Spinal Cord Injury (SCI) Slides PDF

Spinal Cord Injury (SCI) By: Danny Jeans, Cam Clauzel, Seoneung Kim, Simon Kim How the Spinal Cord Works - The spinal cord is a thick bundle of nerves that runs through the vertebrae in your spine. This nerve bundle is about 18 inches long, starting...

Spinal Cord Injury (SCI) By: Danny Jeans, Cam Clauzel, Seoneung Kim, Simon Kim How the Spinal Cord Works - The spinal cord is a thick bundle of nerves that runs through the vertebrae in your spine. This nerve bundle is about 18 inches long, starting at the base of your brain and ending at your buttocks - The spinal cord acts as a super-highway between your brain and the rest of your body. - The message is sent in the form of nerve impulses. Spinal Cord Injury - A spinal cord injury is any sustained damage to the spinal cord, or the nerves at the end of the spinal canal. - When the spinal cord is damaged, the highway is essentially closed. Nerve impulses can’t get through. This results in loss of mobility and sensation below the level of injury. (Spinal Cord Injury Canada)  2 kinds of Spinal Cord Injuries Traumatic (TSCI) Non-Traumatic (NTSCI) A spinal cord injury can also occur because of a A spinal cord injury occurs because of impact to cancerous tumor, inflammation or infection. the spinal cord from a traumatic event like a car crash, a fall, a violent act or a sporting activity. Congenital disorders, such as spina bifida, where the spinal cord is malformed or exposed at birth. (Spinal Cord Injury Canada) Thorogood, N. P Traumatic SCI vs. Non-Traumatic SCI (Rick Hanson Spinal Cord Injury Registry) Forms of Spinal Cord Injury Complete vs. Incomplete Paraplegia vs. Quadriplegia (Spinal Cord Injury Canada) Levels of Spinal Cord Injury - Neck injury - May not be able to breathe on own Cervical C1-C8 - All four limbs affected - May affect speaking including hands - Middle/lower back - May cause Difficulty breathing, Loss of feeling in the genitals or rectal region, Thoracic T1-T12 - Trunk and legs affected Loss of bladder or bowel control, and - Paraplegia Constipation - Lower back - May affectbowel and bladder, the hips and groin area, and may impact the lower Lumbar L1-L5 - Hips and legs affected abdominal muscles and thigh flexion as - Possible Paraplegia well. - Bottom of the Spine - May affect bowel and bladder and Sacral S1-S5 - Hips and legs affected possible loss of function in the hips and - Possible Paraplegia legs. (Spinal Cord Injury Canada)  SCI Globally SCI in Canada SCI in B.C. 15 million + 85,000 + 12,000 + people with spinal cord injury people with spinal cord injury people with spinal cord injury 500,000 4,500 500 new SCI cases every year new SCI cases every year new SCI cases every year SCI BC SCI Canada W.H.O. Traumatic Spinal Cord Injury (rates per 1 million people) Thorogood, N. P Canadian Incidence and Prevalence Rates Thorogood, N. P Canada Age and Sex specific Rates in 2019 (rates per 1 million people) Thorogood, N. P Meet Steve Personal Factors - 41 year old male - Single - Accountant (Option to work from home)) - Lives alone - Traumatic injury - Car accident in 2019 crushed his T-9 vertebrae causing him to lose all motor function at and below the T-9 vertebrae - Incomplete grade B spinal cord injury - Before the accident steve was an athlete, specifically basketball but found it hard post injury to get back into daily exercise Steve Body Functions - Good upper body control - Lack of function in the legs and torso, resulting in paraplegia - Mostly able to control the trunk of the body and abdominal muscles - Good balance while in a sitting position Steve Limitations In the first few years after his car accident, - Steve saw significant negative changes to metabolic and cardiovascular function due to his sedentary lifestyle. - He also developed significant shoulder pain due to increased usage and weight bearing activities they were being used for. - Suffered muscle atrophy due to unuse and sedentary lifestyle - He became quite lonely due to living alone and reduction of his social circle. Steve (ICF) Spinal Cord Injury (1 to 3 years post injury) Body Functions/Structures Activities Participation - Good upper body control - Lack of function in the legs and - Employment torso, resulting in paraplegia - Wheelchair propulsion - Mostly able to control the trunk of - Transfers - Small friend gatherings the body and abdominal muscles - Good balance while in a sitting - Overhead reach - Rehab position - Self care Environmental Factors Personal Factors - 41 year old male - Lack of accessibility - Single - Accountant (able to return to work) - Lots of medication - Lives alone - Cost of outfitting home/car - Traumatic injury - Harder to get around - Car accident in 2019 crushed his T-9 vertebrae causing him to lose all motor function at and below the T-9 - Getting to and from car vertebrae - Getting to and from bed - Incomplete grade B spinal cord injury - Reaching high for things - Before the accident steve was an athlete, specifically basketball but found it hard post injury to get back into - Opening and closing doors daily exercise General Goals for Managing SCI  Approximately 12%–29% of the SCI population meets population-specific exercise guidelines Goal #1 Changes in physical activity participation occur within months following discharge from inpatient rehabilitation, reflected in Exercise rapid changes in fitness levels and physical deconditioning in the first year post-injury Pelletier 4 Reasons Why Exercise is Important for SCI Individuals 1. Improve Cardiovascular health remodelling of the cardiovascular system including smaller cavity sizes and mass, and reduced left ventricle mass and chamber dimension. (Pelletier) 2. Reduce shoulder pain Shoulder problems such as pain, contractions, and decreased range of motions are major issues within the SCI community, especially for manual wheelchair users (Mulroy) 3. Reduce muscle breakdown Atrophy, fiber type conversion, increased intramuscular fat, spasticity, contractures (Pelletier) 4. Protect against bone mass loss Changes in the skeletal system approximately 30%–50% declines in hip and knee region bone mass in the first year following injury. (Pelletier)  Goal #1 Exercise Muscular and Bone Cardiovascular Health and Flexibility and Range of Strength Endurance Motion - Help prevent shoulder - Increase cardiovascular - Help prevent shoulder and arm pain function pain - Protect against bone - Avoid metabolic - Increase flexibility and mass loss syndrome range of motion in - Increase power output - Avoid cardiovascular shoulders - Increase muscle strength disease - Stretch unused muscles - Better trunk stabilization - Better quality of life and support  Functional Electrical Stimulation (FES) or Neuromuscular Electrical Electrical Stimulation (NMES) ○ Simplest manner for exercising paralyzed muscles Stimulation ○ ○ Delays bone loss Offset rapid process of skeletal muscle atrophy & regional adiposity ○ Improves metabolic profile ○ Can prevent other medical complications ○ Can lead to improvement in bone health Gorgey (2014) Functional Electrical Stimulation to peripheral nerves rather than muscle ○ Reduce risk of tissue damage & Stimulation discomfort Developed to facilitate bladder & bowel function Recent study showing FES therapy could significantly increase muscle size, function, and metabolism Dorrian (2023)  Elastic Bands Beneficial ○ Can be used for a wide variety of exercises Exercises ○ ○ Less risk of injury Prepares body for further adaptations Home training Accessibility ○ Affordable ○ Few limitations ○ Easy SCI Action Canada (2011) Home Training Examples SCI (2011) Home training (elastic band) vs. Supervised hospital program (elastic band) Kesiktaş, (2021) Steve After Home training & FES In the first few years - Steve saw significant positive changes to upper trunk strength & bladder function - He also perceived decreased shoulder pain due to proper management of exercises - Was able to stop muscle atrophy due to unuse and sedentary lifestyle - He became strong enough to be involved in other activities & recently joined wheelchair basketball club  Goal #2 Cardiovascular Health and Endurance Muscular and Bone Cardiovascular Health and Flexibility and Range of Strength Endurance Motion - Help prevent shoulder - Increase cardiovascular - Help prevent shoulder and arm pain function pain - Protect against bone - Avoid metabolic - Increase flexibility and mass loss syndrome range of motion in - Increase power output - Avoid cardiovascular shoulders - Increase muscle strength disease - Stretch unused muscles - Better trunk stabilization - Better quality of life and support (Evans, N.)  “Wheelchair exercise capacity is diminished in many persons with SCI because of muscle weakness, loss of autonomic control below the level of injury and subsequent changes in metabolic and cardiovascular function.” Study -Since Steve has a life long injury we have to think of the rest of his life. “Wheelchair exercise capacity is an important determinant of health status of subjects with SCI, especially in Cardiovascular Health the long-term, because a low wheelchair exercise capacity exposes them to increased risk of developing medical conditions, such as metabolic syndrome and cardiovascular disease and is related to a reduced level of functioning, a reduced level of activities and participation and quality of life”. van Koppenhage et.al, 2013 Steve Steve was a basketball player before his injury. He is really missing it and wants improve his aerobic capacity and keep the love of basketball in his life. He also wants to increase his wheelchair force output for his wheelchair basketball league.  18-65 year old participants were tested on their peak aerobic power output and peak oxygen uptake 1 year after injury and 5 years after injury. In these 5 years participants receieved treatment from rehab centers Study Significant changes were made in power and oxygen uptake 5 years after the injury Steve does not have to go to treatment but he can increase Cardiovascular Health his power and aerobic capacity by using treatment center methods such as a hand exercise bike. van Koppenhage et.al, 2013 Hand cycling “Handcycling is a common exercise mode for manual wheelchair users during and after rehabilitation [4,5]. It is shown that handcycle training results in improvement in physical capacity during and after rehabilitation. Furthermore, handcycling has a higher efficiency than wheelchair propulsion and leads to lower shoulder loads This is important as 30–73% of wheelchair users with a SCI experience musculoskeletal pain in the shoulder” Lovell et.al, 2012 For Steve The purpose of this study was to compare the cardiorespiratory response and mechanical efficiency (ME) of highly trained spinal cord injured (SCI) handcyclists with untrained SCI men. The study shows that the handcyclists had a large force output and high aerobic capacity. Loell et al. (2013) Steve Aerobic Capacity benefits - With Steves cardiovascular health he strengthened his heart and blood vessels - He improved his flow of oxygen throughout his body - Steve also lowered his blood pressure and cholesterol - This not only helps with his daily living but his performance on the basketball court. - (Levine. B, 2024)  Goal #1 Exercise Muscular and Bone Cardiovascular Health and Flexibility and Range of Strength Endurance Motion - Help prevent shoulder - Increase cardiovascular - Help prevent shoulder and arm pain function pain - Protect against bone - Avoid metabolic - Increase flexibility and mass loss syndrome range of motion in - Increase power output - Avoid cardiovascular shoulders - Increase muscle strength disease - Stretch unused muscles - Better trunk stabilization - Better quality of life and support  Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Study Chronic Spinal Cord Injury: A Randomized Controlled Trial Eighty individuals with paraplegia from SCI and shoulder pain were assigned to an exercise/movement optimization intervention The shoulder home exercise program consisted of a stretching phase, a warm-up phase, and a resistive shoulder exercise phase, all to be performed 3 times per week for 12 weeks (Mulroy, S. J.)  Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Study Chronic Spinal Cord Injury: A Randomized Controlled Trial Results Shoulder pain, as measured with the Wheelchair User’s Shoulder Pain Index, decreased to one third of baseline levels after the intervention (Mulroy, S. J.) Steve Shoulder Pain Body Limitations Before focusing on Flexibility and Range of Motion - Shoulder joint structure - Muscle strength - Range of motion After Exercising with a focus on Flexibility and Range of Motion Steve is able to participate and perform in activities such as: - Mobility - Wheelchair Propulsion - Transfers - Activities of daily life - Overhead reach - Self care - Other - Play basketball - Perform work tasks - Further exercises  Things To Be Aware Of During And After Exercise Skin Breakdown Temperature Regulation Orthostatic Hypotension Autonomic Dysreflexia Blauwet (2016)  Social support is positively related to physical and mental health, pain, coping, adjustment and life satisfaction. (Muller, R) Goal #2 Social isolation was associated with both current and future depression symptoms, Consistent Social Interactions indicating the need to monitor aspects of social isolation and their potential impact on long-term outcomes after SCI. (Krause, J.)  An exploration of perceived social isolation among persons with spinal Study cord injury in Ontario, Canada: a qualitative study Perceived social isolation is characterized as the subjective feelings of loneliness and not belonging, which has also been associated with adverse health outcomes such as cardiovascular disease, sleep issues/disorders, and heightened inflammatory responses to stress (Mulroy, S. J.)  An exploration of perceived social isolation among persons with spinal Study cord injury in Ontario, Canada: a qualitative study Overall, participants in the study highlighted a major Many of the participants discussed losing individuals disruption of the structure and composition of their from their social networks following their injury social networks and the importance of social support within their networks. Average social Average social network size for network size for Key factors associated with perceived social isolation someone with an SCI general population included physical accessibility, return to employment, hobbies, and other leisure activities, and individual traits 4 10 (Mulroy, S. J.)  An exploration of perceived social isolation among persons with spinal Study cord injury in Ontario, Canada: a qualitative study Results The current study highlights that disruption in an individual’s social network, as well as the quality of the relationships within the network, are important components that impact perceived social isolation in individuals with SCI in the community. Those who had someone embedded into their home who was a part of their social network experienced less social isolation than those who lived alone. (Mulroy, S. J.) Steve Social Interaction Steve’s social circle has decreased significantly and he lives alone so he was feeling quite isolated He decided to - Cherish and value the social network he did have - Go into work rather than work from home - Start playing wheelchair basketball - Keep in touch with his peer to peer mentor assigned to him in the hospital  Chronic pain is one of the most common and debilitation Goal #3 consequences of SCI, impacting activities of daily living, sleep, mental health, and physical activity Pain Prevention/Management participation. (Pelletier, C.)  Include proper warm-up ○ Wheeling forwards & backwards for 2 minutes ○ Shoulder rolls 10 times on each shoulder ○ Arm circles forwards & backwards 10 times ○ Wrist rolls Programming Proper cooldown Avoid strength training 3 days in a row ○ If needed break routine throughout the Exercise is Medicine day (15 min morning 15m noon) KEY: Find activities that reduce risks of physical dysfunction and cardiovascular diseases while not increasing risks of injury promoting musculoskeletal deterioration SCI (2011)  Include as much detail as possible ○ When, Where, What, Equipment Programming At least 2 strength training sessions per week Exercise is Medicine ○ 3 sets of 8-10 reps of each exercise for each major muscle group SCI (2011)  Common Medication and There are various medications for spinal cord injury. They also have some potential Side Effects side effects The main purpose of the medications is not 31-78% of SCI patients take 5 or to cure SCI directly, but to prevent further more medications pain.  Compile Table about Medications for Spinal Cord Injury Medication Representative Purpose Mechanism Side Effects Examples Corticosteroid Methylprednisolone Prevent Reduces swelling Weight gain inflammation and prevents spinal Infection risk cord damage Antispasmodics Baclofen Manage spasticity Acting directly on Drowsiness muscles fibers to Dizziness relax muscles Neuropathic Pain Gabapentin Relief of nerve pain Modulates Fatigue overactive nerve Dizziness signals Edema Anti Inflammatory NSAIDs Chronic pain Reduce Gastrointestinal inflammation and irritation pain Medication Representative Purpose Mechanism Side Effects Examples Bone Health Alendronate Prevent bone loss Support calcium Joint pain balance Gastrointestinal irritation Antidepressants Sertraline Manage Modulate serotonin Weight gain depression to improve mood Nausea Common side effects of these medications are weight gain, gastrointestinal issue, and dizziness These side effects cause environmental factors which affect patient’s life. Steve Environmental Factors - After Steve got SCI, he took Methylprednisolone to control inflammation. It helped to prevent nerve damage. However, he need to be monitored to prevent infection and hyperglycemia. - He also took Gabapentin to manage neuropathic pain. It helped to reduce chronic nerve pain and participate him to live daily activities. However, Steve feel frequent fatigue and dizziness, so hard to use wheelchair for long distance and engage in complicated works. Steve (ICF) Spinal Cord Injury (Year 4/5) Body Functions/Structures Activities Participation - Good upper body control - Lack of function in the legs and - Wheelchair propulsion - Employment - Handcycling torso, resulting in paraplegia - Wheelchair Basketball - Small friend gatherings - Mostly able to control the trunk of the body and abdominal muscles - Resistance training - Exercising - Good balance while in a sitting - Stretching and strength training - Community sport - Transfers position - Overhead reach - Social engagement - Self care - Community participation Environmental Factors Personal Factors - 41 year old male - Easier for him to get around - Single - Accountant (able to return to work) - Only takes muscle relaxants now - Lives alone - Home gym cost - Traumatic injury - Car accident in 2019 crushed his T-9 vertebrae causing - Getting to and from car him to lose all motor function at and below the T-9 - Getting to and from bed vertebrae - Incomplete grade B spinal cord injury - Reaching high for things - Before the accident steve was an athlete, specifically - Opening and closing doors basketball but found it hard post injury to get back into daily exercise References Cimino, S. R., Hitzig, S. L., Craven, B. C., Bassett-Gunter, R. L., Li, J., & Guilcher, S. J. T. (2022). An exploration of perceived social isolation among persons with spinal cord injury in Ontario, Canada: a qualitative study. Disability & Rehabilitation, 44(14), 3400–3409. https://doi.org/10.1080/09638288.2020.1861485 Dvorak, M. F. (2023). Incidence and prevalence of traumatic spinal cord injury in Canada using health administrative data. Frontiers in neurology, 14, 1201025. https://doi.org/10.3389/fneur.2023.1201025 Evans, N., Wingo, B., Sasso, E., Hicks, A., Gorgey, A. S., & Harness, E. (2015). Exercise Recommendations and Considerations for Persons With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 96(9), 1749–1750. https://doi.org/10.1016/j.apmr.2015.02.005 Farkas, G.J., Pitot, M.A., Berg, A.S. et al. Nutritional status in chronic spinal cord injury: a systematic review and meta-analysis. Spinal Cord 57, 3–17 (2019). https://doi.org/10.1038/s41393-018-0218-4 Harvey, L., Herbert, R. Muscle stretching for treatment and prevention of contracture in people with spinal cord injury. Spinal Cord 40, 1–9 (2002). https://doi.org/10.1038/sj.sc.3101241 Krause, J., Cao, Y., Li, C., & Dismuke-Greer, C. (2024). A Five-year Longitudinal Structural Equation Model of Social Isolation and Major Depression among Those with Spinal Cord Injury...National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Advanced Rehabilitation Research and Training (ARRT) Fellows Symposium, October 30, 2023, Atlanta, Georgia. Archives of Physical Medicine & Rehabilitation, 105(4), e30. https://doi.org/10.1016/j.apmr.2024.02.082 Kelly D. Atkins, C. Scott Bickel, Effects of functional electrical stimulation on muscle health after spinal cord injury, Current Opinion in Pharmacology, Volume 60, (2021) Lu, Y., Shang, Z., Zhang, W. et al. Global incidence and characteristics of spinal cord injury since 2000–2021: a systematic review and meta-analysis. BMC Med 22, 285 (2024). https://doi.org/10.1186/s12916-024-03514-9 Maribo, T., Jensen, C. M., Madsen, L. S., & Handberg, C. (2020). Experiences with and perspectives on goal setting in spinal cord injury rehabilitation: a systematic review of qualitative studies. Spinal Cord, 58(9), 949–958. https://doi.org/10.1038/s41393-020-0485-8 Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., Haubert, L. L., Eberly, V., Ting-Ting Ge, Azen, S. P., Winstein, C. J., & Gordon, J. (2011). Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Chronic Spinal Cord Injury: A Randomized Controlled Trial. Physical Therapy, 91(3), 305–324. https://doi.org/10.2522/ptj.20100182 Pelletier, C. (2023). Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines. Applied Physiology, Nutrition & Metabolism, 48(12), 882–895. https://doi.org/10.1139/apnm-2023-0227 Pelletier, C. (2023). Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines. Applied Physiology, Nutrition & Metabolism, 48(12), 882–895. https://doi.org/10.1139/apnm-2023-0227 Rick Hansen Spinal Cord Injury Registry A look at spinal cord injury in Canada in 2020 a Canadian SCI Registry. (n.d.). https://praxisinstitute.org/wp-content/uploads/2022/11/RHSCIR-2020-Report-final.pdf Spinal Cord Injury BC, “About Spinal Cord Injury.” sci-bc.ca/info-centre/spinal-cord-injury/. Spinal Cord Injury Canada, About SCI. (2020, October 4). https://sci-can.ca/about-sci Thorogood, N. P., Noonan, V. K., Chen, X., Fallah, N., Humphreys, S., Dea, N., Kwon, B. K., & van der Scheer J.W., Martin Ginis K.A., Ditor D.S., Goosey-Tolfrey V.L., Hicks A.L., West C.R., Wolfe D.L. 2017. Effects of exercise on fitness and health of adults with spinal cord injury: a systematic review. Neurology, 89: 736–745 World Health Organization. “Spinal Cord Injury.” Who.int, World Health Organization: WHO, 16 Apr. 2024, www.who.int/news-room/fact-sheets/detail/spinal-cord-injury. References Blauwet, C. (2016). Exercise after Spinal Cord Injury. Exercise After Spinal Cord Injury. https://msktc.org/sci/factsheets/exercise-after-spinal-cord-injury Del Toro Aguayo, J. M. (2015). Side effects of steroid use in patients with traumatic spinal cord injury. Coluna/Columna, 14(1), 45–49. https://doi.org/10.1590/s1808-1851201514010r127 Dorrian RM, Berryman CF, Lauto A, Leonard AV. Electrical stimulation for the treatment of spinal cord injuries: A review of the cellular and molecular mechanisms that drive functional improvements. Front Cell Neurosci. 2023 Feb 3;17:1095259. doi: 10.3389/fncel.2023.1095259. PMID: 36816852; PMCID: PMC9936196. Gorgey AS. Exercise awareness and barriers after spinal cord injury. World J Orthop. 2014 Jul 18;5(3):158-62. doi: 10.5312/wjo.v5.i3.158. PMID: 25035817; PMCID: PMC4095007. Guy, S., Mehta, S., Leff, L., Teasell, R., & Loh, E. (2013). Anticonvulsant medication use for the management of pain following spinal cord injury: systematic review and effectiveness analysis. Spinal Cord, 52(2), 89–96. https://doi.org/10.1038/sc.2013.146 Kesiktaş, F. N., Kaşıkçıoğlu, E., Paker, N., Bayraktar, B., Karan, A., Ketenci, A., & Müslümanoğlu, L. (2021). Comparison of the functional and cardiovascular effects of home-based versus supervised hospital circuit training exercises in male wheelchair users with chronic paraplegia. Turkish Journal of Physical Medicine and Rehabilitation, 67(3), 275–282. https://doi-org.twu.idm.oclc.org/10.5606/tftrd.2021.6533 Lovell D, Shields D, Beck B, Cuneo R, McLellan C. The aerobic performance of trained and untrained handcyclists with spinal cord injury. Eur J Appl Physiol. 2012 Sep;112(9):3431-7. doi: 10.1007/s00421-012-2324-x. Epub 2012 Jan 26. PMID: 22278391 Lovell, D., Shields, D., Beck, B., Cuneo, R., & Mclellan, C. (2012). The aerobic performance of trained and untrained handcyclists with spinal cord injury. European Journal of Applied Physiology (Print), 112(9), 3431–3437. Medications for Spinal Cord Injury: What Doctors May Prescribe.” Flint Rehab, 22 Oct. 2020, www.flintrehab.com/medications-for-spinal-cord-injury/.. Park, J., Kim, J., Eun, S.-D., & Kang, D. (2024). Effectiveness of Exercise Programs for Alleviation of Upper Body Pain in Patients with Spinal Cord Injury: A Systematic Review. Journal of Clinical Medicine, 13(11), 3066. https://doi.org/10.3390/jcm13113066 SCI Action Canada. (2011). HOME STRENGTH-TRAINING GUIDE. The “best” cardio workout for a healthy heart: Heart: UT southwestern medical center. Heart | UT Southwestern Medical Center. (n.d.). https://utswmed.org/medblog/heart-cardio-workouts/ van Koppenhagen, C. F., de Groot, S., Post, M. W., van Asbeck, F. W., Spijkerman, D., Faber, W., … van der Woude, L. H. (2013). Wheelchair exercise capacity in spinal cord injury up to five years after discharge from inpatient rehabilitation. Journal of Rehabilitation Medicine, 45(7), 646–652. https://doi.org/10.2340/16501977-1149 THANK YOU