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Does Rehabilitation Facilitate Neurologic Recovery After Spinal Cord Injury?
BRIEF ANSWER
No published studies have randomized patients to a “no rehabilitation” group. Thus, it is not possible to make level I recommendations about whether rehabilitation facilitates neurologic recovery after spinal cord injury (SCI).
Ideally, patients should commence rehabilitation within 2 weeks of the initial injury. Although postponing rehabilitation by more than 6 months from the time of injury may decrease the chance of satisfactory motor recovery, a properly designed and implemented rehabilitation program can still be of benefit to SCI patients who are 1 year or more postinjury.
Locomotor training, whether with body weight support, functional electrical stimulation, or both, is safe and may be useful for improving ambulation in patients with incomplete SCI. On the other hand, neurostimulation and biofeedback techniques, either alone or in combination, appear to be no more efficacious than standard physical exercise therapy for restoring function. Neurostimulation may improve the strength and electromyogram (EMG) activity of individual muscles, however, which may be important if supraspinal control eventually returns.
Background
The care of patients with SCI involves a multidisciplinary approach. In the acute phase of SCI, a team of intensive care specialists, surgeons, and acute care nursing staff management focus on preservation of remaining spinal cord function and prevention of secondary injury to the spinal cord. The emphasis is on resuscitation, treatment of immediately life-threatening injuries, and subsequent stabilization of the injured vertebral column. Once acute problems have resolved, rehabilitation specialists, physiotherapists, nurses, occupational therapists, social workers, and patients themselves all work together to maximize functional outcome following SCI.
Many patients with SCI go on to achieve significant recovery of neurologic function, particularly during the first 6 months after the injury. Since rehabilitation has become an integral part of SCI management, it is difficult to critically assess how much improvement is due to rehabilitation and how much is secondary to the natural healing process. This chapter examines the evidence regarding the timing of rehabilitation and the efficacy of some of the available modalities of facilitating neurologic recovery after SCI.
Literature Review
An Internet-based search of the National Library of Medicine (NLM) database was conducted using PubMed (www.nlm.nih.gov). The medical subject headings (MeSH) “spinal cord injury AND rehabilitation” were used. Only articles reporting human studies in the English language were retrieved. A total of 2513 articles were identified as fitting our selection criteria. Of the 162 retrieved articles concerning clinical trials, 42 studies involved randomized controlled trials.
Timing of Rehabilitation
Sumida et al1 examined the effect of early rehabilitation after traumatic SCI (class III data). In their retrospective, multicenter study, 123 patients from 16 hospitals and one medical school were divided into two groups: an early rehabilitation group (beginning rehabilitation within 2 weeks of injury) and a delayed group. In each of the two groups, the patients were further subdivided according to the type of SCI: tetraplegia excluding central cord injury, central cord injury, and paraplegia. The authors found that SCI patients not receiving rehabilitation for over 6 months postinjury had a low probability of acceptable motor recovery. Also, they found early rehabilitation was more effective than delayed rehabilitation in improving the activities of daily living in all patients with SCI. However, the advantage of early rehabilitation was not apparent in the tetraplegia subgroup when the American Spinal Injury Association (ASIA) motor score was used to measure neurologic improvement.
Pearl
In one study, SCI patients not receiving rehabilitation for more than 6 months postinjury had a lower probability of acceptable motor recovery than patients receiving rehabilitation soon after the injury. Other studies, however, suggest that at least some delayed neurologic improvement is possible with training even in the chronic setting.
Celani et al2 investigated factors influencing the length of stay in a rehabilitation center, the incidence of pressure ulcers, and the neurologic improvement of patients with traumatic and nontraumatic spinal cord injuries (class III data). In their multicenter, retrospective study of 859 consecutive adult patients, the authors found that the presence of pressure ulcers was statistically associated with a longer interval from initial injury to admission to a rehabilitation center. Furthermore, in a multiple logistic regression analysis, the model that best predicted neurologic improvement included, among other factors, absence of pressure ulcers on admission to the rehabilitation facilities. By inference, the authors of this study concluded that early admission to a rehabilitation facility is likely to facilitate clinical recovery.
The Role of Locomotor Training in Spinal Cord Injury Patients
It has been recognized that coordinated stepping movements in patients with complete paraplegia can be induced by weight support and by standing on a moving treadmill (class III data).3 This is the basis for Laufband (treadmill) therapy in SCI patients. Wernig et al4 studied a series of 76 patients who underwent locomotor training by Laufband therapy (class III data). This noncontrolled study found supported treadmill ambulation training to be effective for improving the walking capabilities of patients with either chronic or acute incomplete SCI. However, the measures for assessing gait performance were different at the beginning and end of the study. In addition, the patients’ training regimes were variable in their duration and intensity.
Pearl
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