Rehabilitation in spinal cord injury

Last updated

When treating a person with a spinal cord injury , repairing the damage created by injury is the ultimate goal. By using a variety of treatments, greater improvements are achieved, and, therefore, treatment should not be limited to one method. Furthermore, increasing activity will increase his/her chances of recovery. [1]

Contents

Acute recovery

The rehabilitation process following a spinal cord injury typically begins in the acute care setting. Occupational therapy plays an important role in the management of SCI. [2] Recent studies emphasize the importance of early occupational therapy, started immediately after the client is stable. This process includes teaching of coping skills, and physical therapy. [3] Physical therapists, occupational therapists, social workers, psychologists and other health care professionals typically work as a team under the coordination of a physiatrist to decide on goals with the patient and develop a plan of discharge that is appropriate for the patient's condition. In the first step, the focus is on support and prevention. Interventions aim to give the individual a sense of control over a situation in which the patient likely feels little independence. [4]

As the patient becomes more stable, they may move to a rehabilitation facility or remain in the acute care setting. The patient begins to take more of an active role in their rehabilitation at this stage and works with the team to develop reasonable functional goals. [5]

Respiration

In the acute phase physical and occupational therapists focus on the patient's respiratory status, prevention of indirect complications (such as pressure sores), maintaining range of motion, and keeping available musculature active. [5]

Depending on the Neurological Level of Impairment (NLI), the muscles responsible for expanding the thorax, which facilitate inhalation, may be affected. If the NLI is such that it affects some of the ventilatory muscles, more emphasis will then be placed on the muscles with intact function. For example, the intercostal muscles receive their innervation from T1–T11, and if any are damaged, more emphasis will need to be placed on the unaffected muscles which are innervated from higher levels of the CNS. As SCI patients have reduced total lung capacity and tidal volume [6] it is pertinent that physical therapists teach SCI patients accessory breathing techniques (e.g. apical breathing, glossopharyngeal breathing, etc.) that typically are not taught to healthy individuals.

Functional electrical stimulation

Physical therapists can assist immobilized patients with effective cough techniques, secretion clearance, stretching of the thoracic wall, and suggest abdominal support belts when necessary. The amount of time a patient is immobilized may depend on the level of the spinal cord injury. Physical therapists work with the patient to prevent any complications that may arise due to this immobilization. Other complications that arise from immobilization include muscle atrophy and osteoporosis, especially to the lower limbs, increasing the risk of fractures to the femur and tibia. [7] While passive weight bearing of paralyzed lower extremities appears to be ineffective, stressing the bones through muscular contractions initiated by functional electrical stimulation (FES) has yielded positive results in some cases. [7] The intensity, frequency, and duration of stress to the bones appear to be important determinants of improved bone parameters. [7] Generally, the frequency is effective with three or more weekly exercise sessions. Studies of duration suggest that several months to one or more years of FES are necessary. [7]

Improving locomotor function

Improvement of locomotor function is one of the primary goals for people with a spinal cord injury. SCI treatments may focus on specific goals such as to restore walking or locomotion to an optimal level for the individual. The most effective way to restore locomotion is by complete repair, but techniques are not yet developed for regeneration. Treadmill training, over groundtraining, and functional electrical stimulation can all be used to improve walking or locomotor activity. These activities work if neurons of the central pattern generator (CPG) circuits, [8] [9] which generate rhythmic movements of the body, are still functioning. With inactivity, the neurons of CPG degenerate. Therefore, the above activities are important for keeping neurons active until regeneration activities are developed. [1] A 2012 systematic review found insufficient evidence to conclude which locomotor training strategy improves walking function most for people with spinal cord injury. [10] This suggests that it is not the type of training used, but the goals and the routines that have the biggest impact. [1] Applying spinal cord stimulation (transcutaneous or epidurally) during weight supported walking have been shown to improve locomotor output. [11] [12] [13]

Provision

In the English NHS a serious shortage of specialist beds was identified by a review in December 2016. There were 393 and 54 additional beds were required. Patients waited an average of 52 days for a bed on a specialist ward in 2015–16. This meant patients were "inappropriately" occupying beds at major trauma centres. It was suggested that NHS England's specialised commissioning division would be unable to fund the recommendations. According to the Spinal Injuries Association, of 2,494 referrals in 2017–18 to specialist spinal cord injury centres, only 800 were admitted and many more patients were not referred at all. [14]

Post-discharge rehabilitation therapy

Though rehabilitation interventions are performed during the acute phase, recent literature suggests that 44% of the total hours spent on rehabilitation during the first year after spinal cord injury, occur after discharge from inpatient rehabilitation. [15] Participants in this study received 56% of their total physical therapy hours and 52% of their total occupational therapy hours after discharge. [15] This suggests that inpatient rehabilitation lengths of stay are reduced and that post-discharge therapy may replace some of the inpatient treatment.

Functional independence

Whether patients are placed in inpatient rehabilitation or discharged, occupational therapists attempt to maximize functional independence at this stage. Depending on the level of the spinal cord injury, whatever sparing the patient has is optimized. Bed mobility, transfers, wheelchair mobility skills, and performing other activities of daily living (ADLs) are just a few of the interventions that occupational therapists can help the patient with. [16] A major problem for spinal cord injury patients is restricted range of motion. Massage therapy has been used to aid in range of motion rehabilitation. Literature has shown that participants with spinal cord injuries that had massage therapy added into their rehabilitation had significant improvement observed by physical therapist in functional living activities and limb range of motion. This could be due to the decrease in H-Reflex amplitudes measured by EMG that is critical for the comfort of spinal cord injury patients for reducing cramps and spasms. [17]

ADLs can be difficult for an individual with a spinal cord injury; however, through the rehabilitation process, individuals with SCI may be able to live independently in the community with or without full-time attendant care, depending on the level of their injury. [4]

Further interventions focus on support and education for the individual and caregivers. [4] This includes an evaluation of limb function to determine what the patient is capable of doing independently, and teaching the patient self-care skills. [18] Independence in daily activities like eating, bowel and bladder management, and mobility is the goal, as obtaining competency in self-care tasks contributes significantly to an individual's sense of self-confidence [4] and reduces the burden on caregivers. Quality of life issues such as sexual health and function after spinal cord injury are also addressed. [19]

Assistive devices

Assistive devices such as wheelchairs have a substantial effect on the quality of life of the patient, and careful selection is important. [20] Teaching the patient how to transfer from different positions, such as from a wheelchair into bed, is an important part of therapy, and devices such as sliding transfer boards and grab bars can assist in these tasks. [18] Individuals who are able to transfer independently from their wheelchair to the driver's seat using a sliding transfer board may be able to return to driving in an adapted vehicle. Complete independence with driving also requires the ability to load and unload one's wheelchair from the vehicle. [4] In addition to acquiring skills such as wheelchair transfers, individuals with a spinal cord injury can greatly benefit from exercise reconditioning. In the majority of cases, spinal cord injury leaves the lower limbs either entirely paralyzed, or with insufficient strength, endurance, or motor control to support safe and effective physical training. Therefore, most exercise training employs the use of arm crank ergometry, wheelchair ergometry, and swimming. [21] In one study, subjects with traumatic spinal cord injury participated in a progressive exercise training program, which involved arm ergometry and resistance training. Subjects in the exercise group experienced significant increases in strength for almost all muscle groups when compared to the control group. Exercisers also reported less stress, fewer depressive symptoms, greater satisfaction with physical functioning, less pain, and better quality of life. [22] Physical therapists are able to provide a variety of exercise interventions, including, passive range of motion exercises, upper body wheeling (arm crank ergometry), functional electrical stimulation, and electrically stimulated resistance exercises all of which can improve arterial function in those living with SCI. [23] Physical therapists can improve the quality of life of individuals with spinal cord injury by developing exercise programs that are tailored to meet individual patient needs. Adapted physical activity equipment can also be used to allow for sport participation: for example, sit-skiis can be used by individuals with a spinal cord injury for cross-country or downhill skiing.

The patient's living environment can also be modified to improve independence. For example, ramps or lifts can be added to a patient's home, and part of rehabilitation involves investigating options for returning to previous interests as well as developing new pursuits. [19] Community participation is an important aspect in maintaining quality of life. [24]

Gait training

Body weight supported treadmill training is another intervention that physiotherapists may assist with. Body weight supported treadmill training has been researched in an attempt to prevent bone loss in the lower extremities in individuals with spinal cord injury. Research has shown that early weight-bearing after acute spinal cord injury by standing or treadmill walking (5 times weekly for 25 weeks) resulted in no loss or only moderate loss in trabecular bone compared with immobilized subjects who lost 7-9% of trabecular bone at the tibia. [25] Gait training with body weight support, among patients with incomplete spinal cord injuries, has also recently been shown to be more effective than conventional physiotherapy for improving the spatial-temporal and kinematic gait parameters. [26]

A combination of Body weight supported treadmill training (BWSTT) and robotic-assisted BWSTT is being implemented into some training programs. The benefits include: (1) assist in reproducing leg movements and optimizing gait pattern (speed, step length, amplitude); (2) training sessions can be prolonged and walking speed can be adjusted, increasing motor outcome; (3) provides consistency of movement, where manual interventions/cues by a trainer may be variable (although a trainer should analyze the gait pattern and outcome measures of the training and supervise training). [27] It is important to note that the patient must be an active participant during the robotic movements and try to move with the robot. [27] This type of training would be implemented during the beginning of rehabilitation and progressed to independent locomotion as improvements are made. However, robotic-assisted BWSTT is expensive and often not affordable by physiotherapy clinics. [1] As an alternative, the development of non-motorized exoskeletons are currently being investigated for patients with incomplete SCI. [1] The development of the exoskeleton locomotor device would provide an inexpensive alternative to the robotic devices. The exoskeleton may be used in areas that can not afford robotic devices, or, in areas that can not provide adequate physiotherapy care.

Restorative neurology offers a different paradigm of treating spinal cord injury by focusing on the residual remaining motor control and on the intrinsic function of the sub-lesional spinal cord segments. [28]

See also

Related Research Articles

Hemiparesis, or unilateral paresis, is weakness of one entire side of the body. Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke.

<span class="mw-page-title-main">Physical therapy</span> Profession that helps a disabled person function in everyday life

Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient education, physical intervention, rehabilitation, disease prevention, and health promotion. Physical therapists are known as physiotherapists in many countries.

Spasticity is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.

<span class="mw-page-title-main">Paraplegia</span> Impairment of motor and sensory functions in the lower limbs

Paraplegia, or paraparesis, is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek (παραπληγίη) "half-stricken". It is usually caused by spinal cord injury or a congenital condition that affects the neural (brain) elements of the spinal canal. The area of the spinal canal that is affected in paraplegia is either the thoracic, lumbar, or sacral regions. If four limbs are affected by paralysis, tetraplegia or quadriplegia is the correct term. If only one limb is affected, the correct term is monoplegia. Spastic paraplegia is a form of paraplegia defined by spasticity of the affected muscles, rather than flaccid paralysis.

<span class="mw-page-title-main">Functional electrical stimulation</span> Technique that uses low-energy electrical pulses

Functional electrical stimulation (FES) is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system. More specifically, FES can be used to generate muscle contraction in otherwise paralyzed limbs to produce functions such as grasping, walking, bladder voiding and standing. This technology was originally used to develop neuroprostheses that were implemented to permanently substitute impaired functions in individuals with spinal cord injury (SCI), head injury, stroke and other neurological disorders. In other words, a person would use the device each time he or she wanted to generate a desired function. FES is sometimes also referred to as neuromuscular electrical stimulation (NMES).

Hypotonia is a state of low muscle tone, often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength. Hypotonia is a lack of resistance to passive movement, whereas muscle weakness results in impaired active movement. Central hypotonia originates from the central nervous system, while peripheral hypotonia is related to problems within the spinal cord, peripheral nerves and/or skeletal muscles. Severe hypotonia in infancy is commonly known as floppy baby syndrome. Recognizing hypotonia, even in early infancy, is usually relatively straightforward, but diagnosing the underlying cause can be difficult and often unsuccessful. The long-term effects of hypotonia on a child's development and later life depend primarily on the severity of the muscle weakness and the nature of the cause. Some disorders have a specific treatment but the principal treatment for most hypotonia of idiopathic or neurologic cause is physical therapy and/or occupational therapy for remediation.

Hypertonia is a term sometimes used synonymously with spasticity and rigidity in the literature surrounding damage to the central nervous system, namely upper motor neuron lesions. Impaired ability of damaged motor neurons to regulate descending pathways gives rise to disordered spinal reflexes, increased excitability of muscle spindles, and decreased synaptic inhibition. These consequences result in abnormally increased muscle tone of symptomatic muscles. Some authors suggest that the current definition for spasticity, the velocity-dependent over-activity of the stretch reflex, is not sufficient as it fails to take into account patients exhibiting increased muscle tone in the absence of stretch reflex over-activity. They instead suggest that "reversible hypertonia" is more appropriate and represents a treatable condition that is responsive to various therapy modalities like drug or physical therapy.

<span class="mw-page-title-main">Fall prevention</span> Interventions to prevent injury in domestic settings

Fall prevention includes any action taken to help reduce the number of accidental falls suffered by susceptible individuals, such as the elderly (idiopathic) and people with neurological or orthopedic indications.

Gait training or gait rehabilitation is the act of learning how to walk, either as a child, or, more frequently, after sustaining an injury or disability. Normal human gait is a complex process, which happens due to co-ordinated movements of the whole of the body, requiring the whole of Central Nervous System - the brain and spinal cord, to function properly. Any disease process affecting the brain, spinal cord, peripheral nerves emerging from them supplying the muscles, or the muscles itself can cause deviations of gait. The process of relearning how to walk is generally facilitated by Physiatrists or Rehabilitation medicine (PM&R) consultants, physical therapists or physiotherapists, along with occupational therapists and other allied specialists. The most common cause for gait impairment is due to an injury of one or both legs. Gait training is not simply re-educating a patient on how to walk, but also includes an initial assessment of their gait cycle - Gait analysis, creation of a plan to address the problem, as well as teaching the patient on how to walk on different surfaces. Assistive devices and splints (orthosis) are often used in gait training, especially with those who have had surgery or an injury on their legs, but also with those who have balance or strength impairments as well.

<span class="mw-page-title-main">Central cord syndrome</span> Human spinal cord disorder

Central cord syndrome (CCS) is the most common form of cervical spinal cord injury. It is characterized by loss of power and sensation in arms and hands. It usually results from trauma which causes damage to the neck, leading to major injury to the central corticospinal tract of the spinal cord. CCS most frequently occurs among older persons with cervical spondylosis, however, it also may occur in younger individuals.

Aquatic therapy refers to treatments and exercises performed in water for relaxation, fitness, physical rehabilitation, and other therapeutic benefit. Typically a qualified aquatic therapist gives constant attendance to a person receiving treatment in a heated therapy pool. Aquatic therapy techniques include Ai Chi, Aqua Running, Bad Ragaz Ring Method, Burdenko Method, Halliwick, Watsu, and other aquatic bodywork forms. Therapeutic applications include neurological disorders, spine pain, musculoskeletal pain, postoperative orthopedic rehabilitation, pediatric disabilities, and pressure ulcers.

The Shepherd Center is a private, non-profit hospital in Atlanta, Georgia. Founded in 1975, the hospital focuses on rehabilitation for people with spinal cord injury and disease, acquired brain injury, multiple sclerosis, chronic pain and other neuromuscular problems.

<span class="mw-page-title-main">Swami Vivekanand National Institute of Rehabilitation Training and Research</span> Medical research institutes in India

Swami Vivekanand National Institute of Rehabilitation Training and Research is an autonomous institute functioning under the Ministry of Social Justice and Empowerment of India. It is located in Olatpur, 30 km from Cuttack.

<span class="mw-page-title-main">Spinal locomotion</span>

Spinal locomotion results from intricate dynamic interactions between a central program in lower thoracolumbar spine and proprioceptive feedback from body in the absence of central control by brain as in complete spinal cord injury (SCI). Following SCI, the spinal circuitry below the lesion site does not become silent; rather, it continues to maintain active and functional neuronal properties, although in a modified manner.

<span class="mw-page-title-main">Management of cerebral palsy</span>

Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.

Magee Rehabilitation Hospital, part of Jefferson Health, founded in 1958, is a 96-bed specialty medical rehabilitation hospital providing physical and cognitive rehabilitation services. Magee's flagship facility is located in Center City Philadelphia. In addition to the main campus that offers comprehensive services for spinal cord injury, brain injury, stroke, orthopaedic replacement, amputation, pain management and work injury, Magee provides an expanding outpatient network serving the surrounding communities. In 1985, Magee's brain injury rehabilitation program became the first in the nation to be accredited by the Commission on the Accreditation of Rehabilitation Facilities. Magee partnered with Jefferson Hospital to create one of the nation's 14 federally designated centers for spinal cord injury rehabilitation. Magee has been rated one of America's leading rehabilitation hospitals by U.S. News & World Report. Magee provides treatment to more than 5,000 individuals annually. Magee is authorized to treat wounded military personnel returning from war. Magee is not an Obligated Group Affiliate.

A gait trainer is a wheeled device that assists a person who is unable to walk independently to learn or relearn to walk safely and efficiently as part of gait training. Gait trainers are intended for children or adults with physical disabilities, to provide the opportunity to improve walking ability. A gait trainer offers both unweighting support and postural alignment to enable gait practice. It functions as a support walker and provides more assistance for balance and weight-bearing, than does a traditional rollator walker, or a walker with platform attachments. It also provides opportunities to stand and to bear weight in a safe, supported position.

Upper motor neuron syndrome (UMNS) is the motor control changes that can occur in skeletal muscle after an upper motor neuron lesion.

Vision rehabilitation is a term for a medical rehabilitation to improve vision or low vision. In other words, it is the process of restoring functional ability and improving quality of life and independence in an individual who has lost visual function through illness or injury. Most visual rehabilitation services are focused on low vision, which is a visual impairment that cannot be fully corrected by regular eyeglasses, contact lenses, medication, or surgery. Low vision interferes with the ability to perform everyday activities. Visual impairment is caused by factors including brain damage, vision loss, and others. Of the vision rehabilitation techniques available, most center on neurological and physical approaches.

<span class="mw-page-title-main">Interlimb coordination</span> Coordination of the left and right limbs

Interlimb coordination is the coordination of the left and right limbs. It could be classified into two types of action: bimanual coordination and hands or feet coordination. Such coordination involves various parts of the nervous system and requires a sensory feedback mechanism for the neural control of the limbs. A model can be used to visualize the basic features, the control centre of locomotor movements, and the neural control of interlimb coordination. This coordination mechanism can be altered and adapted for better performance during locomotion in adults and for the development of motor skills in infants. The adaptive feature of interlimb coordination can also be applied to the treatment for CNS damage from stroke and the Parkinson's disease in the future.

References

  1. 1 2 3 4 5 Frood R (2010). "The use of treadmill training to recover locomotor ability in patients with spinal cord injury". Bioscience Horizons. 4: 108–117. doi: 10.1093/biohorizons/hzr003 .
  2. ↑ Krupa T; Fossey E; Anthony WA; Brown C; Pitts, DB (2009). "Doing daily life: how occupational therapy can inform psychiatric rehabilitation practice". Psychiatr Rehabil J. 32 (3): 155–61. doi:10.2975/32.3.2009.155.161. PMID   19136347.
  3. ↑ Pillastrini, P; Mugnai, R; Bonfiglioli, R; Curti, S; Mattioli, S; Maioli, M G; Bazzocchi, G; Menarini, M; et al. (2008). "Evaluation of an occupational therapy program for patients with spinal cord injury" (PDF). Spinal Cord. 46 (1): 78–81. doi: 10.1038/sj.sc.3102072 . hdl:11380/1156811. PMID   17453011.
  4. 1 2 3 4 5 Radomski MV; Trombly Latham CA (2008). Occupational therapy for physical dysfunction (6th ed.). Baltimore, Maryland: Lippincott Williams & Wilkins.
  5. 1 2 Fulk G; Schmitz T; Behrman A (2007). "Traumatic Spinal Cord Injury". In O'Sullivan S; Schmitz T (eds.). Physical Rehabilitation (5th ed.). Philadelphia: F.A. Davis. pp. 937–96.
  6. ↑ Winslow C; Rozovsky J (2003). "Effect of spinal cord injury on the respiratory system". Am J Phys Med Rehabil. 82 (10): 803–814. doi:10.1097/01.PHM.0000078184.08835.01. PMID   14508412.
  7. 1 2 3 4 Dolbow DR, Gorgey AS, Daniels JA, Adler RA, Moore JR, Gater DR (2011). "The effects of spinal cord injury and exercise on bone mass: a literature review". NeuroRehabilitation. 29 (3): 261–9. doi:10.3233/NRE-2011-0702. PMID   22142760.
  8. ↑ Dimitrijevic, MR; Gerasimenko, Y; Pinter, MM (16 November 1998). "Evidence for a spinal central pattern generator in humans". Annals of the New York Academy of Sciences. 860 (1): 360–76. Bibcode:1998NYASA.860..360D. doi:10.1111/j.1749-6632.1998.tb09062.x. PMID   9928325. S2CID   102514.
  9. ↑ Danner, SM; Hofstoetter, US; Freundl, B; Binder, H; Mayr, W; Rattay, F; Minassian, K (March 2015). "Human spinal locomotor control is based on flexibly organized burst generators". Brain. 138 (Pt 3): 577–88. doi:10.1093/brain/awu372. PMC   4408427 . PMID   25582580.
  10. ↑ Mehrholz, J; Kugler, J; Pohl, M (14 November 2012). "Locomotor training for walking after spinal cord injury". The Cochrane Database of Systematic Reviews. 11: CD006676. doi:10.1002/14651858.CD006676.pub3. PMID   23152239. S2CID   12362192.
  11. ↑ Minassian, K; Hofstoetter, US; Danner, SM; Mayr, W; Bruce, JA; McKay, WB; Tansey, KE (March 2016). "Spinal Rhythm Generation by Step-Induced Feedback and Transcutaneous Posterior Root Stimulation in Complete Spinal Cord-Injured Individuals". Neurorehabilitation and Neural Repair. 30 (3): 233–43. doi: 10.1177/1545968315591706 . PMID   26089308. S2CID   42315470.
  12. ↑ Hofstoetter, US; Krenn, M; Danner, SM; Hofer, C; Kern, H; McKay, WB; Mayr, W; Minassian, K (October 2015). "Augmentation of Voluntary Locomotor Activity by Transcutaneous Spinal Cord Stimulation in Motor-Incomplete Spinal Cord-Injured Individuals". Artificial Organs. 39 (10): E176–86. doi:10.1111/aor.12615. PMID   26450344. S2CID   13992274.
  13. ↑ Huang, H; He, J; Herman, R; Carhart, MR (March 2006). "Modulation effects of epidural spinal cord stimulation on muscle activities during walking". IEEE Transactions on Neural Systems and Rehabilitation Engineering. 14 (1): 14–23. doi:10.1109/tnsre.2005.862694. PMID   16562627. S2CID   19678807.
  14. ↑ "NHS England told to act on internal review to end 'avoidable harm'". Health Service Journal. 30 January 2019. Retrieved 5 March 2019.
  15. 1 2 Whiteneck, GG; Gassaway, J; Dijkers, MP; Lammertse, DP; et al. (2011). "Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab Study". Arch Phys Med Rehabil. 92 (3): 361–8. doi:10.1016/j.apmr.2010.07.241. PMID   21353820.
  16. ↑ Pendleton, H. M., & Schultz-Krohn, W. (2006). Pedretti's occupational therapy: Practice skills for physical dysfunction. (6th ed.). St Louis, MO: Mosby Elsevier.
  17. ↑ Field, Tiffany (1998). "Massage Therapy Effects". American Psychologist. 53 (12): 1270–1281. doi:10.1037/0003-066x.53.12.1270. PMID   9872050.
  18. 1 2 Ozelie R; Sipple S; Foy T; Cantoni K; Kellogg K; Lookingbill J; Backus, D; Gassaway, J (2009). "SCIRehab Project Series: The Occupational Therapy Taxonomy". J Spinal Cord Med. 32 (3): 283–97. doi:10.1080/10790268.2009.11760782. PMC   2718817 . PMID   19810630.
  19. 1 2 Atchison BJ; Dirette DK (2007). Conditions in Occupational Therapy. Effect on Occupational Performance (3rd ed.). Baltimore, Maryland: Lippincott Williams & Wilkins.
  20. ↑ Di Marco A; Russell M; Masters M (2003). "Standards for wheelchair prescription". Aust Occup Ther J. 50: 30–9. doi:10.1046/j.1440-1630.2003.00316.x.
  21. ↑ Nash MS (June 2005). "Exercise as a health-promoting activity following spinal cord injury". J Neurol Phys Ther. 29 (2): 87–103, 106. doi: 10.1097/01.npt.0000282514.94093.c6 . PMID   16386165. S2CID   23121538.
  22. ↑ Hicks AL; Martin KA; Ditor DS; Latimer AE; Craven C; Bugaresti J; McCartney N (2003). "Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being". Spinal Cord. 41 (1): 34–43. doi: 10.1038/sj.sc.3101389 . PMID   12494319.
  23. ↑ Phillips AA; Cote AT; Warburton DE (2011). "A systematic review of exercise as a therapeutic intervention to improve arterial function in persons living with spinal cord injury". Spinal Cord. 49 (6): 702–14. doi: 10.1038/sc.2010.193 . PMID   21339761.
  24. ↑ Cohen ME; Schemm RL (2007). "Client-centered occupational therapy for individuals with Spinal Cord Injury". Occupational Therapy in Health Care. 21 (3): 1–15. doi:10.1300/J003v21n03_01. PMID   23941337.
  25. ↑ de Bruin ED; Frey-Rindova P; Herzog RE; Dietz V; Dambacher MA; Stussi E (1999). "Changes of tibia bone properties after spinal cord injury: effects of early intervention". Arch Phys Med Rehabil. 80 (suppl 2): 214–20. doi:10.1016/S0003-9993(99)90124-7. PMID   10025500.
  26. ↑ Lucareli PR; Lima MO; Lima FP; de Almeida JG; Brech GC; D'Andréa Greve JM (2011). "Gait analysis following treadmill training with body weight support versus conventional physical therapy: a prospective randomized controlled single blind study". Spinal Cord. 49 (9): 1001–7. doi: 10.1038/sc.2011.37 . PMID   21537338.
  27. 1 2 Colombo G, Wirz M, Dietz V (May 2001). "Driven gait orthosis for improvement of locomotor training in paraplegic patients". Spinal Cord. 39 (5): 252–5. doi: 10.1038/sj.sc.3101154 . PMID   11438840.
  28. ↑ "Vienna Program for Movement Recovery". Archived from the original on 22 June 2018. Retrieved 13 November 2012.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.