Spinal cord injury refers to damage to the structure and function of the spinal cord caused by various reasons, resulting in partial or complete impairment of motor and sensory function below the level of injury. Injuries to the cervical spinal cord that cause paralysis of the limbs are called tetraplegia, and injuries to the spinal cord below the thoracic level that cause paralysis of the trunk and lower extremities without involving the upper extremities are called paraplegia.
The rehabilitation treatment of spinal cord injury includes rehabilitation treatment in the acute phase and rehabilitation treatment in the recovery phase, and usually adopts rehabilitation measures such as exercise therapy treatment, occupational therapy treatment, orthopedic treatment, psychological treatment, and timely management of comorbidities.
I. Acute rehabilitation
The main purpose of the acute phase is to prevent disuse syndrome, such as prevention of muscle atrophy, heterotopic ossification, joint contracture, etc., and to create conditions for future rehabilitation treatment. The training includes the following aspects.
1. Good limb position placement training.
Patients should pay attention to keep the limbs in a good functional position when they are bedridden.
2.Passive joint movement.
Passive joint movement training for paralyzed limbs, 1 to 2 times/day, to prevent joint contracture and deformity.
3.Change of body position.
Bedridden patients should change position regularly, generally turning every 2 hours to prevent the formation of pressure sores, but be careful not to cause new injuries by turning.
4, early sit-up training.
For spinal cord injury patients with good spinal stability should start sitting training early (about 3 weeks after injury / postoperative), twice a day for 30 minutes each time. Begin by raising or rocking the head of the bed by 30°, if there is no adverse reaction, then raise the head of the bed by 15° every day, until 80°, and maintain continued training. In general, it takes 1 week of adaptation time from the flat position to the upright position, and the length of adaptation time is related to the injury plane.
5.Rising bed standing training.
Patients after sitting up training without postural hypotension and other adverse reactions can be considered for standing training. Training should maintain the stability of the spine, with a waist brace training up and standing activities. The patient should stand up on the bed, starting from 30° inclination, and gradually increase the angle until it reaches 90°. If any adverse reaction occurs, the height of the bed should be reduced in time.
6. Respiratory and sputum evacuation training.
Patients with respiratory muscle paralysis from cervical medullary injury should be trained in abdominal breathing exercises, coughing and coughing ability as well as postural sputum evacuation training to prevent and treat respiratory complications and promote respiratory function.
7, the treatment of large and small stools.
The method of indwelling catheterization is mostly used 1 to 2 weeks after spinal cord injury. The daily water intake reached 2500-3000ml, and record the amount of water in and out. After that, intermittent clean catheterization is used. Constipation can be treated with lubricants, laxatives and enemas.
II. Rehabilitation training during the recovery period
After the fracture site is stabilized, nerve damage or compression symptoms are stabilized, and breathing is stable, the patient can enter the recovery period.
1.Muscle strength training
Complete spinal cord injury patients muscle training is focused on the upper limb muscles. For incomplete spinal cord injury, the residual muscles are trained together. Muscle strength level 3 muscles, you can use the active movement; muscle strength level 2 can be used to assist the movement, active movement; muscle strength level 1 and 0 only use the functional electrical stimulation training.
The goal of muscle strength training is to achieve muscle strength of grade 3 or higher. Spinal cord injury patients in order to apply wheelchair, crutches or walkers, in bed, sitting are to pay attention to exercise shoulder girdle muscle strength, including upper limb support training, triceps and biceps training and grip strength training.
2.Treatment on the mat can be carried out on the mat
(1) Turn over training.
(2) stretching training, mainly stretching the N cord muscle, adductor muscle and Achilles tendon of the lower limb.
(3) Mat mobility training.
(4) Weight-bearing and mobility training on hands and knees.
3.Sitting training
Can be done on the mat and bed. Sitting position can be divided into long sitting position (knee joint extension) and end sitting position (knee joint flexion 90°). Before sitting training, the patient should have some control or muscle strength of the trunk, and the range of motion of the joints of the lower limbs, especially the range of motion of the bilateral hip joints, should be close to normal. Sitting training can be performed in two positions: long sitting position and end sitting position. Sitting training also includes static balance training in sitting position, and dynamic balance training when the trunk is moving forward, backward, left, right and rotating.
4.Transfer training
Transfer is a necessary skill for patients with spinal cord injury. Including help transfer and independent transfer. Transfer training includes transfer between bed and wheelchair, transfer between wheelchair and commode, transfer between wheelchair and car, and transfer between wheelchair and ground. Some assistive devices, such as skateboards, can be used for transfer training.
5.Walking training
The goals of walking training are
Therapeutic walking: generally suitable for patients with injuries in the thoracic 6 – thoracic 12 plane.
Home functional walking: can walk indoors, but the walking distance can not reach 900m, generally seen in the lumbar 1 – lumbar 3 plane injury patients.
Functional walking in the community: Patients with lumbar 4 or below plane injuries wear ankle-foot orthoses, can walk up and down stairs, can carry out activities of daily living independently, and can walk continuously for 900 m. Walking training is divided into walking training in the parallel bar and walking training with crutches. Firstly, we practiced standing and walking in the parallel bar, and gradually transitioned to balance training and walking training with crutches. Walking training requires straight upper body, stable pace and even step speed. After the endurance is increased, you can practice crossing obstacles, going up and down steps, falling and getting up after falling.
6.Wheelchair training
2-3 months after the injury, when the patient has good spinal stability, sitting training has been completed, and can sit independently for more than 15 minutes, wheelchair training can be started. Upper limb strength and endurance are the prerequisites for good wheelchair maneuvering. Wheelchair training includes forward drive, backward drive, left and right turn training, front wheel stilt walking and rotation training, ramp training and barrier crossing training, stair climbing training and stair descending training, crossing roadside stones training, crossing narrow doorways training and safe fall and re-sit training. Note that every 30 minutes of sitting, the upper limbs must be used to support the trunk, or lateral tilt the trunk, so that the buttocks leave the chair surface to reduce pressure, so as to avoid pressure sores in the sciatic nodes.
7.Use of orthoses
The use of appropriate lower limb orthoses is necessary for many paraplegics to stand and walk. There are knee-ankle-foot orthoses, hip-knee-ankle orthoses.
8. Daily life
Training of activities of daily living is especially important for patients with spinal cord injury, especially for patients with quadriplegia.
9.Psychological treatment
Spinal cord injury brings indescribable mental pain to patients, but most patients will face the reality bravely after a period of psychological treatment. The purpose of rehabilitation is to help the patient return to life as normally as possible.