How is a spinal cord injury rehabilitated? 47 latest expert opinions in one article

At present, there is a lack of evidence-based medical guidelines for the rehabilitation of spinal cord injury in China, based on relevant scientific evidence, this guide proposes 47 clinical rehabilitation guidelines and recommendations involving rehabilitation assessment, rehabilitation intervention and rehabilitation management for the rehabilitation of SCI patients, including the full-cycle rehabilitation treatment content of acute, chronic and late stages of spinal cord injury.
The corresponding level of evidence and recommendations are given
.

Recommendation 1: Vital signs assessment, abbreviated as ABCS, should be performed prior to rehabilitation.

Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: Specific contents include airway (A), breathing (B), circulation (C), spinal cord (S).

It should be emphasized that in addition to spinal trauma, S should also include the assessment of the neurological function of the spinal cord, including the assessment of sensory, motor function and damage grading, and it is recommended to use the SCI International Standard for Neurological Classification (ISNCSCI).

During the emergency treatment period, after quickly assessing the overall patient and spinal cord injury in accordance with the ABCS sequence, the occurrence of secondary spinal cord injury was prevented when transporting the patient
.

Recommendation 2: Neurological function assessment
should be performed using the American SCI Society ASIA Damage Classification.
Strength of recommendation: Weak recommendation Quality of evidence: intermediate (B).

Description: It is recommended to use the following sequence: (1) determine the left and right sensory planes; (2) Determine the plane of motion on the left and right sides; (3) determination of the neural plane; (4) determine the degree of damage (complete or incomplete injury); (5) determination of ASIA damage classification [AIS]; (6) Determine the partial retention band
.

Recommendation 3: Rehabilitation physicians should diagnose and treat various complications
early from the acute stage of SCI, in addition to closely monitoring the patient's neurological function and severity of injury.
Strength of recommendation: Quality of evidence for strong recommendation: intermediate (B).

Description: Close monitoring of the patient's neurological function and severity of injury: early diagnosis and treatment of various complications such as neurogenic bladder, intestinal dysfunction, pain, infection, deep vein thrombosis, respiratory dysfunction, cardiovascular dysfunction, etc
.

SCI rehabilitation intervention recommendations

➤ Comprehensive opinions

Recommendation 4: Patients in the acute phase start with adaptive training
.
Strength of recommendation: strong recommendation, quality of evidence: low (C).

Note: Patients in the acute phase start with bedridden to sitting adaptive training and gradually transition to functional training
.

Recommendation 5: Bedside rehabilitation training is mainly adopted in the acute stage, and out-of-bed rehabilitation training is started in the recovery period, and the rehabilitation treatment strategy in the chronic phase is mainly to create conditions for returning to the family and society, focusing on psychological intervention and social support
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: (1) The main contents of the acute phase include: correct positioning, passive movement of joints throughout the body, muscle strength enhancement and endurance training for residual muscle strength and muscles above the injury level, attention to respiratory sputum training and intermittent catheterization bladder training, and prevention of complications such as pressure ulcers
, urinary tract infections, lung infections, and deep vein thrombosis 。 (2) The main contents of the recovery period include: joint range of motion and muscle strength passive training, active muscle strength training, pain treatment, bladder training and rectal management, breathing and sputum training, prevention of osteoporosis, thereby promoting greater functional recovery
of patients.
(3) The chronic period is mainly to return to the family and society, create conditions, and pay attention to psychological intervention and social support
.

Recommendation 6: Physiotherapy such as resistance training, manual assistance, gait guidance, etc.
are used to train
patients with SCI.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: (1) Physical therapy has a definite effect
on the enhancement of residual muscle strength.
(2) Physical therapy can also improve cardiopulmonary function, reduce the occurrence of depression, improve quality of life and independent living ability
.

Recommendation 7: It is recommended to use weight loss plate walking training and robotic gait training to improve patients' walking and moving ability and enhance lower limb muscle strength
.
Strength of recommendation: weak recommendation, quality of evidence: low (C).

Note: Weight loss plank walking training and robotic gait training can effectively improve the walking ability and lower limb muscle strength
of some SCI patients.

Recommendation 8: Patients in the acute phase maintain a good position and use splints, change positions regularly, perform active and passive range-of-motion training in the early stage, and maintain and strengthen muscle strength
in the early stage.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: Early muscle strength maintenance and strengthening training: For muscles close to the injury site, it is recommended to use isometric contraction for training
.

Recommendation 9: Patients with C7 and C8 injuries who can basically take care of themselves should undergo muscle strength training
.
Strength of recommendation: strong recommendation, quality of evidence: advanced (A).

Note: C7 and C8 patients who are basically able to take care of themselves focus on muscle strength training of deltoids, pectoralis majors, biceps, latissimus dorsi, wrist flexor and extensors, triceps and simple gripping and lateral pinch training
of the hands.

Recommendation 10: Patients with SCI after injury or 4 weeks after surgery should undergo aquatic limb function training
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: (1) The greatest therapeutic value of aquatic exercise therapy for spinal cord injury is that it can allow patients to perform many exercise training that cannot be completed on land and strengthen the treatment effect
.
For paralyzed patients, buoyancy significantly reduces the axial pressure and shear force of gravity in the spine, water resistance controls the speed of movement, and movements can be designed with the help of training equipment to improve safe range of
motion.
Spa therapy also has the effect of relieving pain, regulating muscle tone, reducing spasms, improving comfort, and relieving fatigue, which is conducive to the recovery
of SCI patients.
(2) The intervention of hydrotherapy rehabilitation requires that the patient's vital signs be stable, the symptoms are no longer aggravated, and the basic rehabilitation treatment is carried out
for a certain period of time.
It should be emphasized that patients with spinal cord injury have complex conditions, and the specific intervention time needs to carefully evaluate the degree of injury, injury segment, whether surgical treatment has been performed and other factors, and must be fully communicated with clinicians, patients themselves and family members, carefully evaluated, and carried out
under the premise of ensuring patient safety.

Recommendation 11: Postoperative postoperative positioning education
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 12: Perioperative postoperative turnover, getting up and other bedside transfer methods and limb active and passive training methods education
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 13: Regularly turn over (≤2h).

Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: In addition to turning over regularly to prevent pressure ulcers, it is also necessary to prevent friction damage
between the skin and the bed during body position transfer.

Recommendation 14: Passive movement exercises for the affected limb to prevent joint contractures
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 15: Physical motor function training (artificial assistance, robots, exoskeletons, etc.
).

Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

➤ Breathing training

Recommendation 16: Inspiratory muscle strength training
for patients with SCI.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: (1) Aspiratory muscle training can improve the strength of the main inspiratory muscles (diaphragm) and auxiliary inspiratory muscles (intercostal muscles), delay the occurrence of inspiratory muscle (diaphragm) fatigue, reduce its fatigue, and ultimately improve respiratory function and reduce the occurrence
of pneumonia.
(2) Respiratory muscle training can improve vital capacity (VC), maximum voluntary ventilation (MVV), maximum expiratory pressure (MEP) and maximum inspiratory pressure (MIP).

These data can indicate a significant improvement in respiratory muscle endurance and strength, and inspiratory muscle training has been shown to be effective in multiple studies, and it is recommended to include it in
the training of patients with SCI.

Recommendation 17: Cardiopulmonary training
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: Training method to improve cardiopulmonary function: moderate to high intensity 20-minute aerobic training twice a week, and 3 groups of strength training of major muscle groups such as diaphragm, intercostal muscle, abdominal muscle, scalene muscle, sternocleidomastoid muscle twice a week, such as inspiratory muscle resistance training, vocal training, etc
.

Recommendation 18: Music therapy
for patients with SCI.
Strength of recommendation: weak recommendation, quality of evidence: low (C).

Note: Music therapy combined with conventional respiratory muscle rehabilitation can effectively improve patients' respiratory function, increase expiratory power, and improve exhalation and sputum excretion
.

Recommendation 19: Singing training to train respiratory muscles while activating mouth muscle movement; Compared with regular training, lung function
can be significantly improved.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 20: Respiratory function practice education
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 21: Breathing, sputum training, postural drainage, respiratory exercise
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: Breathing, sputum training, postural drainage, respiratory function exercise can prevent and treat respiratory tract infections, atelectasis
.

➤ Mobile training

Recommendation 22: Patients with SCI should undergo physical training and wheelchair mobility training
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: (1) Physical training can help SCI patients improve their activity endurance, complete higher-level and difficult training, and restore more functions
.
(2) Wheelchair mobility training can help patients move themselves, improve the ability to move in complex environments, avoid a series of obstacles, and improve patients' independent daily living activities
.

➤ Physical factor therapy

Recommendation 23: Early hyperbaric oxygen therapy
in patients with SCI.
Strength of recommendation: strong recommendation, quality of evidence: low (C).

Description: Hyperbaric oxygen therapy is effective
in patients with acute traumatic SCI.
Early emergency treatment is recommended to be actively transported to an area or hospital with hyperbaric oxygen
.

Recommendation 24: Patients with incomplete SCI should be treated
with functional electrical stimulation (FES).
Strength of recommendation: strong recommendation, quality of evidence: advanced (A).

Note: For patients with incomplete SCI, FES stimulates the innervated muscles, which can improve the grasp and voluntary motor function
of the patient's hands.

Recommendation 25: Percutaneous electrical spinal cord stimulation for cardiovascular dysfunction
after SCI is not recommended.
Strength of recommendation: weak recommendation, quality of evidence: intermediate (B).

Note: Percutaneous electrical spinal cord stimulation therapy may be a viable therapy for restoring autonomic cardiovascular control after SCI, but there are not enough studies to confirm its effect
.

Recommendation 26: Transcranial, epidural, and percutaneous electrical stimulation promotes the restoration
of muscle strength and muscle autonomy control.
Strength of recommendation: weak recommendation, quality of evidence: low (C).

Recommendation 27: Transcranial magnetic stimulation reduces neuropathic pain
after spinal cord injury.
Strength of recommendation: weak recommendation, quality of evidence: intermediate (B).

Description: Although there are systematic analytical studies showing short-term efficacy of transcranial magnetic stimulation in reducing neuropathic pain after spinal cord injury, there is considerable heterogeneity, no standard generalizable prescriptions, no large randomized double-blind controlled studies, and no definitive evidence
of long-term efficacy.

Recommendation 28: Occupational therapy training
as soon as possible after the acute phase.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: Occupational therapy training should be carried out throughout the patient's rehabilitation training until home and community life
after discharge.

Recommendation 29: Group-based occupational therapy
with "life ability reconstruction".
Strength of recommendation: strong recommendation, quality of evidence: low (C).

Note: Life reconstruction refers to the use of social rehabilitation training methods, from a more positive perspective, for the SCI injured patients who have completed medical rehabilitation, for their needs at different stages of real life, the design of relevant training courses
.
Life reconstruction training refers to a comprehensive life skills training program
developed by SCI Disabled Friends that is suitable for mental and physical conditions.
After SCI training, not only can they re-recognize their own abilities and give full play to them, but they can also recover their lost self-care, mobility, and economic abilities, thereby reducing the psychological and economic burden
of the entire family and society of the injured friends.

Recommendation 30: Hand function training
for patients with SCI.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: Hand function training can effectively improve the fine motor function of the patient's hand, allowing the patient to use the hand function to complete some daily living activities
.

Recommendation 31: Patients with C5 impairment learn to use wrist-hand orthoses (WHO).

Strength of recommendation: strong recommendation, quality of evidence: low (C).

Note: Patients who are weak in finger flexion and extensor muscles can complete the grasping action when the back of the finger touches the opposite hand or nearby objects after wearing a wrist and hand orthosis, and can be completed by touching the switch with the other hand when it needs to be released
.

Recommendation 32: Patients with C6 injury who can partially take care of themselves are recommended to carry out progressive resistance training
due to shoulder adduction and wrist dorsiflex dysfunction.
Strength of recommendation: strong recommendation, quality of evidence: low (C).

Description: Focus on training latissimus dorsi, deltoids, muscles around the shoulder blades, and extensor carpal muscles to improve the stability of the proximal muscles of the upper limbs and the ability to transfer and change the
center of gravity in a wheelchair.
It is recommended that patients use the locking function of the elbow joint to complete the forearm support in the state of pronation of the forearm when the elbow joint is fully extended
.
This action is of great significance
for the protection of the skin, especially the acquisition of transfer action.

Recommendation 33: For patients with C7 and C8 injuries who can basically take care of themselves, use the strong elbow extension of the triceps muscles to complete the support of both arms, raise the body for hip decompression and transfer between the bed and the wheelchair
.
It is recommended that the therapist guide the patient to perform wheelchair operation training in various environments and conditions, and if necessary, field training outside the hospital, such as rough roads, ramps, densely populated streets, narrow road sections, etc
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 34: Modify
the living environment of patients who return to their families after discharge.
Strength of recommendation: strong recommendation, quality of evidence: low (C).

Note: In general, the following adjustments need to be made to the living environment of patients with spinal cord injury: (1) The space under the sink needs to accommodate both lower limbs in a wheelchair, so that the patient's body is closer to the sink
.
(2) The faucet needs to be adjusted and replaced
accordingly.
Depending on the patient's hand function, select easy-to-use faucet types such as touch, sensor, and various shapes of switch
handles.
(3) Modification of nail clippers and combs, such as thickening and lengthening the handle of combs, spoons, forks or toothbrushes, fixing one side of the nail clippers on the wooden board, and enlarging and widening on the other side to facilitate patient compression
.

Recommendation 35: The occupational therapist chooses an individualized treatment
plan that is appropriate for the patient based on the patient's actual situation.
Strength of recommendation: strong recommendation, quality of evidence: low (C).

Note: With the advancement of medicine and science and technology and the joint development of multiple disciplines, the traditional rollers, wooden nail plates, frosted boards, woodworking, leather, weaving, pottery, mosaic, gardening, etc.
have been gradually improved; New types of work activities such as virtual scenario interactive training, exoskeleton upper limb robots, smart gloves, BTE systems, and occupational therapy in hyperbaric oxygen chamber environments have been gradually introduced.
It is recommended that occupational therapists choose a personalized treatment plan suitable for the patient according to the actual situation of the patient, and combine traditional occupational therapy with new equipment to improve the efficiency of treatment, increase the interest of treatment, and fully mobilize the enthusiasm of patients
.

Recommendation 36: Incorporate psychological interventions
in rehabilitation for patients with SCI.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: Timely pain, depression and psychological intervention during rehabilitation training is conducive to improving the psychological state and rehabilitation outcome of SCI patients, improving the initiative of training, and promoting their functional recovery
.

Recommendation 37: Provide health education manuals to patients with subacute phase of whiplash injuries on the importance of illness and recovery activities, and provide simple training recommendations
that can help improve the disease.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: This helps reduce patient fear and improve neck function
.

Recommendation 38: It is recommended that patients with chronic phase whiplash read an educational manual, practice under minimal instruction (verbal or physical) from a physiotherapist, and explain the doubts or concerns raised by the patient, and then have the patient begin to implement the physiotherapist's recommendations and consult over the phone about problems
encountered during the training.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: This ensures that patients with whiplash injuries are treated with similar results
to comprehensive physiotherapy training.

Recommendation 39: Routine mental health education
before surgery.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 40: Psychological counseling, combined with the use of antidepressants to improve depressive symptoms
in patients.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 41: Vocational rehabilitation for SCI patients, vocational rehabilitation is an important embodiment
of the implementation of the patient-centered rehabilitation concept.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 42: Reproductive rehabilitation
for patients with SCI.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: For people with SCI, the restoration of motor and sensory function is important, but sexual and reproductive function is also an area
of concern.
Therefore, education on sexual function and reproductive rehabilitation should be carried out throughout the rehabilitation process
.

Recommendation 43: Patients with SCI should use wheelchairs, wear and use orthoses, self-help devices for training and activities of daily living
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Note: Wheelchairs are essential assistive devices for some SCI patients
.
Electric wheelchairs are available for patients with cervical SCI and manual wheelchairs
are available for patients with thoracic SCI.
Orthoses can help patients with acute SCI to stabilize the spine
.
Patients with cervical SCI may choose an upper limb orthosis to help the patient complete daily living movements
.
Patients with thoracolumbar SCI can use lower extremity orthoses to assist with standing and walking training
.
Patients with cervical SCI can use self-help devices such as universal cuffs, plate retaining rings, water cups with straws, etc.
, to assist in daily life such as eating and writing, and improve independent living standards
.

Recommendation 44: Hip Energy Storage Walking Orthosis (HESWO) can be used as an alternative to
reciprocating gait orthosis (RGO) walking training in paraplegic patients.
Strength of recommendation: weak recommendation, quality of evidence: low (C).

Note: HESWO is more convenient to wear than RGO, which can increase walking speed and reduce energy consumption
.

Recommendation 45: Use a hand brace
in patients with cervical SCI.
Strength of recommendation: weak recommendation, quality of evidence: intermediate (B).

Recommendation 46: Education on how to put on and take off the brace
.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Recommendation 47: Rehabilitation physicians should
follow up patients in the chronic phase of SCI at least once a year.
Strength of recommendation: strong recommendation, quality of evidence: intermediate (B).

Description: Patients in the chronic phase of SCI should be followed up at least once a year to prevent and manage various complications such as neurogenic bladder and bowel dysfunction, pressure ulcers, osteoporosis, low-energy fractures, orthostatic hypotension, cardiovascular and respiratory dysfunction, etc
.

Compiled from: Spinal Cord Injury Rehabilitation Professional Committee of China Association for the Rehabilitation of the Disabled.
Clinical Practice Guidelines for Spinal Cord Injury Rehabilitation.
Spinal Cord Injury Rehabilitation Professional Committee of China Association for the Rehabilitation of the Disabled