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Introduction To Spinal Cord Injury

1. Understanding Spinal Cord Injury

1.1. The spinal cord

Any damage to the spinal cord is a very complex injury. People who are injured are often confused when trying to understand what it means to be a person with a spinal cord injury (SCI). Will I be able to move my hands? Will I walk again? What can I do? Each injury is different and can affect the body in many different ways. The following is a brief summary of the changes that take place after a spinal cord injury. It tells how the spinal cord works and what some of the realistic expectations are for what a person should eventually be able to do following a spinal cord injury.

The Normal Spinal Cord
The spinal cord is a part of your nervous system. It is the largest nerve in the body. Nerves are cord-like structures made up of many nerve fibers. The spinal cord has many spinal nerve fibers that carry messages between the brain and different parts of the body. The messages may tell a body part to move. Other nerve fibers send and receive messages of feeling or sensation back to the brain from the body, such as heat, cold, or pain. The body also has an autonomic nervous system. It controls the involuntary activities of the body; such as, blood pressure, body temperature, and sweating.

The nerve fibers that make up the communication systems of the body can be compared to a telephone system. The telephone cable (spinal cord) sends messages between the main office (the brain) and individual offices (parts of the body) over the telephone lines (nerve fibers). The spinal cord is the pathway that messages use to travel between the brain and the other parts of the body.

Because the spinal cord is such an important part of our nervous system, it is surrounded and protected by bones called vertebrae. The vertebrae, or backbones, are stacked on top of each other. This is called the vertebral column or the spinal column. The vertebral column is the number one support for the body. The spinal cord runs through the middle of the vertebrae (figure A).

The spinal cord is about 18 inches long. The cord extends from the base of the brain, down the middle of the back, to about the waist. The bundles of nerve fibers that make up the spinal cord itself are Upper Motor Neurons (UMNs). Spinal nerves that branch off the spinal cord up and down the neck and back are lower motor neurons (LMNs). These nerves exit (figure C) between each vertebrae and go out to all parts of the body. At the end of the spinal cord, the lower spinal nerve fibers continue down through the spinal canal to the sacrum, or tailbone.

The spinal column is divided into four sections. The top portion is the cervical area. It has eight cervical nerves and seven cervical vertebrae. Moving down the back, the next section is the thoracic area. It includes the chest area and has twelve thoracic vertebrae. The lower back section is the lumbar area and has five lumbar vertebrae. The bottom section has five sacral vertebrae and is the sacral area. The bones in the sacral section are actually fused together into one bone.

Source: Jackson, A.B. (2000). Overview of spinal cord injury anatomy and physiology. Retrieved from on August 20, 2012.

1.2. The spinal cord after injury

Damage to the spinal cord can occur from either a traumatic injury or from a disease to the vertebral column. In most spinal cord injuries, the backbone pinches the spinal cord, causing it to become bruised or swollen. Sometimes the injury may tear the spinal cord and/or its nerve fibers. An infection or a disease can result in similar damage. After a spinal cord injury, all the nerves above the level of injury keep working like they always have. From the point of injury and below, the spinal cord nerves cannot send messages between the brain and parts of the body like they did before the injury.

The doctor examines the individual to understand what damage has been done to the spinal cord. An X-ray shows where the damage occurred to the vertebrae. The doctor does a "pin prick" test to see what feeling the person has all over his body (sensory level). The doctor also asks, "what parts of the body can you move?" and tests the strength of key muscle groups (motor level). These exams are important because they tell what nerves and muscles are working.

A person's injury is described by its level and type. The level of injury for a person with SCI is the lowest point on the spinal cord below which there is a decrease or absence of feeling (the sensory level) and/or movement (the motor level).

Tetraplegia [formerly called quadriplegia] generally describes the condition of a person with a spinal cord injury that is at a level from C1 to T1. This individual can experience a loss of feeling and/or movement in their head, neck, shoulder, arms and/or upper chest.

Paraplegia is the general term describing the condition of a person who has lost feeling and/or is not able to move the lower parts of his/her body. The body parts that may be affected are the chest, stomach, hips, legs and feet. An individual with a level from T2 to S5 has paraplegia.

The higher the spinal cord injury is on the vertebral column, or the closer it is to the brain, the more effect it has on how the body moves and what one can feel. More movement, feeling and voluntary control of the body's systems are present with a lower level of injury. For example, a person with a C-5 level of injury has a decrease or loss of feeling and movement below the 5th cervical spinal cord segment. An injury at the T-8 level means the individual has a decrease or loss of feeling and movement below the eighth thoracic spinal cord segment. Someone with a T-8 level of injury would have more feeling and movement than someone with a C-5 level of injury.

Complete or Incomplete Injury
The amount of feeling and movement that an individual has also depends on whether the injury is complete or incomplete. A complete injury means there is no motor or sensory function in the S4 or S5 area, or anal area. If there is evidence of any motor or sensory function in this area, one of three incomplete injury classifications is given. Some people with an incomplete injury may have feeling, but little or no movement. Others may have movement and little or no feeling. Incomplete spinal injuries differ from one person to another because the amount of damage to each person's nerve fibers is different. This fact makes it impossible to accurately predict how much of an individual's sensory and motor function will return. There is a greater chance of return of some or all of a person's motor and sensory function if an individual is incomplete at the time of injury.

Changes after the Initial Injury
Sometimes the spinal cord is only bruised or swollen after the initial injury. As the swelling goes down, the nerves may begin to work again. There are no tests at this time to tell how many nerves, if any, will begin to work again or when this will occur. Some individuals have involuntary movements, such as twitching or shaking. These movements are called spasms. Spasms are not a sign of recovery. A spasm occurs when a wrong message from the nerve causes the muscle to move. The individual often cannot control this movement. In addition to movement and feeling, a spinal cord injury affects how other systems of the body works.

During rehabilitation, a medical team will assist you in learning new ways to manage your daily activities and stay healthy.

2. Life After Spinal Cord Injury

2.1. Early Emotional Changes

A spinal cord injury (SCI) is one of the most devastating of all traumatic events. It results in a loss of some or all of an individual's sensation and movement. It is common for individuals who are newly injured to have health problems. Plus, it takes time to build enough strength to be able to fully participate in daily activities.

Individuals who are newly injured will likely experience grief. This is a period of mourning that is similar to that following the death of a loved one. The difference is that you are grieving the loss of your sense of touch along with your ability to walk or use your hands. You will likely experience many different thoughts and feelings after injury. Some may seem extreme and others mild. There is no step-by-step grieving process, but some thoughts and feelings are common after injury.

  • Denial/Disbelief: You may first react to your injury as if nothing happened. You may refuse to accept that your loss of feeling and movement is permanent. Instead, you may see the injury as an illness similar to a cold or flu that will soon pass with time.
  • Sadness: Obviously, no one is happy to be injured. It does not matter what your level of injury. Extreme sadness is common after injury because you have experienced a great personal loss. Sadness is that down, or blue feeling that you have when something bad happens. However, it is important that you not confuse sadness with depression. Depression is a medical condition that requires professional treatment. You may be depressed if you have symptoms such as extreme sadness, inactivity, difficulty in thinking and concentrating, a significant increase or decrease in your appetite and/or time spent sleeping, and feelings of dejection, hopelessness or worthlessness. You may even have thoughts about suicide if you have depression.
  • Anger: Some people react to their injury with strong feelings of displeasure. You might lash out verbally or want to become physically violent towards others. You may feel angry toward yourself if your actions resulted in your injury. You may even feel anger toward God or someone else for causing your injury.
  • Bargaining: At some time following your injury, you may begin to admit to yourself that you have a serious condition. However, you may still want to hold onto the belief that your injury is not permanent. You may act as if you accept your injury as "the way things are," but your acceptance may come with the belief that you will be rewarded for your prayers and hard work in therapy and eventually recover from your injury at some point in the foreseeable future.
  • Acceptance: Grieving usually ends as you come to accept a realistic view of your current condition and find meaning in your life. You begin to think about your future as an individual with SCI and set goals to pursue in life.

2.2. Adjusting to spinal cord injury

Individuals who adjust well to unexpected events generally lead healthy, active, and happy lives after their injury. Individuals who do not adapt well to unexpected events tend to be less healthy, less active, and unhappier after their injury. Unhealthy behavior almost always leads to unhealthy results. When you neglect your personal care, you put yourself at greater risk for developing a wide range of health problems such as respiratory complications, urinary tract infection, and pressure sores. These problems can limit your ability to participate in activities. Substance abuse can complicate existing medical problems or lead to other health problems.

When you are first injured, it takes time to get use to your life after injury. Some people grieve longer than others, so the adjustment period is different for everyone. It may take as much as a year for you to accept the realities of your injury. You will also experience a continued process of adjusting to the unique issues that occur in your every day life as a person with SCI.

Healthy Adjustment to SCI
One of the biggest keys to adjusting to spinal cord injury is personal motivation. Individuals who are newly injured are often motivated to attend therapy sessions out of a desire to gain strength and function. You probably have a strong belief that your paralysis is only temporary, and you will soon return to your old, "normal" self. This hope is a common reaction after an injury. Unfortunately, it is far more likely for individuals to recover function based on their level and completeness of injury. In fact, only a few people actually fully recover from their injury. This does not mean that all hope is lost for a full or partial recovery. Almost all individuals with SCI continue to hope that they will walk again one day. However, a cure for paralysis may or may not come in your lifetime. A healthy approach to this reality is to move forward with your life after injury with the continued hope that advances in medicine will one day lead to a cure. In other words, do not wait on a cure to proceed with your life!

People who adjust well to life after injury are usually motivated to meet personal goals. These goals are different for everyone and often change throughout life. For example, your goal today may be to get a job, and you may want to have children in the future. Itt is up to you to find purpose in your life and the motivation to achieve your goals. It may help to think about what you wanted out of your life before you were injured. For example, you may have once strived for good health, an enjoyable job, and a loving family. There is no reason that you cannot continue to strive for the same things now that you have a spinal cord injury.

Healthy Family Adjustment to SCI
As an individual with SCI, it is important to recognize that your injury also has a tremendous impact on your family. Although they may not have to adjust to losing the use of their hands or ability to walk, your family may experience a loss of the way their life was before your injury. For example, they may have to adjust to the role of caregiver. They may need to work to help with family finances. All of the changes that they face can lead to added stress and anxiety. As your family comes to accept the injury, they face issues of adjustment similar to those you may experience.

Children are naturally curious and adjust to events by asking questions. They ask questions because they make few assumptions about how the injury impacts their life. Therefore, children adjust rather quickly to an injury if their questions are answered in a clear, honest manner.

If you are a family member, healthy family adjustment is, essentially, taking care of you. For example, you can take time away from your loved one to do those things that you enjoy. You can help minimize your stress and anxiety by working to replace your own false assumptions, unrealistic ideas, and irrational beliefs. You can start by learning the facts about SCI. Then, challenge your irrational beliefs with evidence to dispute your beliefs. Finally, replace your false information with facts. Hopefully, you will soon discover that you too are living a healthier, happier, and more satisfying life.

No matter if you have a spinal cord injury or not, you have control over your life by choosing how you want to think about your situation. You can be happy and more hopeful about your life, but it will only happen when you work to make it happen. Your thoughts, feelings, and behavior do not change overnight. It takes time to grieve your loss and come to accept the realities of the injury. Then, you face a continued process of adjusting to everyday issues of living with SCI. If you avoid false assumptions, unrealistic ideas, and irrational beliefs, you will give yourself more opportunities to reach your goals and have the life that you desire.

2.3. Pain after spinal cord injury

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. In general, people can experience acute and chronic pain. Most people experience acute pain when they have a disease or injury to the body. It usually begins suddenly and acts as a danger signal telling you that something is wrong and that you need help. This acute pain can be severe or mild, but it usually goes away as the body heals. Chronic pain is like acute pain in that it can start suddenly. However, chronic pain differs because it can build up over time and continue long after the body heals.

Pain after Spinal Cord Injury
Acute pain is common after a spinal cord injury (SCI). The pain may occur as a result of the damage to the spinal cord, or it may occur from damage to other areas of the body at the time of injury. It is also common for many individuals with SCI to experience chronic pain. It can occur in areas where there is normal sensation, and it can occur in parts of the body where there is little or no feeling after injury. The pain is very real and may have a great impact on daily living. A person in pain has difficulty carrying out daily activities. If you have pain, you can take three steps to help improve your overall quality of life:

  • Do not ignore the fact that you have pain! There are options for you to help manage the pain. Plus, pain can be a sign that there is a serious problem.
  • Talk to a doctor! It is important to first find the cause of the pain and the type of pain. Once your pain has been diagnosed, you and your doctor can decide how to best manage your pain.
  • Learn to manage your pain! Your goal is to reduce your pain as much as possible. The more you know about how you can help yourself, the better your overall quality of life.

Pain Management
Pain management usually includes treatment with medications, modified activities or a combination of both. It may not be possible to completely stop the pain, but an effective pain management program can lessen the intensity of the pain.

Pain management can be a very difficult process. Many times it is hard to know what is causing the pain in individuals with SCI. You should talk with a doctor who knows about pain after SCI before you try any medications or methods of managing pain. It can take time to work out how to best manage your pain. An effective pain management program depends on the type of pain you have. Secondary overuse is often managed by modifying activities that use the joint or body part that is in pain. This may include limiting or stopping activities that make the pain worse. For example, it may help to limit pushing a wheelchair if you have shoulder pain. It may be necessary to switch from a manual to a power wheelchair.

It is recommended that you pace yourself during certain activities. Here are some examples on how to effectively pace your activities:

  1. List all activities that you frequently overdo that result in an increase in your pain or fatigue. For example, if typing on a computer tends to increase your pain, list "typing on a computer."
  2. When doing each activity on your list, make a note of the time that it takes for you to experience an increase in pain or fatigue. For example, make a note if your pain or fatigue increases after 30 minutes of typing on the computer.
  3. Set a time limit for doing the activity that is well below the point when you experience an increase in pain or fatigue. When you reach that time, stop and rest. For example, stop and rest after 15 minutes of typing on the computer.
  4. Return to the activity after your rest period. The time that you spend resting will vary. You want to have enough rest time for you to continue the activity as outlined in numbers 2 and 3.
  5. Do not get in a rush to complete any activity. You should slowly increase your endurance by increasing the amount of time that you spend doing the activity and always include adequate rest periods.

If you are unable to relieve your pain through activity modifications like pacing of activities, it may be necessary to use medication such as opiates or nonsteroidal anti-inflammatory drugs.

Keys to Success in Managing Pain

  • Be flexible and cooperative
  • Work collaboratively with health care professionals to find solutions to managing your pain
  • Follow treatment instructions
  • Take an active role in treatment by asking questions, such as; Are there alternate drugs that are cheaper/safer?
  • Is the prescribed drug or treatment FDA approved?
  • Are there side effects from the medications or treatments?
  • Are there articles about a procedure or medication that you can read more about it?
  • Are there others who have used a treatment you can talk with about their experiences?

Pain Affects You
Pain not only affects the body, it also influences how you think and feel. As an individual experiencing pain, you probably have a hard time thinking about anything but pain. This negative thinking then affects your emotional responses. The fear that your pain might get worse if you do something may keep you from participating in enjoyable activities. Pain can also lead to feelings of anger or depression. Depression can make pain worse and result in social isolation.

If you are living with pain, there are some psychological approaches that you can take to help reduce your pain. You can learn to better cope with stress and overcome depression through professional counseling, although severe depression may require medication. Some techniques that you might learn through counseling include relaxation training, biofeedback and hypnosis. The Distraction technique may also help reduce chronic pain. When you have pain, it may increase when you are not active or you begin to relax such as before you go to sleep. This increase in pain occurs because you have time to focus on the pain. When you are participating in enjoyable and meaningful activities, your awareness of pain decreases. For example, when you are busy with work, school, or recreational activities, you are not as likely to focus on your pain.

Pain management can be very important in improving your overall quality of life. If you are in pain, talk with a doctor. Start first with the simple methods of reducing your pain. You may have to try several treatments before finding one, or a combination, that works for you. Do not treat yourself because you may have a serious health problem that may be causing the pain. Ultimately, the solution may not be a cure. You may not be able to live completely pain free. You may only be able to reduce your pain. But easing the pain may be enough for you to live a productive, satisfying life.

3. About Pressure Sores

3.1. How a pressure sore develops

Pressure sores are the most common and devastating medical complication of spinal cord injury. Also referred to as skin sores, decubiti, decubitus ulcers, or bedsores, pressure ulcers are more apt to occur after SCI due to lack of movement and sensation and to changes in circulation. A pressure sore is any redness or break in the skin caused by too much pressure on your skin for too long a period of time. Sitting or lying in the same position will begin to cut off the flow of blood to that area, blocking oxygen and vital nutrients from maintaining healthy tissue. When the tissue becomes starved to too long a period of time it begin to die and a pressure sore starts to form. Normally the nerves send messages of pain or feelings of discomfort to your brain to let you know that you need to change position, but damage to your spinal cord keeps these messages from reaching your brain. A pressure sore is serious. It must NOT be ignored.

What Are The Causes?
Because your blood flows more slowly after SCI, your healing ability is reduced, and your skin cannot tolerate as much pressure as before. The decrease in circulation and lower tolerance for pressure is further aggravated by the lack of sensation after SCI. This lack of sensation means there is no longer a feedback mechanism to tell you that there is a problem – that you have been sitting too long without moving or that you have injured yourself.

The first symptom – your warning signal – is a reddened area of the skin. No damage has occurred if you remove the pressure and the redness fades with 15 minutes after the pressure is removed. Skin damage from pressure usually begins over bony prominences – any place on the body where the bones are close to the skin surface, such as the hip. Due to the decrease in the rate of circulation that occurs following SCI, there is also less oxygen to the skin. This contributes to a lowering of the skin's resistance. If the skin is deprived of oxygen due to pressure, the body will try to compensate by sending more blood to the area. This may result in swelling, which will put even further pressure on the blood vessels and further block circulation.

How a pressure sore develops:

  • Stage I. You will notice that the skin becomes white or lighter in color. Do push-ups and keep to your turning schedule so skin is never deprived of its blood supply for a long time. Blood is not getting to the skin because of pressure.
  • Stage II. Your skin will redden; it is warm and may be swollen when pressure is relieved. Stay off red area until all redness is gone. Do NOT rub red area or put anything on it. If you are dark skinned and can't see redness, feel for warmth with back of fingers. At this point, you can still stop a more serious sore from developing. Redness and warmth is caused by blood rushing to the area when pressure is relieved. If redness is not gone 30 minutes after pressure is relieved, it's a danger signal (too much pressure or pressure for too long was applied.)
  • Stage III. You will notice that a blister develops over the red area. The skin may have a bluish color to it. The blister often opens. This stage occurs if pressure is not completely removed from a red area. At this point the damage is deeper than you can see. Stay off the area. Call your doctor or nurse.
  • Stage IV. The center of open sore turns black or brown and/or there is drainage. Stay off area. Cover with a sterile dressing. Eat foods that are high in protein to raise albumin levels. This sore may be very deep and is probably infected. You may feel very sick. If there is much drainage your body loses protein. Protein is needed for healing. Call your doctor.

3.2. Preventing pressure sores

Pressure Ulcers Are Preventable
Maintaining healthy skin is the key to preventing pressure sores. Skin that is intact, well lubricated with natural oils, and nourished by a good blood supply will not develop pressure ulcers. Skin stays healthy with a good diet, good hygiene, regular skin inspection, and regular pressure relief. Attention should be paid to keeping your skin clean and dry since skin that is moist from urine, sweat, or stool is more likely to break down. Adequate fluids and a well-rounded diet also provide nourishment to the skin. With a good diet containing protein, iron, and vitamins, your skin will remain healthy. By inspecting your skin regularly, you can spot a problem at the very beginning.

In addition to routinely checking your skin, a second important way to prevent pressure sores is to relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area. The purpose of relieving pressure is to let the blood supply get to the skin. If pressure is not relieved, blood will continue to be pressed out of a blood vessel and will not get to the skin to keep it healthy.

Weight Shifts
Weight shifts are the most essential techniques for preventing pressure on the skin and muscle of the sacrum (tailbone) and each hip. Use the method you and your therapists have found to be the most effective for you. Know your skin tolerance at all times.

A cushion for your wheelchair is essential. Cushions provide pressure relief and weight distribution and thus aid in the prevention of pressure sores. Many types of cushions exist, but there is no "ideal" cushion. Use the cushion recommended by your physical therapist/physiatrist. Weight shifts are essential. The cushion alone will not prevent pressure sores.

Tips to Prevent Pressure Ulcers


  • Make sure your wheelchair foot pedals are adjusted to the right height.
  • Use a prescribed cushion on wheelchair seat.
  • Sit up straight in wheelchair (slumping or slouching leads quickly to early skin breakdown over tailbone).
  • Check feet carefully when wearing new shoes – shoes should not be too tight or too large.
  • Keep skin clean and dry
  • Use a firm (not hard) mattress, which provides support for your body.
  • Do your wheelchair push-ups or weight shifts every 15 minutes.
  • Stick to your turning schedule
  • Use lubricating cream if you have dry skin.
  • Drink plenty of fluids to keep skin well hydrated
  • Eat a well balanced diet. Foods high in protein, vitamins and minerals help your skin stay healthy and heal more quickly
  • Check the penis carefully for sores or irritations if you use an external catheters


  • Use a rubber air ring or any kind of doughnut. They create a lot of pressure where you don't want it, and block the flow of blood to skin inside the ring.
  • Wear sanitary belts – they can lead to pressure sores.
  • Wear clothing with heavy seams, nylon underwear or tight clothing.
  • Put articles in pants pockets or on seat of wheelchair.
  • Use alcohol on dry skin.
  • Sit in bed with the head raised for long periods – this causes skin to be squeezed over the lower end of the spine and can lead to sores.
  • Smoke – Research shows that SCI patients who are heavier smokers have more frequent and more serious pressure sores, and when they do get sores, the healing process is slower.
  • Abuse drugs or alcohol. Both can damage your skin and can also lead to other health problems.

4. Urinary System After Spinal Cord Injury

4.1. Understanding the urinary system

The Urinary System is made up of five major parts (Kidneys, Ureters, Bladder, Urethra, and Sphincters) and has three major functions.

1- It makes urine in the kidneys
2- Stores urine in the bladder
3- Removes urine from the body through the urethra.

Urine is made when the kidneys filter out waste products and water from the blood. The urine moves from the kidneys through tubes, called ureters, to the bladder. The bladder temporarily stores the urine. Voiding, or urinating normally occurs when the bladder muscles contract, and the small sphincter muscles, acting as a valve, relax and allow urine to flow from the bladder through the urethra and out of the body. When the process is finished, the bladder is empty.

After Spinal Cord Injury
The bladder, along with the rest of the body, undergoes dramatic changes. Since messages between the bladder and the brain cannot travel up and down the spinal cord, the voiding pattern described above is not possible. Depending on your type of spinal cord injury, your bladder may become either "floppy" (flaccid) or "hyperactive" (spastic or reflex).

The Flaccid (Non-reflex) Bladder
A floppy bladder loses detrusor muscle tone (strength) and does not contract for emptying. This type of bladder can be easily overstretched with too much urine, which can damage the bladder wall and increase the risk of infection. Emptying the flaccid bladder can be done with techniques such as Crede, Valsalva, or intermittent catheterization. It is very important that you do not let your bladder get overfull, even if it means waking up at night to catheterize yourself more frequently.

The Spastic (Reflex) Bladder
The detrusor muscles in a hyperactive bladder may have increased tone, and may contract automatically, causing incontinence (accidental voiding). Sometimes the bladder sphincters do not coordinate properly with the detrusor muscles, and medication or surgery may be helpful.

Dyssynergia occurs when the sphincter muscles do not relax when the bladder contracts. The urine cannot flow through the urethra. This can result in the urine backing up into the kidneys. This is called "reflux" action. The bladder may also not empty completely. Treatments include medications or surgery to open the sphincter.

Bladder Management
A bladder management program will help you effectively prevent infections and avoid bladder accidents. It will also allow you to empty your bladder in an acceptable manner when it is convenient for you. Level of injury, lifestyle, susceptibility to infection, and loss of normal urinary system function must be taken into consideration when deciding which bladder management program works best for you.

Foley (or Suprapubic) Catheter: A tube is inserted through the urethra or abdomen and into the bladder, where a balloon on the end holds it in place. It remains in the bladder and drains constantly, so the bladder is never full.

External Catheterization or Condom Catheters: This method is made of latex rubber or silicone that covers the penis and attaches to a tube that drains into a collection bag. This method attaches only to the tip of the penis using hydrocolloid, a hypoallergenic adhesive commonly used in wound and ostomy care. Urine is directed into a collection bag and does not come in contact with skin.

Intermittent Catheterization: You drain your bladder several times a day by inserting a small rubber or plastic tube. The tube does not stay in the bladder between catheterizations.

Stimulated Voiding:
Voiding is encouraged in one of several ways:

  • Anal or Rectal Stretch – This method involves increasing pressure inside the abdomen by bearing down as if you were going to have a bowel movement.
  • Crede Tapping (Valsalva) – This method for relaxing the urinary sphincter is usually used along with an abdominal corset and valsalva (see below). This method involves manually pressing down on the bladder. The area over the bladder is tapped with the fingertips or the side of the hand, lightly and repeatedly, to stimulate detrusor muscle contractions and voiding.

Surgical Alternatives
Mitrofanoff: A passageway is constructed using the appendix so that catheterization can be done through the abdomen to the bladder.

Spincterotomy: This surgical process weakens the bladder neck and sphincter muscle to allow urine to flow out more easily. After this surgery, you will urinate involuntarily, and must wear a collection device.

Bladder Augmentation: Surgical enlargement of the bladder.

Surgery is a serious matter. Consulting a variety of people with a range of expertise and experience will help give you the information you need to make an informed decision.

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4.2. Urinary tract infections

What is a urinary tract infection?
Individuals with SCI are at a high risk for urinary tract infection (UTI). When bacteria get into your bladder or kidneys and cause you to have symptoms, you have a UTI. It is important to know the difference between an infection and bacteriuria (having bacteria in the urine but no symptoms).

Causes of UTI:

Intermittent Catheterization
Whenever a catheter is passed through the urethra (the channel between the bladder and the outside of the body) it can pick up bacteria that are normally on the skin and push the bacteria into the bladder. Bacteria can grow and multiply in the urine if the urine remains in the bladder for a prolonged amount of time (more than 4-6 hours). You can avoid this by emptying your bladder at least once every 6 hours and by drinking enough fluids to keep the urine volume between 300 and 500 cc (1 to 1.5 cups) at each catheterization. Careful hand washing before and after each catheterization is essential and will help prevent UTIs by decreasing the amount of bacteria on the skin.

Indwelling (Foley) Catheters
Because of your spinal cord injury and the fact that you must use an indwelling catheter, you will always have bacteria in your urine. The catheter provides a direct pathway for the bacteria to enter your bladder. The bacteria that live in your bladder can develop into a UTI if your catheter becomes blocked, if your general resistance to infection decreases, or if you don't drink enough fluids and your urine become concentrated.

Symptoms of UTI Warning Signs of UTI

  • Fever
  • Chills
  • Leakage
  • Increased spasms of legs, abdomen, or bladder
  • Feeling the need to catheterize more often
  • Feeling the need to catheterize immediately
  • Burning of the urethra, penis, or pubic area
  • Nausea
  • Headache
  • Mild low back pain or other aches
  • Feeling "lousy" or tired
  • Sediment (gritty particles) or mucus in the urine or cloudy urine
  • Bad smelling urine (foul odor)
  • Blood in urine (pink or red urine)

When early signs of infection appear, you can take additional steps to help prevent symptoms of illness.

  • Drink more water.
  • Stop drinking beverages with sugar, caffeine, and alcohol.
  • Catheterize more often.

It is important to note that the appearance and smell of your urine may change because of changes in your diet or fluid intake. If you have changes in the urine but no symptoms (see list above) you do not need to seek treatment for a UTI. People who empty their bladders by self-catheterization may occasionally see small blood clots or red blood visible on their catheters because of trauma (bumping against the bladder or urethra or forcing the catheter past the sphincter). This is not cause for worry unless it happens frequently. Larger amounts of blood, or urine that is red from blood, should always be reported to your health care provider.

Preventing urinary tract infections through self-care

Many people are able to prevent a UTI from developing by taking some self care steps. The most important step for people who do intermittent catheterization and begin to develop symptoms of a UTI is to catheterize themselves more frequently (every 2-4 hours) and increase their fluid intake.

The most important step for people who use an indwelling catheter is to drink plenty of water. Your fluid intake should be enough so that your urine has the appearance of water or is only slightly yellow in color and clear. Changing your catheter after increasing your fluids may also help cut down on the number of bacteria living in your bladder since catheters can become "colonized" with the bacteria that are flushed out of your urinary tract. Generally, changing your catheter every month should be enough to keep you healthy, but people who get frequent UTIs or whose catheters tend to become encrusted with built-up mineral deposits may have to change it more often.

When to call your health care provider

If you develop a fever (temperature greater than 100°F) or if your symptoms are interfering with your life, you should call your health care provider. He or she will want to know your temperature, current symptoms, and whether you have any allergies to antibiotics. Your health care provider will also want to get a urine specimen and will discuss with you whether antibiotics should be started right away or after the results of the culture are available.

How To Collect A Good Specimen For A Urine Culture
The accuracy of any urine test depends on careful collection of the specimen to avoid contamination by bacteria from other sources, such as your hands or the specimen container. Following the instructions below will help ensure accurate results.

  • Open your sterile container — either one from the hospital or one you have prepared at home. (To sterilize a jar at home, choose a small jar with a snug-fitting lid. Wash it carefully in soap and water and rinse well. Place the jar and lid in a pan of boiling water and immerse for 10 minutes. Remove jar and lid with metal tongs, invert on a dish drainer, and allow to cool.) Do not touch the inside of the jar.
  • Never collect a urine specimen for culture from a leg bag or a night bag.
  • Refrigerate the specimen and keep it cool until you can get it to your health care provider. It should be delivered within two hours of collection.

Antibiotic Treatment

If your health care provider prescribes an antibiotic for you, ask your pharmacist whether you should take it before meals or with food. Be sure to take all of the medications as prescribed. DO NOT stop taking the antibiotic simply because you no longer feel sick. You need to totally kill the bacteria and prevent the bacteria from becoming resistant. Some antibiotics will change the balance between your body's "good" bacteria and the "bad" bacteria that has caused your UTI. When this happens, an overgrowth of yeast can occur which may result in problems ranging from a skin rash to diarrhea. This can be prevented by taking acidophilus culture, which is available in some brands of yogurt, acidophilus milk, or as a pure culture (available in health food stores).


  • Only take antibiotics when needed. Research shows that UTIs that do not include symptoms of illness usually do not need treatment with antibiotics. Use an antibiotic only when symptoms are present. Excessive use of antibiotics leads to resistant strains of bacteria. This means bacteria become immune to antibiotic medications and can be much harder to kill.
  • If you have more than one or two urinary tract infections per year, it can be an early sign of other problems with the urinary system. A complete urologic examination should be included in your medical check up at least once a year.

5. Bowel Management

5.1. About bowels after spinal cord injury

What is the bowel?
The bowel is the last portion of your digestive tract and is sometimes called the large intestine or colon. The digestive tract as a whole is a hollow tube that extends from the mouth to the anus.

What does the bowel do?

The function of the digestive system is to take food into the body and to get rid of waste. The bowel is where waste products are stored until they are emptied from the body in the form of a bowel movement (stool, feces). A bowel movement happens when the rectum (last portion of the bowel) becomes full of stool and the muscle around the anus (anal sphincter) opens.

After Spinal Cord Injury
After a spinal cord injury, damage can occur to the nerves that allow a person to control bowel movements. If the spinal cord injury is above the T-12 level, the ability to feel when the rectum is full may be lost. The anal sphincter muscle remains tight, however, and bowel movements will occur on a reflex basis. This means that when the rectum is full, the defecation reflex will occur, emptying the bowel. This is known as a reflex bowel A reflex bowel can be managed by having the defecation reflex occur at a socially appropriate time and place. A spinal cord injury below the T-12 level may damage the defecation reflex and relax the anal sphincter muscle. This is known as a flaccid bowel. Management of this type of bowel problem may require more frequent attempts to empty the bowel and bearing down or manual removal of stool. Both types of neurogenic bowel can be managed successfully to prevent unplanned bowel movements and other bowel problems such as constipation, diarrhea and impaction.

5.2. Bowel Management Program

Bowel Programs
With a spinal cord injury, you will need to train your bowels to have a bowel movement at the time you want.

Each person's bowel program should be individualized to fit his/her own needs. The type of disease or nerve damage should be taken into account as well as other factors. Components of a bowel program can include any combination of the following methods:

1. Manual Removal- Physical removal of the stool from the rectum. This can be combined with a bearing down technique called a valsalva maneuver (avoid this technique if you have a heart condition)
2. Digital Stimulation – Circular motion with the index finger in the rectum, which causes the anal sphincter to relax
3. Suppository - Dulcolax (stimulates the nerve endings in the rectum, causing a contraction of the bowel) or glycerine (draws water into the stool to stimulate evacuation)
4. Mini-enema – Softens, lubricates, and draws water into the stool to stimulate evacuation

What to do if...

Stool is too hard (constipation)

    – Add or increase the dose of a stool softener (such as colace) or psyllium hydro-mucilloid (such as Metamucil or Citrucel). Increase your fluid intake and dietary fiber. Increase your activity level. Avoid foods that can harden your stool, such as bananas and cheese.

Stool is liquid or runny (diarrhea)

    – Temporarily discontinue the use of any stool softeners. Try adding or increasing the dose of psyllium hydro-mucilloid (Metamucil, Citrucel), which adds bulk to liquid stool. If diarrhea persists for more than 24 hours or if you have a fever or blood in your stool, consult your health care provider. A frequent cause of diarrhea is a blockage or impaction of stool (liquid stool leaks out around the blockage). If you suspect impaction, consult your health care provider.

Frequent bowel accidents

    - Be sure your rectum is completely empty at the end of your program. Increase the frequency of your program (some people with a flaccid bowel may need to empty their bowels twice daily). Try using only half of a suppository. Evaluate stool consistency — if it's too hard or too soft, see above. Monitor your diet for any foods that may over stimulate your bowel, such as spicy foods.

Mucous accidents

    - If you notice a clear, sticky, sometimes odorous drainage from the rectum, try switching from a suppository to a mini-enema, or using only half of a suppository, or try eliminating suppositories or mini-enemas completely and begin your program with digital stimulation only.

No results in 3-4 days

    – Treat constipation as recommended above. If there are no results in three days, try Milk of Magnesia or a single dose of an herbal laxative at bedtime. Do your bowel program in the morning. If there are still no results, repeat the dose of Milk of Magnesia or herbal laxative the next evening. If there are no results in the morning, consult your health care provider.

Rectal bleeding

    – Keep your stool soft. Be very careful to do digital stimulation gently and with sufficient lubrication, and keep your fingernails short. If you have known hemorrhoids, you may treat them with an over-the-counter hemorrhoidal preparation. If bleeding persists or is more than a few drops, consult your health care provider.

Excessive gas

    – Increase the frequency of your bowel programs. Avoid gas-forming foods, such as beans, corn, onions, peppers, radishes, cauliflower, sauerkraut, turnips, cucumbers, apples, melons and others that you may have noticed seem to increase your own gas. Try simethicone tablets to help relieve discomfort from gas in your stomach.

Bowel program takes a long time to complete

    – Try switching from a suppository to mini-enemas. Increase your intake of dietary fiber and add or increase the dose of psyllium hydromucilloid. Try switching your program to a different time, and be sure you schedule it after a meal to help increase intestinal peristalsis.

Autonomic dysreflexia during bowel program

    – Use xylocaine jelly (available by prescription from your health care provider) for digital stimulation. You may also need to insert some of the jelly into your rectum before beginning the program. Keep your stool as soft as possible. If dysreflexia persists, consult your health care provider. You may need medication to treat or prevent this condition.

In managing your bowel program, it is recommended that you avoid regular use of stimulant laxatives, full-size enemas, skipping or changing your program, rushing though your program, and more than four digital stimulations at a time. Also, the more active you are and the more liquids you drink, the easier it is for food to travel through your digestive system. Foods high in fiber will help control your bowels and will prevent constipation. Try to limit spicy foods, greasy foods, and "junk" foods and include more fruits and vegetables in your diet.

6. Autonomic Dysreflexia

6.1. What is autonomic dysreflexia

Autonomic dysreflexia (AD), also known as hyperreflexia, refers to an over-active Autonomic Nervous System, which causes an abrupt onset of excessively high blood pressure. Persons at risk for this problem generally have injury levels above T-5. AD can develop suddenly and is potentially life threatening and is considered a medical emergency. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.

AD occurs when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure.

Signs & Symptoms

  • Pounding headache (caused by the elevation in blood pressure)
  • Goose Pimples
  • Sweating above the level of injury
  • Nasal Congestion
  • Slow Pulse
  • Blotching of the Skin
  • Restlessness
  • Hypertension (blood pressure greater than 200/100)
  • Flushed (reddened) face
  • Red blotches on the skin above level of spinal injury
  • Sweating above level of spinal injury
  • Nausea
  • Slow pulse (< 60 beats per minute)
  • Cold, clammy skin below level of spinal injury

Avoiding Autonomic Dysreflexia

  • Apply frequent pressure relief in bed/chair
  • Avoid sun burn/scalds
  • Maintain a regular bowel program
  • Well balanced diet and adequate fluid intake
  • Compliance with medications
  • If you have an indwelling catheter, keep the tubing free of kinks, keep the drainage bags empty, check daily for grits (deposits) inside of the catheter
  • If you are on an intermittent catheterization program, catheterize yourself as often as necessary to prevent overfilling.
  • Carry an intermittent catheter kit when you are away from home
  • Perform routine skin assessments

6.2. Causes of autonomic dysreflexia

There can be many stimuli that cause AD. Anything that would have been painful, uncomfortable, or physically irritating before the injury may cause AD after the injury. The most common cause seems to be overfilling of the bladder. This could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder.

Stimuli That Cause Autonomic Dysreflexia:

Bladder (most common)

  • Urinary tract infection
  • Urinary retention
  • Blocked catheter
  • Overfilled collection bag
  • Non-compliance with intermittent catheterization program


  • Constipation / impaction
  • Distention during bowel program (digital stimulation)
  • Hemorrhoids or anal fissures
  • Infection or irritation (e.g. appendicitis)

Skin-related disorders

  • Any direct irritant below the level of injury
  • Pressure sores
  • Ingrown toenails
  • Burns
  • Tight or restrictive clothing or pressure to skin from sitting on wrinkled clothing

Sexual Activity

  • Over stimulation during sexual activity (stimuli to the pelvic region which would ordinarily be painful if sensation were present)
  • Menstrual cramps
  • Labor and delivery


  • Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
  • Skeletal fractures
  • Sitting on one's scrotum

6.3. Treating autonomic dysreflexia

Treatment must be initiated quickly to prevent complications. First, remain in a sitting position, but do apply pressure release immediately. You may transfer yourself to bed, but always keep your head elevated. Since a full bladder is the most common cause, check the urinary drainage system. If you have a Foley or suprapubic catheter, check the following:

  • Is your drainage full?
  • Is there a kink in the tubing?
  • Is the drainage bag at a higher level than your bladder?
  • Is the catheter plugged?

After correcting an obvious problem, and if your catheter is not draining within 2-3 minutes, your catheter must be changed immediately. If you do not have a Foley or suprapubic catheter, perform a catheterization and empty your bladder. If your bladder has not triggered the episode of AD, the cause may be your bowel. Perform a digital stimulation and empty your bowel. If you are performing a digital stimulation when the symptoms first appear, stop the procedure and resume after the symptoms subside. If your bladder or bowel are not the cause, check to see if:

  • You have a pressure sore,
  • You have an ingrown toenail, or
  • You have a fractured bone.

Identify and remove the offending stimulus whenever possible. Often, this alone is successful in allowing the syndrome to subside without need for pharmacological intervention. If symptoms persist despite interventions such as the foregoing, notify a physician. It is also good for the person with the symptoms to be sitting up with frequent blood pressure checks until the episode has resolved.
If the suspected cause is the ...

  • Bladder: Check catheter – remove kinks if found, empty urinary collection bag, irrigate catheter. If catheter is not draining, replace it immediately. If an intermittent catheterization program is in place, a straight catheterization should be performed immediately with slow drainage to prevent bladder spasms.
  • Bowel: If episode happens during digital stimulation, stop stimulation until symptoms and signs subside. Consider use of a prescribed anesthetic ointment to suppress the noxious stimulus. If the issue is impacted stool, disimpact. If it occurs while doing a bowel program in bed, try commode-based bowel evacuation. Consider use of abdominal massage instead of digital stimulation.
  • Skin: Loosen clothing. Check for source of potential offending stimulus – check for pressure sores including the soles and heels of the feet, toenail problems.

Important Reminder:
If you are unable to find the stimulus causing AD, or your attempts to receive the stimulus fail, you need to obtain emergency medical treatment. Since all physicians are not familiar with AD and its treatment, you should carry a card that describes the condition and the treatment required.

7. Respiration After Spinal Cord Injury

7.1. About the respiratory system

The respiratory system, also known as the pulmonary system, is used for breathing. The windpipe and lungs are the two main parts of the respiratory system. When you inhale, or breathe air in through your mouth or nose, oxygen travels down your windpipe and into your lungs. Your lungs then filter the oxygen and send it through your blood stream to all your body parts. When you breathe out, or exhale, you send the left over carbon dioxide out of your body, through your windpipe and out of your mouth or nose.

Respiratory Muscles
Exhaling does not require any effort from the body's muscles. However, in order to you breathe air into your body, a combination of four respiratory muscle groups are used. The diaphragm, a strong, dome-shaped muscle that separates the abdominal and chest cavities, is normally the main muscle that you use when you inhale. The intercostal muscles are located between the ribs. These muscles help to expand your ribs as you inhale. The neck muscles normally work to expand your upper chest when inhaling. The abdominal muscles work with these other muscle groups to help you breath deeply and cough.

Role of the Spinal Cord
The brain normally sends signals through nerves in the spinal cord to control the four respiratory muscle groups. When everything is working properly, the pulmonary system and respiratory muscles work together allowing you to breath in and out without much effort. In fact, most people breath without ever thinking about it.

After SCI the windpipe and lungs are not typically affected by a spinal cord injury. However, respiratory problems may occur when the signals sent from the brain can no longer flow through the spinal cord to control the respiratory muscles. The amount of muscle control that is lost after a spinal cord injury depends on the level of the injury along with the completeness of the injury. Individuals with injuries below the T12 level do not usually lose any control of the four respiratory muscle groups needed for breathing. This means the respiratory system is not usually affected by injuries in the lumbar or sacral regions of the spinal cord.

Individuals with complete thoracic or cervical injuries do experience a loss of their respiratory muscle control. The higher the level of injury, the greater the loss to the respiratory muscle control. Complete injuries in the thoracic or cervical regions usually result in the permanent loss of respiratory muscle function below the level of injury. However, if that injury is incomplete, it is impossible to predict whether the individual will regain some or all of their respiratory function below the level of injury. Injuries in the thoracic area (T1-T12) of the spinal cord affect the control of the intercostal and abdominal muscles. A lower level of injury, such as a T10, results in the individual losing a small amount of muscle control. With a higher level of injury, such as a T2, individuals will lose most of their intercostal and abdominal muscle control.

Complete injuries in the cervical region usually result in a total loss of intercostal and abdominal muscle control. Again, the higher the level of injury, the greater the loss of additional muscle control. For example, a complete injury between levels C3 and C5 loses all control of the diaphragm muscles. With a complete injury at level C3 and higher the individual loses control of all four muscle groups that are needed for breathing. A ventilator is then needed to assist in breathing.

The ventilator does the work of the absent muscles and forces air into the lungs. Many people with a C4 level of injury, and even some people with a C3 level of injury, can eventually breathe without the aid of a ventilator or may only need it for part-time assistance. Those individuals with complete injuries above C3 use a ventilator for full-time assistance.

7.2. Respiratory complications after spinal cord injury

Individuals with a spinal cord injury are at increased risk for developing respiratory complications. Any loss of respiratory muscle control weakens the pulmonary system, decreases one's lung capacity, and increases respiratory congestion. It does not matter what the level of injury or if the injury is complete or incomplete. However, the risk for complications is greater for persons with a complete injury and for persons with tetraplegia. For persons with high level tetraplegia (C5-C1), ventilatory failure is a common complication after injury. The person typically lacks the ability to breathe without assistance. Another common problem is atelectasis. This is when the lungs partially collapse because not enough air is getting into the lungs.

All levels of injury are at risk for pulmonary embolism. Pulmonary embolism is a blockage in the blood vessels of the lungs. This is the primary disease of pulmonary circulation and the second leading cause of death for persons with SCI within the first year after their injury. Ventilatory failure, atelectasis and pulmonary embolism are all very serious, life-threatening respiratory complications. However, pneumonia is the leading cause of death for all persons with spinal cord injury. This is true regardless of your level of injury or how long you have been injured. Therefore, be aware of the symptoms for pneumonia. They include shortness of breath, having pale skin, a fever, along with a feeling of heavy chest and an increase in congestion. If you have symptoms of pneumonia, call a doctor immediately for advice on treatment.

Steps to prevent respiratory complications include:

  • Visiting a doctor at least once per year and getting vaccinated against pneumonia
  • Avoiding buildup of secretion in the lungs by coughing or receiving cough assist treatments
  • Maintaining proper posture and mobility to prevent buildup of congestion.
  • Wearing an abdominal binder to help assist your intercostal and abdominal muscles
  • Following a healthy diet and managing a healthy weight.
  • Drinking plenty of water to keep congestion from becoming thick and difficult to cough up.
  • Not Smoking! The harmful effects smoking include a decrease of oxygen in the blood, an increase in congestion in the chest and windpipe, a reduction in your ability to clear secretions from your lungs, a destruction of lung tissue, and an increase in the risk for respiratory infections such as pneumonia and bronchitis.
  • Breathing Exercises

Sleep apnea is a growing respiratory concern for persons with spinal cord injury. Sleep apnea is a type of breathing disorder. Typically, it is a stop in breathing during sleep. However, apnea can include other respiratory difficulties. Increased research in this area suggests that persons with weakened respiratory muscles may be at high risk for developing sleep apnea, so persons who are older and persons with tetraplegia may be at a very high risk. Symptoms include irregular breathing or snoring, daytime sleepiness, problems with memory or concentration, waking up often during the night, and waking up tired or with a headache. If you think you may have sleep apnea, talk to your doctor for advice on treatment.

A number of respiratory complications can occur after spinal cord injury. This places all individuals at risk for developing complications regardless of level of injury or whether the injury is complete or incomplete. Therefore, it is important to understand these potential respiratory complications and what you can do to help prevent them from developing.

8. Sexuality and Reproductive Health After SCI

8.1. Sexuality and reproductive health for men with SCI

A spinal cord injury (SCI) affects a man's sexuality both physically and psychologically. After injury, men may face changes in relationships, sexual activity, and their ability to biologically father children. Men can also experience emotional changes that can affect sexuality. All of these issues involve both the man with SCI and his partner. Therefore, it is very important to understand and confront these issues as a part of the overall adjustment to life after injury.

Many men with SCI are capable of having an erection. However, the erection may not be hard enough or last long enough for sexual activity. This condition is called Erectile Dysfunction (ED). There are various treatments and products available for treating ED but men with SCI may have special concerns or problems with their use. It is important to see a doctor or urologist for accurate information on the various treatments and products available. Below are some of the treatment options currently available:

Penile injection therapy involves injecting a single drug or a combination of drugs into the side of the penis. This produces a hard erection that can last for one to two hours. These drugs must be used exactly as prescribed by the physician. If not used correctly, the result could be a prolonged erection, called priapism. When priapism occurs, the blood fails to drain from the penis. This can damage the penile tissue and be extremely painful. Other risks from the injection are bruising, scarring or infection of the penis. This method is not recommended for use more than once a week. A penile injection is a difficult option for a man with limited hand function due to spinal cord injury. Therefore, he must have assistance in getting the injection.

Medicated Urethral System Erection (MUSE), or transurethral therapy, is a relatively new treatment option. A medicated pellet is placed into the urethra where it is absorbed into the surrounding tissue. This causes the blood vessels to relax and allows blood to fill the penis. Reported side effects include a risk of infection, a burning sensation and decreased blood pressure and fainting.

The vacuum pump is a mechanical option for producing an erection that, for most men, is sufficient for intercourse. The penis is placed in a vacuum cylinder and air is pumped out of the cylinder causing blood to be drawn into the erectile tissues. The erection is maintained by placing a constriction ring around the base of the penis. This ring also prevents urinary leakage that some men with SCI experience. It is important to remove the ring after intercourse to avoid prolonged pressure and the risk of sores. There are several models of vacuum pumps available. A battery-operated model is an option for those with limited hand function. Other models require good hand function to press the pump against the skin to create the necessary vacuum.

Men with SCI also experience a change in their ability to biologically father a child. The major factor interfering with a man's fertility is primarily due to an inability to ejaculate as a result of damage to the spinal cord. In fact, 90% of men with SCI are not able to ejaculate during intercourse; this is called anejaculation. Another problem men with SCI may experience is retrograde ejaculation. This occurs when semen does not leave the urethra but travels back up the tube and is deposited in the bladder.

Options are available to assist men with spinal cord injury improve their ability to father children. Men who are interested in fathering a child should get medical advice and treatment options from a fertility specialist experienced in issues of spinal cord injury. The fertility specialist needs to be aware of methods that can improve sperm quality in men with SCI, as well as complications that can occur, such as autonomic dysreflexia.

A romantic and an intimate relationship with a partner can be developed or maintained after a spinal cord injury. It is important to keep the lines of communication open as well as an openness to explore and experiment with different ways to be romantic and intimate. Together, you can discover what it takes to maintain a sexually stimulating and fulfilling relationship.

8.2. Reproductive Health for Women with SCI

Women with a spinal cord injury represent about 20% of all individuals with SCI/D and the majority of these women are of childbearing age. Regardless of a woman's level of injury or dysfunction, women with SCI can engage in sexual activity, can have children and will need to use a contraceptive method if they choose not to have children. Education is the key for women with SCI/D to understand the facts related to pregnancy, labor, and delivery.

The first step in the journey towards motherhood is visiting with an obstetrician. If your obstetrician has limited experience in managing pregnancies of women with SCI/D, it is recommended that you take a "team" approach to your pregnancy. You and your obstetrician can consult with an experienced physiatrist, nurse, urologist, anesthesiologist, neurologist, respiratory therapist, physical therapist, and occupational therapist on specific concerns about pregnancy, labor and delivery.

Although women with SCI/D may be considered to have "high risk" pregnancies, it does not mean that pregnancy should be avoided. It simply means that you need to take precautions to prevent and treat complications. Pregnant women with SCI/D are at greater risk for developing:

  • Autonomic Dysreflexia (AD)
  • Changes in bowel function (constipation or diarrhea)
  • Bladder spasms resulting from increased weight on the bladder
  • Urinary tract infections (a UTI might actually trigger premature labor if not properly managed)
  • Pressure sores resulting from weight gain and/or posture changes
  • Respiratory complications
  • Muscle Spasms
  • Swelling of the legs and feet caused by lack of blood flow in the lower extremities

Many prescribed and over-the-counter medications normally used by women with SCI/D can cause problems during pregnancy. Some medications can also have an adverse affect on fetal growth. Therefore, it is essential that all medications be evaluated by your obstetrician before pregnancy and continually re-evaluated each trimester. Some conditions that you might manage with medications include bowel management, pain, sexual dysfunction, muscle spasms, and urinary tract infection (UTI).

Some women with SCI/D may have signs of labor, while others may not. Theref with SCI/D must be aware of the common signs of labor, including abdominal tightening, changes in breathing, backache. Autonomic Dysreflexia is common during labor and can be life threatening if not managed properly.

Most women can, and should, deliver vaginally whenever possible. Some may deliver with ease, while others may need the assistance of a vacuum device or forceps. Some women with SCI/D have skeletal abnormalities such as curvature of the spine, pelvic fracture, or hip dislocation. These conditions can limit the space in the abdomen necessary to carry a full-term fetus. These abnormalities can make vaginal delivery difficult. In these cases, a Caesarean section (C-section) may be necessary.

Once the baby is born, the decision on whether or not to breast-feed must be made. Although breast-feeding is possible for most women, you may notice an increase in your spasticity as you breast-feed. Also, breast-feeding normally stimulates the production of breast milk, so women with limited sensation in their nipples may notice a reduction in milk.

Although there are risks for complications related to pregnancy, risks can be reduced and managed through proper prenatal care and adequate planning.

9. Gait Training & Walking

9.1. About gait training

By Rebecca Kellogg

Offering powerful health benefits and a chance to progress to greater independence, gait training is an attractive option for many individuals with spinal cord impairments (SCI). This article will look at how gait training works, what it can do for you, and what's new in gait training technology and research.

How Gait Training Works

Gait training therapy helps individuals with SCI stand and walk with mechanical or other, sometimes human, assistance. Many researchers agree gait training should be started as soon after injury as is prudently possible.

According to Eric Harness, cofounder and director of research and development at Project Walk in Carlsbad, California, for an individual with SCI to be a good candidate for gait training, his or her joints need to be stable enough so there is limited risk of hyperextension or other types of joint damage. The individual must also be able to tolerate having a harness around the torso and between the legs.

Body Weight Supported Treadmill Training (BWSTT) uses a support system consisting of a winch mechanism that attaches to a crossbar overhead. The harness is clipped to the crossbar and gives lift and support as an individual uses the treadmill.

"Depending on the client's function, from 1 to 4 specialists or aides may be involved in the motion of the legs, providing pelvic support, and spotting," said Harness. "The specialists on the legs position their hands so that one hand is just below the knee and one is holding the ankle."

Robotic gait training, in which a machine does the work of supporting the trainee, is currently done by such devices as the Lokomat ( The upside of robotic training is that it requires fewer therapists working with a trainee—but that is also its downside, according to Harness.

"In my opinion, the problem with the robotic devices currently in use is that they do not allow for errors or discrepancies in a person's gait. The Lokomat is very linear in its gait pattern."

According to experts in the field, there are times when it is advantageous to do BWSTT with human assistants instead of a robot.

"There is no substitute to experienced therapists," said Dr. Bradley A. Marcus, director of San Diego Medical Rehabilitation & Kinematics Lab. "Any facility that has the ability to do robotic BWSTT with the Lokomat will also have the ability to do it manually by taking the robotic legs off when needed."

What Gait Training Can Do for You

When people with SCI participate in standing and gait training exercises, they enjoy a range of health benefits. Gait training, like other forms of exercise, improves cardiovascular and respiratory health, as well as decreases the risk of osteoporosis. People with SCI also enjoy the reduction of secondary conditions, including pressure sores and urinary tract infections.

Individuals with incomplete SCI can also increase their walking speed when they undertake regular gait training, which will contribute to greater independence and efficiency.

"Although an individual may always rely on some form of adaptive equipment support when walking, the opportunity to walk is invaluable for muscle and joint health and cardiovascular endurance, just as active exercise is healthy for every individual," said Lori Potts, a physical therapist with Rifton Equipment, a company that develops new gait training devices.

The Latest Developments

Exciting things are happening in the world of gait training in both research and technology.

On the research front, Spinal Cord Injury Services at Helen Hayes Hospital in West Haverstraw, New York has teamed up with the Wadsworth Institute of New York to study a form of biofeedback therapy they hope will someday regularly help train spinal cord reflexes in people who walk with difficulty due to incomplete SCI.

The research team hopes their form of gait-training therapy, called electrical stimulation (EMG), will help people with SCI need fewer braces and walk with fewer assistive devices.

This therapy trains the dorsi-flexor muscles and tibialis anterior—which allows ankles to bend up to keep toes from the floor.

"We hook participants up to a biofeedback machine," said Program Director Elaine DeFrancesco. "If they contract the muscles correctly, the screen turns green and they get a monetary reward. If it stays red, they haven't gotten the response of the 'H reflex.'"

Over time, the people in the study are able to train their minds and close the loop.

Outcomes of the study are encouraging. Participants in the study increased their walking speed, lessened their need for help, and improved their heart health.

"The hope is to use functional electrical stimulation, locomotor training, and electrical stimulation on reflexes as a combination therapy—a recipe for spinal cord recovery," said DeFrancesco. "Locomotor and functional electrical stimulation are appropriate for any spinal cord injured individual. EMG is currently specifically for incomplete spinal cord injuries, or individuals who have some movement in their legs."

DeFrancesco said that it could be several years before this therapy is widely available, but the group at Helen Hayes is currently accepting new participants with incomplete SCI. Those interested can learn more at

On the technology front, Rifton Equipment has developed an adaptive walker called the Rifton Pacer XL, which is designed to be part of the continuum of rehab after BWSTT but before more independent walking. The Pacer can accommodate even a larger- sized individual and pass through 32" doorways for indoor use.

The Pacer has adjustable supports for postural positioning and for weight-bearing assist," said Potts. "The hip positioner acts as a sling seat to assist weight- bearing, the chest prompt holds the upper body in position, and the arm prompts act as a further support to share weight-bearing and to maneuver the walker. Other supports guide lower extremity position. Transfer into the Pacer occurs either with manual assistance from sitting to standing within the Pacer frame, securing the hip positioner in place, or by using the Rifton SoloLift, a transfer device designed for use with the Pacer."

The Pacer is designed to be able to offer a customized level of support, helping individuals with SCI improve their overall body strength and ability to walk over time. Learn more at

What's Next?

Dr. Marcus of the Medical Rehabilitation and Kinematics Lab in San Diego shared three additional up-and-coming gait- training technologies:

Tibion Bionic Knee: A robotic knee that may help patients with weakness in their quadriceps with the ability to extend their legs. The Tibion device has showed promise in improving the mobility of stroke patients. It will soon be tested for patients in a study being done at Medical Rehabilitation and Kinematics Lab for patients with incomplete SCI, multiple sclerosis, and spina bifida. Learn more at

Re-Walk: The Re-Walk is currently being tested at Moss Rehabilitation in Philadelphia. Learn more at

Lokomat PRO with Augmented Feedback: Medical Rehabilitation and Kinematics Lab is one of three facilities in the country that has this machine. It is more sophisticated and offers more options than the standard Lokomat. Learn more at

Before Beginning a Gait Training Program

Be sure that any gait training program you are considering is a good fit and will meet your needs.

Dr. Marcus stresses the importance of individualized care when it comes to gait training.

"When you are talking about gait training, every patient is not the same, so it is important that the gait training program is not cookie cutter," said Dr. Marcus. "Each case needs to be looked at individually. Gait training needs to take into consideration the individual medical history and situation of each patient to avoid further injury."