SPINAL CORD INJURY:

REHABILITATION
Vipinnath E. Nalupurakkal
MPT (Neuro)
Consultant Neurophysiotherapist
Objectives
In this session we will discuss:
1. The Aims and
2. Goals of SCI Rehab.
3. Levels of injury and their expected
functional outcomes
4. The various PT measures to achieve the
goals
Aims
Prevent the progression of
complications.
Promote recovery
Goals
Characteristics:
Patient-focused
Appropriate and objective
With the co-operation of interdisciplinary
team, led by the patient

Goals
ROM
Strength of all intact and affected
muscles
Muscle tone
Pain
Upright sitting and standing without
complications
Pressure sores
Goals contd
Bladder and bowel
Transfers
Ambulation
Use of assistive devices
FES
Functional Expectations
Levels of injury and outcomes
C
1
-C
3
(Tetraplegia)

Cervical paraspinal,
sternocleidomastoid, neck accessory
muscles, partial innervation of
diaphragm
C1 3 Levels Expected Functional Outcomes Equipment
Respiratory Ventilator dependent
Inability to clear secretions
2 ventilators (bedside, portable)
Suction equipment
Generator/battery backup
Bowel Total assist Padded reclining shower/commode chair
(if roll-in shower available)
Bladder Total assist
Bed Mobility Total assist Full electric hospital bed
side rails
Transfers Total assist Transfer board
Power or mechanical lift with sling
Pressure relief Total assist; may be independent
with equipment
Power recline and/or tilt W/C
W/C pressure-relief cushion
Postural support and head control devices
as indicated
Hand splints may be indicated
Specialty bed or pressure-relief mattress
may be indicated
Eating Total assist
Dressing Total assist
Grooming Total assist
Bathing Total assist Handheld shower
Shampoo tray
Padded reclining shower/commode chair
(if roll-in shower available)
W/C propulsion Manual: Total assist
Power: Independent with
equipment
Power recline and/or tilt W/C with head,
chin, or breath control
Manual recliner W/C
Vent tray
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
Communication Total assist to independent,
depending on work station setup
and equipment availability
Mouth stick, high-tech computer access,
environmental control unit
Adaptive devices everywhere as indicated
Transportation Total assist Attendant-operated van (e.g. lift, tie-downs)
or accessible public transportation
Homemaking Total assist
Assist Required 24-hour attendant care to include
homemaking
Able to instruct in all aspects of
care

C
4
Further innervation of diaphragm &
paraspinal muscles

C4 Level Expected Functional Outcomes Equipment
Respiratory May be able to breathe without a
ventilator
If not ventilator free then same equipment as
for C1-3
Bowel Total assist Padded reclining shower/commode chair
(if roll-in shower available)
Bladder Total assist
Bed Mobility Total assist Full electric hospital bed with
Trendelenburg feature
side rails
Transfers Total assist Transfer board
Power or mechanical lift with sling
Pressure relief Total assist; may be independent
with equipment
Power recline and/or tilt W/C
W/C pressure-relief cushion
Postural support and head control devices
as indicated
Hand splints may be indicated
Specialty bed or pressure-relief mattress
may be indicated
Eating Total assist
Dressing Total assist
Grooming Total assist
Bathing Total assist Handheld shower
Shampoo tray
Padded reclining shower/commode chair (if
roll-in shower available)
W/C propulsion Manual: Total assist
Power: Independent
Power recline and/or tilt W/C with head,
chin, or breath control
Manual recliner W/C
Vent tray
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
Tilt table
Hydraulic standing table
Communication Total assist to independent,
depending on work station setup
and equipment availability
Mouth stick, high-tech computer access,
environmental control unit
Transportation Total assist Attendant-operated van (e.g. lift, tie-
downs) or accessible public transportation
Homemaking Total assist
Assist Required 24-hour attendant care to include
homemaking
Able to instruct in all aspects of
care

C
5
Biceps (elbow flexors), deltoids,
rhomboids, partial innervation of
serratus anterior (shoulder flexion,
extension, & abduction)
C5 Level Expected Functional Outcomes Equipment
Respiratory May require assist to clear secretions
Bowel Total assist Padded shower/commode chair or transfer
tub bench with commode cutout
Bladder Total assist Adaptive devices may be indicated (electric
leg bag emptier)
Bed Mobility Some assist Full electric hospital bed with
Trendelenburg feature
side rails
Transfers Total assist Transfer board
Power or mechanical lift with sling
Pressure relief Independent with equipment Power recline and/or tilt W/C
W/C pressure-relief cushion
Postural support and head control devices as
indicated
Hand splints may be indicated
Specialty bed or pressure-relief mattress
may be indicated
Eating Assist for setup, then independent with
equipment
Long opponens splint
Adaptive devices as indicated
Dressing Lower extremity: Total assist
Upper extremity: Some assist
Long opponens splint
Adaptive devices as indicated
Grooming Some to total assist Long opponens splint
Adaptive devices as indicated
Bathing Total assist Handheld shower
Padded tub transfer bench or
shower/commode chair
W/C propulsion Manual: Independent to some assist
indoors on noncarpet, level surface;
some to total assist outdoors
Power: Independent
Power recline and/or tilt W/C with arm
drive control
Manual lightweight rigid or folding W/C
with handrim projections
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
Hydraulic standing frame
Communication Independent to some assist after setup
and equipment availability
Long opponens splint
Adaptive devices as indicated for page
turning, writing, button pushing
Transportation Independent with highly specialized
equipment; some assist with
accessible public transportation; total
assist for attendant-operated vehicle
Highly specialized modified van with lift
Homemaking Total assist
Assist Required Personal care: 10 hours/day
Homecare: 6 hours/day
Able to instruct in all aspects of care

C
6
Wrist extensors
C6 Level Expected Functional Outcomes Equipment
Respiratory May require assist to clear secretions
Bowel Some to total assist Padded shower/commode chair or transfer tub
bench with commode cutout
Adaptive devices as indicated
Bladder Some to total assist with equipment;
may be independent with leg bag
emptying
Adaptive devices may be indicated
Bed Mobility Some assist Full electric hospital bed
side rails
Transfers Level: some assist to independent
Uneven: some to total assist
Transfer board
mechanical lift
Pressure relief Independent with equipment and/or
adapted techniques
Power recline and/or tilt W/C
W/C pressure-relief cushion
Postural support devices
Pressure-relief mattress or overlay may be
indicated
Eating Assist for setup (cutting), then
independent
Adaptive devices as indicated (e.g. u-cuff,
tenodesis splint, adapted utensils, plate guard)
Dressing Lower extremity: some to total assist
Upper extremity: independent
Adaptive devices as indicated (e.g. button
hook, loops on zippers, Velcro on shoes)
Grooming Some assist to independent with
equipment
Adaptive devices as indicated (e.g. u-cuff,
adapted handles)
Bathing Lower body: some to total assist
Upper body: independent
Handheld shower
Padded tub transfer bench or
shower/commode chair
Adaptive devices as indicated
W/C propulsion Manual: Independent indoors;
some to total assist outdoors
Power: Independent
May require standard upright power or
recline
Manual lightweight rigid or folding W/C
with modified rims
Standing/
Ambulation
Standing: Total assist
Ambulation: Not indicated
Hydraulic standing frame
Communication Independent Adaptive devices as indicated for page
turning, writing, button pushing
Transportation Independent driving from W/C Modified van with lift and tie-downs
Sensitized hand controls
Homemaking Some assist with light meal prep;
total assist for other homemaking
Adaptive devices as indicated
Assist Required Personal care: 6 hours/day
Homecare: 4 hours/day

C
7-8
Triceps (elbow extensors), finger
flexors
C7 8 Levels Expected Functional Outcomes Equipment
Respiratory May require assist to clear secretions
Bowel Some to total assist Padded shower/commode chair or
transfer tub bench with commode cutout
Adaptive devices as indicated
Bladder Independent to some assist Adaptive devices may be indicated
Bed Mobility Independent to some assist Full electric hospital bed or full to king
standard bed
Transfers Level: independent
Uneven: independent to some assist
May need transfer board
Pressure relief Independent W/C pressure-relief cushion
Postural support devices as indicated
Pressure-relief mattress or overlay may
be indicated
Eating Independent Adaptive devices as indicated
Dressing Lower extremity: independent to
some assist
Upper extremity: independent
Adaptive devices as indicated
Grooming Independent Adaptive devices as indicated
Bathing Lower body: independent to some
assist
Upper body: independent
Handheld shower
Padded tub transfer bench or
shower/commode chair
Adaptive devices as indicated
W/C propulsion Manual: Independent indoors and
level outdoor terrain; some assist
uneven terrain
Manual lightweight rigid or folding W/C
with modified rims
Standing/
Ambulation
Standing: Independent to some assist
Ambulation: Not indicated
Hydraulic or standard standing frame
Communication Independent Adaptive devices as indicated
Transportation Independent car if independent with
transfer and W/C loading/ unloading;
independent driving modified van
from captains seat
Modified vehicle
Homemaking Independent light meal prep and light
housecleaning; some to total assist for
complex meal prep and heavy
housekeeping
Adaptive devices as indicated
Assist Required Homecare: 2 hours/day
Personal care: 6 hours/day

T
1-9
(Paraplegia)
Extrinsic & Intrinsic finger flexors,
Intercostals, para and sacrospinalis
T1 9 Levels Expected Functional Outcomes Equipment
Respiratory
Bowel Independent Elevated padded toilet seat or tub
bench with commode cutout
Adaptive devices as indicated
Bladder Independent
Bed Mobility Independent Full to king standard bed
Transfers Independent May need transfer board
Pressure
relief
Independent W/C pressure-relief cushion
Postural support devices as indicated
Pressure-relief mattress or overlay
may be indicated
Eating Independent
Dressing Independent
Grooming Independent
Bathing Independent Handheld shower
Padded tub transfer bench or
shower/commode chair
W/C
propulsion
Independent Manual lightweight rigid or folding
W/C
Standing/
Ambulation
Standing: Independent
Ambulation: Typically not
functional
Standard standing frame
Communicati
on
Independent
Transportatio
n
Independent in car, including
W/C loading/unloading
Hand controls
Homemaking Independent complex meal prep
and light housecleaning; some to
total assist for heavy
housekeeping
Adaptive devices as indicated
Assist
Required
Personal care: 6 hours/day
Homecare: 2 hours/day
T
10-12
Lower abdominals and intercostals
T10-12
Levels
Expected Functional Outcomes Equipment
Respiratory
Bowel Independent Elevated padded toilet seat or tub
bench with commode cutout
Adaptive devices as indicated
Bladder Independent
Bed Mobility Independent Full to king standard bed
Transfers Independent May need transfer board
Pressure
relief
Independent W/C pressure-relief cushion
Postural support devices as indicated
Pressure-relief mattress or overlay
may be indicated
Eating Independent
Dressing Independent
Grooming Independent
Bathing Independent Handheld shower
Padded tub transfer bench or
shower/commode chair
W/C
propulsion
Independent Manual lightweight rigid or folding
W/C
Standing/
Ambulation
Standing: Independent
Ambulation: functional
Standard standing frame, bilateral
KAFO, crutches or walker
Communicati
on
Independent
Transportatio
n
Independent in car, including
W/C loading/unloading
Hand controls
Homemaking Independent complex meal prep
and light housecleaning; some to
total assist for heavy
housekeeping
Adaptive devices as indicated
Assist
Required
Personal care: 6 hours/day
Homecare: 2 hours/day
level Expected Functional
Outcomes

Equipment

L1,2,3
Levels
Gracilis,
Iliopsoas,
QL
House hold ambulation
Wheelchair skills

B/L KAFO, Crutches
Wheelchair
L4,5
ED, LB
muscles,
QF, TA

Functional ambulation
Wheelchair skills
B/L KAFO, Crutches
Wheelchair
SCI Mechanism video
Range of Motion
Active ROM exercises
Passive Stretching
Ankle boots and night splints

CONTRAINDICATIONS
Tetraplegia: stretching shoulder muscles
Paraplegia: SLR above 60; Hip flexion
beyond 90

Exceptions
Tightness of finger flexors will help in
grasping through Tenodesis.
Lengthened hamstrings and tight low back
muscles help in sitting and standing.

Strengthening
B/L exercises for UL
Bad ragaz tech, PRE using manual/mech
resistance
Strengthening crutch muscles
Functional strengthening: under water
walking, static bicycling etc.


Muscle tone
ES of paralysed muscles
Facilitation and inhibition techniques
Emphasis on weight bearing activities
PNF (Bad Ragaz)

Pain
Traumatic: TENS (Richardson 1980)
Nerve root: TENS
SC Dysesthesias: Pharmacological
MSK: Treat the cause- tightness of
muscles and other ST, muscular imbalance.

Orientation to upright position
Tilt table
Abdominal binders & stockings can be used

Pressure sores
Turning and positioning for prevention
Physiotherapy modalities
U/S, High Intensity Electric Stimulation,
Prophylactic Heat, IRR, Cryotherapy and
Kneading
In combination with Medical care

Bowel and Bladder Retraining
Innervation of bladder and bowel: s
2,3,4

Two types
Spastic (Automatic)
Flaccid (Autonomous)
Automatic or Reflex Emptying
Lesions above the conus medullaris
Reflex arc is intact
Empty by giving different stimuli- stroking
the inner thigh, pressure over the lower abd.,
kneading or tapping the supra pubic region,
and hair pulling
Autonomous or Non Reflexive
Emptying
Lower motor neuron disorders. No reflex
action of the detrusor.
Empty by increasing abdominal pressure,
using Valsalva, or manually compressing the
lower abdomen- Crede maneuver
Bladder Training Programs
Primary goal- catheter free and control
bladder function.
Most frequently uses intermittent
catheterization.
Purpose: est. reflex bladder emptying at
regular and predictable intervals.

Intermittent Catheterization
Fluids are restricted to 2000 ml/day. At 150-
180ml/hr. Intake stopped late in the day.
Initially cath pt for every 4h. Prior to cath, pt.
Attempts to void in combination with 1 or
more manual stim. Techniques.
Cath is inserted, residual volume recorded.
Voided and residual urine vol. is recorded
As bladder becomes more effective, residual
volumes will decrease and time intervals will
increase
Autonomous bladder retraining
Pattern of incontinence is est. Residual
volume is measured, to assure it is in safe
limits.
Once incontinence patterns are est. a
comparison is made with intake patterns.
Next an intake and voiding schedule is made
Eventually, the bladder becomes trained to
empty at regular, predictable intervals.
As incontinence decreases, schedules are
readjusted to increase intervals bet. voiding
Bowel Retraining
Reflexive and Autonomous as in the Bladder.
Reflex defecation: digital stimulation of the
anal sphincter with a gloved hand or an
orthotic digital stimulator.
Autonomous: relies on straining heavy
musculature and manual evacuation of the
rectum.
Guidelines for bowel program
Perform at same time each day
Follow a diet high in fiber
Drink at least 8 glasses of water/day
Drink a warm liquid 30 mins before
initiating the program
Perform in an upright position
Consider premorbid bowel schedule
Sexual rehabilitation
Males: Erectile dysfunction: use of silicon
ring
Infertility: Vibratory stimulation
(Pryor, 1995)
Females: Can they conceive?
Yes
Potential for conception remains unimpaired
Conception is possible with close medical
supervision

PT: post-partum care
Mat Programs
Sequence followed:
Achieve stability
Controlled mobility
Skill
Functional use of skill
Specific Mat Activities
Rolling:
Improves bed mobility
Prepares for positional changes in bed
LE dressing
Start teaching from supine
With asymmetry, start towards affected side

Prone on Elbows
Indications:
Enhance bed mobility
Preparation for quadruped and sitting
Facilitates head and neck control
Facilitates glenohumeral and scapular m
cocontraction
Scapula strengthening can be done here
Prone on hands
Used with paraplegics. Requires an excessive L
Lordosis so its not tolerated well by some.
Functional link:with hip hyperextension during gait
necessary for postural alignment.
W/c stand
Rising from the floor with KAFOs

Supine on Elbows
Assists with bed mobility.
Prepares for long sit position.
Without abdominals, pt. Must wedge the hands
beneath the hips or hook thumbs on into pants
pockets or belt loops.
Pt uses the biceps or wrist extensors to pull up
partially into the position then shifts repeatedly
from side to side until elbows are under the
shoulders.


Pull Ups
Strengthening to the Bicep and shoulder
flexors. Good prep for w/c propulsion.
Pt supine, PT grasps pt. supinated forearms
just above the wrist. Pt. Pulls up to sitting
then lowers back to mat.
Sitting
Practice long and short sit for ADL
Required to have ~110 hamstring length for
dressing
In sitting, the higher the lesion, the > the
curve in long sit. The head is maintained
forward for balance.




Quadruped
Paraplegics: important for pregait. Allows
WB through the hips.
Have pt. Start prone on elbows, progressing
WB on hands, one at a time, then forcefully
flex head, neck and upper trunk while
pushing into the mat. This assists with
elevating the pelvis, pt continues to walk
back until hips are over knees.

Kneeling
Functional patterns of trunk control and pelvic
control are developed here.
Important pregait activity. Can be done with mat
crutches.
Start in quadruped: transitions by walking back
with hands, sitting on heels.
Stall bars are good to facilitate. PT guards pelvis
Wheel chair Transfers
Removable/ flip up armrests
Breaks
Sliding boards for assistance








Ambulation
Preamb:
balance inbars
recovery from the beginning of jackknife
position
Turning
TRAIN AS YOU WALK

Orthosis Types
KAFO- T9-T12. Ankles are in 5-10 DF to assist
the hip hyperextension. COG post to hip, ant to
ankles.
RGO ( reciprocal gait orthosis) T2-L1. Two
KAFOS joined at the pelvis by a pelvic band.
Help transmit forces between LE and provide
reciprocal movement. R hip ext facilitates L hip
flexion
AFO- for L3 and below
BWS (body weight support)
Theory of spinal central pattern generators (CPGs)
Generate basic motor patterns. Higher centers
activate the appropriate set of CPGs and can
modify. Spinal CPGs are also influenced by
sensory input that responds to environmental
demands.
Hence there is experimentation at present looking at
Spinal Cord Motor Output in Humans



FES
Functional Electric Stim has been applied to
various nerves in the lower extremities to
facilitate a more normal gait.
Theory is that FES applies the appropriate
sensory input necessary to normalize reflex
output of the spinal cord. Therefore the
disruption caused by the SCI is removed.
Can be used in conjunction with BWS.
References
Umphred, 4
th
Ed
Stokes, Physical Mgmt in Neurorehab.
Sullivan, Physical Rehab, 5
th
Ed
Somers, SCI func Rehab.
Edelle Carmen Field-Fote SC Control of
Movement: Implications for Locomotor
Rehabilitation Following SCI PT: May 2000,
pp.477-483.
A. Behrman, S. Harkema Locomotor Training
After Human Spinal Cord Injury: A Series Of
Case Studies. PT July 2000. Pp. 688-700.