Study On The Effect Of Rehabilitation Bundle Based On Body Weight Support Training On Motor Function Rehabilitation Of Patients With Spinal Cord Injury

Traumatic spinal cord injury（TSCI）leads to the loss of patients’physical function,motor function,and activities of daily life,which is a heavy burden to patients,families and society.With the improvement of the first aid system,the proportion of TISCI increases.Rehabilitation of motor function is of great significance to patients with TISCI.It can not only improve their motor function,but also improve their activities of daily life,and then help them return to society.Therefore,motor function rehabilitation and the best timing of intervention are particularly important.With the continuous development of rehabilitation medicine and nursing,the means and measures of motor function rehabilitation are becoming more and more diversified.Body weight support training（BWST）is an important measure for the rehabilitation of motor function in patients with TISCI.Though the literature review demonstrated that most of the clinical trials used of one or more interventions,the research on the formulation of rehabilitation bundle and the best timing to participate BWST has barely been confirmed.This study explored a scientific approach of the construction of rehabilitation bundle based on BWST for motor function rehabilitation training of patients with TISCI on the basis of evidence-based research,in order to improve the effect of motor function rehabilitation of patients with TISCI,and to find the best timing of BWST.The purpose of this study is to provide a basis for the rehabilitation of motor function in patients with TISCI.Part I Study on motor function and influencing factors in patients with acute traumatic incomplete spinal cord injuryObjective:The motor function and influencing factors of acute TISCI patients were analyzed in order to provide basis for the formulation of scientific and reasonable rehabilitation training program.Methods:A descriptive study was conducted on acute TISCI patients who were admitted to the spinal surgery department of a university affiliated hospital from January 1^st,2013to December 31^st,2017.And the injury level was between T1^L5.Results:（1）86 patients completed this study,most of them were male（88.4%）,35⁵0years old（44.2%）,and most of their highest academic qualifications are senior high school or below（76.8%）.Most patients’lenghth of stay was with in 4 weeks（72.4%）.The level of injury was mainly located in chest（67.4%）,the majority of the injury degree was B（48.8%）,and main the causes of injury were traffic accident injury（40.7%）and fall injury（30.2%）.The interval from injury to operation was mainly between 6¹2 hours（48.8%）,most of the patients did not participate in motor function rehabilitation（62.8%）,and the interval between injury and motor function rehabilitation participation was mainly 2⁴ weeks（56.3%）.（2）Complications:the main complications included atelectasis,pulmonary infection,urinary tract infection,deep venous thrombosis of lower extremities and pressure ulcer,among which deep venous thrombosis of lower extremities was the most（41.9%）.（3）The results of LEMS:there was significant difference in LEMS between admission 1.0（0.0,8.3）and discharge 14.0（10.0,22.0）（p=0.000）.（3）Length of stay（Z=8.308）,injury level（T=2.166,P=0.037）,degree of injury（H=31.994,P=0.000）,whether to participate in motor function rehabilitation（T=4.709,P=0.003）and the interval between rehabilitation and injury（F=12.441,P=0.000）were the influencing factors of LEMS.（5）The results of multivariate linear regression analysis showed that when the interval between injury and rehabilitation increased by 2 weeks,the improvement of LEMS at discharge decreased by 1.670 points.Conclusion:（1）In this study,TISCI patients were mainly young and middle-aged men with low level of education.Traffic accidents and falling injury were the main causes.Most of the patients’injury stay in thoracic segment and were able to receive surgery in time.The main interval between injury and rehabilitation was 2⁴ weeks.（2）The proportion of complications was mildly high among the patients,and the incidence of deep venous thrombosis in lower extremities was the highest.（3）The main influencing factors of motor function rehabilitation in acute TSCI patients include:the level of injury,the degree of injury,whether to participate in motor function rehabilitation and the interval between injury and motor function rehabilitation.（4）The motor function of lower extremities was improved at discharge compared with admission,and the LEMS of lower extremities decreases with the prolongation of the interval between injury and rehabilitation.Part II Establishment and Evaluation of Rehabilitation Bundle of motor function for TISCI PatientsObjective:Based on the method of evidence-based research,combined with bibliometric analysis,the effective interventions of motor function rehabilitation among domestic and foreign patients were extracted,and the initial programme of motor function rehabilitation bundle based on BWST was established.The programmewas evaluated by DEMATEL analysis,and the core measures and auxiliary measures in the rehabilitation bundle were clarified.Methods:（1）This research use the results of bibliometric analysis and Meta-analysis of relevant literature to establish the initial programme of motor function rehabilitation bundle.（2）This research use DEMATEL to evaluate the initial programme of motor function rehabilitation bundle to extract the interventions included in the final rehabilitation bundle,and the center-degree and cause-degree are used to identify the core measures and auxiliary measures.Results:（1）Establishment of the initial programme of motor function rehabilitation bundle based on BWST.1)25 English articles related to motor function rehabilitation of TSCI were obtained by searching Web of Science database.8 clusters were obtained by visualized analysis,which were"Walking scale","Population based study","Health outcome","Spinal cord injury worldwide","International standard","Lumbar spinal trauma","Inpatient spinal cord injury rehabilitation"and"Traumatic center cord syndrome".Based on the co-citation cluster analysis of key words,25 strongest citation burst were detected in the studies of motor function rehabilitation on TSCI.CNKI database was searched and 64 Chinese literatures were included.According to the co-citation cluster analysis of key words,7 keywords with centrality more than 0.1were obtained,including"occurrence and management of complications","traumatic spinal cord injury","epidemiology","rehabilitation"and"rehabilitation nursing"and"rehabilitation training".1 burst key word was detected:"spinal cord injury",and its strength is 9.3609.4 clusters were obtained by visualized analysis of co-citation cluster analysis.2)The results of meta-analysis showed that BWST had a significant effect on walking ability（Z=5.33,P<0.000）,walking speed（Z=5.27,P<0.000）,walking distance（Z=3.3,P<0.009）,WISCIⅡscore（Z=2.06,P<0.0001）.There were significant differences in the improvement of LEMS（Z=3.38,P<0.000 7）and activities of daily life（Z=3.27,P<0.001）.3)The key points of motor function rehabilitation intervention for SCI patients were obtained,including rehabilitation training,physical factor rehabilitation,rehabilitation nursing,vocational rehabilitation and job rehabilitation,which includes22 measurements.（2）Evaluation of the initial programme of motor function rehabilitation bundle based on BWST.1)Ineffective measures,such as"other motor rehabilitation training,such as yoga,tai chi";"Hydrotherapy","wax therapy","vocational skills assessment","vocational skills training","job placement",were excluded to formulate the motor function rehabilitation bundle,and 16 measures were included at last.2)The motor function rehabilitation bundle includes core measures and auxiliary measures.There are 8 core measures.The"motor function rehabilitation"dimension includes BWST,muscle strength training,balance training;the physical factor rehabilitation dimension includes neuromuscular electrical stimulation;"Rehabilitation nursing"dimension includes stool and urine function training,Respiratory and expectoration training;"vocational rehabilitation"dimension includes wheelchair training,ADL training.There were 8 auxiliary measures.The"motor function rehabilitation"dimension includes walking training,drafting training,"rehabilitation nursing dimension"includes axis turning over,range of motion training,posture training,lying position training."Occupational rehabilitation dimension"includes mat exercise,transfer training.Conclusion:The motor function rehabilitation bundle was established,including 8 core measures and 8 auxiliary measures.Part III Clinical empirical study on the motor function rehabilitation bundle based on BWST for patients with TISCIObjective:（1）To compare the effect of the motor function rehabilitation bundle based on BWST and conventional scheme on motor function rehabilitation of TISCI patients,and to verify the effectiveness of the motor function rehabilitation bundle based on BWST.（2）On the basis of the implementation of the motor function rehabilitation bundle based on BWST for TISCI patients,compare the difference of timing to participate BWSTT,and explore the best timing of BWSTT.Methods:（1）Using 1 vs 1 matching non-random historical control study,TISCI patients hospitalized in the department of spinal surgery and rehabilitation of a university facilitated hospital from January 2018 to June 2019 were divided into experimental group.The motor function rehabilitation bundle based on BWST was used.From July2016 to December 2017,TISCI patients who accepted surgery and were matched with the basic information of the experimental group,were selected as the control group and were treated with conventional motor function rehabilitation scheme.（2）A randomized block study was conducted to study TISCI patients hospitalized in the Department of Spinal surgery and Rehabilitation of a university facilitated hospital in from January 2018 to June 2019.According to the starting time of BWSTT,the patients were divided into three groups,which were group A,group B,and group C.Patients assigned to group A,participated BWSTT 4 weeks after surgery,patients assigned to group B participated BWSTT 8 weeks after surgery,patients assigned to group C participate BWSTT 12 weeks after surgery.BWSTT lasted for 12weeks in all the three groups.The patients who met the inclusion criteria were randomly assigned to each treatment group according to the proportion of 1:1:1,and the length of the block was 6.All patients received the motor function rehabilitation bundle from the beginning to the 24^th week after surgery.Results:（1）Non-random historical control study.At the 24^th week,LEMS,BBS and SCIM III of the patients in the bundle group were significantly higher than those in the control group（p=0.000）.There was no significant difference in the incidence of complications such as lower extremity venous thrombosis,urinary tract infection,pulmonary infection,spasm and pressure ulcer between the two groups（p>0.05）.（2）Randomized block study1)At the 24^th week after surgery,there were significant differences in LEMS,BBS and SCIMⅢscores among TISCI patients in group A,B and C（P=0.034,P=0.015 and P=0.020）.The LEMS,BBS and SCIMⅢof TISCI patients in group B was significantly higher than that in group C（P=0.012,Ρ=0.007 andΡ=0.008）.2)After 4 weeks’BWSTT,there was no significant difference in LEMS,SCIMⅢscore and BBS among TISCI patients in group A,B and C（P>0.05）.However,the improvement LEMS,SCIMⅢscore and BBS in group A was slightly higher than that in group B and C.3)After 8 weeks’BWSTT,there were significant differences in SCIMⅢscores and BBS among group A,B and C（Ρ=0.000 andΡ=0.010）.Furthermore,the differences between SCIM III and BBS in group A and B were significantly higher than those in group C（P<0.05）.4)After 12 weeks’BWSTT,there were significant differences in LEMS,SCIMⅢscore and BBS among group A,B and C（P=0.004,P=0.001 and P=0.003）.The scores of LEMS,SCIMⅢand BBS in group A and group B were significantly higher than those in group C（P<0.05）.The scores of LEMS,SCIMⅢand BBS in group B were higher than those in group A,but the difference was not statistically significant.5)At the 24^th week after surgery,there was no significant difference in the incidence of complications among group A,group B and group C（P>0.05）.Conclusion:（1）The motor function rehabilitation bundle can effectively improve the lower limb motor function,balance ability and ADL of TISCI patients,promote the rehabilitation of motor function,and reduce the incidence of pulmonary infection and urinary tract infection in patients with TISCI.But there was no significant effect on the incidence of pressure injury,lower extremity venous thrombosis and spasm.（2）On the basis of motor function rehabilitation bundle based on BWST,participating BWSTT during 4 to 8 weeks after surgery could significantly improve the lower limb motor ability,balance ability and activities of daily living in patients with early TISCI.It is inferred that if the sample size were increased and the observation time were prolonged,BWSTT at the beginning of 8 weeks may be more beneficial to improve the rehabilitation effect of motor function in early patients with TISCI.