ASSIGNMENT

ON
PT MANAGEMENT
IN
SPINAL CORD INJURY

BPT.401: PT in Neurology and psychosomatic conditions

SUBMITTED TO: Dr. SimratjeetKaur (PT)

SUBMITTED BY: Sumandeep Kaur (33)

PHYSICAL THERAPY MANAGEMENT IN

THE ACUTE STAGE OF RECOVERY
While hospitalized during the acute stage of recovery with immobilization in
place, the patient may be on a period of bedrest.The primary goal of
physical therapy is to prevent secondary complications, provide patient
education, and begin early mobilization when medical clearance is
received.

Physical Therapy Examination

Before beginning the initial examination, the patient must be sufficiently
stable to undergo the examination and the therapist must be aware of any
precautions.
Spinal instability, orthotic devices, concomitant injuries, and need for
medical support (e.g., ventilator) may preclude certain movements or
positions. The primary areas of focus during this early stage of recovery are
examination of sensory and motor function, respiratory function, skin
integrity, PROM, and performance of early mobility skills.

1. Motor and Sensory Function

Motor and sensory function should be assessed using the ISNCSCI
described earlier to determine the level of neurological injury.
Care should be taken when performing manual muscle testing particularly if
the spine is not yet stabilized or fully healed after surgery.
Forceful contraction of muscles that originate from the spine may cause
instability at the fracture site. Discretion should be used in applying
resistance around the shoulders in tetraplegia and around the lower trunk
and hips in paraplegia.

2. Respiratory
The physical therapist should assess the strength of the diaphragm and
intercostal muscles through observation while the patient is breathing.
Respiratory rate should be assessed while the patient is unaware that it is
being done. Normal respiratory rate is between 12 and 20 breathes per
minute. To compensate for a weak diaphragm, the respiratory rate will
typically increase.

3. Integument
During the acute phase, meticulous and regular skin inspection is a shared
responsibility of the patient and the entire medical/rehabilitative team. As
management progresses into the active rehabilitation phase, the patient will
gradually assume greater responsibility for this activity.
 4. Passive Range of Motion
Goniometry can be used to assess joint ROM. Shoulder ROM is particularly
important for patients with tetraplegia. Depending on the motor level of
injury, people with tetraplegia may require more than normal ROM to
perform certain mobility skills, and decreased shoulder ROM is associated
with shoulder pain. Hamstring length, hip extension, and ankle dorsiflexion
are important to measure as well, due to the potential for contractures in
these joints.
5. Early Mobility Skills
During this early phase of recovery, patients may have restrictions on
certain motions and positions, as well as limited ability to tolerate an upright
posture for extended periods of time (sitting or standing).

Physical Therapy Interventions

The extent to which the following interventions are implemented is
dependent on the medical stability of the patient, stability of healing fracture
and surgical sites, and status of other injuries that may have occurred
during the initial event that caused the SCI.
The physician should be consulted regarding any rehabilitation activities
that may place stress on the spine while the spine is still unstable. Although
the interventions described below are usually initiated in the early stages of
recovery, they should be continued throughout the rehabilitation process
and be incorporated into the patient’s lifestyle to manage the longterm
consequences of the SCI.
1. Respiratory Management
Respiratory care will vary according to the level of injury and individual
respiratory status. Primary goals of management include improved
ventilation, increased effectiveness of cough, and prevention of chest
tightness and ineffective substitute breathing patterns.49
Individuals with cervical injuries at and above C5 often require ventilatory
support using an intermittent positive pressure ventilator (IPPV).
Approximately 40% of patients with cervical injuries require mechanical
ventilation, with most of these occurring in the first 3 days after injury.
Invasive mechanical ventilation is often done through a tracheostomy and
can be provided through a stationary or portable ventilator. Noninvasive
positive pressure ventilation provides an alternative to invasive mechanical
ventilation. Intubation may impair the function of the airway cilia, leading to
chronic bacterial colonization and chronic inflammatory changes of the
airway. Patients may also prefer noninvasive ventilation.
 2. Deep-Breathing Exercises
Diaphragmatic breathing should be encouraged. To facilitate diaphragmatic
movement and increase VC, the therapist can apply light pressure during
both inspiration and expiration. Manual contacts can be made just below
the sternum. his will assist the patient to concentrate on deep-breathing
patterns even in the absence of thoracic and abdominal sensation. To
facilitate expiration, manual contacts are made over the thorax with the
hands spread wide. His creates a compressive force on the thorax,
resulting in a more forceful expiration followed by a more efficient
inspiration. Patients immobilized in traction devices or limited to recumbent
positions may benefit from use of a mirror to provide visual feedback during
these activities.
3. Glossopharyngeal Breathing
Glossopharyngeal breathing may be appropriate for patients with high-level
cervical lesions who are dependent on a mechanical ventilator for
ventilation, as well as for patients with mid to high cervical level injuries
who are not dependent on mechanical ventilation. Glossopharyngeal
breathing utilizes the lips, pharyngeal muscles, and the tongue to inhale air.
The patient is instructed to take in small amounts of air, using a “gulping”
pattern, thus utilizing available facial and pharyngeal muscles. The patient
repeats this 6 to 10 times. By using this technique, enough air is gradually
inspired. Exhalation occurs due to the elastic recoil of the lungs.
4. Air Shift Maneuver
This technique provides the patient with an independent method of chest
expansion. It involves closing the glottis after a maximum inhalation,
relaxing the diaphragm, and allowing air to shift from the lower to upper
thorax.
Air shifts can maintain and increase chest wall expansion. This technique
may cause the patient to hyperventilate. The physical therapist should
monitor the patient for dizziness and other signs of hyperventilation and
allow for periods of rest as needed.
5. Respiratory Muscle Strengthening
Similar to other muscles, strength training can improve respiratory muscle
strength and endurance. Inspiratory muscles can be trained using relatively
inexpensive handheld devices, which increase the resistive or threshold
inspiratory load on muscles of inspiration. There are generally two types of
handheld inspiratory muscle training devices: resistive or threshold trainers.
Breathing through these devices increases the resistive or threshold
aspiratory load on the muscles. The load can be progressively increased as
the patient progresses. Inspiratory muscle training can improve pulmonary
function, reduce dyspnea, and improve cough function.
6. Coughing
Patients who are not able to produce a functional cough should be taught
to perform a self-assisted cough. Those who cannot perform a self-assisted
cough may benefit from a manually assisted cough to help remove
secretions. To assist with coughing and movement of secretions, manual
contacts are placed over the epigastric area. The therapist pushes quickly
in an inward and upward direction as the patient attempts to cough.
7. Abdominal Binder
An abdominal binder may improve respiratory function40, and cough
ability135 in patients with high thoracic and cervical lesions. An abdominal
binder may improve respiratory mechanics by compensating for
nonfunctioning abdominal muscles. The binder compresses abdominal
contents to increase intra-abdominal pressure, and elevate the diaphragm
into a more optimal position for breathing.
8. Skin Care
Prevention is the most effective intervention for skin care; this entails
positioning, consistent and effective pressure relief, skin inspection, and
education.
Areas that are susceptible to skin breakdown should be adequately
protected when the patient is in bed by using pillows, foam, and positioning
devices.
Positioning should also be used to prevent development of joint
contractures and secondary pulmonary complications.
Specific positioning of the UEs and LEs to prevent contractures will depend
on the level of the SCI.
Certain joints may be more prone to contracture depending on which
muscles surrounding the joint are innervated. For example, a patient with a
C5-level injury may tend to position the shoulder in adduction and the
elbow in flexion.
When positioning this patient the shoulders should be abducted and elbows
extended when possible. When in bed, patients should be repositioned at
least every 2 hours.
The wheelchair and seating system should also assist in promoting optimal
positioning for reducing pressure and shear forces on susceptible areas.
The pelvis should be positioned in a neutral position or slightly tilted
anteriorly and be symmetrical (i.e., left anterior-superior iliac spine [ASIS]
even with the right ASIS). Patients should perform a pressure relief
maneuver every 15 minutes when in the wheelchair, either with assistance
or independently. From the seated position, this can be done by using a
push-up maneuver, leaning to the side, or leaning forward.
If using a forward lean, the lean should be greater than 45 degrees.
Patients who are not able to perform these maneuvers initially can be
assisted or their wheelchair can be tilted back.
If tilting the entire wheelchair back, it should be tilted to at least 65 degrees.
All pressure relief maneuvers should be maintained for at least 2 minutes to
be effective.
A tilt-in-space or reclining wheelchair can also be used to redistribute
pressure. The patient’s skin should be routinely inspected to ensure there
is no developing skin breakdown.
Preparation for assumption of this responsibility will include patient
education about the potential risks of pressure sores, the importance of
hygiene, instruction in skin inspection techniques the use of pressure relief
equipment and procedures, and what to do if a pressure ulcer develops.
If the patient develops a skin ulcer, the preventive measures described
above should continue to be employed.
Various therapies directed at wound healing should be initiated. Electrical
stimulation, hydrocolloid dressings,and occlusive hydrogel dressings can
be used to facilitate the healing process.
9. Early Strengthening and Range of Motion
Range of motion exercises should be completed daily except in those
areas that are contraindicated or require selective stretching. In this early
stage of recovery, ROM or strengthening exercises that are too intense
may place increased pressure and stress on vertebral sites that may be
unstable and are still healing. Motion of the trunk and some motions of the
hip may be contraindicated depending on the location of the SCI. he pelvis
should remain in a neutral position when ROM is performed on the LEs.
When the injury is in the lumbar spine, straight leg raises more than
approximately 60 degrees and hip flexion beyond 90 degrees (during
combined hip and knee flexion) should be avoided. With tetraplegia, motion
of the head and neck is contraindicated pending orthopedic clearance. with
SCIs do not require full ROM in all joints. Some joints benefit from allowing
tightness to develop in certain muscles to enhance function. After the acute
phase, the hamstrings will require stretching to achieve a straight leg raise
of approximately 100 degrees. This ROM is required for many functional
activities such as long sitting and LE dressing. Care should be taken not to
overstretch the hamstring muscles because some tightness in this muscle
group provides passive pelvic stabilization in sitting. This process of under-
stretching some muscles and full stretching of others to improve function is
referred to as selective stretching.

10. Early Mobility Interventions

Once radiographic findings have established stability of the fracture site, or
early fracture stabilization methods are complete, the patient is cleared for
upright, functional activities. The patient typically will experience symptoms
of postural hypotension (dizziness, nausea, ringing in ears, loss of vision,
or loss of consciousness) when initially assuming sitting and standing (if
able). A gradual acclimation to upright postures is necessary. The use of an
abdominal binder and elastic stockings may reduce venous pooling and
prevent orthostatic hypotension.
During early upright positioning, elastic wraps may also be used in
combination with (placed over) the elastic stockings.
Initially, upright activities can be initiated by slowly elevating the head of the
bed and progressing to a reclining or tilt-in-space wheelchair with elevating
leg rests. Use of the tilt-table provides another option for orienting the
patient to a vertical position. Vital signs should be monitored carefully and
documented during this acclimation period. If a patient experiences any of
the signs or symptoms of orthostatic hypotension during sitting activities,
the patient’s legs can be elevated and the trunk reclined.
ACTIVE REHABILITATION
The overarching goal of physical rehabilitation is for the patient to become
as independent as possible and to achieve the functional mobility
necessary for everyday living, work, and recreation. Independent mobility
can be achieved in a way that
 Use new movement strategies to compensate for neuromuscular
impairments;
 Use the neuromuscular system to accomplish the task with a
movement pattern similar to that before the injury.
Compensation refers to use of an alternative or new movement strategy, or
technology to compensate for neuromuscular deficits to accomplish a daily
task. Recovery of function refers to the restoration of the neuromuscular
system so that the motor task is performed in the same manner as it was
before the SCI.

PHYSICAL THERAPY EXAMINATION

All the examination procedures completed during the acute phase are
continued during the active rehabilitation phase.
Commonly Used Outcome Measures and Tests and Measures Categories
Aerobic Capacity/Endurance
• A 6-minute arm test
Arousal, Attention, Cognition
• Mini Mental State Exam and the Montreal Cognitive Assessment
Environmental or Work Barriers Gait, Locomotion, and Balance
• Wheelchair Skills Test, Wheelchair Circuit, Modified Functional Reach
Test, Berg Balance Scale, Walking Index for Spinal Cord Injury, Spinal
Cord Injury Functional Ambulation Inventory, 10-Meter Walk Test, 6-Minute
Walk Test, Neuromuscular Recovery Scale
Integument
• Braden Scale
• Spinal Cord Injury Pressure Ulcer Scale
• Spinal Cord Injury Pressure Ulcer Scale–Acute
Motor Function
• Modified Ashworth Scale, Spinal Cord Injury Spasticity Evaluation Tool
Muscle Performance
• ASIA ISNCSCI, manual muscle test, handheld dynamometer
Pain
• Visual analog scale, International Spinal Cord Injury Basic Pain Data Set,
Wheelchair User’s Shoulder Pain Index
Range of Motion
• Goniometer
Self-Care and Home Management
• Functional Independence Measure, Spinal Cord Injury Independence
Measure, Quadriplegia Index of Function, Capabilities of Upper Extremity
Instrument
Ventilation
• Chest circumference with measuring tape
• Vital capacity with handheld dynamometer
• Respiratory rate
Work, Community, and Leisure Integration or Reintegration
• Craig Handicap Assessment and Reporting Technique, Assessment of
Life Habits, and Reintegration to Normal Living Index

Physical Therapy Interventions

In people with SCI the intervention strategy selected is largely based on the
amount of preserved motor function. There are some common principles
and precautions that can be applied to many interventions. Because SCI
affects many different body systems, certain precautions must be
considered when performing interventions. Common principles used across
compensatory intervention strategies to promote functional independence
in mobility tasks are momentum, head–hips relationship, and muscle
substitution. These strategies allow performance of functional mobility tasks
through compensatory mechanisms that the patient may not be able to
otherwise perform owing to loss of motor function and muscle strength
below the lesion level. For example, a patient with a T1 ASIA A SCI will use
momentum by swinging the arms across the body multiple times to roll from
supine to sidelying to compensate for lost trunk or LE muscles that would
normally assist in performing the task.

1. Strengthening
UE muscles to strengthen include
 serratus anterior
 latissimus dorsi, pectoralis major
 rotator cuff muscles
 triceps brachii.
These muscles are important for independent transfers. Strengthening
exercises should be performed 2 to 4 times a week, performing 2 to 3 sets
of 8 to 12 repetitions at 60% to 80% of one repetition max. Initially,
strengthening exercises may be done daily during early rehabilitation.
A variety of methods can be used to implement strengthening exercises:
 pulley systems
 free weights
 elastic bands
 weight cuffs.
With very weak muscles (grade ≤2) strengthening can be performed in
gravity-reduced positions on a powder board or with active assistive ROM.
Strengthening can be done in functional postures as well. For example,
push-ups can be performed in prone-on-elbows and supine-on-elbows.

2. Cardiovascular/Endurance Training
As with able-bodied people, cardiovascular training has important health
benefits for people with SCI.
Upper extremity–based exercises such as arm ergometry, wheelchair
propulsion, and swimming are the most common method of aerobic
training. In people with iSCI with sufficient walking capacity locomotor
training on a TM with or without BWS is another method of endurance
training. The duration and intensity of the training should be gradually
increased for those not able to initially tolerate these training levels.
Surface Functional Electrical Stimulation (FES)–induced cycling or walking
is also an effective means of improving cardiovascular fitness. Surface
electrodes are attached bilaterally to the hamstrings, quadriceps, and
gluteal muscles; a computer controls the intensity of the muscle stimulation
and cadence based on the position of the pedals.
3. Bed Mobility Skills
Bed mobility skills are necessary to promote independence in functional
mobility. Bed mobility skills include rolling, transitioning supine to/from
sitting on the edge of the bed, and LE management. Independence in these
skills is also necessary for dressing, positioning in bed, and skin inspection.
At first bed mobility skills are learned and practiced on an exercise mat,
which is firmer and larger than a typical bed. However, as skill improves
they should be practiced on a bed similar to that used at home. A patient
may be independent performing these skills on a mat, but still require more
practice to become independent performing the same task on a bed due to
the softer and smaller surface.
Individuals with complete SCI will need to use compensatory movement
strategies (e.g., momentum, muscle substitution, and head-hips principle)
to move the entire body.
4. Rolling
It requires the patient to learn to use the head, neck, and UEs, as well as
momentum, to move the trunk and/or LEs. It is usually easiest to begin
rolling activities from the supine position, working toward the prone
position. If asymmetric involvement exists, rolling should be initiated with
movement toward the weaker side. To develop maximum independence
adaptive devices such as bed rails, ropes, canvas “ladders,” or overhead
devices such as trapezes should be avoided, if possible.
To begin training and facilitate rolling, several strategies can be used:
• Flexion of the head and neck with rotation may be used to assist
movement from supine to prone positions.
• Extension of the head and neck with rotation may be used to assist
movement from prone to supine positions.
• Bilateral, symmetrical UE rocking with outstretched arms produces a
pendular motion when moving from supine to prone positions. The patient
rhythmically rocks the outstretched arms and head from side-to-side and
then forcefully “tosses” them to the side to which the patient is rolling. The
trunk and hips will follow. The head and arms should be synchronized. Use
of wrist cuff weights (2 to 3 lb) may be used initially to increase kinesthetic
awareness and momentum. The number of rocking motions necessary will
depend on the patient’s skill, level of SCI, and body type.
• Crossing the ankles will also facilitate rolling initially. The therapist
crosses the patient’s ankles so that the upper limb is toward the direction of
the roll (e.g., the right ankle would be crossed over the left when rolling
toward the left). When first learning, flexing the hip and knee of the top LE
and placing it over the opposite limb (e.g., the hip and knee of the right LE
would be flexed and placed over the left when rolling toward the left) can
assist.
• In moving from the supine position to the prone position, pillows may be
placed under one side of the pelvis (or scapula, if needed) to create initial
rotation
• Several Proprioceptive Neuromuscular Facilitation (PNF) patterns are
useful during early rolling activities. The UE patterns of D1 flexion, D2
extension, and reverse chop will facilitate rolling toward the prone position.
The UE lift pattern will facilitate rolling toward the supine position from side-
lying.
5. Transitioning Supine to/from Sitting
The ability to transition from supine in bed to sitting on the edge of the bed
is a critical skill necessary for independent mobility.
There are two basic methods (with variations) to transition from supine to
sitting:
(1) “Walking” onto elbows from prone or side-lying and
(2) Coming straight up from supine. Both of these methods transition the
patient from supine to long sitting.
6. Sitting Balance
Independent sitting balance, both in short sitting and long sitting, is an
important skill for many different functional tasks such as transfers,
dressing, and wheelchair mobility.
The following are some suggestions that can be incorporated to improve
sitting balance, both in long and short sitting.
• Sitting balance training is initially done by assisting the patient into a
balanced short or long sitting position.
In short sitting the patient should initially be positioned with the feet firmly
supported on the floor and the hips and knees flexed to 90 degrees. In long
sitting patients should have approximately 90 to 100 degrees of straight leg
raise ROM to avoid overstretching the low back muscles. Initially, it is
easier to maintain balance in long sitting due to the larger BOS. The LEs
can be placed with the hips in external rotation and slight abduction to allow
knee flexion to avoid overstretching the low back muscles.
• Patients may initially need to bear weight through the UEs to maintain the
sitting position. For patients with cervical level lesions who utilize a
tenodesis grasp to hold and manipulate objects, the fingers should be
flexed at the proximal and distal interphalangeal joints when the wrist is in
full extension to prevent overstretching the finger flexor tendons. Patients
who do not have triceps innervation need to learn to keep the elbows
extended through muscle substitution. The patient throws back the
shoulder into full shoulder extension while externally rotating the shoulder
and supinating the forearm. When the
UE is weight-bearing in this position the patient can contract the anterior
deltoids to flex the shoulder in a closed chain, which will extend the elbow.
• Stability in sitting can be enhanced by providing manual resistance to the
upper trunk using PNF techniques of alternating isometrics and rhythmic
stabilization.
• Sitting practice should include altering UE support (bilateral, unilateral,
with progression to no support).
Reaching for objects with one and both UEs can improve anticipatory
balance reactions. Patients should also practice maintaining postural
control while manipulating objects and performing ADL in sitting.
• Patients should safely learn their new limits of stability.
This can be accomplished by weight shifting until the point is reached
where balance can no longer be maintained; close supervision/assistance
is warranted.
• Providing unexpected perturbations in a safe manner can be used to
practice reactive postural control.
• Balance interventions should be practiced on a variety of surfaces: firm
mat, bed, dense foam, sofa cushion, and so forth. Balance interventions
should also be practiced while sitting in the patient’s wheelchair.
7. Transfers
There are three components to the sit-pivot transfer (e.g., bed to/from
wheelchair in a seated position) preparatory phase, lift phase, and descent
phase.
During the preparatory phase, the trunk flexes forward, leans laterally, and
rotates toward the trailing phase. The lift phase starts when the buttocks lift
off the sitting surface and continues while the trunk is lifted halfway
between the two surfaces.The descent phase denotes the period when the
trunk is lowered to the other seated surface, from the halfway point until the
buttocks are on the other surface.
Complementary Skills Necessary for Independence With Transfers
• Position wheelchair
• Set wheel locks
• Remove and replace arm rests on wheelchair
• Remove and replace leg rests on wheelchair
• Manage transfer board
• Manage lower extremities
• Manage body position in wheelchair
8. Locomotor Training
Regaining the ability to walk is a common goal for most individuals
following SCI. A number of factors will influence the success or failure in
attaining this goal. Patients must possess adequate muscle strength,
postural alignment, ROM, and sufficient cardiovascular endurance to
become functional ambulators.
Locomotor Training Strategies
Swing-through and 4-point gait patterns are two common walking patterns
learned by patients with complete SCI using KAFOs. Initial standing
balance and gait training should be done in the parallel bars and then
progressed to the appropriate assistive device when the patient is ready.
Relevant training activities include those described below.
• Putting on and removing orthoses. The patient is first taught the correct
way to don and doff the orthoses. The entire procedure is usually done in
the supine or sitting position. The patient must be cautioned to continuously
monitor skin for pressure areas, particularly after brace removal.
• Assistive device. Forearm crutches are most often selected for patients
with paraplegia. These crutches provide several advantages. hey are
lightweight; they allow use of the hand without the crutch becoming
disengaged; they fit more easily into an automobile; and, most important,
they improve function in ambulation and stair climbing by allowing full hip
extension and unrestricted movement at the shoulders.
• Sit-to-stand activities. These activities should be practiced in the parallel
bars using a wheelchair, then progressed to using the forearm crutches.
The patient must learn to slide to the edge of the chair and unlock and lock
the orthoses. Initially the patient is taught to pull to standing, using the
parallel bars (a progression is made to using the wheelchair armrests to
push to standing). Once in an upright position, the patient pushes down on
the hands and tilt.
• Static standing balance. The patient learns to balance in standing with the
hips in hyperextension and the upper trunk, head, feet, and arms behind
the pelvis. The feet are 3 to 5 in (7.6 to 12.7 cm) apart.
• Weight shifting in standing. his entails controlling the pelvic position using
UE support and positioning the head and shoulders forward ahead of the
pelvis. He head hips relationship applied in transfers also applies in
standing. The patient must be taught recovery to overcome and/or to
prevent jackknifing from happening during ambulation. Jackknifing occurs
when the patient’s center of mass (COM) falls anterior to the hips causing
the patient to flex forward suddenly.
• Push-ups. This includes lifting the body off the floor using elbow extension
and scapulae depression and protraction, tucking the head to gain added
height, and controlled lowering of the body.
• Swing-through pattern. From a balanced standing position with the hands
posterior to the pelvis, the patient moves the hands forward causing the
trunk to flex. Then the patient lifts up by extending the elbows and
protracting/depressing the scapula and tucking the head. Gravity will cause
the trunk and legs to swing forward. When the heels strike the ground the
patient quickly extends the upper trunk and head, and pushes the pelvis
forward to come back to the starting position (Fig. 20.34).
• Four-point pattern. This gait pattern is slower but safer than a swing-
through pattern; three points are always in contact with the ground, as
opposed to a swing-through pattern, in which there are times when only
two points are in contact with the ground.
Locomotor Training for Individuals with Incomplete Spinal Cord Injury
Locomotor training (LT) for patients with iSCI using partial BWS, a TM, and
manual assistance by trainers is an important therapeutic intervention to
retrain walking after iSCI.
Locomotor training occurs across three environments:
(1) on the TM with use of BWS and manual facilitation;
(2) assessment of the patient’s ability to apply new skills, and control
occurs overground (e.g., use of NRS); and
(3) community integration.
Activity-Based Upper Extremity Training
For people with a cervical SCI the recovery of UE function is a primary
goal. Interventions aimed at improving functional use of the UE have
primarily been compensatory in nature. For example, patients with active
wrist extension are taught how to manipulate and pick up objects using a
tenodesis grasp, use the hand as a hook, and use different types of
orthoses to feed themselves.
Locomotor Training for Individuals with Motor Complete SCI
When initiating a locomotor training (LT) program for complete SCI,
therapists should be realistic and provide a clear picture of the costs and
potential benefits.
Individuals with complete SCI rely on orthotic and assistive devices,
adequate ROM, and maximizing strengthen of neurologically intact
musculature for standing and walking. Full ROM in hip extension is
essential in attaining balance in the upright position. The patient learns to
lean into the anterior ligaments of the hip to stabilize the trunk and pelvis.
The absence of knee flexion and plantarflexion contractures is also
important in attaining upright standing balance.

Patient/Client-Related Education
Because SCI can affect many different body systems and drastically
change an individual’s life, ongoing education about the consequences of
SCI is critical.
Education should begin early after injury and continue throughout
rehabilitation and cover the extensive impact of SCI discussed above (e.g.,
skin care, AD, self-directing care, wheelchair mobility and maintenance,
sexuality, and so forth). Without education patients will not be able to make
informed decisions regarding their care or informed choices regarding
community reintegration.