What is the recommended physical therapy rehabilitation protocol for a 12-year-old patient with a T7 spinal cord injury, spastic paraplegia, long bone injury of the lower extremity, and an external fixator?

From the Guidelines

The recommended physical therapy rehabilitation protocol for a 12-year-old with T7 spinal cord injury, spastic paraplegia, long bone injury, and external fixator should prioritize prevention of complications and secondary issues, focusing on a phased approach that includes respiratory care, pressure ulcer prevention, and passive range of motion exercises, as outlined in recent guidelines 1.

Key Components of the Protocol

• Comprehensive evaluation to assess the patient's current condition and set realistic goals
• Initial focus on respiratory care with chest physiotherapy to prevent pulmonary complications
• Positioning to prevent pressure ulcers, with particular attention to high-risk areas such as the sacrum, heels, ischium, and occiput, as highlighted in the Clinical Practice Guidelines for Professionals entitled “Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury” 1
• Passive range of motion exercises to maintain joint mobility while respecting the external fixator, avoiding stress on the fixation points
• Introduction of spasticity management through gentle stretching, positioning, and possibly medications like baclofen, as prescribed by a physician
• Strengthening of upper body muscles with adapted exercises to promote independence, focusing on shoulder and trunk control for wheelchair mobility and transfers
• Functional training for activities of daily living and wheelchair skills when appropriate, with involvement of the family in training and psychological support for the patient

Considerations for the External Fixator

• Exercises must be carefully planned to avoid stress on the fixation points
• Pin site care is essential to prevent infection, with regular monitoring and maintenance as needed

Developmental Considerations

• The rehabilitation protocol should take into account the child's developmental needs during this critical growth period, with adaptations made as necessary to promote functional independence and accommodate bone healing.

From the Research

Critical Physical Therapy Spinal Cord Injury Rehabilitation Protocol

The recommended physical therapy rehabilitation protocol for a 12-year-old patient with a T7 spinal cord injury, spastic paraplegia, long bone injury of the lower extremity, and an external fixator is crucial for preventing complications and secondary issues.

• The primary goal of rehabilitation is to provide services required by the child for maximal recovery and to compensate for lost or impaired function while permitting the fullest development of potential in all areas 2.
• Spasticity is a common complication after spinal cord injury, affecting more than 80% of patients, and can lead to soft tissue and joint contractures and further impairment of function 3.
• The use of botulinum neurotoxin type A (BoNT-A) injections has been shown to reduce spasticity effectively and safely, especially in patients with mild to moderate spasticity 4, 5.
• Surgical management, such as tendon lengthening, release, and transfer, as well as selective neurotomy, may be necessary to reduce spastic muscle hypertonicity, restore balance, prevent further contracture, and improve posture and function 3.
• Spinal cord stimulation and intrathecal baclofen therapy are also treatment options for patients with severe spasticity after spinal cord injury, with both methods having their benefits and limitations 6.
• A personalized treatment algorithm, including experimental spinal cord stimulation and intrathecal baclofen therapy, can be developed for patients with severe spasticity after spinal cord injury 6.
• Early intervention with botulinum toxin injections, within the first 6 months of clinical course, can result in greater improvement in tone, goniometric performance, and pain 5.

Prevention of Complications and Secondary Issues

• Prevention of medical and/or physical complications that could interfere with rehabilitation or lead to greater disability is crucial 2.
• Regular monitoring and assessment of the patient's condition, including spasticity, pain, and range of motion, are necessary to prevent complications and adjust the treatment plan as needed.
• A multidisciplinary team approach, including physical therapists, orthotists, and other healthcare professionals, is essential for providing comprehensive care and preventing complications.

Key Considerations

• The patient's age, injury level, and grade of injury should be taken into account when developing a rehabilitation protocol 2, 5.
• The use of external fixators and other orthotic devices should be carefully considered and monitored to prevent complications and promote optimal healing.
• Patient and family education and involvement in the rehabilitation process are critical for ensuring a successful outcome and preventing complications.