11.1 Spinal Cord Injury Rehabilitation

Quick Answer: Reason from neurological level and completeness (AIS concepts) first. Treat autonomic dysreflexia (typically ≥T6) as an emergency—sit upright if safe, loosen constrictions, remove noxious stimuli, escalate. Protect skin and respiration every session. Choose transfers, equipment, and goals that match residual motor capacity—not a generic “paralysis” protocol.

Spinal cord injury (SCI) cases on the APC Written Assessment test whether you can reason from neurological level and completeness, recognise life-threatening autonomic and respiratory complications, prevent secondary harm (especially pressure injury), and plan mobility and transfers with realistic equipment and team support. You are not expected to run a specialist spinal unit or invent surgical decisions. You are expected to keep people safe, escalate emergencies, dose rehab to capacity, and communicate clearly with medical, nursing, occupational therapy, and social-work colleagues.

Level and Completeness: The Framework That Drives Everything

Neurological level of injury is the most caudal spinal segment with normal sensory and motor function on both sides (clinical definition used in ISNCSCI/ASIA examination frameworks). In practice, physiotherapists use documented level (for example C5, C6, T4, L1) plus key muscle groups and sensory findings to predict function:

Completeness is commonly discussed with AIS (ASIA Impairment Scale) concepts:

• Complete (AIS A): no sacral sparing (no motor or sensory function in the lowest sacral segments).
• Incomplete (AIS B–D): some sensory and/or motor sparing below the level, including sacral sparing patterns that matter for prognosis and rehab intensity.

For exam purposes, you do not need to memorise every motor root table under timed pressure, but you must use level and completeness to set expectations: a complete C4 injury is not “just weaker” than incomplete L3—it is a different medical and rehab universe (ventilation, care needs, transfer method, equipment, goals).

Central cord, Brown-Séquard, anterior cord, and cauda equina / conus patterns may appear as incomplete syndromes. Central cord (often older adults after hyperextension) classically has greater upper-limb than lower-limb weakness. Cauda equina is a lower-motor-neuron pattern with possible pain, areflexia, and bowel/bladder red flags—treat new saddle anaesthesia or bladder retention as urgent medical/surgical referral, not as a routine MSK back case.

Autonomic Dysreflexia: Non-Negotiable Emergency Reasoning

Autonomic dysreflexia (AD) is a sudden, uninhibited sympathetic discharge usually in people with SCI at or above T6 (sometimes reported slightly lower). A noxious stimulus below the lesion (distended bladder, constipation, tight clothing, pressure injury, UTI, fractures, labour, ingrown toenail, kinked catheter) triggers massive vasoconstriction below the level, pounding headache, flushing/sweating above the lesion, bradycardia or other rhythm change, anxiety, and dangerous hypertension.

Immediate physiotherapy-aligned actions (exam gold):

1. Recognise: sudden headache + hypertension + SCI ≥T6 risk = AD until proven otherwise.
2. Sit the person upright (if safe) and lower the legs if possible—do not leave them flat while hypertensive (lying flat can worsen cerebral hyperperfusion risk).
3. Loosen tight clothing, binders, straps, abdominal binders if contributing.
4. Search and remove noxious stimuli—most commonly bladder: check catheter kinks, empty bladder per nursing protocol; check bowels, skin, genitals, fractures, tight footwear.
5. Escalate urgently to medical/nursing emergency response; AD can cause seizure, stroke, or death.
6. Do not continue passive ROM, aggressive stretch, or painful treatment while AD is active.

APC traps: treating AD as “just anxiety,” continuing therapy because the session is booked, or laying the person flat to “rest.” Best answers prioritise upright positioning (if safe), stimulus removal, and emergency escalation.

Bladder and bowel dysfunction after SCI is almost universal above certain levels and is managed primarily by nursing/continence specialists, but physiotherapists must understand that distended bladder and faecal loading are the most common AD triggers. Time therapy around known bladder schedules when possible, and never ignore a sudden request to check the catheter during headache and hypertension.

Pressure Injury Prevention as Core Rehabilitation

Pressure injuries are a leading source of morbidity after SCI. Skin over sacrum, ischia, trochanters, heels, occiput, and scapulae is vulnerable with sensory loss, immobility, moisture, poor nutrition, and shear during transfers. Physiotherapy contribution is not optional education—it is daily system design:

• Scheduled pressure relief in bed (turn/reposition) and in wheelchair (weight shifts, tilt-in-space, push-up relief when triceps allow—only if safe for shoulders and skin).
• Equipment: appropriate mattress/cushion, wheelchair setup, heel offloading; flag inadequate seating early to OT/seating clinic.
• Transfer technique: reduce shear and dragging; train carers and use slide boards/hoists correctly rather than “strong” lifts that abrade skin.
• Inspection partnership: person (with mirror/phone if able) and carers inspect high-risk areas; any non-blanching redness or open area changes mobility and sitting tolerance immediately.
• Load management when skin is threatened: reduce sitting time, modify therapy surfaces, escalate wound care—do not “push through” a stage 1 injury for the sake of extra gym minutes.

Respiratory Complications in High Lesions

Lesions affecting phrenic innervation (C3–C5 roots critical for diaphragm) and thoracic muscles impair tidal volume, cough effectiveness, and secretion clearance. Even mid-cervical injuries with some diaphragm function may have weak accessory and abdominal contribution. Complications include atelectasis, pneumonia, retained secretions, and ventilatory failure.

Entry-level respiratory priorities:

• Assess work of breathing, SpO2 trends, cough effectiveness, sputum, chest expansion, and fatigue with talking or slight effort.
• Position to optimise ventilation (within spinal precautions and comfort); avoid prolonged slumped postures that reduce lung volumes.
• Assisted cough / secretion management when indicated and within local competence and medical clearance—coordinate with nursing and respiratory physiotherapy pathways.
• Early mobilisation and upright sitting when medically allowed support ventilation better than pure bed rest for many people.
• Escalate rising oxygen need, rising CO2 suspicion, silent ineffective cough with retention, or fever with chest change—do not treat evolving respiratory failure as “deconditioning only.”

Spinal precautions (collar, log-roll, bracing) may coexist early post-injury or post-surgery. Follow medical orders for movement; do not “free the neck” for a better stretch if stability is not cleared.

Mobility, Transfers, and Functional Goals

Mobility planning is level- and goal-specific:

• Bed mobility and rolling with adaptive strategies and equipment.
• Sitting balance (long sit, edge of bed) as a foundation for dressing and transfers.
• Transfers: dependent hoist, slide-board, pop-over, standing pivot with or without bracing—chosen by residual strength, body habitus, shoulder health, skin, and carer capacity—not by a single “ideal” method.
• Wheelchair skills (propulsion, wheelies where appropriate, ramps, community access) for many thoracic and cervical levels.
• Standing/walking programs for selected incomplete injuries with orthoses, parallel bars, body-weight support, or robotic systems where available—criteria-based, not universal.

Tenodesis grasp awareness matters at lower cervical levels (commonly taught around C6–C7 patterns): active wrist extension can create passive finger flexion for functional grip. Avoid overstretching finger flexors into full simultaneous wrist and finger extension that permanently lengthens the tenodesis mechanism when that strategy is part of the person’s hand function plan—coordinate with the spinal team and OT.

Shoulder preservation matters lifelong for wheelchair users: avoid extreme repetitive loading without strength base; address pain early. Lower-limb contracture prevention (especially hip, knee, ankle) supports seating, hygiene, and future standing options—gentle, regular ROM within spasticity and AD awareness.

Spasticity can aid transfers or obstruct them; management is multidisciplinary (medication, positioning, therapy). Pain may be musculoskeletal, neuropathic, or visceral—do not assume all pain is “stretch intolerance.”

Team Care, Psychosocial Context, and Discharge

SCI rehab is inherently multidisciplinary: medical/spinal specialists, nursing, physiotherapy, OT, social work, psychology, continence services, dietetics, peer support. Physiotherapists contribute objective motor/sensory/respiratory/mobility data, equipment recommendations, carer training, and realistic goal setting with the person.

Psychosocial adjustment, grief, and autonomy are central. Shared decision-making, cultural safety, and respectful communication about body image, sexuality (refer appropriately), return to work/study, and sport are part of professional practice—not optional soft skills. In Australian contexts, discharge may involve NDIS planning, home modifications, community nursing, and equipment funding pathways; document function in terms funders and teams understand (assistance levels, transfers, wheelchair propulsion distance, sitting tolerance).

APC Case Patterns and Common Traps

Typical traps:

• Ignoring pounding headache and high BP in a T4 complete injury during bladder training or ROM.
• Continuing sitting endurance on a new sacral pressure area.
• Pushing aggressive upright gait trials in an unstable acute complete C5 injury with rising oxygen needs.
• Forgetting that incomplete injuries can still develop AD if the level is high enough.
• Choosing independence goals that ignore carer injury risk or home environment.

Best answers usually: stabilise/escalate emergencies → protect skin and respiration → choose safe transfer/mobility method matched to level → train person and team → review goals as neurological status evolves.

Closing Exam Anchor

If you remember only one sentence from this section: SCI physiotherapy is level- and completeness-driven safety work first—autonomic dysreflexia and respiratory failure kill faster than missed tenodesis training—then progressive, equipment-supported function with relentless pressure care and team partnership.