In patients with spinal cord injury, in whom innovative robots were used in rehabilitation: exoskeleton and locomotive, progress in exercise therapy is accelerated. These are the conclusions of over three years of scientific research conducted with patients of the Research Institute of Innovative Methods of Rehabilitation of People after Spinal Cord Injuries of “Uzdrowisko Kamień Pomorski” SA. The experience gained during the research project is used in the rehabilitation program of patients with spinal cord injury, conducted in a specialized center in Kamień Pomorski.
Spinal Injury in Statistics
Every year, around 250 to 500 people worldwide experience spinal cord injury (URK). The cause of URK is damage to the nerve structures of the spinal cord, including the cone. Spinal injury is often associated with vertebral fracture or dislocation of the vertebrae as a result of mechanical impacts, vessel damage, mechanical pressure, cuts, etc. As a result of the cascade of pressure-related processes and ischemia, mitochondria are damaged, proteolytic enzymes are activated, proteins of the cytoskeleton are broken down and free radicals are produced, which further damages the spinal cord, often leading to the formation of a traumatic cavity in time.
The most common causes of URK are road accidents and falls from heights. Globally, the number of patients with CRC and patients with non-traumatic spinal cord injuries is increasing, and the number of patients requiring permanent or artificial ventilation after cervical injuries is increasing. The average age of patients is also higher due to the increased incidence of injuries in the elderly. The male-to-female ratio for post-CRC patients is 4: 1.
Time from injury important for the effects of rehabilitation
The mortality rate in the first phase after URK is directly related to the availability and quality of primary care and rehabilitation. Life expectancy depends on the degree of integration with complications such as pressure ulcers or urological problems, but patients who have undergone SCR are also at an earlier risk of developing cardiovascular disease due to metabolic syndrome. They are more common in osteoporosis, psychological disorders, intestinal, urinary, musculoskeletal and respiratory disorders; neuropathic pain, skin lesions and many other problems resulting from immobilization. Therefore, an important aspect in the rehabilitation process is the time after the injury.
The most spectacular results are obtained in patients with an injury that occurred within a year from the start of therapy, preferably up to one year after a spinal cord injury, and the best candidates are people with incomplete ASIA type C injury, i.e. a patient with severe limb paresis.
Purpose of rehabilitation after spinal cord injury
One of the biggest challenges in neurorehabilitation is restoring functional independence, improving the quality of life, and regaining the ability to plan and perform movement, mainly walking. Functional training in the field of locomotion is therefore one of the goals of rehabilitation of patients after URK.
Unfortunately, weight training (BWS – body weight suport) on a treadmill in combination with manual assistance often leads to exhaustion of the physical therapist. Due to the rapid technological development, the idea of improving rehabilitation, robotic devices have been developed that take into account the possibility of generating repetitive and progressive movements depending on the motor disability.
Research with patients after spinal cord injury
“Advanced rehabilitation program for patients after spinal cord injury with the use of rehabilitation robots”, Financed by the National Center for Research and Development. The aim of the program was to develop the best treatment regimens in patients after spinal cord injury and to create standards for qualifying these patients for rehabilitation with the use of robotics. On a daily basis, the patients were assisted by an experienced team of specialists led by prof. dr hab. n. med. Beata Tarnacka, head of the Rehabilitation Clinic of the Medical University of Warsaw.
The research conducted at the “Uzdrowiska Kamień Pomorski” Research Institute shows that the therapy with the use of robots, carried out as an addition to the conventional therapy, is more effective and brings better results than rehabilitation without the use of robotics.
Works in rehabilitation
In specialist rehabilitation after a spinal cord injury, at “Uzdrowisko Kamień Pomorski” SA, robotic devices are used, which can be briefly divided into stationary robots (e.g. Lokomat) and overgr devicesound walking systems i.e. exoskeletons and active exoskeletons, otherwise wearable devices that enable walking in this device.
Robots used for gait therapy provide the possibility of goal-oriented rehabilitation, gait patterns similar to natural ones, they also increase the patient’s motivation. The individualization of therapy, orientation towards the patient’s goals and increasing his functional abilities are maintained. Therefore, robotic therapy leads to an increase in the effectiveness of rehabilitation and may accelerate the achievement of subsequent stages of rehabilitation.
The benefits of robotic rehabilitation depend on the ability of each patient to adapt to changes in speed and load generated by the device, improve and strengthen motor functions in therapy, especially in patients with advanced disabilities in early rehabilitation.
The ability to stand for patients who have not previously got out of bed, had limited mobility or were in a wheelchair, has a number of advantages affecting each of the body’s systems: skeletal system, muscular system, vascular system, respiratory system, digestive system and glandular function endocrine. Vertical movement regulates circulation, improves the functioning of the cardiovascular system, regulates the functions of the urinary tract, supports the functioning of the kidneys. Even in those patients who failed to restore the gait function, significant improvements were noted, e.g. in the urinary tract, decreased breathing disorders or improved exercise tolerance.
Specialists from “Uzdrowisko Kamień Pomorski” emphasize that rehabilitation with the use of a locomotive or exoskeleton also has a very positive effect on the psyche of patients who often stand on their own legs for the first time in months.
Comprehensive rehabilitation after a spinal cord injury
The rehabilitation plan in “Uzdrowisko Kamień Pomorski” is established in teams with the participation of a doctor, physiotherapist, nurse and psychologist. In the rehabilitation program, in addition to gait training with the use of robots, individual exercises with a physiotherapist are used, including PNF exercises and classic physiotherapeutic activities in the field of kinesiotherapy, physical therapy, hydrotherapy, and massage that support or prepare for rehabilitation.
During treatment in the center in Kamień, attention is paid not only to the aspect of mobility, but also to other problems that patients with spinal cord injury struggle with, such as depression, urological problems, disorders in the sphere of sexual life, breathing disorders during sleep. . The aim of comprehensive rehabilitation is also to teach a disabled person how to cope with basic life activities, e.g. in the shower, in the swimming pool or in the car.
Qualification process and contraindications
More and more rehabilitation centers in Poland have this type of device. However, a very important aspect is the experience in rehabilitation with these patients and the correct qualification of the patient. This therapy carries a number of dangers for the patient, so it is not a therapy for every patient after CRC.
In “Uzdrowisko Kamień Pomorski”, when qualifying for this therapy, it is taken into account whether the patient has good trunk stabilization while sitting, or whether the patient can move from bed to a wheelchair by himself. For exoskeleton therapy, the patient must have sufficient upper limb function to be able to move with a walker or elbow crutches. Moreover, the patient must be adjusted to a standing position (possibility of a 30-minute upright position) and full verbal and logical contact must be maintained with him.
Contraindications to this therapy are: orthopedic disorders that prevent standing-standing, bedsores, skin lesions that may aggravate the exoskeleton or other stationary system; very severe spasticity on the Ashworth scale 4-5, contractures in the joints, pulmonary and cardiovascular diseases affecting the patient’s performance, colostomy, severe obesity and very tall and short stature.
For people who are not qualified for rehabilitation with the use of robots, the Health Resort has prepared a comprehensive rehabilitation after a spinal cord injury without robotics.
Text in collaboration with prof. dr hab. n. med. Beata Tarnacka
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