I. Overview of early rehabilitation treatment for spinal cord injury
Spinal cord injury rehabilitation therapy emphasizes early intervention, and early rehabilitation training is beneficial to the functional recovery of spinal cord injury patients, reducing complications and improving the quality of life.
1.The general process of early rehabilitation
The general process of early spinal cord rehabilitation is consistent with the process of mid- and late-stage rehabilitation. At present, early rehabilitation emphasizes three phases of rehabilitation evaluation. The first phase of rehabilitation evaluation is conducted when the patient is admitted to the hospital, while setting rehabilitation goals, specifying rehabilitation training plans according to the goals, and carrying out rehabilitation treatment according to the plans; generally, the second rehabilitation evaluation is conducted after one month of treatment, summarizing the problems of the first phase of rehabilitation, the results achieved and the next step of the plan; the third rehabilitation evaluation should also assess the patient’s rehabilitation prognosis and rehabilitation destination.
2.The prevention of disability caused by spinal cord injury is divided into three levels of prevention
Level I prevention mainly refers to the prevention of injury to the spinal cord during pre-hospital emergency and post-hospital emergency transport and examination and treatment.
Level II prevention refers to the prevention of various complications and early rehabilitation after the occurrence of spinal cord injury.
Level III prevention refers to the application of comprehensive rehabilitation measures to maximize the use of all residual functions after the spinal cord injury has caused functional impairment.
3.Multidisciplinary cooperation in the treatment of spinal cord injury
Spinal cord injury rehabilitation requires multidisciplinary collaboration from the post-injury period. Generally, clinicians, rehabilitation physicians, nurses, rehabilitation training staff, psychologists, and other relevant departments to form a treatment team to jointly intervene; do not have the above conditions, at home can be accompanied by the resident to refer to the relevant knowledge for rehabilitation, general hospitals can be carried out in a regular consultation to form a rehabilitation treatment team to carry out early rehabilitation work.
Second, early rehabilitation treatment of spinal cord injury
Early rehabilitation of spinal cord injury is divided into acute unstable rehabilitation and acute stable rehabilitation.
Early rehabilitation staging is divided into acute instability: within 4 weeks after the injury; acute stability: 4 to 10 weeks after the injury.
1, acute instability rehabilitation treatment principles and the main content.
(1) treatment principles
Treatment principle is within 4 weeks after the injury, 1-2 times a day, the intensity of training should not be excessive.
(2) The main content
Joint mobility training: for cervical instability, shoulder abduction should not exceed 90 degrees; for thoracolumbar instability, hip flexion should not exceed 90 degrees.
Muscle strength enhancement training: the principle that all muscles that can be actively exercised should be exercised, which can prevent muscle atrophy and muscle strength loss.
Respiratory function training: including thoracic breathing (thoracolumbar segment injury), abdominal breathing training (cervical segment injury), postural sputum evacuation training, passive thoracic movement training (prohibited for patients with rib fractures), etc.
Bladder function training: indwelling urinary catheters are mostly used in the emergency phase. After stopping intravenous rehydration, start intermittent catheterization and voluntary voiding or reflex voiding training.
2.Principles and main contents of rehabilitation treatment in the acute stable stage.
(1) Treatment principles
Acute stabilization rehabilitation treatment principles are: strengthen the rehabilitation training content; total daily rehabilitation training time of about 2 hours; increase the position change and balance training, transfer or transfer training, wheelchair training, etc.; the training content and intensity are different for each patient; pay attention to the monitoring of cardiopulmonary function changes; after the completion of training in PT and OT training room, train in the ward itself; for those who need to use upper and lower limb supports, they should be equipped with them to facilitate training.
(2) Main contents
Acute stabilization rehabilitation treatment needs to increase the main content are: turning and sitting training, sitting balance training and support mobility training.
3, early spinal cord injury psychological rehabilitation
Early psychological rehabilitation of spinal cord injury patients is also necessary. Helping spinal cord injury patients to correctly understand the importance of rehabilitation training and guiding them to focus on rehabilitation training is the key to recovery, and also helps patients to relieve psychological pressure; the evaluation of the significance of rehabilitation training should be realistic, neither exaggerating the efficacy of rehabilitation training, nor devaluing the role of rehabilitation training.
Third, early spinal cord injury common clinical problems treatment
The clinical problems that often appear in the early stage of spinal cord injury include skin problems, urination problems, and breathing difficulties.
1, skin problems
The most effective preventive measure is to insist on regular turning; reduce the pressure on the protruding part of the bone; keep the wound dry and change medicine regularly for local pressure sores; take surgical treatment if there is necrotic tissue or infection on the wound.
2.Problems of urination
For retention type disorder, the principle of treatment is to promote bladder emptying, and in the early stage, the urethral catheter is usually indwelt. It should be noted that the early indwelling urethral catheter should be opened regularly, flushed regularly, and replaced every 2 weeks to prevent infection; for incontinence type disorder, the principle of treatment is to promote bladder storage function, and an external urinary collector can be used instead of indwelling catheter; except for special cases, suprapubic cystostomy should not be used.
3. Defecation problems
Patients with spinal cord injury generally keep stool once every 2-3 days, and develop the habit of regular defecation; if there is fecal incontinence, feces soaked around the anus, which can easily cause erosion, should be treated in time to keep the perianal skin clean; if the stool is constipated, you can use the appropriate aid to defecate such as cork, or use senna leaves in water as tea; pay attention to dietary regulation, the diet should be high in fiber, high volume and high nutrition.
4, breathing difficulties
There are two common clinical conditions of respiratory distress in spinal cord injury casualties. One is cervical medullary injury with dyspnea; the second is spinal cord injury combined with thoracic organ injury. The treatment of the two are: for acute cervical spinal cord injury, preventive measures should be strengthened and respiratory function exercises should be performed; for spinal cord injury combined with thoracic organ injury, joint treatment between multiple disciplines needs to be implemented.
5.Limb swelling problem
Early spinal cord injury with swelling of the limbs should first determine whether there are limb fractures and soft tissue injuries, and if they can be excluded, then the presence of deep vein thrombosis and heterotopic ossification of the lower limbs should be considered. Generally, ectopic ossification occurs later and mainly manifests as thigh swelling, while lower extremity deep vein thrombosis is often accompanied by lower leg swelling; it can also be differentiated by combining lower extremity deep vein ultrasound, serological examination and X-ray film.
The preventive measures of lower limb DVT mainly include changing the position and elevating the affected limb regularly during bed rest; doing active and passive exercises of the paralyzed limb regularly during bed rest, combined with massage and air wave pressure therapy device; wearing elastic stockings or applying elastic bandages on the paralyzed limb; correcting the hypercoagulable state of blood such as high blood lipid and high blood viscosity; applying anticoagulant drugs prophylactically. And once thrombosis occurs, absolute bed rest for 10-14 days in the acute stage; elevation of the affected limb; prohibition of massage of the affected limb; consultation with relevant departments for thrombolytic or anticoagulant treatment.
Heterotopic ossification is the formation of new bone in areas where bone does not exist anatomically. Osseointegration mostly occurs around the joint; when local inflammatory symptoms appear, slightly reduce joint mobility training; meanwhile, apply cold compresses locally and take anti-inflammatory drugs to reduce the aggravation of inflammation; after the inflammation is reduced, actively carry out joint mobility training to ensure the range of motion of the joint.
6, limb spasm and joint contracture
Muscle spasm is a concomitant symptom in the recovery process after upper motor neuron injury; joint contracture is a joint movement disorder caused by long-term braking of the skin, muscles and tendons around the joint, which is manifested as limited joint mobility. Long-term limb spasm can lead to joint contracture.
Management of myospasm after spinal cord injury: the injured person should be treated early; spasticity is preferred to medication; followed by exercise therapy and physical therapy; hydrotherapy can relieve spasticity of the spinal cord injured limb. For joint contracture, it is important to maintain correct limb position early after injury to prevent joint contracture; meanwhile, joint mobility maintenance training should be started early after injury.
7.High fever problem
Common causes are central regulatory disorders and infections. First of all, we should exclude infectious fever: upper respiratory tract infection, lung infection, urinary tract infection, etc. If the fever is caused by infection, it should be actively treated with anti-infection; it may also be related to central regulation disorder, i.e. central fever: physical cooling should be the main focus, pay attention to heat dissipation.
8. Heart rate and blood pressure problems
Patients with spinal cord injury tetraplegia may have hyper-reflexia of the vegetative nerves, manifested as headache, profuse sweating, breath-holding and skin flushing. Treatment: Immediately adopt a head-high position and exclude the causative factors as soon as possible; if it cannot be relieved, give antihypertensive drugs to relieve the symptoms.
The patient may develop postural hypotension. Emergency treatment measures: change the position immediately and put the patient flat, most patients can be relieved. Preventive measures: change the position regularly, gradually elevate the head of the bed for training, and gradually extend the sitting time; apply lap band and elastic stocking; some patients may apply medication.
At the end of early rehabilitation, a certain period of late rehabilitation training can be carried out according to the patient’s condition, the purpose of which is to guide the patient to return to the family and society .