Initial Evaluation

Successful implementation of any rehabilitation program starts with a comprehensive initial assessment of the primary neurological impairment and also a systematic evaluation of any other medical and musculoskeletal conditions that may affect the development and implementation of a patient’s rehabilitation program. For example, shoulder arthritis or rotator cuff pathology can significantly affect the rehabilitation of a brain-injured or spinal cord–injured patient with severe lower extremity weakness who requires good shoulder strength and mobility in order to transfer and use assistive devices. Likewise, advanced cardiopulmonary disease may impair a patient’s ability to engage in aggressive gait training, in view of the aerobic demands of this activity. The initial rehabilitation evaluation should include an assessment of alertness, cognitive function, speech and language, vision, swallowing difficulties, musculoskeletal limitations, motor impairments, apraxia, sensory deficits, bowel function, bladder function, balance, and coordination.

Numerous disease states can cause injury to the spinal cord, including trauma, spondylosis, demyelinating diseases, tumor, neurodegenerative diseases, infection, vascular injury, and toxic metabolic disorders. There are approximately 11,000 new cases of traumatic SCI per year in the United States.¹ About 700,000 people suffer a stroke each year, and stroke is currently the leading cause of serious long-term disability in the United States.² However, numerous other disorders of brain function cause significant disability, and these patients may also benefit from directed rehabilitation therapies. Examples include encephalopathies, neurodegenerative diseases, hydrocephalus, demyelinating disease, and primary and metastatic brain malignancies. Many different types of rehabilitation programs are available for patients and are stratified in Table 106-1 according to level of medical acuity (the need for close medical supervision or nursing services) and intensity.

TABLE 106-1 Classification of Rehabilitation Programs

* The need for close medical supervision or nursing services.

Assessment Scales

SCI assessment starts with a determination of the level and the completeness of the spinal injury. The American Spinal Injury Association has published standards for classification of SCI level (Fig. 106-1) and a grading system for completeness of neurological injury (Fig. 106-2).³ Incomplete injuries have a much better prognosis for motor recovery than do complete injuries. Since 2000, the most frequent SCI neurological category at rehabilitation hospital discharge of persons reported to the National Spinal Cord Injury database is incomplete tetraplegia (34.3%), followed by complete paraplegia (25.1%), complete tetraplegia (22.1%), and incomplete paraplegia (17.5%).¹

Figure 106-1 American Spinal Injury Association’s (ASIA) classification of spinal cord injury.

Figure 106-2 American Spinal Injury Association’s (ASIA) spinal cord injury impairment scale.

A variety of scales and assessment tools exist for evaluation of function after neurological injury. The primary initial assessment scale administered in traumatic brain injury is the Glasgow Coma Scale. The Glasgow Coma Scale numerical score reflects the depth of unconsciousness and is one of the most significant initial predictors of outcome and recovery.⁴ Table 106-2 summarizes some of the more commonly used scales in rehabilitation medicine. The Functional Independence Measure instrument is probably the most widely used functional assessment tool in the inpatient rehabilitation setting and can be applied irrespective of diagnosis (Fig. 106-3).

TABLE 106-2 Commonly Used Assessment Scales

Figure 106-3 Functional Independence Measure (FIM) instrument.

Flexibility

Flexibility is an integral component of most rehabilitation schemes. Flexibility exercises can reduce contractures, reduce muscle pain, and decrease spasticity. Prolonged gentle passive stretching is preferred over aggressive forced or ballistic stretching,⁵ which can tear myofibrils and supportive connective tissue, leading to increased pain. The pain and microscopic tearing associated with aggressive stretching techniques reduces the potential for progressive gains in flexibility. Heat application before stretching or a gentle aerobic warmup (if the patient is able to perform this) improves blood flow to the muscle and improves tissue elasticity. Ideally, stretches should be held for at least 30 seconds⁶ and, for optimal results, repeated twice a day.

Strengthening

Weakness is a common sequela of neurological injury. Institution of strengthening programs can typically start as soon as the patient has the ability to perform voluntary motor contractions. Often, neuromuscular reeducation techniques are used concomitantly with strengthening programs to facilitate more coordinated return of motor function (see later discussion). A general approach to strengthening starts with focus on core muscles that support the trunk, spine, pelvic girdle, and shoulder girdle. As core strength improves, greater focus is placed on extremity strength training and on coordination of motor control.

In the profoundly debilitated patient who is unable to maintain trunk stability in an upright position, assisted range-of-motion exercises and progressive resistance exercises, with the therapist providing the assistance or resistance, can be implemented for the upper and lower limbs. As mentioned, the only requirement is that the patient have some degree of voluntary contraction. These exercises can be performed in a supine position or in a supported sitting or standing position. A tilt table (a plinth that can rotate 90 degrees from horizontal to vertical) can allow a gradually more upright posture while the patient exercises the arms and legs. The benefit is not only strengthening the legs through weight bearing but also reconditioning the cardiovascular system. Cardiovascular “tone” may be lost with even short periods of bed rest, leading to orthostatism.

For patients with profound motor impairment, neuromuscular electrical stimulation can be used to facilitate strengthening, and in patients with SCI, such stimulation has been demonstrated to reduce disuse-related atrophy.⁷ However, caution should be exercised with use of neuromuscular electrical stimulation in patients with myopathy because it may result in exhaustion of the myopathic muscle.

The primary physiological processes by which normal muscles achieve greater strength are muscle hypertrophy and enhanced neuromuscular control. In the initial 2 weeks of any strengthening program, the improvements in strength are related less to muscle hypertrophy than to enhanced neuromuscular control⁸; thereafter, muscle hypertrophy is the predominant factor. In the patient with neurological injury as the cause of weakness, improvements in strength also depend greatly on the processes of neurological recovery. The mechanisms of recovery vary, depending on the precise nature and extent of neurological injury.⁹ For example, central reorganization of motor control (neural plasticity) occurs after stroke, and collateral sprouting of motor unit nerve endings occurs in peripheral neurological injury.

Balance, Coordination, and Neuromuscular Reeducation

Impairment in balance and coordinated motor control can be a very challenging rehabilitation obstacle. Poor postural control may be a sequela of many neurological disorders such as stroke, hydrocephalus, and vestibulopathy, as well as those causing motor weakness, sensory or proprioceptive loss, or extrapyramidal dysfunction. Rehabilitation schemes for the significantly impaired patient start with an assessment of postural control in a seated position. Patients are taught methods to improve trunk stability and correct transient perturbations of balance. Once sitting balance is sufficiently mastered, patients progress through more challenging exercises. Functional exercises such as mobility training, transfer training, and gait training all provide a challenge to postural control and help facilitate improved balance. Advanced proprioceptive exercises include single-leg standing, balance-training platforms, wobble boards, and hopping.

Rehabilitation of an extremity where injury has significantly impaired voluntary motor control is likewise challenging. Selection of a rehabilitation strategy depends, in part, on whether the limb is flaccid or spastic. Treatment in the flaccid extremity focuses on exploiting synergy patterns of muscle activation to facilitate voluntary movement. In the spastic extremity, techniques such as the Bobath neurodevelopmental training method or proprioceptive neuromuscular facilitation are used along with gentle prolonged stretching to decrease spasticity and improve motor control by using specific tone-reducing postures and movement patterns.^10,11 Biofeedback with surface electromyography can be used to facilitate neuromuscular reeducation.¹¹ Orthoses and adaptive equipment are commonly used thoroughout the rehabilitation process to facilitate improvements in extremity function. These are discussed in more detail in subsequent sections.