Rehabilitation of the Individual with Spinal Cord Injury

Aria Fallah, Derry Dance, and Anthony S. Burns

Key Points

1. Until World War II, severe spinal cord injury (SCI) was almost universally fatal during the initial 2 years following injury.

2. The development of specialized SCI centers has dramatically improved survival rates, health, and functional outcomes of individuals with SCI.

3. SCI rehabilitation is ideally delivered by an interdisciplinary team.

4. Goal setting is a fundamental component of rehabilitation and facilitates the achievement of desired functional outcomes.

5. SCI rehabilitation should embrace and plan for community reintegration to maximize long-term outcomes.

The History of Spinal Cord Rehabilitation

For the majority of humankind’s history, SCI has carried a grave prognosis. The Edwin Smith Surgical Papyrus, dating to ancient Egypt (2500 bc) and named after Egyptologist Edwin Smith, is a medical text containing 48 detailed case histories. In this early document, SCI is referred to as “an ailment not to be treated.”1 Hippocrates, the ancient Greek physician, also believed that individuals with SCIs were destined to die.² During World War I, 80% of individuals with severe SCIs typically died within 2 weeks of injury, and even up to 1934, the mortality rate for paraplegia in the United States exceeded 80% during the first 1 to 2 years postinjury,^3,4 with the majority of patients succumbing to sepsis from urinary tract infections and pressure ulcers. Individuals who survived were largely relegated to institutional care with little hope of reintegration into the community. The picture remained bleak until World War II (WWII).

In 1936, Dr. Donald Munro, with the sponsorship of the Liberty Mutual Insurance Company, established the first civilian SCI unit (10 beds) in the United States at Boston City Hospital. He was able to demonstrate a 200 to 300% reduction in medical and hospital costs.³ The challenges posed by the large number of SCIs related to WWII would inspire the development of additional dedicated SCI units around the globe. In February 1944, the National Spinal Injuries Centre was established at Stoke Mandeville Hospital in Aylesbury, England. The SCI unit at Stoke Mandeville employed a comprehensive, multidisciplinary approach and was a response to the large number of injured servicemen and ex-servicemen. Sir Ludwig Guttmann was the first medical director and is considered by many to be the father of SCI medicine. He had been one of Germany’s leading neurosurgeons at the Jewish Hospital in Breslau before he fled to England in 1939. Guttman espoused some fundamental principles for SCI units.3

Management of a unit by an experienced physician who is prepared to give up part, or all, of his own specialty

Sufficient allied health professionals (e.g., nurses and therapists) to cope with details of care

Technical facilities to establish workshops and vocational outlets

Attention to social, domestic, and industrial resettlement

Regular aftercare, or extended care, over the lifetime of each individual.

Employing these principles, Stoke Mandeville enjoyed great success and served as an example for the rest of the world.

At the conclusion of WWII, Dr. E. Harry Botterell, consultant neurosurgeon to the Canadian army, worked with John Counsell, an injured veteran, to convince the Canadian Veterans’ Affairs Department to establish a dedicated facility for individuals with SCI. As a result, on January 15, 1945, the Lyndhurst Lodge was established in Toronto, Ontario. The first medical director was Dr. Al Jousse. The same year, the US Department of Veterans Affairs followed suit and established six SCI units. In Australia, the Royal Perth Hospital in Western Australia established an SCI unit in 1954, led by Dr. G. M. Bedbrook. Other Australian centers would follow.

In 1970, the first model SCI system was awarded by the US Rehabilitation Services Administration to Good Samaritan Hospital in Phoenix, Arizona. The success of this demonstration project led to the establishment of six additional centers in 1972. The Model SCI Systems (MSCIS) program is now administered by the National Institute on Disability and Rehabilitation Research (NIDRR) within the Office of Special Education and Rehabilitation Services in the US Department of Education. The program has included 26 SCI centers over the years, and currently there are 14 Model SCI Systems dispersed throughout the United States. Model SCI Systems are capable of providing the entire continuum of care, from acute medical management to rehabilitation and lifelong follow-up. Grantees also contribute data to a National Spinal Cord Injury Database. Today, dedicated SCI units exist around the world.

Spinal cord medicine continues to mature and develop as a medical subspecialty. In 1980, the US Department of Veterans Affairs established fellowship programs for SCI. In 1996, the US Accreditation Council for Graduate Medical Education (ACGME) approved spinal cord medicine as a subspecialty, and the first examination was subsequently given in October 1998. Subspecialty certification is conferred through the American Board of Physical Medicine and Rehabilitation; however, any current diplomates in good standing with a member of the American Board of Medical Specialties (ABMS) are eligible, if they otherwise meet training requirements.

Rehabilitation Setting and Team

Advantages of Cohorting and Regionalized Centers

Given the multisystem, multifactorial nature of SCI, in 1984 Donovan and colleagues postulated that SCI patients would experience improved outcomes if treated in a “coordinated” (specialized) system.⁵ It has now been demonstrated that specialist spinal injury units, which encompass rehabilitation, are associated with improved health, functional, and social outcomes. Smith in the United Kingdom found that individuals who received their rehabilitation through dedicated SCI programs experienced fewer health complications, such as pressure-related skin injury, chest infections, urinary tract infections, constipation, uncontrolled autonomic dysreflexia, problematic spasms, disrupted sleep, and depression.6 Significant differences were also observed for functional activities, such as eating, drinking, grooming, dressing, showering, transfers, wheelchair mobility, and managing bowel and bladder function.⁶ These individuals were also less likely to report relationship problems with partners, family, and friends, and were more likely to have a partner, paid employment, voluntary employment, and satisfaction with sex.⁶

The establishment of the Model Systems for SCI in the United States has also yielded important clinical benefits.⁷ Patients admitted to Model Systems experience fewer medical complications, such as pressure ulcers. Other benefits include greater efficiency, as evidenced by increased functional index measure (FIM) gain per day, and a greater likelihood of discharge to the home or community.⁷ Survival rates followed a similar pattern, with reduced mortality demonstrated for Model Systems.⁸ Furthermore, there have been significant reductions in mean length of hospital stay and associated cost savings for both acute care and rehabilitation.⁷

Cohorting of patients in dedicated facilities helps accrue the critical mass of individuals required to perform meaningful research studies and further improve outcomes.⁶ In summary, care provided in a setting dedicated to SCI can minimize complications while enhancing functional outcomes, resulting in shorter hospitalization times and lower economic costs.

Composition of Rehabilitation Team and Interdisciplinary Care

Rehabilitation of the individual with SCI focuses on achieving and maintaining good health, maximizing function, and promoting good quality of life. Medical and rehabilitation needs are extensive following a severe SCI, and routinely extend beyond the scope of any one clinical discipline. For these reasons, rehabilitation is ideally delivered by an interdisciplinary team working in a collaborative fashion. Traditionally, the core rehabilitation team has consisted of physical therapy, occupational therapy, rehabilitation nursing, rehabilitation psychology, social work or case management, and a physician. Other common members of the team include speech language pathology, recreational therapy, respiratory therapy, and rehabilitation aides.

Occupational therapy typically focuses on upper-extremity function for the performance of activities of daily living (ADLs). Strategies address strengthening, active-assisted range-of-motion, and fine motor control, as well as accessibility of the environment both at home and in the community. Assistive devices and splints can also be incorporated into the treatment plan to facilitate and promote functional independence.

Physical therapy has traditionally focused on aspects of mobility, such as ambulation, wheel chair mobility, and the performance of transfers. Maximizing mobility often requires one to address strength, balance, coordination, and endurance. Bracing and other orthotics are often incorporated into the treatment plan.

Rehabilitation nurses provide daily care, monitor health, participate in patient education, and collaborate with the rehabilitation team to maximize patient independence with self-care activities.

Social work can provide emotional support and adjustment counseling related to illness or disability, identify community resources and supports, help address important social needs (e.g., finances, housing), and facilitate community reintegration through discharge planning. Case managers can also serve many of these functions but typically do not provide counseling.

Physicians diagnose conditions and underlying impairments, participatein goal setting and formulation of treatment plans, monitor and manage medical issues, and contribute to educational needs. Physicians have also typically served as the lead of the rehabilitation team.

Rehabilitation psychology provides important mental and emotional support. Examples of activities include the screening and treatment of depression, addressing substance abuse, assessing cognition (particularly with comorbid brain injury), and facilitating client adjustment to new impairments and limitations.

The composition of the rehabilitation team varies depending on the characteristics and impairments of the individual patient and is dynamic in nature because it must constantly adjust to the needs of the patient. Regular meetings and good communication by all team members ensure the optimal environment for rehabilitation.9 The ultimate goal is to achieve the best functional outcome in the most efficient manner. The team approach is also beneficial to clarify goals, coordinate treatment plans, reduce redundancy in efforts, and lessen or avoid secondary medical complications.⁹

Goal Setting

An important and fundamental component of the rehabilitation process is goal setting. The articulated goals to a large extent determine the nature and focus of clinical interventions. For these reasons, it is important that goals be realistic and progress measurable. The assessment of goals should also be multidisciplinary to ensure that important needs are not overlooked.

One approach that has been described is the performance of a comprehensive needs assessment following initial mobilization out of bed.¹⁰ The National Spinal Injuries Centre at Stoke Mandeville Hospital has developed a formal Needs Assessment Checklist (NAC).¹¹

A fundamental principle of goal planning is to target and plan the rehabilitation program in accordance with the individualized needs of the patient.¹⁰ Within the framework of identified needs, rehabilitation goals are then defined in partnership with the patient. Often a specific individual or lead is appointed to oversee and coordinate goal setting for the team. Global goals should also be operationalized. As an example, achieving independence with bladder management can be operationalized into learning how to perform intermittent self-catheterization.

Functional Outcomes of Rehabilitation

Although a detailed description of specific interventions (e.g., body weight support treadmill training) is beyond the scope of this chapter, functional improvements during rehabilitation are typically achieved through compensatory strategies (e.g., driving with hand controls) or the facilitation of improvement in an underlying impairment (e.g., paraparesis) and its accompanying functional activity (e.g., walking). Relatively recent approaches, such as the utilization of weight-supported gait training (Fig. 21.1), are increasingly based on presumed physiology and accompanying concepts, such as the existence of a central pattern generator in the lumbosacral spinal cord. Mechanisms of recovery are addressed in depth in Section V.

Projected functional outcomes are often based on a neurological assessment performed within 72 hours to 1 month following SCI,¹² and long-term outcomes are largely dependent on the level and completeness of the injury. It is important to note that, although the lesion level provides some insight into anticipated recovery, the unique characteristics of each case also have to be taken into account. Patient recovery and accompanying function are influenced by differences in injury characteristics; the course of medical events and comorbidities; psychological, social, and environmental supports; and cognitive abilities. Highly motivated patients may exceed the expected functional outcomes for their level of injury.¹³