University of Mosul, College of Physical Education and Sport Sciences & University of Sfax, High Institute of Sport and Physical Education at Sfax
Phase: NA
Conditions: Spinal Cord Injuries, Rehabilitation, Exercises
Sponsor: University of Mosul

Feasibility of Home-Based Rehabilitation on Body Composition, some 
Anthropometric Measures and Muscular Strength after interruption 4-5 years of 
Spinal Cord Injury: Serial Cases Study on ISIS War Survivors in Iraq 
 
Summary 
Background: The war in Mosul wrecked hospitals and rehab centers, leaving a gap in 
rehabilitation services. This resulted in a need for alternative solutions for 
rehabilitation. Objectives: This study aims to create a home-based rehabilitation 
program (HBRP) that fits the participant; surroundings, and also detect and evaluate 
how effective it is in improving body composition, some anthropometric 
measurements, and muscle strength after a (4-5) year break in rehabilitation. 
Methods: This voluntary controlled trial included 18 volunteers split into three groups: 
13 people with Spinal Cord Injury (SCI) their injuries time since (53.4-55) months. 
They joined voluntarily into Two groups, Eight in the experimental group (Exp.) and 
Five in the first control (1st Con.); while Five were healthy individuals in the second 
control (2nd Con.); all around (21.2) years old on average. The HBRP focused on 
muscles and whole-body joints by using the basic equipment and exercises right at the 
patient’s homes. The program consisted of five weekly sessions with a gradually 
increasing achievement time of (45-120) minutes per session, participants were given 
rest time between exercises based on their level and severity of injury. The assessment 
was every three months. 
Innovatively, this study stands out by introducing an HBRP tailored for individuals with 
SCI after interruption sustained (4 - 5) years ago. This unique approach not only 
addresses the challenges posed by the interruption of previous rehabilitation efforts but 
also seeks to uncover the efficacy of rehabilitation in these specific circumstances. 
Conclusions: The study concluded that HBRP affected positively the muscles 
morphologically and functionally despite a stop in rehabilitation for a long period of 
(4-5) years for individuals with SCI. 
 
Background 
Spinal Cord Injury (SCI) is a complex pathology that requires skills in assessment, 
treatment, and rehabilitation, SCI is a large topic area. Approximately (90%) of SCI 
cases occur as a result of traumatic causes Globally, incidence varies from 40 to 80 
cases per million population.  So, people with injuries consequences are becoming more 
frequent due to conflicts and wars. In Iraq, the main reasons for the occurrence of this 
injury due to were the Islamic State in Iraq and Syria (ISIS) war, which is resulting in 
enormous unmet rehabilitation needs. Alarcon Cieza found in his study Rehabilitation 
the health strategy of the 21st Century that the rehabilitation stakeholders need to bring 

together the distinct portraits of rehabilitation under the concept of functioning because 
much of these unmet needs are concentrated amongst the poorest populations in low- 
and middle-income countries and conflict-affected settings, which are often ill-
equipped to cope with these increasing needs for rehabilitation services. Iraq is regarded 
as one of these countries its health sectors, including rehabilitation, have been 
exhausted due to wars and armed violence. However, rehabilitation can be effective 
across almost all conditions, therefore in some ways, we should have been so backwards 
about recognizing the effectiveness of rehabilitation for many years. 
It is worth noting that healthcare problems are among the most complex problems faced 
by human beings, especially under conditions of war, armed conflicts, terrorist 
operations and post-war secretions. In low-middle income countries, so many people 
would die from SCI within a year, two years, or three years from infection, renal failure, 
and so on, and also people could not work, and they either were at home or in residential 
care, just waiting to die. One of the defining characteristics of rehabilitation is that there 
are many interventions; in contrast to most medical conditions, rehabilitation can take 
place in any setting as a process for problem-solving. 
In Iraq, war-related destruction of health institutions and rehabilitation centers has led 
to a focus on home-based rehabilitation programs (HBRP) and new sporting activities 
as positive and alternative approaches for rehabilitating individuals with SCI. This 
article emphasizes the significance of home-based rehabilitation for individuals with 
SCI to prevent complications that arise from neglecting rehabilitation. Neglecting 
rehabilitation can result in complex health problems, a major concern observed among 
the study participants who discontinued rehabilitation due to ineffective and insufficient 
programs. 
Additionally, 
there 
was 
a 
notable 
mismatch 
between 
the 
participantscircumstances and the available rehabilitation systems and methods. To 
ensure continuous and successful rehabilitation for individuals with SCI, it is important 
to implement exercise regimes that intrinsically motivate them. Robert et al, confirmed 
that rehabilitation can occur at home, and it is a practical matter of what is the best way 
to organize it so that the patient is safe, the necessary equipment is available, and the 
therapists and other team members, time is used appropriately. The process is a standard 
problem-solving process individualized to the patient, which is necessary when solving 
any problem. Reconsidering rehabilitation at home by introducing new sporting 
activities has been recognized as a positive and desirable area of rehabilitation 8. 

 
Objectives: Innovatively, this study stands out by introducing an HBRP tailored for 
individuals with SCI after interruption sustained between (4 - 5) years ago. This unique 
approach not only addresses the challenges posed by the interruption of previous 
rehabilitation efforts but also seeks to uncover the efficacy of rehabilitation in these 
specific circumstances. 
The main contributions of this study are: 
To the best of the authors' knowledge, this is the first study in Iraq that highlighted the 
surviving victims of ISIS with SCIs. 
The preparation of a home-based rehabilitation program (HBRP) that lasted for six 
months and that was compatible with the participants' living and environmental 
conditions as an alternative solution for conditions after the war also, at the time of the 
COVID-19 pandemic when everything was under the closure. 
Assessing the effectiveness of rehabilitation on some anthropometric and physical 
variables in participants with SCI following participants' stopping of rehabilitation for 
(4-5) years after SCI. 
The study raises two questions 
Does the home-based rehabilitation program (HBRP) affect people with spinal cord 
injury through interruption of rehabilitation for 4-5 years? 
Is the HBRP effects on variables such as body composition (Weight, BMI); 
Anthropometric Measures, and Muscle strength? 
Methods 
 This voluntary controlled trial included 18 volunteers split into three groups: 13 people 
with Spinal Cord Injury (SCI) their injuries time since (53.4-55) months. They joined 
voluntarily into Two groups, eight in the experimental group (Exp.) and Five in the first 
control (1st Con.); while five were healthy individuals in the second control (2nd Con.); 
all around (21.2) years old on average. As a first procedure, detailed interviews were 
conducted with each participant at the beginning of the study to gather information 
about their physical, psychological, and social well-being. This information helped the 
authors create personalized rehabilitation plans for each participant to ensure their 

participation in the study for the entire 6 months period. Through our study objectives, 
the authors used body composition such as height, weight, BMI and some 
anthropometric measurements for body parts circumferences by using tape 
measurements, similar to a previous study by Akita et al. Also, muscle strength tests 
were performed on participants&#39; lower and upper extremities, head, and trunk to 
measure various movements. The 2nd control group completed their measurements and 
tests at college. Additionally, a clinical test using the American Spinal Injury 
Association scale (ASIA) was conducted on each participant to assess sensory feeling 
and voluntary movement potential on both sides of the body. 
The physical tests were conducted using a handheld muscle tester called MicroFET2 to 
evaluate the strength of participants&#39; lower extremities, head, and trunk by using 
unit measure kilogram (kg) 11. The Exp. group underwent a 6-month intensive 
rehabilitation program that involved whole-body exercises, including stretching, 
strength, endurance, and aerobic training, which was prepared based on previous 
studies 12. The program included five weekly sessions of (45-120) minutes, gradually 
increasing in intensity. It encompassed various exercises like bed exercises, rubber ball 
exercises for strength and balance, trunk flexibility exercises, crawling, rolling, ball-
related movements, and exercises on parallel bars. Also, aerobic exercises targeted 
cardiorespiratory fitness. While weight exercises focused on the upper limbs, shoulders, 
chest, and back. Rest periods were personalized based on injury severity and overall 
health. The authors updated the exercises based on regular assessments every 3 months, 
tracking muscle strength and endurance. The authors created a contact link for 
coordination among medical, rehabilitative teams, and participants, families, 
overcoming some challenges within the Iraqi healthcare system. 
To address complex complications like bed sores, renal infections, and muscle atrophy, 
the authors followed the method of psychological support. This method aimed to 
stimulate patients, willpower, encouraging them to overcome complications and 
emphasizing the benefits of rehabilitation for improved overall health and 
independence, by made WhatsApp group was created to facilitate information sharing 
and provide visual evidence of successful cases, inspiring and encouraging participants. 
Furthermore, the participant weight and BMI were monitored due to the potential 
impact of factors such as limited movement and hormonal changes on weight 
fluctuations, as recommended in previous studies. 

The study highlights the participants the participants fidelity to treatment, as evidenced 
by positive outcomes and sustained progress beyond the conclusion of the therapeutic 
experiment. The participants demonstrated loyalty through ongoing communication 
with the main author, seeking feedback on their rehabilitation stages who reach it. 
Notably, some participants achieved the significant milestone of walking by standard 
walker with the assistive device Knee-Ankle-Foot-Orthosis (KAFO). 
Statistic Analyze 
The study used Two-way ANOVA repeated measures as a statistical analysis method, 
with effect size and improvement percentage (IP) as measures, and (IBM-SPSS 
statistics processor version 20) for data analysis. A statistical significance level of P≤ 
0.05 (alpha) was used.