Rehabilitation Therapies in Spinal Cord Injury Patients

*Brenda Rodríguez-Mendoza, Paola A. Santiago-Tovar, Marco A. Guerrero-Godinez and Elisa García-Vences*

## **Abstract**

Spinal cord injury (SCI) represents a neurological life-changing condition that causes devastating physical, social, psychological, and economic consequences in the injured patient. It is due to traumatic causes that affect the motor and sensory functions, limiting daily life activities. Since rehabilitation is a fundamental process of recovery, this chapter will review diverse approaches in rehabilitation to restore or improve patients' capability. In the first section, functionality and quality of life tools will be discussed. Subsequently, rehabilitation strategies and their adoption will be explained. Ultimately, rehabilitation goals, according to the level of injury, will be reviewed.

**Keywords:** spinal cord injury, rehabilitation, exoskeleton, functional electrical stimulation, rehabilitation goals

## **1. Introduction**

Spinal cord injury (SCI) is attributable to trauma caused by accidents like car crashes, falls or sports such as diving or gymnastics, and violent causes like gunshots or injuries by cold weapon [1] and also caused by nontraumatic causes like primary or metastatic tumors, compressive myelopathy such as cervical spondylotic myelopathy, neurodegenerative diseases such as motor neuron disease, autoimmune diseases like multiple sclerosis, infections such as epidural abscess, and vascular diseases such as medullary infarction, as well as genetic causes, for example, spinal muscular atrophy [2] that affect spinal cord motor and sensory function, also causing neurogenic bladder or bowel.

The global prevalence rate, including both traumatic and nontraumatic causes, is 40–80 cases per million people; however 90% of cases are due to traumatic causes, with a male-to-female ratio of 2:1, respectively [3], presenting with a bimodal age peak of young people and 60-year-old people [4]. To estimate the economic burden, the first year after injury treatment cost is estimated to be \$334,170 USD rising to \$1,023,924 USD [5]. The main causes of SCI are vehicle accidents, falls, violence [6], compressive myelopathy, tumors, and multiple sclerosis [2]. Most damaged anatomical regions are the lower cervical spine, cervicothoracic union, and thoraciclumbar union [6]. Prognosis depends on the level of injury [4].

To the present day, there are no medical or surgical procedures to reverse neurological damage in SCI patients; therefore new rehabilitation strategies have been designed to avoid deterioration in many patient scopes. This process has to be coordinated by a multidisciplinary SCI expert team so that biopsychosocial impact on patients is reduced.

## **2. Evaluation and assessment tools in rehabilitation**

There are several tools to assess the patient with SCI; some of them are the following, ASIA scale, Spinal Cord Independence Measure (SCIM) scale, Walking Index for Spinal Cord Injury II (WISCI II) scale, and Short-Form Health Survey (SF-36) quality of life test, which will be discussed in detail below. These are very useful instruments that ease decision-making on treatment and rehabilitation, taking into consideration patient capacity and expectations to integrate into society.

#### **2.1 ASIA scale**

This scale developed by the American Spinal Injury Association is considered the gold standard for SCI clinical evaluation. The scale significance relies on its capacity to determine the level of injury, whether it is a complete or incomplete injury, predict prognosis, and serve as guidance for treatment.

It consists of the examination of dermatomes and myotomes. For evaluation of sensory function, 28 key dermatomes are explored using a piece of cotton and a monofilament. For motor examination, five upper and five lower key muscle groups are evaluated. S4 and S5 dermatome evaluation is useful to determine if the injury is complete or incomplete by looking for external anal sphincter contraction and anal pressure sense.

Patients are classified from A, which means an injury is complete, to E, where patients have normal functionality (**Table 1**). This tool provides a long-term reliable prognosis, but it does not take into account pain and spasticity [7, 8].

According to this scale, an accurate prognosis can be established if a 72-h post-injury evaluation is made. 80% of patients with an A-type injury will remain in this classification; meanwhile, 10% will convert into a B-type injury and the 10% remaining will convert into a C-type injury; from the conversion percentage, only 14% of the patients will gain some aided gait capacity. Patients with B-type injury are considered to gain 33% of gait capacity, C-type injury patients will gain approximately 75% of gait capacity, and D-type injury patients will have a very good prognosis since most of them will be able to walk in 1-year post-injury [9, 10].

#### **2.2 SCIM scale**

The Spinal Cord Independence Measure is a tool that assesses an SCI patient capacity to perform daily life activities. This instrument evaluates 19 areas and contains 4 subscales: self-caring (0–20 points), breathing and sphincter control (0–40 points), room and bathroom mobility (0–10 points), and interior and exterior mobility (0–30 points). Besides these subscales, feeding, bed mobility, pressure ulcer prevention, and transfer from wheelchair to the car and floor are included [11].

The maximum score to obtain is 100 points; a high score means that the patient is independent for daily life activities. This is a self-assessment tool, so there is no need for qualified personnel to evaluate it [12].

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


**Table 1.** *ASIA scale.*
