Rehabilitation for Spinal Cord Injury:
Restoring Hope and Functionality
Experiencing a spinal cord injury (SCI) can be life-altering and poses significant challenges in everyday life. However, with comprehensive rehabilitation and the right support including intensive physiotherapy, restoring some functionality, independence, and an enhanced quality of life is not just a dream, but a realistic goal.
This article shines a light on the journey of SCI rehabilitation, highlighting the array of specialised strategies and programs that are designed to cater to the unique needs of each.
A brief video introduction follows.
Understanding Spinal Cord Injury
SCI refers to damage inflicted on the spinal cord, a vital structure of nerves and support cells extending from the brain down the vertebral column. While spinal trauma is often considered a most probable cause, various non-traumatic conditions can also disrupt and injure the spinal cord. The Spinal Injuries Association estimates that some 2500 people will be injured or diagnosed each year in the UK and the number living with the condition is likely to be around 50,000.
This impairment can result in partial or complete loss of sensory and motor function below the level of injury to the spinal cord, with the severity varying across cases. Every individual case will be unique, although medical science will aim to classify each injury and to some extent this will guide the nature of treatment provided. An earlier article on our blog described the classification of injury using the so-called ASIA score.
The functional status and completeness of an injury, alongside the level of the injury, are closely intertwined. Spinal cord injury not only impairs independence and physical function but also gives rise to various complications.
Complications such as neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders can be seen after SCI. The long term necessity is to minimise these complications in order to maximise "healthspan".
Following the acute medical management phase, the critical journey of SCI rehabilitation commences, aiming to optimise functional recovery and enhance quality of life. Before we get into this, let's review what rehabilitation is.
Rehabilitation: A Brief Overview
Rehabilitation, as a concept, is deeply rooted in the belief that every individual deserves the opportunity to live a fulfilling and independent life, regardless of any physical or mental impairments. The fundamental purpose of rehabilitation is not merely to treat the symptoms of a condition, but rather to empower the individual, enabling them to achieve their highest possible level of functional independence and actively participate in society.
The origins of rehabilitation can be traced back to the ancient civilisations of Greece, Rome, and Egypt, where therapeutic exercises were used to help individuals recover from injuries or illnesses. This rudimentary form of rehabilitation evolved over time and was significantly influenced by both World Wars, when the need for comprehensive rehabilitation programs for wounded soldiers became apparent. This led to the development of more structured and specialised rehabilitation therapies, thus forming the basis for modern rehabilitation science.
The First World War led to the development of the first identifiable spinal-injury unit as a practical necessity in the UK. In the early part of the war, hospitals were becoming crowded with ‘incurable’ paralysed patients. Following an appeal in the Times of London newspaper and a public demand to ‘do something’, the Red Cross opened the first Royal Star and Garter Home in Richmond with sixty-four beds. Those patients with spinal cord or brain injuries who survived the early consequences of battlefield trauma were transferred to chronic rehabilitation units at Lonsdale House, the Royal Star and Garter Home and Rookwood.
The Royal Star and Garter Home carried out forms of rehabilitation from the outset – but not rehabilitation as we might envisage it today.
Facilities were provided for handicraft, needlework and embroidery, shoe making and repairs, leather, cane and wood- work, along with recreational and sports facilities. Residents also practised salmon fly dressing, painting, watchmaking and repairing.
Ludwig Guttman
Ludwig Guttmann was the first director of the new Stoke Mandeville Spinal Injuries Unit in 1944. He was pretty much the initiator of the rehabilitation approaches embedded in practice today. By the time of his arrival at Stoke Mandeville, Guttmann had a lot of practical experience in treating peripheral nerve injuries and saw value in using this as the foundation of his treatment of spinal cord injuries. Guttmann recognised that leadership is an essential ingredient for success and is reported to have been an inspiring man who uplifted the morale of patients and staff alike. He was an innovator in the field and demonstrated that something worthwhile could be done for spinal-injury patients.
Guttmann wrote in the Medical Times (Guttmann, 1945):
‘Positive proof of recuperation is invaluable in convincing the man that hope is not lost – over-cheerfulness and self-deception, which some of these cases show, also need attention at later stages.’
The Role of Inpatient Rehabilitation
In the early recovery stages, inpatient rehabilitation plays a pivotal role. Most patients in the UK, certainly those following traumatic injury, are ideally referred to one of the dedicated Spinal Injury Units that have the resources to deal with these complex injuries. There is a unit in each of Scotland, Northern Ireland, Wales and Southern Ireland and eight units across England.
These Units will include specialised rehabilitation facilities where a team of professionals can collaboratively develop a tailored treatment plan that includes physical therapy, occupational therapy, and rehabilitation medicine, amongst other services.
In the Spinal Injury Units, the holistic approach is considered paramount. Within these units, the value of each professional's contribution is recognised. Physical therapists can guide patients to regain mobility, strength, and flexibility, while occupational therapists help them adapt to daily living tasks, ensuring their environment is modified to meet their needs.
Rehabilitation doctors and nurses manage medical needs and monitor progress, adjusting the rehabilitation plan as needed. Neuropsychologists and social workers support the psychological wellbeing of patients, and vocational rehabilitation specialists work to reintegrate patients back into the workforce or education if possible. It's a collaborative process in which everyone's goal is to maximise the patient's independence and quality of life. This is achieved by harnessing the strength of the individual and focusing on the possible, rather than what has been lost.
The early phases of recovery are very important for the prevention of complications. However, few patients will declare their satisfaction with the nature and extent of rehabilitation provided in hospital.
The Significance of Occupational Therapy
Occupational therapy is an integral part of spinal cord injury rehabilitation. Its primary focus is to help patients regain independence in activities of daily living (ADLs). Occupational therapists conduct a thorough assessment of the patient's abilities and provide assistive devices and strategies to optimize function and foster independence. This may include training in the use of adaptive equipment and techniques to compensate for motor deficits caused by the injury.
The Impact of Physical Therapy
Physical therapy is another important cornerstone of spinal cord injury rehabilitation. It aims to boost muscle strength, range of motion, and overall physical function. Therapists design exercise programs tailored to each patient's specific needs and goals. These programs often include functional electrical stimulation (FES), a technique using electrical currents to activate paralyzed muscles and enable functional movements.
At Anatomical Concepts we work with various products that use electrical stimulation such as FES Cycling systems and specialised devices for denervated muscle. Technology can play a very important part in rehabilitation and can act to assist recovery in some cases or to compensate for functional less when necessary. The emergence of exoskeletons is important as some are aimed at supporting functional recovery and some are purely assistive devices.
Addressing Mental and Emotional Well-being
Rehabilitation for spinal cord injury isn't just about physical recovery. It also addresses the mental and emotional well-being of patients, and their families, acknowledging the profound psychological impact that SCI can have. Rehabilitation programs often include counseling and support services to help patients cope effectively with their injury and achieve a sense of direction and emotional well-being.
Emotional well-being often overlaps with the physical aspects of rehabilitation. Life after a spinal cord injury can be emotionally overwhelming, with individuals grappling with feelings of frustration, grief, and anxiety. Thus, mental health professionals, such as psychologists and counsellors, play an instrumental role in the recovery process. They provide individuals with strategies to manage emotions, overcome barriers, and build resilience. Through activities such as cognitive behavioural therapy (CBT), mindfulness, and group support sessions, they help patients adjust to their new realities, fostering a positive mindset and enhancing overall well-being. Moreover, family therapy and education sessions can also be useful, equipping loved ones with the knowledge and skills to provide effective support. This holistic approach to spinal cord injury rehabilitation emphasises that restoring hope, confidence, and positivity is just as critical as regaining physical functionality.
Catering to Different Types of Spinal Cord Injuries
Specialised SCI rehabilitation centers cater to various types of spinal cord injuries, including so called "incomplete" and "complete" injuries.
In incomplete cases, where some sensation or motor function below the injury level is preserved, rehabilitation services aim to maximise neurological healing and regain as much independence and mobility as possible. The goal is to capitalise on any preserved function, encouraging and enhancing the body's natural healing processes to stimulate and foster any remaining neural activity.
Exercise following any SCI is an important part of rehabilitation
In contrast, complete SCI involves total loss of sensory and motor function below the injury level. The goal transitions from restoration of function to maximising quality of life and independence within the new limitations. Even in these cases, rehabilitation can significantly improve daily life by enhancing muscle strength, promoting proper body mechanics, preventing complications, and educating on long-term care.
In both cases, it’s crucial to remember that each individual's journey is unique. Therefore, the rehabilitation programme should be customised to meet each patient's distinct needs and circumstances, while also offering robust emotional and psychological support to manage the impact of the injury on mental and emotional well-being.
The boundary between what is a complete and what is an incomplete injury is not always well defined but is clearly important as this judgement will dictate the beliefs and actions of all concerned.
Outpatient Rehabilitation: The Continued Journey
Following the inpatient phase, outpatient rehabilitation plays a crucial role in the continued progress of spinal cord injury patients. Regular therapy sessions in specialised rehabilitation hospitals or outpatient clinics ensure that patients maintain their gains and prevent regression. The frequency and duration of sessions should be tailored to each patient's specific needs and goals.
However, the ideal NHS model of providing care for free at the point of delivery is being stretched and it is unlikely that individuals will find all their needs provided by the State. The video below by Claire Lomas describes her personal rehabilitation journey where she decided to increase the amount of time spent on her recovery and fitness beyond that provided by the state.
The aim of preventing complications will always remain an important goal but the journey now is a bit more like any individual who might need a personal trainer to improve their fitness.
The UK has a network of private therapists who can provide support and a growing number of specialist rehabilitation facilities who can provide the equipment and guidance to train persons with an SCI. Whilst these are private facilities, and can be expensive to attend, sometimes charities can facilitate access.
Perhaps the ideal for many is be able to learn necessary and sufficient exercises and attend accessible gyms to maintain and enhance their fitness. Exercise is medicine and all individuals that want to have a long healthspan need to take regular exercise "doses".
Injuries Caused by Negligence
If the spinal cord injury was due to someone else’s negligence, the injured party may be able to claim compensation and get practical help with rehabilitation to aid recovery. If this is the case, it is advisable to get early advice from a personal injury lawyer who is experienced in working with spinal cord injury.
In the UK, the Association of Personal Injury Lawyers (APIL) publishes a directory of providers and its ‘Best Practice Guide on Rehabilitation’, which are both good sources of information. The latter is aimed at professionals but can be generally useful.
It’s important to get advice early. As we have seen, starting rehabilitation as soon as possible often leads to the best outcomes.
In catastrophic-injury cases, a medical expert report will likely be commissioned to cover all aspects of care such as the need for therapy, housing, psychology, employment, specialist equipment and more. A case manager, who tends to have a background as a nurse, therapist or other clinical specialist, acts on behalf of the injured person to coordinate and establish the person’s needs in a broad sense. A good case manager will have a range of relevant connections and knowledge to help coordinate the whole rehabilitation process, so they are a great resource.
In my experience, people who have suffered a spinal cord injury due to someone else’s negligence really benefit from the skills personal injury lawyers can bring. Experience counts in this domain, so seek one with specialist knowledge who will then be able to draw on a wealth of practical experience. While monetary compensation would be a real help, the guidance and sense of normality that a good legal team can bring is of equal value.
The Road to Recovery
The journey to recovery for spinal cord injured patients can be challenging and complicated. However, with the right rehabilitation program and a dedicated team of healthcare professionals, significant progress can be achieved. Rehabilitation doesn't only improve physical function but also enhances psychological well-being, allowing individuals with SCI to regain their autonomy and pursue a fulfilling life.
Conclusion
Rehabilitation for spinal cord injury plays a pivotal role in the comprehensive treatment journey. By embracing a multidisciplinary approach that incorporates a wide range of therapies and services, patients are empowered to make significant strides in functional improvements, allowing them to regain a sense of hope, independence, and purpose. With ongoing research and cutting-edge advancements in the field of rehabilitation medicine, the future holds tremendous promise for optimizing the recovery outcomes of individuals with spinal cord injuries, ultimately enhancing their overall quality of life and fostering a brighter tomorrow.
References
Association of Personal Injury Lawyers (APIL), www.apil.org.uk
Silver, JR (2003) History of the Treatment of Spinal Injuries. Springer Science
Wade, DT (2009) ‘Goal setting in rehabilitation: An overview of what, who and how’, Clinical Rehabilitation 23 (4), pp291–5, https://doi. org/10.1177/0269215509103551
Jones, D (2022) 'Don't Back Down. Your Guide to Living Well with a Spinal Cord Injury' Rethink Press (www.rethinkpress.com)
https://www.amazon.co.uk/Dont-Back-Down-living-spinal-ebook/dp/B0BNP1XGZ2