Acute Traumatic Central Cord Syndrome Rehabilitation and the Influence of Biopsychosocial Factors: A Case Report

Background: Incomplete spinal cord injuries are the most common type of spinal cord injury with traumatic central cord syndrome being the most prevalent. Due to this injury being incomplete in nature, there is variability in recovery, which makes it more challenging to come up with interventions. There are many factors, both physical and psychosocial, that contribute to recovery that are important to consider when providing treatment to a patient with central cord syndrome. Therefore, the purpose of this case report is to highlight the influence of biopsychosocial factors during rehabilitation management of a client with traumatic central cord syndrome. Case Description: The patient was a 69-year-old male who was admitted to an inpatient rehabilitation facility after suffering a traumatic central cord spinal injury. He initially presented with strength deficits below the level of the lesion with the upper extremities being more affected than the lower extremities. He had no prior functional deficits and lived with his wife. Intervention: The patient was seen 5 days a week for 3 hours a day by occupational and physical therapy over the course of 35 days. Physical therapy focused on improving functional mobility, upright tolerance, strength, and implementing pain reduction strategies. Therapy staff worked closely with clinical psychology to address negative coping strategies and the patient’s refusal of therapy. Outcome Measures: The outcome measures used in this case were Section GG, Manual Muscle Testing, the Function in Sitting Test and a Numeric Rating Scale for pain. Discussion: The patient did not make the functional gains expected for his diagnosis and his time spent at the inpatient rehabilitation facility. This case report describes interventions and strategies used during the rehabilitation of someone who had central cord syndrome and the different biopsychosocial factors that may have impacted his poor outcome.