In the twentieth century, it was proposed and understood that complete treatment of patients with SCI should include acute hospital care, as well as both acute and ongoing rehabilitation. In general, we can state that, in the past, because of the lack of effective medical and surgical protocols, SCI was considered an untreatable disease; however, medical efforts have been directed toward its cure, by improving the management of both the acute and long-term phases [15]. Indeed, we have passed from an era of therapeutic nihilism to a new concept of SCI, and are able to treat the needs of individuals with SCI by competently treating the direct injury as well as all affected organ systems, including the psychological aspects of SCI.

Although the concept of integrated treatment was also known in the United States after World War II, European figures such as Sir Ludwig Guttman pioneered and made tremendous contributions to the multispecialist treatment of SCI patients. Guttmann (born in Silesia, Germany, in 1899) in 1944 was placed in charge of the SCI Unit at the Stoke Mandeville Hospital, in the United Kingdom. Guttmann introduced postural reduction, divided his patients’ neurological lesions into “complete” and “incomplete”, and then subdivided them into improved, unchanged, and deteriorated. This organization called attention to two basic concepts: the difference between a complete and an incomplete spinal cord lesion, and the prognostic implications of this difference on recovery. Later, this concept was expanded by Dr. Frankel, a pupil and co-worker of Guttmann’s, who reported clinical data from a Stoke Mandeville Hospital series, introducing the scale of neurological involvement that is now universally known as the Frankel Scale [17].

Furthermore, Guttman proposed a model of integrated care of SCI patients from the very acute phase to discharge. He created the very first SCI unit in the world at Stoke Mandeville, and this model of care was accepted and developed only later in the United States and Canada [17]. Guttmann realized that, contrarily to the usual division of specialties, doctors treating this illness had to be rehabilitationists with a commitment to all the needs of the patient, not only those within the scope of one’s specialty. Already in 1944 Guttmann had established “the fundamental rules for the care of SCI patients:

Guttmann was also a great believer in wheelchair sports, and is remembered for founding the Paralympics [20, 34]. Although only a small number of SCI subjects take part in elite and Paralympic sport, recreational sport plays an important part in the rehabilitation and life of paralyzed persons. Furthermore, elite sports and the Paralympics are fundamental in the reintegration of paralyzed persons and in changing the perception of wheelchair users.

Although little of Guttmann’s work was published in the medical literature [20], he was a great teacher and was experienced in what is now known as public relations. Many doctors visited Stoke Mandeville and trained in SCI medicine under the supervision of Guttmann; among these were most of the physicians who then developed SCI units in European countries, as well as in the rest of the world.

At present, after 70 years, SCI rehabilitation is strongly influenced by what we learnt from the Stoke Mandeville experience. Rehabilitation has traditionally focused on maximizing the person’s recovery from the injury and returning them home as independently as possible. However, once the milestone of returning home with a new SCI is crossed, the individual must conquer the barriers of societal reintegration with their altered body habitus. Traditionally, management of the person with SCI involves the determination of the person’s level of injury and functional capacity and then the generation of a problem list and prescription for therapies, with the overall goal of having the patient achieve their maximum functional potential. Therefore, determining the potential neurological and functional outcome of an individual post-SCI is the basis of the rehabilitation process [5]. Functional outcomes are traditionally determined based on the level and severity of the SCI [7] in conjunction with other factors, such as age [33]. The determination of the severity of the lesion is based on the International Standards for Neurological Classification of Spinal Cord Injury, which are a development of the Frankel Classification created in Stoke Mandeville in 1969 [17].

Always, according to Guttmann’s principles, SCI-specific rehabilitation should be initiated as soon as possible (ideally beginning in the intensive care setting) and in a specialized unit capable of providing comprehensive management of a person with SCI with an interdisciplinary approach of the rehabilitation team, which includes the patient and their family [35]. In fact it has been demonstrated that a delay in starting these interventions may negatively influence a patient’s ultimate functional capability and increase their length of rehabilitation stay [32]. Furthermore, early admission to an SCI unit may help in preventing early medical complications, thus facilitating the course of inpatient rehabilitation and reducing the total cost of care. The rehabilitation of SCI patients is a multifaceted problem and needs a multispecialty approach. SCI can disrupt upper and/or lower motor and sensory pathways, and can result in either a complete or an incomplete lesion. Although recent advances in primary damage healing, rehabilitation, and the prevention of complications have improved the prognosis of SCI [2], its consequences are still traumatic and disabling. Paralysis and loss of sensation are only two of several physical consequences of SCI. Therefore, the care of persons with SCI is not limited to the treatment of the neurologic injury. The medical consequences resulting from altered neurologic input, such as the development of respiratory failure, or neurogenic bladder and its resultant complications (pneumonia and urinary tract infections), affect most organ systems. These consequences not only represent an important health issue, as they could be major causes of morbidity and mortality (e.g., respiratory and urinary problems), but they also represent an obstacle to the social and vocational reintegration of patients (e.g., because of urinary incontinence). In addition, the psychological impact of SCI is vast, and complications such as depression and anxiety must be addressed.

The influence of the Stoke Mandeville experience is particularly evident in the care of two of the major causes of morbidity and mortality in SCI patients: pressure sores and urological complications.

With regard to pressure sores, Guttmann was the first to demonstrate that this complication may not only be healed, but may also be prevented, with a careful program of bed-turning (every 2 h) of the patient [16]. Very recently, a group of SCI experts agreed that the best practice to prevent pressure sores is still the bed-turning program established by Frankel [6].

With regard to urological complications, most of the patients admitted to Stoke Mandeville in the 1940s were managed with a suprapubic catheter that was changed only when closed. Guttmann had the intuition of removing the indwelling catheter and beginning to catheterize SCI patients every 4–6 h [16]. Therefore, he started the practice of clean (sterile) intermittent catheterization that later on was demonstrated to be the best practice to prevent renal failure in SCI patients [11].

In the past 30 years the rehabilitation of SCI patients has involved a second aim, which will probably increase in importance as incomplete lesions seem to be increasing: the restoration of impaired functions, in particular of walking. Recently some rehabilitative approaches have received particular attention, most of all in the field of activity-based therapy. After years of evidence from the basic science data, the old rehabilitative principles of compensation and adaptation are changing. Strategies for stimulating the nervous system to optimize functional recovery and elicit lost abilities are becoming more and more important [31]. Activity-based therapy refers to “interventions that target activation of the neuromuscular system below the level of the lesion, with the goal of retraining the nervous system to recover a specific motor task”. Intense physical activity has been shown to improve physiological function and health outcomes in individuals with chronic (> 1 year post-injury) SCI [3].

In this field of rehabilitation, European scientists have made important contributions. Following the concept of a central pattern generator (CPG) introduced by Grilner [19] and according to the idea of “spinal locomotion” [38], scientists from Germany and Switzerland introduced body weight supported treadmill (BWST) training [12, 38]. BWST training holds promise for walking recovery. In motor-complete SCI patients, unsupported walking seldom, if ever, recovers. However, this therapy showed the ability to induce a locomotor pattern even in patients with complete paraplegia, in conjunction with increases in leg extensor electromyographic responses [38]. In motor-incomplete SCI patients, daily locomotor training with BWST training often results in significant improvements in locomotor function [12]. More recently, robotic orthoses have been used for training SCI patients on the treadmill [25]. These orthoses have been designed to address some of the problems of BWST training (in particular the personnel costs) and to ensure that patients have a constant, safe, and regular repetition of the exercise. Although the cost-effectiveness and benefits of these devices compared with conventional therapies targeting the improvement of gait post-SCI are still to be demonstrated [26, 36], the robotic rehabilitation of walking is experiencing increasing success and is, at present, an integral part of the treatment in several SCI units.