitate some modification in sexual behavior, individuals with spinal cord injury continue to be sexual beings. Sexual adjustment is an integral and necessary part of total psychological adjustment. Individuals with traumatic spinal cord injury should be provided with opportunities to obtain accurate and complete information about sexual activity in conjunction with spinal cord injury, and information should be provided in the context of their personal values. Discussion of sexual needs and reassurance that sexual expression is still possible in their life are important parts of rehabilitation. Alteration of physical mobility after spinal cord injury may alter certain aspects of sexual relations and will most probably necessitate modification of technique. Elimination of physical barriers and provision of appropriate accommodations are important aspects of enabling individuals with spinal cord injuries to engage in sexual activity. Depending on the extent of immobility associated with the injury regarding use of upper extremities, personal assistance may be required to engage in sexual activities, meaning that more than two people may be involved in the process. This type of accommodation, like any other accommodation, should be handled with delicacy and sensitivity. Bowel and bladder care may need to be performed prior to engaging in sexual activity to prevent incontinence during the activity. Concerns about experiencing bladder or bowel incontinence during sexual activity may be a deterrent to engaging in sexual activity. Learning bladder and bowel management techniques and performing them prior to sexual activity can reduce some of the stress and anxiety associated with concerns about incontinence. Sexual attraction to others, sexual desire, and the need to express oneself as a sexual being continue after spinal cord injury. Many men and women remain sexually active after spinal cord injury. Modification of sexual techniques, assistive devices, and other accommodations provide the means by which sexual activity can be continued after spinal cord injury.

Altered Manifestations of Other Health Conditions

Because of the lack of sensation that accompanies most spinal cord injuries as well as the interruption to nerve pathways, manifestations of various conditions unrelated to the spinal cord injury itself may not be recognized and, as a result, may not receive prompt attention and management. For example, because pain is not felt, appendicitis may not be discovered until the appendix ruptures. In some instances, manifestations of a condition may be expressed differently in individuals with traumatic spinal cord injury than in individuals without spinal cord injury. For example, individuals without spinal cord injury may experience severe flank pain in response to a kidney infection, whereas individuals with spinal cord injury may experience an abrupt increase in spasticity with the same infection. As a result, the manifestation may not be recognized as being related to kidney infection and, consequently, the kidney infection may not be immediately identified and managed. Individuals with traumatic spinal cord injuries, caregivers, and professionals should be made aware of alterations in the presentation of manifestations of infectious or other conditions and should be alerted to report or investigate new manifestations or accentuated old manifestations as soon as they are noted.

difficulty with sweating and thermoregulation

Body temperature is under the direct control of the autonomic nervous system. Normally when cold or warm is perceived by peripheral receptors a message is sent to the hypothalamus in the brain. The message is interpreted and an appropriate response stimulated (i.e., shivering in order to maintain heat, or perspiring in order to cool the body). With spinal cord injury, this connection is lost due to autonomic nervous system dysfunction, and individuals are unable to regulate body temperature effectively. Consequently individuals with spinal cord injury may experience abnormal regulation of body temperature or may be less able to respond to changes in environmental temperatures. The inability to effective respond to changes in temperature put individuals at risk of developing hyperthermia (abnormally high body temperature) or hypothermia (abnormally low body temperature). This may place individuals at risk in situations in which there are extreme environmental temperatures, or during some activities, such as exercise. Although normally sweating can help individuals regulate body temperature, individuals with spinal cord injury, due to autonomic nervous system dysfunction may experience hyperhidrosis (excessive sweating) above or below the level of injury. The condition can be a source of embarrassment as well as discomfort for the individual.

osteoporosis

Bone is a dynamic substance that is characterized by continual deposition and reabsorption of calcium. The combined stress of weight bearing and muscle pull that occurs with activity helps bones maintain their calcium content. Conversely, inactivity can contribute to softening and weakening of bones (osteoporosis). Bone mineral density is lost in paralyzed limbs after spinal cord injury due to mechanical, hormonal, and neural factors (Dudley-Javoroski et al., 2016). Individuals with spinal cord injuries have an increased rate of calcium removal from the bone and, therefore, are more susceptible to fractures, which could be caused by either falls or simple activities such as wheelchair transfer (Frotzier, Cheikh-Sarraf, Pourrtehrani, Krebs, & Lippuner, 2015). Calcium, which is excreted through the urinary system, can also contribute to formation of urinary tract stones. In some instances, calcium is deposited in soft tissues so

cardiovascular complications

Cardiovascular complications after spinal cord injury are of major importance since they account for the highest cause of death in this group (Phillips & Krassioukov, 2015). In the acute stage after a spinal cord injury, individuals are susceptible to thrombophlebitis (formation of blood clots in the legs) or pulmonary embolism (a blood clot that travels to the lungs), a potentially life-threatening disorder (Partida, Mironets, Hou, & Tom, 2016). Individuals may also experience orthostatic hypotension, a condition in which the blood pressure becomes significantly lower when the individual moves from a flat position to an upright position, resulting in manifestations such as dizziness or fainting (syncope). In some individuals, orthostatic hypotension may persist after the initial rehabilitation period. Orthostatic hypotension or postural hypotension can affect activities of daily living and interfere with ability to participate in a variety of other activities (Partida et al., 2016). Management of orthostatic hypotension is directed toward individuals recognizing factors that may precipitate an episode— for example, heat stress or alcohol ingestion. Some individuals may use compression bandages or support stockings on the lower extremities to prevent pooling of blood in the extremities. In other instances, medications may be utilized to ward off this complication. Individuals with spinal cord injury also have a more sedentary lifestyle, which can affect the cardiovascular system as a whole. Because of increased susceptibility to cardiovascular conditions, individuals with spinal cord injuries should refrain from smoking or use of tobacco products as well as excessive alcohol consumption. Good nutrition, an exercise program, and weight control are other important measures for prevention of cardiovascular disease. Individuals with spinal cord injuries, because of their increased risk of developing cardiovascular conditions, should undergo regular healthcare examinations and seek out comprehensive healthcare programs that are familiar with and accommodate the needs of individuals with spinal cord injury.

chronic pain

Chronic pain is a significant issue for individuals with traumatic spinal cord injury (Cardenas etal., 2013). The frequency and severity of pain in those who experience it varies widely. Although the degree to which chronic pain interferes with daily functions inside and outside the home differs from individual to individual, in general pain can contribute to increased distress and decreased social integration. Pain in spinal cord injury can be incapacitating and persistent and can occur both above and below the level of injury. The most common type of chronic pain experienced in individuals with traumatic spinal cord injury is neuropathic pain, which is the result of atypical processing of sensory messages due to the spinal cord injury (Ling, 2016). Individuals may also experience musculoskeletal pain due to poor posture or overuse of musculoskeletal structures during activities such as transfer. A variety of interventions are utilized for management of chronic pain after traumatic spinal cord injury, including medication and alternative interventions such as massage and acupuncture. Pain relief is often achieved only over short periods of time; in many individuals, pain proves to be refractory to management. Because pain is an individual phenomenon, in most instances management of pain in individuals with traumatic spinal cord injury is also individualized. It may encompass, in addition to medication, a holist approach that includes exercise, stress reduction, counseling, or alternative interventions such as acupuncture.

Activities and Participation Environmental Modifications

Given the physical ramifications of traumatic spinal cord injury and the environmental constraints imposed by such injury, individuals must make modifications not only in their daily routines but also in their personal, social, and occupational spheres. For example, extra time may be needed for daily activities related to personal hygiene. Individuals may need to conform their daily routines to a structured bowel and bladder program. Transportation or moving from one place to another may require extra time and planning. Awareness of environmental constraints, environmental modifications that are needed, and assistive devices that can support functional capacity enables individuals to establish and adjust daily routines and enhance their ability to participate in social and occupational activities. For individuals using wheelchairs, the environment should be conducive to wheelchair use. There needs to be accessible entrance into buildings and interior doors wide enough for wheelchair passage. If the entrance to a building is not level with the ground, a ramp can provide access. For multilevel buildings, elevators are needed in lieu of stairs. Thick carpeting can also impede smooth wheelchair passage. Furniture of standard height may be uncomfortable or awkward, especially for transfer. Modification of furniture legs to shorten them may be necessary. Counter or desk heights may also need to be modified for the wheelchair to fit under the structure. Bathroom facilities may need to be altered— for example, by lowering the toilet seat or providing hand bars— or devices such as a toilet transfer board may be needed. Individuals with spinal cord injuries must adopt new behaviors and mobility techniques to function in the environment, but they must also continually adapt to their changing environment. Although spinal cord injury causes radical changes in mobility and independence, most individuals are able to return to their community, and many can return to their own homes with environmental modifications. The degree of successful reentry into the community depends to a great degree on the individual's social support, access to adequate housing and transportation, and availability of quality attendant care if needed.

potential complications

In addition to altered functional capacity, individuals with traumatic spinal cord injury are confronted with a number of short-term and long-term issues that require ongoing constant attention (Guertin, 2016). Individuals with traumatic spinal cord injury are at risk of developing additional health problems that could result in a secondary condition and, consequently, more functional implications. Development of complications can hamper individuals' ability to work as well as interfere with their social relationships. Some complications associated with spinal cord injury can also be fatal. The risk of developing complications is related to the level of injury. In general, the higher the level of injury, the greater the risk of developing secondary incapacitating conditions. It is, therefore, imperative that individuals with spinal cord injuries, family members, and professionals working with them be aware of this risk and the prevention strategies to lessen the risk. When complications do arise, it is crucial that they be treated immediately.

manifestations

Manifestations experienced as a result of traumatic spinal cord injury relate not only to whether or not the spinal cord is completely severed but also to the level at which the injury occurred. If spinal nerves are unable to transmit messages between the central nervous system and the peripheral nervous system, function below the level of injury will be disrupted. The degree of functional loss depends on the degree to which the spinal cord is injured and the location of injury. In the case in which the spinal cord is only partially severed the individual may experience paraparesis meaning that some function exists below the level of injury. For example, if afferent nerve roots (sensory tracts), which carry messages to the brain were injured, some degree of sensory loss below the level of injury may exist, or if efferent nerve roots (motor tracts), which carry messages from the brain were injured, some motor loss below the level of injury may be experienced. When both sensory and motor tracts are injured, both motor and sensory loss below the level of injury can be affected In general, the higher the level of the spinal cord injury, the greater the functional implications. When the individual's injury affects only the lower extremities, they experience paraplegia (paralysis of lower extremities). If all four extremities are affected they experience tetraplegia (paralysis of all four extremities).

operating a motor vehicle

Motor vehicles, in addition to being a mode of transportation, serve as a symbol of independence. A wide range of vehicle options and special assistive devices are available for use after spinal cord injury. Hand-operated controls and other modifications enable individuals with paraplegia as well as individuals with quadriplegia who have gross motor movement of the upper extremities to operate motor vehicles and transport wheelchairs. The vehicle should meet the needs of the specific individual

Pressure Sores (Decubitus Ulcers)

One of the most common complications associated with spinal cord injury is pressure sores, also called decubitus ulcers (Joseph & Nilsson-Wikmar, 2015). Pressure sores develop when continuous pressure is exerted to a body part over time (van Weert et al., 2014). These wounds are formed when soft tissue is pressed between bony areas of the body and an external surface. People with spinal cord injuries are at increased risk of developing pressure sores, which result from lack of blood supply (ischemia) to a body pressure point. Areas of the body that are particularly vulnerable include the buttocks, sacrum, heel, and back. Pressure on a body part interferes with blood supply, eventually resulting in breakdown and ulceration of the skin. Because individuals with spinal cord injury are often immobile, areas of pressure on certain bony prominences are more likely to develop. As individuals with spinal cord injury usually have no sensation below the level of injury, they are unable to feel pressure; moreover, because of the paralysis, they are unable to easily shift their weight to relieve the pressure. Inadequate skin care, irritation, and nutritional deficiency can further contribute to the development of pressure sores.

Pneumonia and other pulmonary problems

Pneumonia and other pulmonary complications are common in individuals with spinal cord injuries, especially those with quadriplegia (Johnson etal., 2008). Although these complications become less likely 1 month after the injury, individuals with spinal cord injuries continue to be more prone to developing pulmonary conditions, such as pneumonia, which can be both incapacitating and life threatening. Individuals with high cervical or high thoracic injuries, because of their weakened chest muscles, have more difficulty in expanding the lungs and clearing secretions. Consequently, they are more susceptible to infection of the lungs. Individuals with higher-level injuries may also have difficulty deep-breathing and removing secretions, contributing to their increased risk of pulmonary complications. Individuals with spinal cord injuries should avoid exposure to persons with pulmonary infections as much as possible, as well as avoid smoking and air pollution.

recreational activities

The focus of many rehabilitation programs specializing in spinal cord injury is on helping individuals attain optimal function related to self-care or employment. Typically, only minimal attention is given to recreational activities, which could enable individuals to become active in a larger social sphere. Lack of structured peer recreation activities and peer support can lead to social isolation and impede individuals' feeling of living effectively with their condition. After spinal cord injury, the level of participation in social and recreational activities will depend on the attitude and interests of the individual, the number of recreational opportunities and resources available, access to appropriate assistive devices, and adequate sources for equipment repair. Assistive devices that enable individuals with spinal cord injuries to participate in many sports and other recreational activities are available, although other considerations— such as adequate transportation, quality attendant care if needed, and other environmental restrictions— must also be considered. The trend toward increased access to public buildings, businesses, and services is enabling individuals with spinal cord injuries to participate more fully in a broader range of community activities as well as to explore and pursue a number of social roles. Unfortunately, many architectural and attitudinal barriers still exist. Consequently, to live most effectively with their condition, individuals with spinal cord injuries must learn self-efficacy and take on the role of self-advocate

social and family participation

Traumatic spinal cord injury affects the individual who has been injured as well as the network of others around him or her. Societal reactions may vary depending on the degree of experience persons have had with individuals with spinal cord injury. People in the social environment may be uneducated about how to interact with someone in a wheelchair. There may be instances of insensitivity, such as standing in front of the individual in a wheelchair at an art museum, thereby blocking the person's view, or asking insensitive questions. In other instances, individuals in the social environment may attempt to assist without being asked, and without help being needed, such as by grabbing the handles of the wheelchair and pushing the individual in a direction he or she may not wish to go. In still other instances, people in the social environment may avoid the individual with spinal cord injury altogether because they are unsure how they should behave. Although public education programs can be useful, the most beneficial solution may be for the individual with spinal cord injury to be prepared for societal reactions he or she may encounter and to learn to be assertive and how to respond. Although many families adjust to changes associated with spinal cord injury of the family member, some relationships and roles may need to be reexamined, negotiated, and redefined. In some instances, family members may experience shock, denial, anger, or depression after the injury. Depending on the circumstances surrounding the injury, they may blame the individual or others for the injury, which may in turn contribute to hostility, pessimism, anxiety, and higher levels of social distress. In other instances, families may feel overwhelmed because of financial strains, caregiving responsibilities, or role changes. Family relationships may be further strained if there is stress related to financial strains or if responsibilities related to providing assistance to the individual with spinal cord injury are perceived as overwhelming. Family members may need education about spinal cord injury as well as encouragement and support so they can cope and, in turn, offer support to the individual. Role obligations may need to be shifted, negotiated, and shared. A variety of professionals can assist family members in addressing pertinent issues and managing stress. Education and feedback can facilitate communication between the individual and family members, thereby providing a structure for understanding and problem solving..

Personal and Psychosocial Issues

Traumatic spinal cord injury can bring about drastic life changes in terms of both physical and psychosocial functioning. Manifestations of spinal cord injury may necessitate change in employment, bring about changes in social patterns and relationships, and alter general activities of daily living. In addition to experiencing changes in movement and sensation, individuals with traumatic spinal cord injury experience decreased mobility and independence, changes in bowel and bladder functioning, and changes in sexual functioning. These changes can contribute to altered self-concept or loss of self-esteem. How individuals adjust to changes associated with traumatic spinal cord injury will, to some degree, be related to how they conceptualize the losses experienced, their individual coping style, and the amount and type of social support available. Adaptation to incapacitation varies from individual to individual. Life satisfaction does not appear to be related to the severity of the injury but rather to how individuals perceive alteration in function related to life goals and meaning or purpose in their life. Perception of the degree of loss of physical function, and its relationship to family and social relationships, work, or other life goals, may be more important in predicting any individual's subjective well-being than the manifestations of the injury itself. Although depression is common after spinal cord injury, this condition is not universal and is not necessary for adjustment to occur. Some individuals are more likely to exhibit depressive manifestations after traumatic spinal cord injury than others. Individuals who had difficulty coping with stress or who had a history of substance abuse or relationship problems prior to the injury may demonstrate difficulty adjusting after injury, consequently psychological manifestations after injury may have greater impact on overall rehabilitation than the physical consequences of the injury. After spinal cord injury, changes in function that affect perceived roles in work, social, or family environment can alter personal identity and can trigger loss and stress reactions. Posttraumatic stress disorder (PTSD) has also been linked to traumatic spinal cord injury in some. Not all individuals with spinal cord injury experience incapacitating psychological manifestations. In general, individuals who demonstrate greater internal locus of control and a sense that the world is manageable and meaningful also exhibit less psychosocial distress and better adaptation.

Urinary tract and bowel complications

Urinary tract infections are the most frequent complication of spinal cord injury. Individuals with spinal cord injuries are especially prone to urinary tract infections because of the inadequate emptying of their bladder. The bladder may not empty often enough or may not empty completely, leaving urine in the bladder that then acts as a reservoir for infection. Because individuals with spinal cord injury are generally unable to control their bladder, they may need to have a catheter inserted into the bladder to drain urine and prevent incontinence. The bladder and its contents usually contain no pathologic organisms, but there is always the potential for the introduction of infectious organisms when a catheter is inserted into the bladder. For individuals with spinal cord injury, urinary tract infection can be a serious, incapacitating, and, at times, life-threatening problem. Untreated urinary tract infection can lead to pyelonephritis (infection of the kidney) and, in severe cases, septicemia (infection in the blood). Due to inactivity because of paralysis, the amount of calcium in the blood increases. As a result, the risk of developing kidney stones (renal calculi) is increased. A stone may form in the kidney itself or may lodge in the ureters (tubes leading from the kidney to the bladder) so that it obstructs urine flow, causing urine to back up into the kidneys (urinary reflux) and eventually damaging the kidney itself. Education of individuals with spinal cord injuries about the urinary tract, risk of its infection, and ways to decrease the risk of infection or stone formation is crucial in preventing secondary urinary tract complications. In addition, individuals with spinal cord injuries should be made aware of the importance of self-monitoring and promptly reporting manifestations so that immediate identification of infections or other conditions and appropriate management may be instituted. Secondary conditions related to bowel elimination may also be problematic. Incontinence of fecal material may not only contribute to skin breakdown and urinary tract infection but also result in social isolation if individuals become concerned about the possibility that incontinence might occur. Other problems may relate to impaction (fecal matter that becomes hardened and is unable to be evacuated) and paralytic ileus (a condition in which the intestine ceases to function). Individuals can decrease their risk for developing these conditions by establishing a pattern of regular elimination, monitoring their diet and fluid intake, and learning specific techniques to enhance optimal bowel function.

Spasticity

refers to exaggerated involuntary movement of muscles that results in exaggerated muscle jerks, hyperexcitability of reflexes, and muscle spasms. It can restrict activities of daily living, cause pain and fatigue, disturb sleep, contribute to the development of contractures, and affect individuals' self-image (Hagan, 2015). Not everyone with traumatic spinal cord injury develops spasticity. Some persons who do not experience spasticity immediately after injury may nevertheless experience it long after leaving the rehabilitation facility. Because communication between the peripheral nervous system and the brain is interrupted by spinal cord injury, signals received by the peripheral nerves are "short-circuited." Rather than traveling to the brain to be interpreted and appropriately adapted, the signal instead returns from the spinal cord directly to the muscle. The resulting muscle contractures can sometimes be violent and can occur with even slight stimulation. Spasticity can be incapacitating, not only because it is disruptive and can potentially cause embarrassment to the individual but also because in some instances it can be so strong that it causes individuals to fall from their wheelchairs. In addition, spasticity can contribute to formation of contractures. Although in some instances spasticity can be useful to help individuals perform certain functions, such as shifting position or standing, more often it is a source of discomfort. There is no unique way to successfully manage spasticity in all individuals. Instead, how spasticity is managed is based on individual goals. For example, management may be focused mainly on preventing complications such as contractures. In other instances, management may be directed toward increasing individuals' ability to perform various motor tasks. When spasticity is a cause of concern for an individual, a physical rehabilitation program using a variety of modalities may help diminish its frequency. In other instances, antispasticity medications may be used