Rehabilitation for spinal injury
Medical advances have increased the chances of surviving the initial trauma of a spinal cord injury. It is therefore vital to put in place the most effective rehabilitation program possible.
Read on to learn more about spinal cord injury treatments and rehabilitation.
4 of the main goals of rehabilitation are:
- To improve the quality of life after injury
- To maximise independence
- To keep levels of activity as high as possible, despite reduced function
- To facilitate neural recovery, when and where possible
Every spinal injury is unique, so rehabilitation programs are customised specifically to cater for the level of injury suffered and to set achievable goals.
A typical rehabilitation program involves several specialists that combine counselling and emotional support with physical therapy and skill-building exercises. As an example, a spinal cord injury rehabilitation program may include some of (but not limited to) the following specialists:
- Physiatrist (or physical medicine and rehabilitation physician – usually leads the rehab program)
- Physical and occupational therapists
- Recreational therapists
- Rehabilitation nurses
- Social workers
Spinal cord injury rehabilitation programs are a team effort, and the injured person is just as much a part of the team as the medical staff. Charities and supportive organisations may also be involved, and ultimately, everybody works together to help achieve improvements to day-to-day life.
We help to arrange rehabilitation and care for our spinally injured clients. To learn more about how our services can help you, please visit About Us.
Stages of therapy
Spinal cord injury rehabilitation programs can be broadly divided into three stages:
- Acute rehabilitation – This is the treatment administered immediately after the injury, usually in hospital
- Inpatient rehabilitation – Various intensive therapies conducted in hospital
- Outpatient rehabilitation – Continuous therapy after leaving hospital, either at home or in another rehabilitation centre, or both
This is the first stage of rehabilitation, which begins as soon as medical attention can be paid to the spinal cord injury. In order to prevent any further injury, the spine is immobilised and realigned if necessary. Respiratory help is provided if there has been sufficient spinal cord damage in the upper neck. Depending on the extent of the injury suffered, there may be a period spent in an intensive care unit, but in any case, the patient will most likely be transferred to a specialised spinal hospital.
A steroid called methylprednisolone may be administered to reduce damage to spinal nerve cells and to decrease the inflammation around the cord, known as spinal shock. This makes it easier for medical specialists to do three things quickly:
- Complete a full neurological assessment
- Diagnose the severity of the injury
- Predict the most-likely extent of recovery
Once this has been determined, the next stage of the rehabilitation process begins.
As soon as the treating consultant allows, inpatient rehabilitation can begin. At this stage, the primary focus will include:
- Improving function and strength in the legs and where possible, the arms
- To improve communication skills
These are two of the most important areas of function affected by a spinal cord injury so must be attended to as soon as possible. Meanwhile, every care will be taken to minimise secondary complications. As function improves, the rehabilitation team addresses the wider range of issues such as mobility, bowel and bladder training, diet and nutrition, exercise, sexual function and general daily living. Family members are encouraged to participate in some of these therapies so they become familiar and understand their loved one’s needs and prepare for life outside the hospital.
The inpatient rehabilitation phase is a time for learning and re-learning: learning how to adapt to new circumstances and re-learning how to perform day-to-day tasks. The goal is to enable the injured person to regain their independence and return home.
Once the patient has shown sufficient improvement following the first two phases, they can be discharged from hospital and begin outpatient rehabilitation. Throughout this phase, the team works continuously to improve all aspects of life; be it through rehabilitation sessions at home or at designated medical centres.
The number of rehabilitation sessions required depends on the patient’s personal situation. Some may require weekly sessions, some daily, and some even several times per day. The general aim is to reduce the number of sessions gradually as the patient’s condition improves, enabling them to live at the optimum level of independence.
Types of therapy
As discussed previously, a spinal cord injury rehabilitation program requires a whole team to provide separate specialist therapies. This section takes a general look at some of the main types of these therapies and discusses what is involved in each:
The nature of the physical therapy will depend upon the level of the spinal cord injury. Each therapy plan is specific to the needs of the individual.
Physical therapists may work to strengthen the patient’s muscle groups, improve neural recovery (where possible) and focus on improving general motor skills. This can be a very painful and fatiguing experience, especially soon after the injury. In early stages, therapists may also assist with breathing and where necessary, help patients to develop coughing techniques that clear the windpipe.
As conditions improve and the patient moves out of the acute phase, various techniques may be used to attempt to improve mobility, for example people with incomplete spinal cord injuries may take part in treadmill training and gait training. There may be retraining for bowel and bladder management and over time, coping strategies may be developed for spasms, autonomic dysreflexia and pain symptoms such as pins and needles sensations and chronic aches.
Physical therapy is very important because not only does it endeavour to improve physical functionality, it can be a communal therapy. More so than many other therapies, it encourages the patient and their family to get involved, to provide valuable input and define achievable goals in order to cope with their situation in the best way possible.
Occupational therapists teach the skills that promote as high a level of independence as possible.
Inpatient occupational therapy prepares the patient for life outside the hospital by improving the skills that are the foundation of functionality, such as the general techniques/guidance for strength, coordination, balance, feeding, dressing and self-grooming and how to use necessary adaptive equipment.
Outpatient occupational therapy continues the skill-building exercises, but constantly re-evaluates the patient’s needs and the areas they need to focus on such as changes in motor function, posture, hand and arm problems and changes in sensation.
Psychological therapy during the inpatient and outpatient phases of rehabilitation provides emotional support for both the patient and their family as they come to terms with what are life-changing injuries.
After a spinal cord injury, people are understandably susceptible to depression and anxiety. This can affect a person’s ability to function, so when physical abilities are already limited by injury, it is vital to address and treat depression and anxiety if they arise.
Social workers assist the patient and family by planning and implementing strategies that cater for future needs, such as arranging for assistive equipment, the regularity of home visits and identifying local community resources.
Vocational rehabilitation assesses whether the patient’s physical and mental abilities are strong enough to return to the workplace and if so, assists with making any necessary adaptations to the workplace. Vocational rehabilitation can also identify alternative work options in the event that the injured person is unable to return to their former role.
For those unable to re-join the workforce, alternatives are offered such as recreational therapy programs. These involve physical pursuits that encourage an active body and mind as well as providing great opportunities for social interaction. It is clear that no matter the severity of the injury, the level of rehabilitation required after a spinal cord injury is high. A strong rehabilitation team is vital, and together with a strong and committed patient, they can make significant gains.
Read more about spinal cord injury rehabilitation in action through our client stories.
Past, present and future of treatment
Modern medicine has made great advancements in treating spinal cord injury, and here we discuss its progression from World War II through to its potential future developments.
1939 onwards: New methods
Prior to World War II, spinal cord injuries almost always resulted in death, usually caused by urinary tract infections and pressure sores. Paradoxically, the onset of the most devastating war in history was the catalyst for the increased chance of survival after spinal cord injury. British consultant neurologists helped to establish the Emergency Medical Service and twelve specialised spinal hospitals. One was Stoke Mandeville, and from 1944 its director was Ludwig Guttmann (1899-1980), a Jewish clinical neurologist who had escaped persecution in Germany, and was to become the father of modern spinal cord injury treatment.
Guttmann was the first to unify several previously established spinal injury principles. With a benevolently dictatorial style, he demanded regular bi-hourly turning of patients to eliminate pressure sores and he implemented urinary tract catheterisation (though some staff and patients were initially resistant to his new methods). Ultimately, Guttmann successfully reduced fatalities. After his studies on peripheral nerves, Guttmann’s ideas on physiology, neurosurgery and rehabilitation enforced his conviction that a complete spinal injury treatment system was required.
This consisted of specialised spinal units; immediate specialist treatment; after care; immediate and ongoing patient supervision; detailed documentation; mental wellbeing; rehabilitation and exercise (he began the Stoke Mandeville games in 1948, later becoming the Paralympic Games). Guttmann’s integrated methods are now the worldwide standard.
Present day: Improved treatment
Since Guttmann’s standardisation of spinal cord injury treatment, a host of ever-improving technologies, medication and practices have been developed. MRI scanning has played a vital role in assessing the extent of damage sustained whilst the introduction of anticonvulsant and antidepressant medications have been beneficial in suppressing or relieving some post-injury pain.
Similarly, vast and rapid clinical advances have made surgery much safer. Equipment such as the surgical microscope has been introduced and the spinal column may now be approached from any angle to allow bone fusion and stabilisation. Treatment for bladder, bowel, skin and spasticity management have all improved considerably whilst rehabilitation services and lightweight aids are now more freely available.
Notably, there is more robust legislation in place for people with spinal cord injuries, and for those with disabilities in general. Public places are now more accessible and under the Equality Act 2010 and UN Convention, governmental disability rights extend to employment and education.
As a result of such improved treatment and socio-economic factors, life expectancy after a spinal cord injury has increased and continues to do so; something almost unthinkable just decades previously.
The future: Potential cure
Past research has led to a vast increase in human survival rates after spinal cord injuries and an incredible improvement in successful rehabilitation methods. With continued research, the goal is to achieve complete repair of an injured spinal cord.
However this is, of course, not an easy task. The spinal cord is part of the Central Nervous System and is connected to the brain, an incredibly complex organ of which we have a relatively small understanding in comparison to other parts of the body.
The spinal cord’s complexity is further increased due to its behaviour both during and after injury. The spinal cord’s cells can shift and change for months on end before finally settling, at which point it could allow repair work to begin. In addition, after a spinal injury, molecules known as Nogo receptors and Nogo proteins prevent the natural regeneration of the cord and the central nervous system as a whole.
Despite such complexity, there are four main areas of research for spinal cord repair:
- Preventing damage to surviving nerve cells
- Replacing damaged nerve cells
- Stimulating the regrowth of nerve fibres (also known as axons)
- Retraining neural circuits to provide normal body functionality
In addition, there are other various secondary effects that will need to be managed:
- Controlling inflammation – currently this is often minimised with methylprednisolone, but there is ongoing research to find a more efficient method that also harnesses the cell repairing benefits of inflammation. One such method is an induced mild state of hypothermia, cooling the body to protect its spinal cord tissue and nerve cells.
- Preventing excitotoxicity – this is to prevent the spine’s dead nerve cells from releasing a cell-destructing amino acid called glutamate.
- Preventing apoptosis – apoptosis is when healthy cells self-destruct after injury, often referred to as programmed cell death.
Some experiments have attempted to transplant cell grafts into the injured spinal cord, behaving like bridges and linking together the previously broken nerve fibres; others are bringing together computer interfaces and prosthetics in a huge step forward for bioengineering.
Spinal Cord Regeneration
One of the most well-known methods of spinal cord regeneration, and one that has shown hugely positive results in early tests, is through the use of stem cells.
Stem cells are able to divide and bring forth nearly all the types of cells within the human body and though stem cell research is considered controversial in some quarters, astonishing breakthroughs in nerve cell and fibre regrowth have been confirmed by Harvard Medical School, the University of California and King’s College London amongst others.
Their three main findings indicate that:
- It is possible to grow nerve fibres back into the spinal cord
- The nerve fibres are able to reconnect with nerve cells
- The ability to feel can be regained
Researchers and medical experts are optimistic that recent discoveries will soon be transferred from the lab to humans.
To learn more about spinal cord injury rehabilitation and making a claim, please contact us.