Occupational Therapy and Spinal Cord Injury

 Acute spinal cord injury (SCI) is a traumatic event that results in
disturbances to normal sensory, motor, or autonomic function and
ultimately affects a patient’s physical, psychological, and social
well-being.
 Acute SCI consists of a primary phase and a secondary phase.
The initial traumatic impact to the spinal cord, in the form of
fracture or dislocation, causes micro hemorrhages in the white and
grey matter, axonal damage, and cellular membrane destruction
 Following the primary injury, a cascade of pathophysiological
events results in impaired neuronal homeostasis, apoptosis, and
tissue destruction. These include
- (1) Edema and the release of coagulation factors and vasoactive
amines
- (2) Ionic imbalance and formation of free radicals
- (3) An increased release of the excitatory neurotransmitter
glutamate

 Acute SCI can significantly impair a patient’s quality of life,
functional status, and social independence.
 There is a high male-to-female ratio of patients suffering from SCI
and an age of peak incidence of younger than 30 years.
 Motor vehicle accidents are the primary cause of SCI, followed by
falls in the elderly population
 Along with motor and sensory deficits, instabilities of the
cardiovascular, thermoregulatory and broncho-pulmonary system
are common after a SCI.
 Disturbances of the urinary and gastrointestinal systems are typical
as well as sexual dysfunction.

 Frequent complications of cervical and high thoracic SCI are
neurogenic shock, bradyarrhythmias, hypotension, ectopic beats,
abnormal temperature control and disturbance of sweating,
vasodilatation and autonomic dysreflexia.
 Autonomic dysreflexia is an abrupt, uncontrolled sympathetic
response, elicited by stimuli below the level of injury. The symptoms
may be mild like skin rash or slight headache, but can cause severe
hypertension, cerebral haemorrhage and death
 Disturbance of respiratory function are frequent in tetraplegia and
a primary cause of both short and long-term morbidity and
mortality is pulmonary complications.
 Due to physical inactivity and altered haemostasis, patients with
SCI have a higher risk of venous thromboembolism and pressure
ulcers.

 Spasticity and pain are frequent complications which need to be
addressed.
 The psychological stress associated with SCI may lead to anxiety
and depression.
 Knowledge of possible complications during the acute phase is
important because they may be life threatening and/ or may lead to
prolonged rehabilitation

Mechanisms of Injury
• Compression
• Flexion Injury
• Extension Injury
• Rotation
Compression Injury
• Vertebral body fracture
• Disc herniation
• Epidural hematoma
• Displacement of posterior wall of the vertebral body
Flexion Injuries
• Tearing of interspinous ligaments
• Disruption of capsular ligaments around facet joints
• Fracture of posterior elements
• Disruption of posterior ligaments
• Often unstable fractures

Extension Injury
• Tearing of anterior longitudinal ligament
• Separation of vertebral bodies
• Rupture of Disc
• Avulsion of upper vertebral body from
Rotational Injury
• Associated with unilateral facet dislocation

 A person’s functional independence has a major impact on their
quality of life, sense of self worth and consequential social
participation.
 Some people with a spinal cord injury (SCI) will have the ability to
achieve a high level of independence while others, limited by their
physical ability, will be able to achieve a level of independence
through directing their care and by using technology options.
 Whilst it is reasonable to expect that the degree of functional
independence achievable is dependent on a person’s level of injury,
a person’s neurological level should not be viewed as strictly
predictive but rather as indicative of potential function.
 It is important to avoid comparisons between individuals with
similar levels of injury as there are many factors that have an
impact on an individual’s functional performance

Factors having an impact on functional performance
• Neurological level (tetraplegia/paraplegia).
• Degree of impairment (complete or incomplete, ASIA or AIS score).
• Age at time of injury and years since injury.
• Other injuries or medical conditions (e.g. fractures, nerve injuries,
cardiac disease, arthritis, etc.).
• Physique (body proportions/weight distribution).
• Cognition/motivation (impact of Traumatic Brain Injury (TBI),
depression).
• Mental illness (e.g. depression, schizophrenia, personality disorder).
• Drug and alcohol abuse.
• Social supports.
• Cultural expectations.
• Financial resources.
• Environmental factors.

 Musculoskeletal changes associated with ageing have a greater
impact on people with a SCI and their level of independence than
on the able-bodied population.
 Therefore a person’s functional status may change as they age with
a SCI.
 There is a complex interaction of age at injury, duration post-injury
and impairment.
 Musculoskeletal problems with overuse syndromes are common.

Complete Spinal Cord Injuries
 A complete spinal cord lesion is the term used to describe damage
to the spinal cord that is absolute.
 It causes complete and permanent loss of ability to send sensory
and motor nerve impulses and, therefore, complete and usually
permanent loss of function below the level of the injury. This will
result in complete paraplegia or tetraplegia.
 The completeness of many injuries isn't fully known until 6-8
weeks post injury. The spinal cord normally goes into what is
called spinal shock after it has been damaged.
 The swelling and fluid masses showing on any resultant X-ray,
MRI or CT scans, may well mask the true extent of the underlying
injury.

Complete Paraplegia
 Complete paraplegia is a term used to describe complete and
permanent loss of ability to send sensory and motor nerve impulses
to the muscle groups and body functions that are controlled by
nerves leaving the spinal column at T1 level or below.
 T1 injuries are the first level with normal hand function. They can
use their arms with all the motor functions of a non-injured person.
 As thoracic levels proceed down the spinal column, abdominal
musculature recovery is present, and there is improved respiratory
function and trunk balance (sitting balance) as a result.
 Sensation below the level of injury is lost and bladder, bowel and
sexual function will not work normally either (see Treatment of
SCI for more information)

Complete Paraplegia
 Some complete lower injuries have partial trunk movement and
may be able to stand, with long leg braces to support their paralyzed
legs, and a walker taking their body weight through their arms,
balancing on the leg braces.
 They may be able to walk short distances using this equipment,
with assistance. T6-12 patients also have partial abdominal muscle
strength, and may be able to walk independently for short distances
with long leg braces and a walker or crutches, again taking all
their body weight through their arms, balancing on the leg braces.
(The working abdominal muscles are used to throw the paralysed
legs forward whilst the body weight is taken on a frame or
crutches)

Complete Tetraplegia
 Tetraplegia is far more debilitating than paraplegia as the arms are
paralyzed too.
 C1-4 Tetraplegia: Patients with C-1 and C-2 lesions may have
functional phrenic nerves. In these cases, implanted phrenic nerve
pacemakers can be used, and pacing of the diaphragms may be
simultaneous or alternating.
 If secretions are not a problem, tracheostomies may be plugged or
discontinued. Less equipment may be needed for C-1 and C-2
patients than for C-3 and C-4 patients.

 Patients with C-3 lesions have impaired breathing and may be
ventilator-dependent.
 They can shrug their shoulders and they have neck motion, which
permits the operation of specially adapted power wheelchairs and
equipment, such as tape recorders, computers, telephones, page
turners, automatic door openers, and other environmental control
units with mouth control (sip and puff), voice activation, chin
control, head control, eyebrow control, or eye blink.
 Patients with C-4 lesions may be free of respiratory equipment
beyond the initial acute care stage, but may have the same
functional equipment needs as ventilator-dependent patients.

 In addition to powered wheelchairs, C1-4 tetraplegics require
assistance for all personal care, turning, and transfer functions.
Head rests, troughs or a lapboard, for the upper extremities, and
lifts may be necessary.
 Bed surfaces with two or more segments that are alternately
inflated and deflated may be indicated for patients who do not have
assistance for turning.
 Functional electrical stimulation (FES) may restore elbow flexor
function in patients with C-4 lesions.
 For patients with lesions at C-5 or higher, power recliners to
achieve pressure relief while sitting are recommended..

 Patients with partial C-4 lesions and inadequate elbow flexors and
patients with C-5 lesions may initially require a balanced forearm
orthosis, for enhanced arm placement, or a long opponens orthosis
with utensil slots and pen holders, for wrist stability, during
activities such as feeding, writing, and typing.
 C-5 Tetraplegia: C-5 tetraplegics
- Have functional deltoid and/or biceps musculature.
- They can internally rotate and abduct the shoulder, which causes
forearm pronation by gravity.
- Wrist flexion is similarly produced.
- They can externally rotate the shoulder and cause supination and
wrist extension.
- They can bend the elbow, but elbow extension can only be produced
by gravity, or by forceful horizontal abduction of the shoulder and
inertia or shoulder external rotation.

 C-5 patients require assistance to perform
- Bathing and lower body dressing functions
- Bowel and bladder care
- Transfers.
 With the use of balanced forearm orthoses, long opponens
orthoses, or universal cuffs and adaptive equipment, C-5 patients
can:
- Feed themselves
- Perform oral facial hygienic and upper body dressing activities
- Operate computers, tape recorders, telephone, etc.
- Participate in leisure activities.


 They can propel manual wheelchairs short distances on level
surfaces, although the hand-hand rim interface should be modified
with vertical or horizontal lugs (or plastic tubing can be wrapped
around the rims), and gloves should be worn to protect the hands.
 Powered wheelchairs, propelled with a hand control, are needed for
community distances and outdoor terrain.

Complete Tetraplegis
 C-6 Tetraplegia: C-6 patients have musculature that permits most
shoulder motion, elbow bending, but not straightening, and active
wrist extension which permits tenodesis, opposition of thumb to
index finger, and finger flexion.
 Wrist extensor recovery is common in C-6 patients, but its return
can be delayed.
 Tenodesis orthoses support tenodesis training early in recovery.
 Wrist-driven flexor hinge splints permit pinching strength, needed
for catheterization and work skills.
 Short opponens orthoses with utensil slots, writing splints, Velcro
handles, and cuffs permit feeding, writing, and oral facial hygiene.

 C-6 patients can perform upper body dressing without assistance
and may also perform lower body dressing without assistance.
 They can catheterize themselves and perform their bowel program
with assistive devices.
 They can perform some transfers independently with a transfer
board, turn independently with the use of side rails, and relieve
pressure by leaning forward, alternating sides, or possibly by push-
ups.
 Water mattresses can lower pressure sufficiently to eliminate the
need for turning during the night.
 They can propel a manual wheelchair short distances on level
terrain, operate power wheelchairs, and may drive with a van and
special equipment.

 They can cook, perform light housework, and live independently
with limited attendant care.
 Upper extremity reconstructive surgery, or functional
neuromuscular stimulation of the upper extremity, or surgery and
stimulation in the same patient can improve function in C-6
patients.
 Surgery is recommended only for patients who are neurologically
stable and without spasticity.
 Stimulation can be provided by external, percutaneous, or
implanted electrodes, by shoulder motion utilizing an external
system, or by key and palmar grip and release, or by a bionic glove,
an electrical stimulator garment that provides controlled grasp and
hand opening.

 C7-8 Tetraplegia: C-7 patients have functional triceps, they can
bend and straighten their elbows, and they may also have enhanced
finger extension and wrist flexion. As a result, they have enhanced
grasp strength which permits enhanced transfer, mobility, and
activity skills.
 They can turn and perform most transfers independently. They can
propel a manual wheelchair on rough terrain and slopes, and may
therefore not need a powered wheelchair. They may drive with a
van and specialized equipment.
 They can perform most daily activities, they can cook and do light
housework, and therefore they may live independently. They may,
however, require assistance for bowel care and bathing.

 C-8 patients have flexor digitorum profundus function which
permits all arm movement, with some hand weakness.
 They can propel a manual wheelchair community distances,
including in and out of a car and over curbs, and may even become
wheelchair independent.
 They can drive with a van or car and special equipment. They can
perform all personal care and daily activities, except heavy
housework.

Incomplete Spinal Cord Injury
 An incomplete spinal cord injury is the term used to describe
damage to the spinal cord that is not absolute. The incomplete
injury will vary enormously from person to person and will be
entirely dependant on the way the spinal cord has been
compromised.
 The true extent of many incomplete injuries isn't fully known until
6-8 weeks post injury. The spinal cord normally goes into what is
called spinal shock after it has been damaged.
 The swelling and fluid masses showing on any resultant X-ray,
MRI or CT scans, may well mask the true nature of the underlying
injury. It is not uncommon for someone who is completely
paralysed at the time of injury to get a partial or very near full
recovery from their injuries after spinal shock has subsided.

Types of Incomplete Spinal Injury
 An incomplete lesion is the term used to describe partial damage to
the spinal cord. With an incomplete lesion, some motor and sensory
function remains.
 People with an incomplete injury may have feeling, but little or no
movement. Others may have movement and little or no feeling.
 Incomplete spinal injuries differ from one person to another
because the amount of damage to each person’s nerve fibres is
different.
 The effects of incomplete lesions depend upon the area of the cord
(front, back, side, etc) affected. The part of the cord damaged
depends on the forces involved in the injury.

 Anterior Cord Syndrome: is when the damage is towards the front
of the spinal cord, this can leave a person with the loss or impaired
ability to sense pain, temperature and touch sensations below their
level of injury. Pressure and joint sensation may be preserved. It is
possible for some people with this injury to later recover some
movement. This is a type of incomplete spinal cord injury
 Central Cord Syndrome: is when the damage is in the centre of the
spinal cord. This typically results in the loss of function in the
arms, but some leg movement may be preserved. There may also be
some control over the bowel and bladder preserved. It is possible
for some recovery from this type of injury, usually starting in the
legs, gradually progressing upwards. This is a type of incomplete
spinal cord injury.

 Posterior Cord Syndrome: is when the damage is towards the back
of the spinal cord. This type of injury may leave the person with
good muscle power, pain and temperature sensation, however they
may experience difficulty in coordinating movement of their limbs.
This is a type of incomplete spinal cord injury
 Brown-Séquard syndrome: is when damage is towards one side of
the spinal cord. This results in impaired or loss of movement to the
injured side, but pain and temperature sensation may be preserved.
The opposite side of injury will have normal movement, but pain
and temperature sensation will be impaired or lost. This is a type of
incomplete spinal cord injury

 Cauda equina lesion: The Cauda Equina is the mass of nerves
which fan out of the spinal cord at between the first and second
Lumbar region of the spine.
 The spinal cord ends at L1 and L2 at which point a bundle of
nerves travel downwards through the Lumbar and Sacral
vertebrae. Injury to these nerves will cause partial or complete loss
of movement and sensation. It is possible, if the nerves are not too
badly damaged, for them to grow again and for the recovery of
function. This is a type of incomplete spinal cord injury

Impact of SCI on ability to move
 When your spinal cord was injured, the signals necessary to
generate movement could not travel up and down because of the
damage to the pathway they travel along. (The connection between
the movement control center and the moving parts was lost).
Movement relies on several components:
- Desire / need / intention to move
- Brain function to plan and initiate the movement (the brain is the
movement control center)
- Functioning spinal cord and nerves to transmit signals to and from
the brain
- Muscles that can contract with enough force to result in movement
(the muscles, along with joints, skin and other soft tissues are the
moving parts)
- Skin and other receptors that sense the pressure, speed, force and
trajectory of the movement
- Brain function to fine tune movement based on sensory feedback

Recovery of movement after SCI
 Spinal Shock occurs in the initial stages after SCI (first 4-6 weeks).
During this time, paralyzed muscles are floppy (or flaccid) and stay
still during attempts to contract them to move.
 After this time, the paralyzed muscles seem to come to life as they
start twitching on their own. Sometimes when you touch your
paralyzed legs or someone else moves them, the muscles contract
and cause your leg to move. This muscle activity is call spasm. It is
a reflex response of the muscles and is not within your voluntary
control (that is, you can’t make your muscle perform the movement
simply by thinking about doing the movement).
 This is a normal part of your body’s recovery after SCI but doesn’t
necessarily mean you are on your way to recovery of the control of
movement.

Recovery of movement after SCI
 It is important to monitor for changes in your motor and sensory
function during this early time and to talk to the health
professionals involved in your care about changes you observe.
They can help you monitor this recovery and develop an
appropriate physical rehabilitation program to maximize recovery
of function.
 While your physical rehabilitation is essential for maximizing
neurological recovery, it is not able to repair your damaged spinal
cord and will not be helpful if the signals for movement can not
travel up and down your spinal cord.
 When no signals are able to travel the length of the spinal cord, the
injury is described as complete. If you have a complete injury, you
will need to learn new, compensatory ways to

Expected Functional Outcomes for Complete Spinal Cord Injury
C1-3
Neck Muscles
- Sternocleidomastoid
- Paraspinal Muscles
- Accessory muscles
- Physical dependence for personal care and ADLs
- Physical dependence for mobility (hoist transfers) and pressure care
- Often require ventilator to breathe due to diaphragm paralysis
- Able to operate an electric wheelchair with head/chin control
- Able to control aspects of environment through assistive technology

C4
Neck/Shoulder Muscle
- Upper Trapezius
- Respiratory Muscle
- Diagphragm (C3-5)
- Physical dependence for personal care and ADLs
- Physical dependence for mobility (hoist transfers) and pressure care
- Able to breathe without a ventilator
- Able to operate an electric wheelchair with head/chin control
- Able to control aspects of environment through assistive technology

C5
Shoulder Muscles
- Deltoid
- Elbow Muscles
- Biceps
- Brachialis
- Brachioradialis
- Can assist with personal care and ADLs
- Independently able to complete some physical tasks such as feeding
using assistive devices e.g. splints
- Can assist with bed mobility and hoist transfers
- Able to operate an electric wheelchair with hand control; may be able
to propel a MWC on flat surfaces indoors for short distances

C6
Shoulder Muscles
- Pectoralis Major (partial)
- Latissimus Dorsi
- Serratus Anterior
- Wrist Muscles
- Radial Wrist Extensors
- Potential for physical independence with some personal care and
ADLs tasks (e.g. self-catheterisation for bladder management) with
assistive devices & splints, potential for independence with bowel
care
- Presence of wrist extension provides potential for functional grasp
through tenodesis
- Potential to be independent with bed mobility and slideboard
transfers
- Capacity to use a manual wheelchair - may require electric
wheelchair for uneven ground, slopes and longer distances Potential
to drive with vehicle modifications Potential to live independently
with support/care

C7
Elbow Muscles
- Triceps
- Wrist/Hand Muscles
- Wrist Flexors
- Long Finger Extensors
- Ability to be physically independent with personal care and ADLs
- Independent with bed mobility
- Can transfer independently with potential to use lift transfer
- Greater function use of hands including stronger grasp and
increased dexterity therefore less reliant on splints
- Able to use a manual wheelchair
- Able to drive with vehicle modifications
- Potential to live independently with support
- Require assistive equipment

C8/T1
Hand Muscles
- Finger Flexors
- As for C7 with greater dexterity of hand function
- Do not require splints to support hand function
T1-6
Trunk Muscles
- Upper Intercostals
- Thoracic Extensors
- Full function of upper limbs and hands means physical
independence for personal care and ADLs
- Able to lift transfer independently
- May require assistive equipment due to lack of trunk stability
- Independent with manual wheelchair
- Able to drive with hand controls
- Able to live independently

T7-12
Trunk Muscles
- Abdominals
- Lumbar Extensors
- Lower Intercostals
- As for T1-T6 with greater preservation of trunk function, improving
balance and therefore able to complete more challenging tasks e.g.
180 degree transfers with greater ease

L1-S5
Lower Limb Muscles
- L1/2 Hip Flexors
- L3 Knee Extensors
- L4 Ankle Dorsiflexors
- L5 Long Toe Extensors
- S1/2 Ankle Plantarflexors
- Independent for personal care and ADLs
- Able to lift transfer independently with potential to stand transfer
- Independent with manual wheelchair with potential to be able to
ambulate with the aid of lower limb orthoses (such as callipers or
AFOs) and a walking aid
- Able to drive with hand controls
- Able to live independently

Skin Management
 A person with a SCI is at risk of developing a pressure injury due to
impaired sensation and muscular atrophy.
 Occupational therapy intervention should occur as part of a
multidisciplinary team review.
It is appropriate when the person:
- Has intact skin however the clinician has identified that they have a
high risk of developing a pressure injury
- Is on bed rest with a pressure injury
- Has recently had a pressure injury and their skin has healed.

Occupational Therapy review
 When the person with a SCI has intact skin yet has a high risk of
developing a pressure injury the occupational therapist should:
• Provide education about skin care management;
• Review equipment, posture, transfers and functional ability.
When the person with a SCI is on bed rest with a pressure injury the
occupational therapist should:
• Inspect their skin
• Discuss possible causes of the pressure injury
• Organize an appropriate mattress
• Provide advice about positioning and bed mobility
• Examine their equipment
• Gather information about their daily routine including how
functional activities are performed
• Consider care needs – to facilitate bed rest and to prepare for
gradual return to seating when skin has healed

 When the pressure injury has healed and the person with a SCI is
able to start a return to seating protocol the occupational therapist
should consider the following:
Pressure relief
- Do seating surfaces provide the person with adequate pressure
relief?
- Consider wheelchair cushions, toileting & showering equipment
and car cushions.
Is their method of pressure relief safe?
- Consider ability to lean forward, side lean or use tilt-in-space
function.
Seating
- Does the person have a symmetrical sitting posture?
For example, someone with a pelvic obliquity may bear more weight
(and more pressure) on one ischial tuberosity than on the other.

Equipment
- Does it meet the person’s needs?
- Does it fit them well?
- Is it well maintained?
- Consider wheelchair & cushion, mobile shower commode,
mattress, hoist & sling, car and exercise equipment.
Mattress
- Does it provide the person with adequate pressure relief?
- Do they “bottom out” on it?
Transfers
- Does the person clear all surfaces well during all transfers?
- Are their transfers level or downhill?
- If transferred with a hoist, does the person shear in the sling
during transfers?
- Is the edge of the sling in contact with the healed skin?

Skin
- Can the person check his/her own skin?
- Long-handled mirrors or assistive technology, such as a web-cam,
can assist. Alternatively, ensure that a carer performs regular skin
checks.
Function
- Has the person’s level of functioning declined?
- When assessing seating and sleeping surfaces it may be useful to
use a system to measure interface pressure - this may require a
referral to a seating clinic.

Bedroom Equipment
Beds Clinical rationale
 An electrically operated bed enables a person with a SCI to change
position and to adjust the height of the bed so that their transfers
in/out of bed are level or downhill.
 Both actions help preserve shoulder function by eliminating the use
of equipment such as monkey bars.
Client considerations
• Height and weight.
• Bed mobility.
• Method of transferring.
• Upper limb function: ability to operate controls.
• Flexibility: presence of internal “fixation hardware” may restrict
movement.
• Sleeping alone or with partner.

Occupational Therapy and Spinal Cord Injury

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