Advances in the Rehabilitation of the Spinal Cord–Injured Patient

The Orthopaedic Surgeons' Perspective

Brian K. Kwon, MD, PhD, FRCSC; Dan Banaszek, MD, FRCSC; Steven Kirshblum, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(21):e945-e953. 

In This Article

Spinal Cord Rehabilitation

Rehabilitation in the acute, subacute, and chronic phases after injury is extremely important to help the injured individual reach their physical, social, emotional, recreational, vocational, and functional potential. A well-coordinated rehabilitation program can begin in the intensive care unit, including initiation of ROM to help prevent pain (eg, of the shoulder) and prevent contractures of joints affected by the SCI. Specific examples of ROM activities include preventing elbow flexion contracture with C5 level of injury or Achilles tendon plantar flexion contracture.

Transition to acute comprehensive rehabilitation as soon as possible is important. Early discharge to comprehensive SCI rehabilitation has been shown to improve functional outcomes for patients with SCI, likely because of multiple factors including minimizing complications that can have a setback on functional change and being able to harness neuroplasticity that is important for functional recovery.[40,41] A recent review did not find comparative articles directly addressing time to onset of rehabilitation on patient outcomes,[42] although a recent CPG suggested initiation of rehabilitation whenever patients are medically fit to participate and able to comply with program intensity.[26] Although there are many locations where one can receive inpatient acute rehabilitation, the choice of facility should be made carefully. The level of experience of the staff and the number of SCI patients served by that facility, as well as available resources are all important parameters. An interdisciplinary approach on the rehabilitation team with specialized SCI is important to optimize outcome.

The most important factors in determining functional outcome from rehabilitation include the motor level, and the degree of impairment, that is, AIS classification.[43] Functional goals expected to be achieved by most patients with a motor complete injury at one year is available including suggested equipment. For ventilator-dependent individuals, options of phrenic nerve or diaphragmatic muscle pacemakers can be considered for weaning off the ventilator, and wheelchair mobility controlled using head control or sip-and-puff controls to allow for independence.[43] For each subsequent level of motor recovery, additional areas of independence can be expected. Adaptive equipment as well as technology (eg, electronic activities of daily living, power wheelchairs) and surgical intervention (eg, tendon transfers or nerve grafts) can assist the patient become independent in such activities.

As interventions for improved walking function are so vital to SCI patients, these have been a major focus of SCI rehabilitation. Previously gait training occurred during in-patient rehabilitation and now with shorter lengths of stays, may instead be a component in the outpatient program. There are a number of gait training programs available. General gait training emphasizes strengthening of paretic muscles and compensation through the use of orthotic devices as well as technology (including functional electrical stimulation). A more recent intervention is locomotor training (LT) that uses repetitive practice intended to activate neural locomotor centers promoting use-dependent neuroplasticity (and motor learning effects). LT is based on animal model evidence of the presence of spinal central pattern generator circuits that produce locomotor outputs.[44] As such, LT trials in humans have been undertaken for persons with chronic motor-incomplete SCI with some benefit seen in overground walking and other parameters.[45,46] Many questions remain related to LT including the most appropriate training environment (ie, overground versus treadmill), training speed, the need for body weight harness support, manual versus robotic assistance, and the most ideal candidate for training. Advanced technologies including the use robotic exoskeletons have become more popular, but to date, there is no evidence that exoskeletons are more successful than conventional therapies in improving walking function.[47]

Recognizing that inpatient rehabilitation and transition to outpatient services are only the first part of rehabilitative SCI care is important. Long-term follow up by the SCI physician and multidisciplinary team is important to address ongoing needs from both a medical and rehabilitation perspective. As many complications after SCI are preventable, ongoing surveillance helps to optimize patient's quality of life.

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