Musculoskeletal Issues in Pediatric Spinal Cord Injury

Posted by Nurse Linda in Life After Paralysis on March 30, 2022 # Health

Due to issues after spinal cord injury or brain injury, the musculoskeletal (muscles and bones) system can be affected in both pediatrics and adults. However, issues in the pediatric skeletal system can be more prevalent due to do the developing body, even into adolescence. Much of the source of skeletal issues can be directly due to bone injury, muscle dysfunction, but it also is highly affected by the nervous system.

The anatomy of the bones is the skeleton. We do not think much about our bones unless there is a disruption in their structure. The feeling of a change in the bones can be noted through sensation and alignment, but it typically is not really noticed, especially by the pediatric aged individual. Arthritis is an inflammation, especially at bone joints, that can develop in children, but their skeletal system is mostly just there performing as it should in structure and function.

Muscles attach to the bones through tendons. When muscles work, the tendons pull on the bones, making the bones stronger or ensuring bone density. Bones that have lost a bit of bone density are called osteopenia; a major loss in bone density is osteoporosis. Typically, decreases in bone density are thought of in women who have achieved menopause, not in children. However, lack of muscle use reduces the pull on the tendons and can lead to poor bone density at any age and in any gender.

The nervous system controls movement, which activates the muscles to contract and relax. Most movement happens without really thinking about the details of the nerve communication, as it happens instantly. So many of our movements are patterned in the nervous system that a lot of thought is not necessary. Messages are disrupted for movement if there is an injury in the spinal cord that does not let those messages pass. In injuries to the brain, the disruption of the message may be stalled from being formed or developed in the brain.

There are some common issues in the musculoskeletal system that can occur at any age but are especially concerning in the pediatric population. These include bone fractures or breaks, tone (spasticity), heterotopic ossification (H.O., bone growth into muscle tissue), and musculoskeletal imbalances such as contracture and scoliosis. Overuse syndrome is also an issue.

Bone fractures can occur at any age. Before puberty, children may have greenstick fractures which are more like splintering of bones. If you have tried to remove a limb from a young tree, you will see the limb splinters but does not completely separate. Other types of bone fractures are actual breaks to the bones that can occur in children of any age. These are from more forceful incidences. Fractures can also be from the compression of bones, such as when vertebrae are crushed.

After SCI or brain injury, fractures are divided into two categories, fragility and incident. Fragility fractures occur from accidents to bones with poor bone density and usually with little force. Examples include activities such as turning or being lifted by not using the trunk but by use of the legs or arms, rolling, and falling. Incidence fractures occur by unusual force to the bone, as in getting your foot, leg, hand, or arm caught in your wheelchair or against a solid surface. Motor vehicle accidents are the primary reason for incident fractures in children. Physical abuse can result in bone fractures as well, both fragility and incident.

Having your child’s bone density evaluated yearly is an important health check. Early detection of low bone density can be treated. Early treatment is always best. Oral medication can be provided. Careful moving of body parts should always be a part of care. Especially when children are older and move themselves, they may not realize the force of their movement if the sensation is limited. Swinging body parts around is not unusual with decreased sensation so teaching a child to care for their bodies is critical. Also, looking to ensure body parts are in place is important. Checking periodically to make sure your leg is positioned on the footrest or your arm is on the are rest is important. If your mobility is stopped for some reason, teach your child to check to make sure it is not a body part that is impeding movement. Use safety devices such as seatbelts and positioning equipment to keep body parts where they should be. Create a diet with normal amounts of calcium for strong bones. Provide movement, exercise, and standing in a standing frame to help keep bones healthy. Movement and exercise provide that tendon tension on the bones to strengthen them.

Tone or spasticity is an issue of involuntary motor function where the body part uncontrollably twitches at a variety of levels. Muscles have a need to be stretched. This reflex, called the muscle stretch reflex, is typically satisfied with voluntary movement. When it is not, the movement needs to be supplied. The nervous system will send messages for movement, but if this message is interrupted, tone occurs.

Tone can be uncomfortable, painful, for some embarrassing, and can trigger episodes of autonomic dysreflexia. It can be significant enough to disrupt sitting, sleeping, play, and other activities. Stretching is a first-line defense. Exercise can fatigue the muscle and reduce tone. Medication can help resolve tone, either orally, which affects the entire body or intrathecally through a pump placed in the spinal canal to deliver medication. Botox injections are the most frequently used treatment.

Low tone can occur with some injuries. These are typically seen in children with lower-level spinal cord injury and some brain injury. The body or body parts may appear ‘floppy’ or may quickly reduce muscle tone. Exercise should be provided to the affected body parts. Extra care in movement should be taken to ensure damage to the body does not occur.

Heterotrophic Ossification is typically referred to as H.O. This is bone that grows outside of the existing bone. It can be thought of as bone growth that has lost its way. The bone grows in the muscle tissue, usually around larger joints at the shoulder, elbow, hips, and knees but can grow around any joint. It is typically first seen as swelling, decreased range of movement, hyperemia (an increase of blood and blood vessels in the affected area), pain, or autonomic dysreflexia. Diagnosis is by x-ray, CT scan, bone scan, or ultrasound.

NSAIDs are oral medications that can be taken to slowly reduce the extra bone formation if caught early. Radiation therapy is also used. If the bone formation has contracted the joint, surgery may need to be done. The bone is growing in the soft tissue around the joint, so separation of the H.O. and tissue is a difficult surgical challenge. In rare cases, the joint may need to be replaced. Early diagnosis is critical to ensure H.O. does not progress this far. Forcing the joint to move when H.O. is present can lead to significant damage.

Muscles are arranged in the body that will push or pull. Typically, muscles are companions; those for pushing are balanced with those for pulling. If messages are not being communicated, and movement is not being supplied to the muscles, an imbalance can occur.

Imbalances in muscles can result in contractures. Most often, the muscles that pull the body part toward the heart become stronger than the muscles for pushing. This can include extremities, the trunk, neck, or any muscle group. Moving the extremity becomes difficult and painful if the sensation is felt, or autonomic dysreflexia can occur. Contractures are a complication of tone, especially if untreated. It can make function and hygiene difficult.

For early contractures, stretching, as taught by a healthcare professional, can be used to slowly stretch the muscle. This cannot be done quickly without a muscle tear or injury. Sometimes serial casting can be applied to continuously apply small, adjustable stretches to the muscle. In severe cases, surgery may be needed to ‘feather’ the muscle to elongate it. Ongoing treatment for the cause of the contracture should be performed to prevent a recurrence. This might include treatment for tone or splints to keep the muscle supple.

Another muscle imbalance is scoliosis. The back muscles also have a configuration of two muscles on each side of the spine that balance each other. If one set of back muscles becomes stronger than the other set or tone is in one set, the spinal vertebrae can become twisted or rotated. This can lead to spinal cord damage, breathing issues and positioning concerns if left untreated.

Fortunately, when diagnosed early, therapy to strengthen the less strong set of muscles is a start. In some cases, a brace may be needed. In severe cases, spinal stabilization surgery may be needed. This is done by inserting rods attached to the spinal vertebrae (bones). New soft rods that are made from a flexible substance allow some trunk movement which is very helpful to maintain function. The soft rods may need to be replaced as your child grows through minimally invasive surgery.

Joints in the body are designed to achieve the functions of typical use. For example, arms have less weight-bearing capacity than legs that are made to hold the entire body weight. When a child has an injury to the spinal cord or brain injury, they may need to use their bodies in different ways. Transferring or moving the body from one location to another may be accomplished by lifting the body with the arms instead of the legs. Pushing a wheelchair can result in the overuse of the shoulders. Walking with braces and crutches or a walker can place additional weight on the shoulders, elbows, and wrists as well as hips, knees and ankles.

Overuse syndrome can become an issue if too much is expected of specific parts of the body. Monitoring of body joints is an important health concern. Ensuring correct positioning during movement, correctly fitted mobility devices, and exercises to maintain muscle strength are ways to keep your child’s joints healthy. If a joint is achy, it may be time for a rest. Investigate equipment supplements such as wheelchair power assists, transferring assists, or any equipment that will help maintain the joints of your child.

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

And if you want more Nurse Linda, sign up for her monthly webinars here. Don’t worry, we archive her answers so you can refer back and sift through her advice. Consider it Nurse Linda on-demand!

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.