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Publication date: 15.06.2024
DOI: 10.24412/2782-6570-2024_03_02_5
UDC 616.83
EFFECTS OF PHYSICAL REHABILITATION IN CERVICAL SPINAL CORD INJURY
N.V. Lunina1,2, P.D. Trofimova1
1Russian University of Sport “GTSOLIFK”, Moscow, Russia
2FSBI “North-Caucasian Federal Research-Clinical Center of the Federal Medical and Biological Agency”, Essentuki, Russia
Annotation. The article presents the effects of physical rehabilitation for cervical spinal cord injury in men aged 25 to 30 years. The studied parameters changed significantly (p≤0.05): patients’ mobility improved in the following domains: d4100 “Lying down” by 50%; d4103 – “Sitting” by 50%; d4153 – “Maintaining a sitting position” by 25%; d4200 – “Transferring oneself while sitting” by 25%. There was a significant increase in the power of the upper limb muscles: the anterior serratus muscle – by 38%, the biceps brachii – by 29%, the triceps brachii – by 38%, and the rotator cuff muscle – by 13.3%. The patients’ quality of life also improved (according to the Spinal Cord Independence Measure) in the sections: “Self-Care” – by 80%; “Respiration and Sphincter Management” – by 40%; “Mobility” – by 100%. The results obtained indicate the high significance and effectiveness of the applied means and methods of physical rehabilitation for the studied contingent in matters of habilitation and reintegration into society.
Keywords: physical rehabilitation, men, cervical spinal cord injury, International Classification of Functioning, domains, muscle power, mobility, functional independence measure.
Introduction. Spine injuries and spinal cord injuries are a serious medical and socioeconomic problem in society due to the limited treatment options for the resulting neurologic deficit and disability [1]. Their prevalence amounts to 20-40 per million people per year [2], but there is considerable variation in epidemiological data on the international level [3]. The clinical picture of spinal cord injury is described within the neurological syndromes of commotion, complete and incomplete nerve fiber damage. Tetraplegia is a consequence of spinal injury to the cervical spine, characterized by partial (tetraparesis) or complete loss of function below the level of injury. Secondary complications of spinal cord injury are numerous and significantly reduce a patient’s quality of life. The most common complications include urinary, gastrointestinal, skin, musculoskeletal, neurological, respiratory, cardiovascular, endocrine and psychological complications [4]. The proprioception loss after spine injuries significantly affect the musculoskeletal function. Patients with incomplete spinal cord injuries rely on visual information as a compensation of proprioception deficit and weakened balance, which leads to a higher risk of falling. Therefore they face difficulties when participating in activities that would allow them to fully reintegrate into society.
A wide range of physical rehabilitation currently in use for patients with cervical spinal cord injury (CSCI) at the cervical spine level [5-6]. At the same time, the physical rehabilitation effects for this category of patients can be extremely diverse due to the severity of the injury.
Aim of the study to develop and scientifically substantiate a physical rehabilitation program for patients with CSCI.
Methods and organization. The mobility assessment of patients with CSCI according to the International Classification of Functioning (ICF) from the Chapter 4 “Mobility” in the following domains: d4100 “Lying down” d4103 – “Sitting”; d4153 – “Maintaining a sitting position”; d4200 – “Transferring oneself while sitting”. We evaluated the patients’ ability to turn to the right and left sides of the bed, the transfer from lying to sitting, measured the time spent while sitting with legs down from the bed with support on the arms and without support under the back.
The following scale was used in the evaluation:
0 points – NO difficulties (0-4%);
1 point – MILD difficulty (5-24%);
2 points – MODERATE difficulty (25-49%);
3 points – SEVERE difficulty (50-95%);
4 points – COMPLETE difficulty (96-100%).
Power of the girdle and upper limb muscles was assessed with the manual muscle testing on a scale in points. The assessment was done according to ICF from the Chapter 7 “Neuromusculoskeletal and movement-related functions”, the following domains were evaluated: b7300 – Muscle power functions (inclusions: impairments such as weakness of small muscles in hands). We assessed the anterior serratus muscle, the biceps brachii, the triceps brachii, and the rotator cuff muscle.
Scale of the muscle power assessment:
0 points – contraction in the tested muscle cannot be found either visually or through palpitation;
1 point – visible or palpable contractions in the tested muscle or partial performance of the tested movement with minimal gravity;
2 points – the muscle may perform a full-amplitude movement with minimal gravity. To reduce the friction, a piece of cloth should be placed between the tested part of the body and the surface on which it is resting;
3 points – the muscle can perform a full-amplitude movement by overcoming gravity;
4 points – the muscle can perform a full-amplitude movement by overcoming gravity and moderate counteraction (designed for the patient and the tested movement);
5 points – the muscle can perform a full-amplitude movement by overcoming gravity and maximum counteraction (designed for the patient and the tested movement);
Quality of life of the patients was investigated according to the Spinal Cord Independence Measure (SCIM), which is a disability scale especially designed for people with a spinal cord injury for evaluating different activities in everyday life. Assessment of test results is made separately by sections with the following maximum score: “Self-Care” – 20 points; “Respiration and Sphincter Management” – 40 points; “Mobility” – 40 points.
Results interpretation: the “Self-Care” section: 15-20 points – independent, assistance not needed, less than 15 points – total assistance required; the “Respiration and Sphincter Management” section: 30-40 points – independent, assistance not needed, less than 30 points – total assistance required; the “Mobility” section: 35-40 points – independent, assistance not needed, less than 35 points – total assistance required.
The statistical data processing was performed in Statistica 13, we calculated mean arithmetic values and standard deviation. The reliability of the results obtained was determined with the Wilcoxon's signed-rank test if p≤0.05.
The study was carried out in the “Tri sestry” (“Three sisters”) early rehabilitation center (Rajki village, Moscow Oblast) between June 2023 and March 2024, males (n=5) were included in the study. Inclusion criteria:
1) age – from 25 to 30 years;
2) verified diagnosis: spinal cord injury at the С4-С5 level (tetraplegia) of the cervical spine;
3) age of injury – 4 months;
4) non-athletes;
5) informed voluntary consent to participate in the rehabilitation program with the clinical testing of rehabilitation methods.
The 30-day physical rehabilitation program (PR) included the following methods: verticalization therapy, positional therapy, therapeutic gymnastics, Proprioceptive Neuromuscular Facilitation (PNF), therapeutic massage, physiotherapy (heat therapy, electromagnetic stimulation), occupational therapy, and stimulator sessions (MOTOmed).
Results and discussion. After physical rehabilitation, an improvement in locomotion performance was found in the ICF domains of the Chapter 4 (“Mobility”), particularly in the area of mobility in bed (table 1).
Table 1
Comparison of patients with CSCI according to ICF domains before and after physical rehabilitation
|
Before PR |
After PR |
||
|
Points |
Interpretation |
Points |
Interpretation |
|
d4100 – Lying down |
|||
|
.44 |
Could turn on right and left side in bed with total assistance |
.22 |
Could turn on right and left side in bed with minimum assistance (bend the leg at the knee) |
|
d4103 – Sitting |
|||
|
.44 |
Could change the position from sitting with legs down to lying down with total assistance |
.22 |
Could change the position from sitting with legs down to lying down with minimum assistance |
|
d4153 – Maintaining a sitting position |
|||
|
.44 |
Could not sit |
.32 |
Could sit with legs down from the bed without back support, but with support on arms and legs under visual supervision and support for up to 5 minutes |
|
d4200 – Transferring oneself while sitting |
|||
|
.44 |
Could move from bed to wheelchair and back with total assistance |
.33 |
Could move from bed to wheelchair and back with moderate assistance and verbal cues |
Note: CSCI – cervical spinal cord injury; IFC – International Qualification of Functionality; PR – physical rehabilitation
Result interpretation according to the IFC domains;
1) d4100 – Lying: before rehabilitation – d4100.44 (COMPLETE difficulty – patients could turn in bed with total assistance only); after rehabilitation – d4100.22 (MODERATE difficulty – patients could turn in bed with minimum assistance).
2) d4103 – Sitting: before rehabilitation – d4103.44 (COMPLETE difficulty – patients could change the position from sitting to lying down with total assistance only); after rehabilitation – d4103.22 (MODERATE difficulty – patients could change the position from sitting to lying down with minimum assistance).
3) d4153 – Maintaining a sitting position: before rehabilitation – d4153.44 (COMPLETE difficulty – patients could not sit with legs down without support on the back and arms without losing balance); after rehabilitation – d4153.32 (SEVERE difficulty – patients could sit with legs down with legs down without support on the back but with support on the arms without losing balance for up to 5 minutes).
4) d4200 – Transferring oneself while sitting: before rehabilitation – d4200.44 (COMPLETE difficulty – patients could move from bed to wheelchair and back with total assistance only); after rehabilitation – d4200.33 (SEVERE difficulty – patients could move from bed to wheelchair and back with moderate assistance).
After physical rehabilitation the power indices of the studied muscle groups significantly improved (table 2). The average power indices of the studied muscles ranged from 1 to 2 points, indicating a pronounced deficit of muscle power. After rehabilitation, the average power gain in some studied muscle groups increased more than 1.5 times, the range of power indices amounted from 2 to 3 points.
Table 2
Assessment of the girdle and upper limb muscle power in manual muscle testing (in points) according to ICF b730 domains, X̅±σ
|
Studied muscles |
Primary values |
Final values |
P< |
|
Anterior serratus muscle, points |
2.10±1.03 |
3.10±0.55 |
0.05 |
|
Biceps brachii, points |
2.30±1.2 |
3.10±0.55 |
0.05 |
|
Triceps brachii, points |
1.20±0.61 |
2.20±0.55 |
0.05 |
|
Rotator cuff muscle, points |
2.60±1.31 |
3.40±0.55 |
0.05 |
Note: ICF – International Classification of Functioning
The greatest positive changes were observed in the triceps brachii, which amounted to 58% of the primary result. Such increase is due to the fact that at the beginning of physical rehabilitation this muscle was the weakest and had the lowest average muscle power. In the other muscle groups studied, changes of strength recovery were as follows: the anterior serratus muscle – 38%, the biceps brachii – 29%, the rotator cuff muscle – 13.3%.
We also found an improvement in quality of life according to the SCIM score with a mean score of 6 points in the “Self-Care” section, representing 30% out of 100%, 21 points in activities associated with “Respiration and Sphincter Management”, representing 52.5 out of 100%, and 7 points in activities associated with movement and locomotion (“Mobility”), representing 17.5% out of 100% (fig.)
Fig. Changes in the functional independence measure indexes (in points) in patients with cervical spinal cord injury during physical rehabilitation according to SCIM
Note: PR – physical rehabilitation; SCIM – Spinal Cord Independence Measure
The data obtained show that patients with CSCI remain dependent in self-care, respiration and sphincter management, and they require moderate and total assistance in motor activity. However, in comparison with the pre-rehabilitation scores, i.e. 1 point out of 20 (5% out of 100%) in self-care, 13 points out of 40 (32.5% out of 100%) in activities related to breathing and sphincter management, and 0 points out of 40 (0% out of 100%) in activities related to movement and locomotion, there were significant improvements in all of these indices.
Conclusion. The effects of physical rehabilitation for young-aged patients with CSCI are represented by a significant (p<0.05) change of the studied indices. The patients’ mobility has improved according to the following domains: d4100 “Lying down” – by 50%; d4103 – “Sitting” by 50%; d4153 – “Maintaining a sitting position” by 25%; d4200 – “Transferring oneself while sitting” by 25%. The power of the upper limb muscles has also improved: the anterior serratus muscle – by 38%, the biceps brachii – by 29%, the triceps brachii – by 38%, and the rotator cuff muscle – by 13.3%. The quality of life of the patients (according to SCIM) improved in the following sections: “Self-Care” – by 80%; “Respiration and Sphincter Management” – by 40%; “Mobility” – by 100%.
The results obtained testify to the high significance and effectiveness of the applied methods of physical rehabilitation for the studied group in the matters of habilitation and reintegration of patients with CSCI into society.
Conflict of interest. The authors declare no conflict of interest.
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INFORMATION ABOUT THE AUTHORS:
Natal’ya V. Lunina – Candidate of Biological Sciences, Associate Professor, Associate Professor of the Department of Physical Rehabilitation, Massage and Health-Improving Physical Culture named after I.M. Sarkizov-Serazini, Russian University of Sport “GTSOLIFK”, Moscow; Senior Researcher of the Center for Biomedical Technologies, FSBI “North-Caucasian Federal Research-Clinical Center of Federal Medical and Biological Agency”, Essentuki, e-mail:
Polina D. Trofimova – Bachelor of the Department of Physical Rehabilitation, Massage and Health-Improving Physical Culture named after I.M. Sarkizov-Serazini, Russian University of Sport “GTSOLIFK”, Moscow.
For citation: Lunina N.V., Trofimova P.D. Effects of physical rehabilitation in cervical spinal cord injury. Russian Journal of Sports Science: Medicine, Physiology, Training, 2024, vol. 3, no. 2. DOI: 10.24412/2782-6570-2024_03_02_5