HANDLING OF THE PATIENTS. SPECIFIC DISEASES

Cauda, Cauda-Conus lesions. Flaccid paralyses.

In the acute state the rule is to enable active movements by maximally reducing the load. Remember that in these diseases the connections between spinal cord and muscles (and the afferents vice versa) are disrupted. Spontaneous nerve regeneration occurs to some degree, but this takes time and there is no convincing evidence that it can be accelerated by exercise or drugs. Axons grow about 1 - 4 mm per day, thus for reaching muscles and skin in the foot (say 1000 mm away from the site of injury) they would thus take 250 to 1000 days.

Keep in mind that those parts of the muscles which remained innervated or are first re-innervated are already doing the work of the whole muscle and must not be overworked: From animal experiments we know that eccentrically worked muscles which are stretched while contracted, may undergo focal muscle fiber damage (which is repaired again but we don't know about long term effects).

We do not train acute patients who are still completely paralyzed after cauda or cauda-conus lesion. With incomplete acute patients you may start early for psychological reasons, but postpone start of daily LB therapy and start with 1 -2 -3 times a week. A minimum voluntary activity for start would be: Hip flexion 1-2, knee extension: 2; BWS 30-50 %, and it is important to use the "static" suspension system which provides more support. Due to spontaneous regeneration of axons, improvements may go on for 1-2 years (see above). Still, the first goal of therapy is to make the patient capable of walking (at least for a short distance with e.g. two canes). For those who cannot achieve ambulating during the first stay in the clinic an interval regimen might be adequate: Resume intensive rehabilitation after a longer domestic period (1 year from the event) . According to current knowledge we cannot influence speed of peripheral regeneration but also cannot keep the patient in the clinic for such long periods of time till regeneration is completed.