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From PEKN 1P93 Winter 2014: Group 02: Treatment/Rehab, Spinal Cord Injury

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[edit] Background

[edit] What is the Spinal Cord?

The spinal cord travels from the brain and all the way down the back as an assembly of nerves connected together. The nerves allow commands to be sent from the brain to different muscles throughout the body causing movement. There are 31 pairs of nerves branching out from the spinal cord through the arms, legs, abdomen and chest of the body(Behrman & Harkema, 2000). These nerves are also in control of organ functions. The upper portion of the spinal cord controls the upper half of the body as the lower portion controls the lower half of the body. There are also nerves that travel from the muscles of the body back to the spinal cord relaying information that the muscles send in response to pain, temperature, touch and positioning (Behrman & Harkema, 2000). The spinal cord is protected by vertebrae, which are bones that make up the backbone.

[edit] What is a Spinal Cord Injury/an acquired Spinal Cord Injury?

A Spinal Cord Injury (SCI) is trauma or injury to the spinal cord that causes impairment to functions the spinal cord is responsible for. This can cause abridged feeling and immobility through parts of the body including paralysis (What is a Spinal Cord Injury). An acquired spinal cord injury is an injury to the spinal cord that is induced, often because of a traumatic accident, infection or compression from a tumor, or loss of normal blood supply (Behrman & Harkema, 2000). People who have acquired an SCI are not born with it and therefore obtain it during a traumatic time in their life. SCI can be classified as either complete or incomplete, where a complete SCI refers to complete defeat of feeling and function from the point of injury and below, paralyzing all of the body parts that receive neural connections from that section of the spinal cord, and where an incomplete SCI refers to select function and feeling remaining from the point of injury and below. Most often the body is affected symmetrically with injury equal on either side (Behrman & Harkema, 2000). If an injury occurs lower on the spinal cord, paraplegic-paralysis of both legs can occur, however if an injury occurs higher up toward the neck of the spinal cord, quadriplegic-paralysis can occur to both arms and both legs of the body. Paralysis immobilizes these body parts causing them to lose feeling and function. Unlike other body parts such as bones and tissues, the spinal cord is not able to repair and heal itself as it is extremely sensitive to injury (Behrman & Harkema, 2000).

[edit] Why is treatment of SCIs important?

Treatment and rehabilitation is extremely important to SCI patients because treatment can be more efficiently and effectively distributed when more knowledge is gained toward these specific types of injury. It is vital that the most elite form of treatment is administered and all precautions are made aware of to avoid further damage because lacerations or further damage to the spinal cord can provoke paralysis to parts or even the whole body. However not only is mobility hindered with SCI, but sometimes other issues can arise including respiratory problems. To ensure patients obtain the best possible outcome, they must receive a customized plan of treatment specific to their own needs, training and adaptation methods to their daily routine, medical care and emotional support from family, friends and caregivers (Spinal Cord Injury Ontario). New forms of exercise, activity, recreation and leisure must be relearned to assist in their ability to participate. It has been shown that with increased studies of SCI and the more knowledge gained, more people have benefitted from treatment and rehabilitation. Before the 1940s, 80-90% of people with acquired SCI did not live and died within a matter of weeks from the initial injury due to insufficient knowledge and research about the injuries (Trieschmannm, 1988). With this evidence, it is obvious that treatment of SCI is crucial to survival and rehabilitation. Much progress has been made already to better the lives of those with SCI and improvements can continue to be made through studies to continue improving treatment.

[edit] History

[edit] Ancient Egypt

Spinal cord injuries have been noted throughout history, from Ancient Egyptian times to present day. The earliest medically documented spinal cord injuries were found within The Edwin Smtih Papyrus, written in Ancient Egypt during 2500-3000 B.C.E (Schiller & Mobbs, 2012, p. 1348). The Papyrus was purchased in 1862 by Edwin Smith, an American Egyptologist, and translated by James Henry Breasted (Donovan, 2007, p.85). The Edwin Smith Papyrus documents 48 different medical cases, six of which reference spinal cord injury (Middendorp et al., 2010). Fractures, sprains and wounds to the spinal region are found throughout these cases (Lifschutz & Colohan, 2004) and as well as diagnoses for the six spinal injuries recorded; these diagnoses were even based on anatomical location of the injury (cervical, thoracic etc.). Signs and symptoms of injury to the spinal column were also noted and commonly included neck stiffness and pain while bending or flexing the neck (Middendorp et al., 2010). While treatment was noted throughout the Papyrus, the definitive principle was that spinal cord injuries were an “ailment not to be treated”, a perception that persisted throughout many centuries (Lifschutz & Colohan, 2004; Schiller & Mobbs, 2012).

[edit] Ancient Greece & Ancient Rome

While the first medically documented spinal cord injury was in the Papyrus, the first general reference to spinal cord injury was found within the Odyssey, an epic poem written by the Greek poet, Homer (Lifschutz & Colohan, 2004; Schiller & Mobbs, 2012). Greeks are presumably the first civilization to establish SCI treatment, such as reduction, a treatment performed by Hippocrates (Schiller & Mobbs, 2012, p. 1348). As noted by Lifschutz and Colohan (2004), it is difficult to determine the sequence of events as records between the Ancient Egyptian period and the Greek period were poorly kept.

Lifschutz and Colohan (2004) noted Hippocrates (460-337 BC) as the Father of Medicine who produced some of the earliest findings on injuries of the vertebrae and the resulting impacts on spinal cord injury. The works produced by Hippocrates detail the first descriptions of spinal cord injury complications, such as bladder control, bed sores and venous stasis (Lifschutz & Colohan, 2004). Additionally, Hippocrates is credited with the invention of the scamnun, a device used to create traction and reduce spinal deformities, according to Lifschutz and Colohan (2004). Despite his studies of the spinal cord, Hippocrates ultimately believed that SCI were not to be treated (Lifschutz & Colohan, 2004).

Throughout the Greek period, Hippocrates ideas were perpetuated by Aulus Cornelius Celsus (30 B.C.), who was the first to document the rapid occurrence of death following spinal cord injury (Lifschutz & Colohan, 2004). In their article, Lifschutz and Colohan (2004) also state that Hippocrates ideas were improved upon by Aretaeus (150 B.C.) who identified the varying levels at which spinal cord injuries can occur.

Claudius Galen, a Greek physician in the Roman Empire, also contributed significantly to the research of SCI and pioneered many experiments relating to SCI (Schiller & Mobbs, 2012, p.1348). Schiller and Mobbs (2012) wrote that Galen conducted much of his studies on corpses and Roman gladiators and some of his most notable records are noted within his works on Anatomical Procedures and on the Affected Areas. His notes include information on the functioning of the spinal cord as well as the paralysis and loss of sensation that occurs below the point of damage on the spine (Lifschutz & Colohan, 2004).

Further contributions to the understanding of the spine and the consequences of injury were made by Paulus of Aegin, a physician in the Byzantine Empire during the seventh century (Lifschutz & Colohan, 2004; Schiller & Mobbs, 2012). While, like many others, he supported the ideas of Hippocrates, he also modified some of the original Hippocratic concepts, and additionally introduced the concept of decompression, as well as the surgical removal of damaged vertebrae (Lifschutz & Colohan, 2004). However,Lifschutz and Colohan (2004) note that these invasive surgeries were not universally supported throughout history, and the appropriate timing for surgery, if deemed necessary, also became a major debate in the works of Roland of Parma (1210 CE) (Schiller & Mobbs, 2012, p.138).

[edit] The Renaissance Period: 14th Century to 17th Century

The Renaissance period, notable for its progressive movements in the science, arts and overall knowledge (Lifschutz & Colohan, 2004), produced the first major piece of published literature solely interested in the spinal cord, which was written by Blasius in 1666 (Schiller & Mobbs, 2012). In Blasius’ book, titled Anatome Medullae Spinalis Nervorum, he described the anatomical origin of the spinal nerve roots as well as distinguished between grey and white spinal matter (Naderi et al., 2004). Despite this milestone, the opinions of this period regarding the prognosis for spinal cord injury, ultimately remained unchanged, with the Hippocratic therapeutic techniques prevailing (Lifschutz & Colohan, 2004).

[edit] 18th Century

According to Naderi, Ture and Pait (2004), Huber, a Swiss anatomist, made the first detailed anatomical description of the spine during the 18th century. His works primarily focused on the spinal cord and nerves, but later on, in 1739, he established the first account of spinal roots and denticulate ligaments (Naderi et al., 2004)

[edit] 19th Century

Debates regarding the use of invasive, surgical procedures continued over the next 200 years, into the eighteenth century—it was at this point that surgical procedures saw a positive light (Lifschutz & Colohan, 2004). Both Lifschutz and Colohan (2004) and Schiller and Mobbs (2012) note that although many surgeons advocated surgical intervention for spinal cord injuries, a controversial debate was sparked between British surgeons, Sir Astley Cooper and Charles Bell in 1824, following the Napoleonic Era. Cooper held the belief that an untreated spinal cord injury would result in death with or without surgery, so there was nothing to lose in intervening, but Bell, however, rejected this idea, believing surgical intervention caused unnecessary death as well as perpetuated damage to the spine (Lifschutz & Colohan, 2004;Schiller & Mobbs, 2012).

Despite the debate regarding the necessity of surgery for patients with spinal cord injuries persisting into the 19th century, this century saw several advancements in the spinal cord research field. The accomplishments of many individuals led to the invention of blood transfusions, anaesthesia, antiseptic techniques, wound drainage and surgical gloves which allowed for the effective and sanitary management of spinal cord injuries (Donovan, 2007; Schiller & Mobbs, 2012, p. 1351). The 19th century also witnessed the first successfully performed lumber laminectomy, performed in 1829 by Dr. Albin Gilpin Smith from Kentucky (Lifschutz & Colohan, 2004). A lumbar laminectomy, also known as an open decompression, is used to relieve leg pain resulting from lumber spinal stenosis, and involves removing the bone's nerve root covering (Ullrich, 2009). Further advancements during the 19th century include the introduction and improvement of the fixation method (Schiller & Mobbs, 2012, p.1351), which is done to increase stability and correct anatomical alignment (Slone et al.,1993).

[edit] 20th Century

The 20th century held many new advancements for the spinal cord injury field, dramatically improving the life expectancy of those with SCI’s; as, according to Spinal Cord Injury Ontario (n.d.), only 1%-10% of SCI patients survived longer than a year prior to 1945 . These major improvements were primarily catalyzed by the World Wars, which caused a dramatic increase in the number of victims of SCI’s (Spinal Cord Injury Ontario, n.d.). However, life expectancy wasn’t the only aspect of life improved for patients with spinal cord injury, this time period is also characterized by the recognition that victims of these traumas were not required to be institutionalized or hospitalized—a prior belief that was detrimental to the lives of those with SCI (Spinal Cord Injury Ontario, n.d.).

The optimism toward spinal cord injuries during 1945 ultimately led to the formation of the Canadian Paraplegic Association (CPA), which was formed by World War II veterans who had sustained spinal cord injuries in battle (Spinal Cord Injury Ontario, n.d.). As reported by Spinal Cord Injury Ontario (n.d.), the Canadian Paraplegic Association is now referred to as Spinal Cord Injury Ontario— this name changed as the life expectancy of quadriplegics improved and a more encompassing name was required. John Counsell, one of the founders of the Canadian Paraplegic Association who was injured at Dieppe, made several significant contributions to the rehabilitation and treatment aspect of spinal cord injuries by opening Lyndhurst Lodge, a rehabilitation facility, as well as bringing the first self-propelled, folding wheelchair to Canada (Spinal Cord Injury Ontario, n.d.).

As reported by Donovan (2007), Sir Ludwig Guttmann (1899-1980) was another primary figure in spinal cord history during the 19th century. As a neurosurgeon during World War II, Guttmann had particular interest for patients with spinal cord injuries, after being placed in an SCI unit in England-- where the ancient principle of an “ailment not to be treated” persisted (Donovan, 2007). He was challenged by this principle and realized the patients with SCI required long term, rehabilitative care (Donovan, 2007). With his determination to change the hopeless destiny for patients with SCI, Guttmann’s SCI unit eventually became a model unit for successors, and later on he founded the Paralympics, a competition that exists presently (Donovan, 2007).

Spinal Cord Injury Ontario (n.d.) also notes distinguished advancements in spinal cord injury treatment and rehabilitation which include the creation of sporting opportunities for individuals with SCI through the formation of the Canadian Wheelchair Sports Association, established in 1967 by the CPA. The CPA was also responsible for the establishment of the Canadian hospital dedicated to spinal injury treatment in 1974, as well as the providing of Employment Opportunities in Toronto during 1982 (Spinal Cord Injury Ontario, n.d.).

While rehabilitation treatments were occurring rapidly during the 20th century, scientific research in terms of promoting axon growth, increasing growth of uninjured axons to compensate for those that are damaged, replacing lost cells, preventing scar formation and redesigning rehabilitation programs also occurred (Reeve Foundation, 2014).

[edit] 21st Century

Many substantial advancements have occurred since the Ancient Egyptian Times when the first spinal cord injury was medically documented, and vast amounts of research are continuing. According to Spinal Cord Injury Ontario(n.d.), the life expectancy of individuals has increased greatly, with 85%-90% of SCI patients surviving-- a tremendous improvement for this field.

[edit] Target Audience

The audience that would benefit most from this Wikipedia page would be people between the ages of 16 and 30 who have acquired and suffer from SCI as well as researchers in this field. This specific audience was chosen because most acquired SCI happen to people in this age range and they will require specific treatment that will benefit them in their everyday lives. SCI are most commonly found among young, white males, as 80% of SCI are males and 20% females, and 65% of those males are white (Behrman & Harkema, 2000). Some people are born with spinal cord injuries, however our group decided to focus on people who have acquired this type of injury through some sort of accident.

[edit] Research

Many studies that have been done up to this point have proven that physical activity plays an important role in the recovery and conditioning of (moving) muscles of people who have acquired a spinal cord injury. Many patients who have a SCI are unable to regain their ability to walk however it is crucial for these people to continue participating in physical activities in order to keep the muscle tone and strength in the other parts of their bodies (Behrman and Harkema, 2000). Studies have shown that locomotor training (such as running, gliding, walking, etc.) helps provide sensory information that corresponds with locomotion to improve the patient’s ability to step and walk (Behrman and Harkema, 2000). In this specific study, four adults who have had an acquired SCI for 6 months, had received the locomotor training. All participants had enhanced their stepping ability onto a treadmill. One subject was even able to walk overground while two more subjects had improved their overground walking ability (Behrman and Harkema, 2000).

Another study tested the arm movement of subjects who have acquired SCI. In this study researchers were examining the effects of a 9 month period of bi-weekly physical activities that would test arm ergometry performance and overall well-being of these patients (Hicks et al., 2003). There was a control group of 34 people who did not participate in the training program and an exercise group of 23 people who did participate in the training program. Subjects would be assessed based on their one repetition max strength, their arm ergometry performance, and a variety of other tests that would evaluate their psychological well-being. After the 9 month period, there was a significant increase in the exercise groups arm ergometry output, upper body muscle strength, less pain when exercising or moving, less stress and a decrease in depression following this regime (Hicks et al., 2003). Surprisingly, the control group showed no improvements in any of these areas. This proves that physical activity does in fact increase the overall well-being of people who have acquired SCI and can have a positive impact of patients both physically and psychologically.

Physical activity is not only important for maintaining health, but also increasing the ability of performing daily tasks. SCI patients must face new difficulties in their day-to-day lives and physical activity has helped their possibilities of living a more independent life (Kerstin et al., 2006; Jacobs and Nash, 2004). This elevates the moral and psychological well-being of SCI patients which is just as important as the physical side of patients. Not only this, but the quality of a person’s life is closely associated with an independent living style and is important when measuring the success rate of rehabilitation (Noreau and Shepard, 1995).

In this study completed by Kerstin, Gabriele, and Richard, 16 participants with SCI were interviewed in hopes of increasing the psychological side of health and encourage people to take part in physical activities in order to aid in performing simple daily tasks that would ultimately give them a greater sense of independence (Kerstin et al., 2006). Four themes were used to identify promoting factors: using cognitive and behavioural strategies; exploring motivation post injury; finding supporting environmental solutions; and capturing new frames of reference (Kerstin et al., 2006). With the help of using role models along with motivational factors such as identifying relevant motives for individuals post injury, it was found that the movement towards physically active lives may be facilitated.

A study was done in Canada to enhance the overall physical fitness in persons who have acquired SCI by systematically establishing evidence-informed guidelines (Ginis et al., 2011). A developmental protocol entitled, The Appraisal of Guidelines, Research, and Evaluation II, was created in order to help patient’s muscular strength and physical capacity (Ginis et al., 2011). This protocol was generated by a team of experts from differing disciplines and who were able to construct and refine the protocol so it was effective for testing (Ginis et al., 2011). The results of the guidelines stated that: for critical fitness advantages, adults who have acquired a SCI should perform both 20 minutes of moderate to vigorous intensity aerobic activity twice a week, as well as strength training involving 8-10 repetitions of each major muscle exercise for three sets at a time (Ginis et al., 2011). These meticulous guidelines are now used and patients with SCI, researchers, clinical workers, etc. are encouraged to apply them to help improve muscle conditioning and physical capability (Ginis et al., 2011).

A systematic review was done in Canada to determine the effects of physical exercise on muscular strength, physical capacity, body composition, and functional performance amidst adults who have acquired a spinal cord injury (Hicks et al., 2011). Established procedures were used in order to evaluate the quality of evidence from each study in the experiment. 82 studies (69 chronic SCI patients and 13 acute SCI patients) were observed after screening and included in the review (Hicks et al., 2011). The effects of the four main elements of physical fitness (muscular strength, physical capacity, body composition, and functional performance) were evaluated (Hicks et al., 2011). The studies showed that at least one outcome (listed) was recorded: oxygen consumption/uptake, peak work capacity, power output, body composition, muscle strength, experience/functional performance. Despite the decreased quality of the results, the data proved to be consistent throughout and determined that physical exercise is in fact beneficial in strengthening at least one of the four main components of physical fitness in patients who have a SCI (Hicks et al., 2011). When exercise was performed 2-3 times a week at moderate-to-vigorous levels, the physical capacity of chronic SCI patients increased as well as their muscular strength (Hicks et al., 2011). However, with respect to the experience/functional performance of these patients, the data showed that the effect of exercise was not as strong (Hicks et al., 2011). Due to the limited number of participants in the acute SCI group, the data was insufficient and no conclusions could be drawn (Hicks et al., 2011). Overall, the experiment proved that through the use of physical exercise, chronic SCI patients would increase their muscular strength as well as physical capacity; however no there was no data suggesting that exercise benefited their body composition or functional performance (Hicks et al., 2011).

Research was conducted in the University of Saskatchewan laboratory where 38 participants were enlisted to volunteer for a spinal cord injury (SCI) study (Manns & Chad, 1999). This study included 17 quadriplegic and 21 paraplegic subjects (Manns & Chad, 1999). Each patient was correlated between quality of life, handicap, fitness and physical activity (Manns & Chad, 1999). Results stated that physical activity gave a higher quality of life to patients with paraplegia (Manns & Chad, 1999). On the other hand, the level of handicap for quadriplegic subjects rated higher in physical activity levels, however the subjective quality of life was significantly lower (Manns & Chad, 1999). With the five handicap domains, physical independence, mobility and occupation gave higher results for quadriplegic patients who participated in physical activity, whereas social integration and economics were rated higher for paraplegic patients who played a part in physical activity (Manns & Chad, 1999). Since a person with quadriplegia would have more of an unlikely chance to compete in physical fitness, it is not a shock that the ratios between quadriplegia and paraplegia were significantly different (Manns & Chad, 1999). Essentially, the patients who involved themselves in physical activity could possibly have a lower handicapped level (Manns & Chad, 1999).

Physical fitness is just as important for a disabled individual as it is for a physically abled person. Especially in spinal cord injuries (SCI), it is crucial to strengthen the upper extremities for paraplegic patients as they cannot rely on the strength of their legs due to their paralysis. Starting any exercise program for these individuals may be overwhelming as they are in the process of accepting their injuries, however the importance of the programs helps them to excel in their future and do the best they can.

[edit] Existing Physical Activity Programs

[edit] SCI Action Canada

SCI Action Canada is a program that is responsible for advancement of physical activity, knowledge and participation among Canadians with spinal cord injuries (SCI Action Canada, 2008). The mission statement of SCI Action Canada is to develop and mobilize strategies to inform, teach and enable people living with spinal cord injuries to initiate and maintain a physically active lifestyle(SCI Action Canada, 2008).

[edit] Get in Motion

Get in Motion is a program run through the SCI Action Canada organization. It is a national physical activity program for Canadians with spinal cord injuries. Get in Motion is a free service provided to Canadian citizens that offer them information and support they may need to achieve personal physical activity goals(SCI Action Canada, 2008). Some of the example topics Get in Motion review with the Canadian citizens are goal setting, finding accessible physical activities in your community and overcoming barriers to physical activity(SCI Action Canada, 2008). This program is supported by Rick Hansen and his foundation (SCI Action Canada, 2008).

[edit] Active Homes

Active Homes is another program done by SCI Action Canada that originally began as a research study. The ultimate purpose of the study was to determine a home-based introductory strength-training visit aimed to increase thoughts and feelings about strength-trainings activity among people with spinal cord injuries(SCI Action Canada, 2008). In the course of the study a manual was created and used for people who wanted to incorporate regular physical activity into their daily lives (SCI Action Canada, 2008). The manual was an excellent source for people with spinal cord injuries to give them the necessary guidelines to exercise regularly and stay healthy (SCI Action Canada, 2008).

[edit] Support in Motion

Support in Motion is a charitable organization that is responsible for raising funds to provide children and youth in Ontario with spinal cord injuries (Support in Motion, 2014). This organization uses the funds raised to allow children and youth to access specialized rehabilitation therapy (Support in Motion, 2014). The main goal of Support in Motion is to enhance the quality of life of all children and youth with spinal cord injuries province wide (Support in Motion, 2014).

[edit] Project Walk

Project Walk is a spinal cord injury recovery centre, which is acknowledged world-wide as one of the best recovery centres for individuals with spinal cord injuries (Project Walk, 2013). Project Walk offers two different programs, a facility and a home recovery program. The facility program is where the client goes into the facility to go through the proper rehabilitation exercises necessary (Project Walk, 2013). This is the most effective way to recover and rehabilitate as all the necessary and proper equipment is on hand for the client to use(Project Walk, 2013). The other program is a home recovery program, where itineraries are laid out for you over the computer that you complete the exercises at home(Project Walk, 2013). This program takes little to no equipment but still gives you the proper rehabilitation exercises.

[edit] Push to Walk

Push to Walk is a non-profit gym offering a specialized exercise program for people with spinal cord injuries and other neurological conditions (Push to Walk, 2012). Push to Walk offers activity based training to their clients to ensure they are physically and emotionally healthy throughout their recovery process (Push to Walk, 2012). Each client receives an assessment of personal and individual abilities, where the personal trainer configures an exercise plan that is designed for the client specifically (Push to Walk, 2012).

[edit] Best Practice Activity Suggestions

[edit] Sledge Hockey

Sledge hockey is a sport that allows people who have a physical disability to play the game of ice hockey. It is slowing becoming one of the most popular games played in the Paralympic Games.(Canadian Paralympic) Sledge Hockey is a game played on the ice that is fast-paced, highly physical and played by athletes who have a physical disability in the lower body (Canadian Paralympic).

(DeejBTNL, 2013)

[edit] Step Training on a Treadmill

This is an activity for people with spinal cord injuries who could not balance or maintain their full body weight load while stepping and executing the proper limb kinematics (Behrman & Harkema, 2000). A harness is worn by the individual to give the individual the proper body weight support in an effort to provide a safe and effective environment for locomotor training (Behrman & Harkema, 2000). This is an activity that is very popular within physiotherapists for spinal cord injury patients.

[edit] Over ground Walking

Over ground walking is a locomotor activity that works in conjunction with step training. Patients have to be able to support 80% of their body weight and independently generate the appropriate stepping kinematics on at least one limb (Behrman & Harkema, 2000). One way to use over ground walking is the trainer to stand facing the patient holding hands, the trainer than walks backwards while the patient walks with the trainer using him for support and following the proper motions of walking (Behrman & Harkema, 2000). Over ground walking is a more difficult activity for people with spinal cord injuries.

[edit] Wheelchair Volleyball

Wheelchair volleyball is the Paralympic version of volleyball that is played in the Olympic Games. Wheelchair volleyball can also be referred to as sitting volleyball. In wheelchair volleyball players must have one buttock in contact with the floor whenever they make contact with the ball, it is possible to block the serve because the net is only 1.15 meters high. (Ng, 2012). Wheelchair volleyball is a very popular game among people with spinal cord injury as it is very physically active.

[edit] Wheelchair Basketball

Wheelchair basketball is just regular basketball played by people in wheelchairs who have had a physical disability. Wheelchair basketball is the major disabled sport practiced. (Canadian Paralympic) The measurements for the net and court are the same a regular basketball. (Canadian Paralympic) One of the major differences is the 5 people of the team on the court can only score a total of 14 points before new players have to come on the court. (Canadian Parlympic)

[edit] Future Directions

Spinal Cord Injury patients (SCI) should undergo certain types of therapy to strive to provide a beneficial future for themselves. As Jason C. Eck (2014) illustrates, each individual should have rehab therapists to emphasize the regaining of leg and arm strength. Rehab highlights skill building and counselling to provide social and emotional support for the spinal cord injury patient (Eck & Marks, 2014). The best chance at recovery is to maintain a positive outlook, and using assistive devices, as well as aggressive physical therapy and occupational therapy (Eck & Marks, 2014).

[edit] External Links

http://www.facingdisability.com/spinal-cord-injury-experts?gclid=CMbBq4qawrwCFa9aMgod-CoAzQ

http://sciactioncanada.ca/guidelines/

http://www.science.mcmaster.ca/pace/education/resources/physical-activity-guidelines

http://sciactioncanada.ca/docs/home-strength-training-guide-paraplegia.pdf

http://www.rowontario.ca/para-rowing.htmlc

[edit] Notes and References

1. Behrman AL, Harkema SJ.(2000). Locomotor training after human spinal cord injury: a series of case studies. Phys Ther. 2000;80:688-700

2. Canadian Paralympics. (n.d.). Sledge hockey. Retrieved from http://www.paralympic.ca/sledge-hockey

3. Canadian Paralympics. (n.d.). Wheelchair basketball. Retrieved from http://www.paralympic.ca/wheelchair-basketball

4. Donovan, W.H. (2007). Spinal cord injury- past, present and future. The Journal of Spinal Cord Medicine, 30(2), 85-100.

5. DeejBTNL. (2013, October 10). Sledge hockey Canada- Road to Socchi 2014 #INSPIRE. Retrieved March 23, 2014 from http://www.youtube.com/watch?v=3EzKdb0wrA8

6. Eck, C. J., Marks, J. W. (2014). How Does Rehabilitation Help People Recover From Spinal Cord Injuries? Spinal Cord Injury: Treatments and Rehabilitation (cont.). Retrieved from http://www.medicinenet.com/spinal_cord_injury_treatments_and_rehabilitation/page12.htm#how_does_rehabilitation_help_people_recover_from_spinal_cord_injuries on March 18th, 2014.

7. Ginis, K. M., Hicks, A. L., Latimer, A. E., Warburton, D. E. R., Bourne, C., Ditor, D. S., ... & Wolfe, D. L. (2011). The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord,49(11), 1088-1096.

8. Hicks, A. L., Ginis, K. M., Pelletier, C. A., Ditor, D. S., Foulon, B., & Wolfe, D. L. (2011). The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review. Spinal Cord, 49(11), 1103-1127.

9. Hicks, A. L., Martin, K. A., Ditor, D. S., Latimer, A. E., Craven, C. C., Bugaresti, J. J., & McCartney, N. N. (2003). Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord. 41(1). 43.

10. Jacobs, P. L., & Nash, M. S. (2004). Exercise recommendations for individuals with spinal cord injury. Sports Medicine, 34(11), 727-751.

11. Kerstin, W., Gabriele, B., & Richard, L. (2006). What promotes physical activity after spinal cord injury? An interview study from a patient perspective. Disability & Rehabilitation, 28(8), 481-488.

12. Lifschutz, J., & Colohan, A. (2004). A Brief History of Therapy for Traumatic Spinal Cord Injury. Retrieved from http://www.medscape.com/viewarticle/468461

13. Manns, J. P, Chad, E, K. (1999). Determining the relation between quality of life, handicap, fitness, and physical activity for persons with spinal cord injury. Physical Medicine and Rehabilitation, 80(12), 1566-1571.

14. Naderi, S., Ture, U., & Pait, G. (2004). History of the spinal cord localization. Retrieved from http://www.medscape.com/viewarticle/468471_4

15. Ng, K. (2012). When sitting is not resting: sitting volleyball. Bloomington, IL Authourhouse. P 152

16. Noreau, L., & Shephard, R. J. (1995). Spinal cord injury, exercise and quality of life. Sports Medicine, 20(4), 226-250.

17. Push to Walk (2012). Our Program. Retrieved from http://www.pushtowalknj.org/program.html#

18. Project Walk (2013). Facility Programs. Retrieved from http://www.projectwalk.org/Programs/Facility-Program.aspProject Walk (2013). Home Recovery Programs. Retrieved from http://www.projectwalk.org/Programs/Home-Recovery-Program.asp.

19. Reeve Foundation. (2014). Then and now: accomplishments in spinal cord research. Retrieved from http://www.christopherreeve.org/site/c.ddJFKRN oFiG/b.4434393/k.290F/History_of_spinal_cord_research.htm

20. Schiller, M.D., & Mobbs, R.J. (2012). The historical evolution of the management of spinal cord injury. Journal of Clinical Neuroscience, 19 (10), 1348-1353.

21. SCI Action Canada (2008). Active Homes. Retrieved from http://sciactioncanada.ca/activehomes.

22. SCI Action Canada (2008). Get in Motion. Retrieved from www.sciactioncanada.ca/get-in-motion.

23. SCI Action Canada (2008). Vision/Mission/Objective. Retrieved from http://sciactioncanada.ca/vision-mission-objectives.

24. Slone, R.M., MacMillan, M., & Montgomery, M.J. (1993). Spinal fixation. Part 1. Principles, basic hardware, and fixation techniques for the cervical spine [Abstract]. Radiographics, 13(2), 341-356.

25. Spinal Cord Injury Ontario. (n.d.). Milestones of SCI Ontario- a brief history. Retrieved from http://mesacc.libguides.com/content.php?pid=38266&sid=281078

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