Initial Evaluation

Successful implementation of any rehabilitation program starts with a comprehensive initial assessment of the primary neurological impairment and also a systematic evaluation of any other medical and musculoskeletal conditions that may affect the development and implementation of a patient’s rehabilitation program. For example, shoulder arthritis or rotator cuff pathology can significantly affect the rehabilitation of a brain-injured or spinal cord–injured patient with severe lower extremity weakness who requires good shoulder strength and mobility in order to transfer and use assistive devices. Likewise, advanced cardiopulmonary disease may impair a patient’s ability to engage in aggressive gait training, in view of the aerobic demands of this activity. The initial rehabilitation evaluation should include an assessment of alertness, cognitive function, speech and language, vision, swallowing difficulties, musculoskeletal limitations, motor impairments, apraxia, sensory deficits, bowel function, bladder function, balance, and coordination.

Numerous disease states can cause injury to the spinal cord, including trauma, spondylosis, demyelinating diseases, tumor, neurodegenerative diseases, infection, vascular injury, and toxic metabolic disorders. There are approximately 11,000 new cases of traumatic SCI per year in the United States.¹ About 700,000 people suffer a stroke each year, and stroke is currently the leading cause of serious long-term disability in the United States.² However, numerous other disorders of brain function cause significant disability, and these patients may also benefit from directed rehabilitation therapies. Examples include encephalopathies, neurodegenerative diseases, hydrocephalus, demyelinating disease, and primary and metastatic brain malignancies. Many different types of rehabilitation programs are available for patients and are stratified in Table 106-1 according to level of medical acuity (the need for close medical supervision or nursing services) and intensity.

TABLE 106-1 Classification of Rehabilitation Programs

* The need for close medical supervision or nursing services.

Assessment Scales

SCI assessment starts with a determination of the level and the completeness of the spinal injury. The American Spinal Injury Association has published standards for classification of SCI level (Fig. 106-1) and a grading system for completeness of neurological injury (Fig. 106-2).³ Incomplete injuries have a much better prognosis for motor recovery than do complete injuries. Since 2000, the most frequent SCI neurological category at rehabilitation hospital discharge of persons reported to the National Spinal Cord Injury database is incomplete tetraplegia (34.3%), followed by complete paraplegia (25.1%), complete tetraplegia (22.1%), and incomplete paraplegia (17.5%).¹

Figure 106-1 American Spinal Injury Association’s (ASIA) classification of spinal cord injury.

Figure 106-2 American Spinal Injury Association’s (ASIA) spinal cord injury impairment scale.

A variety of scales and assessment tools exist for evaluation of function after neurological injury. The primary initial assessment scale administered in traumatic brain injury is the Glasgow Coma Scale. The Glasgow Coma Scale numerical score reflects the depth of unconsciousness and is one of the most significant initial predictors of outcome and recovery.⁴ Table 106-2 summarizes some of the more commonly used scales in rehabilitation medicine. The Functional Independence Measure instrument is probably the most widely used functional assessment tool in the inpatient rehabilitation setting and can be applied irrespective of diagnosis (Fig. 106-3).

TABLE 106-2 Commonly Used Assessment Scales

ADL, activity of daily living; ASIA, American Spinal Injury Association; NIH, National Institutes of Health.

Figure 106-3 Functional Independence Measure (FIM) instrument.

Flexibility

Flexibility is an integral component of most rehabilitation schemes. Flexibility exercises can reduce contractures, reduce muscle pain, and decrease spasticity. Prolonged gentle passive stretching is preferred over aggressive forced or ballistic stretching,⁵ which can tear myofibrils and supportive connective tissue, leading to increased pain. The pain and microscopic tearing associated with aggressive stretching techniques reduces the potential for progressive gains in flexibility. Heat application before stretching or a gentle aerobic warmup (if the patient is able to perform this) improves blood flow to the muscle and improves tissue elasticity. Ideally, stretches should be held for at least 30 seconds⁶ and, for optimal results, repeated twice a day.

Strengthening

Weakness is a common sequela of neurological injury. Institution of strengthening programs can typically start as soon as the patient has the ability to perform voluntary motor contractions. Often, neuromuscular reeducation techniques are used concomitantly with strengthening programs to facilitate more coordinated return of motor function (see later discussion). A general approach to strengthening starts with focus on core muscles that support the trunk, spine, pelvic girdle, and shoulder girdle. As core strength improves, greater focus is placed on extremity strength training and on coordination of motor control.

In the profoundly debilitated patient who is unable to maintain trunk stability in an upright position, assisted range-of-motion exercises and progressive resistance exercises, with the therapist providing the assistance or resistance, can be implemented for the upper and lower limbs. As mentioned, the only requirement is that the patient have some degree of voluntary contraction. These exercises can be performed in a supine position or in a supported sitting or standing position. A tilt table (a plinth that can rotate 90 degrees from horizontal to vertical) can allow a gradually more upright posture while the patient exercises the arms and legs. The benefit is not only strengthening the legs through weight bearing but also reconditioning the cardiovascular system. Cardiovascular “tone” may be lost with even short periods of bed rest, leading to orthostatism.

For patients with profound motor impairment, neuromuscular electrical stimulation can be used to facilitate strengthening, and in patients with SCI, such stimulation has been demonstrated to reduce disuse-related atrophy.⁷ However, caution should be exercised with use of neuromuscular electrical stimulation in patients with myopathy because it may result in exhaustion of the myopathic muscle.

The primary physiological processes by which normal muscles achieve greater strength are muscle hypertrophy and enhanced neuromuscular control. In the initial 2 weeks of any strengthening program, the improvements in strength are related less to muscle hypertrophy than to enhanced neuromuscular control⁸; thereafter, muscle hypertrophy is the predominant factor. In the patient with neurological injury as the cause of weakness, improvements in strength also depend greatly on the processes of neurological recovery. The mechanisms of recovery vary, depending on the precise nature and extent of neurological injury.⁹ For example, central reorganization of motor control (neural plasticity) occurs after stroke, and collateral sprouting of motor unit nerve endings occurs in peripheral neurological injury.

Balance, Coordination, and Neuromuscular Reeducation

Impairment in balance and coordinated motor control can be a very challenging rehabilitation obstacle. Poor postural control may be a sequela of many neurological disorders such as stroke, hydrocephalus, and vestibulopathy, as well as those causing motor weakness, sensory or proprioceptive loss, or extrapyramidal dysfunction. Rehabilitation schemes for the significantly impaired patient start with an assessment of postural control in a seated position. Patients are taught methods to improve trunk stability and correct transient perturbations of balance. Once sitting balance is sufficiently mastered, patients progress through more challenging exercises. Functional exercises such as mobility training, transfer training, and gait training all provide a challenge to postural control and help facilitate improved balance. Advanced proprioceptive exercises include single-leg standing, balance-training platforms, wobble boards, and hopping.

Rehabilitation of an extremity where injury has significantly impaired voluntary motor control is likewise challenging. Selection of a rehabilitation strategy depends, in part, on whether the limb is flaccid or spastic. Treatment in the flaccid extremity focuses on exploiting synergy patterns of muscle activation to facilitate voluntary movement. In the spastic extremity, techniques such as the Bobath neurodevelopmental training method or proprioceptive neuromuscular facilitation are used along with gentle prolonged stretching to decrease spasticity and improve motor control by using specific tone-reducing postures and movement patterns.^10,11 Biofeedback with surface electromyography can be used to facilitate neuromuscular reeducation.¹¹ Orthoses and adaptive equipment are commonly used thoroughout the rehabilitation process to facilitate improvements in extremity function. These are discussed in more detail in subsequent sections.

Gait and Mobility

Many of the treatment principles outlined in the preceding sections are incorporated into the rehabilitation programs designed to improve mobility and gait. The mobility goals depend on the degree of neurological impairment. The ability to safely transfer independently is a critical factor determining a patient’s level of overall independence. Likewise, a safe method of household mobility (with or without assistive devices) is typically a principal goal of acute rehabilitation.

Specific techniques taught to patients to facilitate transfers include sliding board transfers and standing pivot transfers. Good trunk stability and triceps strength are requirements for sliding board transfers when patients have significant lower extremity weakness. Standing pivot transfers require good trunk stability, hip girdle strength, and quadriceps strength. Parallel bars and hemibars (a single bar for stroke rehabilitation) are used for gait training. The focus is on trying to achieve a fluid reciprocal gait. Specialized harness and treadmill apparatuses have been developed for gait training, including that for patients with significant impairments such as hemiplegia, paraplegia, and gait abnormalities associated with Parkinson’s disease.^12,13 Adaptive equipment and lower extremity orthoses are widely used throughout the rehabilitation process to facilitate improvements in mobility and ambulation.

Activities of Daily Living

Activities of daily living (ADLs) can be classified as basic ADLs and instrumental ADLs. Basic ADLs include such activities as feeding, grooming, bathing, dressing, and toilet use. Instrumental ADLs include higher level functions such as housekeeping, bookkeeping, shopping, telephoning, and managing medications.

Occupational therapists are specifically trained in ADL assessment and rehabilitation. The overall therapeutic goal is to use the fundamental rehabilitation schemes of flexibility, strengthening, and aforementioned methods of improving motor control as a means of acquiring independent ADLs. Specific ADL training and repeatedly practicing the skilled movements of daily activities, such as dressing and grooming, are also highly beneficial and are commonly incorporated into most rehabilitation programs. Adaptive equipment can be very helpful in allowing patients to achieve independence in ADLs as well.

Adaptive Equipment

As previously mentioned, rehabilitation of the neurologically impaired patient consists of two parts: (1) skilled therapeutic exercise to maximize function (as detailed in the preceding sections) and (2) prescription and incorporation of specific adaptive equipment to facilitate optimal function, mobility, and independence. Table 106-4 outlines some of the more commonly prescribed orthoses and their primary rehabilitation applications. Figures 106-4 to 106-9 depict common ambulatory aids. It is important for the physician and physical therapist to ensure that the prescribed orthosis or ambulatory aid is properly fitted and has the desired effect on function. Proper training with the assistive device to promote maximal function is particularly important with the prescription of ambulatory aids.

TABLE 106-4 Commonly Prescribed Orthoses and Their Primary Applications

Figure 106-4 Canes. Three different grip types are demonstrated with three single-point canes (left to right, C-handle, straight handle, and ergonomic grip) and a four-point cane (quad cane) (far right).

Figure 106-5 Crutches. Left to right, Platform crutch with arm tray and hand grip, Lofstrand crutch, and axillary crutch.

Figure 106-6 Aluminum walkers with (left) and without (right) wheels.

Figure 106-7 Hemi Walker. This is useful for patients with hemiplegia who cannot use a standard walker because of unilateral upper extremity weakness or spasticity.

Figure 106-8 Three-wheeled walker with large castor-type wheels, hand breaks, and a basket. This is useful for the more active and mobile patient who does not require an extremely stable base to lean upon. The large wheels are useful for negotiating uneven terrain.

Figure 106-9 U-Step walker. This walker provides a very stable base of support. The wheels are released when hand levers are gripped and then lock again upon release. A laser light projects on the floor at the patient’s feet to assist with the freezing gait pattern of Parkinson’s disease.

Before discharge from inpatient rehabilitation centers, patients should have their home environments thoroughly assessed. Some patients may require significant modification of their homes and need additional durable medical equipment to ensure a safe environment and provide the patient with maximal independence. Table 106-5 lists some of the more common equipment needs.

TABLE 106-5 Common Adaptive Equipment and Durable Medical Equipment Needs

Spasticity

Numerous therapeutic strategies exist for the management of spasticity in patients with upper motor neuron syndrome, including rehabilitation strategies, oral medications, intrathecal medications, focal chemodenervation, and surgery. Rehabilitation treatment strategies are variably effective¹⁴ and are summarized in Table 106-6. Spasticity scales, such as the Modified Ashworth Scale (Table 106-7), are helpful in monitoring response to treatment.

TABLE 106-6 Rehabilitation Strategies for Spasticity Management

TABLE 106-7 The Modified Ashworth Scale

Before aggressive medical or interventional therapies for spasticity are initiated, the patient should undergo a detailed assessment to determine which functional limitations or possible functional benefits their hypertonicity creates. For example, Ashworth grade 3 tone in the lower extremities of a paraparetic patient with multiple sclerosis may impair lower extremity dressing and personal hygiene. However, the spasticity may make standing pivot transfers easier, particularly if the patient has very poor lower extremity strength. The patient and physician may desire to reduce the spasticity through treatment; however, if therapy is successful and tone is significantly reduced, the patient may lose the ability to perform standing pivot transfers. Thus, both positive and negative effects on function must be considered before treatment, particularly if irreversible treatments such as neurolysis and surgery are being considered.¹⁵

The evaluation of a patient with worsening spasticity starts with a thorough assessment of potential noxious stimuli that may create amplification of muscle tone. Common causes of worsening spasticity in patients with SCI include bowel impaction, urinary tract infection, decubitus ulceration, acute abdomen, and pathological fracture. Rapid identification and treatment of these problems can result in a quick return to baseline tone.¹⁵

Neurogenic Bowel

Neurogenic bowel associated with SCI and other upper motor neuron disorders typically results in constipation and difficulty with stool evacuation. Rehabilitation interventions are aimed at bowel retraining and establishment of a routine bowel regimen.^16,17 The goals of a bowel program are to use either digital rectal stimulation or chemical stimulation (mini-enema or suppository) to trigger reflex evacuation of stool in the distal colon. For this to work appropriately, stools must be soft but well formed so that peristalsis can propagate the stool toward the rectum. Bulking agents such as fiber supplements and stool softeners aid in establishing optimal stool consistency. In a bowel program, patients typically evacuate daily or every other day.

For patients with incomplete neurological injury in which some voluntary motor function is preserved in the sacral segments, a bowel retraining program can be pursued. The goal is to restore the coordinated activation and relaxation of the muscles necessary to have a bowel movement. Intrarectal balloon training can facilitate voluntary evacuation.

Patients who have sustained lower motor neuron injury to the sacral segments face a more challenging task in maintaining stool continence.¹⁸ With partial nerve injuries, bowel retraining is focused predominantly on strengthening the pelvic floor, especially the puborectalis and the external anal sphincter. Persistent and significant fecal incontinence reduces patient dignity and may lead to avoidance of socialization. For severe persistent problems that jeopardize skin care, surgical sling procedures or colostomy are options.

Neurogenic Bladder

Neurological injury can cause a variety of problems with bladder function. In the first few weeks after an acute SCI, the bladder is usually flaccid (as a result of spinal shock), and urinary retention occurs. Indwelling catheters are usually placed on initial hospitalization, but as soon as appropriate, patients should be transitioned to an intermittent catheterization schedule. Patients are typically taught to self-catheterize at a frequency of four to five times a day. Oral hydration schedules are created to balance the patient’s needs for hydration without making it necessary to self-catheterize every few hours. The aim is to prevent accumulation of more than 500 mL in the bladder at one time and prevent overdistention, as well as overflow incontinence.¹⁹

If the patient regains sacral segment sensorimotor function, bladder training ensues. Patients follow timed voiding schedules and learn techniques to facilitate bladder emptying such as suprapubic compression or reflex-stimulated voiding. Patients can also undergo more intensive electromyographically assisted bladder retraining programs to improve coordinated activation and relaxation of the muscles necessary to evacuate the bladder.¹⁹ Postvoid residuals are monitored to ensure complete emptying. When patients can consistently achieve postvoid residuals of less than 100 mL, intermittent catheterization can be discontinued.

Many patients with SCI are at risk for developing detrusor sphincter dyssynergia, which results in a high-pressure bladder. In dyssynergia, the detrusor muscle spontaneously contracts, and the urethral sphincter does not concomitantly relax to allow bladder emptying. This creates high pressures in the bladder that force urine up the ureters into the kidneys; serious renal injury can develop. Dyssynergic bladders can be diagnosed with voiding cystomyography.²⁰ Patients with neurogenic bladder (especially high-pressure bladders) need to undergo periodic reevaluation with cystomyography and lifelong renal surveillance.²¹

Pressure Ulcers

Pressure ulceration of the skin can be a devastating complication of immobility. Patients with neurological injury are particularly at risk for pressure ulcers because of immobility and insensate skin. The body areas at highest risk are, first, the sacrum and then bony prominences such as the greater trochanters and heels. Furthermore, bowel and bladder incontinence can increase the risk of skin maceration and secondary infection.²²

Patients with the ability to reposition themselves should do so frequently. Paraplegic patients use triceps press-ups to provide transient pressure relief to their buttocks and legs. Dependent patients must be turned by a caregiver every 2 hours and have bony prominences padded. Wheelchairs should be fitted with pressure-reducing cushions, and patients who spend considerable time in bed need a pressure-reducing mattress.²²

Dysphagia

A clinical swallowing evaluation can be administered at the bedside to establish a basic understanding of a patient’s aspiration risk. A more extensive evaluation with video fluoroscopy can help determine how different food consistencies are handled at the oral, pharyngeal, and esophageal phases of swallowing.²³ Patients are taught protective and compensatory techniques for swallowing, such as the supraglottic swallow and the Mendelsohn maneuver.²⁴ Liquids may be particularly difficult to control during the oral phase and are easily aspirated. This risk can be minimized by using a flavorless gelatin to increase the consistency of the liquid without altering its taste. Avoiding foods with multiple consistencies (e.g., stews or soups) also decreases the risk of aspiration.

Communication

Speech and language disorders can be generally classified into four categories: aphasias, dysarthrias, dysphonias, and apraxia of speech. Speech-language pathologists can further characterize these disorders and formulate appropriate speech therapy interventions. Rehabilitation approaches vary according to diagnosis and target the patient’s primary impairments.²⁵ Other difficulties in communication may also result from confusion, ventilator dependency, and cognitive impairment, among other sequelae of significant neurological injury. Further discussion on evaluation and treatment of speech and language disorders can be found in Chapter 3.

Autonomic Hyperreflexia

Autonomic hyperreflexia is a potentially life-threatening condition that can occur in patients with SCI above the T6 level. Autonomic hyperreflexia develops when a noxious stimuli creates a sudden surge in sympathetic outflow that is not appropriately modulated by descending supraspinal inhibitory signals as a result of the SCI. This results in severe hypertension, headache, facial flushing, and reflex bradycardia (caused by stimulation of carotid sinus receptors).²⁶ Treatment consists of sitting the patient upright, quickly identifying and eliminating the noxious source, and, when necessary, administering antihypertensives such as nitrates or nifedipine.²⁶

Heterotopic Ossification

Heterotopic ossification is aberrant bone formation that can occur with a variety of neurological injuries, such as SCI, stroke, and traumatic brain injury. It most commonly occurs about the hips, knees, shoulders, and elbows. Early clinical manifestations are warmth and swelling of the affected area. If new bone formation is exuberant, loss of range of motion and even joint ankylosis can occur. Radiographs demonstrate new bone formation; however, the most specific test for early identification is the triple-phase bone scan. The blood flow and blood pooling phases show areas of angiogenesis and matrix formation even before ossification.²⁷ Initial treatment is institution of an aggressive range-of-motion program to prevent ankylosis of the joint. Bisphosphonates can reduce the severity of heterotopic ossification when they are initiated soon after the diagnosis is made.²⁸