کتاب TRX exercises on the functional factors of Parapelgia patients

Chapter One 5
Introduction 5
Chapter Two 8
Spinal cord and spine anatomy 8
Spinal cord anatomy 10
Spinal cord functions 11
Spinal cord injury 11
Prevalence and epidemiology of spinal cord injury 12
Etiology of spinal injuries 12
Classification of spinal cord injury 13
of spinal injuries resulting from external injuries 13
Spinal cord after injury 14
Complete and incomplete spinal cord injury 14
Tetraplegia (quadriplegia) or paraplegia 15
Determining the level and severity of spinal cord injury 16
Functional outcomes 16
Lumbar paraplegia 17
Movement in society after spinal cord injury 17
Complications of spinal injuries 18
Common skeletal-muscular problems after spinal cord injuries 19
Nursing care in spinal cord injuries 19
Nursing care and how to deal with pain in spinal cord injury 20
Pain control 20
The most significant general aspects of rehabilitation programs 21
Recovery of motor abilities 21
Learning new skills 21
Creating a new attitude 21
Cares 21
Treatment design 22
The significance of physiotherapy for people with spinal cord injury 22
Is physiotherapy effective for all people with spinal cord injury? 22
Goals of sports rehabilitation 23
Range of motion exercises after spinal cord injury 23
Gait cycle 25
Gait of paraplegic spinal cord injury patients 26
Communicating with physically disabled people effectively 27
Quality of life in spinal cord injury patients 29
TRX exercises 30
Review of the literature 31
Conclusion 34
Chapter Three 35
Population and sample 35
Sampling method 35
Inclusion criteria 35
Exclusion criteria 36
Variables 36
Independent variable 36
Dependent variables 36
Measurement tools 36
Modified functional accessibility test 36
Gait speed 37
Quality of life 38
TRX exercises program 38
Research design 39
Data analysis method 39
Chapter Four 40
Descriptive findings 40
Demographic information 40
Descriptive indicators of variables 40
Description of the results related to the normality of variables 41
Inferential statistics 41
Results of first hypothesis analysis 41
Results of the second hypothesis analysis 43
Results of the third hypothesis analysis 45
Results of the fourth hypothesis analysis 47
Results of the first sub-hypothesis analysis 47
Results related to the second sub-hypothesis analysis 49
Chapter Five 52
Discussion and conclusion 53
The results obtained in the field of balance 53
Results of evaluating the core muscle strength 54
Results of evaluating the gait speed 55
Results of evaluating the physical-mental health 56
Conclusion 57
References 58

Spinal cord injury is considered an injury to the spinal cord causing to the loss of movement and sensation in the lower parts of the injured area. The amount of this injury is specified by the person’s performance, the lost sensation, and the inability to walk and stand (Esrafilian et al., 2012). Spinal cord injuries are divided into two groups traumatic and non-traumatic and 71% of spinal cord injuries are caused by trauma. In traumatic injuries, there is direct injury is made to the vertebral column or direct pressure on it, resulting in fracture or displacement of the vertebral bodies or torn ligaments. Non-traumatic injuries involve infections, tumors, inflammation of the spinal cord, blood clots in the spinal arteries, and congenital deformities such as spina bifida. The most common causes of spinal cord injuries are blows to the spinal cord because of road accidents (48%), falls (23%), sports injuries (9%), violence (14%), infection, virus, spinal cord tumor, and surgical complications, etc. (6%). Spinal cord injury often occurs with different physical and psychological symptoms and causes different sensory and motor function disorders in sufferers depending on the injured area (Moghadam et al., 2007).

Spinal cord injury affects all physical, social and psychological aspects of a person’s life (Zampa et al., 2003). Carelessness in the use of modern industrial tools results in accidents and incidents causing spinal cord injury. Based on recent statistics, about 32 spinal cord injuries per million people occur annually in the United States (Durstineet al. 2009). In this regard, no detailed and accurate statistics are available in Iran. However, this number can easily be increased due to the lower level of safety compliance on roads and industrial centers. Such figures are estimated according to the comparison of deaths caused by road accidents in the United States and Iran (1 in 7000 and 1 in 2300 people, respectively) (Naqavi et al., 2009). Epidemiological studies indicated that about 50% of patients with traumatic spinal cord injury suffer from an incomplete spinal cord injury (Wirzet al., 2005).
This study aimed to investigate the effect of a relatively new TRX exercise on the physical performance and quality of life of Paraplegia spinal cord injury patients. Today, the relatively high prevalence of spinal cord injuries is one of the consequences which can cause disturbances in different body systems (Raisi Dehkordi et al., 2014). Such problems involve movement problems, sensory problems, bowel and bladder sphincter disorders, body temperature regulation disorders, particularly in T2 and above injuries, low blood pressure caused by long-term immobility, disorder in the automatic expansion reflex of the bladder and rectum, bedsores and harmful skin injuries, bladder infection, pain, muscle spasm and shortening, osteoporosis, low vital capacity, sexual and sterility problems in males due to urinary tract infection, testicular atrophy, changes in temperature, injury in sperm, low ejaculation, psychological problems (which vary in terms of age, sex, cause of injury, personality background and many other factors), as well as occupational-social problems (Durstineet al., 2009). Anxiety and depression are spinal cord injury patients who have pain and their sleep quality is lower than those who have no pain. Chronic pain spreads extensively and is a devastating problem which causes morbidity and mortality among patients. In addition, its economic and social burden is both on the shoulders of the patient, the family, and the policy makers of the health system. Furthermore, chronic pain is considered as the third health problem after cardiovascular problems and cancer. Pain control is considered a critical component of care so that American Pain Association has introduced the term “Pain: The Fifth Vital Sign” in order to emphasize its significance and increase awareness among health care team members about pain control. There are different medicinal and non-medicinal methods to prevent, relieve and reduce pain and the use of each method has its own advantages and disadvantages. To relieve the chronic pain of such patients, nurses should be familiar with all kinds of pain relief methods, especially non-pharmacological methods, if necessary. In this regard, such methods monitor the side effects of medicines and play the role of the patient’s advocate when the interventions are ineffective helping to relieve the patient’s pain (Nikbakht Nasrabadi et al., 2017). In addition to motor impairment, spinal cord injury affects different body systems such as metabolic changes and body composition (Araghizadeh, 2007). Injuries in the lower back and waist due to paralysis of the legs are called paraplegia (Raisi Dehkordi et al., 2014).Movement problems are one of the basic problems of people with spinal cord injury and paralysis of the lower limbs (Bozorgnia, 1989). The primary pathology among people with spinal cord injury is normally limited to paralysis of the lower body, preventing activities such as walking, running, and riding a bicycle. Thus, most tasks such as arm activity, pushing a wheelchair, and walking with orthoses and prostheses or crutches are inevitably performed with hands (Zampa et al., 2003; Durstineet al., 2009).

Most patients have the potential to regain gait function depending on the severity of the injury. Moreover, recovery in gait is one of the major goals after spinal cord injury and is regarded as the most essential goal for the patient with spinal cord injuries. One of the main goals for patients with incomplete spinal cord injury is to recover the ability to walk. As a rehabilitation strategy, movement exercises focus on body posture control, balance, standing, walking, health and quality of life after injury (Lee et al., 2012).
Age, muscle strength and balance are the main factors which influence gait performance in spinal cord injury patients. In addition, the goal of most rehabilitation methods is to strengthen the lower limbs. Nevertheless, other evidence shows that balance is a significant factor in the improvement of gait. Several reports dealt with the issue of balance in patients with spinal cord injury, indicating the significance of balance in gait performance. Different methods of physical rehabilitation such as sports exercises a non-invasive treatment which actively and passively enables the patient with a spinal cord injury to stimulate and affect the injured area by engaging in movements (Sandrow et al. , 2015). Studies indicated that exercise preserves muscle mass (Hibel and Weisel, 1963), returns sensorimotor function (Hat Chinsen et al., 2004, Sandro et al., 2009), stimulation synaptic plasticity by the production of neurotrophic factors (Weinman et al., 2003), increased accumulation of neurotrophic factors in the spinal cord and muscle tissue (Gomez et al., 2005; Gardiner, 2001), and reduced swelling around the injury site (Sandrowet al., 2009).
TRX exercises are considered one of these relatively new methods used in Iran. TRX exercises are a method of suspension exercises that is an effective and new dimension for intervention. Such exercises can be combined with normal physiotherapy methods and can be successfully combined with most rehabilitation exercises and sports equipment to provide stability to enhance independence and safety and significantly improve balance and coordination of the body, as well as the function of the vestibular system. In addition, such exercises allow more complete use of the patient’s strengths and abilities (Naqavi, 2009). This device enables individuals to have free movements while suspended and in a safe state. This feature allows the individual and the therapist to adjust the weight of the limb as required by the straps (Kawamura, 1993). The safety of exercises is one of the critical factors in choosing an exercise due to the movement limitations in spinal cord injury patients.
Regarding the features of suspension and TRX exercises and the studies conducted on the positive effects of these exercises on gait parameters, this study aims to investigate the effect of eight-week TRX exercises on balance, core muscle strength, gait speed, and quality of life among Paraplegia spinal cord injury patients.

Chapter Two
Spinal cord and spine anatomy
Physical health and good physical condition are of paramount significance in human life, while positive and negative changes can affect other aspects of human life. In this regard, it seems highly important to consider the spine as an influencing factor in the physical condition because the spine as the movement axis of the body can result in injury and deformity in different actions and activities for different reasons (Vinik et al., 2017). The skeletal structure includes two axial parts and its appendages. The axial part involves the skull and the vertebral column, as well as their connections to the ribs which form the primary skeleton. In addition, its appendages involve the organs which are added later. (Mohareri, 2002). The length of the vertebral column is 60-70 cm, which is directly proportional to the height. Moreover, the length of the vertebral column in females is less than that of males. The number of vertebrae is 33, including 24 movable vertebrae and nine non-movable vertebrae. The spine is a C-shaped curve at birth. while it has four cervical-dorsal, lumbar and sacro-coccygeal curves in adulthood, (Vinik et al., 2017).
Furthermore, the number of back vertebrae is 12. The length of the transverse appendages from the first to the twelfth dorsal vertebra reduces regularly and the length of the spinous appendages in the fifth to eighth dorsal vertebrae is longer. The spines are drawn downward and backward while the trunk of the back vertebrae becomes larger from top to bottom (Daneshmandi et al., 1993). If the spine is observed in profile, we can see a series of dents and ridges in its various parts. The cervical spine has a curve (concave) inwards in the normal state. The dorsal spine is curved outward (convex) while the lumbar region is curved forward (concave). The presence of such curves plays a key role in humans and many abilities are created by such ridges and dents. In addition, and the ability to stand is largely related to such curves (Sokhangouei, 2001) (Figure 2.1)

The normal alignment of the spine is dependent on its structural, muscular, bone and joint function. Thus, the weakness of the muscles supporting the spine can disrupt the static and dynamic balance, as well as the height of a person, that is generally called postural abnormalities. Skeletal abnormalities occur because of the lack of mobility, environmental stimuli, and inappropriate movement patterns, leaving adverse effects on people’s psychological, social and physiological performance (Peter, 1987). The spinal cord is considered the biggest nerve in the body. Nerves are rope-like structures which are composed of numerous nerve fibers. The spinal cord is regarded as part of a system called the central nervous system. The central nervous system includes two main parts such as the brain and the spinal cord. The spinal cord is a soft and delicate tissue protected by the bones of the vertebral column called the vertebra. The spinal cord is within the core space of the vertebrae called the spinal canal. In addition, the spinal cord acts like a telephone cable connecting the brain with other parts of the body. If you consider the spinal cord as a telephone cable, this cable or the spinal cord of the central office. In other words, it connects the brain with many other offices or various parts of the body. Messages are transmitted through the spinal cord in two ways.

1) The messages are transmitted to the brain from various parts of the body through the spinal cord to give the brain information about sensations such as touch, sense of position (body position), temperature, and pain.
2) The messages are transmitted from the brain and through the spinal cord to various parts of the body to create movement in the body.
The length of the vertebral column is 72 cm in adult males and 62 cm in adult females. Furthermore, the spinal cord starts from the end of the brain and extends to the waist. The nerves which come from the upper parts of the spinal cord are called upper motor neurons. Lower motor neurons leave from the two vertebrae and move to all parts of the body. At the point where the spinal cord ends, the lower motor nerve fibers move to the sacral vertebra or the coccyx through the spinal canal.
There are 21 pairs of lower motor neurons which separate from various areas of the spinal cord and control different parts of the body. Such nerves have the same vertebra through which they exit. The division of these nerves is as follows:
Cervical: Eight pairs of nerves (such nerves control the neck, arms and hands)
Thoracic: 12 pairs of nerves (such nerves control the upper abdominal muscles)
Lumbar: Five pairs of nerves (such nerves control the upper parts of the leg)
Sacral: Five pairs of nerves (such nerves control the lower legs, intestines, bladder and sexual function)
Coccyx: One pair of nerves (such nerves provide sensations to the ends of the vertebral column).
The vertebrae are placed on top of each other in such a way that each vertebra is on top of the other one. The vertebrae aim to provide support, flexibility, and protection for the body.
Discs separate the vertebrae and are made of tough fibrous material containing a thick substance. In addition, discs act as a cushion and protection against sudden blows and make the movement of the back of the body painless. Vertebrae are connected to each other by ligaments. Ligaments help us keep the spine in a straight position and enable spinning. Ligaments are often injured when a spinal cord injury occurs. A situation where the vertebra is injured but the spinal cord is healthy is so common, although spinal cord injury can occur with vertebral column injury or alone without vertebral column damage
Spinal canal: It is a cylindrical space limited to the pikes from different sides, to the vertebral body from the front, and to the blade from the back while the spinal cord along with the layers of the meninges and nerve roots are placed inside it (Mohareri, 2002).

Spinal cord anatomy
The spinal cord is a cylinder of nervous tissue, the thickness of which is almost the size of a little finger with a length of 38-45 cm. This cord starts from the foramen magnum and is connected with the medulla from the top and it is pulled down inside the vertebral canal to the level of the base of the body of the first lumbar vertebra L1 where it ends in a group of nerve fibers called cauda equina nerves. Such nerves come out of the lumbar and sacral areas of the spine. The spinal cord includes 31 parts, each of which has a pair of nerves. The thickness of this cord varies in different places and is slightly thicker in the neck and waist areas since a large nerve for the hand and foot comes out of the spinal cord in this area. Such two areas are called the cervical and lumbar ridges of the spinal cord (Mohareri, 2002).

Spinal cord functions
1- It is the connection between the brain and the nerves which go to the lateral parts of the trunk, arms and legs.
2- It is an essential center of reflex actions.
Spinal nerves are as follows:
Eight pairs of cervical, 12 pairs of thoracic, five pairs of lumbar, five pairs of sacral, and one pair of coccyx (Mohareri, 2002).

Spinal cord injury
It refers to a person suffering from any trauma or blow, congenital diseases, infectious diseases, brain tumor or cancer, cerebral and vascular diseases or even the advanced stages of discopathy lesions and the spinal cord is injured due to below the medulla region to the end of the cauda equina, which is protected by the spine. At this point, the amount of injury is from partial to complete cut or crush, resulting in the creation of motor, sensory or autonomic complications of one or more organs and the trunk.
The patients who suffer from spinal cord injury are divided into two groups of tetraplegia and paraplegia (paralysis of the lower limbs). Paraplegia refers to spinal cord injury under the T1 level. This type of injury normally results in weakness and sensory changes in the trunk and legs. The individuals suffering from paraplegia have an injury in the spinal cord from the thoracic nerve T2 to the bottom of the sacral nerve S5. A paraplegic person loses his sensory and motor functions in his trunk or lower limbs. This kind of injury is caused to the spinal cord in the thoracic, lumbar, or sacral regions. The control of certain parts of the body is lost depending on where the injury occurs. The higher the injured area, the more the sensory and muscle function is lost in comparison to someone who has suffered a sacral injury. Car and sports accidents cause the most cases of paraplegia. Moreover, falling from a height is one of the main causes of spinal cord injury. After an accident, extreme care should be taken regarding those with spinal cord injury. If the injured person is not moved appropriately, he may suffer from additional spinal cord injury. As a result, a person with neck and back injuries should not be moved except by trained medical personnel. Inappropriate care can turn temporary paraplegia into permanent paraplegia and turn paraplegia into quadriplegia. Tetraplegia refers to spinal cord injury at the spinal level T1 or higher. Tetraplegia usually results in weakness or sensory changes in the hands and feet. Moreover, this type of injury is called quadriplegia. In this case, the injury occurs in the neck and the person loses control of the sensory and motor function of the upper limb, trunk and lower limb (Vinik et al., 2017).

Prevalence and epidemiology of spinal cord injury
Spinal cord injury is one of the most adverse injuries to an individual and family. Driving injuries, falls, sports and violence are among the causes of spinal cord injuries. Among the different factors, road accidents have allocated the highest number of spinal cord injuries. Based on the statistics, there was mortality of more than 23000 people in road accidents and disability of more than 280000 people in 2009, most of which were spinal cord injuries. It should be noted that spinal cord injury affects people of any age. Statistics show that approximately 200000 spinal cord injury patients live in the United States and 12000-20000 new patients are added to them annually. The average medical expenses are 15 to 30% dollars per year. Almost 80% of patients with spinal cord injury are males.
In the traumatic type, the blows to the spine mostly because of vascular damage or fracture, dislocation of the vertebra or a combination of endo (fracture-dislocation) can result in spinal cord injury. Non-traumatic (non-blow) is in charge of about 30% of spinal cord injuries such as tumors, infectious agents, severe arthritis of the spine, disc herniation, poliomyelitis (polio), syringomyelia, Spina bifida, MS (multiple sclerosis disease) and Amyothrophic Lateral Sclerosis, etc. Special surgeries, spinal injections, radiation, and vaccination rarely play a key role in the occurrence of spinal injuries (Nikbakht Nasrabadi et al., 2017)

Etiology of spinal injuries
Based on the report of the National Center for Spinal Cord Injury Statistics in the United States, more than 12000 new cases of spinal cord injury occur in that country annually, and the five main reasons for their occurrence are as follows:
1. Car accidents: Spinal cord injuries due to car accidents are the most common types of spinal cord injuries. In fact, 40 to50% of all spinal injuries are caused by this factor. In general, severe vehicle accidents often cause severe blows to the spine and its soft tissues and result in the compression or injury of the nerve tissues inside the spinal cord. Accidents have sometimes been associated with alcohol and drug use.
2. Sports injuries: Based on the report of the spinal cord injury network, sports injuries have accounted for a small percentage of the annual statistics of spinal cord injuries. In the group of sports injuries, the injuries caused by diving in shallow water are the most common cause. Generally, spinal injuries caused by sports traumas are about 7.6% of all injuries.

3. Violence: Unfortunately, violence is responsible for 15% of all spinal cord injuries. Based on the statistics of the United States Spinal Cord Injury Center, most of these injuries are caused due to gunshots or stab wounds or generally due to direct blow of an object with the spinal cord.
4. Falling: Falling is considered the most common cause of spinal cord injury among adults over 65 years old. Keeping the body active and maintaining appropriated balance in different ways can play a key role in preventing the falls which may result in spinal cord injury. Falling is regarded as the cause of about 25% of all spinal cord injuries.
5. Tumors: There are different tumors including cancerous or non-cancerous, which can affect the spinal cord. Such tumors include astrocytoma, neurofibromatosis, and meningioma. The origin of these tumors might be inside the nerve tissue cells or around them, causing pressure on the spinal cord as a result of growth. In addition, cancerous tumors may develop in other parts of the body and metastasize inside the spinal cord (Nikbakht Nasrabadi et al., 2017).

Classification of spinal cord injury
Spinal cord injury can be divided into three categories of cervical, sacral and lumbar, depending on the areas of injury in the spine. Tetraplegia or quadriplegia refers to an injury at the level of the neck which leads to the loss of movement and sensation in the limbs and trunk, as well as the disruption of the urinary and fecal systems and sexual function. Furthermore, it determines the degree of involvement of the upper limbs at the exact level of the injury. Paraplegia refers to an injury in the thoracic, lumbar or sacral level leading to a lack of sensorimotor function in the lower limbs and trunk. The exact amount of involvement is dependent on the level of injury. One of the results of spinal cord injury with any cause is the disorder and loss of sensation and movement and other factors in the trunk and limbs (or both). This is due to the injury in the nerve elements inside the spinal canal.
Injury in the cervical part (C8-C1) and the highest thoracic part (T1) leads to tetraplegia and disorders in the arms, trunk, legs and pelvic organs (bladder, intestines and sexual organs). Thoracic injury (T2-T12) causes paraplegia and injury in the trunk, legs, pelvic organs or some of them in a combined way. Lumbar (L1-L5) and sacral (S1-S5) injury causes disorders in the legs, pelvic organs, or both. The level of the nerve and completeness of injury specify the degree of the disorder (Vinik et al., 2017).