New concept of medical rehabilitation for spinal cord injury

What is medical rehabilitation?

Comprehensive rehabilitation includes four major aspects: medical rehabilitation, education rehabilitation, vocational rehabilitation and social rehabilitation. Medical rehabilitation is the use of all medical techniques and methods for rehabilitation, functional assessment, and rehabilitation of disabled people to alleviate various adverse effects caused by disability and achieve rehabilitation goals. The intervention of clinical medicine and rehabilitation medicine received by patients in the hospital belongs to the category of medical rehabilitation. Patients with spinal cord injury need to be fully recovered, first of all, medical rehabilitation is needed. The medical rehabilitation of spinal cord injury has experienced a process from scratch, from weak to strong, and it also faces the renewal of ideas.

The development of medical rehabilitation of spinal cord injury in China and its current situation

During the Second World War, a large number of patients with spinal cord injury occurred. Mr. Guttmann fled to the United Kingdom to establish a British spinal cord injury rehabilitation center, and gradually summarized the concept of modern rehabilitation of spinal cord injury from the rehabilitation practice of spinal cord injury. In the Tangshan earthquake in 1976, the recovery of spinal cord injury in China was almost blank. The patients with spinal cord injury in China still could not enjoy rehabilitation. In 1988, the China Rehabilitation Research Center was established, and the Chinese Disabled Rehabilitation Association Committee for Spinal Cord Injury was established. Zhou Tianjian The older generation of experts in the field of spinal cord injury have introduced the modern rehabilitation concept of spinal cord injury to China.

Professor Zhou Tianjian, founder of Spinal Cord Neurospatial Reconstruction, China Rehabilitation Research Center

Therefore, the rehabilitation of spinal cord injury in China has experienced two stages: the “pre-modern rehabilitation era” before 1988 and the “modern rehabilitation era” after 1988.

The modern rehabilitation concept of spinal cord injury has been introduced into China, which has made great progress in the rehabilitation of spinal cord injury in China. For decades, traditional rehabilitation methods for spinal cord injury have played a crucial role in preventing complications and improving the quality of life of patients.

However, due to the late start of rehabilitation medicine in China, the development of rehabilitation medicine is lagging behind. After decades of development, there are still some misunderstandings about rehabilitation in China: 1. It is considered that rehabilitation is the treatment after treatment; Rehabilitation is to support the elderly; 3, that rehabilitation is physical therapy; 4, that rehabilitation is Chinese medicine treatment and so on.

In addition to the misunderstanding of understanding, there is still a shortage of rehabilitation talents in China. The Capital Medical University established the first rehabilitation medical school in China. The number of graduated medical students is 30-40, and the number of graduates in the country is about 2,000. This is far from meeting the needs of society. At present, most of the rehabilitation doctors or therapists in China are transferred from nursing and Chinese medicine practitioners. The knowledge structure is seriously unreasonable and needs continuing education.

Dissection of clinical and rehabilitation in medical rehabilitation

The above reasons lead to serious disconnection between rehabilitation and clinical practice in China, mainly in the following aspects: 1. The knowledge structure of the rehabilitation physician and the clinician is out of line, the clinical knowledge of the rehabilitation physician is seriously lacking, and the rehabilitation knowledge of the clinician is seriously lacking; 2. Workflow The disconnection, although there is theoretical Teamwork, but the clinical doctor often does not know what the patient is doing, what should be done, and the rehabilitation therapist does not know the patient's overall condition, whether there are rehabilitation contraindications, etc.; 3, the concept of disconnection, the concept of rehabilitation physicians is the recovery of function, often overlooking the important link in the application of clinical treatment intervention to improve function in medical rehabilitation, often in the rehabilitation platform period will not break through, so that the rehabilitation effect is greatly reduced; clinical The philosophy of the physician is to treat the disease, often lacking the concept of functional recovery, making many clinical operations unfavorable for functional recovery.

In recent years, the incidence of spinal cord injury in China is relatively high. The medical rehabilitation status of patients with spinal cord injury is the same as the above-mentioned situation. There are many disadvantages such as disconnection between clinical and rehabilitation, late start of rehabilitation, and lack of rehabilitation personnel. Therefore, the concept of medical rehabilitation after spinal cord injury needs to be updated.

New concept of medical rehabilitation for spinal cord injury in China

The author believes that the concept of medical rehabilitation after spinal cord injury needs to be updated from the following aspects. The first is to establish an integrated management concept of spinal cord injury clinical and rehabilitation; the second is to predict the complications of spinal cord injury in the clinical and rehabilitation of spinal cord injury; the third is to create a new system for the assessment of spinal cord injury prognosis, for scientific development The fourth is to break the bottleneck of traditional thinking and create an era of functional reconstruction of spinal cord injury.

First, the integrated management concept of clinical and rehabilitation of spinal cord injury

1. Doctor: Starting from the aspect of medicine, create an integrated management system for clinicians and rehabilitation physicians.

In order to achieve this goal, the university curriculum must take into account both clinical and rehabilitation; it is necessary to stipulate that medical students can only learn rehabilitation courses after learning certain clinical course knowledge, and must learn rehabilitation courses.

From the perspective of government policy formulation, it is necessary to call on the government to allow doctors to register both clinical and rehabilitation practice; the work injury, insurance, and medical insurance policies need to be more humanized, and the rehabilitation and clinical separation will not be separated, and clinical and rehabilitation reimbursement will be included.

In terms of hospital development and department setting, major hospitals need to set up a comprehensive clinical department. All the medical staff are professionals who are both good at clinical practice and good at rehabilitation. The doctors are qualified for clinical practice and rehabilitation.

Under the guidance of the concept of integration of clinical and rehabilitation, the knowledge structure of medical talents is optimized to realize the integrated management of clinical and rehabilitation of patients with spinal cord injury. Make clinical work and rehabilitation work lay the foundation for each other; rehabilitation work and clinical work serve each other; clinical and rehabilitation are mutually infiltrated. Realize the optimal combination of clinical treatment process and rehabilitation process to maximize the recovery of patient function; truly realize “clinical plus rehabilitation integration: Teamwork”.

2. Suffering: The patient achieves the optimization of medical rehabilitation; enjoys the integrated and comprehensive service of clinical treatment and rehabilitation; enjoys the combined treatment plan of clinical treatment and rehabilitation.

3. Improve the relationship between doctors and patients. The role of doctors can only be to develop and implement clinical and rehabilitation treatment programs; all clinical and rehabilitation measures must be carried out through the patient's own physical and psychological repair compensation and rehabilitation mechanisms; both doctors and patients can fully understand this. They have a more scientific attitude towards their roles, tasks, and treatment of disease prognosis. Therefore, the realization of the integration of doctors and patients is the best weapon for doctors and patients to overcome the disease together, and is also the best realm of harmonious doctor-patient relationship.

Second, predictive treatment of complications of spinal cord injury

With the in-depth study of the clinical and rehabilitation of spinal cord injury, the treatment process of various complications and even the evidence-based medicine will be published one after another. Our department has already developed a process for the treatment of various complications. If patients with spinal cord injury are treated according to these procedures Will greatly reduce or avoid complications. The effects of complications can be minimized.

For example, in the treatment of heterotopic ossification after spinal cord injury, we should take refrain from violent rehabilitation training or nursing activities to prevent it from happening as much as possible; take MRI examination in the early stage of suspected heterotopic ossification, and determine the diagnosis as soon as possible; After that, a series of procedures such as anti-inflammatory analgesic drugs such as indomethacin, local cold compresses, maintaining a good posture of the limbs, and preventing joint mobility are limited, and prevention, diagnosis and treatment of heterotopic ossification after spinal cord injury. The treatment was carried out with satisfactory results.

Third, create a new system for the evaluation of prognosis of spinal cord injury, and develop a medical rehabilitation program for science

At present, the commonly used spinal cord injury evaluation method is the ASIA classification evaluation method. However, since the accuracy of the method is interfered by subjective and objective factors such as the proficiency of the evaluator, the subjective difference of the judge, and the guess of the patient, the letter Degrees and sensitivities have certain limitations, and there are clinically biased assessments.

In recent years, neuroelectrophysiology has demonstrated certain advantages in the evaluation of spinal cord injury. Some scholars have applied such as quantitative evaluation of sensory, quantitative evaluation of proprioception, somatosensory evoked potential (SEP), quantitative evaluation of motor function, H reflex, estimation of the number of motor units, etc. to judge the prognosis of patients.

The authors believe that the diagnosis of spinal microscopic imaging will be a rapidly emerging and emerging discipline. The development of this discipline will enable clinical and rehabilitation physicians to clearly determine the microscopic structure of spinal cord injury and the extent of damage to these structures. Therefore, the development of this discipline will also lead the SCI prognosis trend.

Therefore, the comprehensive prognostic assessment of scientific spinal cord injury will be the future trend; the comprehensive score of "ASIA score + neuroelectrophysiological score + microscopic imaging score" may be published soon. This will provide clinical and rehabilitation physicians with an accurate system for predicting the prognosis of spinal cord injury. Of course, we don't have to worry that this process will take up too much time. The development of computer information technology will make this evaluation easy, and it will be a good thing to hit a few times.

Based on scientifically correct prognosis assessment of spinal cord injury, clinical and rehabilitation physicians can develop more scientific and rational treatment and rehabilitation programs for patients with spinal cord injury. For patients with incomplete spinal cord injury, the main function of the spinal cord should be promoted. The rehabilitation training program is mainly aimed at promoting the recovery of the spinal cord's own function, while preventing complications; after a certain period of time, for the function of hopeless recovery, After the nerve function recovery stops, the function is reconstructed as soon as possible. For complete spinal cord injury, the rehabilitation goal is not to restore the function of the spinal cord itself; the rehabilitation training is mainly to prevent complications and improve self-care ability; to take functional reconstruction as soon as possible to determine that the spinal cord's own function cannot be restored. Measures to improve the patient's limb function.

Fourth, break the bottleneck of traditional thinking and create an era of functional reconstruction

Under the circumstance of traditional medical rehabilitation knowledge and ideas, people tend to stick to the rules, rigid ideas, and conservative methods. It is often the case that a large number of valuable drugs are still being applied in the case where the spinal cord function is impossible to recover, and it is hoped that a miracle will occur. It is also often in the spinal cord injury rehabilitation process stepping into the platform period, only through functional reconstruction surgery can improve or improve the function, but stick to the rules, too conservative, resulting in missed opportunities, so that the limb function is difficult to improve.

With the development of medicine, the discipline of functional reconstruction after spinal cord injury has gradually emerged. The medical rehabilitation after spinal cord injury is no longer pure PT, OT, physiotherapy, etc., but includes a series of complex interdisciplinary means to improve or improve limb function. In addition to the above-mentioned traditional rehabilitation methods, these comprehensive methods mainly include the reconstruction of surgical functions, the application of intelligent assistive devices, and the transformation and application of bioelectronics.

1, surgical function reconstruction

Surgical function reconstruction after spinal cord injury is based on modern rehabilitation, comprehensive application of surgical techniques to reconstruct or improve the physiological function of patients with spinal cord injury. When the recovery of spinal nerve function is stagnant, the improvement of the limb function of the patient enters the plateau stage. If the traditional rehabilitation methods and concepts are adhered to, the limb function of the patient is difficult to improve; on the contrary, if the function reconstruction surgical technique is properly applied, the patient's limb function And the quality of life can be a big step. "The shot will be shot when it is shot." This is the new concept of functional reconstruction of medical rehabilitation after spinal cord injury: break through the traditional concept of rehabilitation, seize the opportunity, make full use of functional reconstruction surgical techniques, and improve limb function.

(1) Upper limb function reconstruction: Comprehensive surgical methods such as tendon transfer and neurotransfer surgery to reconstruct the function of upper limbs and hands at appropriate time can greatly improve the quality of life of patients. Since the establishment of the Department of Spinal Cord Neurosynthesis in Beijing Bo'ai Hospital, China Rehabilitation Research Center, the patients with cervical spinal cord injury have been treated with tendon transfer surgery since 2009. Many non-functional hands have regained their functions and achieved satisfactory results.

Patients with cervical spinal cord injury are fed by their families all the year round. They can eat themselves after the hand function reconstruction surgery, and the quality of life is greatly improved.

(2) Reconstruction of lower limb function: Many patients with spinal cord injury have serious complications such as limb paralysis and limb malformation, which seriously affect standing and walking. After removing sputum, balancing muscle strength, correcting deformities, and expanding the weight-bearing area, you can improve standing and walking functions – something that traditional rehabilitation methods can't match. China Rehabilitation Research Center Beijing Bo'ai Hospital Spinal Cord Neurospatial Function Reconstruction Department Since the establishment of the Department of Medicine in 2009, the use of the above comprehensive surgical methods to reconstruct the lower limb standing and walking function of patients with spinal cord injury has enabled many patients to stand up again and obtain satisfactory results.

Patients with spinal cord injury can improve standing and walking functions by removing sputum, correcting deformities, expanding the weight-bearing area, and improving the mechanical conduction.

(3) Reconstruction of respiratory function: Reconstruction of respiratory function by nerve transfer, transfer of scapular muscle to chest wall to improve respiratory function is a reconstruction of respiratory function in our department in recent years, and has achieved satisfactory clinical results. The clinical application of sacral nerve stimulator and diaphragm pacemaker will also bring good news to patients with high cervical spinal cord injury and respiratory dysfunction.

Respiratory dysfunction in patients with high cervical spinal cord injury is prone to respiratory failure. The intervention of surgical techniques for respiratory function reconstruction will improve respiratory function and make the patient's smoothness overcome difficulties.

  (4) Reconstruction of other functions: sexual function reconstruction, bladder function reconstruction, rectal function reconstruction, etc. have been developed in the field of surgical function reconstruction, and will become the exciting content of functional reconstruction surgery in the future.

2. Application of intelligent auxiliary equipment

In recent years, the development of intelligent rehabilitation aids has made great achievements. Improving walking ability is an important goal for patients with complete or incomplete spinal cord injury. Patients with complete spinal cord injury can compensate for their function with intelligent aids. Such as the application of rehabilitation robots to achieve lower limb motor function reconstruction. For patients with incomplete spinal cord injury, intelligent assistive devices can be used for rehabilitation training to enhance their standing and walking functions.

3. Conversion and utilization of bioelectronic technology

(1) Development and application of brain-computer interface technology

Brain-computer Interface (BCI) is an advanced technology that extracts, collects, and analyzes human brain thinking signals and transmits these signals to computers or related devices. After effective signal processing and pattern recognition, The computer completes the desired actions and behaviors of the patients with spinal cord injury, and achieves the control of the environment or the purpose of self-care. The human brain signals currently available for BCI are: EEG (electroencephalogram), EMG (brain magnetography) and fMRI (functional magnetic resonance imaging), which is undoubtedly a high-level, complete spinal cord injury patient. An ideal choice.

(2) Development and application of artificial neural prosthesis technology

The working principle of the neuroprosthesis belongs to the category of FES and can be divided into in vitro transcutaneous electrical stimulation (TENS) and in vivo implantation of electrical stimulation. Implants are generally divided into in vivo implants (electrodes, leads and subcutaneous receptor-stimulators) and in vitro control sections (control boxes and emitters). Four kinds of neuroprostheses have been developed: surface functional electrical stimulation devices, implantable muscle-mediated functional electrical stimulation devices, microelectrode electrical stimulation in peripheral nerves, and spinal microstimulation in the lumbosacral segment.

The BCI system completes the detection and classification and recognition process of the EEG signal, and then outputs the command to the neural prosthesis, compensates the peripheral nerve that has lost its function, and completes the functions of exercise, walking, etc., so that the patient with complete limb loss can be in the unmanned Take care of some simple activities or perform functional assisted training.