Spinal Cord Injury (SCI):

🧠 General Impact

 Low incidence, high cost

 Affects mobility, self-care, and social participation
 Multiple systems involved: musculoskeletal, cardiopulmonary, integumentary, GI,
GU, sensory, psychosocial
 Emotional effects: body image, dependence, sexual dysfunction

📊 Demographics & Etiology

 ~11,000 new cases/year in the U.S.

 Most common in males (78%)
 Increasing cases in older adults (due to falls)
 Causes:
o Traumatic (61%): MVAs (40%), falls (28%), violence (15%), sports (8%)
o Non-traumatic (39%): diseases like MS, ALS, infections, vascular issues

📍Common Injury Patterns

 Tetraplegia (56%) – Cervical lesions → all 4 limbs + trunk affected

 Paraplegia (43%) – Thoracic/lumbar lesions → trunk + legs affected
 Incomplete injuries increasing due to better emergency care

📅 Length of Stay & Prognosis

 Hospital stay ↓ since 1970s:

o Acute care: 24 → 12 days
o Rehab: 98 → 37 days
 Life expectancy ↓ compared to general population:
o Incomplete injury: 52.6 yrs
o Complete paraplegia: 45.2 yrs
o Low tetraplegia: 40 yrs
o High tetraplegia: 35.7 yrs

💸 Cost

 First-year costs (2009):

 o High tetraplegia: ~$986k
o Low tetraplegia: ~$712k
o Paraplegia: ~$480k
 Lifetime cost (injured at 25 yrs):
o High tetra: $3.5M
o Low tetra: $2.5M
o Paraplegia: $1.6M

🧬 Classification of SCI
Types

 Tetraplegia: Cervical cord → paralysis of all limbs + trunk

 Paraplegia: Thoracic/lumbar/cauda equina → trunk & lower limbs

Spinal Cord Anatomy Basics

 Cord ends at L1 (Conus medullaris)

 Cauda equina = bundle of lumbar/sacral roots
 White matter: sensory/motor tracts
 Gray matter: sensory (dorsal), interneurons (middle), motor (ventral)

🔍 Determining Injury Level: ISNCSCI & ASIA Scale

Neurological Level

 Lowest level with normal motor & sensory on both sides

Motor Level

 Tested with key muscles (scored 0–5)

 Intact if ≥3/5 and level above is 5/5

Sensory Level

 Tested via light touch & pinprick at each dermatome

 Scored: 0 = absent, 1 = impaired, 2 = normal

Complete vs. Incomplete Injury

 Complete: No sensory/motor at S4-S5 (tested via anal sensation/sphincter)

 Incomplete: Some sensory/motor preserved below level, including S4-S5
  Zone of Partial Preservation (ZPP): Some function below lesion, but not at S4-S5

🧪 ASIA Impairment Scale (AIS)

Grade Description
A Complete: No motor/sensory in S4–S5
B Sensory incomplete: Sensory preserved below level, including S4–S5, no motor
Motor incomplete: Motor preserved, > half of key muscles below level have <3/5
C
strength
Motor incomplete: Motor preserved, ≥ half of key muscles below level have ≥3/5
D
strength
E Normal: Motor and sensory are normal

🧠 Spinal Cord Injury (SCI) Clinical Syndromes – Easy

Notes
About 1 in 5 SCIs show specific clinical patterns. Understanding these helps set realistic
rehab goals and plan treatment.

🟤 1. Brown-Sequard Syndrome (Hemisection)

  Cause: Usually from penetrating injuries (stab, gunshot)
 What’s affected: One side of the spinal cord
 Symptoms:
o ✅ Same side (Ipsilateral):
 Muscle weakness or paralysis (due to corticospinal tract damage)
 Loss of proprioception, light touch, vibration (dorsal column
damage)
o ❌ Opposite side (Contralateral):
 Loss of pain and temperature (spinothalamic tract)
 This starts a few segments below the lesion
 Prognosis: Usually good functional recovery

🔴 2. Anterior Cord Syndrome

 Cause: Often from flexion injuries (neck bent forward hard) or anterior spinal
artery damage
 What’s affected: Front 2/3 of the spinal cord
 Symptoms:
o ❌ Loss of motor function (corticospinal tract)
o ❌ Loss of pain and temperature (spinothalamic tract)
o ✅ Preserved: Proprioception, light touch, vibration (dorsal column is intact)
 Prognosis: Poorer recovery, longer rehab stay

🔵 3. Central Cord Syndrome

 Most common SCI syndrome

 Cause: Hyperextension injuries of neck, often in older adults or with narrowed
spinal canal
 What’s affected: Center of spinal cord
 Symptoms:
o Arms > legs affected (because arm tracts are more central)
o Some sensory loss (less severe)
o ✅ Often preserved bowel, bladder, sexual function
 Prognosis:
o Good: Many recover walking
o May have lasting arm/hand weakness, fine motor issues

🟡 4. Cauda Equina Syndrome

 Cause: Damage to nerve roots below spinal cord (L1 level and below)
 What’s affected: Peripheral nerves (LMN type)
 Symptoms:
o Areflexic (flaccid) bladder and bowel
 o Saddle anesthesia (numbness in inner thighs, buttocks)
o Leg weakness or paralysis (variable)
 Regeneration Potential:
o Possible (like other peripheral nerves)
o But full recovery is rare due to:
1. Long distance for regrowth
2. Misrouted regeneration
3. Scar tissue blocking regrowth
4. Target muscles/organs may lose function before nerve regrows
5. Nerve regrowth slows after ~1 year

📌 Summary Table for Quick Revision:

Syndrome Cause Key Symptoms Prognosis

Brown- Ipsilateral motor + proprioception loss;
Penetrating trauma Good
Sequard contralateral pain/temp loss
Anterior Flexion, vascular Loss of motor + pain/temp; proprioception
Poorer
Cord issue spared
Hyperextension, Arms > legs affected; sacral function Moderate-
Central Cord
elderly spared Good
Cauda Nerve root LMN signs; bowel/bladder issues; saddle
Variable
Equina compression numbness

NEUROLOGICAL COMPLICATIONS AND ASSOCIATED

CONDITIONS FOLLOWING SPINAL CORD INJURY (SCI):

🔹 1. Spinal Shock

 Definition: A temporary period of areflexia post-SCI due to abrupt loss of

communication from higher CNS centers.
 Phases:
o 0–24 hrs: Total areflexia.
o 1–3 days: Initial reflex return.
o 1–4 weeks: Increasing hyperreflexia.
o 1–6 months: Final phase of hyperreflexia.
 Features: Loss of all reflexes including bulbocavernosus, cremasteric, Babinski
response; autonomic dysfunction like hypotension, loss of sweating.

🔹 2. Motor and Sensory Impairments

  Motor Loss: Paralysis or paresis below level of injury.
 Sensory Loss: Impaired/absent sensation below lesion.
 Depends on: Neurological level and completeness of injury.

🔹 3. Autonomic Dysreflexia (AD)

 Definition: Life-threatening reflex causing acute autonomic response to noxious

stimuli below lesion (commonly occurs in lesions above T6).
 Causes:
o Bladder/Bowel issues (most common).
o Skin irritation, tight clothing, pressure sores, fractures, labor, sexual activity.
 Symptoms:

Sudden ↑ BP (systolic rise >20–30 mmHg), bradycardia, severe pounding headache,

sweating, flushing above lesion, piloerection, blurred vision, nasal congestion.Aka autonomic
hyperreflexia

o Lesions above T6

o Characterized by:

Increased BP

Bradycardia

Severe pounding headache

Profuse sweating

Increase spasticity

Restlessness

Vasoconstriction below the lesion

Vasodilation above the lesion

Pupil constriction

Nasal congestion

Piloerection

o Blurred vision
 Intervention:
o Sit upright, loosen clothing, identify & eliminate triggers (check catheter,
bowel impaction).
o Monitor vitals, administer antihypertensives (e.g., nifedipine, nitrates,
captopril).
o Education is essential for prevention.

🔹 4. Spastic Hypertonia

 Seen in: ~65% of SCI patients, especially with cervical injuries.

  Features:
o Increased muscle tone, spasms, hyperactive reflexes, clonus.
o Emerges post-spinal shock and peaks by 1 year.
 Triggers: Positional change, tight clothes, UTI, stress, decubitus ulcers.
 Management:
o Stretching (limited effectiveness), medications (baclofen, tizanidine,
diazepam, dantrolene).
o Intrathecal baclofen pump, botulinum toxin for focal spasticity.
o Surgery (myotomy, tenotomy, dorsal rhizotomy) in severe cases.

🔹 5. Cardiovascular Impairments

 Due to: Loss of sympathetic control (T1–L2).

 Common issues:
o Bradycardia, vasodilation, orthostatic hypotension (especially in lesions
above T6).
 Symptoms: Light-headedness, fainting, blurred vision, ringing ears.
 Management:
o Gradual upright positioning, compression stockings, abdominal binders,
monitor vitals.
o Medications (e.g., ephedrine) as needed.
o Cardiovascular training for improved tolerance post-acute stage.

🔹 6. Impaired Temperature Control

 Mechanism: Loss of hypothalamic control over sweating and blood flow.

 Common in: Complete cervical SCI.
 Symptoms:
o Hypothermia initially (vasodilation), later hyperthermia (impaired
sweating).
 Note: Long-term problem in tetraplegia; worse in extreme environmental conditions.

🫁 Pulmonary Impairment After SCI

🔹 Respiratory Function Depends on Level of Lesion

 High cervical injuries (C1–C4): Most severe pulmonary issues.

 Below T10: Near-normal respiratory function.

🔹 Key Respiratory Muscle Innervation by Level

Level of Injury Muscles Affected
C1–C2 SCM, upper trapezius, cervical extensors
C3–C4 Partial diaphragm, scalenes, levator scapulae
C5–C8 Full diaphragm, pecs, serratus anterior, rhomboids, lats
T1–T5 Some intercostals, erector spinae
T6–T10 Intercostals and abdominals
T11 & below All of the above muscles

🔹 Clinical Implications

 C1–C2: Need ventilator or phrenic nerve stimulator.

 C3–C4: Partial diaphragm function → mechanical ventilation often needed acutely,
may wean off.
 C5–C8: Better function, weak cough, no abdominal muscle support.
 Tetraplegia: Higher pneumonia/atelectasis risk (10% in first year).
 Abdominal muscle paralysis (T5–T12):
o ↓ Expiratory reserve volume
o ↓ Cough effectiveness
o Diaphragm assumes lower position → inefficient breathing

🔹 Paradoxical Breathing

 Seen with intercostal/scalene paralysis.

 Features: ↓ chest expansion, ↑ epigastric rise.
 Leads to quick fatigue and inefficient respiration.

🚽 Bladder Dysfunction After SCI

🔹 Normal Micturition Control

 Originates at S2–S4 spinal segments.

🔹 Types of Bladder Dysfunction

Type Lesion Level Characteristics

Spastic/UMN Above conus Reflexive emptying, hyperreflexive detrusor,
Bladder medullaris dyssynergia possible
Flaccid/LMN No reflex action, urine retention, overflow
At/below S2–S4
Bladder incontinence

🔹 Bladder Management

 Early stage (spinal shock): Indwelling catheter.

 Long-term: Intermittent catheterization preferred.
o 2000 mL/day fluid intake
 o Catheterize every 4 hours initially
 Other methods:
o Condom catheter (males)
o Valsalva maneuver (LMN bladder)
o Suprapubic tapping (UMN bladder, no dyssynergia)
o Surgical suprapubic catheter if needed

💩 Bowel Dysfunction After SCI

🔹 Types of Bowel Dysfunction

Type Lesion Level Characteristics

Spastic/Reflex Bowel (UMN) Above S2 Reflex defecation possible
Flaccid/Areflexive Bowel S2–S4/cauda No reflex emptying, risk of
(LMN) equina impaction/incontinence

🔹 Bowel Management Program

 Goals: Regularity, continence, prevent skin damage & AD.

 Reflex bowel: Digital stimulation, suppositories.
 Areflexive bowel: Manual evacuation, gentle Valsalva.
 Additional methods:
o Abdominal massage
o High fiber diet, fluids
o Stool softeners, laxatives

❤️‍🔥 Sexual Dysfunction After SCI

🔹 General Considerations

 Highly individualized; includes both physiological and psychosocial components.

 Major QoL issue for both men and women with SCI.

🔹 Male Sexual Function

Feature UMN Lesion LMN Lesion

Erection Reflexogenic preserved Psychogenic may be preserved
Ejaculation Less likely More likely
Orgasm 45% report experiencing orgasm (all types)

 Assisted options: Medications (Viagra, Cialis), vibratory/electroejaculation for

fertility.
🔹 Female Sexual Function

Feature UMN Lesion LMN Lesion

Arousal Reflexogenic preserved Psychogenic preserved
Fertility Mostly unaffected Menstrual cycle resumes after 4–5 months

 Pregnancy Risks: UTIs, anemia, thrombosis, labor without sensation, risk of AD.

🩺 Overview of Secondary Complications

 SCI affects multiple body systems due to immobility and neurological impairments.
 During rehab: 82% develop secondary issues.
 1-year post-injury:
o Pressure ulcers: 15%
o Pneumonia: 4%
o Deep vein thrombosis (DVT): 2.5%
 25 years post-injury:
o Pressure ulcers: 25% prevalence

1️⃣ Pressure Ulcers (Decubitus Ulcers)

 Cause: Unrelieved pressure/shear → skin/subcutaneous tissue breakdown.
 Sites: Sacrum, heels, ischium, trochanter, scapula, elbows, knees, iliac spines.
 Risk Factors:
o Tetraplegia
o Spasticity
o Incontinence (bladder/bowel)
o Immobility
o Poor nutrition
o Smoking
o Sensory loss
o Non-compliance with skin care
 Complications: Infection → bone involvement, delayed rehab, increased hospital
cost, death.
 Prevention: Regular repositioning, skin checks, nutrition, pressure-relief
cushions/mattresses.

2️⃣ Deep Vein Thrombosis (DVT)

 Cause: Blood stasis due to lack of LE movement → clot formation.
  Signs: Local swelling, heat, redness (similar to fracture or HO).
 Danger: Clot may become embolus → Pulmonary Embolism (PE).
 Highest Risk: Acute stage.
 Prevention:
o Early mobilization
o Compression devices (stockings/boots)
o Pneumatic sleeves
o Anticoagulants (e.g., heparin for 2–3 months)
o IVC filter in high-risk cases

3️⃣ Pain After SCI

 Prevalence: 26–96% report chronic pain
 Impact: Affects ADLs, sleep, QoL

Types:

➤ Nociceptive Pain

 Origin: Musculoskeletal (shoulders, wrists, elbows) or visceral

 Causes:
o Overuse, poor posture
o Transfers, wheelchair propulsion
o Muscle imbalance, spasm, inflammation
 Common injuries:
o Biceps tendinitis
o Rotator cuff tear
o Carpal tunnel
o Shoulder impingement
o Lateral epicondylitis

➤ Neuropathic Pain

 Origin: Nerve root or spinal cord damage

 Locations:
o Below level of injury (diffuse, burning/shooting pain)
o At level of injury (allodynia, hyperalgesia)
o Above lesion (due to nerve compression)
 Management:
o Non-drug: TENS, massage, acupuncture, imagery
o Drugs: Gabapentin, pregabalin, valproic acid, amitriptyline, tramadol

4️⃣ Contractures
  Cause: Prolonged muscle shortening, spasticity, immobility
 Common Sites: Ankle, knee, hip, elbow, shoulder
 Impact: Affects mobility, ADLs, hygiene, causes pain, leads to pressure sores
 Prevention:
o Daily ROM exercises
o Proper positioning
o Splinting and bracing

5️⃣ Heterotopic Ossification (HO)

 Definition: Bone formation in soft tissues near joints
 Incidence: 10–53%
 Common Sites: Hips, knees
 Risk Factors:
o Complete injury
o Spasticity
o UTIs
o Pressure sores
o Trauma from PROM
 Symptoms: Swelling, warmth, ↓ ROM, joint/muscle pain
 Complications: Contractures, pressure ulcers, ↓ mobility
 Management:
o Drugs: NSAIDs, bisphosphonates
o Therapy: Gentle PROM, avoid trauma
o Devices: Low-intensity electromagnetic field
o Surgery: For severe HO affecting ADLs

6️⃣ Osteoporosis & Fractures

 Bone Loss Timeline:
o Starts within 4–6 months, continues up to 3+ years
 Cause: Lack of muscle activity + no weight-bearing
 Common Areas: LEs (also UEs in cervical SCI)
 Fracture Risk Factors:
o Female, low BMI
o Complete SCI
o Paraplegia
o Long time since injury
 Common Triggers: Transfers, dressing, stretching, falls
 Prevention:
o Bisphosphonates
o Weight-bearing activities (standing frames, FES)
 Note: Effectiveness of rehab interventions still under study
📦 Box 20.1 – Common Secondary Complications in SCI
 Pressure ulcers
 Deep vein thrombosis
 Pain (nociceptive & neuropathic)
 Contractures
 Heterotopic ossification
 Fractures / Osteoporosis
 Syringomyelia

Prognosis for Spinal Cord Injury (SCI)

The prognosis for recovery following a spinal cord injury (SCI) depends on several factors,
primarily the neurological level and completeness of the injury. Recovery potential tends to
be better for individuals with incomplete lesions (ASIA B, C, or D), while those with
complete lesions (ASIA A) typically have a lower chance of recovery. However, 70% of
cervical SCI patients with complete lesions show at least one level of motor recovery below
the neurological level. Pinprick sensation in the lower extremities or sacral region at 4
months post-injury is a strong indicator of a positive prognosis for motor recovery.

Motor function recovery typically plateaus around 12-18 months after injury. Factors
influencing walking ability recovery are discussed separately but often involve early
rehabilitation and medical interventions.

Early Medical and Rehabilitation Management in the Acute Stage

Emergency Care

Immediate management begins at the scene of the accident, focusing on stabilizing the spine
to prevent further injury. Key actions include:

 Minimizing spine movement with a spinal backboard or full-body adjustable

backboard.
 Using cervical collars to prevent further movement and damage.
 Ensuring ventilation and circulation are maintained at the emergency department.

Fracture Stabilization

 The spinal column is stabilized to prevent further injury to the spinal cord.
 Fracture reduction can be achieved via surgical or conservative methods, depending
on the injury type. Surgical decompression is recommended within 24 hours after
injury to prevent further spinal cord damage.
Immobilization

Once the injury site is stabilized, the patient is immobilized using various orthoses:

 Cervical orthoses such as the Halo and Minerva are used to stabilize the cervical
spine.
 Thoracolumbosacral orthoses (TLSOs) are used to stabilize thoracic or lumbar
injuries.

Types of Orthoses

1. Halo Orthosis: Consists of a ring fixed to the skull with screws, connected to a body
jacket. It is highly effective for limiting cervical motion but can restrict mobility and
cause shoulder issues.
2. Minerva: A cervical orthosis similar to the halo but without skull screws, allowing
for easier rehabilitation.
3. Philadelphia, Miami J, Aspen Collars: Used for cervical stabilization, primarily
after the removal of more rigid devices.
4. Thoracolumbosacral Orthosis (TLSO): Used for stabilizing the thoracic or lumbar
spine; typically involves a custom-fitted body jacket for optimal immobilization.

These management strategies help prevent further injury and facilitate early recovery,
especially in the acute phase after the injury.

Physical Therapy Management in the Acute Stage of

Recovery (SCI)
Main Goals

 Prevent secondary complications

 Educate the patient
 Start early mobilization when medically allowed

Physical Therapy Examination Focus

✅ Patient must be medically stable before examination.
✅ Be aware of precautions: spinal instability, orthotics, ventilators, other injuries.

Key Examination Areas

1. Motor and Sensory Function
  Use ISNCSCI to assess.
 Be gentle with manual muscle testing (MMT) if spine is unstable.
 Test key muscles and related myotomes (e.g., if C5 is intact, check deltoid,
supraspinatus too).
 Record any changes in standard testing.

2. Respiratory Function

 Observe breathing: Look at chest and stomach movement.

 Check respiratory rate: Normal = 12–20 breaths/min.
 Measure chest expansion with a tape:
o Normal = 2.5–3 inches (6.35–7.62 cm)
o Negative value = paradoxical breathing.
 Vital Capacity (VC) using spirometer:
o High cervical injury (above C3): VC < 25% normal
o Mid cervical injury: 25–50% normal
o Lower cervical/upper thoracic: 50–75% normal
o Mid/lower thoracic: 70–80% normal

Cough assessment:

 Functional cough = strong, 2+ coughs per breath (clears secretions)

 Weak functional cough = soft, 1 cough per breath (small clearance)
 Nonfunctional cough = throat clearing (needs help)

3. Skin (Integumentary System)

 Frequent skin inspections are crucial!

 Teach the patient about skin care early.
 Focus on pressure points:
o Supine: Occiput, scapulae, sacrum, heels
o Prone: Ears, shoulders, iliac crest, knees
o Side-lying: Ears, greater trochanters, malleoli
 Warning signs: Redness, warmth, swelling, cracks
 Risk Factors: Spasticity, incontinence, poor nutrition
 Use Braden Scale or SCIPUS to assess risk.

4. Passive Range of Motion (PROM)

 Use goniometry to measure.

 Important joints:
o Shoulders (especially for tetraplegia)
o Hamstrings, hips, ankles (prevent contractures)
5. Early Mobility Skills

 Only if medically safe!

 Focus on basic movements:
o Rolling in bed
o Supine to/from sitting
o Lower Extremity (LE) management
o Short and long sitting balance
o Transfers
 Full detailed assessment happens later in active rehab.

Physical Therapy Interventions in Spinal Cord Injury (SCI):

General Precautions

 Interventions depend on medical and spinal stability.

 Activity should be restricted until fracture healing is confirmed by the surgeon.
 Always consult the physician before doing activities that might stress the spine.

Respiratory Management

 Goals: Improve ventilation, cough effectiveness, and prevent chest tightness and poor
breathing patterns.
 Mechanical Ventilation: Common in cervical injuries at or above C5; can be
invasive (tracheostomy) or noninvasive.
 Deep-Breathing Exercises:
o Diaphragmatic breathing encouraged.
o Use light manual pressure for inspiration/expiration assistance.
 Glossopharyngeal Breathing:
o “Gulping” air using tongue and throat muscles.
o Useful for high cervical injuries, with or without ventilator dependence.
 Air Shift Maneuver:
o Helps expand the chest by shifting air from lower to upper thorax.
 Respiratory Muscle Strengthening:
o Handheld inspiratory trainers used to strengthen breathing muscles.
 Coughing Techniques:
o Self-assisted or manually assisted coughs to help clear secretions.
 Abdominal Binder:
o Supports breathing by positioning the diaphragm better, also helps prevent
postural hypotension.
 Manual Chest Wall Stretching:
 o Improve thoracic mobility by applying a “wringing” motion with the hands.

Skin Care

 Prevention Focus: Through positioning, pressure relief, inspections, and education.

 Positioning:
o Reposition every 2 hours in bed.
o Use pillows, foam, and special mattresses to relieve pressure.
 In Wheelchair:
o Perform pressure relief every 15 minutes (push-up, side lean, or forward lean
>45°).
o Use proper cushions (foam, gel, air, matrix) to redistribute pressure.
 Education:
o Teach skin inspection with mirrors and pressure relief techniques.
 If Ulcer Develops: Continue prevention plus initiate wound healing interventions
(e.g., electrical stimulation, hydrogel dressings).

Early Strengthening and Range of Motion (ROM)

 General ROM:
o Daily unless contraindicated; avoid excessive stress on healing spine.
 Precautions:
o No trunk or neck motion until cleared by orthopedics.
o Hip motions limited in lumbar SCI.
o Shoulder ROM (flexion/abduction >90°) limited initially in tetraplegia.
 Selective Stretching:
o Tightness encouraged in some areas (e.g., long finger flexors for tenodesis
grasp, lower trunk muscles for sitting stability).
 Hamstring Stretching:
o Goal: 100° straight leg raise for functional sitting and dressing.
 Tenodesis Grasp:
o Taught by positioning the wrist in extension to create passive finger flexion
for gripping objects.
 Splinting:
o Intrinsic-plus splint used early to prevent contractures and support function.
 Strengthening:
o All innervated muscles are strengthened, but initially avoid resistance
exercises at the fracture site.
o Strengthening delayed for shoulder/scapula (tetraplegia) and pelvis/trunk
(paraplegia) early on.

Cardiovascular/Endurance Training in SCI

  Importance: Just like in able-bodied people, cardiovascular training improves health
and aerobic fitness in individuals with spinal cord injury (SCI).
 Common Methods:
o Arm ergometry
o Wheelchair propulsion
o Swimming
o Treadmill (TM) locomotor training (with/without body weight support,
especially in incomplete SCI - iSCI).
 Recommendations (American College of Sports Medicine - ACSM):
o Frequency: 3–5 days/week
o Duration: 20–60 minutes/day
o Intensity: 50–80% of peak heart rate
o Start low and gradually increase for those who cannot initially tolerate.
 Functional Electrical Stimulation (FES):
o Surface electrodes stimulate hamstrings, quadriceps, and gluteals.
o Used for cycling or walking exercises to improve cardiovascular fitness.

Bed Mobility Skills in SCI

 Purpose: Promote independence for daily activities like dressing, repositioning, and
skin checks.
 Skills Include:
o Rolling
o Moving from supine to sitting
o Managing lower extremities (LE)
 Training Progression:
o Start on a firm exercise mat.
o Progress to practicing on a regular bed (softer, smaller surface).
 Techniques:
o Complete SCI:
 Use compensatory strategies:
 Momentum (e.g., swinging arms for rolling)
 Muscle substitution (e.g., using arms to lift legs)
 Head-hips principle
o Incomplete SCI (iSCI):
 May use more normal movement patterns depending on motor
recovery.
 Precautions:
o Protect elbows from friction (use elbow pads if needed).
 Assessment: Attempt normal movement first; assess with tools like the
Neuromuscular Recovery Scale.
Cardiovascular/Endurance Training for SCI
 Importance: Endurance training improves aerobic fitness and overall health, similar
to able-bodied individuals.
 Common Methods:
o Arm ergometry
o Wheelchair propulsion
o Swimming
o Treadmill locomotor training (with/without body weight support) for iSCI
with walking capacity
o Surface FES-induced cycling or walking (stimulates hamstrings, quadriceps,
gluteals)
 Training Recommendations (ACSM):
o Frequency: 3–5 days/week
o Duration: 20–60 minutes/day
o Intensity: 50%–80% of peak heart rate
o Gradual progression if starting below targets

Bed Mobility Skills

 Purpose: Essential for independent functional mobility (e.g., dressing, skin
inspection).
 Key Movements:
o Rolling
o Supine ↔ Sitting transitions
o Lower Extremity (LE) management
 Practice Surface:
o Start on a firm mat → Progress to a soft bed
 Movement Strategies:
o Momentum
o Muscle substitution
o Head-hips principle

Rolling Techniques
 Approach:
o Start from supine → Roll toward weaker side first
 Training Tips:
o Avoid adaptive devices unless necessary
o Practice rolling under sheets and blankets
 Facilitation Methods:
o Head/neck flexion and rotation
o Bilateral UE rocking
o Crossing ankles toward rolling side
 o Use pillows initially for rotation
o PNF patterns (e.g., D1 flexion, D2 extension)

Transitioning Supine ↔ Sitting

 Prerequisite Skills:
o Prone-on-elbows
o Supine-on-elbows

Prone-on-Elbows

 Method:
o From prone: Weight shift elbows under shoulders
o From side-lying: Push through elbow, roll to prone
 Training:
o Weight shifts
o Rhythmic stabilization
o Serratus anterior strengthening (prone-on-elbows pushups)

Supine-on-Elbows

 Method:
o Wedge hands under hips or hook into pockets
o Bicep/wrist extensor contraction → Push onto elbows
o Alternatively, transition from side-lying
 Training:
o Weight shifts
o Stability exercises (rhythmic stabilization)
 Precaution:
o Watch for anterior shoulder joint pain

Methods for Moving to Long Sitting

1. Walking on Elbows:
o Walk elbows toward one side into a "C" position
o Hook arm around knees → Pull trunk up
2. Coming Straight from Supine:
o Requires strong shoulder extension & elbow flexion
o Flex elbows under hips → Push trunk up
o Shift weight, "throw" arms back one at a time into sitting
Managing Lower Extremities (LEs)
 Strategies:
o Slide wrist under leg (palm down) and extend wrist
o Use leg loops if needed for lifting legs

Here’s a cleaner and more organized summary of what you shared about Sitting Balance
and Transfers (especially for spinal cord injury rehab):

Sitting Balance
Purpose:
Essential for functional tasks: transfers, dressing, wheelchair mobility.

Key Points:

 Posture varies based on lesion level:

o Low thoracic lesions: relatively erect trunk.
o Low cervical/high thoracic lesions: forward head and trunk flexion to maintain
balance.
 Retraining Needed:
Patients must relearn:
o Center of balance
o Limits of stability
o Postural control

Training Guidelines:

 Initial Setup:
o Short sitting: feet supported on the floor; hips and knees at 90°.
o Long sitting: requires 90–100° straight leg raise ROM; legs placed with slight
hip abduction and external rotation.
 Support:
o UE weight-bearing may be needed initially.
o Tenodesis grasp protection for cervical lesion patients: fingers flexed during
wrist extension.
o No triceps? Use muscle substitution: shoulder extension + external rotation +
supination → anterior deltoid contracts → elbow extends.
 Exercises:
o Use PNF techniques: alternating isometrics and rhythmic stabilization for
trunk.
o Progress UE support: bilateral → unilateral → no support.
o Reaching tasks to improve anticipatory balance.
o Weight shifting to safely explore limits of stability.
o Unexpected perturbations for reactive control.
  Practice on various surfaces: mat, bed, foam, cushion, and wheelchair.

Transfers
Sit-Pivot Transfer Phases:

1. Preparatory phase: Trunk flexes, leans, and rotates toward the trailing arm.
2. Lift phase: Buttocks lift off and trunk moves halfway across.
3. Descent phase: Trunk and buttocks lower onto the new surface.

Training Strategies:

 Build confidence in sitting balance first.

 Teach head–hips relationship:
Moving head/trunk one way → hips move opposite.
 Arm positioning:
o Hands placed forward of hips.
o Trailing UE generates more force.
o If one UE is weaker, use it as the lead arm (closer to destination).
 Head-hips + scapular protraction:
Practice lifting and shifting laterally (left/right).
 Lower limb position:
Feet supported, hips/knees at ~90°.
 Focus on lifting vs. sliding to avoid skin shearing.
 Assistive devices:
Push-up blocks, wrist cuffs, or a transfer board if needed.
 Practice different surfaces and heights (bed, sofa, toilet, car).

Floor-to-Wheelchair Transfers
Three techniques:

 Backward approach
 Forward approach
 Sideways approach

(More detailed descriptions found in specialized rehab resources.)

Locomotor training (LT) is a key focus for individuals with spinal cord injury (SCI) aiming
to regain the ability to walk. The approach depends significantly on the severity of the injury,
with differences between motor complete SCI and motor incomplete SCI (iSCI). Here's a
breakdown of the strategies and considerations for both groups:
Locomotor Training for Individuals with Motor Complete SCI

For individuals with complete SCI, the likelihood of regaining independent ambulation is
lower, but standing and walking with assistive devices may still be beneficial for overall
health and well-being. The training includes:

1. Realistic Expectations: Therapists should ensure patients understand the limitations

of their ability to walk independently, especially for complete SCI cases. However,
standing exercises can improve circulation, skin integrity, bowel and bladder function,
and general health.
2. Postural Alignment and ROM: Proper postural alignment and full range of motion
(ROM) are essential. Key factors include:
o Full hip extension to attain standing balance.
o Avoidance of knee flexion and plantarflexion contractures to allow for upright
balance.
3. Cardiovascular Endurance: Ambulation for a person with paraplegia is more
energy-intensive, so improving cardiovascular endurance is a critical factor in long-
term success. However, severe spasticity, loss of proprioception, and complications
like decubitus ulcers may affect progress.
4. Assistive Devices and Orthoses: Patients often rely on orthotics and assistive
devices. The most common orthotics for those with complete SCI are KAFOs (Knee-
Ankle-Foot Orthoses), which help stabilize the lower limbs. Other options include the
Scott-Craig orthosis and Reciprocating Gait Orthosis (RGO), which help with
reciprocal leg movement during ambulation.
5. Motivation: A motivated patient can learn to walk with assistive devices and
orthotics, even if they never regain independent walking. However, the energy cost of
ambulation may lead some patients to rely on wheelchairs for mobility.
6. Gait Patterns: Patients often learn either a swing-through or 4-point gait pattern
using crutches and orthotics. The goal is to increase standing balance and perform
tasks like sit-to-stand movements, weight shifting, and push-ups.

Locomotor Training for Individuals with Motor Incomplete SCI (iSCI)

For individuals with motor incomplete SCI (ASIA C and D), the chances of regaining
functional ambulation are higher. The focus is on improving functional independence through
activity-based training:

1. Activity-Based Approach: This approach includes interventions to promote recovery

and increase activity, such as strength training, weight bearing, and sensory
stimulation to improve function.
2. Training Tasks: Training for iSCI patients may include activities such as walking
with the use of orthoses and assistive devices, as well as weight-shifting exercises to
maintain balance during ambulation.
3. Assistive Devices and Orthotics: Devices like AFOs (Ankle-Foot Orthoses) are
often used for lower-level injuries (e.g., L3 and below). These devices support the
ankle and provide stability, helping to facilitate a more functional gait.
4. Gait Training Strategies: For motor iSCI, the patient may progress from parallel
bars to crutches, with gait training focused on improving strength, coordination, and
endurance to regain walking ability.
By focusing on strength, endurance, and postural control, patients with SCI, especially those
with motor iSCI, can regain functional mobility. However, for those with complete SCI, the
goal may shift toward maximizing standing function and improving quality of life rather than
independent walking.