Susan ayers cambridge handbook of psychology he

892
Spinal cord injury
Paul Kennedy
University of Oxford
Aetiology, incidence and prevalence
The successful rehabilitation and community reintegration of
people with spinal cord injury (SCI) has only occurred in the past
60 years. Until rehabilitation was pioneered by Guttmann at Stoke
Mandeville in 1944, 90% of persons with a spinal cord injury died
within the first year. Now, most industrialized economies provide
comprehensive treatment and rehabilitation care for people with
traumatic and non-traumatic injuries. Almost half (47%) of traumatic
spinal cord injuries are caused by road traffic accidents
(see ‘Road traffic accidents’). Domestic and industrial falls are
the cause of 27%, and between 15 and 20% are from sporting
injuries. In the UK, 5% are caused by self-harm and 0.5%
from acts of violence. In the USA, 15% of injuries are caused by
criminal assault (Duff & Kennedy, 2003; Go et al., 1995). Causes of
non-traumatic injuries include infective diseases, ischaemic insults,
neoplastic disorders and multiple sclerosis (see also ‘Multiple
sclerosis’ and ‘Stroke’).
There are four males for every one female spinal cord injury.
The mean age is 28 and the mode is 19. The annual incidence of
spinal cord injury in the UK, like most other European countries,
is between 10 and 15 per million; in the USA it is thought to be
between 30 and 40 and in Japan, 27 per million. There are an estimated
40 000 people in the UK and 200 000 in the USA with spinal
cord injury. Life expectancy estimates vary: for a young, person with
an incomplete injury the relative (to normal population) survival
is 96%, but for complete tetraplegics over 50, it is estimated
to be 33%. A reasonably good life expectancy is probable for most
people. Primary causes of early mortality include pneumonia,
septicaemia, heart disease and pulmonary emboli.
The physical impact
An injury to the spinal cord occurs when sufficient force causes
the cord to be compressed, lacerated, or stretched and may be
associated with a fracture or fracture–dislocation of the vertebral
column and displacement of the inter-vertebral discs. These
hyper-extension injuries are often the consequence of sudden
impact as with car accidents and falls. The neurological losses will
depend upon completeness of the injury. Cervical (neck) injury may
result in tetraplegia (quadriplegia). Injuries to the thoracic, lumbar
and sacral levels (upper, middle and lower back) may result in
paraplegia. Of injuries, 53% are neck injuries and 47% are back
injuries. A complete injury is one in which all motor and sensory
functions are lost below the level of the injury, as well as the loss
of control of visceral functions, such as bladder, bowel and sexual
function. In paraplegia, lower trunk muscles are impaired whilst
cervical injuries result in loss of function in the hands, arms,
shoulder and diaphragm, as well as the lower thorax. Complete
injuries above the seventh cervical segment may preclude the
possibility of independent living. Sensory losses are similar to the
areas of motor loss, and include loss of touch, pressure, temperature
regulation and position. The loss of sexual sensation and responsivity,
control of bladder and bowel function are common to all
complete lesions above the sacral roots. Incomplete injuries may
result in partial damage of the cord. Complications post-discharge
include pressure sores, urinary tract infections, muscular spasm
and chronic pain.
Rehabilitation
Most people are transferred to a specialist spinal cord injury
treatment and rehabilitation centre shortly after the onset of the
disorder. Once any fracture is stabilized, generally through internal
fixation, or, more rarely, external fixation or postural reduction, the
person begins a period of rehabilitation which can last between
three and six months, depending on the level of the injury and
social circumstances. Rehabilitation enables the person to acquire
new skills to address their needs and adjust physically, socially
and psychologically to their physical disability (see ‘Disability’).
This includes learning to manage bladder and bowel functions,
wheelchair use and the maintenance and development of functional
independence skills. Exploring adaptations to accommodation,
financial independence and personal assistance needs may also
be necessary. People also require information about their new
needs and emotional support in maintaining general psychosocial
wellbeing.
Psychological reactions
A spinal cord injury requires major adjustments to physical, psychological
and social domains. The extent to which people manage
the consequences of the disability will depend on internal psychological
factors, such as self-efficacy, beliefs about disability and
coping strategies and external factors, such as prevailing social
attitudes and social support (see ‘Self-efficacy and health’, ‘Social
support and health’ and ‘Lay beliefs about health and illness’).
The cultural beliefs that underpin social policy are important,
given that it is not the specific disability that causes most of the
difficulties, but existing within physical, psychological and socially
disabling environments.