Therapeutic Interventions for Spinal Cord Injury

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Introduction

Respiratory Management

Spasticity Management

Contracture Management

Mobility

Transfers

Wheelchair Training

Gait Training

The ability to walk independently is a prerequisite for most daily activities. The capacity to walk in a community setting requires the ability to walk at speeds that enable an individual to cross the street in the time allotted by pedestrian lights, to step on and off a moving walkway, in and out of automatic doors, walk around furniture, under and over objects and negotiate kerbs. A walking velocity of 1.1 - 1.5 m/s is considered to be fast enough to function as a pedestrian in different environmental and social contexts. The major requirements for successful walking include; 

• Support of body mass by lower limbs
• Propulsion of the body in the intended direction
• The production of a basic locomotor rhythm
• Dynamic balance control of the moving body
• Flexibility, i.e. the ability to adapt the movement to changing environmental demands and goals.

Walking dysfunction is common in individuals with an incomplete spinal cord injury, arising not only from the impairments associated with the spinal cord lesion but also from secondary cardiovascular and musculoskeletal consequences of disuse and physical inactivity. Muscle weakness and paralysis, poor motor control and soft tissue contracture are major contributors to walking dysfunction post spinal cord injury.

Overground Training

Treadmill Training

The incentive to provide a challenging environment, in which there is an opportunity to practise repetitively the missing components of gait, has underpinned another task-specific activity. This involves using a treadmill for gait re-training and also for improvements in cardiovascular function. A harness can be used for individuals with significant functional limitations, and this also offers the opportunity to grade the amount of body weight support provided. Therapists help to facilitate alternating stepping and weight-bearing, and as many as three therapists may be required to assist with the complete gait cycle. It has been suggested that treadmill training can support Gait Re-education as it allows a complete practice of the full gait cycle, with opportunity for improvements in speed and endurance, which optimises cardiovascular fitness.

Task-specific training on a treadmill has also been shown to induce expansion of subcortical and cortical locomotion areas in individuals following stroke and spinal cord injury. It can result in an increase in cadence and a shortening of step length as compared to overground walking.

Upper Limb Management

Key muscles are innervated at each level of spinal cord injury and it is these muscles that determine the optimal level of upper limb function that individuals with a complete spinal cord injury can achieve.

Upper Limb Function Post Spinal Cord Injury

Level of Lesion	Upper Limb Function
C4 Tetraplegia	No Upper Limb Function
C5 Tetraplegia	Perform Simple Hand to Mouth Activities
C6 Tetraplegia	Tendonesis Grip
C7 Tetraplegia	Tendonesis Grip
C8 Tetraplegia	Active Grasp and Release

Understanding the way individuals with tetraplegia use their upper limbs and hands functionally is essential for effective management which includes:

• prevention and treatment of contracture
• prevention and treatment of musculoskeletal pain
• management of the shoulder
• improving strength and skill
• promoting and preserving a tenodesis grip when appropriate
• management of hand swelling
• awareness of potential for tendon transfers or electrical stimulation

Robotics

Over the past decade robotics technologies are more commonly incorporated into the daily treatment schedule of many individuals post spinal cord injury. These interventions hold greater promise than simply replicating traditional therapy, because they allow therapists an unprecedented ability to specify and monitor movement features such as speed, direction, amplitude, and joint coordination patterns and to introduce controlled perturbations into therapy.

Rehabilitation robotics is a field of research dedicated to understanding and augmenting rehabilitation through the application of robotic devices. Rehabilitation robotics includes development of robotic devices tailored for assisting different sensorimotor functions (e.g. arm, hand, leg, ankle, development of different schemes of assisting therapeutic training, and assessment of sensorimotor performance). Rehabilitation using robotics is generally well tolerated, and has been found to be an effective adjunct to therapy in individuals with motor impairments as a result of a spinal cord injury.

Robotic devices provide safe, intensive and task oriented rehabilitation allowing;

1. precisely controllable assistance or resistance during movements
2. objective and quantifiable measures of subject performance
3. good repeatability
4. increased training motivation through the use of interactive biofeedback

You can read more about Robotic Rehabilitation for the Lower Extremity and Upper Extremity Rehabilitation using Robotics on Physiopedia.

Exercise

Strength Training

Strength training is generally defined as training where the resistance against which a muscle generates force is progressively increased over time. The maximal weight or resistance a person can lift or move to complete the movement is defined as One Repetition Maximum (1 RM). Prescriptions of repetitions vary depending on prior experience of strength training and co-morbidities. Progressive resistance training is the most common form of strength training. It is thought to be most effective when it incorporates resistance, is appropriately progressed based on etc individuals capacity and the mode of training is similar to the task in which strength gains are required

It is more challenging to apply the principles of progressive resistance training to partially paralysed muscles because it is difficult to apply resistance when a muscle is unable to move through full range against gravity, which is a greater problem for weak and very weak muscles more than it is for muscles that are closer to normal strength. When partially paralysed muscles are strong enough to move through range against gravity the principles of progressive resistance training can be more easily followed. When partially paralysed muscles are not strong enough to move against gravity, training occurs in a gravity eliminated plane. Resistance can be added manually or by rotating the plane of movement away from the horizontal.

One example of an effective dosage of progressive resistance training is:

• 1 - 3 sets of 8 - 12 Repetitions with a rest of 1-3 minutes between sets
• A load corresponding to 8 - 12 Repetition Maximum (60-70% of 1RM)
• 2-3 times a week

Muscle hypertrophy and increased strength, along with the changes in body composition, the hormonal and nervous systems, have a positive impact on the daily activities of living and functional independence of the individuals with a spinal cord injury.

Cardiovascular Training

Pain Management

Electrotherapy

Resources

References