What are the guidelines for acute spinal cord injury rehabilitation?

From the Guidelines

Rehabilitation for acute spinal cord injury should begin as soon as the patient is medically stable, typically within 24-48 hours after injury, with a comprehensive approach including early mobilization, physical therapy, occupational therapy, respiratory management, bowel and bladder management, and pharmacological management. The goal of rehabilitation is to prevent complications, promote neurological recovery, and improve quality of life. According to the French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury 1, the prevalence of pressure ulcers can reach 26%, and prevention strategies should be implemented early.

Key Components of Rehabilitation

• Early mobilization with passive range of motion exercises to prevent contractures and maintain joint flexibility
• Physical therapy to strengthen preserved muscle groups
• Occupational therapy to address activities of daily living
• Respiratory management, including chest physiotherapy and assisted coughing techniques to prevent pneumonia
• Bowel and bladder management programs, including intermittent catheterization and a regular bowel routine
• Pharmacological management, including methylprednisolone, gabapentin, pregabalin, baclofen, tizanidine, or botulinum toxin injections for neuropathic pain and spasticity

Rehabilitation Intensity and Duration

Rehabilitation intensity should be tailored to the patient's tolerance, typically 3 hours of therapy daily, with goals regularly reassessed and modified based on neurological recovery, which may continue for up to 18 months post-injury 1. The French Society of Anaesthesia and Intensive Care recommends that all neurological rehabilitation centres have the equivalent of 2.5 full-time physiotherapists per 15 patients 1.

Psychological Support

Psychological support is essential as patients adjust to their injury, and should be included as part of the comprehensive rehabilitation approach 1. The management of patients with spinal cord injury requires cooperation between several care providers, and each stage of care is critical to enhance neurological recovery 1.

From the Research

Acute Spinal Cord Injury Rehabilitation Guidelines

The guidelines for acute spinal cord injury rehabilitation are multifaceted and involve a range of interventions to minimize secondary injury and optimize outcomes. Key aspects include:

• Stabilization of vital signs and prevention of secondary injury, following the Advanced Trauma Life Support (ATLS) algorithm 2
• Spinal stabilization using cervical collars and long backboards to prevent further injury during prehospital transport 2
• Early surgery to stabilize the spine after addressing life-threatening injuries 2, 3, 4
• Intensive care unit (ICU) admission for patients with high spinal cord injuries or hemodynamic instability 2, 4
• Maintenance of mean arterial pressure above 85 mmHg for 7 days to allow for spinal cord perfusion 2, 4
• Avoidance of hypotension and hypoxia to minimize secondary neurologic injury 2, 4

Bowel Management

Bowel management in the acute phase of spinal cord injury is crucial to prevent complications. Recommendations include:

• Establishment of a daily bowel program, including manual removal of stool, to manage areflexive bowel patterns 5
• Adjustment of factors such as rectal and oral medications, fluid, fiber, and activity to improve emptying of stool 5
• Individualized bowel management plans, frequently reevaluated with changes in condition 5

Respiratory Care

Respiratory care is critical in the acute phase of spinal cord injury, particularly for patients with high cervical cord injuries. Interventions include:

• Early tracheostomy in patients with lesions above C5 to reduce ventilator days and ventilator-associated pneumonia 2
• Aggressive measures, such as CoughAssist and Intermittent Positive Pressure Breaths (IPPB), to maintain lung recruitment and aid in secretion mobilization 2
• Consideration of diaphragmatic pacer placement in select patients 2

Rehabilitation and Secondary Prevention

Rehabilitation and secondary prevention strategies are essential to optimize outcomes and prevent complications. These include:

• Early mobilization of patients and a multidisciplinary approach to care 2, 6
• Aggressive assessment and management of secondary complications, such as deep vein thrombosis, pulmonary embolism, and pressure ulcers 4, 6
• Recognition and early intervention for problems such as bradycardia, orthostatic hypotension, and early ventilatory failure 6
• Comprehensive and integrated rehabilitation by specialized spinal cord injury teams 6