(A) Timing and criteria for intervention.
Rehabilitation treatment can be started when the injured person’s vital signs are stable after injury or surgery, and the spine is stable after spinal fracture and dislocation fixation.
(B) Treatment principles and methods.
1, acute instability period.
Refers to 4 weeks after injury or after spine and spinal cord surgery. The following applies to the rehabilitation of all types of spinal cord injury.
(1) Respiratory function training, including thoracic breathing (applicable to thoracolumbar segment injury) and abdominal breathing (applicable to cervical segment injury) training, postural sputum evacuation training and passive thoracic movement training.
(2) In the emergency phase, indwelling catheterization is mostly used, and bladder function training such as intermittent catheterization (4-6 times a day), voluntary voiding or reflex voiding should be started after stopping intravenous rehydration.
(3) Active and passive movements of limb joints should be performed as early as possible. To prevent secondary injury, shoulder joint abduction should not exceed 9O° for cervical instability; hip joint flexion should not exceed 90° for thoracolumbar instability. Attention should be paid to the placement of the limb to prevent joint contracture deformity.
(4) In principle, all muscles that can be actively moved should be trained for muscle strength enhancement to prevent muscle atrophy or muscle strength loss.
(5) Conduct adaptive training to promote blood circulation and autonomic function, including gradually sitting up from the supine position, from sitting on the edge of the bed to sitting in a wheelchair, etc. When available, standing training should be carried out in a timely manner using a tilting bed.
(6) To prevent pressure sores, axial turning should be performed once every 2 hours, and a lower extremity blood circulation pump should be used to prevent deep vein thrombosis when available.
(7) For casualties with simple spinal fractures, this period is mainly for trunk muscle isometric training, with braces to protect the spine and prevent further injury.
2.Acute stabilization period.
It refers to about 4-12 weeks after the injury or spine and spinal cord surgery. The rehabilitation treatment in this period should be based on the continuation of the above training, according to the type of injury to add the following:
(1) Standing training, position change and mobility and activities of daily living (ADL) training for tetraplegic casualties with the help of electric rising beds, assistive devices and therapists. Urinary and bowel control training, such as clean catheterization, regular water intake, regular urination, reflex urination and defecation training, are given in a timely manner.
(2) In paraplegic casualties, residual muscle strength training is added to the tetraplegia training program. For those with good spinal stability, experienced therapists can instruct the injured person to start walking training with the aid of a knee-ankle-foot orthosis (KAFO), ankle-foot orthosis (AFO) or a weight-shifting walking orthosis (such as Walkabout or RGO) under close supervision.
Acute casualties should wear protective supports such as neck brace (cervical spine injury) and lumbar brace (lumbar spine injury) during training.
(C) rehabilitation care points.
1. The skin condition of the site where pressure sores occur should be checked daily, and bedridden casualties should be axially turned once every 2 hours.
2. The urinary catheter should be kept open when indwelling, and attention should be paid to clamping and opening the urinary catheter at regular intervals. Drink 2000ml-2500ml of water daily, control the urine volume at about 400ml each time, and control the urine volume at 1000ml-1500ml in 24 hours. the urine volume can be increased during critical resuscitation. Drink water regularly and quantitatively, try to stop indwelling catheterization and apply intermittent catheterization when possible.
3. Develop the habit of regular defecation, keep defecating 1-2 times a day. If there is fecal incontinence, it is easy to cause perianal skin rupture and induce pressure sores, so the perianal skin should be washed with water and coated with protective oil in time.
4, cervical medullary injury to tetraplegia of the wounded if the following injury site by adverse stimuli (such as bladder filling, pressure sores, muscle spasm, constipation, etc.) can suddenly appear headache, sweating, breath-holding, skin flushing, tachycardia or bradycardia, increased blood pressure and other signs of autonomic reflex hyperactivity. When the above symptoms appear, you should immediately adopt a head-high, foot-low position and eliminate the trigger as soon as possible. If the bladder is full, the urinary tract is not smooth or the stool is difficult to pass, the casualty should be assisted to defecate immediately. For those who cannot relieve elevated blood pressure can use antihypertensive drugs as appropriate.
(D) the matching of assistive devices.
1, cervical medullary injury should be optional high-backed wheelchair or ordinary wheelchair depending on the casualty, upper cervical medullary injury can be optional electric wheelchair. Early activity can be equipped with a neck brace, if necessary, the configuration of functional hand orthoses.
2, thoracic 1-4 spinal cord injury casualties are routinely equipped with ordinary wheelchairs, toilets, bath chairs and pick-up devices. Those who are eligible can be equipped with paraplegic walking orthoses or hip, knee, ankle and foot orthoses, with walking frames, crutches, lumbar circumference, etc. for therapeutic standing and walking training.
3, most of the thoracic 5 – lumbar 2 spinal cord injury injuries can be paraplegic walking orthosis or knee ankle foot orthosis with walking frame, crutches, waist circumference, etc. for functional walking training.
4, lumbar 3 and the following spinal cord injury most of the injured can walk independently with the help of ankle-foot orthosis, elbow crutches or cane.