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Evidence‐based approaches

Principles of care

Stable spine

The general principles of positioning mentioned earlier in this chapter are all relevant to this group of patients. However, patients need to be assessed for adequate pain control prior to moving and positioning, and care should be taken to avoid excessive rotation of the spine when turning.
Mobilization requires a graduated and carefully monitored approach, and sitting must be trialled with regular review of neurology and observations (CRGSCI [23]). Clinical vigilance should be exercised with moving and positioning patients with an SCC. Such interventions should be ceased if there is worsening of pain or neurological symptoms. Medical advice should be sought regarding spinal stability.

Unstable spine

For patients with an unstable spine or severe mechanical pain suggestive of spinal instability, specific instructions for moving must be followed until bony and neurological stability is radiologically confirmed and discussed with appropriate medical teams. This is to ensure spinal alignment and reduce the risk of further spinal damage and potential loss of function. If a thoracolumbar injury is suspected, do not flex the hip more than 45° (CRGSCI [23]).
This patient group will require particular considerations to enable safe practice without compromising their clinical condition. These may include (CRGSCI [23]):
  • lateral surface transfer (e.g. bed to trolley) using a spinal board or scoop stretcher
  • manual support of the patient's head and neck for any flat surface transfer of patients with lesions above T6 (this ensures appropriate spinal alignment and patient comfort)
  • log rolling for personal and pressure care for patients with unstable SCI.
When moving and turning patients with confirmed or suspected spinal instability who are being nursed flat, log rolling must be used. This is a technique used to maintain neutral spinal alignment. It is an essential method to enable continence and pressure area care.
Repositioning frequency will be determined by the individual's skin integrity, continence needs and degree of spinal instability (GAIN [38]). Patients should only be moved by adequate numbers of staff who have been fully trained in moving patients with SCC or SCI. Differing methods are recommended depending on the level of the lesion or injury:
  • Cervical and high thoracic lesions (T6 and above): log roll with five people (MASCIP [69]; see also Procedure guideline 7.13: Log rolling a patient with suspected or confirmed cervical spinal instability (above T6)).
  • Thoracolumbar lesions (T7 and below): log roll with four people (MASCIP [69]; see also Procedure guideline 7.14: Log rolling a patient with suspected or confirmed thoracolumbar spinal instability (T7 and below)).
The general principles of care mentioned earlier in this chapter are all relevant to individuals with SCI. However, there are some other factors that need to be considered for these patients. Early and accurate diagnosis and, if appropriate, treatment are necessary to optimize neurological functioning. Timely referral to rehabilitation services (such as physiotherapists and occupational therapists) is imperative for assessment and appropriate intervention, and thorough discharge planning is required to enable a smooth transition back into the community (GAIN [38]).
Active rehabilitation may be postponed until the medical team has confirmed that the patient's spine is stable. However, there is a significant role for members of the rehabilitation team in the management of these patients in terms of:
  • assessing motor and sensory function
  • minimizing further complications, such as chest infections, which may arise as a result of prolonged bedrest and respiratory muscle weakness
  • effective, co‐ordinated discharge planning – the positioning and moving needs of these patients are often complex and so discharge planning may be lengthy and multifaceted, with the patient requiring ongoing support and rehabilitation in the community to optimize their functional independence (GAIN [38]).
Patients with neurological symptoms will require a physiotherapist to ensure correct manual handing is carried out, especially the first time a patient is moved out of bed. Patients may be able to assist with moving, positioning and transfers depending on:
  • spinal stability
  • pain
  • level of lesion
  • muscle power
  • sensory impairment
  • exercise tolerance
  • patient confidence.
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