SPINAL CORD INJURY:

REHABILITATION

Vipinnath E. Nalupurakkal
MPT (Neuro)
Consultant Neurophysiotherapist
 Objectives

 In this session we will discuss:

2. The Aims and
3. Goals of SCI Rehab.
4. Levels of injury and their expected
functional outcomes
5. 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

 C1-C3 (Tetraplegia)

Cervical paraspinal,
sternocleidomastoid, neck accessory
muscles, partial innervation of
diaphragm
C1 – 3 Levels Expected Functional Outcomes Equipment
Respiratory • Ventilator dependent • 2 ventilators (bedside, portable)
• Inability to clear secretions • 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 • Power recline and/or tilt W/C
with equipment • 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 recline and/or tilt W/C with head,
Power: Independent with chin, or breath control
equipment • Manual recliner W/C
• Vent tray

Standing/ Standing: Total assist

Ambulation Ambulation: Not indicated

Communication Total assist to independent, • Mouth stick, high-tech computer access,

depending on work station setup environmental control unit
and equipment availability • 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
 C4

Further innervation of diaphragm &

paraspinal muscles
C4 Level Expected Functional Outcomes Equipment

Respiratory May be able to breathe without a If not ventilator free then same equipment as
ventilator 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 • Power recline and/or tilt W/C
with equipment • 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 recline and/or tilt W/C with head,
Power: Independent chin, or breath control
• Manual recliner W/C
• Vent tray

Standing/ Standing: Total assist • Tilt table

Ambulation Ambulation: Not indicated • Hydraulic standing table

Communication Total assist to independent, • Mouth stick, high-tech computer access,

depending on work station setup environmental control unit
and equipment availability

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
 C5

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 • Long opponens splint
equipment • Adaptive devices as indicated
Dressing Lower extremity: Total assist • Long opponens splint
Upper extremity: Some assist • 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 • Power recline and/or tilt W/C with arm
indoors on noncarpet, level surface; drive control
some to total assist outdoors • Manual lightweight rigid or folding W/C
Power: Independent with handrim projections

Standing/ Standing: Total assist • Hydraulic standing frame

Ambulation Ambulation: Not indicated
Communication Independent to some assist after setup • Long opponens splint
and equipment availability • Adaptive devices as indicated for page
turning, writing, button pushing

Transportation Independent with highly specialized • Highly specialized modified van with lift
equipment; some assist with
accessible public transportation; total
assist for attendant-operated vehicle

Homemaking Total assist

Assist Required • Personal care: 10 hours/day
• Homecare: 6 hours/day
• Able to instruct in all aspects of care
 C6

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; • Adaptive devices may be indicated
may be independent with leg bag
emptying

Bed Mobility Some assist • Full electric hospital bed

• side rails

Transfers Level: some assist to independent • Transfer board

Uneven: some to total assist • mechanical lift

Pressure relief Independent with equipment and/or • Power recline and/or tilt W/C
adapted techniques • W/C pressure-relief cushion
• Postural support devices
• Pressure-relief mattress or overlay may be
indicated

Eating Assist for setup (cutting), then • Adaptive devices as indicated (e.g. u-cuff,
independent tenodesis splint, adapted utensils, plate guard)
Dressing Lower extremity: some to total assist • Adaptive devices as indicated (e.g. button
Upper extremity: independent hook, loops on zippers, Velcro on shoes)
Grooming Some assist to independent with • Adaptive devices as indicated (e.g. u-cuff,
equipment adapted handles)
Bathing Lower body: some to total assist • Handheld shower
Upper body: independent • Padded tub transfer bench or
shower/commode chair
• Adaptive devices as indicated

W/C propulsion Manual: Independent indoors; • May require standard upright power or
some to total assist outdoors recline
Power: Independent • Manual lightweight rigid or folding W/C
with modified rims

Standing/ Standing: Total assist • Hydraulic standing frame

Ambulation Ambulation: Not indicated

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; • Adaptive devices as indicated
total assist for other homemaking

Assist Required • Personal care: 6 hours/day

• Homecare: 4 hours/day
 C7-8

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 • May need transfer board

Uneven: independent to some assist

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 • Adaptive devices as indicated

some assist
Upper extremity: independent

Grooming Independent • Adaptive devices as indicated

Bathing Lower body: independent to some • Handheld shower
assist • Padded tub transfer bench or
Upper body: independent shower/commode chair
• Adaptive devices as indicated

W/C propulsion Manual: Independent indoors and • Manual lightweight rigid or folding W/C
level outdoor terrain; some assist with modified rims
uneven terrain

Standing/ Standing: Independent to some assist • Hydraulic or standard standing frame

Ambulation Ambulation: Not indicated

Communication Independent • Adaptive devices as indicated

Transportation Independent car if independent with • Modified vehicle

transfer and W/C loading/ unloading;
independent driving modified van
from captain’s seat

Homemaking Independent light meal prep and light • Adaptive devices as indicated
housecleaning; some to total assist for
complex meal prep and heavy
housekeeping

Assist Required • Homecare: 2 hours/day

• Personal care: 6 hours/day
 T1-9 (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 Independent • W/C pressure-relief cushion

relief • 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 Independent • Manual lightweight rigid or folding

propulsion W/C

Standing/ Standing: Independent • Standard standing frame

Ambulation Ambulation: Typically not
functional

Communicati Independent
on

Transportatio Independent in car, including • Hand controls

n W/C loading/unloading

Homemaking Independent complex meal prep • Adaptive devices as indicated

and light housecleaning; some to
total assist for heavy
housekeeping

Assist • Personal care: 6 hours/day

Required • Homecare: 2 hours/day
 T10-12

Lower abdominals and intercostals

T10-12 Expected Functional Outcomes Equipment
Levels

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 Independent • W/C pressure-relief cushion
relief • 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 Independent • Manual lightweight rigid or folding

propulsion W/C

Standing/ Standing: Independent • Standard standing frame, bilateral

Ambulation Ambulation: functional KAFO, crutches or walker

Communicati Independent
on

Transportatio Independent in car, including • Hand controls

n W/C loading/unloading

Homemaking Independent complex meal prep • Adaptive devices as indicated

and light housecleaning; some to
total assist for heavy
housekeeping

Assist • Personal care: 6 hours/day

Required • Homecare: 2 hours/day
level Expected Functional Equipment
Outcomes

L1,2,3 House hold ambulation B/L KAFO, Crutches

Levels Wheelchair skills Wheelchair
Gracilis,
Iliopsoas,
QL
L4,5 B/L KAFO, Crutches
ED, LB Functional ambulation Wheelchair
muscles, Wheelchair skills
QF, TA

SCI Mechanism video

 Range of Motion
 Active ROM exercises
 Passive Stretching
 Ankle boots and night splints

CONTRAINDICATIONS
 Tetraplegia: stretching shoulder muscles
 Paraplegia: SLR above 60º; Hip flexion
beyond 90º
 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: s2,3,4

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 it’s not tolerated well by some.
 Functional link:with hip hyperextension during gait
necessary for postural alignment.
 W/c stand
 Rising from the floor with KAFO’s
 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 ~110º 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 in║bars
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
KAFO’S 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, 4th Ed
 Stokes, Physical Mgmt in Neurorehab.
 Sullivan, Physical Rehab, 5th 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.