Early Rehabilitation of Spinal Cord Injury Rehabilitation of spinal cord injury should begin at the site of injury and should begin on the first day after the injury, i.e. early rehabilitation. After spinal cord injury, the stability of the spine is damaged and various compound injuries can cause instability of the vital signs. Therefore, a series of clinical treatments such as emergency treatment, medication and surgical treatment should be given to patients in the early stage of spinal cord injury. At the same time, spinal cord injury immediately causes systemic multi-system dysfunction, and early rehabilitation and prevention of various early complications are important for the patient’s healing. Especially once spinal stability has been established and clinically important issues have been resolved, rehabilitation becomes the only thing that matters.
For a long time, spinal cord injury rehabilitation has been considered to be carried out in the later stages of spinal cord injury or recovery, and rehabilitation is considered to be a continuation of clinical treatment. Therefore, after receiving emergency treatment and surgical treatment in the orthopedic or neurosurgery departments of general hospitals, most domestic spinal cord injury patients were considered to be finished with clinical treatment and were discharged or transferred to a convalescent-style hospital to recuperate, passively waiting for possible recovery. As early rehabilitation was not carried out, patients had a high incidence of complications such as pressure sores, droopy feet, and urinary tract infections, and were bedridden for longer periods of time. As a result of prolonged bed rest, patients undergo physical and psychological changes that are detrimental to recovery. Early Intensive Rehabilitation (EarlyIntensiveReha-bilitation) for spinal cord injury patients can achieve the goal of short rehabilitation period and good rehabilitation effect.
The results of a 1997 clinical study at the Shepherd Center, the largest spinal cord injury center in the United States (28), showed that those who began rehabilitation within two weeks of injury had the shortest average length of stay (30 d) and the highest increase in functional recovery (FIM) (41 points); those who began rehabilitation 85 days after injury had an average length of stay of 35 days and only a 22-point increase in functional recovery (FIM). The study concluded that functional recovery and length of hospital stay in spinal cord injury patients were related to the time between injury and the implementation of the rehabilitation program, with the earlier the post-injury rehabilitation was implemented, the shorter the hospital stay and the less money spent, while the more functional recovery (FIM) was obtained and the fewer complications. Therefore, in a sense, early and intensive rehabilitation of spinal cord injuries is necessary. The meaning of “early” for early rehabilitation of spinal cord injury is: from the day of injury, from the admission to the hospital, from the immediate postoperative period, and from the ICU. In order to improve the rehabilitation effect and shorten the inpatient rehabilitation time, “intensive rehabilitation” is emphasized.
Intensive rehabilitation Intensification means that the rehabilitation process is determined according to the spinal cord injury and the duration of rehabilitation is increased as much as the body can tolerate. Increase the content of rehabilitation. Improve the training method during rehabilitation and increase the intensity appropriately. Such as water PT during hydrotherapy, water balance training, and active sports competition activities to improve the efficiency of rehabilitation. It is a principle of the Shepherd Center that “from the time of admission, all muscles that are still available must be strengthened”.
(I) Early rehabilitation staging
1.Acute instability stage
After acute spinal cord injury or within about 2-4 weeks after spinal cord surgery. At this time, the stability of the spine is damaged by trauma, by surgical internal fixation or external fixation brake but not yet completely stable or just stable. At the same time, the combination of thoracic and abdominal, cranial and extremity complex injuries in about 5% of patients, as well as spinal cord injury, especially high spinal cord injury causing multi-organ system disorders, can cause instability of important vital signs. The relative instability of the spine and condition is characteristic of this period. However, this period is also an important time for early rehabilitation. DrApple, a famous American spinal cord injury expert, pointed out that rehabilitation should be started within the ICU on the basis of stabilizing the condition as soon as possible. We have learned that early rehabilitation training, such as respiratory function training and bladder function training, is not only important for preventing early serious complications and stabilizing the condition, but also lays a good foundation for future rehabilitation. In the acute instability phase, rehabilitation training must pay attention to the relative instability of their spine and condition. Therefore, bedside rehabilitation training should be performed. When carrying out ROM training and muscle strengthening training, the stability of the spine should be avoided, the range and intensity of limb activities should be controlled, and should be carried out gradually. PT therapy nurses and OT therapy nurses should understand the condition and clearly know which training cannot be carried out, and should pay attention to the changes in the condition during the training process.
2.Acute stabilization period
After the acute instability period until about 8 weeks after the injury. Patients in this period have reconstructed spinal stability through the application of internal fixation or external fixation stents. The life-threatening compound injury has been treated or controlled, and the pathophysiological changes caused by spinal cord injury have entered a relatively stable stage. The spinal shock period has mostly passed, and both the level and type of spinal cord injury have been basically determined. The patient should gradually leave the bed and enter the PT room or OT room for evaluation and training.
(B) Early 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 early management of spinal cord injury includes first aid and clinical treatment, so the early rehabilitation evaluation also includes clinical contents related to functional disorders.
1, the content of the rehabilitation evaluation
(1) spinal cord function evaluation should generally include: spinal fracture type and spinal stability, the level and extent of spinal cord injury, muscle strength score and sensory score, spinal orthosis assessment, independent capacity assessment.
(2) Somatic function assessment: joint function assessment, muscle function assessment, upper extremity function assessment, lower extremity function assessment, self-help and walking orthosis assessment, urinary and sexual function assessment, cardiopulmonary function assessment.
(3) Psychological function assessment generally includes psychological state assessment, personality assessment and pain assessment, which should be conducted by a psychologist.
(4) Social function assessment generally includes: assessment of living ability, assessment of employability, assessment of independence, etc. In general clinical hospitals, the assessment should be conducted by a rehabilitation physician. The assessment of employability can be done at the end of rehabilitation.
2.Form of rehabilitation assessment
The rehabilitation assessment should be conducted by the physician in charge (orthopedics, neurosurgery) or the rehabilitation physician, with the participation of nurses, PT therapists, OTs and, if necessary, psychologists, etc., in the form of a rehabilitation therapy team meeting. At the meeting, the patient’s clinical information and the content of the rehabilitation evaluation are discussed, the rehabilitation goals are determined and a rehabilitation plan is formulated, and a rehabilitation prescription is issued by the supervising physician or rehabilitation physician. Rehabilitation goals should include milestones and overall or basic goals. The rehabilitation treatment plan is to determine the sequential arrangement of various rehabilitation treatment measures according to the rehabilitation goals and the overall condition of the patient. During the implementation process, the rehabilitation goals and rehabilitation plan can be adjusted and modified according to the patient’s condition. In the early rehabilitation assessment of spinal cord injury, the assessment of spinal stability has an important significance. Patients with unstable spine or in acute instability should be assessed and trained at the bedside. Any assessment and rehabilitation treatment that causes instability should strengthen the contact and communication between the physician in charge, OT, PT teacher and nurse practitioner, and adjust the training content and arrangement when necessary.
3, rehabilitation assessment in general hospitals
At present, the first consultation of spinal cord injury is mostly in the orthopedic department or neurosurgery department of general hospitals. After emergency or surgery in general hospitals, how to carry out rehabilitation assessment and rehabilitation treatment is a real problem. Since there are very few formal rehabilitation centers or spinal cord injury centers in China, it is important to use and should make full use of the rehabilitation medical resources of general hospitals, and make use of patients’ hospitalization time in general hospitals to carry out early rehabilitation in a timely manner. At present, many patients with spinal cord injury are basically bedridden after emergency or surgery in general hospitals, waiting for recovery, or are transferred to convalescent “rehabilitation hospitals”, which not only misses the time for early recovery, but also wastes resources. According to our limited experience, a “multidisciplinary consultation” approach can be adopted in general hospitals for evaluation and treatment on a trial basis. The competent orthopedic surgeon or neurosurgeon will preside over the consultation, and according to the need of the consultation, the rehabilitation and urology physicians will be consulted, and the responsible nurses will be invited to participate in the consultation to conduct early rehabilitation assessment and formulate rehabilitation goals and rehabilitation plans. After the rehabilitation treatment plan is determined, the physician of the corresponding department will be responsible for implementing the rehabilitation treatment plan, and the responsible nurse will coordinate the implementation of the rehabilitation treatment plan. Early rehabilitation treatment
Early rehabilitation treatment should be carried out in stages according to early rehabilitation staging. In the acute unstable phase, rehabilitation treatment should be carried out at the bedside and combined with clinical treatment. Once in the stable phase, the person should gradually leave the bed and go to the rehabilitation training room for training. During the process of bed training to bed release training, it should be carried out step by step under the guidance of nurses, with support devices if necessary. First, the head of the bed should be raised gradually, from the prone position to the sitting position. In order to prevent positional hypotension, patients with cervical spine injury can also apply lumbar girth belts and elastic stockings for the lower extremities. Generally through 1 to 2 weeks of time transition, the patient can leave the bed.
1.Acute instability period
In this period clinical treatment and rehabilitation are carried out at the same time, but also with each other. For example, patients with spinal cord injury are prone to pulmonary infections and other respiratory complications, and respiratory function training is very beneficial while treating pulmonary infections. In recent years, the early survival rate of cervical high paraplegia has improved significantly and is associated with respiratory function rehabilitation. At the Shepherd Spinal Cord Injury Center, the largest in the United States, there is already a specialization in respiratory rehabilitation (RT, Respiratorytherapy). Patients fitted with tracheal cannulas can be seen performing PT training. The main elements of early rehabilitation training include: joint mobility training: for cervical instability, shoulder abduction should not exceed 9O degrees, for thoracolumbar instability, hip flexion is not easy to exceed 90 degrees; muscle strength training: the principle that all muscles that can be actively exercised should be exercised so that muscle atrophy or muscle strength decline does not occur in the course of the acute phase; respiratory function training: including thoracic breathing (thoracolumbar segment injury) and Abdominal respiratory training (cervical segment injury), postural sputum evacuation training, passive thoracic movement training: moderate compression of the sternum twice a day to make the ribs move and prevent adhesions of the cribriform or transverse cribriform joints, but it is prohibited for those with rib fractures and other thoracic injuries. Bladder function training: In the emergency phase, indwelling urinary catheters are often used because of the difficulty in controlling the intake volume. After stopping intravenous rehydration, intermittent catheterization and voluntary or reflex urination training are started. In the acute unstable phase, rehabilitation training should be conducted once or twice a day, and the intensity of training should not be excessive.
2. In the acute stabilization period, the main clinical treatment is basically finished, and the patient’s spine and condition have been stabilized, so rehabilitation becomes the first or only task. On the basis of strengthening the training in the acute unstable stage, we should add postural change and balance training, transfer or transfer training, wheelchair training, etc. Since the age and physical condition of each patient are different, and the level and degree of spinal cord injury are different, the content and intensity of training are different. However, the content of rehabilitation training should be strengthened during this period, and the total time of rehabilitation training should be about 2 hours per day. Pay attention to the monitoring of cardiopulmonary function changes during the training process. After the completion of training in PT and OT training rooms, patients should train by themselves in the ward under the guidance of nurses. For those who need to use upper and lower limb braces during this period, they should be trained with the use of them. At the same time, necessary preparations should be made for the patient to return to the community and family and continue rehabilitation. Paraplegic patients may have different degrees of muscle spasm and joint contracture, which may affect the effect of rehabilitation treatment.
Thanks to muscle spasm can be dealt with by physiotherapy, medicine and even surgery; the most important thing is to prevent joint contracture, so that it should not appear.
Physical therapy: cold, heat, electricity, ultrasound, waxing, traction, massage, etc.;
Medications: Myona, baclofen, tizanidine, botulinum toxin, phenol, etc.;
Surgery: muscle lengthening, tendon transfer, nerve cutting, spr, etc.