Why does life get harder as you get older when you have a spinal injury and what can you do about it?

There is no denying how awful the first few weeks and months are after a spinal injury. The shock of what has happened to you; possibly an operation; the medical procedures that are required and the practical difficulties of simply “being”, can all be overwhelming. Many patients spend time in a spinal injuries unit for rehabilitation, and form strong and long lasting friendships. Then there is the move home, to reality, when the enormity of what has happened can really impact upon you.

After this acute period, you have to get on with life and adapt to living with your new difficulties. You may find that as you get older, especially two or three decades post injury, even though the actual injury hasn’t changed, life gets harder. The practicalities of daily life can become more of a struggle and more assistance or higher medicine doses are required. This could result in you not going out as much, putting on weight because you are less active and becoming depressed. Why is this?

A reduction in flexibility and strength is part of everyone’s aging process but when the body has abnormal stresses and strains to deal with, these age-related changes can be different. This applies whether you have a complete or incomplete spinal injury.  For example, some physical stresses are less for people with a spinal injury; a person with a T8 injury will not be able to walk, therefore the stresses passing through their leg bones, joints and muscles will be less than normal. This in turn renders the bones thinner and more likely to break. This is osteoporosis and once diagnosed can require medication to control. Altering the transfer technique, using a dynamic standing frame and using FES (Functional Electrical Stimulation) assisted exercise bikes or rowers can all help with osteoporosis. Carrying out a standing program using a dynamic standing frame or FES equipment is now recommended from the early stages of rehabilitation but can be started years after the initial injury with good effect.

Alternatively if you are a wheelchair user you will experience higher than normal stresses through your shoulders from self-propelling and lifting during transfers. This can result in earlier than normal wear and tear through the shoulders and wrists in particular. The front of the rotator cuff system of muscles over the shoulder joint can be affected or impingement of part of the protective shoulder joint capsule can produce symptoms of stiffness and pain. Left unchecked, this can often require surgery which then has its own post-operative rehabilitation period when you are temporarily less independent. Wheelchair users also suffer from a higher than average incidence of carpal tunnel syndrome in their wrists which can also result in surgery.

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One of the most common problems of spinal injury sufferers is the slow subtle changes in posture. For wheelchair users and those walking with aids this is usually an increase in the flexed forward position in your chest and back, with the shoulders becoming increasingly rounded and the head jutting forwards. A flexed spine or “slumped” posture can become painful when it is difficult to straighten up and pressure is then taken through the base of the spine, which can cause pressure areas. This can be reduced with regular wheelchair clinic reviews and ensuring your seating system (wheelchair, cushion and back support) and bed mattress is optimal to assist you to achieve an upright posture. This is also something that the spinal injuries unit can help with at your annual review appointment.

The postural changes that occur can be controlled with daily stretches and exercises. These will be much more effective if you don’t view them as a “20 minute exercise chore” but build them into the day. For example, pull your shoulder blades back, lift your chest and straighten your back every time you have a meal.  Also, lift your head upwards and backwards every time you go through a doorway. A physiotherapist will be able to advise you on the best exercises to do. Back, neck and hip pain can often be relieved in this way, before it has a big impact upon function, e.g. transfers becoming more difficult

If you don’t stand frequently, the paralysed muscles in your thighs and calves can get short and tight, whilst others become long and lax. This imbalance muscle can increase the occurrence and severity of spasms which can be painful and have a knock on effect upon the quality of your sleep.  Spasms can wake you at night and prevent you getting back off to sleep. Physiotherapy to relieve the short tight muscles and move the paralysed limbs or trunk can reduce the painful spasms and prevent the need for increased analgesia or muscle relaxants.

As time passes a self-propelling wheelchair user’s body shape can alter; your arms become heavier and more muscular but your legs become thinner and lighter and the trunk shape is more flexed. This alters your centre of gravity and the transfer technique may need to be refined to allow you to retain your independence.

If you have been unable to position your feet flat on the floor or footplates then your calves can become contracted. Your heels are permanently raised and transfers with the feet on the floor are much more difficult and unsafe as your feet can slide forwards. Botulinum toxin injections or splints for the ankles can be effective in managing this problem alongside physiotherapy.

Other complications of spinal injury such as urinary tract infections, chest infections, pressure sores or broken skin and deep vein thrombosis can lead to temporary periods of reduced mobility, increased spasms and pain.  It is very important you take steps to ensure you regain your previous level of mobility and strength after the complication has resolved. Otherwise there is a risk of a gradual stepwise deterioration in function with every infection. The new reduced level of function can soon become the “new normal” and it can be very hard to regain the previous level of mobility or strength. A referral from the GP to the local community or outpatient neurological physiotherapist for a short course of physiotherapy to regain the pre complication level of function is very sensible.

There are so many new ways of helping individuals with spinal injury:

·         Electrical stimulation to increase muscle bulk on your legs or buttocks can prevent pressure areas,

·         Dynamic standing frames where you can move and strengthen your trunk and arms and improve your balance.

·         FES gym equipment

·         New wheelchair cushions and trunk supports

·         Splints and braces to support an area

In conclusion, some body changes are inevitable as spinal injury sufferers get older, but they can be well managed with good advice; other changes are avoidable with effective physiotherapy techniques; and some temporary changes can be recovered from with a course of neurological physiotherapy. The important factor is to spot when life is getting harder, work out why and then see what can be done about it. Spinal Injury Centres offer “care for life” and welcome re-referrals to the original centre for specialist input. As a neurological physiotherapist, I have never seen a spinal injury patient and find there is nothing I can offer them to improve their function.  

Life doesn’t have to get harder as you get older, and if you’d like some help achieving this please contact us