Seven directions of research · All six steps
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Clinical context and today's care How an injury presents, which states appear early, which complications are known, and the context rehabilitation works in. Not advice, not a plan.
This is educational context. It is not a diagnosis, not a prognosis, not a treatment plan and not advice about any individual person. For anything urgent, seek professional help rather than an answer from a website.
Plate 15 Atlas of a spinal cord injury 15 of 19 How it presents Motor signs Motor signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 1 Motor signs Sensory signs Sensory signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 2 Sensory signs Autonomic signs Autonomic signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 3 Autonomic signs Respiratory signs Respiratory signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 4 Respiratory signs Signs that need urgent help Signs that need urgent help — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 5 Signs that need urgent help Open this plate
Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. × Plate 15 Atlas of a spinal cord injury 15 of 19 How it presents Motor signs Motor signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 1 Motor signs Sensory signs Sensory signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 2 Sensory signs Autonomic signs Autonomic signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 3 Autonomic signs Respiratory signs Respiratory signs — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 4 Respiratory signs Signs that need urgent help Signs that need urgent help — Five rows, each with its own drawing and, at the far side, the body the group of signs is seen in with the region below the injury shaded: a slack muscle for movement, the two test points for sensation, a bladder, a heart and a rising dial for autonomic function, lungs over a weakened diaphragm for breathing, and last, set apart in red, the signs that mean somebody needs help now. 5 Signs that need urgent help 1
Motor signs Weakness, loss of voluntary movement, a change in tone. What exactly, and where, depends on the level and the completeness.
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Sensory signs Numbness, altered pain and temperature, loss of the sense of position.
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Autonomic signs Changes in bladder and bowel function, changes in blood pressure, difficulty regulating temperature, changes in sexual function.
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Respiratory signs Weakened breathing, reduced vital capacity, a weak cough and the infection risk that comes with it. Most relevant at high cervical levels.
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Signs that need urgent help Sudden loss of movement or sensation, severe neck or back pain after an injury, difficulty breathing, sudden loss of bladder or bowel control, a sudden severe headache with rising blood pressure. This is not a checklist to score yourself against: with any of these, seek urgent professional help.
Where this goes in the corpus Motor function 31 measurements Sensory function 6 measurements Safety 6 measurements ← Previous plate The examination All six steps Next plate → Two early states, not one Plate 16 Atlas of a spinal cord injury 16 of 19 Two early states, not one Spinal shock Neurogenic shock Spinal shock — Two panels facing each other. On the left the reflex loop that closes inside the cord, drawn faint and going nowhere, with the hammer and a slack muscle. On the right the sympathetic outflow leaving the cord and cut, the vessel wide, and two dials reading low. Below them the same six questions answered on both sides — mechanism, tone, reflexes, pressure, rate, course — each as a small drawing rather than a word. Neurogenic shock — Two panels facing each other. On the left the reflex loop that closes inside the cord, drawn faint and going nowhere, with the hammer and a slack muscle. On the right the sympathetic outflow leaving the cord and cut, the vessel wide, and two dials reading low. Below them the same six questions answered on both sides — mechanism, tone, reflexes, pressure, rate, course — each as a small drawing rather than a word. BP HR VS Side by side Mechanism The cord itself falls temporarily silent Sympathetic control of the vessels is lost Muscle tone Muscles are flaccid, there is no tone Tone is not itself changed by this Reflexes Reflexes are absent, then return Says nothing about reflexes Blood pressure May stay normal Low Heart rate May stay normal Slow — and that is what separates it from blood loss How it runs Days or weeks, with reflexes gradually returning An emergency, treated at once Open this plate
Two panels facing each other. On the left the reflex loop that closes inside the cord, drawn faint and going nowhere, with the hammer and a slack muscle. On the right the sympathetic outflow leaving the cord and cut, the vessel wide, and two dials reading low. Below them the same six questions answered on both sides — mechanism, tone, reflexes, pressure, rate, course — each as a small drawing rather than a word. × Plate 16 Atlas of a spinal cord injury 16 of 19 Two early states, not one Spinal shock Neurogenic shock Spinal shock — Two panels facing each other. On the left the reflex loop that closes inside the cord, drawn faint and going nowhere, with the hammer and a slack muscle. On the right the sympathetic outflow leaving the cord and cut, the vessel wide, and two dials reading low. Below them the same six questions answered on both sides — mechanism, tone, reflexes, pressure, rate, course — each as a small drawing rather than a word. Neurogenic shock — Two panels facing each other. On the left the reflex loop that closes inside the cord, drawn faint and going nowhere, with the hammer and a slack muscle. On the right the sympathetic outflow leaving the cord and cut, the vessel wide, and two dials reading low. Below them the same six questions answered on both sides — mechanism, tone, reflexes, pressure, rate, course — each as a small drawing rather than a word. BP HR VS Side by side Mechanism The cord itself falls temporarily silent Sympathetic control of the vessels is lost Muscle tone Muscles are flaccid, there is no tone Tone is not itself changed by this Reflexes Reflexes are absent, then return Says nothing about reflexes Blood pressure May stay normal Low Heart rate May stay normal Slow — and that is what separates it from blood loss How it runs Days or weeks, with reflexes gradually returning An emergency, treated at once 1
Spinal shock A temporary state right after an injury in which reflexes below the level disappear and muscles go flaccid. Reflexes usually return over time. It is a state of the reflexes, not of the circulation.
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Neurogenic shock A state of the circulation: loss of sympathetic tone, dilated vessels, low blood pressure and a slow pulse. More common at high levels. It is dangerous, and it is constantly confused with spinal shock, which is a different thing.
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Autonomic function What a person does not steer consciously: blood pressure, temperature, bladder, bowel and sexual function. These changes are rarely visible from outside and they often decide the shape of a day.
What may change after an injury Some of these changes are dangerous rather than inconvenient — and they are asked about constantly and reported on rarely.
Where this goes in the corpus Acute 6 studies Safety 6 measurements Electrophysiology 3 measurements ← Previous plate How it presents All six steps Next plate → What is managed, and where Plate 17 Atlas of a spinal cord injury 17 of 19 What is managed, and where What is managed The rehabilitation context Pressure injuries — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Pressure injuries Pressure injuries Deep vein thrombosis — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Deep vein thrombosis Deep vein thrombosis Respiratory complications — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Respiratory complications Respiratory complications Autonomic dysreflexia — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Autonomic dysreflexia Autonomic dysreflexia Neurogenic bladder and bowel — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Neurogenic bladder and bowel Neurogenic bladder and bowel Spasticity — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Spasticity Spasticity Positioning and pressure relief — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Positioning and pressure relief Positioning and pressure relief Range of motion — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Range of motion Range of motion Strengthening what is spared — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Strengthening what is spared Strengthening what is spared Respiratory physiotherapy — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Respiratory physiotherapy Respiratory physiotherapy Transfer training — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Transfer training Transfer training Getting about: gait or wheelchair — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Getting about: gait or wheelchair Getting about: gait or wheelchair Open this plate
Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. × Plate 17 Atlas of a spinal cord injury 17 of 19 What is managed, and where What is managed The rehabilitation context Pressure injuries — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Pressure injuries Pressure injuries Deep vein thrombosis — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Deep vein thrombosis Deep vein thrombosis Respiratory complications — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Respiratory complications Respiratory complications Autonomic dysreflexia — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Autonomic dysreflexia Autonomic dysreflexia Neurogenic bladder and bowel — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Neurogenic bladder and bowel Neurogenic bladder and bowel Spasticity — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Spasticity Spasticity Positioning and pressure relief — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Positioning and pressure relief Positioning and pressure relief Range of motion — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Range of motion Range of motion Strengthening what is spared — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Strengthening what is spared Strengthening what is spared Respiratory physiotherapy — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Respiratory physiotherapy Respiratory physiotherapy Transfer training — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Transfer training Transfer training Getting about: gait or wheelchair — Two columns facing each other. On the left six drawings of what is managed day to day: pressure on skin over a bone, a clot in a vein of the leg, lungs and diaphragm, a rising pressure with a trigger below the level, bladder and bowel, a muscle held tight. On the right six drawings of what is done: turning, moving joints, strengthening, breathing work, getting from bed to chair, and getting about. Getting about: gait or wheelchair Getting about: gait or wheelchair 1
Pressure injuries Damage to skin and tissue from sustained pressure where sensation has changed and the signal to shift never arrives.
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Autonomic dysreflexia A sudden rise in blood pressure in response to something below the level of injury — a full bladder, tight clothing, a wound. Seen at levels of about T6 and above. It is an emergency.
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Respiratory complications A weakened cough and reduced ventilation raise the risk of airway infection. Most relevant at high cervical levels.
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Neurogenic bladder and bowel Changed storage and emptying, retention or incontinence, and the infections that come with them. These functions decide how many hours of a day belong to care.
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The rehabilitation context Rehabilitation works with what remains: positioning, range of movement, strength, breathing, transfers, wheelchair skills. What is done, and how much, is decided by a team that knows the individual person. This map makes no such decision and gives no plan.
Also on this plate
Deep vein thrombosis Clots forming in the veins of the legs when movement is reduced; the risk is that a clot travels.
Spasticity Increased muscle tone and involuntary contractions. For some people it gets in the way; for others it partly helps hold a position — so it is not simply a bad thing.
Positioning and pressure relief Changing position regularly and choosing surfaces so that pressure does not stay long in one place. It is aimed at pressure injuries.
Range of motion Passive and active movement at the joints to keep them mobile and to keep fixed restrictions from forming.
Strengthening what is spared Training the muscles that still work above the level of the injury. Most everyday actions depend on their strength.
Respiratory physiotherapy Exercises that expand the chest and help with clearing a cough. The higher the level of injury, the more it matters.
Transfer training Moving from bed to chair and back is a skill of its own, broken into steps and practised. It decides independence more than most.
Getting about: gait or wheelchair Practising walking with support, or handling a wheelchair. Which of the two is possible depends on the level and the completeness of the injury.
Where this goes in the corpus Safety 6 measurements Tissue integrity 6 measurements ← Previous plate Two early states, not one All six steps Next plate → Seven directions, one lesion What is missing at this step This layer names the axes the corpus is indexed by. Where an axis holds no records, the panel says so and says what would change it — the gap is part of the answer.
What is still missing → · What is covered →
Where to look next The same corpus, entered a different way: by question, by place, by connection, and by what changed recently. Every one of these reads the records this step has been pointing at.
124 medical statements · 6 authorities · 124 stand on an address that answered · 0 have been read against the source by a person
The last of those numbers is nought, and it is printed rather than left to be assumed. These explanations are ordinary anatomy and ordinary clinical vocabulary, written for this product, and each one names the authority it stands on; nobody has yet sat down and compared them, sentence by sentence, with the text at those addresses.