Savonia Article: Spinal Cord Injury and Rehabilitation
In 20 – 25. 2 . 2023, Blended Intensive program in Neurological rehabilitation ran. More than 30 physiotherapy students and teachers from three universities (Savonia University of Applied Sciences, Finland, Third Faculty of Medicine, Charles University, Czech Republic and University of Thessaly, Greece) actively participated. Students worked together and wrote articles devoted to on the following themes: stroke and rehabilitation, multiple sclerosis and rehabilitation, Parkinson’s disease and rehabilitation, children with neurological disorders and rehabilitation, spinal cord injury and rehabilitation and virtual reality and exergames in rehabilitation of neurological patients. We are going to present their great work here. (Äijö et al 2022.)
The spinal cord is a cylindrical structure that is part of the central nervous system (CNS) and runs through the center of the spine; from the base of the skull to the lower back. The vertebral column consists of 31 vertebra segments containing nerve bundles and cells that carry information from the brain to the rest of the body. Its main purpose is to carry nerve signals throughout the body having three crucial functions such as controlling body movements and functions, reporting senses to the brain and managing your reflexes. In detail, traumatic spinal injury (TSI) includes a variety of injuries related to the spinal cord and the anatomical structures surrounding it such as nerve roots, discs and ligaments (Harvey, 2016).
The symptoms are various according to the level of injury. The cervical spine represents the most severe, life-threatening symptoms. Including problems or complete stop of heart and breathing functions. Diaphragm complications and causes tetraplegia (paralysis). With injury to the thoracic spine muscles of the chest might be affected. Injuring lumbar spine includes disruption of the innervation to the abdominal muscles (bladder dysfunctions etc.) paraplegia.
Even though the underlying pathology in spinal cord injury is neurological and the obvious consequence is paralysis, there are many other organ systems affected. The condition is very complex and requests a multidisciplinary complex rehabilitation. There are widespread consequences from any body functions, including bladder, bowel, respiratory, cardiovascular and sexual function. It also has significant 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 (Harvey, 2016).
Worldwide epidemiological data report 10.5 cases of TSIs per 100,000 people with mortality up to 60% and an average age of 40 years. In contrast, only ⅓ of patients with TSI suffer SCI and it is estimated that over 226,000 people are impacted yearly worldwide (Kumar et al., 2018). The etiological factors that are interconnected with SCIs are road traffic accidents (39.5%), falls (38.8%), sports-related injuries, violence and medical or surgical implications. Moreover, the economic burden of billions of dollars causes worse survival rates in low- and middle-income countries (Alizadeh et al., 2019).
Spinal cord injury can occur in a number of ways. The most common are SCI from traumatic injury, SCI from outgoing vascular damage or tumor and SCI can also be a congenital defect. There are three stages of SCI. The initial stage is mechanical injury of spinal cord tissues and is caused by a temporary compression that leads to contusion of the SC. The second phase contains self-destructive biomechanical and biochemical changes that lead to cell death, that begins locally and then spreads rostrally and caudally. The third phase is the spread of secondary injury that begins in the second phase which leads to structural and functional imbalance (Quadri et al. 2018).
Conducting thorough assessment is really important to determining a patient’s condition, so that the best therapy option can be chosen. One of the most used assessment scales is the Impairment Scale of American Spinal Injury Association (AIS – ASIA Impairment Scale), which evaluates the motor and sensory functions. The level of SCI corresponds to the lowest segment with preserved motor and sensory functions on both sides. AIS uses letters A, B, C and E to describe the magnitude of the SCI. (A stands for complete motor and sensory loss, B stands for motor loss etc.).
The key complications in SCI are weakness, contractures and poor motor control. The course of treatment needs to be guided by assessment results and goal-setting process. The physiotherapy intervention in SCI is extensive with approaches such as Functional Electric Stimulation, Task-specific training, resistance exercises and stretching following other organ system symptoms.
Weakness is an eminent impairment that prevents people with SCI from performing motor tasks. Using a progressive resistance training program where the load is appropriately increased provides strong evidence that patients with partial paralysis get stronger over time. Other researchers suggest that the use of robotic gait training and overhead gait training can also help patients with partial paralysis to be improved.
Stretching and passive movements are the methods that physiotherapists use to treat and prevent contractures. To make this method effective it is necessary to repeat it every day for long periods, in order to become part of the patient’s daily regimen. During the intervention, it is necessary to focus only on the contractures that have the biggest effect on the quality of life.
Motor control and performance are also integral parts of the rehabilitation curriculum and are directed towards improving daily tasks that are connected with the patients’ preferences. One of the key points when addressing motor control deficits is the importance of repetitions, so that new or already established neural connections can grow. Although overground training can be used; it is reported that treadmill and robotic training show superiority (Harvey, 2016).
There are some new methods that can be used in the rehabilitation of spinal cord injury (SCI) patients such as epidural electrical stimulation (EES), robot-assisted gait training and hydrotherapy.
Positive results were depicted in a study concerning EES that helped people with lower limb paralysis to stand, walk, swim, cycle and control their trunk movements (Rowald et al. 2022). Creating a new and very interesting approach that should be researched more so it could be used more effectively in the rehabilitation of SCI in the future.
Neuro-dance can bring a social viewpoint to the rehabilitation of spinal cord injury patients and offer group support. The idea of Neuro-dance is to do rhythmic movements and dance to the music. Everyone can be who they are and participate in the programme in their own way. In addition to social support, it can improve the rehabilitation and motor skills of spinal cord injury patients.
There is one systematic review article concerning robot-assisted gait training in patients with spinal cord injury. The research was done using a machine called Lokomat in the gait-training of the test group. For the control group conventional overground gait-training was used. The conclusion is that the Lokomat robot-assisted group showed significantly better improvements in gait distance, speed and balance in comparison to the control group (Ki Yeun Nam et al. 2017). These results indicate that this might be an efficient way to improve the rehabilitation and gait of spinal cord injury patients. In Finland, this kind of rehabilitation is possible for example in Live organization.
In conclusion, even though there is an extensive number of types of intervention in physiotherapy of SCI, a patient-oriented approach is vital to create a tailored course of treatment and provide motivation.
Kitixis Pavlos, Physiotherapy students, Department School of Health Sciences, University of Thessaly, Greece
Vokacova Zuzana, Physiotherapy students, Third Faculty of Medicine, Charles University, Czech Republic
Hanurova Adela, Physiotherapy students, Third Faculty of Medicine, Charles University, Czech Republic
Hasu Emma, Physiotherapy students, Savonia University of Applied Sciences, Kuopio, Finland
Nurmiaine Riina, Physiotherapy students, Savonia University of Applied Sciences, Kuopio, Finland
Pliakas Christos, Physiotherapy students, Department School of Health Sciences, University of Thessaly, Greece
Dr. Marja Äijö, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Kuopio, Finland
Dr. Kamila Řasová, Ph.D., Associative professor of Physiotherapy, Third Faculty of Medicine, Charles University, Czech Republic
Dr. Thomas Besios, Assistant Professor, Department School of Health Sciences, University of Thessaly, Greece,
Alizadeh, A., Dyck, S. M., & Karimi-Abdolrezaee, S. (2019). Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury Mechanisms. Frontiers in Neurology, 10(282). https://doi.org/10.3389/fneur.2019.00282
Harvey L. A. (2016). Physiotherapy rehabilitation for people with spinal cord injuries. Journal of physiotherapy, 62(1), 4–11. https://doi.org/10.1016/j.jphys.2015.11.004
Ki Yeun Nam, Hyun Jung Kim, Bum Sun Kwon, Jin-Woo Park, Ho Jun Lee & Aeri Yoo. 2017. Robot-assisted gait training (Lokomat) improves walking function and activity in people with spinal cord injury: a systematic review. Journal of NeuroEngineering and Rehabilitation. 14: 24. doi: 10.1186/s12984-017-0232-3.
Kumar, R., Lim, J., Mekary, R. A., Rattani, A., Dewan, M. C., Sharif, S. Y., Osorio-Fonseca, E., & Park, K. B. (2018). Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume. World Neurosurgery, 113, e345–e363. https://doi.org/10.1016/j.wneu.2018.02.033
Quadri, S. A., Farooqui, M., Ikram, A., Zafar, A., Khan, M. A., Suriya, S. S., Claus, C. F., Fiani, B., Rahman, M., Ramachandran, A., Armstrong, I. I. T., Taqi, M. A., & Mortazavi, M. M. (2018). Recent update on basic mechanisms of spinal cord injury. Neurosurgical Review. https://doi.org/10.1007/s10143-018-1008-3
Rowald A, Komi S, Demesmaeker R, Baaklini E, Hernandez-Charpak SD, Paoles E, Montanaro H, Cassara A, Becce F, Lloyd B, Newton T, Ravier J, Kinany N, D’Ercole M, Paley A, Hankov N, Varescon C, McCracken L, Vat M, Caban M, Watrin A, Jacquet C, Bole-Feysot L, Harte C, Lorach H, Galvez A, Tschopp M, Herrmann N, Wacker M, Geernaert L, Fodor I, Radevich V, Van Den Keybus K, Eberle G, Pralong E, Roulet M, Ledoux JB, Fornari E, Mandija S, Mattera L, Martuzzi R, Nazarian B, Benkler S, Callegari S, Greiner N, Fuhrer B, Froeling M, Buse N, Denison T, Buschman R, Wende C, Ganty D, Bakker J, Delattre V, Lambert H, Minassian K, van den Berg CAT, Kavounoudias A, Micera S, Van De Ville D, Barraud Q, Kurt E, Kuster N, Neufeld E, Capogrosso M, Asboth L, Wagner FB, Bloch J, Courtine G. 2022. Activity-dependent spinal cord neuromodulation rapidly restores trunk and leg motor functions after complete paralysis. Nat Med. 28(2):260-271. doi: 10.1038/s41591-021-01663-5.
Äijö M, Řasová K & Besios T. 2022. Neurological rehabilitation, Blended Intensive program has started. Savonia Article, Savonia-ammattikorkeakoulu. In available: https://www.savonia.fi/en/articles/savonia-article-neurological-rehabilitation-blended-intensive-program-has-started/