Anatomical and Physiological

After a spinal cord injury, all nerves above the level of the injury continue to work as they always have. Most persons with injury at or above cervical vertebrae level 3 (quadriplegia) require a ventilator to breathe and have no extremity function. Persons with C-4 injuries regain breathing functions, but have no function in their extremities. Thus, they need assistance with nearly all daily activities, including feeding and dressing. People with injuries at C-5 are usually able to bend the arm at the elbow and have some wrist and hand function, but have no lower extremity functioning. However, people with C-5 injury are able to use a power wheelchair for mobility. Depending upon the location and severity of the injury, people with injuries below C-5 can generally lead independent lives. With certain modifications, they can operate a manual wheelchair, transfer from the wheelchair to chair or automobile, drive a properly equipped van or regular automobile, and use assistive devices to carry out daily activities.

Injuries at or below thoracic level 1 result in paralysis of the lower extremities (paraplegia). People with SCI below T-12 may be able, with much effort, to ambulate using crutches or braces. The nerves in the sacral area control the bowel, bladder, and sexual functioning. Thus, most SCI individuals lose voluntary control of their bowel and bladder functions.

While people with injuries at or below lumbar level 1will experience impairment of bowel and bladder functioning, reflex emptying (for example, tapping on the lower abdomen to trigger voiding) may provide some degree of control over these functions. People with injuries to the sacral region usually can ambulate with little or no equipment. Their bowel and bladder functioning will usually be impaired, and they likely will not develop bowel or bladder reflexive responses.

The resulting immobility and physiological changes resulting from SCI outlined above can result in a number of complications that cause discomfort and can contribute to further debilitation, hospitalization, and sometimes, death.

• Pressure sores are constant and major problems for people with SCI. These ulcerations develop when pressure on a certain part of the body (usually the sacral or buttocks area) interferes with the blood supply and causes a breakdown and ulceration of skin in that region. Most SCI individuals cannot feel the pressure and/or, because of paralysis, cannot shift their weight to alleviate the pressure.

• Loss of range of motion or fixed deformity of a joint caused by paralysis (contractures) will result if the joints are not moved through their range of motion. These contractures interfere with the use of assistive devices including positioning in a wheel chair.

• Urinary tract infections are a recurring problem for people with SCI. People who do not retain reflexive functioning in the bladder will need catheterization in order to void. Infections commonly occur because of unsanitary procedures in using a catheter. In addition, people do not empty often enough or completely, which allows bacteria to grow and multiply. People who have no feeling in the lower part of their bodies do not receive signals telling them the bladder needs to be emptied. If the bladder becomes overly full, the urine can back up into the kidney and cause damage to these essential organs.

• People with SCI above T6 may develop autonomic dysreflexia characterized by a sudden rise in blood pressure, profuse sweating, dizziness, and headaches. Autonomic dysreflexia can result in response to a urinary tract infection, a blocked catheter, or some other kind of harmful stimuli. Unless immediate treatment is administered to bring the blood pressure down, the person is at risk of having a stroke.

• SCI causes the muscles of the lower extremities to atrophy (become smaller). Even though there may not be voluntary muscle function, there may be sudden and involuntary movement (spasticity) of the legs. Spasticity may cause discomfort, embarrassment and, in the most extreme cases, project an individual out of bed or a wheelchair. These involuntary movements may impede the effective use of a wheelchair or other motorized vehicle.

• Sexual dysfunction is especially prevalent in male SCI individuals. In addition to sensation loss, men may experience an inability to achieve or sustain an erection. However, reflex erections may be possible depending upon the location and severity of the injury.

• An individual with a complete SCI above the level of C4 will most likely require a ventilator to breathe. However, because of weakened chest muscles, individuals with thoracic or higher injuries may not be able to cough to clear their lungs and are prone to infections, particularly pneumonia.

• Osteoporosis, particularly in the lower extremities, begins to develop immediately after a spinal cord injury. In addition, the decrease in bone density may make an individual more prone to broken bones.

• Some individuals with SCI experience occasional severe or persistent dull, aching pain below the point of injury. In addition, persons who use a manual wheelchair and are able to transfer from one surface to another often experience pain in their shoulders, arms, and wrists.

Psychosocial

A person's response to a spinal cord injury evolves through a number of coping mechanisms prior to their ability to accept and adjust to the injury. Personal responses may include shock, denial, anger (rage, envy, resentment), and depression. Individual use of the coping responses will vary. Some people may fluctuate back and forth between responses, while others may employ more than one coping mechanism at a time. At one time, it was thought that a person had to go through all of the stages leading to adjustment before adjustment could be achieved. It is now recognized that people move through the various stages in different ways and may or may not pass through each stage en route to the level of adjustment that is finally achieved. The person's personality traits, cultural and ethnic background, and social support systems will play important roles in the adjustment and acceptance process.

The first reaction to spinal cord injury will be one of shock because of the sudden and irreversible consequences of the spinal cord injury and the realization that one's life has been irrevocably altered. A common reaction to being told you have sustained a spinal cord injury and are paralyzed is, "No, not me, it can't be true." This initial denial is a necessary phase and functions as a buffer after unexpected shocking news. Following this initial period of denial, individuals with spinal cord injury will react differently depending upon their personality makeup and the style and manner in which they have coped with difficult situations in the past. People who used denial as a main defense prior to the injury are likely to remain in denial for a longer period than will others who have used more constructive adjustment methods to dramatic life changes. People who confronted past stressful situations openly will be more likely to confront their injury in an open, constructive, problem-solving manner.

When the person can no longer deny the seriousness of the injury, denial is replaced with anxiety, anger, rage, envy, and resentment. The question then becomes, "Why me?" Anger is displaced in all directions and projected on the environment almost at random. This anger can be particularly devastating to family members and caregivers. During this stage, anger is directed at everything and everyone.

Following this period of stoicism, anger, and rage, persons with spinal cord injury may experience periods of depression. Approximately 25% to 40% of persons with SCI experience some form of depression. The incidence of suicide in persons with SCI is high. However, depression is a normal part of the process in mourning the loss of independence, loss of mobility, loss of body functions, financial losses due to the inability to work and the addition of extensive medical expenses, loss of normal sexual function, and the inability to participate in many of the normal activities of life.

These defense mechanisms allow a person with SCI to deal with an extremely difficult, life-altering event. The one thing that persists through all these stages is hope. Even individuals who are the most accepting, the most resilient, and the most realistic about their injury, hope for some "magic" cure. The glimmer of hope maintains them through days, months, and years of dealing with the effects of SCI.

There are personal factors that can aid or hinder a person's acceptance and adaptation to a spinal cord injury. A strong self-image and concept of self, an independent and optimistic attitude, motivation to overcome obstacles, and a realistic appreciation of one's body image can aid in the adjustment. A person's socio-economic status, age, education, intellect, financial resources, social support network, and available medical treatment can likewise impact their adjustment to the injury. The severity of the injury and the level of pain associated with the injury also impact acceptance and adaptation.

Other factors that may impact a person's adjustment include a tendency toward shorter hospital stays for persons with SCI. This may result in less time to accept the injury and to begin to plan for the future in a controlled, relatively risk free environment. Since SCI is a very visible disability, persons with SCI will be confronted with societal and attitudinal barriers that will impact their social relationships and job opportunities. For those who are married, divorce following injury is somewhat higher among people with SCI. Conversely, opportunities for marriage are generally lower for persons with SCI. Because of the debilitating effects of SCI, work may not be an option. Workplace accommodations required of prospective employers may adversely impact SCI individuals in their search for employment. Nearly 50% of individuals admitted to the hospital with severe trauma injuries, including SCI, were intoxicated at the time of injury. Persons with SCI and substance abuse problems experience additional psychological problems in adjusting to their injury.

• Ambulation

• Strength, coordination, stamina

• Self-care (eating, food preparation, dressing, toiletry, grooming, hygiene, shifts in body position)

• Control of bowel and/or bladder

• Range of motion in extremities

• Muscle control, reflex control

• Grasping, handling, hand/finger dexterity

• Muscle atrophy

• Pain

• Susceptibility to infections

• Preoccupation with limitation (adjustment to disability)

• Self-image, self-confidence

• Lack of initiative, inflexibility, irritability

• Feelings of isolation, aggressiveness

• Anger, depression, anxiety, low self-esteem

Research has shown that people with SCI who are gainfully employed stand a much better chance of surviving SCI for a longer period. Employment enriches their lives and can play a major role in their overall health and adjustment to SCI.

The primary obstacle to employment or reemployment of people with spinal cord injuries is paralysis. However, with assistive devices and special accommodations at the work site, people with SCI may still enjoy rewarding and productive employment. The development of new technologies such as voice activated computers and the growing number of people working from their homes may provide opportunities for employment for people with SCI. Statistically, people who were employed prior to their injury have higher employment outcomes, particularly those with less severe injury. However, they may need additional education or training prior to reemployment.

The costs to employers in accommodating people with SCI will be a deterrent in their hiring decisions. People with SCI have a higher than average rate of absenteeism due to illness. Employers may be reluctant to spend the money to remove environmental barriers and to provide a climate-controlled environment necessary for some people with SCI. They may see no cost benefit to adapting the necessary equipment or providing assistive devices that are necessary for persons with SCI to perform their work tasks. In addition, most employers provide group health insurance for their employees. The annual medical costs a person with SCI may require could substantially increase an employer's health insurance costs.

In addition to the physical impediments, age, intelligence, educational level, race or ethnicity, vocational interests, and socioeconomic variables may impact people with SCI in their ability to secure gainful employment. Primary among these personal variables is education and training which are vital to employment success for people with SCI. Research has shown that the higher the educational level, the higher the probability of employment. The mental functioning of people with SCI is the same as existed prior to injury unless there has been a specific injury to the brain. Therefore, education and training produce positive and rewarding outcomes. The level of intelligence of people with SCI will significantly impact their interest and motivation toward further education and training.

Younger people are likely to accept and adapt to their injury more quickly than an older person. They will be more prone to return to or seek out educational and training opportunities. As a result, there is a greater likelihood for employment. Older people with SCI may experience more medical problems that impair their return to work and they have less time to acquire new skills or benefit from vocational training. Minority status also impacts the ability of a person with SCI to acquire gainful employment since people in minority groups may face racial bias.

The vocational interests of a person prior to SCI will impact their employment options. It is unlikely that their interests will change because of the injury. Therefore, decisions related to education, training, and employment will reflect their personal interests and desires regardless of the physical impairments. One approach to addressing this issue is to examine the individual's transferrable job skills. By identifying the person's existing skills, the counselor can look for other types of employment where these skills can be used.

The support and stability of the family unit to persons with SCI may also play an important role in employment success. The loss of independence impacts all persons with SCI. Thus, preparations for going to work may take inordinate amounts of time and energy, and increased levels of stress if the caregiver is a stranger. Family support is particularly important for persons with quadraplegia, who must rely on another person for the most basic and personal care.

The level and availability of community resources and services, including transportation, medical facilities, counseling, physical therapy, and all of the other services required by people with SCI, will impact their employment options. If the needed resources and services are not readily available within their community, the time away from the workplace to travel to the service center will increase and may detrimentally affect their work.