For many people with a spinal cord injury (SCI), the rehabilitation process begins when the individual is still an in-patient. At this stage, primary goals include maximizing independence with basic skills such as bed mobility, wheelchair management and transfers, progression to ambulation when appropriate, caregiver training, provision of equipment, and general education on topics like pressure relief and medical complications. (Taylor-Schroeder, 2011)
Assessing a patient with SCI is an important initial step in physiotherapy management. This is the time to set realistic goals and to identify key problems. Often, assessments conducted for this purpose are subjective. For example, a physiotherapist may subjectively assess the patient’s ability to transfer from their wheelchair to the bed in an attempt to identify any underlying problems. The assessment could involve watching and analysing the action to determine which part of the transfer the patient is having difficulties performing and to isolate the underlying issues (Biering-Sørensen, 2006)
Despite the obvious importance of assessments for physiotherapists, there is no general international consensus on the best series of physiotherapy-specific assessments. However, representatives of the Spinal Cord Injury Group of the American Physical Therapy Association have put together a list of their recommendations, and the international SCI community has developed basic datasets for people with SCI. Some of the basic datasets are relevant to physiotherapists and include assessments that could be used to both guide treatment and monitor improvements over time: (Biering-Sørensen, 2006)
Spinal Cord Injury Assessment Guides
Chart 1 Progressive resistance training versus control on the voluntary strength of non-paralysed muscles and quality of life in people with SCI
Chart 2 Effect of electrical stimulation versus control on the torque of partially paralysed muscles in people with SCI
Chart 3 Effect of (a) stretch and (b) passive movements versus control on the joint range of motion in people with SCI
Chart 4 Effect of treadmill gait training with overhead suspension versus control on (a) walking speed and (b) walking index of SCI (WISCI, 21-point scale) in people with SCI
Chart 5 Choosing a rehabilitation program after a spinal cord injury (SCI) – Consumer Guidelines
Chart 6 Individual and group therapy
Chart 7 Individual therapy
Charts 8 and 9 Variation in time spent on PT activities during individual therapy sessions
Physical Therapy Schedules for SCI
The CDC recommends at least 150 minutes of moderate physical activity per week, as well as two days spent strength training, and these guidelines apply even to people who have experienced spinal cord injuries. (CDC, 2018)
Exercise for individuals with a spinal cord injury can be divided into three broad categories (Gilbert, 2015): (1) Aerobic Exercise to Maintain Cardiovascular Health (2) Strength-based training to maintain the ability to perform activities of daily living and mobility, as well as preventing injury from muscle weakness or imbalance (3) Flexibility training to improve range of motion and reduce spasticity
Note: Currently, exercise is the only known intervention that can have lasting effects on function after a spinal cord injury, both in promoting neural recovery and in reducing secondary complications.
Self Range-of-Motion Exercises for SCI
Self range-of-motion exercises can be done solo. When first starting out, the injured individual may want someone nearby to assist until they are comfortable with the movements.
Neck Flexion and Extension
Bring the chin slowly in towards the chest. Hold for a count and then return your head to its upright position. Then tuck your chin back in and slowly pull it back to gently stretch the muscles in the back of your neck. Some people should not do this exercise, so be sure to check with your therapist before beginning an exercise routine. If the neck needs more support, some of the weight can be supported with your hands.
Supine Shoulder Stretch
Lie on your back with palms turned up and arms extended straight out to your sides. Hold this position for as long as is comfortable.
Seated Hamstring Stretch
Sit facing a bed or chair that is the same height as the wheelchair. Place one leg on the object while keeping the knee straight. Do not bend forward as it will stretch your leg too much. Simply hold the position, then alternate legs.
Ankle and Toe Stretch
From a seated position, cross one foot over the other leg. Using the hand, move the foot through its full range of motion, and subsequently move each toe up and down.
Seated Back Stretch
From a seated position, rotate the head and shoulders while twisting the waist to each side of the body.
Lying on Stomach
Individuals with spinal cord injuries tend to spend most of their time sitting and over time can tighten and shorten the muscles in the front of the hips. Lying prone on the stomach for at least 30 minutes daily helps to relax and stretch those muscles. If physically able, add to this simple stretch by pushing up with your upper body away from the bed, keeping your legs straight.
Passive Range-of-Motion Exercises for SCI
Passive range-of-motion (PROM) exercises are done with a partner. Speak with a therapist to determine an appropriate schedule. In general, stretching exercises should be held for 20–30 seconds and repeated 2–5 times. (Saebo, 2017)
Shoulder Flexion and Extension
The partner stands at the injured individual’s side while they are seated. With one hand, hold onto the patient’s forearm, and with the other, hold onto the elbow joint to provide stability. Be sure to keep the elbow straight while slowly moving the patient’s entire arm up over their head and then back down. This exercise can also be done while the patient is lying down.
Stand behind a seated patient. Place one hand on the forearm while using the other to stabilize the elbow. Slowly move the arm upwards, and be sure the palm is facing up once above shoulder height. Bring the arm above the head, and then slowly lower it back down.
Elbow Flexion and Extension
Place one hand on the patient’s wrist and the other on their upper arm. Slowly bend the elbow until their hand is touching their shoulder, then fully extend and straighten the arm down.
Wrist and Hand Flexion and Extension
With one hand, hold onto and support the patient’s wrist. Now, with the other hand, curl their fingers into their palm and slowly stretch the wrist back. Then allow the wrist to drop and the fingers to straighten. Assist the patient by fully extending their fingers if they are unable to do so by themselves.
Hip and Knee Flexion
With the patient lying face up, place one hand underneath their knee while using the other to stabilize the heel. Lift the knee and bend it towards the chest. Keep the foot and knee in a straight line with the hip. Do not twist.
Start with the patient lying face up, and stand to their side. Place one hand underneath their knee and use the other to stabilize the heel. Keep the knee straight, and slowly move the leg toward you until it is at approximately a 45-degree angle with the other leg, then slowly return the leg to its original position.
With the patient’s knee straight, stabilize the ankle with one hand and place the other around the foot. Slowly turn the foot inward and outward.
Toe Flexion and Extension
Stabilize the patient’s foot just below the toes with one hand. With the other, grasp their toes and slowly move them forward and backwards.
Physical Therapy Manuals for Patients with SCI
The After and Beyond Spinal Cord Injury Resource Manual. Canadian Spinal Research Organization/American Spinal Research Organization. 2004 (Accessible here)
General Info: The manual contains a basic introduction, a local directory, a section describing the fundamentals of a spinal cord injury, and a segment of biographies of people living with some form of injury to the spinal cord. One free download per person.
Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. 2017 (Accessible here)
General Info: Through a systematic, rigorous, and participatory process involving international scientists and stakeholders, a new exercise guideline was formulated for cardiometabolic health benefits.
Spinal Cord Injury; Rehabilitation after a spinal cord injury, Hamilton Health Sciences. 2015 (Accessible here)
Researchers from the NCSEM-EM and the Peter Harrison Centre for Disability Sport have developed scientific guidelines to inform people with a spinal cord injury (SCI) how much exercise is necessary for important fitness and health benefits. (More information on the SCI Guidelines can be found here)
Download the guidelines here
Download the infographic describing the process of developing the guidelines here
Studies on SCI and Physical Therapy
Study Physical therapy treatment time during inpatient spinal cord injury rehabilitation 2011
Description: Describes the nature and distribution of activities during physical therapy delivered in inpatient spinal cord injury rehabilitation and discuss predictors (patient and injury characteristics) of the amount of time spent in PT for specific treatment activities.
Result: Providing therapeutic strengthening treatments consumed the greatest proportion of PT time. About one-quarter of all PT services were provided in group settings.
Study A Clinical Practice Guideline for the Management of Patients With SCI: Recommendations on the Type and Timing of Rehabilitation 2017
Results: (1) Rehabilitation should be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity; (2) Body weight–supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise; (3) Functional electrical stimulation as an option to improve hand and upper extremity function.
Study Physical therapy after spinal cord injury: A systematic review of treatments focused on participation 2014
Results: interventions applied were 9- and 12-month body weight-supported treadmill training in two studies, a supervised 9-month exercise program, a 12-week home exercise program, and a 10-week multidisciplinary cognitive behavioural program for coping with chronic neuropathic pain. Four of five PT interventions positively impacted the individual’s perceived participation and satisfaction with participation.
Study Type and Timing of Rehabilitation Following Acute and Subacute Spinal Cord Injury: A Systematic Review 2017
General Info: The objective of this study was to conduct a systematic review of the literature to address the following clinical questions: In adult patients with acute and subacute complete or incomplete traumatic SCI, (1) Does the time interval between injury and commencing rehabilitation affect outcome? (2) What is the comparative effectiveness of different rehabilitation strategies, including different intensities and durations of treatment? (3) Are there patient or injury characteristics that affect the efficacy of rehabilitation? (4) What is the cost-effectiveness of various rehabilitation strategies?
Study Predictors of functional outcomes in adults with traumatic spinal cord injury following inpatient rehabilitation: A systematic review 2017
General Info: Higher functioning individuals at discharge can experience a decrease in independent mobility by one-year follow-up. However, functional gains after discharge have also been reported and associated with recovery.
Result: At discharge, variables in the Body Structure and Function domain were the most consistent predictors of mFIM score. At one-year follow-up, variables in the Activity and Participation domain were the most consistent predictors of mFIM score. Contextual factors were the least frequent predictors at both discharge and one-year follow-up.
Taylor-Schroeder, S. et al., 2011. Advances in pediatrics. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066500/ [Accessed September 4, 2018].
Biering-Sørensen, F. et al., 2006. International SCI Data Sets. Available at: https://www.iscos.org.uk/international-sci-data-sets [Accessed September 4, 2018].
Burns, A.S. et al., 2017. Type and Timing of Rehabilitation Following Acute and Subacute Spinal Cord Injury: A Systematic Review. Advances in pediatrics. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29164023 [Accessed September 4, 2018].
AlHuthaifi, F. et al., 2017. Predictors of functional outcomes in adults with traumatic spinal cord injury following inpatient rehabilitation: A systematic review. Advances in pediatrics. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27852160 [Accessed September 4, 2018].
Ginis, K.A.M. et al., 2017. Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Nature News. Available at: https://www.nature.com/articles/s41393-017-0017-3 [Accessed September 4, 2018].
Eerden, S., Dekker, R. & Hettinga, F.J., 2018. Maximal and submaximal aerobic tests for wheelchair-dependent persons with spinal cord injury: a systematic review to summarize and identify useful applications for clinical rehabilitation. Advances in pediatrics. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28637157 [Accessed September 4, 2018].
CDC, 2018. Physical Activity. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/physicalactivity/basics/pa-health/index.html [Accessed September 4, 2018].
Gilbert, B., 2015. The Benefits of Exercise after Spinal Cord Injury. Burke Rehabilitation Hospital. Available at: https://www.burke.org/blog/2015/10/the-benefits-of-exercise-after-spinal-cord-injury/56 [Accessed September 4, 2018].
Saebo, 2017. Range of Motion Exercises for Spinal Cord Injuries. Saebo. Available at: https://www.saebo.com/range-motion-exercises-spinal-cord-injuries/ [Accessed September 4, 2018].