I'd like now to move into the rehabilitation phase. The first piece of rehabilitation that I always think about is how much neurologic recovery is going to be expected because our rehabilitation program is different based on the degree of completeness and the level of injury. The literature is fairly consistent indicating that there is improvement of at least one level adjacent to the last normal level. This is segmental recovery and it's expected in all injuries and one or two is not uncommon, sometimes more. This segmental recovery is based on the improvement of the circulation and the recovery of the penumbra of the stunned neurons at the level of injury and as those recover over time, you will see the segments, the levels drop one or two levels. If you are seeing no improvement or the person loses a level, imaging of the spinal cord, talking with their neurosurgeon is important because the loss of a single level can have huge functional implications. Distal improvement is due to recovery of long tracks that are traversing the injury site and is most commonly seen in people with incomplete SCI. The more incomplete your spinal cord injury, the more recovery you're like to have. The use of the 72-hour exam is very useful at predicting function at one year. Those who have a complete injury, ASIA Impairment Scale A at 72 hours, only 7% improved to ASIA B and none of them in this study improved to ASIA C or D. Those with Sacral Sparing of Sensation, ASIA B, 54% of them continued to improve to motor function, motor incomplete C or D and nearly all patients with ASIA C at 72 hours who are under 50 years of age walk at the time of discharge from rehabilitation and all people with ASIA D are expected to walk at the time of discharge from rehabilitation. The neurologic exam earlier than 72 hours can sometimes be unpredictable because the individual may not be able to respond well and neurologic exam later may not have as much prognosis as that first 72 hours. Most of the recovery is seen in the first six months, but can be seen in two years. There are always reports of dramatic neurologic recovery of one person here or there and if it happens to you, it's 100%, but if it doesn't happen to you, the patient, it's 0%. So while these numbers are helpful for prognosis, we need to remember that the individual will experience recovery or not and that recovery is likely to occur at both segmental levels and at distal levels based on long track recovery. Now based on the level of injury, we can predict very well what their functional outcomes will be and again, the Consortium for Spinal Cord Medicine has published a clinical practice guideline that describes based on the level of injury, what function is likely to occur and what equipment is likely to be required. Now these determinants of functional outcomes are based on the level of injury and for the clinical practice guideline, assume a complete injury or at least no functional motor presence below the level of injury, but the degree of completeness we know has a significant impact on functional outcome and so those people who have more incompleteness will have more ability to gain function over time and so the level of injury and the degree of completeness is critical, but so is the overall health of the person with spinal cord injury. If this is a 75-year-old man with COPD and congestive heart failure, even though he may have an ASIA-D injury, his potential may not reach that of a typical 20-year-old with ASIA-D injury because of comorbidities and these all need to be taken into account when we are looking at expected functional outcomes in predicting the future. So let's start by looking at the high tetraplegics, C1 through 4. These people typically are on a ventilator if they're C1 or 2, ventilator except for short periods of time if they're C3, and potentially ventilator independent at C4, however they will remain total assist with their ADLs and depending on their tolerance to positioning and blood pressure fluctuations, they should be able to be up in a power wheelchair and be fully independent in that wheelchair for mobility and tilt and recline pressure relief. They may need a head switch, a chin switch, a mouth controller, generally they need a tilt and or tilt and recline for pressure relief and most will require head and postural support and if they're on a ventilator, a vent tray needs to be added as well, which makes for a large power chair. They should go home with a ventilator and suction equipment if they have a need for a ventilator and continue to have a tracheostomy, a full electric hospital bed and various degree of environmental control units, many of which now are available through non-medical mechanisms as well as the DME side using Google Home and Alexa and those sorts of devices can allow a person to control their home using off-the-shelf technology. Mouth sticks continue to be helpful. Transfers typically will require a lift with a sling, but if there is an assistant who prefers to transfer, using a transfer board for safety is beneficial, however our recommendation typically is to use a sling for this sort of transfer. A padded reclining commode chair and shower chair is also necessary for these folks with the very highest level of injury. With the gain of a single level to C5, these individuals are now able to become more independent. They can require simple setup for feeding and some grooming. They remain minimal to moderate assist for grooming and upper body dressing, but they remain a total assist for the remainder of their ADLs. Likewise they are continuing to be dependent with their transfers, but now a power wheelchair with a joystick and a tilt and recline is useful. So their equipment is the same as a person with a high tetraplegia except the vent and many times people are able to, with the use of a wrist-stabilizing splint such as a long opponent splint and a universal cuff or D-rings, Velcro closures, something to give grip, they're able to perform many of these activities of daily living. Transportation typically requires a van with lift equipped and with the right technology, a person with a C5 level of injury is able to drive with adaptation and training. C6, with the improvement of one more level of function, they can be independent or modified independent for feeding, grooming, upper body dressing and bathing and minimal assist for lower body dressing, bathing and toileting. They can often be independent for transfers from level surfaces, although that may put a lot of extra force on elbows and shoulders and alternative dependent transfers may be important to investigate as well. People with C6 injury typically can propel a manual wheelchair, oftentimes with hand rim modifications that allow them to push. Again, the determination of what can they do and what is functional for them in their environment needs to be considered and many times a power wheelchair may be superior. Equipment needed would include potentially a tenodesis orthosis to allow them to create active hand closure and grip, various ADL equipment and then a manual chair as mentioned with hand rim modifications if they are not using a power chair. Again, a van with minimal modifications, hand controls and a steering knob, for example, can be used for driving in a person with C6 tetraplegia. For those with C7 and C8 tetraplegia, we're talking about modified independents and all their ADLs. Independent transfers even on uneven surfaces and a manual wheelchair without hand rim modifications, a transfer board, a commode or shower chair and various ADL devices are recommended and transportation can be either in a car or a van depending on their transferability. The transfers into a car and the putting in of the wheelchair can be challenging, but it is definitely possible for anybody with a low cervical level of injury at C7 and C8. And again, driving with hand controls is reasonable and should be expected. Now, if we start talking about the paraplegics, let's talk first about the upper paraplegics, T1 through T9. They will have the same independence in ADLs as the low tetraplegics. They'll be able to transfer from uneven surfaces, typically using a manual wheelchair. And for those with T6 and below levels, there's a potential for exoskeletal-assisted ambulation. Much of this depends on truncal balance and desire. Equipment, transfer board, commode chair, ADL devices, and transportation with minimal adaptation is expected. Although driving with a van modified is easier simply because, again, transfers are not necessary. For people with T10 to L2 spinal cord injury, now they should be able to transfer to their back from their chair from all surfaces, including from the ground. They should be able to propel a wheelchair up and down inclines, and there's a potential for adaptive gait in many different ways. Typically, depending on their desire for ambulation, a knee-ankle-foot orthosis and crutches may be necessary. For those with very low paraplegia, adaptive gait using ankle-foot orthoses to stabilize the ankles, and a cane or two to stabilize the pelvis. Because remember, the sacral nerves not only innervate the distal foot, but also the proximal hip stabilizers. Now, who is going to walk is often a tricky question, because we can answer that based on a couple of pieces of information. The first has to do with their level of injury. Pretty much anybody below T10 who has a desire and is physiologically, meaning cardiopulmonary, stable enough for ambulation, can ambulate. Also, degree of completeness. Those people who are very incomplete, even if they have a cervical level of injury, are able to ambulate. But then those with an Asian motor score, the lower extremity motor score, typically correlates with the walking spinal cord injury index. And as you can see from this graph on the right, it's fairly scattered throughout. And some people with a very low lower extremity motor score still are able to ambulate, probably because they have a low level of injury. And then other people who have a higher level or a higher lower extremity motor score, almost all of them are able to ambulate because of their lower extremity strength. Now, if a person has a presence of bilateral hip flexors and at least one knee extensor that is a normal strength, they can have a reciprocating gait. This is key because of the efficiency of ambulation. Walking with long leg braces and crutches is very energy dependent. And many people will not continue this over time. Cardiovascular conditioning is vital and motivation is essential if they are not able to have spontaneous neurologic recovery. But many people with spinal cord injury are able to walk in spite of the absence of neurologic recovery simply because of rehabilitation techniques. I wanna talk a little bit about gait training because this is often one of the highest goals that a person coming into rehabilitation has. Although honestly, it is one of the least necessary because in a community that is adapted for accessibility, wheelchair function can be as effective as ambulation and in some cases, more effective. There are basically three types of locomotor training, treadmill training, overground training and robotic gait training. The treadmill training, typically using a body weight support can be either use the therapist moving the legs in sequence on the treadmill or using the locomat or robotic assistance. This can be helpful in initiating gait training and can progress to overground training continued with some body weight support and some manual assistance. And as people get stronger, the body weight support can be removed and they can support themselves overground with various orthotic devices. Functional electric stimulation can also provide functional gait for people with upper motor neuron spinal cord injury. The key is they have to have upper motor neuron lesion that allows their muscles to respond to electrical stimulation. People with lower motor neuron injury do not respond to electrical stimulation. Now, robotic gait training has gained a significant following and there are a number of different devices out there on the market, either for rehabilitation therapy or for home use. All of these have been demonstrated to allow people with levels of injury in the mid thoracic and even higher to be able to ambulate. Again, the key here is truncal stability, being able to maintain an upright posture and cardiovascular adaptation because even though the robot is taking the steps, it's not simple and easy. It requires energy on the part of the patient to be successful. Typically, locomotor training that starts in the first year after injury can result in improved gait velocity and walking distances. And there is evidence for modest support for increased benefits of the body weight support, treadmill training and robotic assistance over conventional gait training. These allow people to get up earlier and start working and maybe that modest increase is related to the motivation that is gained by early mobility or it may be that these techniques are able to get people going first and preventing some of the consequences of immobility. If you start gait training more than a year after injury, there is no benefit using one or the other, whether it's body weight supported, conventional gait training or robotic assistance, it really depends on the motivation and the cardiovascular conditioning. Thus, the ideal time to initiate locomotor training remains unclear from current data. Now, what are the justifications for the value of rehabilitation? Has always been that people can go back to work with good rehabilitation. What we find in spinal cord injury is that the younger men who are white, who have a high level of formal education, are reported smarter, higher level of IQ, have a nonviolent etiology of injury and are employed at the time of injury are more likely to return to work. Now, many of these demographics are simply associations and many of them go together. So it is hard to piece out which of these really makes a difference. Definitely those who have a greater functional capacity and a less severe injury and those able to drive have a better prediction for return to work. Again, motivation and time since injury is important as well. Time since injury is important because according to one study, while less than 60% of people are employed at the time of their injury, at year one, it's barely 10%. But by year 10, it's up to 25 or 27%. By year 20, it maximizes a little bit over 30, close to 35% and then starts decreasing as people retire. In the first year of injury, many go back to school, but that also decreases with time. There are some very encouraging studies that show that supported occupation, supported vocational rehabilitation in which people are able to learn a task in a business and have a guided and assisted entry are able to then achieve full employment and maintain that over time as opposed to simply trying to place an individual into a job in which they then fail. That the key of the supported entry, I believe is the key to success there. Now, most people, well over 85% go home after their rehabilitation. A small percentage discharge to nursing homes. In this one report, 6.5% were discharged to a nursing home. And the predictors of discharge to a nursing home included complete tetraplegia, Asia A, B or C, ventilator dependency, dependent in their ADLs, non-ambulatory, indwelling urethral catheter or an external catheter, older age, unmarried, unemployed and had either Medicaid or HMO insurance. And I suspect that these also are interrelated so that these correlations impact each other. I believe that the dependent in ADLs and unmarried are the two that stand out most in the predictors of nursing home discharge. Most people who are married, if their wife or husband is able to take care of them or they make it home. If they're unmarried, getting adult children back into the home or getting caregivers into the home if they're dependent in ADLs is very unlikely.

rehabilitation phase

spinal cord injuries

neurologic recovery

distal improvement

functional outcomes

gait training