PRM interventions for disorders of the spine and spinal cord. Degenerative spinal disorders, intervertebral disc disease, disc herniation, and radiculopathies. Spinal cord injuries. Functional assessment, prevention of secondary complications, and comprehensive rehabilitation

01Degenerative spinal disorders

Rehabilitation of the spine starts with one idea: the spine is a stack of moving parts, and moving parts wear. Each segment has three joints, the disc in front and two small facet joints behind. As the disc dries and loses height, the load shifts to the facets and ligaments, and the body adds bone at the edges to steady things. That wear goes by several names:

Most back and neck pain has no single structure to blame and is called non-specific. Low back pain is the leading cause of years lived with disability worldwide. What turns it into long-term disability is often not the tissue but fear of movement, low mood, an unhelpful belief that the back is "damaged", and work and social factors. That is why modern rehabilitation is biopsychosocial: it treats the tissue, the movement and the person together.

Red flags first

Before any physical treatment, the doctor looks for the few causes that need something else.

02Intervertebral disc disease and disc herniation

The disc is like a jam doughnut: a tough fibrous outer ring, the annulus fibrosus, round a soft jelly centre, the nucleus pulposus. Years of load and small tears weaken the ring. When it gives way, the jelly pushes out. The stages run from a bulge (the ring is intact but the disc spreads), to a protrusion, to an extrusion (the nucleus breaks through the ring) and a sequestration (a free fragment in the canal).

The ring is thinnest at the back and sides, where the posterior longitudinal ligament does not cover it, so most herniations go posterolateral, straight towards the nerve root. The commonest levels are L4/5 and L5/S1 in the low back and C5/6 and C6/7 in the neck, the segments that move most.

A herniation hurts in two ways:

• Pressure. The fragment squeezes the root and its blood supply.
• Chemistry. The nucleus is foreign to the immune system, so it sets off inflammation around the root. This is why a small herniation can hurt a lot, and why pain often eases before the disc shrinks.

Risk factors follow the same logic of wear and load: age, heavy lifting with twisting, vibration (drivers), long sitting, smoking (it starves the disc of its blood supply), obesity, weak trunk muscles and genetic make-up.

03Radiculopathies

A radiculopathy is a disorder of a spinal nerve root: compressed, irritated or inflamed. Each root has its own strip of skin (a dermatome), its own muscles (a myotome) and often its own reflex. So the pattern of symptoms tells you which root is affected, like an address.

Causes are mostly a herniated disc in younger people and foraminal stenosis from spurs and facet arthritis in older ones; more rarely spondylolisthesis, tumour, infection or herpes zoster.

In the neck, the root leaves above the vertebra of its number, so a C6/7 disc catches C7. In the low back, a posterolateral L4/5 disc catches L5, the root travelling down to the next foramen; only a far-lateral disc catches the root leaving at its own level (L4).

The tests stretch or close down on the sore root:

• Straight leg raise (Lasègue's sign): lifting the straight leg pulls the L5 and S1 roots through the foramen. Leg pain below the knee between about 30 and 70 degrees is positive. Pain in the sore leg when the other leg is raised (crossed sign) points strongly to a disc.
• Femoral stretch test: knee bent with the patient prone, stretching L2 to L4.
• Spurling test: extending, side-bending and pressing down on the head narrows the cervical foramen and reproduces arm pain.

Radicular pain is sharp, shooting or burning, follows the dermatome, and is worse with coughing, sneezing and straining, which raise the pressure in the canal. Leg or arm pain worse than back or neck pain is the clue that a root is involved.

04Functional assessment

Assessment answers three questions: is it safe to treat, what exactly is wrong, and how does it limit this person's life? It uses the ICF layers: body functions, activities and participation (see functional assessment).

05Rehabilitation of degenerative disorders, disc disease and radiculopathy

The plan follows the stage: in the acute phase, calm the pain and keep the patient moving; later, restore strength, endurance and confidence and prevent the next episode.

1. 1

   Explain and reassure

   Most back pain and sciatica settle. Hurt does not mean harm. Stay as active as the pain allows; bed rest slows recovery and is not advised.
2. 2

   Relieve the pain

   Painkillers as needed (an NSAID first if suitable), positions that unload the root, heat or cold, and a short period of modified activity.
3. 3

   Restore movement

   Directional exercises, gentle mobility, nerve gliding, walking.
4. 4

   Rebuild the trunk

   Stabilisation and strength of the deep trunk and hip muscles, endurance, aerobic fitness.
5. 5

   Return to life

   Graded return to work and sport, ergonomics, self-management to prevent recurrence.

Exercise and kinesiotherapy

Exercise is the treatment with the best evidence. No single type wins, so what the patient will keep doing matters most.

• McKenzie method. Repeated movements in one direction are tested to find the one that makes leg pain retreat towards the spine (centralisation). Centralisation predicts a good outcome; the patient then repeats that movement at home.
• Stabilisation and core training. The deep trunk muscles (transversus abdominis, multifidus) first, then the whole trunk and hips, then loaded tasks.
• Strength and endurance of the back, abdomen and legs, and low-impact aerobic exercise: walking, cycling, swimming.
• PNF (Kabat concept). Diagonal movement patterns against resistance for trunk and limb control.
• Neurodynamic techniques. Gently sliding an irritated root through its tunnel to make it less sensitive.
• Correcting muscle imbalance. Tight muscles (hip flexors, hamstrings, upper trapezius) are stretched, for example with post-isometric relaxation; weak ones (gluteals, deep neck flexors, abdominals) are strengthened.
• Ergonomics and back school. How to lift, sit, set up a workstation and pace activity.
• With a psychological approach. For persistent pain with high fear or distress, exercise with a cognitive behavioural approach does better than either alone.

Manual therapy (mobilisation, manipulation, soft tissue techniques) and massage can help in the short term, but only as part of a programme that includes exercise. Manipulation is avoided with a progressive deficit, osteoporosis or instability.

Positioning and traction

Positioning puts the spine where the root has the most room: for an acute lumbar disc, on the back with hips and knees bent over a roll (the step position) or curled on the side; for stenosis, bent forward. Long static positions are avoided.

Traction pulls the segments apart with a controlled force, by hand, by a machine, under water, or by the patient's own body in autotraction (the Nachev method of the Bulgarian school combines traction with movement). The professor's material sorts it by direction: longitudinal, oblique, angled (kyphotic, lordotic, lateral flexion), rotational and combined, with a manual trial first to find a direction that eases the pain.

Physical agents

The professor's slides list many physical agents for the spine. Know them and why each is used; the table groups them.

When surgery

Surgery (discectomy, decompression) is for cauda equina syndrome and severe or progressive weakness, as an emergency or urgently, and for persistent disabling sciatica that has not settled with good conservative care, usually after about six to twelve weeks. It brings faster relief of leg pain, but at one to two years outcomes with and without surgery are often similar. After surgery, rehabilitation starts early, with walking from day one and a graded exercise programme.

06Spinal cord injuries

The spinal cord is the main cable between the brain and the body. A spinal cord injury (SCI) cuts some or all of the wires at one level: everything below loses some of its movement, feeling and automatic control. Most traumatic injuries come from road accidents and falls (falls now lead in older Europeans, as the population ages); others come from tumours, infection, ischaemia or degenerative cervical myelopathy.

The level of injury decides which functions are lost:

• Tetraplegia (cervical): arms, trunk, legs and the pelvic organs are affected.
• Paraplegia (thoracic, lumbar or sacral): the arms are spared.
• Below about L1 or L2 the cord has ended, so a lesion there damages the cauda equina, the roots: a lower motor neuron picture with flaccid paralysis and an areflexic bladder.

Straight after injury comes spinal shock: the cord below the injury goes silent, with flaccid paralysis and no reflexes, for days to weeks. As it fades, reflexes return and, in an upper motor neuron lesion, become overactive: spasticity, brisk reflexes and a reflex bladder.

The ASIA examination and grade

The ISNCSCI examination (International Standards for Neurological Classification of SCI, from ASIA, the American Spinal Injury Association, and ISCoS; revised in 2019, with a 9th edition in 2026) is the shared language of SCI. The core examination and the AIS grades below are long-standing. It tests:

• Sensation at a key point in each of the 28 dermatomes from C2 to S4–5, each side, for light touch and pinprick, scored 0 (absent), 1 (altered) or 2 (normal).
• Strength in ten key muscles each side (C5 to T1 in the arm, L2 to S1 in the leg), scored 0 to 5 as in manual muscle testing.
• The anorectal examination: voluntary anal contraction and deep anal pressure.

From these come the neurological level (roughly, the lowest segment where feeling is normal and the key muscle still lifts against gravity, grade 3 or more, with normal segments above it) and the grade on the ASIA Impairment Scale (AIS):

Incomplete injuries often follow patterns named after the part of the cord damaged: central cord syndrome (arms weaker than legs, typically an older person with a stiff, narrow neck after a hyperextension fall), Brown-Séquard syndrome (half the cord: weakness and loss of position sense on the same side, loss of pain and temperature on the other), anterior cord syndrome (motor loss and pain loss, position sense spared; worst prognosis) and conus and cauda equina syndromes.

What the level means for function

The muscles that still work set the goals. The table gives the usual best outcome of a complete injury in a fit young adult; incomplete injuries do better.

Functional assessment in SCI

Alongside ISNCSCI, the team measures what the person can do:

• SCIM (Spinal Cord Independence Measure): self-care, respiration and sphincter management, mobility; made for SCI and more sensitive than FIM or the Barthel index here.
• WISCI II (Walking Index for SCI): how much help walking needs; with the 10-metre walk, 6-minute walk test and Timed Up and Go.
• Balance (Berg Balance Scale, sitting balance), the Modified Ashworth Scale for spasticity, pain (VAS, DN4), bladder and bowel function, skin and pressure-ulcer risk (Braden scale), breathing (vital capacity, peak cough flow), mood, and participation.

07Prevention of secondary complications

A cord injury does damage in a moment; complications do damage for years and cause most of the deaths and readmissions afterwards. Each follows from what the cord no longer controls.

Autonomic dysreflexia

The sympathetic nerves to the big splanchnic (gut) blood vessels leave the cord from about T6 down. So in an injury at T6 or above, those vessels are still wired to the cord below the injury but cut off from the brain. A full bladder, constipation, an ingrown toenail or a pressure sore sends a signal up the cord that triggers a sympathetic surge. The vessels below the lesion clamp down and blood pressure rises; the brain feels it through the baroreceptors and slows the heart, but its brake signal cannot pass the injury.

Signs: a systolic pressure more than 20 mmHg above the patient's own baseline (resting pressures in tetraplegia are often low, near 90 to 110 mmHg, so 140 can already be dysreflexia), pounding headache, flushing and sweating above the lesion, pale cold skin below it, a stuffy nose, often a slow pulse. Some patients have few symptoms, so the pressure is measured.

1. 1

   Sit up

   Sit the patient upright with the legs down, loosen clothing, binders, stockings and leg-bag straps. This pools blood in the legs.
2. 2

   Check the pressure

   Every 2 to 5 minutes.
3. 3

   Find the trigger

   Bladder first: check and unblock the catheter or catheterise, with lidocaine gel. Then the bowel (with anaesthetic gel), then skin, tight shoes, ingrown nails.
4. 4

   Treat if it stays high

   If the systolic pressure is 150 mmHg or more, give a fast, short-acting antihypertensive (a nitrate or nifedipine, as local protocols say) before going on to check the bowel. No nitrate if a sildenafil-type drug was taken recently. Untreated, dysreflexia can cause seizures, stroke and death.

08Comprehensive rehabilitation after spinal cord injury

Rehabilitation runs from day one in intensive care to life back in the community, ideally in a specialised SCI centre, where teams see many patients and outcomes are better.

1. 1

   Acute phase

   Spine stabilised (surgery or orthosis). Positioning and turning, passive range of motion, breathing exercises and assisted cough, tilting up gradually, bladder and bowel programme, clot prevention.
2. 2

   Subacute phase

   The main inpatient programme: strengthening what works, sitting balance, transfers, wheelchair skills, self-care with aids, standing, gait training if the injury allows.
3. 3

   Community reintegration

   Home adaptation, driving, return to school or work, sport, sexuality and fertility, peer support.
4. 4

   Lifelong follow-up

   Annual review of skin, bladder and kidneys, bones, weight, heart and mood. Ageing with SCI brings shoulder pain from years of pushing and transfers.

The main methods

• Therapeutic exercise. Strengthening every working muscle, above all the shoulder depressors, triceps and latissimus that lift the body for transfers; arm-crank aerobic training; sitting balance.
• Task and locomotor training. Practising the real task: rolling, transfers, dressing. In incomplete injuries, body-weight-supported treadmill or robotic gait training, then walking with orthoses (AFO, KAFO). PNF and motor learning recruit what is left.
• Functional electrical stimulation (FES). Upper motor neuron lesions leave the lower motor neurons and the muscle intact, so stimulating the nerve makes a useful contraction: FES cycling for muscle bulk, circulation and bone, FES for grasp, standing and stepping.
• Stimulation of denervated muscle. In a lower motor neuron lesion (conus, cauda equina) the nerve is gone, so ordinary short pulses no longer work; long-duration triangular or exponential pulses, which the nerve-free muscle can still answer while nerve fibres accommodate to them, keep it from wasting while a root regrows (see electrodiagnosis). The evidence for this is modest.
• Positioning and spasticity management. Positioning in bed and chair, stretching, standing, splints, cold or warm water, post-isometric relaxation for short muscles, and the drugs in the table above.
• Assistive technology and education. Wheelchairs and seating, orthoses, environmental controls, adapted cars; teaching the patient and family skin, bladder, bowel and dysreflexia care.

The team

The PRM physician leads physiotherapists (kinesitherapists), occupational therapists, rehabilitation nurses, a psychologist, a urologist, a social worker and an orthotist, with others as needed. Goals are set with the patient, written down, and checked at regular team meetings.

any function here makes the injury incomplete

S4–5sacral segmentsany function here makes the injury incomplete

the injuries that risk autonomic dysreflexia

T6and abovethe injuries that risk autonomic dysreflexia

between weight shifts in the wheelchair

15–30minutesbetween weight shifts in the wheelchair

of good conservative care before elective disc surgery is usually considered

6–12weeksof good conservative care before elective disc surgery is usually considered