Spinal Cord Injury Rehabilitation - SCI Rehabilitation

Five findings from a bedside examination in the first two weeks predict, with 96 percent accuracy, who will walk independently one year after a spinal cord injury. Rehabilitation is planned from that answer, and it starts before the answer is certain.

The rule combines age with the strength of two leg muscles and the sensation in two patches of skin, and it was built from 492 patients in 19 European centers and confirmed in a second group (van Middendorp and colleagues, The Lancet, 2011). It matters because spinal cord injury rehabilitation, or SCI rehabilitation, is a program measured in months, and its goals differ completely between a person who will walk again and a person who will live from a wheelchair. Both can reach a full and independent life. The route is different. This page explains what the injury does, how the level and completeness are established, what the months of rehabilitation involve, what can be predicted and what cannot, what research says about walking training and technology, the complications that have to be prevented for life, and how patients from abroad can arrange a program at Biruni Hospital in Istanbul.

What the injury does

The spinal cord carries every command from the brain to the body and every sensation back. An injury interrupts the traffic at one point, and everything below that point is affected. Two facts describe an injury.

1. The level. The lowest segment of the cord that still works normally, named by the vertebra, such as C6 or T10. Injuries in the neck affect arms, trunk and legs, and are called tetraplegia. Injuries below the neck affect trunk and legs, and are called paraplegia.
2. The completeness. Whether any movement or sensation survives below the level. The ASIA Impairment Scale grades this from A, meaning complete, through B, C and D, meaning increasingly preserved function, to E, meaning normal.

The first weeks

What rehabilitation works on

The program

Inpatient rehabilitation for spinal cord injury runs two to five months, longer for high tetraplegia, and it is the most comprehensive program in rehabilitation medicine, because the injury touches every system of the body. A rehabilitation physician leads. Physiotherapists, occupational therapists, nurses, a psychologist, a dietitian, a urologist, a respiratory therapist, an orthotist and a social worker each own part of the plan, and the patient learns to direct all of them, since after discharge the patient becomes the expert on his or her own body.

What can be predicted

The most common question is whether the patient will walk again. For most patients the answer comes early and with confidence, in either direction, and giving it early lets rehabilitation aim at the right target.

1. Recovery continues past the hospital. Most neurological recovery happens in the first six months, and gains in function, strength and skill continue for years.
2. A prediction is not a limit. The rule was built for planning, and a patient graded A who regains movement is examined again and the plan changes.
3. Some questions have no early answer. Bladder recovery, pain and spasticity follow their own course, and the team says so.

Walking, technology and evidence

Few areas of rehabilitation attract as much technology as walking after spinal cord injury, and few have been tested as carefully.

Cochrane reviewed five randomized trials with 309 participants and found no walking training method superior to any other. Treadmill training with body-weight support did not raise walking speed or distance over other physical rehabilitation (Mehrholz and colleagues, 2012).

Complications and life afterward

What shortens life after spinal cord injury is the complications rather than the injury itself. Nearly all of them are preventable, and prevention is a daily habit taught in rehabilitation and kept for life.

Going home

Discharge planning begins in the first week and takes as long as the therapy. The home is assessed and adapted, with ramps, door widths, a roll-in shower and a bed at chair height. A properly fitted wheelchair and cushion are ordered, and a second chair or a powered attachment for outdoors is considered. Driving with hand controls is assessed. Most paraplegic patients drive. Return to study or work is planned, in stages, and vocational services are involved early because employment after spinal cord injury is possible and common where the path is prepared. Sexuality and fertility are discussed openly by the team, since both are affected and both have answers. Peer mentors, people some years past their own injury, make the most credible teachers of all. The patient leaves with a written bowel, bladder and skin program, a supply chain for catheters and equipment, and a schedule of yearly reviews of kidneys, skin, lungs and shoulders, which carry the wheelchair user's whole body and wear accordingly.

Pain, spasticity and sleep

Three problems follow patients home.

Nerve pain below the injury, burning or shooting, affects a large share of patients and responds partly to medicines used for nerve pain, to exercise and to psychological techniques, and rarely disappears entirely. It is real. It is not imagined. Shoulder and wrist pain come later, from years of pushing and transferring, and are prevented by good technique, a light chair and strength work for the muscles that protect the shoulder. Spasticity, the stiffness and jumping of paralyzed muscles, is useful in small amounts, since it keeps muscle bulk and helps some transfers, and troublesome in large amounts, when stretching, positioning, tablets, botulinum toxin injections and, in severe cases, a pump delivering baclofen into the spinal fluid bring it down. Sleep suffers. All three disturb it, along with bladder routines at night and breathing disturbance, which is common in tetraplegia and treatable once found.

None of this is a reason for despair. All of it is a reason for a team that knows the condition.

The family's part

A spinal cord injury lands on the family as hard as on the patient, and the program trains them on purpose. Relatives learn transfers without hurting their backs, skin checks, catheter care, bowel routines, the signs of autonomic dysreflexia and the response to them, and how to step back and let the patient do what the patient can do, which is the hardest lesson of all. The psychologist sees relatives as well as patients. Many families arrive expecting to become full-time carers and leave having discovered that the person they feared for needs less help than they feared and a different kind of help than they imagined.

Plan for one relative to be present throughout, and for others to rotate.

Coming from abroad

Families seek rehabilitation abroad when the program at home is short, distant or absent. Send the operation note, the spine imaging reports, the neurological examination with level and ASIA grade, the current bladder method, any pressure injury details with photographs, and a short video of transfers and sitting balance. The rehabilitation team reviews the file without charge and replies with goals, a program and the expected length of stay, which for a first program after injury runs two to four months and for a later skills-focused program four to eight weeks. Transfer from abroad needs planning. Start it early. Airlines carry patients on a stretcher or in a seat with medical clearance, a nurse or doctor may need to travel with a ventilated or newly injured patient, and the coordinator advises on the forms. One coordinator from the international patients office handles every arrangement from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for sessions. It arranges the visa invitation letter, ambulance or accessible transfer from the airport, accessible accommodation near the hospital for relatives and accessible daily transport. Ward rooms have a companion bed. Meals fit the bowel program. The kitchen prepares halal, vegetarian and diabetic meals, with fiber adjusted to the bowel program. A prayer room is on site, and a request for a female therapist or physician is met wherever the rota allows. Patients are fit to fly home once skin is intact, the bladder program is stable and the doctor confirms it, and the team writes a full handover for the services at home.

Cost

The estimate follows the file review and depends on the length of stay, therapy hours, room type, and equipment such as the wheelchair, cushion and orthoses, which are itemized because their specification depends on the patient. Hospitals in this market quote spinal cord injury rehabilitation by the week or the month.

Confirm what the weekly figure includes. Ask how equipment is priced.