**6. Pulmonary rehabilitation**

Pulmonary rehabilitation is critical in the acute and chronic phases of SCI, particularly in patients with high-level injuries because there are respiratory muscle paralysis limiting thoracic expansion, low pulmonary volumes, and weak cough [52]. Previously mentioned issues cause hypoventilation, mucus plugs, surfactant decrease, pneumonia, atelectasis, or respiratory failure that may result in death if not properly cared [53].

Additionally, due to respiratory mechanics compromise, certain voice characteristics are affected such as less syllable production per breathing, less volume, and more roughness [54].

The next section discusses the strategies to improve pulmonary function: (1) postural changes and early mobilization; (2) breathing techniques, spontaneous cough, and cough aid; (3) secretion management and respiratory muscle training [19, 34, 53]; and (4) pulmonary percussion and vibration therapy [26].

#### **7. Neurofacilitation techniques**

Neurofacilitation techniques are frequently used in patients who suffered a stroke but these can also be applied to patients with SCI. It consists of a group of techniques whose main objectives are functionality recovering through noninvasive neuropsychological stimulation, promoting nerve regeneration, and neural systems reorganization [55]. Some of these techniques are mentioned below.

#### **7.1 Constraint-induced movement therapy**

It is useful for upper limb rehabilitation. It consists of repeatedly training the limb mobility; meanwhile the contralateral limb is immobilized. However, there has to be some mobility remaining to be applied [55].

#### **7.2 Body weight-supported treadmill training**

This is a functional movement training in which the patient stands over a treadmill with a harness, aided by therapists to move the legs and keep balance. It can be beneficial since it is an aerobic exercise [55].

#### **7.3 Bobath method**

Bobath method consists of a group of complex, specific, and individualized techniques based on postural control and task execution, taking advantage of neuromuscular plasticity to achieve problem-solving in people with movement disorders. It is possible to control posture, reduce spasticity, increase muscle tone, and improve standing ability through this method [56, 57].

#### **8. Neurogenic bladder**

Up to 80% of patients with SCI suffer neurogenic bladder as a result of detrusor hyperactivity disorder, sphincter dyssynergia, or detrusor areflexia; they have an

#### *Rehabilitation Therapies in Spinal Cord Injury Patients DOI: http://dx.doi.org/10.5772/intechopen.92825*

increased risk of urinary incontinence, recurrent infections, vesicoureteral reflux, and renal and bladder lithiasis [58].

Most of the patients will need management for dry, incomplete voiding, to ensure the low-pressure reservoir function of the bladder. This management begins with anticholinergic medication and intermittent catheterization; patients who failed these treatments need more invasive treatments such as sphincterotomy, botulinum toxin applications, and stent insertion [59].

Imaging and urodynamic studies should be performed for the initial evaluation of the patient [60]. Catheterization techniques are detailed below.

#### **8.1 Clean intermittent catheterization**

This is the most used method for bladder drainage without the need for a permanent catheter. A catheter is inserted in an interval of 4–6 h. It prevents complications such as hydronephrosis and kidney and bladder stones. It must be done by patients who have enough manual ability (writing and feeding) or a caregiver willing to do it [60].

#### **8.2 Permanent catheterizations**

It consists of the insertion of a suprapubic or urethral catheter. This catheterization is suggested for patients with poor manual ability, cognitive deficits, and limited assistance [60].

#### **8.3 Credé method**

It is the application of suprapubic pressure for drainage of the bladder. It is used when the bladder is flaccid or when it is necessary to increase the contraction; the Valsalva method is also used to drain the bladder [60].

#### **8.4 Surgery**

Transurethral sphincterotomy, stent colocation, or ileocystoplasty can be done.

## **9. Neurogenic bowel**

Neurogenic bowel dysfunction occurs 95% of the time as constipation and 75% as fecal incontinence. Hemorrhoids, abdominal pain, prolapse, rectal bleeding, and anal fissures also occur and can trigger episodes of autonomic dysreflexia.

The management of this dysfunction requires a history of bowel habits in addition to a complete physical examination [61]. It is recommended to establish a schedule to defecate in a comfortable position, implementing changes in diet and lifestyle before using laxatives or suppositories. The caregiver must perform an examination or digital stimulation; manual removal of feces is also preferable [60, 61]. Enemas are another treatment [62].

### **10. Sexual rehabilitation**

After SCI, sexual function is affected since it alters the motor, sensory, and autonomous functionality, and its importance relies in the fact that the number of patients with SCI is young in a childbearing age. There is damage to male fertility, vaginal lubrication, erection, and ejaculation [63].

The causes of sexual dysfunction are multifactorial: altered sensitivity, erectile dysfunction, and side effects of medical therapy.

In men with SCI, some dysfunctions can present as a delayed orgasm, erectile or ejaculatory disorder, seminal abnormalities such as hypomotility, or low sperm viability [64].

#### **10.1 Male sexual quotient (MSQ )**

It is a questionnaire designed to assess the sexual function and satisfaction in men. This instrument includes 10 questions where physical and emotional aspects are considered; scores go from 0 to 100 points [65].

#### **10.2 Medical management for erectile dysfunction**

Administration of phosphodiesterase-5 inhibitors is helpful in inhibition of guanosine monophosphate degradation causing smooth muscle relaxation. Other methods are intracavernous application of phentolamine, papaverine, and alprostadil or intraurethral application of alprostadil [64].

#### **10.3 Management for ejaculatory dysfunction**

Vibratory stimulation can be done until antegrade ejaculation is achieved. Another method is electroejaculation, which electrically stimulates prostatic nerves and muscles and seminal vesicles; if retrograde ejaculation occurs, a catheter is needed to collect residual semen from the bladder [64].

In women, sexual function after SCI has not been sufficiently studied as in male dysfunction. Sexual rehabilitation in women focuses on psychological matters and sphincter control during sexual activities. In addition, vaginal lubrication depends on neurological factors and vascular factors [66, 67].

#### **11. Skin care**

SCI causes an alteration in the microenvironment of the skin, causing excessive sweating, thinning, onychogryphosis, paronychia, tinea, seborrheic dermatitis, and cellulitis [68, 69]; besides, keeping the same position for a long time damages the integrity causing pressure ulcers [70].

Pressure ulcers are the result of applying pressure to tissue over a bone prominence, exceeding the 12–32 mmHg capillary pressure collapsing the capillaries and causing ischemia. Pressure ulcers represent a major problem for patients with SCI in the acute and chronic stages, also considering the cost involved in treatment [71]. For correct management, pressure must be decreased, and special mattresses, heel protectors, and turns and transfers are recommended. Regarding turns, these must be done in intervals of 2–4 h. Lateral positioning should be limited to minimize pressure on bony prominences. When the patient is in supine position, the bed must incline less than 30° or the limbs must be elevated. Patients using a wheelchair should be trained to distribute pressure by tilting at intervals of 15–30 min [62].

#### **12. Nutritional support**

Since life expectancy in patients with SCI has been prolonged, the incidence of metabolic syndrome, diabetes, cardiovascular diseases, but also malnutrition has increased substantially; therefore, it is important to make a nutritional plan.

There are no nutritional guidelines for patients with SCI; however, the following general measures are suggested:


Nutritional plans must be individualized according to the objectives, the age of the patient, and the level of the injury [72, 73].
