Therapeutic Interventions for Spinal Cord Injury
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- 1 Introduction
- 2 Spasticity & Contracture Management
- 3 Mobility
- 4 Upper Limb Management
- 5 Robotics
- 6 Physical Activity & Exercise
- 7 Respiratory Management
- 8 Pain Management
- 9 Electrotherapy
- 10 References
Spinal cord injury has a significant impact on quality of life, life expectancy and economic burden, with considerable costs associated with primary care and loss of income. While the most obvious consequence of spinal cord injury is paralysis, there are much wider consequences for many body functions including bladder, bowel, respiratory, cardiovascular and sexual function as well as social, financial and psychological implications. 
Individuals with quadriplegia rank recovery of arm and hand function as a priority, while individuals with paraplegia rate recovery of sexual function as most important, when measured against recovery of bladder/bowel function, eradicating autonomic dysreflexia, improving gait and trunk stability, regaining normal sensation and eliminating chronic pain. 
A wide range of therapeutic interventions addressing these and other important priorities such as recovery of cardiovascular performance, muscular properties, and reducing spasticity are utilised in spinal cord injury Rehabilitation. Physiotherapists treat an array of different problems related to spinal cord injury and these involve many body systems, even though the underlying pathology is neurological in nature. This section provides a brief overview of some of the therapeutic approaches and the principles of physiotherapy rehabilitation for individuals with a spinal cord injury and the evidence underpinning the effectiveness of commonly used physiotherapy interventions. 
Spasticity & Contracture Management
Patients should be given individualised positioning and early mobilisation management plans as soon as possible after a neurological impairment to prevent complications and to regain function. It is based on reducing the effects of gravity on alpha motor neuron and consequently inhibiting muscle tone. Relaxation achieved by this technique is not permanent and unless motor learning or central program adaptation is actualised it is reversible. Hence, modifications in a number of systems are required for this treatment to be effective. The effects of muscle tone on autogenic inhibition, reciprocal innervation, labyrinthic or somatosensory effects and cerebellar regulation can be affected. It should be kept in mind that active participation of the patient is required for the changes in the CNS to occur and motor learning to take place. Positioning is used widely to prevent the development of contracture and to discourage unwanted reflex activity. After a spinal cord injury, muscles can be affected in various ways, causing pain, spasticity, and problems with speed and range of motion. One way to minimise these effects is to properly support, position, and align the body. Proper positioning can be useful to minimise or prevent pain and stiffness that are commonly present post-impairmnet. It can also regain movement that was lost, or limit future problems with movement. In addition, proper positioning has been shown to increase awareness and protection of the weaker side of the body.
The presence of increased tone can ultimately lead to joint contracture and changes in muscle length. When we look at the use of stretch to normalise tone and maintain soft tissue length we employ a slow, prolonged stretch to maintain or prevent loss of range of motion. While the effects are not entirely clear the prolonged stretch produces inhibition of muscle responses which may help in reducing hypertonus, e.g. Bobath's Neuro Developmental Technique, Inhibitory Splinting and Casting Technique. It appears to have an influence on both the neural compnents of muscle, via the Golgi Tendon Organs and Muscle Spindles, and the structural components in the long term, via the number and length of sarcomeres.
- Muscle Immobilised Short Position = Loss of Sacromeres and Increased Stiffness related to increase in connective tissue
- Muscle Immobilised in Lengthened Position = Increase Sacromeres
Studies in mice show that a stretch of 30 mins daily will prevent the loss of sacromeres in the connective tissue of an immobilised muscle, although the timescale in humans may not relate directly. Stretching may be achieved through a number of methods which include;
Prolonged manual stretch may be applied manually, using the effect of body weight and gravity or mechanically, using machine or splints. Stretch should provide sufficient force to overcome hypertonicity and passively lengthen the muscle. Unlikely to provide sufficient stretch to cause change in a joint that already has contracture.
Weight bearing has been reported to reduce contracture in the lower limb through use of Tilt-tables, and standing frames through a prolonger stretch. Angles are key to ensure the knees remain extend during the prolonged stretch as the force exerted on the knee can be quite high. Some research also challenges the assumption of the benefits of prolonged standing.
Splints and casts are external devices “Splints and casts are external devices designed to apply, distribute or remove forces to or from the body in a controlled manner to perform one or both basic functions of control of body motion and alteration or prevention in the shape of body tissue.”Splinting can be used to produce low-force, long duration stretching although there is a dearth of evidence to support this. A wide range of splint have been used to influence swelling ,resting posture, spasticity, active and passive ROM.
Serial casting is a common technique that is used and most effective in managing spasticity related contracture. Serial casting is a specialised technique to provide increased range of joint motion. The process involves a joint or joints that are tight which are immobilised with a semi-rigid, well-padded cast. Serial casting involves repeated applications of casts, typically every one to two weeks as range of motion is restored. The duration of stretch to reduce both spasticity and to prevent contracture are not yet clear from the research and require further research to determine the most appropriate technique and duration to produce the required effect.
Muscle vibration has been used as a technique to reduce muscle tone and spasticity in individuals with neurological conditions. Vibrations of the muscle are thought to increase corticospinal excitability as well as inhibitory neuronal activity in the antagonistic muscle. Three motor effects achieved through muscle vibration have been identified;
- Sustained contraction of the vibrated muscle via tonic vibration reflex
- Depression of the othor neurones innervating the antagonistic muscles via reciprocal inhibition or antagonistic inhibition
- Suppression of the monosynaptic stretch reflexes of the vibrated muscle while being vibrated.
Questions still remain as to whether vibration has any sustained effect on the muscle. Muscle Vibration is generally applied to directly to the chosen muscle or tendon and may be applied in two ways;
The high frequency vibration is driven from a vibrator that optimally operates at a frequency of 100 - 200 Hz and at amplitude of 1 – 2 mA. This type of vibration produce facilitation of muscle contraction through what is known as tonic vibration reflex. This facilitatory effect sustained for a brief time after application. Therefore it can be used for stimulating muscles whose primary function is one of tonic holding.
The low frequency stimulation occurring between 5 -50 Hz has an inhibitory effect on muscle through its activation of spindle secondary endings and golgi tendon organs.
While Vibration has the potential as a good treatment technique there is still limited evidence on its effectiveness the therapist must be aware of the precautions that must be considered when using it as a treatment option including heat generation at the point of application that has the potential for skin damage, particularly at high amplitude. Further studies are needed in the future well-designed trials with bigger sample size to determine the most effective frequency, amplitude and duration of vibration application in the neurorehabilitation.
- Murillo N et al (2014). Focal vibration in neurorehabilitation. Eur J Phys Rehabil Med. Apr;50(2):231-42.
The ability to walk independently is a prerequisite for most daily activities. The capacity to walk in a community setting requires the ability to walk at speeds that enable an individual to cross the street in the time allotted by pedestrian lights, to step on and off a moving walkway, in and out of automatic doors, walk around furniture, under and over objects and negotiate kerbs. A walking velocity of 1.1 - 1.5 m/s is considered to be fast enough to function as a pedestrian in different environmental and social contexts. The major requirements for successful walking include; 
- Support of body mass by lower limbs
- Propulsion of the body in the intended direction
- The production of a basic locomotor rhythm
- Dynamic balance control of the moving body
- Flexibility, i.e. the ability to adapt the movement to changing environmental demands and goals.
Walking dysfunction is common in individuals with an incomplete spinal cord injury, arising not only from the impairments associated with the spinal cord lesion but also from secondary cardiovascular and musculoskeletal consequences of disuse and physical inactivity. Muscle weakness and paralysis, poor motor control and soft tissue contracture are major contributors to walking dysfunction post spinal cord injury.
The incentive to provide a challenging environment, in which there is an opportunity to practise repetitively the missing components of gait, has underpinned another task-specific activity. This involves using a treadmill for gait re-training and also for improvements in cardiovascular function. A harness can be used for individuals with significant functional limitations, and this also offers the opportunity to grade the amount of body weight support provided. Therapists help to facilitate alternating stepping and weight-bearing, and as many as three therapists may be required to assist with the complete gait cycle. It has been suggested that treadmill training can support Gait Re-education as it allows a complete practice of the full gait cycle, with opportunity for improvements in speed and endurance, which optimises cardiovascular fitness.
Task-specific training on a treadmill has also been shown to induce expansion of subcortical and cortical locomotion areas in individuals following stroke and spinal cord injury. It can result in an increase in cadence and a shortening of step length as compared to overground walking.
Upper Limb Management
Key muscles are innervated at each level of spinal cord injury and it is these muscles that determine the optimal level of upper limb function that individuals with a complete spinal cord injury can achieve.
|Level of Lesion||Upper Limb Function|
|C4 Tetraplegia||No Upper Limb Function|
|C5 Tetraplegia||Perform Simple Hand to Mouth Activities|
|C6 Tetraplegia||Tendonesis Grip|
|C7 Tetraplegia||Tendonesis Grip|
|C8 Tetraplegia||Active Grasp and Release|
Understanding the way individuals with tetraplegia use their upper limbs and hands functionally is essential for effective management which includes:
- prevention and treatment of contracture
- prevention and treatment of musculoskeletal pain
- management of the shoulder
- improving strength and skill
- promoting and preserving a tenodesis grip when appropriate
- management of hand swelling
- awareness of potential for tendon transfers or electrical stimulation
Over the past decade robotics technologies are more commonly incorporated into the daily treatment schedule of many individuals post spinal cord injury. These interventions hold greater promise than simply replicating traditional therapy, because they allow therapists an unprecedented ability to specify and monitor movement features such as speed, direction, amplitude, and joint coordination patterns and to introduce controlled perturbations into therapy.
Rehabilitation robotics is a field of research dedicated to understanding and augmenting rehabilitation through the application of robotic devices. Rehabilitation robotics includes development of robotic devices tailored for assisting different sensorimotor functions (e.g. arm, hand, leg, ankle, development of different schemes of assisting therapeutic training, and assessment of sensorimotor performance). Rehabilitation using robotics is generally well tolerated, and has been found to be an effective adjunct to therapy in individuals with motor impairments as a result of a spinal cord injury.
Robotic devices provide safe, intensive and task oriented rehabilitation allowing;
- precisely controllable assistance or resistance during movements
- objective and quantifiable measures of subject performance
- good repeatability
- increased training motivation through the use of interactive biofeedback
Physical Activity & Exercise
Strength training is generally defined as training where the resistance against which a muscle generates force is progressively increased over time.  The maximal weight or resistance a person can lift or move to complete the movement is defined as One Repetition Maximum (1 RM). Prescriptions of repetitions vary depending on prior experience of strength training and co-morbidities. Progressive resistance training is the most common form of strength training. It is thought to be most effective when it incorporates resistance, is appropriately progressed based on etc individuals capacity and the mode of training is similar to the task in which strength gains are required
It is more challenging to apply the principles of progressive resistance training to partially paralysed muscles because it is difficult to apply resistance when a muscle is unable to move through full range against gravity, which is a greater problem for weak and very weak muscles more than it is for muscles that are closer to normal strength. When partially paralysed muscles are strong enough to move through range against gravity the principles of progressive resistance training can be more easily followed. When partially paralysed muscles are not strong enough to move against gravity, training occurs in a gravity eliminated plane. Resistance can be added manually or by rotating the plane of movement away from the horizontal.
One example of an effective dosage of progressive resistance training is:
- 1 - 3 sets of 8 - 12 Repetitions with a rest of 1-3 minutes between sets
- A load corresponding to 8 - 12 Repetition Maximum (60-70% of 1RM)
- 2-3 times a week
Muscle hypertrophy and increased strength, along with the changes in body composition, the hormonal and nervous systems, have a positive impact on the daily activities of living and functional independence of the individuals with a spinal cord injury.
Modern electrotherapy practice needs to be evidence based and used appropriately. Used at the right place, at the right time for the right reason, it has phenomenal capacity to do good. Used unwisely, it will either do no good at all, or worse still, make matters worse. The skill of electrotherapy is to make the appropriate clinical decision as to which modality to use and when.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous Electrical Nerve Stimulation (TENS) is a method of electrical stimulation which primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the opioid system. The different methods of applying TENS relate to these different physiological mechanisms. The effectiveness of TENS varies with the clinical pain being treated, but research would suggest that when used ‘well’ it provides significantly greater pain relief than a placebo intervention. In the clinical context, it is most commonly assumed to refer to the use of electrical stimulation with the specific intention of providing symptomatic pain relief.
You can read more about Transcutaneous Electrical Nerve Stimulation (TENS) on Physiopedia.
Functional Electrical Stimulation
Functional Electrical Stimulation (FES), is an assistive technology that can be used to aid the recovery of muscle function post spinal cord injury. FES uses electrical pulses to stimulate motor neurons or denervated muscle fibers directly to elicit a contraction during a functional activity in weakened or paralysed limb.  FES has an extensive history for its treatment of orthopedic and neurological conditions.  It has been used since the mid 1960’s, traditionally to aid mobility through activation of tibialis anterior to help dorsiflex the foot throughout the gait cycle in individuals with foot drop and more recently it has been considered as a promising treatment modality for upper-limb recovery. 
Read more about the use Functional Electrical Stimulation Cycling for Spinal Cord Injury on Physiopedia.
Biofeedback is the technique of using equipment to reveal to human beings some of their internal physiological events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals.  The ultimate purpose is that the patient gets to know his own body signs and that he can control them consciously. In first place using biofeedback equipment, afterwards even without. 
Further, neuromuscular training or biofeedback therapy is an instrument-based learning process that is based on “operant conditioning” techniques. The governing principal is that any behaviour - be it a complex manoeuvre such as eating or a simple task such as muscle contraction-when reinforced its likelihood of being repeated and perfected increases several fold. 
You can read more about Biofeedback on Physiopedia.
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- Thuret S, Moon LD, Gage FH. Therapeutic Interventions after Spinal Cord Injury. Nature Reviews Neuroscience. 2006 Aug;7(8):628.
- Forssberg H (1982) Spinal locomotion functions and descending control. In Brain Stem Control of Spinal Mechanisms (eds B Sjolund, A Bjorklund), Elsevier Biomedical Press,New York.
- Liu C, Latham NK. Progressive Resistance Strength Training for Improving Physical Function in Older Adults (Cochrane Review). Cochrane Database Syst Rev 2009; (3): CD002759.
- Berkelmans R. FES Cycling. Journal of Automatic Control. 2008;18(2):73-6
- Martin R, Sadowsky C, Obst K, Meyer B, McDonald J. Functional Electrical Stimulation in Spinal Cord Injury: from Theory to Practice. Topics in Spinal Cord Injury Rehabilitation. 2012 Jan 1;18(1):28-33
- Basmajian J. (1989), Biofeedback: Principles and Practices for Clinicians, Williams and Wilkins (level 4)
- Biofeedback Vereniging Nederland (2012), What is biofeedback?, geraadpleegd op 1/05/2013, (level 4), http://www.biofeedbackvereniging.nl/index.html
- Satish S.C. Rao, DYSSYNERGIC DEFECATION and BIOFEEDBACK THERAPY, Gastroenterology Clinics of North America, Volume 37, Issue 3, Pages 569-586, September 2009 (level 2A)fckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575098/