9.3 Spinal Cord Injury Rehabilitation (C1-T12+)

Spinal Cord Injury Rehabilitation (C1 to T12+)

Spinal Cord Injury (SCI) results in profound sensorimotor, autonomic, and psychological disruptions. Rehabilitation of individuals with SCI is one of the most rigorous and specialized domains of occupational therapy practice.

The Certified Occupational Therapy Assistant (COTA), under the supervision of an OTR, implements targeted interventions to maximize functional independence, preserve critical biomechanical tenodesis grasp, prescribe complex assistive technology, prevent pressure ulcers, and respond instantaneously to life-threatening autonomic emergencies.

1. SCI Classification & The ASIA Impairment Scale (AIS)

The American Spinal Injury Association (ASIA) Impairment Scale (AIS) is the international gold-standard clinical tool for classifying neurological level and completeness of spinal cord injuries.

+-----------------------------------------------------------------------------+
|                   ASIA IMPAIRMENT SCALE (AIS) GRADES                        |
|                                                                             |
|   [GRADE A: COMPLETE]                                                       |
|   • No motor or sensory function is preserved in the sacral segments S4–S5. |
|                                                                             |
|   [GRADE B: SENSORY INCOMPLETE]                                             |
|   • Sensory but NOT motor function is preserved below the neurological level|
|     and includes the sacral segments S4–S5.                                 |
|                                                                             |
|   [GRADE C: MOTOR INCOMPLETE]                                               |
|   • Motor function is preserved below the neurological level, and MORE THAN |
|     half of key muscle functions below the NLI have a muscle grade < 3/5.   |
|                                                                             |
|   [GRADE D: MOTOR INCOMPLETE]                                               |
|   • Motor function is preserved below the neurological level, and AT LEAST  |
|     half (half or more) of key muscle functions below NLI are >= 3/5.       |
|                                                                             |
|   [GRADE E: NORMAL]                                                         |
|   • Motor and sensory functions are completely normal.                      |
+-----------------------------------------------------------------------------+

Clinical Incomplete Cord Syndromes

2. Functional Outcomes & Key Muscle Innervations by Spinal Level

The neurological level of injury (NLI) determines the available key muscle motor power and dictates realistic functional goals, adaptive equipment needs, and caregiver requirements.

+-----------------------------------------------------------------------------+
|                  KEY UPPER EXTREMITY MYOTOMES (C1 - T1)                     |
|                                                                             |
|   • C1–C3: Neck flexion, extension, rotation (Ventilator Dependent)         |
|   • C4:    Diaphragm (breathing) & Upper Trapezius (Shoulder shrug)         |
|   • C5:    Deltoids (Shoulder flexion/abduction) & Biceps (Elbow flexion)   |
|   • C6:    Extensor Carpi Radialis (Wrist extension -> TENODESIS GRASP)     |
|   • C7:    Triceps Brachii (Elbow extension) & Wrist flexors                |
|   • C8:    Flexor Digitorum Profundus (Finger flexion / Power grasp)        |
|   • T1:    Hand Intrinsics (Interossei / Lumbricals -> Abduction/Adduction) |
+-----------------------------------------------------------------------------+

Comprehensive SCI Functional Outcome Matrix (C1 to T12+)

3. Tenodesis Grasp Action & Preservation Rules (C6 SCI)

At the C6 spinal cord level, innervation of the Extensor Carpi Radialis Longus and Brevis enables active wrist extension, while the finger flexors (Flexor Digitorum Profundus and Superficialis, innervated by C8) remain paralyzed.

The Tenodesis Biomechanical Mechanism:

• When the client actively extends the wrist, the passive mechanical tension of the finger flexor tendons pulls the fingers into functional flexion (grasp) against the thumb.
• When the client passively flexes the wrist, tension is released, and gravity allows the fingers to open (release).

+-----------------------------------------------------------------------------+
|                     TENODESIS BIOMECHANICAL ACTION (C6)                     |
|                                                                             |
|   [ACTIVE WRIST EXTENSION]  ===================>  [PASSIVE FINGER FLEXION]  |
|   • Extensor carpi radialis contracts.            • Tendons shortened.      |
|   • Pulls finger flexor tendons taut.             • Functional grasp forms. |
|                                                                             |
|   [PASSIVE WRIST FLEXION]   ===================>  [PASSIVE FINGER EXTENSION]|
|   • Wrist drops into flexion.                     • Tendons relaxed.        |
|   • Flexor tension released.                      • Fingers open/release.   |
+-----------------------------------------------------------------------------+

[!CAUTION] CRITICAL COTA CLINICAL RULE: Preserving Tenodesis Tightness: To ensure a functional tenodesis grasp, the practitioner must foster slight tightness (contracture) in the finger flexor tendons:

1. When stretching the wrist into extension, ALWAYS KEEP THE FINGERS FULLY FLEXED into a fist!
2. When stretching the fingers into extension, ALWAYS KEEP THE WRIST FULLY FLEXED!
3. NEVER stretch the wrist and fingers into extension simultaneously! Overstretching finger flexors permanently destroys the passive tenodesis grasp, rendering a C6 client unable to hold a cup, fork, or pen.

4. Autonomic Dysreflexia (AD) vs. Orthostatic Hypotension

Individuals with spinal cord injuries at or above the T6 level are susceptible to two opposing, potentially life-threatening cardiovascular emergencies.

+-----------------------------------------------------------------------------+
|               AUTONOMIC DYSREFLEXIA vs. ORTHOSTATIC HYPOTENSION             |
|                                                                             |
|   [AUTONOMIC DYSREFLEXIA (AD)]               [ORTHOSTATIC HYPOTENSION (OH)] |
|   • Level: T6 and ABOVE.                     • Level: T6 and ABOVE.         |
|   • Blood Pressure: EXTREME HYPERTENSION     • Blood Pressure: SEVERE DROP  |
|     (e.g., 200/100 mmHg; >20-40 above base).   (Systolic drop >= 20 mmHg).  |
|   • Heart Rate: BRADYCARDIA (<60 bpm).       • Heart Rate: TACHYCARDIA.     |
|   • Symptoms: Pounding headache, profuse     • Symptoms: Dizziness, pallor, |
|     sweating/flushing ABOVE lesion, cold/      lightheadedness, syncope/    |
|     pale/goosebumps BELOW lesion.              fainting upon sitting up.    |
|                                                                             |
|   [IMMEDIATE EMERGENCY ACTION - AD]          [IMMEDIATE EMERGENCY ACTION - OH|
|   1. IMMEDIATELY SIT CLIENT UPRIGHT (90°)!   1. IMMEDIATELY RECLINE CLIENT! |
|   2. Loosen tight clothing & binders.        2. Elevate lower extremities.  |
|   3. Check/drain catheter for kinks.         3. Apply abdominal binder and  |
|   4. Notify medical team immediately.           elastic compression hose.   |
+-----------------------------------------------------------------------------+

Step-by-Step Emergency Protocol for Autonomic Dysreflexia (AD):

1. IMMEDIATELY SIT THE PATIENT FULLY UPRIGHT (90°): Lower the legs over the side of the bed or keep feet on wheelchair footrests. Rationale: Upright sitting creates orthostatic pooling of blood in the splanchnic and lower extremity vascular beds, immediately reducing blood pressure and preventing intracerebral hemorrhage or stroke. NEVER LAY AN AD PATIENT SUPINE!
2. Loosen All Constrictive Attire: Immediately unfasten tight abdominal binders, compression hose, tight pants, belts, and shoes.
3. Inspect the Urinary Drainage System: Bladder distension is the #1 cause of AD ($>80%$ of cases). Check for kinked, twisted, or clamped Foley catheter tubing; check catheter bag for overfilling; gently irrigate if plugged.
4. Check for Bowel Impaction or Skin Irritants: If the catheter is clear, check for fecal impaction, ingrown toenails, or sharp objects pressing against skin.
5. Alert Medical Staff & Monitor Vitals: Summon the emergency medical team/nursing staff immediately; recheck blood pressure every 2 to 5 minutes.

5. Wheelchair Seating, Skin Integrity & Pressure Relief Schedules

Due to the complete loss of cutaneous sensation and vasomotor control below the level of injury, clients with SCI face extreme risks of ischemic pressure injuries over bony prominences (ischial tuberosities, sacrum, greater trochanters, heels).

Standardized Pressure Relief Protocols:

• Wheelchair Pressure Relief Schedule: The client must perform weight shifts every 15 to 30 minutes for a duration of 30 to 60 seconds.
• Weight Shift Techniques:
  • Power Tilt-in-Space Wheelchair: Tilt back $\ge 45^\circ$ to achieve complete offloading of ischial tuberosities (essential for C1–C4 clients).
  • Forward Lean: Leaning forward chest-to-knees to offload sacral and ischial pressures (C5–C6 clients).
  • Lateral Lean: Leaning to one side for 30–60 seconds, then alternating to the opposite side.
  • Depression Push-Up: Pushing straight up off wheelchair armrests (C7–T1 clients with functional triceps).
• Skin Inspection: Perform complete visual skin checks twice daily (morning and evening) using a long-handled inspection mirror.