Spinal Cord Injury Notes

 A spinal cord injury (SCI) is damage to the spinal cord that can be caused by
traumatic injury such as motor vehicle accidents, injuries from sports, violence
and fall, or non-traumatic damage such as pathological influences.

 There is a bimodal distribution of age at injury.

a) The average age at injury is 42.
b) The first peak occurs in young adults between the ages of 15 and 29.
c) The second peak occurs in older adults (65 or older).

 The majority of persons with SCI are male.

a) 80% male
b) 20% female

 Injuries to the spinal cord can be broadly categorized into two main causes:
traumatic and non traumatic.
a) Trauma is the most frequent cause of injury in adult rehabilitation
populations.
b) Injuries resulting from trauma occur due to events like motor vehicle
accidents, falls, acts of violence, and sports-related incidents.
c) Falls are the most common cause of SCI in older adults.
d) In adult populations, nontraumatic injuries typically stem from diseases
or pathological factors.

 Conditions that may damage the spinal cord.

a) Vascular dysfunction (arteriovenous malformation, thrombosis, embolus,
or hemorrhage)
b) Spinal stenosis
c) Spinal neoplasms
d) Syringomyelia
e) Infection
f) Neurological diseases (multiple sclerosis, amyotrophic lateral sclerosis)

 Neurological category of SCI.

a) Incomplete tetraplegia is the most common.
b) Followed by incomplete paraplegia.
c) Then, complete paraplegia.
d) Lastly, complete tetraplegia.

 Factors that influence life expectancy for people with SCI.

a) Age at onset
b) Level of neurological injury
c) Extent of neurological injury

 Individuals with an incomplete neurological SCI have a longer life expectancy

than those with complete injury.

 Mortality rate is also higher during the first year after injury.
 Spinal cord injury is characterized by:
a) Lengthy hospitalization
b) Medical complications
c) Extensive follow-up care
d) Attendant care
e) Recurrent hospitalizations

 Spinal cord injuries can be categorized as either tetraplegia or paraplegia.

a) Tetraplegia is characterized by motor or sensory impairment affecting
all four extremities and the trunk, resulting from damage to the cervical
segments of the spinal cord.
b) Paraplegia is characterized by motor or sensory impairment in the trunk
and both lower extremities, resulting from injuries to the thoracic or
lumbar segments of the spinal cord.

 The American Spinal Injury Association (ASIA) created the International

Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to
provide a standardized examination method to determine the extent of motor and
sensory function loss after a SCI.
a) The neurological level of injury is identified as the caudal level of the
spinal cord where there is intact motor and sensory function on both the
left and right sides of the body.
b) Motor level is determined testing the strength of 10 key muscles on the
right and left side of the body using the 6-point ordinal scale.
c) Sensory level is determined by testing the patient’s sensitivity to light
touch and pinprick on the left and right side of the body based on a 3-
point ordinal scale.
 0 is absent.
 1 is impaired.
 2 is normal.

 Spinal cord injuries can be classified as either complete injury or incomplete

injury.
a) A complete injury is characterized by the absence of sensory or motor
function in the lowest sacral segments, without any sacral sparing.
b) The determination of sacral sparing involves assessing sensory function
at the S4 to S5 dermatome, the ability to perceive deep anal pressure, or
the presence of voluntary anal sphincter contraction.
c) An incomplete injury is characterized by having motor or sensory
function below the neurological level, which includes sensory or motor
function at S4 and S5, with the presence of sacral sparing.
d) If an individual has motor and/or sensory function below the
neurological level but does not have sacral sparing, then the areas of
intact motor and/or sensory function below the neurological level are
referred to as zones of partial preservation.

 ASIA Impairment Scale is a classification system used to grade the severity of

spinal cord injuries based on the extent of sensory and motor function loss. It was
created to distinguish among different types of SCI - complete, sensory
incomplete, and motor incomplete.
  A = Complete. No motor or sensory function is preserved in the sacral
segments S4-S5.
 B = Sensory Incomplete. Sensory but not motor function is preserved
below the neurological level and includes the sacral segments S4-S5.
 C = Motor Incomplete. Motor function is preserved at the most caudal
sacral segments for voluntary anal contraction and has some sparing of
motor function.
 D = Motor Incomplete. Motor function is preserved at the most caudal
sacral segments for voluntary anal contraction and has some sparing of
motor function, with at least half of key muscle functions having a
muscle grade 3.
 E = Normal. Sensation and motor function are graded as normal in all
segments.

 Spinal cord injuries can result in various clinical syndromes, depending on the
location and severity of the injury.
a) Brown-Sequard Syndrome arises from the hemisection of the spinal
cord or damage to one side, usually resulting from penetrating wounds
like stabs or gunshot injuries. There is ipsilateral (same side) loss of
proprioception, light touch and vibration sense, and contralateral
(opposite side) loss of pain and temperature sensation.
b) Anterior Cord Syndrome is frequently caused by flexion injuries in the
cervical region, resulting in damage to the anterior spinal artery. This is
characterized by loss of motor function, pain and temperature sensation,
while preserving proprioception, vibration sense, and light touch.
c) Central Cord Syndrome is the most common spinal cord injury
syndrome, often linked to congenital or degenerative narrowing of the
spinal canal. It occurs due to hyper-extension injuries in the cervical
region. There is more severe involvement of the upper extremities than
of the lower extremities.
d) Cauda Equina Injuries are peripheral nerve or lower motor neuron
injuries and are frequently anatomically incomplete owing to the great
number of nerve roots involved and the comparatively large surface area
they encompass.
e) Conus medullaris syndrome occurs when the very distal portion of the
spinal cord is damaged. This often results in a mixture of lower motor
neuron (LMN) and upper motor neuron (UMN) damage.

 Spinal cord injuries lead to body structure or function impairments that includes:
a) Spinal Shock.
 There is a period of areflexia resulting from the very abrupt withdrawal
of connections between higher centers and the spinal cord.
 Absence of all reflex activity and impairment of autonomic regulation,
resulting in hypotension and loss of control of sweating and piloerection.
 There is loss of the bulbocavernosus reflex, cremasteric reflex, Babinski
response, and delayed plantar response.
 The initial period of total areflexia lasts approximately 24 hours.
 Followed by a gradual return of reflexes 1 to 3 days after injury and a
period of increasing hyperreflexia lasting 1 to 4 weeks.
b) Motor and Sensory Impairments.
 There will be either complete (paralysis) or partial (paresis) loss of
function below the level of the lesion.

c) Autonomic Dysreflexia.
 Also referred as autonomic hyperreflexia.
 A pathological autonomic reflex that can be life-threatening.
 AD occurs in lesions about T6.
 More common in the chronic stages of recovery (more than 3 to 6
months after injury)
 More common with complete injury, but may also occur with an
incomplete SCI.
 Produces an acute onset of autonomic activity from noxious stimuli
below the level of the lesion.
 Most common cause of this pathological reflex is bladder and bowel
distention.
 The symptoms of AD include hypertension, bradycardia, headache,
profuse sweating, increased spasticity, restlessness, vasoconstriction
below the level of the lesion, vasodilation above the level of the lesion,
constricted pupils, nasal congestion, piloerection, and blurred vision.
 A rise in systolic blood pressure of 20 to 30 mm Hg is diagnostic of an
episode of AD.
 During an episode of AD, systolic blood pressure may rise to 250 to 300
mm Hg and diastolic to 200 to 220 mm Hg.

d) Spastic Hypertonia.
 Spasticity is a velocity-dependent increase in resistance to passive
stretch.
 Approximately 65% of people with SCI have spasticity and more
common in people with cervical-level injuries.
 Spastic hypertonia typically emerges below the level of the lesion after
spinal shock evolves.
 There is a gradual increase in spastic hypertonia during the first 6
months, and plateau is usually reached 1 year after injury.
 Various stimuli, including positional changes, cutaneous stimuli,
environmental temperatures, tight clothing, bladder or kidney stones,
fecal impactions, catheter blockage, urinary tract infections, decubitus
ulcers, and emotional stress, may trigger or increase spasticity and
muscle spasms.
 Spasticity is generally managed through a variety of methods including
stretch, modalities, and medications.
 Although stretch is commonly used in the clinic, a recent systematic
review found that stretch had no clinically important impact on spasticity
in people with neurological conditions.
 Medications typically used include muscle relaxants and spasmolytic
agents such as baclofen, tizanidine, diazepam, and dantrolene sodium.
 Surgical approaches also have been used to combat spasticity in more
severe cases and are only considered after all other alternative
interventions have been tried.
  Surgical procedures used include myotomy, a sectioning or release of a
muscle; tenotomy, a sectioning of a tendon that allows subsequent
lengthening, and a dorsal rhizotomy.

e) Cardiovascular Impairment.
 A rostral SCI will result in a loss of sympathetic communication between
the brainstem and the heart, while parasympathetic input remains intact.
This causes bradycardia and dilation of the peripheral vasculature below
the level of the lesion.
 Orthostatic hypotension is often experienced during early transitions to a
more upright posture.
 Orthostatic hypotension is usually only significant in people with SCI
above T6.
 Vital signs should be monitored carefully, and the patient should always
be moved very slowly.
 A regular cardiovascular fitness exercise program is an important
component of rehabilitation.

f) Impaired Temperature Control.

 After damage to the spinal cord the hypothalamus can no longer control
cutaneous blood flow or level of sweating. This autonomic (sympathetic)
dysfunction results in loss of internal thermoregulatory responses.
 Individuals with cervical-level injuries and complete injuries
demonstrate more impairment.
 Patients with tetraplegia typically experience long-term impairment of
body temperature regulation, especially in response to extreme
environmental changes.

g) Pulmonary Impairment.
 People with high cervical injuries, pulmonary problems are the leading
cause of death both in the early and late stages of recovery.
 Individuals with injuries below T10 are likely to have near-normal
ventilatory and respiratory function.
 Paralysis or paresis of the muscles of respiration leads to poor
ventilation, which may then cause impaired respiration leading to
atelectasis and pneumonia.
 Ten percent of people with complete tetraplegia develop pneumonia or
atelectasis 1 year after injury.
 With high spinal cord lesions at C1 and C2, phrenic nerve innervation
and spontaneous respiration are lost.
 The only muscles of respiration that are intact are accessory muscles:
sternocleidomastoid, upper trapezius, and cervical extensors.
 An artificial ventilator or phrenic nerve stimulator is required to sustain
life.
 Expiration is passive; as a result, individuals with SCI at these levels
require assistance for airway clearance.
 In the acute stage of recovery individuals with an injury at these levels
will require mechanical ventilation. With recovery and training they will
likely be able to breathe on their own.
  Paralysis or paresis of the scalenes and intercostal muscles also results in
the development of an altered breathing pattern, called paradoxical
breathing pattern.

h) Bladder Dysfunction.
 Spinal cord injury alters the complex reflexive and voluntary control of
micturition. As a result, people with SCI often require a catheter to drain
the bladder.
 Patients with lesions that occur above the conus medullaris and sacral
segments develop a spastic or hyperreflexic bladder. This is also termed
a UMN bladder.
 Following a lesion of the sacral segments or conus medullaris, a flaccid
or areflexic bladder develops. This is also termed a LMN bladder.
 Two types of bladder dysfunction: failure to store urine and failure to
empty urine.
 Inability to store urine may be due to an areflexive sphincter or spastic
detrusor muscle.
 Inability to empty the bladder sufficiently may be due to an areflexive
bladder or a sphincter that is unable to relax.

i) Bowel Dysfunction.
 As with bladder dysfunction, bowel dysfunction is a major concern after
SCI.
 Neurogenic bowel conditions that develop after spinal shock subsides are
of two main types.
 In spinal cord lesions above S2 there is a spastic or reflex bowel (UMN
lesion).
 In S2–S4 or cauda equina (peripheral nerves) lesions a flaccid or
areflexive bowel (LMN lesion) develops.

j) Sexual Dysfunction.
Male Response
 Erectile capacity is greater in UMN lesions than in LMN lesions and
greater in incomplete lesions than in complete lesions.
 Two types of erections: reflexogenic and psychogenic.
 Reflexogenic erections occur in response to external physical stimulation
of the genitals or perineum. An intact reflex arc is required (mediated
through S2, S3, and S4).
 Psychogenic erections occur through cognitive activity such as erotic
fantasy. They are mediated from the cerebral cortex either through the
thoracolumbar or sacral cord centers.
 There is a higher incidence of ability to ejaculate with LMN lesions than
with UMN lesions and incomplete as compared with complete lesions.

Female Response
 In patients with UMN lesions, the reflex arc remains intact. Components
of sexual arousal (vaginal lubrication, engorgement of the labia, and
clitoral erection) will likely occur through reflexogenic stimulation, but
psychogenic response will be lost.
  With LMN lesions, psychogenic responses will most likely be preserved
and reflex responses lost.
 Fertility is not affected as severely in women as men with SCI.
 The menstrual cycle typically is interrupted for a period of 4 to 5 months
following injury.
 Women with SCI who want to bear children should be closely
supervised during pregnancy. They are more likely to encounter
complications during pregnancy and childbirth than woman without SCI.
 Women with SCI appear to be less likely to achieve orgasm than women
without SCI.
 Those with LMN are less likely to achieve orgasm than those with
UMN.

k) Pain.
 Pain is a common occurrence following SCI both in the acute and
chronic stages of recovery.
 Pain can limit the performance of activities of daily living (ADL), affect
sleep, and contribute to a lower quality of life.
 Pain can be grossly divided into two broad categories: nociceptive pain
and neuropathic pain.
 Nociceptive pain can be musculoskeletal or visceral in origin.
 Neuropathic pain can be below, at, or above the level of injury.

 Individuals with SCI are at great risk for secondary impairments throughout their
life because of prolonged immobilization. This includes contractures, heterotropic
(ectopic) ossification, and osteoporosis and skeletal fracture.
a) Contractures.
 Contractures develop secondary to prolonged shortening of structures
across and around a joint, resulting in limitation in motion.
 All joints are at risk for contractures.
 Contractures of the ankle, knee, hip, elbow, and shoulder joints may
have significant negative impact on a person’s ability to perform
important activities and participate in valued social roles.
 A consistent and concurrent program of range of motion (ROM)
exercises, positioning, and splinting is important to maintain joint motion
and prevent contracture.

b) Heterotropic (Ectopic) Ossification.

 Heterotopic ossification (HO) is osteogenesis in soft tissues, usually near
joints, below the level of the lesion.
 The etiology of this abnormal bone growth is unknown.
 Factors associated with HO include complete injury, trauma, severe
spasticity, UTI, and pressure sores.
 Care should be taken while performing passive range of motion
(PROM).
 Heterotopic ossification can lead to contractures, pressure sores, and
impaired mobility skills and ability to perform ADL.
 Management of ectopic bone formation utilizes several approaches,
including pharmacological management, physical therapy, and, with
severe activity limitations, surgery.
  Nonsteriodal anti-inflammatory medications are effective in preventing
the formation of HO.

c) Osteoporosis and Skeletal Fracture.

 Individuals with SCI may experience significant loss of bone both early
after injury and long term.
 There is a rapid bone mineral loss in the first 4 to 6 months after injury.
 Bone mineral density (BMD) continues to decrease up to 3 years after
injury. It is most common in the LEs, although osteoporosis may also
occur in the UEs in people with cervical SCIs.
 Risk factors for fracture include female, lower BMI, complete injury,
paraplegia versus tetraplegia, and longer time since injury.
 Falls or a forced maneuver during a transfer, ADL such as dressing, and
stretching are common activities that precipitate a fracture.
 The onset of fracture can also be non traumatic.

 Prognosis of SCI.
 The potential for recovery from SCI is directly related to the neurological
level of lesion and completeness of the injury.
 An incomplete lesion (ASIA B, C, or D) is a good prognostic indicator of
greater likelihood of recovery of motor function.
 Preservation of pinprick sensation at 4 months after injury in the LEs or
sacral region is associated with a good prognosis for motor recovery at 1 year
after injury.
 Recovery of motor function generally plateaus around 12 to 18 months after
injury.

 The early medical management of SCI includes emergency care, fracture

stabilization, and immobilization.
a) Emergency Care.
 Management of SCI begins at the location of the accident.
 Techniques used in stabilizing, moving, and managing the patient
immediately following the trauma can influence prognosis significantly.
 Rescue personnel must be adept at questioning and examining for signs
of SCI before moving the individual.
 Signs of SCI after a traumatic event include paresthesias, lack of or
impaired movement or sensation in the extremities, spinal pain, and
altered cognitive status or level of alertness.
 When an SCI is suspected, efforts should be made to avoid both active
and passive movements of the spine.
 Movement of the spine is minimized by strapping the patient to a spinal
backboard or a full-body adjustable backboard, using a supporting
cervical collar, immobilizing the head, and obtaining assistance from
multiple personnel in moving the patient to safety.
 On arrival at the emergency department, initial attention is focused on
stabilizing the patient medically with a primary emphasis on ventilation
and circulation.
 Cardiac, hemodynamic, and respiratory status are closely monitored.
 b) Fracture Stabilization.
 The goal of fracture/spinal injury site management is to stabilize the
spinal column to prevent further damage to the cord.
 Reduction and immobilization of spinal injuries can be achieved via
conservative or operative methods.
 Indications for surgical stabilization are unstable fracture site, gross
malalignment, cord compression, and deteriorating neurological status.

c) Immobilization.
 Following reduction of the fracture site, through either conservative or
surgical means, the spine is immobilized for a period of time through the
use of spinal orthoses and recumbent positioning.
 Halos are used commonly to immobilize cervical fractures after both
open and closed reduction.
 The Minerva is another type of cervical orthosis (CO) that also
effectively limits motion in all planes.

 Physical Therapy Management Early After Injury

Physical Therapy Examination.
 Motor and Sensory Function.
1) Motor and sensory function should be assessed using the ISNCSCI
described earlier to determine the level of neurological injury.
 Respiratory.
1) The physical therapist should assess the strength of the diaphragm
and intercostal muscles through observation while the patient is
breathing.
2) 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.
3) Maximal chest excursion can be assessed using a tape measure with
the patient supine.
 Integumentary.
1) Assessment for pressure ulcers should combine both direct skin
inspection, which combines both visual observation and palpation,
with assessment of risk factors.
2) The patient’s entire body should be observed regularly with
particular attention to areas most susceptible to pressure.
3) Palpation is useful for identifying skin temperature changes that may
be indicative of a hyperemic reaction.
4) The Braden Scale is commonly used for a variety of patient groups
who are at risk for developing pressure sores, including people with
SCI.
5) The Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) and
SCIPUS-Acute were designed specifically for people with SCI in
acute care and in active rehabilitation.
 Range of Motion.
1) Goniometry can be used to assess joint ROM.
2) Shoulder ROM is particularly important for patients with tetraplegia.
  Mobility Skills.
1) An initial screening of functional ability may be done during the
early acute stage, but the therapist must be aware of any
contraindications or precautions to movement necessitated by
healing and potentially unstable fracture sites.
2) Basic mobility skills that should be examined when appropriate are
rolling in bed, transitioning supine to and from sitting, management
of LEs, long and short sitting balance, and transfers.

Physical Therapy Interventions.

 Respiratory Management.
1) Primary goals of management include improved ventilation,
increased effectiveness of cough, and prevention of chest tightness
and ineffective substitute breathing patterns.
 Respiratory Muscle Training.
1) Inspiratory muscles can be trained using relatively inexpensive
handheld devices, which increase the resistive or threshold
inspiratory load on muscles of inspiration.
 Glossopharyngeal Breathing.
1) Glossopharyngeal breathing utilizes the lips, pharyngeal muscles,
and the tongue to inhale air.
2) 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.
 Abdominal Binder.
1) An abdominal binder may improve respiratory function and cough
ability in patients with high thoracic and cervical lesions.
2) An abdominal binder may improve respiratory mechanics by
compensating for non-functioning abdominal muscles.
 Manual Stretching.
1) This is done by placing one hand around the side of the chest wall
with the fingertips on the transverse processes and the other hand on
top of the chest with the heel on the edge of the sternum.
2) The hands are moved in a wringing motion. Pressure should be
distributed across the surface of the hands.
 Skin Care.
1) Prevention is the most effective intervention for skin care; this
entails positioning, consistent and effective pressure relief, skin
inspection, and education.
2) Areas that are susceptible to skin breakdown should be adequately
protected when the patient is in bed by using pillows, foam, and
positioning devices.
3) When in bed, patients should be repositioned at least every 2 hours.
4) Increased and consistent pressure over bony prominences, shear
forces, heat, and moisture should be minimized.
5) Patients should perform a pressure relief maneuver every 15 minutes
when in the wheelchair, either with assistance or independently.
6) 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.
  Strength and Range of Motion.
1) Range of motion exercises should be completed daily except in
those areas that are contraindicated or require selective stretching.
2) Motion of the trunk and some motions of the hip may be
contraindicated depending on the location of the SCI.
3) The pelvis should remain in a neutral position when ROM is
performed on the LEs.
4) 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.
5) Generally, shoulder flexion and abduction beyond 90 degrees is
contraindicated until orthopedic clearance is received indicating the
spine is fully healed and stable.
6) Patients with SCIs do not require full ROM in all joints.
 Mobility Interventions.
1) The use of an abdominal binder and elastic stockings may reduce
venous pooling and prevent orthostatic hypotension.
2) During early upright positioning, elastic wraps may also be used in
combination with (placed over) the elastic stockings.
 Education.
1) Living with a SCI requires significant adaptations and changes on
the part of the patient and his or her family.
2) Patients must fully understand all the consequences of the injury.
3) Patient and family/caregiver education should begin early after
injury about the impact of SCI on the different body systems,
secondary complications, and prognosis.

 Active Rehabilitation
Physical Therapy Examination.
 Aerobic Capacity/Endurance.
1) A 6-minute arm test (6MAT) can be used to assess aerobic capacity
and cardiovascular endurance.
2) The 6MAT requires the patient to perform 6 minutes of submaximal
cycling on an arm ergometer at a single, steady-state power output.
It is a valid and reliable measure for people with either tetraplegia or
paraplegia.
 Mental Functions.
1) Although they have not been validated in people with SCI, the Mini
Mental State Exam and the Montreal Cognitive Assessment are tools
that could be used to screen for cognitive impairment.
 Motor Function/Sensory Integrity.
1) The modified Ashworth Scale (MAS) is commonly used to assess
tone. The MAS is a 6-point ordinal scale that rates the amount of
resistance to passive movement of the joint.
2) The Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) is a
selfreport measure of the impact of spasticity on everyday life
activities. The individual rates how spasticity has affected 35
different areas on a 7-point ordinal scale that ranges from (3
(extremely problematic) to +3 (extremely helpful).
 Pain.
1) A visual analog scale can be used to identify the intensity of pain.
The patient rates pain on a scale from 0 to 10, where 0 is no pain and
10 is severe, disabling pain.
 ROM.
 Reflex Integrity.
 Activity/ Participation.
 Gait.
 Mobility.

Physical Therapy Interventions.

 Strengthening.
a) 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.
b) A variety of methods can be used to implement strengthening
exercises: pulley systems, free weights, elastic bands, and weight
cuffs.
 Cardiovascular Training.
a) The American College of Sports Medicine (ACSM) recommends
endurance training 3 to 5 days a week, with a total duration per day
of 20 to 60 minutes at 50% to 80% of peak heart rate.
b) Surface Functional Electrical Stimulation (FES) - induced cycling or
walking is also an effective means of improving cardiovascular
fitness.
 Bed Mobility Skills.
a) 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.
 Rolling.
a) Rolling requires the patient to learn to use the head, neck, and UEs,
as well as momentum, to move the trunk and/or LEs.
b) It is usually easiest to begin rolling activities from the supine
position, working toward the prone position.
 Transitioning Supine to/From Sitting.
a) 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.
b) The patient then must learn to manage the LEs to move into short
sitting on the edge of the bed.
 Sitting Balance.
a) Sitting balance training is initially done by assisting the patient into
a balanced short or long sitting position.
b) 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.
 c) In long sitting patients should have approximately 90 to 100 degrees
of straight leg raise ROM to avoid overstretching the low back
muscles.
 Transfers.
a) Provide support and assistance so the patient feels safe and
comfortable while learning transfers.
b) Confidence and skill in maintaining sitting balance is critical.
c) The head–hips relationship is important. Moving the head and upper
trunk in one direction causes the lower trunk and buttocks to move
in the opposite direction.
d) Lower extremities should be positioned with the feet supported and
the hips and knees at approximately 90 degrees of flexion or slightly
more at the hips.
e) Transfer training should include a variety of surfaces from the
wheelchair (bed, sofa, toilet, car, and so forth) and to varying
heights (higher and lower than the wheelchair surface)
 Activity-Based Upper Extremity Training.
a) Interventions aimed at improving functional use of the UE have
primarily been compensatory in nature.
b) Patients with cervical iSCI practiced four main types of unimanual
or bimanual UE activities: finger isolation, grasp, grasps with
rotation, pinch, and pinch with rotation.
 Health and Wellness.
a) Just as with people without SCI, regular exercise is an important
part of a healthy lifestyle.
b) Patients should be provided a comprehensive home exercise
program (HEP) that incorporates stretching, balance, aerobic, and
strengthening exercises.
 Patient-Related Education.
a) Education should begin early after injury and continue throughout
rehabilitation and cover the extensive impact of SCI discussed
above.
b) Peer mentoring with others who have experienced an SCI and are
living in the community can be an effective method of providing
education, support, and assistance with the rehabilitation process.