1) Early management of spinal cord injuries focuses on immobilization, fracture stabilization, and preventing secondary complications. Physical therapy aims to improve respiratory function, prevent skin breakdown, and begin early mobility. 2) During active rehabilitation, the goals are to increase independence and functional mobility. Physical therapy focuses on strengthening, cardiovascular training, and learning mobility skills like transfers, bed mobility, and locomotion. 3) Locomotor training uses body weight support treadmills, orthoses like KAFOs, and assistive devices to retrain walking patterns after spinal cord injury. Training occurs both on the treadmill and overground.

1. PHYSIOTHERAPY IN SPINAL
CORD INJURY
DR. Vaibhavi Parmar (PT)

2. Early medical and rehabilitation
management in the acute stage
1)Emergency Care
Management of SCI begins at the location of the accident. Techniques
used in stabilizing, moving, and managing the patient immediately
following the trauma can influence prognosis significantly
Signs of SCI after a traumatic event include paresthesias, lack of or
impaired movement or sensation in the extremities, spinal pain, and
altered cognitive status or level of alertness. When an SCI is suspected,
efforts should be made to avoid both active and passive movements
of the spine

3.  Immobilization : maintaining the spine in a neutral, anatomical position and may
prevent further neurological damage.
 Cardiac, hemodynamic, and respiratory status are closely monitored
 A urinary catheter typically is inserted, and secondary injuries are addressed.
 2) Fracture Stabilization
 Reduction and immobilization of spinal injuries can be achieved via conservative
or operative methods.
 Indications for surgical stabilization are unstable fracture site, gross
malalignment, cord compression, and deteriorating neurological status.

4.  Closed reduction is indicated for patients with
cervical subluxation or fracture dislocation
injuries.
 It is achieved with the use of traction devices.
Patients with thoracic or lumbar injuries that
are managed conservatively without surgery
require immobilization by positioning in a
regular or rotating bed

5.  3) Immobilization : Following reduction of the fracture site, through either
conservative or surgical means, the spine is immobilized for a period of time
through the use of spinal orthoses and recumbent positioning.
 1) Cervical Orthoses
HALO device
Minerve cervical orthosis
sterno–occipital– mandibular immobilizer (SOMI)
2) Thoracolumbosacral Orthoses
Jewett orthosis

6. Halo orthosis

8. PHYSICAL THERAPY MANAGEMENT IN
THE ACUTE STAGE OF RECOVERY
 Respiratory Management
 Goals : Improved ventilation,
Increased effectiveness of cough,
Prevention of chest tightness and
Ineffective substitute breathing patterns
Individuals with cervical injuries at and above C5 often require ventilatory
support using an intermittent positive pressure ventilator (IPPV).

9.  Invasive mechanical ventilation is often done through a tracheostomy and can be
provided through a stationary or portable ventilator.
 Noninvasive positive pressure ventilation provides an alternative to invasive
mechanical ventilation.
 Intubation may impair the function of the airway cilia, leading to chronic bacterial
colonization and chronic inflammatory changes of the airway

10.  Deep-Breathing Exercises:
To facilitate diaphragmatic movement and increase VC, the therapist can apply light
pressure during both inspiration and expiration.
Glossopharyngeal Breathing :
Appropriate for patients with high-level cervical lesions
Technique

11.  Air Shift Maneuver
It involves closing the glottis after a maximum inhalation, relaxing the diaphragm,
and allowing air to shift from the lower to upper thorax.
Air shifts can maintain and increase chest wall expansion.
 Respiratory Muscle Strengthening
Inspiratory muscles can be trained using relatively inexpensive handheld devices,
which increase the resistive or threshold inspiratory load on muscles of inspiration
Breathing through these devices increases the resistive or threshold inspiratory load
on the muscles. The load can be progressively increased as the patient progresses.
Inspiratory muscle training can improve pulmonary function, reduce dyspnea, and
improve cough function

13.  Coughing
Patients who are not able to produce a functional cough should be taught to perform
a self-assisted cough. Those who cannot perform a self-assisted cough may benefit
from a manually assisted cough to help remove secretions
Eg. Epigatric thrust
 Abdominal Binder
An abdominal binder may improve respiratory mechanics by compensating for
nonfunctioning abdominal muscles. The binder compresses abdominal contents to
increase intra-abdominal pressure, and elevate the diaphragm into a more optimal
position for breathing

14.  Manual Stretching Mobility and compliance of the thoracic wall can be facilitated
by manual stretching chest wall muscles in supine.

15. Skin Care
 Skin Care Prevention is the most effective intervention for skin care. It includes
positioning, consistent and effective pressure relief, skin inspection, and education.
 Areas that are susceptible to skin breakdown :

16.  The wheelchair and seating system should also assist in promoting optimal positioning for
reducing pressure and shear forces on susceptible areas. The pelvis should be positioned
in a neutral position or slightly tilted anteriorly and be symmetrical
 Patients should perform a pressure relief maneuver every 15 minutes when in the
wheelchair, either with assistance or independently.
 From the seated position, this can be done by using a push-up maneuver, leaning to the
side, or leaning forward
 If the patient develops a skin ulcer, the preventive measures described above should
continue to be employed. Various therapies directed at wound healing should be
initiated. Electrical stimulation,hydrocolloid dressings,and occlusive hydrogel dressings

17. Early Strengthening and Range of Motion
 In this early stage of recovery, ROM or strengthening exercises that are too intense
may place increased pressure and stress on vertebral sites that may be unstable and
are still healing.
 Individuals with functional, active wrist extension can learn to use a tenodesis
grasp to use the hand and fingers to perform ADL, manipulate objects, and hold
objects without active finger control.
 An intrinsicplus splintcan be used to position the wrist to maintain the joints in
optimal intrinsic-plus position. This position helps reduce edema, preserve
tenodesis function, and prevent contractures

19. Early Mobility Interventions
 To prevent Postural Hypotension:
 Teach Bed mobility skills
 Patient and family/caregiver education should begin early after injury about the
impact of SCI on the different body systems, secondary complications, and
prognosis

20. ACTIVE REHABILITATION
Goal : to become as independent as possible and
To achieve the functional mobility necessary for everyday living, work, and
recreation.
Independent mobility can be achieved in a way that (1) either uses new movement
strategies to compensate for neuromuscular impairments
Eg tenodesis grasp
with KAFO pt achieve standing
(2) uses the neuromuscular system to accomplish the task with a movement pattern similar
to that before the injury.

21. Physical Therapy Interventions
 Strengthening:
Key UE muscles to strengthen include serratus anterior, latissimus dorsi, pectoralis major,
rotator cuff muscles, and triceps brachii.
These muscles are important for independent transfers. Strengthening exercises should be
performed 2 to 4 times a week, performing 2 to 3 sets of 8 to 12 repetitions at 60% to 80%
of one repetition max.
Strengthening can be done in functional postures as well. For example, push-ups can be
performed in prone-on-elbows and supine-on-elbows.

22.  Cardiovascular/Endurance Training:
Upper extremity–based exercises such as arm ergometry, wheelchair propulsion, and
swimming are the most common method of aerobic training.
In people with iSCI with sufficient walking capacity locomotor training on a TM with or
without BWS is another method of endurance training.
The American College of Sports Medicine (ACSM) recommends endurance training 3 to 5
days a week, with a total duration per day of 20 to 60 minutes at 50% to 80% of peak heart
rate. The duration and intensity of the training should be gradually increased for those not
able to initially tolerate these training levels.
Surface Functional Electrical Stimulation (FES)–induced cycling or walking is also an effective
means of improving cardiovascular fitness

23.  Bed Mobility Skills:
To promote independence in functional mobility.
Bed mobility skills include rolling, transitioning supine to/from sitting on the edge of the
bed, and LE management. Independence in these skills is also necessary for dressing,
positioning in bed, and skin inspection.
Individuals with complete SCI will need to use compensatory movement strategies (e.g.,
momentum, muscle substitution, and head-hips principle) to move the entire body.

25. LOCOMOTOR TRAINING
 A number of factors will influence the success or failure in attaining this goal. Patients
must possess adequate muscle strength, postural alignment, ROM, and sufficient
cardiovascular endurance to become functional ambulators. Becoming a functional
ambulator following a complete SCI is very difficult.
 Individuals with complete SCI rely on orthotic and assistive devices, adequate ROM,
and maximizing strengthen of neurologically intact musculature for standing and
walking.
 Full ROM in hip extension is essential in attaining balance in the upright position. The
patient learns to lean into the anterior ligaments of the hip to stabilize the trunk and
pelvis. The absence of knee flexion and plantarflexion contractures is also important
in attaining upright standing balance.
 Other factors that may restrict ambulation include severe spasticity, loss of
proprioception (particularly at the hips and knees), pain, obesity, and the presence of
secondary complications such as decubitus ulcers, heterotopic bone formation at the
hips, or deformity.

26. Locomotor Training Strategies
 Swing-through and 4-point gait patterns are two common walking patterns learned
by patients with complete SCI using KAFOs.

27.  Relevant training activities include those described below.
1) Putting on and removing orthoses
2) Assistive device: Forearm crutches are most often selected for patients with
3) Sit-to-stand activities: These activities should be practiced in the parallel bars using a
wheelchair, then progressed to using the forearm crutches.
4) Weight shifting in standing: This entails controlling the pelvic position using UE
and positioning the head and shoulders forward ahead of the pelvis. Jackknifing
when the patient’s center of mass (COM) falls anterior to the hips causing the patient
flex forward suddenly.
5) Push-ups. This includes lifting the body off the floor using elbow extension and
depression and protraction.
6) Swing-through pattern.
7) Four-point pattern.This gait pattern is slower but safer than a swing-through pattern;
three points are always in contact with the ground, as opposed to a swing-through
pattern

29. Locomotor Training for Individuals with Incomplete Spinal
Cord Injury
 Locomotor training (LT) for patients with iSCI using partial BWS, a TM, and manual
assistance by trainers is an important therapeutic intervention to retrain walking
after iSCI.
 Locomotor training occurs across three environments: (1) on the TM with use of
BWS and manual facilitation; (2) assessment of the patient’s ability to apply new
skills, and control occurs overground and (3) community integration