Read Full Text: Type and Timing of Rehabilitation Following Acute and Subacute Spinal Cord Injury: A Systematic Review
Journal: Global Spine Journal
Year Published: 2017
Ranked 67th on our 2017-2021 list of the 100 Most Influential OT Journal Articles
CEU Podcast: OT for Spinal Cord Injury with Simon Carson
Our spinal cord injury clients leave their mark on our hearts and minds. We accompany them as they navigate tremendous life changes—and we are often the ones who address the most challenging questions about life post-injury.
This week’s article gives us a great big-picture review of what we know (and don’t know) about spinal cord injury rehab. You’ll learn about commonly used assessments, as well as which treatments are gaining traction (and which ones aren’t).
Most importantly, the article serves as a good reminder that there are simply no magical, easy answers in this type of rehab. Instead, these patients benefit most from your occupational therapy lens and your commitment to staying on top of evidence-based care.
Let’s dive in.
Introduction to SCI rehab
Spinal cord injury (SCI) can lead to profound motor, sensory, and autonomic impairments. In many ways, these patients’ outcomes are linked to the severity and level of their injuries.
It can feel somewhat demoralizing when things seem so predetermined. Yet, our understanding of neuro-recovery continues to grow, and this article does a great job of giving us the lay of the land.
The authors specifically mention the principles of motor control and activity-based neuroplasticity as how we understand the mechanisms of recovery post-SCI.
They also note that SCI rehab is divided into 3 phases:
1. The acute phase and 2.) The subacute phase
The acute and subacute phases span the first 12-18 months post-SCI. This is the time in which the natural course of recovery is expected to occur. Rehab during these phases focuses on:
- Preventing secondary complications
- Promoting and enhancing neuro-recovery
- Maximizing function
- Establishing optimal conditions for long-term maintenance of health and function
3.) The chronic phase
The chronic phase is when the natural course of neurorecovery has plateaued. Rehab in this phase focuses on:
- Compensatory and assistive approaches
Why was this systematic review completed?
The authors sought to understand the existing evidence behind specific rehab approaches.
Their intention was to inform clinical decision-making and highlight our current knowledge gaps.
4 main questions guided their research:
- Does the time between the injury and starting rehab affect outcomes?
- What is the comparative effectiveness of different rehab strategies?
- Are there specific patient/injury characteristics that affect outcomes?
- What is the cost-effectiveness of different SCI rehab strategies?
What were the authors’ methods?
The article is a systematic review of existing research. The authors sought studies published prior to April, 2015.
Studies were included if they were conducted with an adult population who received rehab for acute or subacute SCI, at any level or any degree of severity. Please see the article for exclusion criteria.
As part of the data extraction, risk of bias was assessed. The body of evidence was evaluated using the GRADE method.
What were the results?
19 publications were included in this review.
The outcome measures included the following relevant assessments:
Assessments for SCI
- American Spinal Cord Injury Association (ASIA) Impairment Scale
- Berg Balance Scale (BBS)
- Canadian Occupational Performance Measure (COPM)
- Functional Independence Measure (FIM)
- Mini Mental State Examination (MMSE)
- SCI Falls Concern Scale (SCI-FCS)
- Spinal Cord Independence Measure (SCIM)
Results for Questions #1 & #4
No studies were identified for the following questions:
- Does the time between the injury and starting rehab affect outcomes?
- What is the cost-effectiveness of different SCI rehab strategies?
Results for Question #2: What is the comparative effectiveness of different rehab strategies?
5 different studies looked at 3 specific interventions, comparing each one to conventional rehab.
Intervention 1: Body weight supported treadmill training (BWSTT)
Low-grade evidence found some specific range of motion improvements, but no functional differences were identified on the FIM, LEMS, distance walked in 6 min, or gait velocity.
Intervention 2: Functional electrical stimulation (FES) + OT
Low-grade evidence found some improvements over the conventional group in both FIM and SCIM scores.
Intervention 3: Additional time spent on unsupported sitting
No significant difference was found in across 4 outcome measures when more time was spent on unsupported seating.
Results for Question #3: Are there patient/injury characteristics that affect outcomes?
10 studies (3 prospective and 7 retrospective) evaluated which patient characteristics were predictive of outcomes. (Of course, these do not mean a patient’s story is set in stone—it just means there is correlation between these factors and outcomes.)
Patient/injury factors that are correlated with worse outcomes:
- Medicaid recipients
- Workers compensation recipients
- Increased blood alcohol level at admission
- Low FIM score at admission
- Complete injuries
Patient/injury factors correlated with better outcomes:
- Increased level of education
- Having a higher body mass index
- Stronger somatosensory-evoked potential readings
Conclusions and discussion
Past research has shown us that rehab does improve both function and outcomes following an SCI. However, determining the contribution of individual interventions has been difficult.
Factors that contribute to this difficulty include:
- Lack of standardization of interventions, doses, and outcome measures
- Heterogeneity of patient population
- Differentiating the role of spontaneous recovery
- Ethical implications of withholding rehab from the control group (therefore conventional therapy is the de facto control group)
- Multiple interventions are often delivered simultaneously, via an interdisciplinary team
Due to all of these research barriers, rehab for SCI has been likened to a “black box” or “Russian nesting dolls.”
Outside of the low-grade support for BWSTT and FES, there is simply no compelling evidence for specific rehab interventions.
I really need to say something here, though.
This does NOT mean that rehab itself is ineffective!
In fact, in the brightest light, we could say that new therapeutics have simply failed to outperform conventional rehab.
Finally, the results remind us that social determinants of health impact the outcomes of the SCI population. (As is true with all of our patients.)
Takeaways for OT practitioners
(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)
1. Your conventional OT approach is needed.
There are no easy, set-in-stone answers when it comes to SCI rehab. What our participants need most from us is our holistic, function-focused approach to care.
I found this OT + SCI Rehab Guide as a helpful illustration of what conventional care can entail. I’ll be curious to hear your favorite resources!
2. Consider the addition of FES to your toolkit.
FES training comes up regularly when we’ve looked at neurological conditions. (This 2015 article on stroke and FES really stuck with me.) FES can be utilized in a variety of ways for SCI. It can be used for upper or lower extremities, and it can even be used concurrently for both. FES can also be used to retrain or even replace muscle movement during specific exercises.
The impact of FES can be much broader than just the specific muscle group being activated at any given time. Studies have shown it can also increase overall cardiovascular health. Here’s a great 2020 article specifically focused on FES and how it can help retrain reaching and grasping after SCI. I’ll be so curious to hear any experience you might have with FES!
Here’s the full APA citation for this article:
Burns, A. S., Marino, R. J., Kalsi-Ryan, S., Middleton, J. W., Tetreault, L. A., Dettori, J. R., Mihalovich, K. E., &; Fehlings, M. G. (2017). Type and timing of rehabilitation following acute and Subacute Spinal Cord Injury: A systematic review. Global Spine Journal, 7(3_suppl).
Earn one hour of continuing education by listening to the podcast on this article!!
In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Simon Carson. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!