ROLE OF ROBOTIC THERAPY IN SPINAL

CORD INJURY REHABILITATION

Project work submitted to the

Dr. Y.S.R UNIVERSITY OF HEALTH SCIENCES, ANDHRA PRADESH, in

partial fulfillment of the requirements for the

Degree of Bachelor of physiotherapy

Submitted by

D.SHALEM RAJ

Regd No. 19P101033006

KKC COLLEGE OF PHYSIOTHERAPY

(AFFILIATED TO THE Dr. Y.S.R UNIVERSITY OF HEALTH & SCIENCES)

Parameshwara Mangalam, Puttur – 517 584, Tirupati Dist.

December – 2023

1
 ROLE OF ROBOTIC THERAPY IN SPINAL

CORD INJURY REHABILITATION

Project work submitted to the

Dr. Y.S.R UNIVERSITY OF HEALTH SCIENCES, ANDHRA PRADESH, in

partial fulfillment of the requirements for the

Degree of Bachelor of physiotherapy

Under the guidance

Of
Dr.M.N.MAGESH (PT) MPT., F.N.R MIAP

Submitted by

D.SHALEM RAJ

Regd No. 19P101033006

KKC COLLEGE OF PHYSIOTHERAPY

(AFFILIATED TO THE Dr. Y.S.R UNIVERSITY OF HEALTH & SCIENCES)

Parameshwara Mangalam, Puttur – 517 584, Tirupati Dist.

December – 2023

2
 KKC COLLEGE OF PHYSIOTHERAPY

(AFFILIATED TO THE Dr. Y.S.R UNIVERSITY OF HEALTH & SCIENCES)

Parameshwara Mangalam, Puttur – 517 584, Tirupati Dist.

certificate

This is to certify that this project is a Bonafide record work done by D. SHALEM RAJ

final year B.P.T. towards partial fulfillment of the requirements for the Degree of

Bachelor of Physiotherapy and submitted in December 2023 to Dr. Y.S.R

UNIVERSITY OF HEALTH & SCIENCES, ANDHRA PRADESH.

Regd No. 19P101033006

GUIDE PRINCIPAL

INTERNAL EXAMINER EXTERNAL EXAMINER

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 ACKNOWLEDGEMENT

First and foremost, my grateful thanks to almighty for his divine blessing and grace in

making this project successful and I thank my father D. Sunil Kumar and my mother

D. Sajani for giving me all this life and opportunity.

My deepest appreciation goes to Prof. Dr. M.N. MAGESH(PT) MPT, F.N.R MIAP,

Principal of KKC college of Physiotherapy and also my guide an ideal head of the

institution and an ideal supervisor and a living legend in my opinion. Sir, thank you for

your expertise, enthusiasm and especially for your precious time and for kind help and

support valuable suggestions and constant guidance throughout the academics.

My profund gratitude and heartful thank to Prof. Dr. T. REDDI KUMAR(PT) MPT ortho

vice principal of KKC college of Physiotherapy and ideal supervisor and my class

incharge. Never negative, always looking ahead with new ideas, guiding with patience

and support.

My profound thanks goes to all the faculty members specially Dr. S. Saradha (PT)

MPT, Dr. N. Sivaharish (PT) MPT, Dr. A. Dhanapal (PT) MPT, Dr. M.A. Sundar Raj, Dr.

N. Reshma, Dr. P. Alekhya, Dr. Chasmitha, Dr. Meena Gayathri. For spending time in

helping and giving support throughout the process and completion of this project.

Last but not least, I would like to show my humble gratitude to my family members and

all my friends who were the back bone for me to complete this project successfully.

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 CONTENTS

S.NO DESCRIPTION PG.NO

1 LIST OF ABBREVIATIONS 6

2 INTRODUCTION 7

3 DEFINITION 12

4 EPIDEMOLOGY 14

5 ANATOMY 17

6 RISK FACTORS 22

7 CAUSES 24

8 CLASSIFICATION 27

9 PATHOPYSIOLOGY 35

10 CLINICAL FEATURES 43

11 INVESTIGATIONS 48

12 MANAGEMENT 51

13 PT ASSESSMENT 55

14 ROBOTIC THERAPY 80

15 CONCLUSION 89

16 BIBLIOGRAPHY 91

17 ANNEXURE 95

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LIST OF ABBREVIATIONS

1. SCI - Spinal Cord Injury

2. CSF - Cerebrospinal fluid

3. ASIA - The American Spinal Cord Injury Association

4. UMN - Upper Motor Neuron

5. LMN - Lower Motor Neuron

6. GFAP - Glial Fibrillary Acidic Protein

7. CNS - Central Nervous System

8. NMDA - N- Methyl- D- Aspartate

9. AMPA - Alpha- Amino- 3- Hydroxy- 5- Methyl- 4- isoxazole propionic Acid

10. ATP - Adenosine Tri Phosphate

11. ROS - Reactive Oxygen Species

12. RNS - Reactive Nitrogen Species

13. HNE - Hydroxynonenal

14. ECM - Extra Cellular Matrix

15. CT - Computed Tomography

16. MRI - Magnetic Resonance Imaging

17. NSIAD - Non Steroidal Anti Inflammatory Drugs

18. ADL - Activities In Daily Living

19. ROM - Range Of Motion

20. EEG - Electro Encephalon Gram

21. EMG - Electromyogram

22. HOH - Hand Of Hope

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INTRODUCTION

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 INTRODUCTION OF SPINAL CORD INJURY

 A Spinal cord injury (SCI) is a serious medical condition, which often results in

severe morbidity and permanent disability.

 It occurs when the axons of nerves running through the spinal cord are disrupted,

leading to loss of motor and sensory function below the level of injury.

 Injury is usually the result of major trauma, and primary injury is often irreversible.

 In India, the average annual incidence of SCI is 15,000 with a prevalence of 0.15

million.

 Approximate 20,000 new cases of SCI are added every year and 60-70% of them

are illiterate, poor villagers. Majority of them are males in the age group of 16-30

years, signifying higher incidence in young, active and productive population of the

society.

 These injuries are particularly costly and disabling as they disproportionately affect

patients under 30-years-old, lead to significant functional impairment for the

remainder of the individual’s life, and put the individual at risk for numerous

complications leading to increased morbidity and mortality.

 Today, the estimated lifetime cost of an SCI patient is $2.35 million per patient.

 According to the National Spinal Cord Injury Statistical Center, there are 12,500

new cases of SCI each year in North America.

 More than 90% of SCI cases are traumatic and caused by incidences such as

traffic accidents, violence, sports, or falls.

 The Male-to-female ratio of 2:1 for SCI, which happens more frequently in adults

compared to children.

 Demographically, men are mostly affected during their early and late adulthood

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 (3rd and 8th decades of life) while women are at higher risk during their

adolescence (15–19 years) and 7th decade of their lives i.e. age distribution is

bimodal, with a first peak involving young adults and a second peak involving

adults over the age of 60.

 Those over 60 years of age who suffer SCI have considerably worse outcomes
than younger patients their injuries usually resulting from falls and age-related

bony changes

Figure No: 1

Figure No: 2

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 INTRODUCTION TO ROBOTICS

 Robot-assisted therapy can be used by physical therapists in conjunction with

traditional physiotherapy approaches.

 Rehabilitation robotics include a wide range of training devices with the main

purpose to train lost body functions caused by neurological or traumatic events.

 Lower and upper extremity rehabilitation can require significant time and physical

effort on the part of physiotherapists.

 The use of robotic devices is a highly motivating method, as it allows for repetitive,

intensive and task specific training, whilst potentially offloading therapist’s burden.

 Robotic rehabilitation technology is a great opportunity for rehabilitation clinics and

therapists to deliver high-dosage and high-intensity training for patients with a

physical disability.

 Rehabilitation robots are often classified into two types, end-effectors and

exoskeletons according to their mechanical structure.

 An end-effector device is connected to the patient at a distal segment, for example

feet and the force generated at this point change position of other joints

simultaneously.

 An exoskeleton are connected to multiple points on the patient and each single

joint is guided along a pre-programmed trajectory.

 Some benefits you can expect from using robotic technology in therapy:

 High-dosage and high-intensity training

 Lower burden on therapists

 Save time and resources

 Safe handling

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ROBOTIC REHABILITATION DEVICE

Figure No: 3

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DEFINITION

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 DEFINITION

A spinal cord injury is damage or trauma to the spinal cord that results in a loss

of impaired function of muscle, sensory loss or autonomic dysfunction.

Figure No: 4

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EPIDEMIOLOGY

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 EPIDEMOLOGY

 A recent systematic review found the prevalence of spinal cord injury to be

dependent on the region.

 The studies were conducted in, ranging from 906/million in the USA up to

250/million in Rhone Alpes, France.

 Annual incidence rates also varied significantly between regions, ranging from

49.1/million in the New Zealand to 8.0/million in Spain.

 A further review found similar results with prevalence ranging from 1298/million

to 50/million and incidence ranging from 246/million to 3.3/million.

 The results indicate that the incidence, prevalence, and causation of spinal cord

injury can differ significantly between developing and developed countries.

 Strong inconsistencies in data were noted when analysed between countries

but the most frequent causes of spinal cord injury reported are, in order;

 Motor vehicle accidents

 Falls

 Sports injuries

 Violence

 Self-harm

 Work related accidents.

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 Data from the National Spinal cord injury statistical centre(USA) 2010-2014

provided the following statistics for Aetiology.

 Other interesting statistics from this report includes:

 Males account for 80% of new cases.

 The average age at injury has gone up from 29yrs old (1970) to 42yrs

old currently.

 Only about 12% of patients are employed 1year after trauma, rising

to 34.4% 20yrs post injury.

 Life expectancy decreases for all individuals with spinal cord injury,

compared to those without a spinal cord injury.

 The prevalence of SCI in India is 1.85-2.19%.

 SCI generally occurs in young adults between 20 and 40 years of age.

 Males are more affected than females.

 In India, fall from height is the most common cause of traumatic SCI.

Figure No:5

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ANATOMY

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 ANATOMY OF SPINAL CORD

 The spinal cord is a long bundle of nerves and cells that extends from the lower

portion of the brain to the lower back.

 It carries signals between the brain and the rest of the body.

 The length of the spinal varies from person to person. Females have a spinal cord

of about 43(cm), while males have a spinal cord about 45(cm).

 The spinal cord comprises three parts: the cervical, thoracic, and lumbar regions.

 Three layers of tissue protect the spinal cord: the dura mater, arachnoid mater, and

pia mater. And these layers are called “meninges”. The layers are as follows:

 DURA MATER: - This is the outermost layer of the spinal cord meninges. It is a

tough, protective coating.

 EPIDURAL MATER: - Between the dura and arachnoid space is the epidural

space. This is where doctors may insert local anaesthetic to reduce pain during

childbirth and some surgical procedures, such as those to operate on a lung or

abdominal aneurysm.

 ARACHNOID MATER: - The arachnoid mater is the middle layer of spinal cord

covering.

 SUBARACHNOID SPACE: - This located between the arachnoid mater and pia

mater. The cerebrospinal fluid (CSF) is located in this space.

 PIA MATER: - The pia mater is the layer that directly covers the spinal cord.

 Covering the spinal cord and its protective layers is the vertebral column, or the

spinal bones. These bones start at the base of the skull and extend down to the

sacrum, a bone that fits into the pelvis.

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 The cervical, thoracic, and lumbar regions have different numbers of bones. The

spinal bones are in the cervical are 7, in the thoracic column are 12, and 5 in the

lumbar column.

Figure No: 6

CROSS-SECTION OF THE SPINAL CORD: -

 If we take a slice of the spinal cord horizontally, they would see a circular area in

the middle covered in protective layers.

 Extending from this circular area are nerve projections. This extends from the

spinal cord to provide sensation to different areas in the body.

 The areas of a cross-section of spinal cord include:

 GRAY MATTER: The Gray matter is the dark, butterfly shaped region of the spinal

cord made up of nerve cell bodies.

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 WHITE MATTER: The white matter surrounds the grey matter in the spinal cord

and contains cells coated in myelin, which makes nerve transmission occur more

quickly. Nerve cells in the grey matter are not as heavily coated with myelin.

 POSTERIOR ROOT: The posterior root is the part of the nerve that branches of

the back of the spinal column. Looking at the spinal cord cross-section, the top

wings of the grey matter “butterfly” reach toward the spinal bones. The bottom

wings are toward the front of the body and its internal organs.

 ANTERIOR ROOT: The anterior root is the part of the nerve that branches off the

front of the spinal column.

 SPINAL GANGLION: The spinal ganglion is a cluster of nerve bodies that contain

sensory neurons.

 SPINAL NERVE: The posterior and anterior roots come together to create a spinal

nerve. There are 31 pairs of spinal nerves. These control sensation in the body, as

well as movement.

 The spinal cord does not extend for the entire length of the spine. It usually stops

in the top parts of the lumbar spine.

 For adults, this usually the first or second lumbar vertebrae. Children’s spinal cords

may stop slightly lower, at the second or third lumbar vertebrae.

FUNCTIONS: -

 The spinal cord plays a vital role in various aspects of the body’s functioning.

Examples of these key functions include:

 CARRYING SIGNALS FROM THE BRAIN: The spinal cord receives signals from

the brain that control movement and autonomic functions.

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 CARRYING INFORMATION TO THE BRAIN: The spinal cord nerves also transmit

messages to the brain from the body, such as sensations of touch, pressure, and

pain.

 REFLEX RESPONSES: The spinal cord may also act independently of the brain

in conducting motor reflexes. One example is the patellar reflex, which causes a

person’s knee to involuntarily jerk when tapped in a certain spot.

 These functions of the spinal cord transmit the nerve impulses for movement,

sensation, pressure, temperature, pain.

Figure No:7

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RISK FACTORS

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 RISK FACTORS OF SPINAL CORD INJURY

 Although a spinal cord injury is usually the result of an accident and can happen to

anyone, certain factors can predispose you to being at higher risk of having a spinal

cord injury, include:

 In Males Spinal cord injuries affect a disproportionate number of men. In fact,

female account for only about 20% of traumatic spinal cord injuries.

 In between the ages of 16 and 30. More than half of spinal cord injuries occur in

people in this age range.

 In age 65 and older. Another spike in spinal cord injuries occurs at age 65. Falls

cause is most injuries in other adults.

 Alcohol use. Alcohol use is involved in about 25% of traumatic spinal cord injuries.

 Engaging in risky behaviour. Diving into too shallow water or playing sports without

wearing the proper safety gear or not taking proper precautions can lead to spinal

cord injuries. Motor vehicle crashes are the leading cause of spinal cord injuries

for people under age 65.

 Having certain diseases. A relatively minor injury can cause a spinal cord injury if

you have another disorder that affects your joints or bones, such as osteoporosis.

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CAUSES

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 CAUSES OF SPINAL CORD INJURY

 The spinal cord is a bundle of nerves that carries signals from the brain to the body,

and back to brain.

 When the spinal cord is damaged, nerve impulses cannot communicate below the

area where the damage has occurred. This results in loss of motor or sensory

function and even paralysis. Damage to any part of the spinal cord is very serious

and medical professionals should treat the patient quickly.

 Spinal cord injuries occur for many different reasons. Depending upon the severity

of injury, patient’s symptoms may mild, moderate, or severe enough to cause

death.

 Spinal cord injuries should be treated as quickly as possible to avoid further

damage. Some patients may experience temporary symptoms while others will be

left with lifelong symptoms.

 Causes for spinal cord injuries are characterised as “traumatic” or “non traumatic”.

 Traumatic injuries are caused by an abrupt traumatic hit to the spine which results

in damage to one or more of the vertebrae, or a severing of the spinal cord.

 Non-traumatic injuries are the result of slow internal damage to the spinal cord

region.

 Traumatic spinal cord injuries occur due to:

 Motor vehicle accidents (38%)

 Slips/falls (30.5%)

 Acts of violence (13.5%)

 Sports-related injuries (9%)

 Medical/ surgical (5%)

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  Other (4%)

 Non-traumatic spinal cord injuries occur due to:

 Degeneration of the spinal column

 Infections

 Cancer/tumours

 Inflammation

 Congenital medical issues.

 Another way to categorize spinal cord injury causes is whether the damage is

‘complete’ or ‘incomplete’.

 A complete spinal cord injury is where the patient loses all function below the

point of injury. Complete spinal cord injuries cause paralysis.

 An Incomplete spinal cord injury is where the patient has some feeling and

sensation below the point of injury and does not always cause paralysis.

Incomplete spinal cord injuries are common than complete injuries.

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CLASSIFICATION

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 CLASSIFICATION OF SPINAL CORD INJURIES

TRAUMATIC SPINAL CORD INJURIES: -

The severity of the spinal cord injury is based on the level of injuries and

neurological category.

Neurological Level: -

The American Spinal Cord Injury Association (ASIA) defines neurological level

as the lowest segment of the spinal cord with normal sensory and motor

function on both sides of the body.

Neurological Category: -

Traumatic spinal cord injury is classified into five categories on the ASIA

Impairment scale.

Category Description

A Indicates a “complete” spinal cord

injury where no motor or sensory

function is preserved in the sacral

segments S4-S5.

B Indicates an “incomplete” spinal cord

injury where sensory but not motor

function is preserved below the

neurological level and includes the

sacral segment S4-S5. This is typically

a transient phase and if the person

recovers any motor function below the

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 neurological level, that person

essentially becomes a motor

incomplete, i.e., ASIA C or D

C Indicates an “incomplete” spinal cord

injury where motor function is

preserved below the neurological level

and more than half of key muscles

below the neurological level have a

muscle grade of less than 3, which

indicates active movement with full

range of motion against gravity.

D Indicates an “incomplete” spinal cord

injury where motor function is

preserved below the neurological level

and at least half of the key muscles

below the neurological level have a

muscle grade of 3 or more.

E Indicates “normal” where motor and

sensory scores are normal. Note that it

possible to have spinal cord injury and

neurological deficits with completely

normal motor and sensory scores.

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CLINICAL CLASSIFICATION: -

Anterior cord syndrome: -

Anterior cord syndrome describes the damage to the spinothalamic tract and

corticospinal tract.

There is complete motor loss below the level of lesion due to involvement of

corticospinal tract.

There is a loss of pain and temperature at and below the level of injury due to

involvement of lateral spinothalamic tract.

Preservation of the 2-point discrimination sense vibrations and proprioception

senses due to intact posterior column.

There is autonomic dysfunction leading to orthostatic hypotension.

Bladder and Bowel dysfunction may arise depending on the level of lesion.

Figure No: 8

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Posterior Cord Syndrome: -

This is a rare condition producing damage to the dorsal columns (sensations of

light touch, proprioception and vibrations).

There is preservation of motor function and pain and temperature pathways.

Figure No: 9

Brown-Sequard Syndrome: -

It is a rare form of incomplete spinal cord injury which results after the damage to

one side of the spinal cord (hemisection). It accounts for up to 4% of all traumatic

spinal cord injuries.

It is characterized by a loss of sense of vibration, deep touch or pressure, joint

position sense and motor paralysis below the level of spinal cord injury on same

side (ipsilateral).

Loss of sense of light touch, pain and temperature on the opposite side

(contralateral) of the body.

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 Figure No: 10

Central Cord Syndrome: -

It is the most common type of incomplete spinal cord injury. It is the resultant of the

contusion of the central portion of the cervical spinal cord.

The patients present with upper limb weakness, urinary retention and sensory loss

below the level of lesion.

The upper limbs are classically more affected than the lower limbs with motor

dysfunction more than the sensory loss.

Figure No: 11

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Conus Medullaris Syndrome: -

It is caused by the injury to the conus medullaris and lumbar nerve roots.

Injuries at the level of T12 to L2 vertebra are most likely to result in the conus

medullaris syndrome.

Patients present with a combination of UMN and LMN palsies characters: Saddle

anaesthesia, urinary retention, loss of bowel reflex, lower limb motor weakness,

paraesthesia and numbness and chronic low back pain.

Cauda Equina Syndrome: -

It is caused by the injury in which there is damage to the cauda equina portion of the

spinal cord.

Complete lesion of cauda equina is rare due to larger surface area and large number

of nerve roots.

In extramedullary lesions, there will be sensory loss and motor dysfunction more in the

distal lower limbs than the proximal area.

In intramedullary lesions, there will be sensory loss and motor dysfunction more in the

proximal than the distal lower limbs.

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Figure No: 12

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PATHOPYSIOLOGY

35
 PATHOPYSIOLOGY OF SPINAL CORD INJURY

 Spinal Cord Injury pathophysiology comprises interrelated events, each serving

as the facilitator for the other. In some instances, multiple events occur

simultaneously and cause complicated attributes, thus rendering this illness

difficult to treat.

 The most vulnerable clinical manifestation immediately after injury is the

interruption of spinal cord vascular supply and hypotension/hypoperfusion,

producing hypovolemia, neurogenic shock and bradycardia.

 These signs occur because of extensive bleeding and neurogenic shock leading

to spinal cord ischemia. The rupture of small blood vessels and capillaries

promotes the extravasation of leukocytes and red blood cells.

 These extravasations of immune cells at the injury site exert pressure on the

injured spinal tissues and further disrupt the blood flow, thus producing

vasospasm. The state continues up to 24hrs. occurrence of vascular ischemia,

hypovolemia and hyper-perfusion eventually leads to cell death and tissue

destruction.

 Spinal cord ischemia causes cytotoxic, iconic and vasogenic oedemas. In normal

physiology, the influx of Na+ occurs due to the passive influx of Cl- through

chloride channels.

 During a pathophysiology state, the balance between solute and water influx at

the intracellular compartment is disturbed, thereby causing cell swelling and loss

of cytoskeletal integrity and promoting cell death.

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 Iconic oedema occurs due to the increased permeability of the blood-spinal cord

barrier that increases trans endothelial ion transport and causes the loss of ions

and water from the interstitial space.

 Endothelial injury and inflammation subsequently increase the pore size and thus

allow large plasma derived molecules to pass through the cell membrane,

resulting in vasogenic oedema. This acute secondary injury phase continues from

2hrs to 48hrs.

 Continuous haemorrhage, oedema and inflammatory and the presence of

structural biomarkers, e.g., glial fibrillary acidic protein [GFAP] or IL-6 in

cerebrospinal fluid [CSF]. These processes provoke free radical formation,

glutamate-mediated excitotoxicity and neurotoxicity.

 Glutamate is an excitatory neurotransmitter that is released I the central nervous

system (CNS) and interacts with N-methyl-D-aspartate (NMDA), α-amino-3-

hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and kainite ionotropic and

metabotropic receptors.

 The activation of glutamate receptors during SCI greatly increases glutamate

concentrations and produces persistent excitotoxicity and cell death.

 Abnormal increases in glutamate excitation are caused by diverse events, such

as mechanical stress, formation of apoptotic and necrotic cells, failure of Na+/k+

ATPase in the axonal membrane, lipid peroxidation and formation of 4-

hydroxynonenal.

 Hyper activation of NMDA and AMPA receptors increases the influx of Ca2+ and

Na+ ions which further promotes apoptosis and necrotic cell death.

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 High levels of glutamate in necrotic cells alter the ionic flux by increasing

intracellular Na+ and Ca2+ concentrations and decreasing intracellular K+

concentrations.

 An increasing in Ca2+ concentration inhibits mitochondrial respiration and energy

depletion and consequently disturbs ionic homeostasis.

 Alteration in the function of Na+/K+ ATPase elevates axonal membrane

depolarisation and leads to excessive Na+ influx within axon membranes.

 This ionic dysregulation causes cell cytotoxic oedema, axonal acidosis, increased

Ca2+ membrane permeability, activation of phospholipases, increased reactive

oxygen species (ROS) generation and mitochondrial dysfunction.

 Mitochondria are an integral component for cellular metabolism because they

generate ATP molecules through phosphorylation.

 These organelles have four components, i.e., an outer mitochondrial membrane,

inner mitochondrial membrane, intermembrane space and inner matrix.

 High Reactive Oxygen Species (ROS) and Reactive nitrogen species (RNS)

generation includes various deleterious effects, including lipid peroxidation on

different body organs.

 Lipid peroxidation transpires in three steps:

 ROS reacts with the membrane’s polyunsaturated fatty acid component and
snatches an electron from it. This electron binds to lipid molecules and

generates reactive lipid species.

 Which quenches other radicals, generates additional reactive species.

38
  Finally produce other reactive species including 4-hydroxynonenal (HNE)
and 2-propneal.

 Neuroinflammation is key process associated with SCI and involved numerous

cell types such as neutrophils, microglia, macrophages, astrocytes, dendritic cells

and B-and T-lymphocytes and molecular components such as cytokines and

proteinoids.

 The complex inflammatory responses following SCI produce neurotoxic or

neuroprotective effects depending on the duration and time of responses.

 Early inflammatory cells and mediators such as macrophages may also have

beneficial functions by assisting in inflammation, repair and recovery.

 Acute axonal degeneration is another important clinical manifestation of early

acute SCI phase.

 This process includes other effectors such as cystine protease calpain and

Wallerian degeneration which further promote axonal degeneration.

 Acute axonal degeneration is initiated by a high Ca2+ influx into axons. A high

Ca2+ deposition increases acute axonal degeneration risk in axons.

 This phenomenon occurs in two phases, the earlier phase occurs within

15minutes post injury, and the later phase called Wallerian degeneration occurs

after a few hours (24-48h).

 The Wallerian degeneration is manifested by the formation of retraction bulbs, a

microtubule network that inhibits axonal regeneration.

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 The anterograde degenerative mechanism is termed as Wallerian degeneration;

however, retrograde degeneration of axon is termed as axonal dieback.

 Demyelination occurs when myelin, the protective coating of nerve cells, is

damaged. This process slows down the messages sent along axons and

deteriorates axon and oligodendrocytes.

Figure No: 13

 Glial scar formation is a reactive cellular mechanism that is facilitated by

astrocytes and occurs during the chronic secondary phase of SCI.

 The scarring of astrocytes is the body’s natural process that shields and starts

the healing post-SCI.

 Astrocytes are an important component of the nervous system. The astrocytes

are sensitive towards changes such as alteration in the gene expression,

hypertrophy, and excitations.

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 The major constituents of the scar tissue are pericytes and the connective tissues.

 In normal physiology, the number of astrocytes is 10 times higher in spinal cord

parenchyma that of pericytes.

 Pericytes secrete specific markers that promote fibroblast to express ECM such

as fibronectin which serves as the main component of scar connective tissues.

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Figure No: 14

42
CLINICAL FEATURES

43
 COMPLETE SPINAL CORD INJURY CLINICAL FEATURES

 Loss of movement

 Loss of or altered sensation, including the ability to feel heat, cold and touch.

 Loss of bowel or bladder control.

 Exaggerated reflex activities or spasms.

 Changes in sexual function, sexual sensitivity and fertility.

 Pain or an intense stinging sensation caused by damage to the nerve fibres

in your spinal cord.

 Difficulty breathing, coughing or clearing secretions from the lungs.

 Extreme back pain or pressure in your neck, head or back.

 Weakness, incoordination or paralysis in any part of the body.

 Numbness, tingling or loss of sensation in hands, fingers, feet or toes.

 Loss of bladder or bowel control.

 Difficulty with balance and walking.

 Impaired breathing after injury.

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 INCOMPLETE SPINAL CORD INJURIES CLINICAL FEATURES

 CENTRAL CORD SYNDROME: -

 Paralysis or loss of fine control of movements in the arms and hands, with

relatively less impairment of leg movements .

 Loss of or charge in sensation below the site of the injury.

 Loss bladder control.

 Painful sensations such as tinging, burning, or dull ache.

 POSTERIOR CORD SYNDROME: -

 Loss of proprioception

 Loss of vibration sense

 Ataxic gait

 Positive Romberg sign

 Hypotonia

 Abolition of deep tendon reflexes

 BROWN-SEQUARD SYNDROME: -

 Ipsilateral lower motor neuron paralysis in the segment of the lesion.

 Contralateral loss of pain and temperature sensations below the level of

lesion.

 Ipsilateral loss of tactile discrimination, vibratory and proprioceptive

sensations below the level of lesion.

 Contralateral partial loss of tactile sensation.

45
  Ipsilateral spastic paralysis below the level of lesion.

 ANTERIOR CORD SYNDROME: -

 Loss of pain

 Loss of temperature

 Loss of motor function

 Light touch, position, and vibration sensation remain intact.

 CAUDA EQUINA SYNDROME: -

 Numbness or different sensations in the backs of your legs, butt, hip and

inner thighs.

 Sciatica type pain.

 Sexual dysfunction.

 Bowel and bladder incontinence.

 Weakness or paralysis in lower extremities.

 Lower back pain.

 Paraesthesia.

 Reflexes issues.

46
 CONUS MEDULLARIS SYNDROME: -

 Urinary incontinence

 Bowel incontinence

 Lower limb motor weakness

 Paraesthesia

 Numbness

 Saddle anaesthesia.

47
INVESTIGATIONS

48
 Diagnostic Tests and Procedures

 Imaging Studies:

i. Radiography: -

 Detects vertebral compression, fractures, or problems with alignment.

 X-rays can reveal vertebral problems, tumours, fractures, or

degenerative changes in spine.

Figure No: 15

49
 ii. Computed tomography (CT)

 A CT scan can provide a clearer image of abnormalities seen on X-ray.

 This scan uses computers to form a series of cross-sectional images that can

define bone, disk and other problems.

iii. Magnetic resonance imaging (MRI):

 MRI uses a strong magnetic field and radio waves to produce computer

generated images.

 This test is helpful for looking at the spinal cord and identifying herniated

disks, blood clots or other masses that might compress the spinal cord.

50
MANAGEMENT

51
 MEDICAL MANAGEMENT

PHARMACOLOGIC THERAPY
Corticosteroids:

 Corticosteroids are a type of medication that can help minimize damage in the

early phases of spinal cord injury.

 After spinal cord injury, the body activates the release of biochemical processes

intended to stabilize the spinal cord.

 NSAIDs:

 Non-steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen and naproxen

are easily accessible medications that can help relieve pain after spinal cord

injury.

 Anticonvulsants:

 Anticonvulsants like gabapentin can help spinal cord injury patients

manage neuropathic pain.

 Neuropathic pain is caused by damage to the nerves, which can affect the

hyperexcitability of pain signals.

 Antispasmodics and Muscle Relaxants:

 Antispasmodics (also commonly called anticholinergics) and muscle relaxants

can help reduce the effects of bowel or bladder problems and spasticity after

spinal cord injury.

52
  A spinal cord injury can disrupt the transmission of messages between the brain

and body. As a result, muscles below your level of injury may involuntarily

contract.

 Antispasmodics and muscle relaxants help block the transmission of signals

that cause muscle contractions.

SURGICAL MANGEMENT: -

 The spinal cord injury surgery is an immediate and necessary need.

 However, some SCI patients have to wait weeks, months, or even years after their

initial injury to undergo surgery due to other health-related factors.

 The goals of spinal cord injury surgery are to:

 Decompress or relive pressure from the spinal cord (from bone fragments,

tumours, or anything else that may be compressing the spinal cord).

 Stabilize the vertebral spine (which protects the spinal cord).

 Mitigate further damage to the spinal cord nerves and spine.

 Remove bone fragments or foreign objects that may impede the spinal cord.

 Tend to blood clots or repair herniated disks.

 Repair fractured vertebrae.

 Improve the patient’s quality of life.

 A Laminotomy, which involves the surgical removal of bone to decompress the

spinal cord nerves, is a common form of spinal cord injury surgery for spinal

stenosis.

53
 Foraminotomy: This procedure enlarges the area around one of the bones in your

spinal column to relive pressure on compressed nerves.

 Interspinous process spacer: This device is used to open the vertebral foramen

(the space in which spinal cord runs vertically throughout the spine) to create

additional space for your spinal cord and nerves in spinal column without needing

to remove any bone (as in a traditional laminectomy) while also causing less

trauma to ligaments and muscles.

54
PT ASSESSMENT

55
 ASSESSMENT

SUBJECTIVE ASSESSMENT:

 Patient ID

 Name

 Age

 Gender

 Occupation:

 Address

 Chief complaints: -

 HISTORY: -

 Present history:

 Mode of onset:

 Nature and severity:

 Site:

 Duration:

 Frequency:

 History of trauma:

 Any associated symptoms: seizures, headache, vomiting,

incontinence, etc.

56
 Past history:
 Enquire about disease related history

 Status of ambulation & ADL in the past

 Similar presentations in the past, etc.

 Medical history:

 History of previous surgery

 History of previous treatments (medical/physiotherapy etc.)

 History of any autoimmune diseases

 Personal history:

 Habits (alcoholic/smoker/drug addict/tobacco)

 Type of birth

 Food habits:(veg/nonveg)

 Family history:

 Type of marriage

 No of children:

 socio-economic status:

57
OBJECTIVE ASSESSMENT: -

 On Observation: -

 Built:(ectomorphic/endomorphic/mesomorphic)

 Mode of ventilation:(independent/ventilated/O2 mask)

 Breathing pattern:

 Facial asymmetry:

 Skin changes/wounds/oedema/allergic changes etc.,

 Attitude of limbs:

 Posture examination:

 Gait:

 External appliances:(catheter/IV lines/splints/drain tubes etc.)

 On Palpation:

 Type of oedema; (pitting/ nonpitting)

 Warmth

 Swelling

58
 On Examination:

VITAL SIGNS:

Blood pressure

Respiratory rate

Pulse rate

Temperature

Heart rate

Assessment of Higher Mental Function

Conscious level of the patient – GLASSCOW COMA SCALE

Eye Opening:

Spontaneous to speech - 4

Verbal command - 3

To pain - 2

No response - 1

Visual response

Oriented - 5

Disoriented - 4

Inappropriate - 3

Incomprehensible - 2

No response - 1

59
 Motor response

Obeys command -6

Localising to pain -5

Flexion withdrawal -4

Only flexion movement -3

Only extension movement -2

No response -1

Normal - 15

Moderate - 8 -12

Mild - >13

Severe - <8

 SENSORY EXAMINATION:

SUPERFICIAL SENSATION:

Touch

Temperature

Pain

DEEP SENSATION:

Proprioception

Kinaesthesia

Vibration

60
 CORTICAL SENSATION:

Stereognosis

Two-point discrimination

Tactile Localisation

Recognition texture

Graphesthesia

 MOTOR EXAMINATION

TONE:

Earliest stage – Hypotonicity

Later stage - Hypertonicity

SPASTICITY GRADING:

MODIFIED ASHWORTH SCALE: -

0 - No increase in muscle tone

1 - A slight increase in muscle tone, manifested by catch and release or by minimal

resistance at the end ROM when the affected moved into flexion and extension.

1+- A slight increase in muscle tone manifested by catch, followed by minimal

resistance throughout the remainder of ROM.

2 - More marked increase in muscle tone through most of ROM, but affected parts

easily moved.

3 - Considerable increase in muscle tone, but passive movement is difficult.

4 - Affected part is rigid in the flexion and extension.

61
VOLUNTARY CONTROL

Ask the patient to voluntarily flex or extend the limb or any movement grades of

voluntary motor control.

1+ - gravity eliminated plane with 1/3 movement possible.

1++ - gravity eliminated plane with 2/3 movement possible.
1+++ - gravity eliminated plane with full range of motion.
2+ - against gravity 1/3 movement possible.
2++ - against gravity 2/3 movement possible.
2+++ - against gravity with full range of motion.
3+ - against gravity with resistance 1/3 movement possible.
3++ - against gravity with resistance 2/3 movement possible.
3+++ - against gravity with resistance full range of motion possible.
4 - skilled movement.

62
ROM EXAMINATION:

Decreased range of motion in affected side. Compare both affected and

unaffected limb.

It is measured by therapist passively by using goniometer.

Joint Movement Normal Side Limitation Limitation

Right Left factor

Shoulder

Elbow

Fore arm

Wrist

Hand and

wrist

Knee

Ankle joint

HAND FUNCTION: Patient is difficult to do the hand function in affected side.

63
REACHING THE OBJECT

Front Back Up Down Right Left

Right

hand

Left hand

GRASPING
MASS GRASP:

Mass grasp Right Left

Spherical

Cylindrical

Hook

FINE GRASP:
Fine grasp Right Left

Tripod

Tip to tip

Tip to pad

64
REFLEXES
Superficial reflexes
Deep reflexes

SUPERFICIAL REFLEX:
 Corneal reflexes
 Abdominal reflexes
 Cremaster reflexes (L1)
 Anal reflexes (S4, S5)
 Plantar reflexes (S1, S2)

DEEP REFLEXES:
BICEPS REFLEX:
Ensure patient arm is related and slightly flexed. Palpate the biceps tendon.

Strike it with the knee hammer.

Figure No: 16

TRICEPS REFLEX:
Strike the patient elbow with a few inches above the olecranon process. Look for

elbow extension.

65
 Figure No: 17

BRACHIORADIALIS REFLEX:

Strike the lower end of the radius with the hammer and watch elbow flexion and finger

flexion.

Figure No: 18

66
KNEE REFLEX:
Ensure the patient leg is relaxed by resting it over examiners arm or by

hanging it over the edge of the bed. Tap the patellar with the hammer and observe

quadriceps contraction.

Figure No: 19

ANKLE REFLEX:
Extremely rotate the patient leg. Hold the foot slightly in dorsiflexion. Tap the

Achilles tendon and watch for the calf muscle contraction and ankle dorsiflexion.

Figure No: 20

67
 GRADINGS OF REFLEX:

1+ - Diminished
2+ - Brisk or normal reflex
3+ - Exaggerated reflex
4+ - clonus

BALANCE EXAMINATION
Berg Balance scale:
DESCREPTION SCORE (0-4)

a. Sitting to stand -

b. Standing unsupported -

c. Sitting unsupported -

d. Standing to sitting -

e. Transfers -

f. Standing with eyes close -

g. Standing with feet together

-
h. Reaching forward with outstretched arm -

i. Retrieving object from the floor -

j. Turning to look behind -

k. Turning to 360 degrees -

l. Placing alternate foot on stool -

m. Standing with one foot in front -

n. Standing on one foot. –

TOTAL (maximum 56)

68
POSTURAL EXAMINATION

ANTERIOR VIEW

Head (aligned, forward, flexed, extended)

Mandible (resting position, retracted)

Shoulders (level, uneven)

Rib cage (symmetric, asymmetric)

Scoliosis (left, right, lumbar, thoracic, cervical)

Pelvis (level, anterior/posterior tilt)

Hip (coxavara, coxavalga, Antero version, retroversion)

Femur (alignment, torsion)

Knee (level, genu valgum, genu varum)

Patella position

Tibialis (alignment, torsion)

Ankle (inversion, eversion)

Rearfoot forefoot alignment

Feet (pes cavus, pes planus, supination, pronation)

Toes (alignment, deformity)

LATERAL VIEW

Head (forward, flexed/extended)

Mandible (resting, protracted/retracted)

Scapula (winging, elevation/depression)

Thoracic kyphosis (increases/decreased)

Lumbar lordosis (increased/decreased)

69
Pelvis (anterior/posterior)

Knees (hyper extension/flexion)

Feet (Longitudinal arch)

POSTERIOR VIEW

Head (alignment, tilt)

Shoulder (level)

Scapulae (bilateral symmetry)

Spine C-1 to sacrum (rotation, deviation)

Pelvis (level, tilt)

Sacrum (level at base and inferior lateral angle)

Hip (level, uneven)

Knees (creases level, uneven)

Leg (rear foot, alignment)

Ankle (inversion, eversion)

Calcaneal position (inverted, everted)

COORDINATION EXAMINATION

Non-equilibrium test

Equilibrium test

70
NON-EQUILIBRIUM TEST

Finger to nose test

o Ask the patient to repeatedly touch their nose and then the examiner

fingers.

o Test done slow and fast.

o Repeated with eyes open and closed.

Figure No: 21

Finger opposition:

Ask the patient to touch the tip of each finger with the thumb.

Figure No: 22

71
Supination and pronation:

The patient is asked to repeatedly and quickly pronate and supinate the hand.

Figure No: 23

 Mass grasp

 Rebound test

 Tapping hand, foot

 Heel to knee

 Drawing circles with hand and foot

GRADINGS:

5 - Normal performance

4 - Minimal impairment

3 - Moderate impairment

2 - Severe impairment

1 - Activity impossible

72
EQUILIBRIUM TESTS:

 Standing with normal posture and with vision occluded

 Standing feet together

 Standing lateral trunk flexion

 Standing on one foot

 Waling sideways, backward, circle

 Waling on heel and toes

 Ask the patient to stand in one leg.

Figure No: 24

Tandem walking:

 Ask the patient to walk a straight line in a heel – to – toe fashion.

 This decreases the base of support and will accentuate any

problem with coordination.

Figure No: 25

73
GRADINGS:

4 - able to accomplish activity

3 - can complete activity minimal physical contact

2 - can complete activity significant (moderate to maximal)

1 - activity impossible

GAIT

Type of gait:

Temporal variable:

o Cadence

o Velocity

o Stride time

Spatial variable:

o Degree of foot angle

o Width of base of support

o Step length

o Stride length

FUNCTIONAL EVALUATION

FIM SCALE

BARTHEL INDEX

BARTHEL INDENX: -

74
FEEDING

10 - Independent, able to apply any necessary drink, feeds in responsible

time

5 - Needs help

BATHING

5 - Independent

PERSONAL TOILET

5 - Independently washes face, comb hair, brush teeth, shares.

DRESSING

10 - Independent, ties, shoes, fastens fastners applies braces

5 - Needs help but does at least half of work in responsible time

BOWEL

10 - No accidents, able to use enema or suppository if needed.

5 - occasional accidents as a need helps with enema or suppository

BLADDER

10 - No accidents able to care for collecting devices if

used

5 - occasional accidents or needs help with device

75
TOILET TRANSFER

10 - Independent with toilet or bad pan handles clothes,

wipes, flushes or cleans pan

5 - Need help for balance, handling cloths or toilet paper

TRANSFER CHAIR AND BED

15 - Independent, including locking of wheelchair, lifting foot

Rests

10 - Minimum assistance or supervisor

AMBULATION

15 - Independent for yards, may use assistive device except

for rolling walker

10 - With help 50 yards

5 - Independent with wheelchair for 50 yards if unable to

walk

STAIR CLIMBIMG

10 - Independent, may use assistive devices

5 - Needs helps for supervisions

76
 SPINAL INJURY: Frankel scale

SCORE DESCRIPTION
A Complete injury: No motor or sensory

function below the level of injury

B Sensation Only: Some preserved

sensation below the level of injury; this

does not apply to a slight discrepancy

between the motor and sensory level, but

does apply to sacral sparing.

C Motor function useless: Some preserved

motor function below the level of injury,

but it is of no practical use to the patient.

D Motor function useful: Preserved useful

motor function below the level of the

injury; patients in this group can walk

with or without aids

E Recovery: Normal motor and sensory

function; abnormal reflexes may be

present

Spinal Cord Injury Motor Index and Sensory Indices

The following ten joint movements are assessed on both sides using the scoring

system given.

77
 Scoring system:

0 = Absent, total paralysis

1 = Trace; palpable or visible contraction

2 = Poor; active movement through range of movement (ROM)

with gravity eliminated

3 = Fair; active movement through RoM against gravity

4 = Good; active movement through RoM against resistance

5 = Normal

MOTOR INDEX

Level Movement Left Right

C5 Shoulder _/5 _/5

abduction
C6/7 Wrist _/5 _/5
extension
C7/8 Elbow extension _/5 _/5

C7/8 Grip _/5 _/5

C8/T1 Finger abduction _/5 _/5

L1-3 Hip flexion _/5 _/5

L3/4 Knee extension _/5 _/5

L4/5 Ankle _/5 _/5

dorsiflexion
L5 Great toe _/5 _/5
extension
S1/2 Ankle plantar _/5 _/5
flexion

Total _ /50 _ /50

78
Sensory testing

Pinprick sensation is assessed for each dermatome level of injury.

Scoring is:

1 = normal

0.5 = impaired

0 = absent

The total can be expressed as a percentage of the maximum possible from

that level.

Joint position sense is assessed in both great toes, scored as:

1 = present

2 = absent

79
ROBOTIC THERAPY IN SPINAL CORD

INJURIES

80
 Use Of Robotic Therapy In Spinal Cord Injuries

 Robots have been used for a long time to replace humans in certain tasks that may

be dangerous or to reduce the ergonomic load.

 With the advent of technology, the efficiency of the motors improved and the size

to power ratio got optimised with smaller powerful and lightweight motors.

 Similarly, the batteries making them very lightweight with more power available for

a longer duration.

 These advances were harnessed to make more efficient exoskeletal orthoses.

 Robotic exoskeletons have different components depending on the usage.

 The basic components of the exoskeletons are the motors, fixed to the orthosis to

move the joint, and lift the weight of the limb.

 The motors are actuated to create a particular motion of the particular joint as per

the expected activity to be done, say flexion, extension or rotation in different

planes as per the requirement of the limb.

 The actuation can be done using some remaining movement of the limb or using

sensors of different kinds in which sense the weight, motion, angle, acceleration,

friction, tightness, and other parameters.

 Some sensors are also used to gather signals from the muscles, brain or motion

of the limb like that from electroencephalogram (EEG) or electromyogram (EMG)

or from the movements of the limbs picked by the gyroscopes or accelerometers,

etc.

 These give the feedback to the control centre in the computer.

81
 Using the movement algorithm fed onto the software, the information received from

the sensors is fed to the actuators in the different joints of the orthosis to place the

limb in a particular position in order to move it as per the requirement.

 The control centre has the database of the different human beings performing

different movements including walking, climbing stairs, lifting, picking, getting up

from sitting, etc.

 This database is made from the motion analysis of a large sample of human beings.

Robotic Exoskeletons for the Upper Limb

 Cervical SCI can result in partial or complete tetraplegia.

 The higher and more complete the injury to the cervical spinal cord, the more

pronounced the paralysis of the arms, wrists, and fingers will be. In this population,

arm and hand function consistently ranks highest in priority of recovery.

 Subsequently, rehabilitation for the upper extremities typically focuses on

strengthening any intact motor pathways to the arm and hand. There are a number

of different robotic devices currently used for neurorehabilitation of the upper

extremities of SCI.

 These devices typically target either the shoulder and elbow, or the wrist and

fingers, and can be categorized as either exoskeletons or robotic end-effectors.

82
AREMO DEVICES

 Were the first commercially available unilateral upper extremity exoskeletons for

combined hand and arm rehabilitation.

 The devices include ArmeoPower for the most impaired users, ArmeoSpring,

ArmeoSpring Paediatrics, and ArmeoSenso for the least impaired.

 The Armeo Spring is reliable as a clinical tool to measure movement

workspace and to measure functional changes in the upper extremity during

rehabilitation and can be clinically applicable within the Spinal Cord Independence.

Figure No: 26

In Motion Device

 It is a commonly used fixed frame upper limb rehabilitation robot.

 It was designed to provide high intensity and reproducible upper limb

rehabilitation in adults and older children.

 The device is able to deliver assistance to user-initiated movements or perform

movements with no user input.

83
 The InMotion WRIST can be used independently as a stand-alone device or

combined with the ARM feature.

Figure No: 27

The Hand of Hope device

 Is a neuromuscular rehabilitation exoskeleton designed to help users regain

hand mobility.

 The hand and forearm are strapped into this molded device, which uses

electromyography sensors on the forearm to control the hand for a number of

different tasks.

 The HoH also has a visual feedback component: using biofeedback techniques

to report to users the strength of their activated target muscles.

Figure No: 28

84
The ReoGo device

 Is a stationary fixed based, end-effector arm rehabilitation robot, which is

capable of producing a wide range of reproducible movements in three-

dimensional space.

 The ReoGo allows for movements at the elbow (flexion/extension), wrist

(flexion/extension), and shoulder (flexion/extension; abduction/adduction;

internal/external rotation).

 The ReoGo uses a real-time visual feedback monitor to display tasks and

games for the user to perform.

Figure No: 29

85
 Robotic Exoskeletons for Lower Limb

 Thoracic and lower SCIs can result in partial to complete paralysis of the lower

extremities, and recovery can be limited.

 Independent mobility for many can only be achieved at a wheelchair level,

although walking oftentimes remains a priority for recovery and improved

quality of life.

 Powered exoskeleton devices have emerged as potential upright mobility

devices for those with both incomplete or complete paralysis.

The Re Walk robotic device: -

 ReWalk is a wearable robotic exoskeleton that provides powered hip and knee

motion to enable individuals with spinal cord injury (SCI) to stand upright, walk,

turn, and climb and descend stairs.

 ReWalk offers a comprehensive training program for clinics that want to offer

their clients exoskeleton training and reimbursement support for individuals with

spinal cord injury who would like their own devices to use at home and in the

community.

 The system allows independent, controlled walking while mimicking the natural

gait pattern of the legs.

86
 Figure No: 30

Indego Robotic device: -

 Ekso Indego is the only exoskeleton to offer a modular quick connect design,

which allows you to put on and take off the device without assistance.

 At just 29 lb (13 kg), Ekso Indego is the lightest commercial exoskeleton

available offering ease of handling, transportation, and storage.

 Ekso Indego is a powered lower limb orthosis, also known as a powered

exoskeleton, which enables people with mobility impairments the opportunity to

walk independently.

 Power is provided by sophisticated motors in the knee and hip joints, and

combined with advanced sensors and control strategies, the device allows

individuals with gait impairments to stand and walk again, granting them a new

level of independence at home and in the community.

 Ekso Indego can currently be used with spinal cord injury levels of T3 to T5 in

community or home settings but is not intended for sports or stair climbing.

87
 Figure No: 31

Self-Balancing Wheelchairs: -

 Like the segway, wheelchairs balancing over two wheels have been

developed which keep the balance with seat in the normal horizontal

position irrespective of the terrain or going up or down the slopes like the

hilly terrains.

 These have special sensors like gyros which maintain the balance of the

wheelchair whether going up or down the slope, uneven surfaces or

going up and down the ramps, staircases, or hills.

Figure No: 32

88
CONCLUSION

89
 CONCLUSION

 As technology advances, the frontiers of rehabilitation are constantly redefined,

and the concept of inclusiveness, mainstreaming and productivity for the differently

abled are only going to be enhanced.In the words of the great writer of science

fiction Arthur Clarke “Any sufficiently advanced technology is indistinguishable

from magic”.The famous inventor Dean Kamen has said “Our healthcare system

has seen some of the greatest achievements of the human intellect since we

started recording history: We’re developing incredible devices and implantables to

improve the quantity of people’s lives”.

 There are many promising interventions using robotics to improve the mobility,

function, and quality of life of those living with spinal cord injury. Larger, more

extensive studies of upper extremity robotics are needed to further explore their

efficacy given the positive outcomes of the limited current literature.Studies of

lower extremity robotic exoskeletons have been more extensive and have shown

them to be feasible, safe, and deliver results in gait that could in the future begin

to near comfortable walking speeds.Already, robotic technology and the adjunct

methods discussed above are being used therapeutically with positive outcomes,

and that opens the door to push further and to develop more innovate ways to

promote plasticity and recovery. The current state of neurorehabilitation with

robotics is promising and the future exciting. With time, robotic technology for both

upper and lower extremities could push the limits of SCI rehabilitation.

 We have to wait and see what incredible surprises await us in the future of

rehabilitation.

90
BIBILIOGRAPHY

91
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15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357530/#:~:text=Posterior%0

cord%20syndrome%20is%20a,abolition%20of%20deep%20tendon%20reflex

es.

16. https://www.physio-pedia.com/Brown-Sequard_Syndrome

17. https://www.slideshare.net/SachinDwivedi15/spinal-cord-injury-sci-166109243

18. https://my.clevelandclinic.org/health/diseases/22132-cauda-equina-

syndrome#:~:text=There%20are%20several%20red%20flags,%2For%20legs

%20(sciatica).

19. https://www.ncbi.nlm.nih.gov/books/NBK545227/#:~:text=Clinical%20Significa

nce,onset%20bowel%20and%20bladder%20dysfunction.

20. https://www.slideshare.net/SachinDwivedi15/spinal-cord-injury-sci-166109243

21. https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/diagnosis-

treatment/drc-20377895

22. https://www.flintrehab.com/medications-for-spinal-cord-injury/

23. https://www.spinalcord.com/blog/everything-you-need-to-know-about-spinal-

cord-injury-surgery

24. Textbook of rehabilitation: Sunder, S., author.

25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095795/

93
26. https://rewalk.com/about-products-

2/#:~:text=ReWalk%20is%20a%20wearable%20robotic,gait%20pattern%20of%20the

%20legs.

27. https://eksobionics.com/indego-

personal/#:~:text=Ekso%20Indego%C2%AE%20Personal%20is,first%20time%20with

%20the%20device.

28. Textbook of rehabilitation: Sunder, S., author.

29. Textbook of rehabilitation: Sunder, S., author.

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94
ANNEXURE

95
 CASE STUDY

Name: xxxxx
Age: 57years
Gender: male
Occupation: driver
Address: xxxxx

Chief complaints:
 Weakness of both lower limbs
 Unable to walk, stand
 Difficulty in ADL
History of illness

Past medical history: -

Asthma no
Hypertension yes
Previous attack of stroke no
Transient ischemic attack no
Diabetes mellitus yes
Chronic disorder like epilepsy no

Present medical history: -

Duration - chronic
At present any physiotherapy treatment are taken - yes
Presently taken any drugs - yes
Any systemic disorders - yes

Personal history: -

96
 Smoking - yes
Alcoholism - yes
OBJECTIVE ASSESSMENT

Vital signs: -
Blood pressure - 150/100 mm hg
Respiratory rate - 16 times per minute
Pulse rate - 82 beats per minute
Temperature - 97.8 f

ON OBSERVATION

Built of the patient - endomorphic

Attitude of the limb - spastic
Any deformity - no
Posture of the person - kyphotic
Gait pattern of the person - unable to assess

ON EXAMINATION

SENSORY EXAMINATION : Intact

MOTOR EXAMINATION

Tone - hypertonicity

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 Muscle power: -

Right Left

Upper limb Grade 4 Grade 4

Lower limb Right Left

Hip flexion Grade 1 Grade 1

Hip extension Grade 2 Grade 2

Hip abduction Grade 1 Grade 1

Hip adduction Grade 2 Grade 2

Hip internal rotation Grade 1 Grade 1

Hip external rotation Grade 1 Grade 1

Knee flexion Grade 2 Grade 2

Knee extension Grade 2 Grade 2

Plantar flexion Grade 1 Grade 1

Dorsi flexion Grade 0 Grade 0

Ankle eversion Grade 1 Grade 1

Ankle inversion Grade 1 Grade 1

ROM EXAMINATION : decreased range of motion in both lower limbs

HAND FUNCTION : good
GRASPING : good
REFLEX : exaggerated
CO ORDINATION : not testable – lower limb
Upper limb - normal
BALANCE : not testable

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POSTURE : kyphotic
GAIT : patient is in wheel chair.

PROBLEMS LIST :

Muscle weakness
Tightness of the muscle in lower limb
Unable to stand, walk
Reduced mobility
Difficulty in ADL
AIMS
To improve muscle strength
To decrease muscle tone/ normalise tone
To increase ROM
To correct posture
To improve mobility
MEANS
Lower limb robotic rehabilitation
Lower limb and gait rehabilitation

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