Rehabilitation for patients with spinal cord injuries
The most obvious consequence of spinal cord injury (SCI) is paralysis. However, SCI also has widespread consequences for many body functions, including bladder, bowel, respiratory, cardiovascular and sexual function. It also has social, financial and psychological implications, and increases people's susceptibility to late-life renal complications as well as musculoskeletal injuries, pain, osteoporosis and other problems.
There is limited high quality evidence to guide clinicians in their interventions, so a sensible trial-and-error approach is extensively discussed with practical examples.
This review outlines the principles of physiotherapy rehabilitation for people with SCI and the evidence underpinning the effectiveness of commonly used physiotherapy interventions. It is divided in:
- recommendations on objective, standardized assessment, using the SCIM and WISCI scales to set treatment goals, monitor progress and predict long term outcome.
- presentation of interventions with focus on three common problems: 1) weakness, 2) contractures and 3) poor motor control.
- discussion of the wide scope of practice, future developments and clinical and interpersonal skills needed in SCI rehab.
1) Weakness: progressive resistance training is beneficial for partially paralysed muscles, applied in a functional context, and possibly supported by electrical stimulation. Electrical stimulation alone is unlikely to increase voluntary strength, although it may be therapeutic for minimising atrophy in paralysed muscles, preventing secondary peripheral nerve deterioration, encouraging neural repair and promoting healing of pressure ulcers.
2) Contractures: about 70% of patients will develop contractures (some of them functional!) within a year. Stretching and passive movements are commonly used, but most likely only effective when administered in high doses over long periods of time (ie self-administered). Some contractures (like an elbow flexion contracture in C6 tetraplegia) have significant impact on ADL and transferring, hence have a high priority.
3) Performance of motor tasks: A lot of time is spent by therapist teaching transfers, walking and using the upper limbs. There is no evidence about the best strategies for each type of SCI; theories of motor learning, notably repetitive practice and functional application of skills, and clinical experience are most helpful. Recent developments around treadmill training and robotic devices are debatable: intensive repetitive functional practice is key, not the device used.
There are several challenges in SCI rehab poorly addressed in current research:
- how do we assess and predict potential neurological recovery?
- should all patients be encouraged to walk or should we direct treatment to gain independence from a wheelchair, awaiting neurological recovery?
- is optimizing function and neural recovery below the level of injury possible, or can we only train compensatory strategies?
- how effective is spasticity management by physiotherapeutic techniques? Or respiratory interventions in acute SCI?
Recent evidence supports activity-based therapy, context-specific and task-specific intensive practice involving many hours of exercise a day.
New developments around exoskeletons and stem cell therapy may open up doors in SCI rehab, but we need to prove our input is effective and essential.
Interested in the physiotherapy management of people in the period immediately after injury? Visit the free online learning modules of the International Spinal Cord Society here.
Check physiotherapyexercises.com for practical home stretching regimens for people with different types of SCI.
What clinical problem in SCI rehab would you like to be researched?
> From: Harvey, J Physiother 62 (2016) 4-11(Epub ahead of print). All rights reserved to Australian Physiotherapy Association. Click here for the Pubmed summary.