“Spinal cord paralysis is not the end of life, it is the beginning of a new life” – Sir Ludwig Guttmann
Every year, around the world, between 250 000 and 500 000 people suffer a spinal cord injury (SCI). The majority of spinal cord injuries are due to preventable causes such as road traffic accidents, falls or violence. People with a spinal cord injury are 2 to 5 times more likely to die prematurely than people without a spinal cord injury, with worse survival rates in low- and middle-income countries. Males are most at risk in young adulthood (20-29 years) and older age (70+). Females are most at risk in adolescence (15-19) and older age (60+). Studies report male-to-female ratios of at least 2:1 among adults, sometimes much higher. Mortality risk is highest in the first year after injury, increases with injury level and severity and is strongly influenced by availability of timely, quality medical care. Transfer method to hospital after injury and time to hospital admission are important factors. Preventable secondary conditions (e.g. infections from untreated pressure ulcers) are no longer among the leading causes of death of people with spinal cord injury in high-income countries, but these conditions remain the main causes of death of people with spinal cord injury in low-income countries.
Effective spinal cord rehabilitation is best delivered in specialised spinal cord injury rehabilitation units, wherever possible. Such specialised units obviously allow for skilled and experienced staff to work together in delivering an optimal rehabilitation programme, but in addition to this, patients and families are able to share the rehab experience with other people on the same journey as themselves. This can afford an invaluable platform of emotional support, motivation and encouragement on the path to recovery.
A common approach to rehabilitation in inpatient SCI rehabilitation units is the interdisciplinary team. In this approach, various professionals (doctors, nurses, physiotherapists, occupational therapists, social workers, psychologists, dieticians etc) assess and treat the patient separately with discipline specific goals, but also share assessments and common overall goals. The goals of each discipline are coordinated into a unified plan. The patient and family are considered part of this planning group and have a central role in the team’s considerations.
Communication between the role players is optimised by regular meetings, including goal setting meetings, team meetings and family meetings.
While the primary goal of rehabilitation is to restore maximal function, the attainment of this goal necessitates the successful management of a number of issues which, left unattended, could result in long term complications. Failure to manage these potential complications could not only ultimately lead to a loss or reversal of the desired function, but could have far reaching consequences including sustained length of hospital stay, further hospitalisations after discharge and even death. A comprehensive rehabilitation programme aims to prevent these long term complications, through the successful management of the following (non-exhaustive) risks prevalent in patients suffering from acute spinal cord injury:
• Spasticity and associated abnormalities of tone
• Pressure sores
• Respiratory complications
• Cardiovascular complications such as venous thromboembolism, orthostatic hypotension, neurogenic shock
• Musculoskeletal complications such pain, deformities, contractures, osteoporosis, fractures, heterotopic ossification
• Bladder and bowel dysfunction and infections
Autonomic dysfunction such as Autonomic Dysreflexia (AD), a life-threatening medical emergency which occurs as a consequence of uncontrolled sympathetic activity in patients with SCI at or above T5
Rehabilitation teams ensure that the progress of the patient is measured using standardised outcomes measures, of which the FIM (Functional Independence Measure) is the most widely recognised, by rehabilitation professionals as well as funders and other stakeholders.
The acute spinal cord rehabilitation service is only the first step in the individual’s recovery process. It affords patients and families their first opportunity to make some sort of sense out of their newly disordered worlds, within a secure and supportive environment. The rehabilitation process equips patients and their families with the basic physical, functional and emotional skills that will form the foundation on which they will be able to rebuild their lives after discharge. Rehabilitation aims to provide a solid framework on which patients will be able to forge a number of new abilities which will be refined and developed over time. Referral to outpatient therapists, community support services and ongoing medical support functions is imperative if a rehabilitation programme is not to flounder once a patient is discharged from the acute inpatient environment. Rehabilitation should thus be viewed as a progressive and continuously evolving process, with numerous players, but none more important than the patient himself.
Walking Therapy Using the Lokomat®
The Lokomat® is an electromechanical-assisted device for gait training. It comprises of an exoskeleton which facilitates the movement of the hips and knees during the phases of walking and can be used with or without body weight support. The patient is supported in a harness over a treadmill and the frame (exoskeleton) of the robot, attached by straps to the outside of the patient’s legs, then facilitates the legs in a natural walking pattern. A computer controls the pace of walking and is able to measure the body’s response to the movement.
Task Specific Training has repeatedly been shown to be associated with improvements in walking distance and speed as well as enhanced sit-to-stand transfer ability. Trying to facilitate walking in disabled patients can be extremely labour-intensive and strenuous for therapists, which ultimately limits the frequency and duration of the therapy aimed at improving gait task-specific training. The use of the robotic exoskeleton of the Lokomat®, with the option of utilising the unweighing system, makes gait rehabilitation more efficient and sustainable over a longer period of time and may encourage better gait rehabilitation outcomes.
It is believed that the Lokomat® may have many other benefits, including:
- Strengthening of innervated muscles
- Improved circulation
- Reduced risk of osteoporosis (weight bearing exercise is known to increase bone mass and density
- Reduced spasticity
- Increased range of movement in joints
- Improved proprioception (sense and awareness of the position in space of your body)
- Increased patient engagement through the emotive component of being able to stand and “walk”