Dr. Sandeep Singh on Person-Centric Rehabilitation for Spinal Cord Injuries

A spinal cord injury (SCI) can cause changes in strength, feeling and function below the damage point on the spinal cord or spinal nerve roots. Temporary or permanent loss of movement and feeling, and other health complications make timely rehabilitation critical to regain the highest level of functional independence possible.

Sandeep Singh, MD, FAAPMR, is Good Shepherd Rehabilitation’s Chief Medical Officer, the Senior Vice President of Medical Affairs and Medical Director, Spinal Cord Injury. We asked Dr. Singh to provide an overview of SCIs and share how Good Shepherd’s CARF-accredited Spinal Cord Injury Rehabilitation Program is helping patients regain physical function and psychological well-being.

What’s the difference between a traumatic SCI and non-traumatic SCI?

Dr. Singh: “A traumatic SCI is a sudden injury to the spinal cord followed by pathological changes in the anatomy, including inflammation of the spinal cord followed by scarring. A complete SCI injury means that there is no nerve communication below the injury site, and muscle control, feeling or function below the injury is lost. Traumatic SCIs are often from diving accidents, auto accidents and gun shots.

“A nontraumatic SCI may have a slower progressive state of compression on the spine from the effects of a tumor, epidural hematoma, post-surgical event or hyper-profusion event, among others. We see less permanent loss of function with nontraumatic SCI.”

What is the most common cause of SCIs?

Dr. Singh: “Falls are the most common cause of SCIs. Our geriatric population is at a higher risk for falls that result in center-core SCIs with more involvement of the upper extremity. Many are on medications that play a role in blood pressure stability and many have underlying arthritis in the cervical spine — both contribute to the fall risk and scope of injury.”

What is life like for someone after an SCI?

Dr. Singh: “There are several phases for someone who experiences an SCI. The acute (or initial) phase is an adjustment period for the traumatic or nontraumatic SCI event. The patient has to acclimate to a new equilibrium in the body, adjusting to their environment and new positioning and posturing, while navigating pain. They also must become mindful that organ systems — like the bowel, bladder, skin and sexual functions — may be disrupted.

“A physiatrist (physical medicine and rehabilitation physician) and the care team will address these issues with each patient. We understand this phase involves grieving, so we are empathetic to the patient’s situation and mental health impact and develop individualized care plans.

“The acute phase can last days, weeks or several months, based on the patient’s injury, how well they are supported and their mental health state. Studies show that structured SCI programs like Good Shepherd’s help patients through this phase faster thanks to more care oversight that allows them to engage more fully in activities.

“The subacute phase is known as the golden period because patients often put forth their best effort to improve their quality of life and engage with activities like strength and locomotion training. In the subacute phase, the patient is focused on restoring function inside and outside the body. For some, this phase may start with functional electrical stimulation to help preserve muscles and nerve-muscle communication as a precursor to gaining function. 

“At Good Shepherd, we provide education to patients in the subacute phase so they can drive their care. We want them to become the “owner” of their bowel and bladder management and skin care. We teach how to look out for potential fractures, skin injuries and other bodily events that could become serious.

“Community re-entry is the next phase, and that looks different for each patient. Some patients can get back to their community setting or home after leaving the hospital. They then participate in a home-based program or outpatient program. 

“Other patients may need more therapeutic intervention and will spend time doing day therapy or outpatient therapy for several weeks or month as they progress to community re-entry.

“For patients with a higher level of SCI and who may be of advanced age, more extensive care is often needed for a longer period. They may continue rehabilitation at a skilled nursing facility or become a resident due to a lack of functional improvement and other health and caregiver issues.

“At Good Shepherd, we are focused on preventing rehospitalization and promoting overall wellness. We work with each patient to help prevent health issues such as obesity, osteoporosis and metabolism disorders like diabetes and heart disease.

“Thoracic and lumbar SCI patients typically gain more independence through rehabilitation and have more favorable community re-entry success.”

What are common physical impairments resulting from an SCI?

Dr. Singh: “For thoracic and lumbar paraplegic patients, bowel, bladder and sexual function are the biggest issues. They are at a higher risk of musculoskeletal injuries. Because they may frequently use their upper extremity, shoulder, elbow and wrist injuries are common. Since these patients are more active, they are at a higher risk for falls, injuries and fractures.

“Cervical SCI patients may see compromises to the cardiopulmonary organ system, and they may be more prone to infections and have lung capacity issues. As a result, they may require more strategic energy conservation techniques to engage with their environment. In addition, for cervical SCI patients, there may be heavy involvement of the sacrum. Spasticity, blood pressure management issues and bladder infections frequently are issues.”

Can someone with a complete SCI walk again?

Dr. Singh: “The most common question I have had throughout my career is, “Will I walk again?” Thanks to our growing knowledge from scientific research and the assistance of leading-edge technology, we can engage patients in activities that advance neuroplasticity, which is the ability of the brain to form and reorganize synaptic connections following an injury.

“There is a role for conventional and atypical interventions that can help regain functions like walking. We use conventional rehabilitation tools like treadmill gait training and balance systems. Exoskeletons allow us to place the patient in a secure robot to assist with postural support and muscle activation of gain that promotes neurological recovery over time. Good Shepherd has been a leading user of exoskeleton technologies for a decade.”

How important is the care team and patient relationship during SCI rehabilitation?

Dr. Singh: “The provider and patient relationship is the epicenter of how a patient progresses.

“One of Good Shepherd’s goals is to avoid rehospitalization, so we focus on overall patient wellness, including the prevention of obesity, osteoporosis and metabolism disorders. Our care team truly understands the drastic change in life quality that an SCI patient undergoes. That’s why our multi-disciplinary care includes physiatrists, nurses, physical, occupational, speech and recreational therapists, respiratory therapists and care managers.

“With mental health care being imperative to SCI patients, our team includes neuropsychologists who specialize in how brain function relates to neurological and physical function. They work with patients on the challenges of meaningful relationships, life and work re-entry and daily stressors.”

What is the recovery time for an SCI?

Dr. Singh: “Recovery times are contingent on the type and severity of the injury, pre-existing medical conditions and psychological well-being. They all play a role in recovery, and recovery is very individualized. I like to tell patients that the first six to 12 months are pivotal for gross motor and neurological function recovery.”

How vital is it to receive rehabilitation immediately following an SCI?

Dr. Singh: “Rehabilitation care is vitally important within several days to the first week after the injury. The quicker patients receive education and rehabilitation expertise, the less likely they will have a negative outcome during the acute stages.

“Science shows that early mobilization and rehabilitation care result in better mortality, quality of life and overall outcomes. Part of that is psychological, because there is a positive impact from moving from an acute-care hospital to a rehab setting where patients can engage with peers with similar injuries and clinical team members who are experts in SCI care and motivation.”

What does inpatient and outpatient rehabilitation for a SCI involve?

Dr. Singh: “Good Shepherd’s multidisciplinary approach includes a care team captained by the physiatrist, who works to mitigate risks and ensures the patient gains the most function possible through physical, occupational, speech and recreation therapy programs, medication adjustments, and psychological support. Good Shepherd Rehabilitation Hospital offers 24/7 nursing care.

“Our outpatient SCI rehabilitation carries forward what the patient learned during the acute-care stay. Our outpatient teams understand the scope of the injury and how neuroplasticity can be optimized. They provide ongoing education and help patients achieve realistic goals, while preserving joints and reducing risk.

“Our outpatient resources help patients with occupation/vocational rehab, work modifications, psycho/social support in the community and home, and disability engagement. Other outpatient resources at Good Shepherd include our wheelchair clinic, peer mentorship and SCI support group.”

What rehabilitation technology does Good Shepherd use with SCI patients?

Dr. Singh: “Functional electrical stimulation is important during the first several weeks of injury, as it is proven to keep muscle bulk preserved and helps with neuroplasticity and retaining strength.

“Overhead treadmills, like the Lokomat and Zero-G Gait and Balance System, support neuroplasticity.

“Robotic technologies used in the acute-phase for neuroplasticity training — mainly in our outpatient rehabilitation facilities — include a variety of robotic exoskeletons.”

How does Good Shepherd’s SCI rehab differ from what is available in the region?

Dr. Singh: “Good Shepherd continues to be a pioneer in SCI rehabilitation and continues to invest resources to advance our care model. We have a long-standing reputation for our comprehensive SCI program that no one else in the region can match.

“Our therapists hold many certifications and competencies that give them distinction in caring for SCI patients. In fact, we train most of the therapists in the region who work with SCI patients.

“I am proud that Good Shepherd’s SCI care is person-centric. Whether you are an inpatient, outpatient or long-term care resident, Good Shepherd customizes our care plans around each individual’s needs.”

For more information on Good Shepherd’s Spinal Cord Injury Rehabilitation Program, call 1-888-44-REHAB (73422).