Diagnosis and rehabilitation of spinal cord injury:
Spinal cord injury is a structural and functional damage to the spinal cord due to various causes, resulting in impairment of spinal cord nerve function (motor, sensory, sphincter and vegetative nerve function) below the level of injury. Spinal cord injuries often result in varying degrees of quadriplegia or paraplegia, which is a serious disabling trauma. Prior to World War II, 80% of spinal cord injury patients died within 3 years due to comorbidities. Only one case of World War I U.S. Army spinal cord injury survived 20 years later. The rapid development of rehabilitation medicine after World War II, especially the establishment of SCI centers, has greatly improved the prognosis of SCI patients. In developed countries, except for a few patients who died within a short period of time after the injury, 80% of SCI patients can return to work and social life after vocational training. At the same time, they can return to their families, get married or have children. At present, SCI cannot be cured, and formal rehabilitation training is an effective treatment for SCI. Through rehabilitation, SCI patients can give full play to their residual functions, maximize the development of potential functions, prevent various complications, significantly reduce the disability rate and improve the quality of life of patients. Studies have shown that early implementation of comprehensive and systematic rehabilitation treatment can significantly shorten hospitalization time, reduce medical costs, and facilitate patients’ early return to their families and society.
I. Etiology
1, traumatic spinal cord injury.
In developed countries, the incidence of traumatic SCI is 20~60 cases per year per million population. In China, there are no accurate statistics on the national incidence rate. The results of a 5-year (1982~1986) retrospective survey in Beijing showed that the incidence rate was 6.7 per million population, which was significantly lower than that of developed countries, but there has been an increasing trend in recent years. According to the survey, the incidence rate of SCI in Beijing was 60/million in 2002; the most common cause of injury was fall from height, followed by car accident and heavy object smash [2]. In addition, natural disasters such as the Tangshan earthquake also caused a large number of SCI patients, and there was a group of SCI patients among the survivors of the Wenchuan earthquake.
Understanding the specific causes of traumatic SCI is important for taking appropriate measures to prevent or reduce the occurrence of spinal cord injury. For example, the application of safety belts for working at height, the application of safety belts for car driving, the prohibition of driving after drinking, the application of anti-collision systems in cars, and the escape drills for dealing with emergencies, etc., are all of great significance to the prevention of SCI.
2.Non-traumatic spinal cord injury.
(1) Developmental etiology
Including spinal vascular malformation, congenital scoliosis, spina bifida, spondylolisthesis, etc.
(2) acquired etiology
Mainly including infection (spinal tuberculosis, septic infection of the spine, transverse myelitis, etc.), spinal cord tumors, degenerative diseases of the spine, metabolic diseases and diseases of medical origin, etc.
II. Clinical manifestations
Because there are many important nerve conduction bundles passing through the spinal cord with little cross-section, after injury, the motor, sensory, reflex and autonomic functions below the damaged level are impaired, and depending on the injury site, it is generally clinically divided into quadriplegia and paraplegia.
1.Quadriplegia.
Quadriplegia refers to damage to the cervical spinal cord nerves in the vertebral canal, excluding the arm from or peripheral nerve injury outside the vertebral canal. It is characterized by different degrees of paralysis of the extremities and trunk, and urinary and fecal disorders.
2.Paraplegia.
Paraplegia refers to injury within the spinal canal of the thoracic, lumbar or sacral segments of the spinal cord (excluding the cervical segment). The upper extremity function is not involved, but depending on the injured segment, the trunk and lower extremities are paralyzed to different degrees, and urinary and fecal disorders.
3, complications.
Spinal cord injury can lead to multi-system and multi-organ dysfunction of the body and various complications, such as pressure sores, urinary tract infections, spasticity, osteoporosis, heterotopic ossification, deep vein thrombosis of the lower extremities, upright hypotension, paraplegic neuralgia, autonomic hyperreflexia, etc. SCI complications can prolong patients’ hospitalization, increase medical expenses and affect the effectiveness of rehabilitation treatment, and in severe cases, can lead to death. Surveys in 2003 and 1988 showed that uremia had been the first cause of death among SCI patients in the Tangshan earthquake. Correct rehabilitation treatment and rehabilitation care play a significant role in the prevention and treatment of SCI complications, and SCI complication prevention and treatment is an important part of SCI rehabilitation.
III. Rehabilitation assessment
Rehabilitation assessment is the basis of rehabilitation treatment. Rehabilitation assessment is similar to the diagnosis of disease in clinical medicine, but instead of determining the nature and type of disease, it determines the nature and degree of functional impairment. The rehabilitation assessment is presided over by a rehabilitation physician and attended by PT therapists, OT therapists, cultural and physical therapists, orthopedic technicians, rehabilitation nurses, psychotherapists, social workers and other professionals, and if necessary, patients and family members can be invited to participate. Rehabilitation assessment is generally divided into initial assessment (one week after admission), mid-term assessment (one month after treatment) and final assessment (one week before discharge). The rehabilitation assessment mainly includes the following contents.
1, classification and diagnosis.
The SCI diagnosis is based on the International Standard for Classification of Neurological Function of Spinal Cord Injury (hereinafter referred to as ASIA standard), which mainly includes the following five aspects.
(1) Sensory score.
According to the ASIA standard, the pinprick sensation and light touch sensation of 28 key sensory points on both sides of the torso were examined. If the key sensory points cannot be examined due to plaster, wound, dressing or amputation, any point within the same recommended skin segment can be used as an alternative examination point. The choice of alternative examination points should be specifically noted. The practical procedure for the recommended sensory examination is to perform a sharp/obtuse sensory examination starting at the site of suspected injury and proceeding cephalad toward the cephalic end, skin segment by skin segment, until the patient reports that both sharp/obtuse sensations become normal. The key sensory points within the area of injury are then carefully examined and graded for sharp/blunt and light touch sensations are recorded. After each key sensory point was examined, a score was recorded according to the following grading definitions. A total score of 224 points was assigned.
0 : Absent
1 : Impaired (heavier, lighter, or otherwise different)
2 : Normal
NT cannot be checked
Note: Use a standard safety needle as an inspection tool for pinprick sensation. Open and straighten it before use. The pointed end is used to check for sharp sensations and the blunt end is used to check for dull sensations. Alternate touching the patient’s cheek with the blunt end and the pointed end to make sure the patient can distinguish between sharp and blunt sensations that are normal for the body. The patient’s eyes are closed or the vision is obscured during the examination. For suspicious cases, 8 out of every 10 examinations must be said to be correct as a reference standard for accuracy so that the probability of guessing is less than 0.05. The examination tool for light touch is a pointed cotton bundle, made by stretching the cotton ball end of a cotton ball or swab. The examination is performed by gently but quickly running the cotton bunch across the skin, touching no more than 1 cm of skin. Alternative instruments such as the tip of a finger, an object of some kind, or the blunt end of a safety pin may also be used, but must then be specifically indicated [5]. The wrist and ankle can be selected for joint kinesthesia and deep pressure sensory examination if necessary. The findings of joint kinesthesia are graded as absent, impaired, normal, and uncheckable; the findings of deep pressure sensation are graded as present and absent.
(2) Motor score.
The muscle strength of the 10 key muscles on both sides of the trunk was examined according to the ASIA standard. The muscle strength was graded by the traditional 6-step freehand muscle strength examination method. To calculate the motor score, the 10 key muscles on each side should be graded on a scale of 0-5 according to the above-mentioned motor examination scoring criteria. The normal muscle strength of each key muscle is 5 levels, 50 points for each of the two limbs, and a total of 100 points for all four limbs.
Note: In patients with spinal cord injury, especially during the acute phase of the injury (when appropriate braking of the spine is necessary), the examination of the patient must be performed in the supine position. Because the supine position allows for examination from the acute phase through all subsequent phases, the ASIA Standard Reference Manual recommends that all motor function examinations of the patient be performed in the supine position to facilitate comparison of outcomes between periods. Since pain, posture, elevated muscle tone, disuse, and other inhibitory factors can reduce muscle strength, the examiner should be careful to identify muscles with less than grade 5 strength that are likely to have intact innervation. If the presence of the above factors prevents a standardized measurement of muscle strength, the muscle should be marked as unexamineable (NT). However, if the above factors do not affect the contraction of the examined muscle and the examiner is confident that the muscle strength can be normal if the interference of the above factors is excluded, then the muscle strength should be classified as grade 5 [5].
(3) Determination of the nerve plane.
The neural plane, also known as the neural level, is the lowest spinal cord segment where both sensory and motor functions are normal. According to the ASIA criteria, the determination of the neural plane needs to be based on the examination results of key sensory points and key muscles, which are determined by the sensory and motor functions bilaterally. A single neural plane is the plane when there is bilateral symmetry and the motor and sensory planes are the same.
The sensory plane is the lowest spinal cord segment with normal pinprick and light touch function on both sides of the body, or the segment with abnormal sensation in its next plane. To determine the sensory plane, the examination must begin at segment C2 and continue until the plane of pinprick sensation or light touch sensation is less than 2 points. Since the sensory planes of the right and left sides may not be the same, they should be evaluated separately
The motor plane is defined as the lowest spinal cord segment with normal motor function or complete spinal innervation. To determine the motor plane, the key muscles representing the plane must have a strength equal to or greater than level 3 to be considered fully innervated, and the key muscles innervated by the segment above must have a strength of level 5.
In some spinal cord planes, such as C1-C4, T2-L1, and S2-S3, the muscle strength of the corresponding muscle segment cannot be obtained by freehand examination, and it can only be assumed that the motor plane is the same as the sensory plane. That is, if the sensory function of the segment is normal, the motor function is also normal; and vice versa.
(4) Degree of injury and partial preservation of the band.
According to the ASIA standard, complete injury refers to the complete loss of sensory and motor functions in the lowest sacral segment (S4-S5).
Incomplete injury is defined as having preserved sensory and/or motor function in the sacral segment (S4-5). Sacral sensation includes sensation at the anal mucosal skin junction as well as deep anal sensation. Motor function examination of the sacral segment refers to the determination of preserved voluntary contractile function of the external anal sphincter by anal fingering.
Partially preserved banding is only indicated in patients with complete spinal cord injury and refers to the preservation of partially innervated dermatomes or muscle segments below the neural plane. The range of segments with partial sensory and motor function is called the partial preservation zone, and they should be recorded separately according to sensory and motor function on each side of the body. The lowermost segment with preserved sensory or motor function defines the extent of the partially preserved sensory or motor band. When recording the partial preservation zone, the left and right sides should be described separately.
(5) ASIA residual impairment grading.
This classification is derived from the Frankel classification.
The following are the specific provisions of the ASIA residual impairment classification.
A: complete impairment, no sensory and motor function preservation in the S4-S5 segment.
B: Incomplete impairment. Sensory function is preserved below the nerve plane including the S4-S5 segment, but no motor function.
C: Incomplete injury. Preservation of motor function below the nerve plane and at least half of the key muscles below the nerve plane with muscle strength less than grade 3.
D: Incomplete impairment. Motor function is preserved below the nerve plane and at least half of the key muscles below the nerve plane have muscle strength greater than or equal to grade 3.
E: Normal. Normal sensory and motor function.
Note: If a patient is graded C or D, he or she has an incomplete impairment, meaning that there is preserved sensory or motor function in the S4-S5 segment. In addition, the patient must have one of two things: (i) voluntary contraction of the anal sphincter; and (ii) more than three segments below the motor plane with preserved motor function. grade E is only indicated for cases with a history of prior spinal cord injury that return to normal function at follow-up. It is not applicable to cases without nerve injury in the initial examination.
2. Spinal stability.
The determination of spinal stability requires some clinical experience and usually requires consideration of a variety of factors such as the patient’s age, time of fracture, type of fracture, presence or absence of dislocation and repositioning, good or bad internal fixation position, etc. Specialist physicians should be consulted when necessary. For patients who have been injured for a short time and have poor spinal stability but do not require secondary surgery, external spinal fixation orthoses, such as collars and undershirt supports, can be used.
3.ADL assessment.
Commonly used methods for assessing the activities of daily living (ADL) of SCI patients include Barthel index and functional independence assessment (FIM). For patients with tetraplegia, it is recommended to use the tetraplegia functional index assessment method, which can reflect the small but important progress of ADL in the training process of tetraplegia patients.
4. Prediction of spinal cord injury rehabilitation goals
Functional walking in the community is considered to be achieved by meeting the following criteria.
① Wearing a brace throughout the day and being able to tolerate it.
(ii) Able to walk approximately 900 m continuously.
③ Able to walk up and down stairs.
Those who can achieve all of the above criteria except ② can be classified as functional walking at home, i.e., those who do not meet the speed and endurance requirements but can perform at home. Those who do not meet any of the above criteria for functional walking in the community (① to ④), but can walk briefly with a knee ankle foot orthosis (KAFO) and crutches, are called therapeutic walkers. Although therapeutic walking is not practical, it has obvious therapeutic value: for example, it has therapeutic effects on patients such as psychological support, reducing the chance of pressure sores, preventing the occurrence of osteoporosis, improving blood circulation, preventing the formation of deep vein thrombosis in the lower extremities, and promoting the discharge of urine and stool.
5. Complications.
Various SCI complications may affect the effect of rehabilitation treatment, and their management is detailed in the relevant contents. Special attention should be paid to the management of spasticity. Spasticity has both positive and negative effects on the patient. In addition, spasticity can reduce the formation of deep vein thrombosis, and some patients can use spasticity to complete some transfer movements with appropriate guidance and training. However, excessive spasticity can severely limit the range of motion of the joints, causing pain and joint contractures, and seriously hindering the completion of the patient’s daily activities, such as dressing and undressing, shoes and socks, and completing transfer movements. Therefore, severe spasticity must be treated [7].
6, spinal cord injury rehabilitation efficacy assessment
Fourth, rehabilitation treatment
1, physical therapy.
Bedridden period (acute instability): attention should be paid to the braking and protection of the spinal fracture site. Mainly bedside joint movement training, muscle strength strengthening training, respiratory function training, bladder function training and bed turning training. To avoid the occurrence of postural hypotension, the head of the patient’s bed can be elevated gradually to adapt to it. The angle of head elevation should start from 15°-30°, and according to the patient’s adaptation, gradually increase the inclination of the posture to 60° and finally 90°. If the patient has severe postural hypotension, elastic bandages and lap belts for the lower limbs can be added to reduce blood pooling in the lower limbs and abdominal cavity. On this basis, sit-up training is started.
Out-of-bed period (wheelchair period): Patients can gradually carry out sitting balance training, wheelchair transfer training, wheelchair up and down the road edge stone training, wheelchair and ground transfer training, walking up and down the steps using supports and double crutches, etc. When possible, weight loss walking training and water walking training can also be carried out.
2.Operational therapy.
In the bedridden period, the content of OT therapy for SCI patients is basically the same as that of PT therapy. In the wheelchair period, for tetraplegic patients, most of them do not have hand grasping function, so they need to use self-help device (universal cuff) to complete the feeding action. This self-help device can also be used for brushing teeth, writing, and keystrokes. However, the patient must have at least elbow flexion to perform them. Patients with neck 5 can eat on their own using the aid, and patients with neck 6 and 7 can do it independently after training. Training utensils such as bowls and plates should be specially made with anti-slip and anti-spill functions. According to the economic situation of the patients, the environmental control unit (ECU) with head control, jaw control, hand control or air control can be used to switch on and off lights, curtains, watch TV and make phone calls to improve the quality of life of the patients. For paraplegic patients, the upper limbs function normally, so they can complete feeding and grooming actions independently. The focus is on training in defecation, dressing, putting on and taking off pants, taking a bath, doing housework, and going out shopping. In the future, if the control device of the car is appropriately modified, SCI patients below neck 7 can also be trained to drive a car.
3.Sexual rehabilitation treatment.
Female SCI patients, after injury, have little effect on sexual function and can have normal pregnancy and delivery. Male SCI patients, using auxiliary means, can also lead a conjugal life (see related content for details). At present, there are precedents of both male and female SCI patients who have successfully conceived and delivered normal fetuses by using artificial insemination method.
4.Cultural and physical therapy.
Choose some recreational and sports activities within the ability of SCI patients to train them for functional recovery, such as wheelchair basketball, tennis, billiards, table tennis, archery, javelin, fencing, wheelchair racing, swimming, etc., to restore their functions on the one hand and entertain them on the other. The benefits of cultural and sports activities are that they can increase the activities of the patient’s motor system, thus improving their functions and physical fitness, and increasing their endurance; psychologically, they can enhance the patient’s self-confidence and self-esteem. In addition to this, participation in cultural and sports activities can distract them from their disability, and together with the fact that many cultural and sports activities can be performed with able-bodied people, it is beneficial for them to reintegrate into society and actively participate in social activities. Therefore, cultural and sports activities should be actively carried out in the rehabilitation of SCI.
5.Psychotherapy.
Psychological reactions of spinal cord injury patients: from the time of injury usually go through a shock period, denial period, anxiety and depression period, and recognition of the adaptation period.
At the beginning of the injury, due to the sudden disaster, so that patients feel confused, no knowledge of the disease or disability caused by trauma, then the reaction is slow, belong to the psychological reaction shock period. After this period, patients often do not understand the disability, do not believe in the arrival of disability and its severity, firmly believe that they can heal, this is the denial period. As time goes by, patients gradually realize that disability will be inevitable, then their temperament becomes violent, and they vent their inner dissatisfaction and pain to the outside, and after they calm down, they often feel pessimistic and disappointed, and their emotions become anxious and depressed. After this period, they will gradually recognize the reality, accept the disability and treat people and things around them more correctly, which is the period of recognition and adaptation. Training personnel and nursing staff should understand the basic characteristics of each period, take the initiative to cooperate with psychologists in the training process, and adopt cognitive, behavioral, supportive and other psychotherapy to make patients enter the period of recognition and adaptation as soon as possible.
6.TCM treatment.
Chinese medicine treatment is also helpful for SCI rehabilitation, such as acupuncture for the recovery of incomplete paralysis muscle strength, improvement of bladder function, and Chinese herbal medicine for moistening and clearing the bowels have good effects.
V. Housing accessibility modification
After PT and 0T treatment, SCI patients have mastered certain daily living skills, which creates the necessary conditions for these patients to return to their families or return to society; however, these patients need other important conditions to really return to their families or society, which is environmental modification. For SCI patients, a more important prerequisite exists for anything important: the need for an unobstructed pathway when going out. Environmental modification is the adaptation of the environment to the needs of the person with a disability in terms of living, learning, or working by making appropriate adjustments to the environment. The purpose of environmental modification is to create basic conditions for people with disabilities to participate in social activities by establishing barrier-free facilities and eliminating various obstacles caused by the environment.
The basic requirements of environmental modification: the entrance of the building should have a ramp instead of steps, and its slope should be no more than 1/12; the width of the clear corridor of the door should be more than 0.8 meters; the rooms should be smooth and barrier-free; the location of the kitchen and the width of the kitchen door must be adapted to the access of the wheelchair, and the height of the stove must be adjusted so that the patient can see the bottom of the pot clearly while sitting in the wheelchair, and only in this way can the patient finish the frying Only then can the patient finish the stir-fry; the toilet should use a seat toilet with handrails, and the door partition should be made into an outward-opening type or a sliding type to ensure that the internal space is easy for the wheelchair to enter.
In developed countries, social workers coordinate with relevant departments to solve the problem of housing accessibility modification before SCI patients are discharged, and PT and 0T are responsible for specific technical guidance. The work in this area is still in the initial stage in China.
VI. Vocational training
Patients with SCI are mostly young adults, and labor and employment are their basic requirements and their basic rights [8]. Patients with SCI who have undergone systematic rehabilitation have the ability to take care of themselves, and if they have the opportunity to receive vocational skills training suitable for their physical conditions, they are fully capable of taking up jobs within their ability and contributing to society. Prior to vocational training, professional departments organize patients to conduct occupational ability measurements, and according to the results, some patients can return to their original occupations without special training, while others can be trained to take up new occupations or be employed in welfare factories [9]. The recently promulgated and newly revised Article 33 of the Law on the Protection of Persons with Disabilities [10] stipulates that the state implements a proportional employment arrangement system for persons with disabilities. The implementation of this provision will create very strong conditions for vocational training and employment of SCI patients, and is a legal guarantee for SCI patients to return to society.