Innovative treatments for incomplete tetraplegia
One of the most devastating conditions resulting in long-term impairment is a spinal cord injury (SCI) with significant neurological deficits. Over the past three decades, incomplete spinal cord injuries have increased dramatically, accounting for 50% of all injuries in 1991 to 66% in 2016, according to the National SCI Database.
Studies have also shown that a therapeutic focus on regaining function can be more effective for these patients than teaching compensatory movement patterns for the extremities and trunk – including therapeutic techniques that stimulate neuroplasticity, commonly used in rehabilitation for hemiplegia after CVA.
A specialized inpatient rehabilitation program that includes such innovative therapies to promote normal functional recovery can increase the likelihood of discharge to home rather than to a long-term care or nursing facility.
The interdisciplinary inpatient SCI team at Kessler Institute for Rehabilitation in West Orange, N.J., one of 14 centers in the United States to receive federal designation as a model system for spinal cord injury treatment and research, provides a variety of interventions to facilitate neurorecovery.
Developing a Plan of Care
Upon admission to Kessler Institute, a patient who has sustained an SCI is evaluated by a physiatrist and other members of the interdisciplinary team, including occupational and physical therapists, all of whom are trained specifically in the treatment of SCI.
Based on this initial evaluation, an integrated plan of care with short- and long-term goals is developed and subsequently updated as warranted at weekly team meetings. The patient will also interact with other team members including a case manager, respiratory therapist, recreation therapist, dietician, psychologist or neuropsychologist, art therapist, music therapist, driver rehabilitation specialist and vocational counselor. Working together with these healthcare professionals, the primary OT and PT guide the patient to become as functionally independent as possible and facilitate a safe discharge to home.
Patients with incomplete tetraplegia can gain functional independence through rehabilitation techniques that foster normal movements of the upper and lower extremities rather than compensatory patterns. These patients experience a degree of motor and sensory return below the level of injury and can better accomplish activities of daily living with less adaptive equipment.
With conditions such as central cord syndrome, with greater impairment of the upper extremities, and Brown-Sequard Syndrome, in which one side of body is more impaired than the other, the interdisciplinary team must provide innovative treatment to achieve varying amounts of sensory and motor return.
Keeping patients “ready for recovery” also includes preventing contractures of the extremities, core stability training and educating the patient on the progression of functional return. For this population in particular, the OT and PT must collaborate to balance upper-extremity, trunk and lower-extremity facilitation. For example, a patient may perform closed-chain exercises for the shoulder while weight-bearing on elbows in a standing rather than seated position.
Upper-Extremity Function and Self-Care
The occupational therapist treating a patient with SCI will typically set these long-term goals regarding upper-extremity function: The patient will complete self-feeding, dressing and grooming with the use of adaptive equipment, as well as accessing a cell phone and computer with the use of assistive technologies.
It’s important to note that the patient with an incomplete cervical injury has an improved chance to achieve modified independence for these goals with less adaptive equipment than a patient with a complete injury with little or no motor return below the injury level.
The patient can participate in bedside morning sessions with an OT to learn basic care strategies for dressing, bathing, grooming and feeding with adaptive equipment as needed.
The OT may also request that lead-ups and components of these activities are also applied during PT sessions in the gym. In addition, the OT and PT communicate regarding appropriate assistive device use for ambulation, along with strategies to preserve the upper extremity with all functional activities including wheelchair propulsion and transfers.
For the patient with emerging upper-extremity function, the occupational and physical therapists can work individually and also refer the individual to Kessler’s Arm-Hand Program.
With both treatment options, the focus is on core stability and alignment, upper-extremity strengthening and both gross- and fine-motor retraining to improve coordination and control.
For example, a patient with limited arm strength may initially feed himself with a balanced forearm orthosis and universal cuff to hold the utensil. He may progress to feeding without these devices as the OT helps retrain the muscles to produce functional grasp as well as the necessary shoulder and elbow muscle patterns.
To further enhance his abilities, a patient may participate in a lunch group to practice with trialed equipment or participate in repetitive task exercises.
Lower-Extremity Function and Gait
For patients with a complete cervical injury, the long-term goal for upright tolerance and standing typically incorporates a tilt table or standing frame only.
However, for a patient with incomplete tetraplegia, the physical therapist may establish long-term goals that address lower-extremity function and gait: The patient will ambulate household or community distances – as well as negotiate stairs, ramps and curbs – with appropriate assistive device(s) and/or lower-extremity bracing as needed.
This patient with neurological recovery may receive therapeutic interventions from his PT and OT to facilitate core stability and pre-gait activities to address lower-extremity weight-bearing with a progression to standing in parallel bars or a platform walker.
To promote functional movement patterns, neuromuscular electrical stimulation can be applied to the legs in the form of specific muscle strengthening/orthotic substitution devices and a lower-extremity cycling system. Early gait training trials may incorporate bodyweight-supported treadmill training and over-ground training in a harness system as well.
As the patient’s lower-extremity control improves, he may progress to gait training with an assistive device or lower-extremity bracing. The physical therapist, with consideration of preservation of the upper extremities, will choose the most appropriate ambulation device to promote weight-bearing, symmetry and a more normal gait pattern.
If the patient achieves a degree of household or community ambulation using the trial lower-extremity bracing, he may be referred to Kessler’s brace clinic to be fitted for the proper knee-ankle-foot orthosis or ankle-foot-orthosis.
A patient with Brown-Sequard Syndrome, for example, may initially require a rolling walker with a platform for the weaker upper extremity and a long leg brace for household ambulation, and then progress to a straight cane and an orthosis to prevent foot drop for community ambulation.
Preparing for Discharge to Home
Patient and family education is an integral part of the rehabilitation process to meet the goal of a successful discharge to home. In the weeks leading up to discharge, the therapeutic focus is on training the patient and his family and caregivers to perform functional activities with the prescribed equipment.
Returning to work or school is also considered, and site visits or simulation of those environments can help address any accessibility issues and ease the transition. Especially for patients with incomplete tetraplegia, a home exercise program is critical in helping reinforce emerging function and promotes further neuromuscular return in the upper and lower extremities.
Patients, depending on their discharge destination, are also encouraged to build on the gains they have made by participating in Kessler’s specialized outpatient spinal cord injury programs, which are designed to ensure the continuity of care.
A medically complex patient who has sustained an SCI with neurological deficits requires an extensive, intensive and individualized course of acute rehabilitation to regain function and quality of life. Because incomplete cervical injuries are increasingly prevalent, the focus on regaining function and keeping patients “ready for recovery” is more essential and effective than teaching compensatory movement patterns.
As we have seen, long-term functional goals for these patients are best achieved when the occupational and physical therapists working as part of interdisciplinary team collaborate to provide complementary treatment interventions.
At Kessler Institute for Rehabilitation, the inpatient SCI program combines this strong interdisciplinary approach with innovative treatment, as well as patient and family education and training to maximize functional outcomes.