Spinal Cord Injury: The Bridge Between Basic Science and Clinical Practice.

The goal of this special series is to prepare you for a potential revolution in the physical therapist's plan of care for people with spinal cord injury (SCI). Three major events supported the need for this special series on SCI.

First, Congress declared the 1990s the "Decade of the Brain," so it seemed fitting to end one decade and begin another with a focus on the spinal cord. Second, on Memorial Day in 1995, Christopher Reeve, an actor known for playing the role of Superman, was thrown from his horse and sustained injury to his spinal cord between cervical spinal vertebrae C1 and C2. Since his injury, Mr Reeve has focused the attention of the public, Congress, and the scientific community on seeking a cure for SCI. Third, the American Physical Therapy Association's Section on Research hosted a retreat entitled "Neuroplasticity: Interface of Basic and Applied Sciences in Clinical Practice" in August 1998, where it became clear that new knowledge about how the nervous system responds to injury needs to be shared with Journal readers.

A review of literature over the past 50 years indicates that automobiles designed to sustain greater impact and the use of seat belts, air bags, and helmets have decreased the severity of spinal cord injury. Vertebral fixation, decompression of the spinal cord, and reduction of the inflammatory process have reduced the extent of the initial spinal cord insult. Better medical management of secondary conditions has decreased the incidence of adverse events, including deep vein thrombosis, pressure ulcers, urinary tract infections, and pneumonia. Improved assistive technology has increased mobility; improved bowel, bladder, and sexual function; provided the individual with independent control over the environment; and improved the quality of life.[1] Finally, the 1990 Americans With Disabilities Act, the first comprehensive civil rights law for people with disabilities, provides a framework to ensure accessibility and employment for all people regardless of disability. Although progress has been remarkable, the emphasis has been on minimizing the extent of both the initial injury and the sequelae.

The principles that have been used to guide physical therapy intervention during this 50 year period have been based on early mobilization, preserved range of motion, proper positioning, and compensation to enhance mobility and independence. The Journal's first article about SCI appeared in 1947.[2] Saxton and Bailey began with the following statement: "Recent experiences ... have somewhat changed our previous opinions in regard to the apparent hopelessness of this type of injury. The patient is not always the total cripple that he appears to be."[2(p283)] Three different case examples stressed "mobilizing" the patient as soon as possible. The final conclusion was that "[t]herapeutic perseverance and interest along the lines pointed out cannot help but accomplish much good in a great many cases ordinarily considered helpless."[2(p286)]

In 1955, Bell outlined principles for rehabilitation of people with spinal paraplegia to include "compensatory training and readjustment of the normal parts of the body to substitute for the lost function of the paralysed muscles."[3(p235)] Examples of the compensatory training are clear in the description of walking patterns, pelvis tilt walking, swing-to gait, and swing-through gait.

In a section of the Journal in 1971 entitled "What's the answer?" physicians responded to a query about recommending long leg braces for patients with paraplegia.[4] Dr Robert R Jackson, Director of Craig Rehabilitation Hospital in Denver, Colo, stated that "experience with approximately one thousand such injuries indicates that most patients are going to find someone to brace them at some future date."[4(p823)] In other words, although some clinicians were of the opinion that walking occurred at great metabolic cost and was cumbersome and slow, in Dr Jackson's experience, people with paraplegia wanted to ambulate. The goal of the clinician has historically been at odds with the dream of the person with SCI. The clinical literature from 1971 through today indicates that the goal of compensating for "permanent" SCI has been enhanced with new types of tools, including biofeedback, electrical stimulation, improved orthotic materials and design, and improved assistive technology.

This Journal series will highlight ongoing work in both the basic science research laboratory and the clinical practice setting so that we can begin to evaluate the adequacy of the direct interventions listed in the Guide to Physical Therapist Practice,[5] beginning with Neuromuscular Practice Pattern F, "Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Spinal Cord." This series will address advances in medical and physical therapy management that enhance compensatory strategies for bowel, bladder, and sexual function; proper seating; wheelchair mobility or stability; and motor control through functional neuromuscular stimulation. The series will also present scientific evidence in animal models and humans that demonstrate that the spinal cord is capable of reorganization following injury, that the macroenvironment for the neurons is complex, and that the vasculature and vertebral integrity cannot be ignored in considering the goal of recovery. The articles will demonstrate that a clear bridge has been established between basic science and clinical practice. They suggest that we should be able to develop a sound theoretical basis for clinical practice.

Does the current evidence suggest that we are close to a cure for SCI? The relationships among the lesion site, the size of the lesion, the integrity of the vasculature, the amount of tissue sparing, and movement are yet to be established. Can physical therapy intervention enhance as well as retard spinal cord reorganization? Is there a critical period for physical intervention? What is an adequate "dose" of physical intervention? Is specificity of training an issue? How do we enhance motor learning? Is stepping induced on the treadmill related to independent ambulation that requires postural control? Does electrical stimulation promote spinal cord reorganization? What do we do to promote adaptive reorganization and minimize maladaptive reorganization? Should we encourage patients to forego surgery that will enhance function through tendon transplant and wait for a cure? Should we use limited direct intervention time to focus on treadmill training rather than conventional training in wheelchair mobility and transfer skills? All of these questions must be addressed as we proceed along this exciting new avenue.

Christopher Reeve is pushing for a cure. Others share the beliefs of Charles Krauthammer, who argued that "the newly paralyzed young might end up emulating Reeve, spending hours on end preparing their bodies to be ready to walk the day the miracle cure comes.... These kids should instead be spending those hours ... preparing themselves for the opportunities in the new world that high technology has for the first time in history made possible for the disabled."[6] We need to take an informed stand on the public debate that is raging about a cure for SCI. We need to continue with the conduct of the types of research discussed in this special series. It is our hope that this special series will provide a framework for meaningful discussion and additional research so that the person with SCI receives optimal direct intervention.

References

[1] Special issue: spinal cord injury--current research from the model spinal cord injury systems. Arch Phys Med Rehabil. 1999;80:1363-1514.

[2] Saxton L, Bailey G. Posttraumatic "cord" paralysis: role of physical therapy in rehabilitation. Phys Ther Rev. 1947;27:283-286.

[3] Bell DT. Principles and techniques of physiotherapy in the treatment of spinal paraplegia. Phys Ther Rev. 1955;35:235-237.

[4] Do you recommend long leg braces for patients with paraplegia? If so, what type of bracing do you prefer? What's the answer? Phys Ther. 1971;51:823-824.

[5] Guide to Physical Therapist Practice. Rev ed. Alexandria, Va: American Physical Therapy Association; 1999.

[6] Krauthammer C. Restoration, reality, and Christopher Reeve. Time. 2000;155:100.

[Craik RL. Spinal cord injury: the bridge between basic science and clinical practice. Phys Ther. 2000;80:671-672.]

RL Craik, PT, PhD, FAPTA, is Associate Professor, Department of Physical Therapy, Beaver College, 450 S Easton Rd, Glenside, PA 19038-3295 (USA) ([e-mail]).