Hong Kong West Cluster (HKWC) Session - Advances in Musculoskeletal Rehabilitation

The first ever described case of spinal cord injury was dated as early as 2500 BCE in ancient Egyptian medical texts. During that time, SCI was considered to be an ailment so devastating it was “not to be treated”. In the modern era, the study of spinal cord injury represents a rapidly advancing field that involves a wide spectrum of knowledge, spanning the basic sciences, to precisely executed clinical management pathways, and sophisticated assistive technologies for rehabilitation. Suffice to say, a cure for spinal cord injury is still beyond the horizons. Over the past several decades, a considerable amount of preclinical research has been invested into developing effective neuroprotective and neural regeneration strategies, and hospital systems around the globe have begun exercising the optimal perioperative algorithms which are imperative to improving patient outcomes. Our society as a whole has evolved from one that has adopted a futile attitude towards this orphaned group of patients, to one that embraces patients’ community reintegration and their equal opportunities. It remains ever more hopeful that the clinical outcomes of this group of severely injured patients will continue to improve, and that an ultimate cure to this ailment be discovered.

Number of patients with amputation is expected to be doubled by 2050. Traditional prosthesis is limited in its use by the frequent problems related to the socket-stump interface. Osseointegration is implantation of endoprosthesis into stump bone and connection to prosthesis with a connector. It is a viable option with many biological and biomechanical advantages. It has better fit, no skin problem, no interface movement. It allows better biomechanics, better joint range of movement, and provides perception on ground contact. This improves the quality of life of patient with amputation. The recognized risks and complications of osseointegration include infection, the need of stoma care, and potential peri-prosthetic fracture. The process of osseointegration requires a careful protocol starting from pre-operative assessment and selection of patient, the surgical procedure, early postoperative care, and rehabilitation. The benefits of osseointegration has been reported in international journals since it is started in 1990. It is expected osseointegration will be a viable mobility solution for an increasing spectrum of patient with amputation in the future.

For patients with amputation, apart from having to go through and accept the impact of losing a limb either from trauma, tumor or peripheral vascular disease, many have to endure the continuous pain which feels like it is coming from the loss limb i.e., phantom limb pain. While the pain may vary in severity, its persistence can affect the working capacity and daily activities of the patients. As a result, many need to seek help from a pain specialist and/or a psychiatrist (for depression) and rely on different kinds of analgesics to carry on their daily lives.


Targeted muscle reinnervation (TMR) is a decade old surgical procedure designed to permit intuitive control of upper limb prostheses through a set of novel nerve transfers. It has been popularized in Europe and USA, mainly for the traumatic amputee. Yet by providing both a distal target and a vascularized scaffold on which to guide sprouting nerve axons, TMR has been noted that it can be a novel technique for the treatment of painful neuromas.


It has been observed that for patients who undergo TMR for prosthesis fitting, the prevalence of suffering from phantom limb pain is much less. Subsequent studies show that TMR can eliminate phantom limb pain in both acute setting and chronic setting. A randomized control trial also showed that a superior improvement in phantom limb pain in major amputees (both upper and lower limb amputees) can be achieved with TMR when compared with conventional surgical treatment 


WE report our experience of performing TMR on patients who have suffer from phantom pain for many years as well as patients who need amputation acutely in Queen Mary Hospital. We report the tips and peals of doing TMR and highlight its pros and cons of performing TMR on acute and chronic patients.

The health and quality of life of patients with spinal cord injury can be greatly improved by appropriate selection from a wide range of currently available assistive technology for preventing complications and for restoring function that might otherwise be lost for life. Furthermore, devices developed for spinal cord injury often find use in many other disabilities and can often be cost-effective for health care systems. 
Rapidly improving capabilities of these new technologies now provide exciting prospects of neurorehabilitation early after injury. In addition to the physical restoration of movement, the concept of neural reconditioning via locomotion has evolved from animal and human studies focused on the neural plasticity of the spinal cord. The capacity for neuroplasticity of the central nervous system – much like a toddler learning to walk – presents us with a tremendous opportunity to retrain the neural network after injury. When guided with repetition and habituation, locomotor training and neuromuscular activation below the level of the lesion can promote meaningful functional reorganization of the neural networks, leading to more substantial functional improvement even with incomplete regeneration.