Introduction
Traumatic spinal cord injury (SCI) is a leading cause of disability, especially among younger people, and it has a high impact on the length of life after disability. Globally, SCI is estimated to have an incidence of 90,000 people every year, with a prevalence of more than 20 million [1,2]. However, these numbers remain to be underestimated because most developing countries do not have a formal spine registry for accurate documentation. Rehabilitation of patients with SCI plays an important role in preventing secondary complications and aiding their early reintegration into society [3,4]. Regardless of its completion, SCI rehabilitation is a long process that requires patience and motivation of patients and their relatives. Early rehabilitation is important for preventing joint contractures and muscle strength loss, preserving bone density, and ensuring normal functions of the respiratory and digestive systems [5].
The socioeconomic impact of SCI is a major obstacle to comprehensive rehabilitation. The development status and socioeconomic markers, such as Human Development Index, of a country have been found to directly affect the rehabilitation of patients with SCI [6]. This trend is especially relevant in the developing countries of Asia and Africa and contributes to the global burden of SCI. In India, most patients with SCI belong to the lower and middle socioeconomic strata and are unable to access or afford timely rehabilitation services, leading to increased morbidity and secondary complications [7–11]. The effect of SCI on mental health is another important factor that determines outcomes. Several studies have confirmed the role of rehabilitation in the psychological well-being of patients at risk. Moreover, patients with SCI who lack livelihood and social support were more likely to develop clinical depression and have increased suicide rates [12,13].
Currently, only few studies have compared the outcomes of early and late rehabilitation for SCI. A Japanese multicenter study by Sumida et al. [14] reported that early rehabilitation was effective in hastening and promoting improvements in activities of daily living (ADLs). In 2017, the clinical practice guidelines published by AO spine suggested initiation of rehabilitation as soon as the patient is medically fit [15]. However, this recommendation was based on expert opinion and not on quality clinical evidence. A systematic review by Burns et al. [16] reported that the current evidence for early rehabilitation after acute and subacute SCI is limited and has methodological issues. In view of these challenges, we conducted a study to understand the role and clinical, psychological, and socioeconomic impact of the timing of rehabilitation for traumatic SCI.
Materials and Methods
This study was conducted at our Spine Injury Rehabilitation Center (SIRC), which is a dedicated unit for patients with SCI and is under a tertiary care center for spinal trauma. After receiving approval from the Institute Ethics Committee (IEC no. 2022/12/04) of Ganga Medical Centre and Hospitals, Coimbatore, we conducted a retrospective study on patients with traumatic SCI who underwent rehabilitation at the SIRC between January 2018 and December 2022 and were regularly followed up. Need for individual patient consent was waived off as this was a retrospective study. The SCIs involved the thoracic and thoracolumbar levels (e.g., T2–L2 fractures) with complete motor paralysis (American Spinal Injury Association [ASIA] grades A and B). Patients with cervical injuries; incomplete injuries, such as ASIA grades C and D, cauda equina, and conus medullaris syndromes; nontraumatic etiology; low-lying spinal cord or tethered cord; and age <18 years were excluded from the study.
Admission to the SIRC
Patients admitted to the SIRC were referred from Ganga Medical Centre and Hospitals, Coimbatore, directly after management of spinal injuries, referred from other centers where the injuries were initially managed, or consulted us as outpatients for rehabilitation after being managed at other centers for SCI. All patients were initially evaluated clinically and radiographically by the physicians and SCI rehabilitation team for their general fitness to undergo rehabilitation. The surgical site was assessed for wound healing, and the baseline neurological status was recorded using the ASIA impairment scale [18] and Lower Extremity Motor Score (LEMS). Functional status was assessed using the Functional Independence Measure (FIM) score [19]. The Beck Depression Inventory (BDI-2) was used to document psychological status [20]. Medical complications or possible events, such as urinary tract infection (UTI), deep vein thrombosis (DVT), and early-grade pressure sores, were documented before admission for rehabilitation.
In a study of 123 patients with SCI, Sumida et al. [14] concluded that the chances of motor recovery and FIM score improvement were significantly higher when rehabilitation was started within 2 weeks after the injury. Gorgey and Dudley [17] found >45% loss of muscle mass in patients with SCI within 6 weeks of injury. Based on these studies, we divided our patients into the following three groups according to the timing of rehabilitation initiation:
Group 1 (early rehabilitation within 2 weeks of the injury)
In this group, rehabilitation was started in the postoperative period during hospital stay. The program included in-bed exercises, continuous passive motion exercises, incentive spirometry, chest physiotherapy, and wheelchair mobilization. After hospital discharge, the patients were immediately transferred to the SIRC for continuity of rehabilitation.
Group 2 (subacute rehabilitation)
This group comprised patients who were admitted for rehabilitation at 2–6 weeks after injury, including those who were treated at our hospital for spinal injuries and preferred to return home and be admitted to the SIRC later because of personal or financial reasons or those who were referred to the SIRC from other hospitals after initial management.
Rehabilitation protocol
The rehabilitation plan was based on the characteristics of ADLs. All rehabilitation sessions began within 24 hours of admission. At the SIRC, we follow a uniform protocol for all patients with paraplegia secondary to traumatic SCI (Tables 1, 2). The rehabilitation endpoint was adjusted according to the likelihood of significant functional limitations based on the level of injury. In addition, all patients underwent 45 minutes of hydrotherapy twice weekly and 45 minutes of occupational therapy 3 days a week. The education of caregivers and family members was also an important part of the rehabilitation strategy. All patients and their caregivers were taught about back care, catheter care, clean intermittent self-catheterization (CISC), breathing exercises, pulmonary toilette, and transporting oneself to and from the bed and wheelchair. Caregivers were encouraged to perform these tasks multiple times under supervision before discharge planning.
Checklist before discharge
Patients were discharged from the SIRC after demonstrating the following tasks independently or with minimal assistance: (1) pelvic lifting, (2) trunk control (not for patients with injuries above T7), (3) transfers (wheelchair, toilet, or vehicle), (4) accustomed to using a wheelchair for ambulation, and (5) able to do CISC.
Data collection
After discharge from the SIRC, patients were followed up in person at our clinic at 6 and 12 months postoperatively and then once a year thereafter. During each follow-up, the functional outcomes, current job status, and any complications were documented. Data were collected from the outpatient visit records. Length of stay at the SIRC, change in LEMS, and FIM scores at the time of SIRC discharge and on the last follow-up were compared among the three groups. The socioeconomic impact of rehabilitation and change in socioeconomic status were assessed using the Modified Kuppuswamy Socioeconomic Scale 2019 (MKSS) [21]. The incidence of readmissions; complications, such as UTI, pressure sore, DVT, and pulmonary embolism; and mortality were compared among groups.
Statistical analysis
We performed statistical analysis using jacobi ver. 2.5 (https://www.jamovi.org/). Descriptive statistics were presented as mean (standard deviation [SD]) for continuous variables or as frequency (percentage) for categorical variables. Continuously distributed data were compared among groups using repeated measures analysis of variance. Statistical significance was set at a p-value of <0.05.
Results
Demographics
After data screening, 82 patients qualified for inclusion; 12 patients who did not regularly undergo follow-up were excluded. The remaining 70 patients were classified as group 1 (n=30), group 2 (n=18), and group 3 (n=22). The demographic characteristics are summarized in Table 3. The mean±SD age was 33.6±12.65 years (range, 18–62 years) overall; 34.2±13.92 years for group 1; 34.55±12.68 years for group 2; and 32.18±10.84 years for group 3. There was no significant difference in mean age among the three groups. Overall, there were 62 men and eight women; groups 1 and 2 included two women each, and group 3 included four women. In all groups, there were more men than women (p<0.05, by chi-square test). The mean body mass index (BMI) of the cohort was 24.66 kg/m2 (range, 18.2–33.9 kg/m2). Overall, five patients were classified as obese (BMI >30 kg/m2), and 27 were overweight (BMI >25 to 29.9 kg/m2).
Nine students and six housewives were dependent on their family even before the injury. The most common mode of injury was falling from a height (n=41), followed by road traffic accident (n=28) and physical assault (n=1). Of the 70 patients, 14 were manual laborers/daily wage workers. Only three of 18 patients were admitted for early rehabilitation (group 1).
Level of injury and timing of surgery
The most common injuries were translational (AO type C, n=44), followed by flexion-distraction (AO type B2, n=14) and burst fractures (AO A4 type, n=12) (Table 3). The most common vertebral levels involved were T7–T10 (n=29) and T11–L2 (n=24); levels above T7 were the least common (n=17). The mean FIM scores on follow-up significantly differed according to the level of SCI (p<0.05), as follows: 58.96 overall, 53.42 for above T7, 55.8 for T7–T10, and 67.66 for T10–L2.
Surgical intervention was early (within 72 hours of the injury) in 61 of 70 patients. Of the nine patients who received late interventions, two underwent surgery within 5 days of optimized care, and seven underwent surgery after 5 days. Notably, the FIM scores on follow-up did not significantly differ between the early and delayed surgery groups (63.1 vs. 58.4, respectively).
Length of stay
The mean length of stay in the SIRC was significantly higher in group 3 than in groups 1 and 2 (9.75 weeks vs. 6.1 weeks vs. 5.9 weeks, respectively; p<0.01).
Functional outcomes
The overall mean±SD FIM score was 22.6±10.2 at admission and increased to 45.08±15.6 at discharge. On the last follow-up after rehabilitation, the mean FIM score significantly increased to 60.75±15. In the subgroup analysis, the baseline FIM score at the time of admission to SIRC was higher in group 3 than in the other groups. However, improvement in FIM score was significantly lower in group 3 than in groups 1 and 2 (Fig. 1). The comparison of all parameters among the groups is summarized in Table 4. Improvement in FIM scores was not significantly correlated with BMI (p=0.37) and neurological improvement.
Effects of income and socioeconomic status
The overall preinjury mean MKSS score was 16.98±5.5; 46 of 70 patients belonged to the middle class (27 in lower middle and 19 in upper middle). The mean MKSS score before enrolment to rehabilitation was significantly lower in group 3 than in groups 1 and 2 (13.9 vs. 18.2 vs. 17.3, respectively; p=0.007). After injury, 38 patients were classified as lower class due to loss of livelihood. On follow-up, 30 patients remained unemployed; most were laborers and had agricultural backgrounds. On subgroup analysis, the proportion of unemployed persons was significantly lower in groups 1 and 2 (30% and 27.7% respectively) than in 72.2% in group 3 (Table 5, Fig. 2).
Psychological outcome
The overall mean BDI score was 23.26±7.6, indicating mild to moderate depression in all patients with SCI. Compared with the other groups, group 3 had a significantly higher BDI score of 32.6±8.4. Of the 14 patients, 14 were classified as having severe depression, of whom 12 belonged to group 3.
Neurological recovery
Of the 70 patients, 12 achieved neurological recovery with a mean LEMS score improvement of 6.7; eight patients were in group 1 and four patients were in group 2. Of the 12 patients who achieved neurological recovery, nine had American Spinal Injury Association Impairment Scale (AIS) grade B on admission. None of the patients in group 3 achieved neurological recovery. The hip flexors and knee extensors were the most common muscle groups that showed some recovery. Of the 12 patients who showed some motor recovery, nine showed improvement only in the L2 and L3 myotomes (i.e., hip flexors and knee extensors), and the other three patients showed additional improvements in the toe flexors. In all these cases, the AIS grade improved to C from A/B. There was no association between neurological recovery and level of injury.
Readmissions and complications
Of the 70 patients in this study, seven patients were readmitted because of pressure sores (n=3) and UTI (n=4). Overall, eight patients developed pressure sores; three patients had to be readmitted for debridement and flap coverage (one from group 2 and two from group 3), whereas the remaining five patients were managed by regular dressings at home and did not need readmission. Four patients (one from group 1, two from group 2, and one from group 3) developed UTI, which was managed by a course of intravenous antibiotics. None of the patients developed pulmonary embolism, DVT, or myocardial infarction. There was no mortality in our study population. There were no differences in the incidence of complications among the groups.
Discussion
In this study, we evaluated the functional outcomes and reintegration into society of patients with SCI. According to the World Health Organization, SCI occurs in 250,000 to 500,000 people annually, with more than 80% of injuries sustained by people under 25 years old, leading to significant disability and demographic loss for the society [22]. Although permanent damage to neural structures and weakness cannot be reversed, their effects on the ADLs of a person can be mitigated by a robust rehabilitation program after SCI. In a study on the molecular/cellular basis of the benefits of early rehabilitation on rat models, Asano et al. [23] reported decreased production of M1 microglia/macrophages with a concomitant increase in M2 microglia production at the lesion site. These cellular dynamics might suppress neuroinflammation at the lesion site, thereby, inhibiting the progression of tissue destruction and promoting nerve regeneration for recovery of motor function.
Obesity is an important factor that can negatively impact the outcomes of patients with SCI. In a study on 3,413 patients with traumatic SCI, Kao et al. [24] reported that obesity had a negative impact on the functional recovery of 821 patients (24.1%) and that longer length of stay at the rehabilitation center corresponded to better improvements in the motor FIM score. In this study, the absence of a correlation between BMI and outcomes may be attributed to the relatively small number of obese patients in our study population. On the other hand, the level of injury was found to significantly influence functional outcomes. Patients with injuries above T7 have abdominal muscle paralysis, which weakens trunk support. A study by Lee et al. [25] showed significantly higher 1-year FIM scores in patients with sensory level at T10–L2 than in those with T2–5 and T6–9 level injuries (p<0.05). In this study, the FIM scores of patients with T2–T6 injuries were significantly worse than the overall mean, whereas those who sustained T10–L2 injuries had the best FIM scores on follow-up.
The timing of surgery has been shown to play an important role in neurological recovery after spinal injury, especially incomplete injury. However, in patients with complete neurological injury (AIS grade A), the functional outcomes did not seem to improve despite early intervention. A study by Landi et al. [26] showed that the initial AIS grade was the most important determinant of neurological outcome and that surgical timing did not affect the outcome when the ASIA score was A or E.
Access to affordable care remains one of the major challenges for patients with SCI [27–30]. In a survey of 150 patients with SCI. Chhabra and Bhalla [7] observed that access to and affordability of SCI rehabilitation services were significantly challenging for almost all patients, except those in the upper socioeconomic class. In this study, the socioeconomic status changed from middle to lower in 38 patients. Moreover, 30 of 70 patients were unemployed after the injury, and the delayed rehabilitation group had an unemployment rate of 77.3%. Delayed rehabilitation can be both the cause and effect of poor socioeconomic status and forms a vicious cycle; poor patients who are unable to afford and access rehabilitation services will have poor functional outcomes that can hinder their reintegration into society and chances of employment. Goel et al. [31] reported that of 166 patients with quadriplegia secondary to SCI, 47% lost their jobs after injury and spent nearly 20% of their family income on medical and rehabilitation expenses, which led to a significant decrease in the socioeconomic scores postinjury. The authors also concluded that surgery alone without a good rehabilitation and vocational training program did not yield satisfactory results.
The incidence rates of depression and suicidal tendencies were reported to be high in patients with SCI. Khazaeipour et al. [32] reported a 49% incidence of depression among patients with SCI. In this study, 14 of 42 patients who showed signs of depression were categorized as having severe depression based on the BDI score. All patients with severe depression were unemployed and the sole breadwinner of the family, causing them to further spiral into poverty. This situation highlights the role of early rehabilitation in the mental health of patients.
The only theoretical risk associated with early rehabilitation is frequent readmissions due to medical instability that precludes treatment tolerance. This can be prevented by careful evaluation, risk stratification, and monitoring of patients before and during admission for rehabilitation. A multicenter prospective study of six rehabilitation centers by DeJong et al. [33] reported 36.2% readmission rates in the first year, with the three most common reasons being UTI, pneumonia, and pressure ulcer. An Italian multicenter study of 1,039 patients with SCI who were readmitted also reported UTI as the most common cause, followed by pressure sore and spasticity [34]. In this study, 10% (seven of 70 patients) had late readmissions; of these, the most common cause was UTI (n=4), followed by pressure sores (n=3).
Some limitations of this study should be considered. This was a retrospective study with a relatively small sample size. We included only patients with paraplegia, because those with quadriplegia had different sets of challenges and much higher morbidity, which could not be addressed in a single research paper. We plan to conduct a separate study on the factors affecting rehabilitation services for cervical spine injuries in the future. Our study population did not adequately represent all socioeconomic groups, because most patients belonged to the middle class. Therefore, the results cannot be generalized, and larger studies to confirm our findings are required. Further studies that focus on the challenges faced by lower socioeconomic groups can help policy makers identify the bottlenecks and improve the status of rehabilitation for patients with SCI. Nevertheless, this study showed that early initiation of rehabilitation and vocational training after SCI was key to better functional outcomes and higher chances of employment, enabling patients to lead a life of dignity.
Conclusions
Early rehabilitation after traumatic SCI significantly improved functional outcomes, chances among employment, and reintegration into society among patients with paraplegia. Financial constraints and lack of awareness of the benefits of rehabilitation were major hindrances to these services.
Key Points
Rehabilitation of patients with spinal cord injury (SCI) plays an important role in preventing secondary complications and aiding their early reintegration into society
Initiation of rehabilitation within 6 weeks after SCI significantly improved their functional outcomes and psychological well-being and increased their chances of employment and reintegration into society.
Financial constraints and lack of awareness of the benefits of rehabilitation were major hindrances for SCI patients which can be addressed through appropriate policy changes.
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