Spinal Cord

Management
• Lecture pattern
• Theory/ concept
• Activity

• Assignments

• FAIR method
 Books
• Management of spinal cord injury by Lisa
Harvey
• Tetraplegia and paraplegia by Ida Bromly
• Neurological rehabilitation by Darcy A
Umphered (567-657)
• Physical rehabilitation O Sullivan (938-996)
• www.Physiotherapyexercises.com
• Related materials
• Length of spinal cord
• Development

• Central pattern generators

• Sensory, motor and reflexes
 Gross Anatomy of the Spinal Cord
 The spinal cord is an elongated structure, Roughly
cylindrical And slightly flattened antero- posteriorly
occupying the Upper 2/3rd of the vertebral column.
Superiorly it is continuous with the medulla oblongata
and inferiorly it has a tapering end the conus medullaris.
 The diameter of the spinal cord changes along its
length because the amount of gray matter and white
matter and the function of the cord vary in different
regions. It tappers cranio-caudally except for the
enlargements.
 The cervical enlargement is the source of the spinal
nerves to the upper limb and extends from the level of
the 3rd cervical segment to the level of the 2nd thoracic
segment. The lumbosacral enlargement is the source of
the spinal nerves to the lower limb and extends from the
level of the 1st lumbar to the 3rd sacral spinal segments.
 Average Length is : 42 -45 cm. Average weight is 30g.
 Gross Anatomy of the Spinal Cord
 In the fetus, during the third month
the spinal cord is as long as the vertebral
column. At birth it ends at the level of the
3rd lumbar vertebra. In adults it ends at the
lower border of the 1st lumbar vertebra
however it may end as high as the caudal 3rd
of the 12th thoracic vertebra or as low as
the disc Between 2nd and the 3rd lumbar
vertebra. At first all the spinal segments
are located at the level of the corresponding
vertebra. As the spinal cord ascends the
roots of the spinal nerves are stretched
upwards forming a bundle of nerves
extending
form the spinal cord to the approriate
intervertebral foramen, this bundle of
nerves is called cauda acquina (horse tail).
 The Spinal Cord
• Link between the brain and the body.
• Pathway for sensory and motor impulses.
• Responsible for reflexes .

16-9
Anatomy of the Spine
 POSTURE AND BIOMECHANICAL INFLUNCE

• Alignment
– Curves of the spine
• The adult spine is divided into four curves:
A) Two primary/posterior curves
A) Thoracic region
B) Sacral region

B) Two secondary/compensatory curve

A) Cervical region
B) Lumber region
 Lumbar Spine Anatomy
• Typical lumbar vertebra
(L2)
– Body
– Vertebral foramen/canal
– Intervertebral foramen
Superior A Lateral P
– Pedicle
Superior
– Transverse process
inferior – Lamina
– Spinous process
– Facet joints
superior Inferior
Anterior (oblique) Posterior – Pars interarticularis
(oblique)
 Lumbar Spine Anatomy
• Ligaments
1 1. Anterior longitudinal
ligament
6 2. Posterior longitudinal
ligament
3. Ligamentum flavum
2 4. Interspinous ligaments
5. Supraspinous ligament
5 6. Intertransverse ligaments
4

3
Dr Abdul Ghafoor Sajjad 19
Dr Abdul Ghafoor Sajjad 20
 There are four classifications of disk pathology
• A protrusion may occur where a disk
bulges without rupturing the annulus
fibrosis.
• The disk may prolapse where the
nucleus pulposus migrates to the
outermost fibers of the annulus
fibrosis.
• There may be a disk extrusion, which
is the case if the annulus fibrosis
perforates and material of the
nucleus moves into the epidural
space.
• The sequestrated disk may occur as
fragments from the annulus fibrosis
and nucleus pulposus are outside the
disk proper.
 Structure of the Spinal Cord
• Typical adult spinal cord
– Ranges between 42 and 45 centimeters (cm) (16
to 18 inches) in length.
• In cross section
– Roughly cylindrical
• External surface has two longitudinal
depressions:
– The posterior (dorsal) median sulcus
– The anterior (ventral) median fissure

16-26
 Regions of the Spinal Cord
• The cervical region
– continuous with the medulla oblongata
– contains neurons whose axons form the cervical spinal
nerves (8)
• The thoracic region
– attached to this region are the thoracic spinal nerves (12)
• The lumbar region
– contains the neurons for the lumbar spinal nerves (5)
• The sacral region
– contains the neurons for the sacral spinal nerves (5)
• The coccygeal region
– one pair of coccygeal spinal nerves arises from this region
16-28
 Structure of the Spinal Cord
• The spinal cord is shorter than the vertebral canal
that houses it.
• Conus medullaris:
– tapered inferior end of the spinal cord
– marks the official “end” of the spinal cord proper.
• Cauda equina
– Inferior to conus medularis
– nerve roots (groups of axons) that project inferiorly from
the spinal cord.
• Filum terminale
– Within the cauda equina
– thin strand of pia mater
– helps anchor the conus medullaris to the coccyx.

16-30
31
1. Vertebral body
2. Spinal cord
3. Conus medullaris
4. Intervertebral disc
5. Filum terminale (internum)
6. Subarachnoid space
 Arrangement and Functions of the Spinal
Meninges
• Are continuous with the cranial meninges.
• Structures that encircle the spinal cord, listed from superficial
to deep are:
1. Vertebra
2. Epidural space
3. Dura mater
4. Subdural space
5. Arachnoid
6. Subarachnoid space
7. Pia mater
16-34
35
 Location and Distribution of White Matter
• The white matter of the spinal cord is external
to the gray matter.
• Fibers run in three directions — ascending,
descending, and transversely
• Divided into three funiculi (columns) —
posterior, lateral, and anterior
• Each funiculus contains several fiber tracks
• Fiber tract names reveal their origin and
destination
• Fiber tracts are composed of axons with similar
functions
16-38
40
41
• 1) Dorsal root ganglion 2) Dorsal root
• 3) Lateral horn 4) Posterior horn
• 5) Posterior median sulcus
• 6) Epidural space 7) Central canal
• 8) Posterior funiculus 9) Lateral funiculus
• 10) Anterior median fissure
• 11) Anterior funiculus
• 12) Anterior horn
• 13) Ventral root
ASCENDING TRACTS
• The bundle of the ascending fibers
that are referred to as the
ascending tracts

ASCENDING TRACTS
 Transmit sensation from organs to CNS
 Serves as link between the peripheral NS &
CNS
 Channels through which information are sent
to brain for interpretation

ASCENDING TRACTS
 • The information may be divided
into two main groups
1. Exteroceptive
2. Proprioceptive

ASCENDING TRACTS
• The ascending pathways consist of three neuron

 First Order
• detects stimulus & transmits a signal to spinal cord or
brainstem

Second Order

• carry sensation from 1st order neuron to thallamus

 Third Order

• carry signal from thallamus to cerebral cortex

ASCENDING TRACTS
FUNCTION OF THE
ASCENDING TRACTS
• For conscious perception:
Spinothalamic system
Medial Lemniscal system
• For unconscious perception:
Spinocerebellar
Spino-olivary
Spinotectal
Spinoreticular

Ascending Pathways
1. LATERAL SPINOTHALAMIC TRACT
2. ANTERIOR SPINOTHALAMIC TRACT

Spinothalamic System
• Carries pain and temperature
• Primary fibers ascend or descend 1-2 spinal cord
segments before synapsing with secondary fibers.
• Secondary axons decussate through anterior gray and
white commissures.

Lateral Spinothalamic Tract

• Carries light touch (crude touch), pressure, tickle, itch
• Primary neurons may ascend 8-10 spinal cord segments
before synapsing with secondary neurons.
• Secondary fibers decussate in anterior gray or white
commissures.
• Secondary fibers ascend to synapse with tertiary fibers
in VPL nucleus of thalamus.
• Tertiary fibers ascend through internal capsule to
primary sensory cortex.

Anterior Spinothalamic Tract

• Receive muscles joint information from the muscles
spindles, tendon organs, and joint receptors of the
trunk and lower limb.
• Consists of uncrossed fibers that enter cerebellum
through inferior cerebellar peduncles.
• Transmits ipsilateral proprioceptive information to
cerebellum.

Posterior Spinocerebellar Tract

• Receive muscles joint information from the muscles
spindles, tendon organs, and joint receptors of the
trunk, upper and lower limb.
• Consists of crossed fibers that recross in pons and
enter cerebellum through superior cerebellar
peduncles.
• Transmits ipsilateral proprioceptive information to
cerebellum.

*Anterior Spinocerebellar Tract

• Also called posterior column system.
• Carries sensations for two-point sensation (fine
touch), pressure, and vibration.
• Primary fibers ascend entire length of spinal cord and
synapse with secondary neurons in medulla:
1. Fasciculus gracilis
2. Fasciculus cuneatus

Medial Lemniscus System

• Project to accessory olivary nuclei and cerebellum.
• Contribute to movement coordination associated
primarily with balance.

Spino-Olivary Tracts
Spino-Olivary Tracts
• Project to superior colliculi of midbrain.
• Involved in reflexive turning of the head and eyes
toward a point of cutaneous stimulation.

Spinotectal Tracts
Spino-tectal Tracts
• Involved in arousing consciousness in the reticular
activating system through cutaneous stimulation.

Spinoreticular Tracts
DESCENDING TRACTS
 Descending Spinal Tracts

• Originate from the cerebral cortex & brain

stem
• Concerned with:
 Control of movements
 Muscle tone
 Spinal reflexes & equilibrium
 Modulation of sensory transmission to
higher centers
 Spinal autonomic functions
 Motor or Descending Tracts of the Spinal Cord

Name Location Function

Lateral Lateral Muscles of the limbs,

Corticospinal Column hands, and feet

Anterior Anterior Muscles of the axial

Corticospinal Column skeleton

Rubrospinal Lateral Skeletal muscles of the

Column limbs, hands, and feet

Tectospinal Anterior Skeletal muscles of the

Column head and eyes in response
to visual stimuli
 Motor or Descending Tracts of the Spinal Cord

Name Location Function

Vestibulospinal Anterior Muscle for maintaining balance
column in response to head movements

Lateral Anterior Facilitates flexor reflexes

reticulospinal column Inhibits extensor reflexes

Medial Anterior Facilitates extensor reflexes

reticulospinal column Inhibits Flexor reflexes
• The motor pathways are divided into two
groups
1. Direct pathways
(voluntary motion pathways)
The pyramidal tracts

2. Indirect pathways
(postural pathways),
The extrapyramidal pathways
 Direct (Pyramidal) System

• Regulates fast and fine (skilled) movements

• Originate in the pyramidal neurons in the
precentral gyri,
• Impulses are sent through the corticospinal
tracts and synapse in the anterior horn
• Stimulation of anterior horn neurons activates
skeletal muscles
• Part of the direct pathway, called corticobulbar
tracts, innervates cranial nerve nuclei
 Indirect (Extrapyramidal) System

• Complex and multisynaptic pathways

• The system includes:
• Rubrospinal tracts: control flexor muscles
• Vestibulospinal tracts: maintain balance and
posture
• Tectospinal tracts: mediate head neck, and eye
movement
• Reticulospinal tracts
 Descending Spinal Tracts

• Pyramidal
– Corticospinal
• Extrapyramidal
– Rubrospinal
– Tectospinal
– Vestibulospinal
– Reticulospinal
 Prevalence with spinal cord injury
(US Prevalence (650-900 per million )

20 % complete
ASIA
52 % tetraplegic
People with 32 % Incomplete ASIA B 9%
spinal cord injury ASIA
48 % paraplegic ASIA C 5%

27 % Complete ASIA D 18 %
ASIA

21 % Incomplete
ASIA ASIA B 6%

ASIA C 4 %

ASIA D 12 %
 SPINAL CORD INJURY

Low incidence
High cost disability
Age 16-30yr
Male to female 4:1
Average length of hospital
Acute condition 2to 3 weeks
In rehabilitation 2 to 3months for paraplegics
and 4 to six months tetraplegics
 Etiology

Traumatic

Non-Traumatic
Mechanism
Mechanism
Mechanism
 Traumatic

Most common
Motor vehicle accident
Fall
Gun shot
Earthquake
 Non-Traumatic

Pathological condition
AVM(arteriovenous malformation)
Vertebral subluxation
R.A
DJD
Spinal neoplasm
Infections
MS
ALS
 Classification

Tetraplegia
Complete
Partial
Paraplegia
Complete
Partial
 Designation of lesion level

Most distal uninvolved nerve root segment with normal

function together with skeletal level.
C7 intact
Below C7 no sensory no motor so it will called
C7 Complete Tetraplegia
If some sensation and some muscle function below C7
C7 incomplete or partial Tetraplegia
 Types of Lesion

Complete Lesion

No Sensory sensation below lesion

No Motor function below lesion
 Types of Lesion

Incomplete Lesion

Some Sensory function below lesion

Some Motor function below lesion
 Types of Lesion

Brown Sequard Syndrome

Hemi-section
Stab wounds
Ipsilateral Loss of motor function
Loss of proprioception,light
touch,kinesthesia,two point discrimination

Contralateral Pain and temperature

Reflexes Decreased
Superficial No
Clonus Present
Bibinski’sign Positive
 Types of Lesion

Anterior cord syndrome

Flexion injuries
Anterior damage
Fracture,dislocation,disc protrusion
Loss of motor function
Loss of pain and temperature
Kinesthetic and proprioception preserved
Types of Lesion

Central cord syndrome

Hyperextension injuries
Congenital
Degenerative
More upper extremity (cervical tracts are more centrally)
Normal bowl and bladder control
Types of Lesion

Posterior cord syndrome

Loss of proprioception,kinesthesia and touch

Motor function,pain and temperature are preserved
Loss of stereognosis
Wide based gait
 Types of Lesion

Sacral sparing

Intact sensation
Perianal sensation
Toe flexors active
 Types of Lesion

Cauda equina injuries

Spinal cord ends???

What is cauda equina???
Upper motor and lower motor neuron lesion????

Mostly incomplete
Lower motor lesion
Regeneration power
 Types of Spinal Cord Paralysis
• Depending on the location and the extent of the
injury different forms of paralysis can occur.
• Monoplegia- paralysis of one limb
• Diplegia- paralysis of both upper or lower limbs
• Paraplegia- paralysis of both lower limbs
• Hemiplegia- paralysis of upper limb, torso and lower
leg on one side of the body
• Quadraplegia- paralysis of all four limbs
Dermatome
 Test Dermatome Points at Dots
• Upper Body Test Points
C2 - Occipital Protuberance
C3 - Supraclavicular Fossa
C4 - Acromioclavicular Joint
C5 - Lateral Antecubital Fossa
C6 - Thumb
C7 - Middle Finger
C8 - Little Finger
T1 - Medial Antecubital Fossa
T2 - Apex of Axilla
• Lower Body Test Points
L1 - Upper Anterior Thigh
L2 - Mid Anterior Thigh
L3 - Medial Femoral Condyle
L4 - Medial Malleolus
L5 - Dorsum 3rd MTP Joint
S1 - Lateral Heel
S2 - Popliteal Fossa
S3 - Ischial Tuberosity
S5 - Perianal Area
• V1 - Ophthalmic Division of Trigeminal Nerve (Upper Face)
V2 - Maxillary Division of Trigeminal Nerve (Mid Face)
 Myotomes
• Myotome distributions of the upper and lower extremity are as follows;
C1/C2: neck flexion/extension
C3: neck lateral flexion
C4: shoulder elevation
C5: shoulder abduction
C6: elbow flexion/wrist extension
C7: elbow extension/wrist flexion
C8: finger flexion
T1: finger abduction
L2: hip flexion
L3: knee extension
L4: ankle dorsi-flexion
L5: great toe extension
S1: ankle plantar-flexion/ankle eversion/hip extension
S2: knee flexion
The levels at which muscles receive sufficient innervations to enable reasonable movement

C4 Diaphragm

C5 Shoulder Flexors
Abductors
Elbow Flexors*

C6 Shoulder Extensors
Adductors
Wrist Extensors *

C7 Elbow Extensors *
Thumb Abductors and adductors

C8 Finger Flexors *
Thumb Flexors and extensors

T1 Finger Abductors *
Adductors

T1-T12 Intercostals ,abdominals ,and

trunk
The levels at which muscles receive sufficient innervations to enable reasonable movement

L2 Hip Flexors *
Adductors

L3 Knee Extensors*

L4 Hip Abductors
Ankle Dorsiflexors *

L5 Hip Extensors
Toe Extensors*

S1 Knee Flexors
Ankle Planterflexors *

S2 Toe Flexors
 Ambulation Potential
• ASIA A 3-6%

• ASIA B 50%

• ASIA C 75%

• ASIA D 95%
 Classification of Spinal Cord Injury
ASIA Impairment Scale
• A = Complete: no motor or sensory function preserved in the sacral
segments S4-5 (ie. NO perianal sensation, deep anal sensation, or
voluntary anal contraction)
• B = Incomplete: Sensory but no motor function preserved in the
sacral segments (may not be normal, but is present!)
• C = Incomplete: Motor function is preserved below the neurologic
level, & > ½ of the key muscles below the NLI have a muscle grade of
< than 3
• D = Incomplete: Motor function is preserved below the neurologic
level, & ≥ ½ of the key muscles below the NLI have a muscle grade of
≥ than 3
 The ASIA motor level
A motor assessment is used to define two motor levels: one for the
right and one for the left side of the body.
An ASIA motor assessment involves testing the strength of ten
key muscles. Each key muscle group represents one myotome
between C5 and T1, and between L2 and S1.
Each muscle is tested for strength on the original six-point manual
muscle testing scale where:
• 0 = no muscle contraction
• 1 = a flicker of muscle contraction
• 2 =full range of motion with gravity eliminated
• 3 =full range of motion against gravity
• 4 = full range of motion with added resistance
• 5 = normal strength
 Motor Exam
• 10 “key” muscles (5 upper & 5 lower ext)
• C5-Elbow flexion L2-hip flexion
• C6-wrist extension L3-knee extension
• C7-elbow extension L4-ankle dorsiflexion
• C8-finger flexion L5-toe extension
• T1-finger abduction S1-ankle plantarflexion

– Sacral exam: voluntary anal contraction

(present/absent)
 Clinical Manifestations

Spinal Shock

Period of areflexia
Abrupt withdrawal from higher centers
Loss of reflexes
Flaccidity

Loss of sensation
Several hours to several weeks
24hours typically
 Clinical Manifestations

Impaired temperature control

Hypothalamus
No control of vasodilatation to heat
No control of vasoconstriction to cold
Diaphoresis
 Clinical Manifestations

Respiratory impairments

C1-C3 lesion
Artificial ventilator or phrenic nerve stimulator
Bronchopneumonia and pulmonary embolism
High mortality in acute stage of tetraplegia
Normal breathing pattern??male & female??
Inspiratory muscles and expiration???
Vertical diameter and horizontal diameter
Horizontal diameter decreased in SCI
Clinical Manifestations
Spasticity

Definition
Characteristics
Types
Rigidity
Tone
 Clinical Manifestations
Spasticity
Velocity dependent
Hypertonicity & Exaggerated reflexes
Clonus & Babinski’sign
Gradual increase in first 6 month and plateau reached 1 yr after injury
Spasticity increased by
Positional change
Cutaneous stimuli
Environmental temperature
Tight clothing
UTI
Pressure sores
Emotional stress
• Drugs
– Baclofen
– Dantrolene
– Botulinum toxin
– Phenol

• PT
• Verticalization
• Heat , cold, TENS, electrical stimulation,
hydrotherapy , weight bearing etc
 Clinical Manifestations

Bladder & bowl control

UTI most common in acute stage

Spinal shock Bladder flaccid
Muscle tone absent
Reflexes absent

Micturation center is Conus Medullaris

S2,S3 and S4 reflex control
 Clinical Manifestations

Bladder & bowl control

Two types of bladder

Depends on level of lesion

 Clinical Manifestations

1-Spastic /reflex /autonomic /UMNL

Reflex intact

Contract reflexively empties in response to filling pressure

Triggered by Manual stimulation

Stroking,
Taping
Hair pulling
 Clinical Manifestations

2-Flaccid /non-reflexive /LMNL

No reflex intact

No muscle action (detrusor muscle)

Bladder emptied by increase intra-abdominal pressure (Valsalva

Maneuver)

Crede maneuver (manual compression lower abdomen)

 Indirect impairments

Pressure sore

Pressure area????
Grading
Etiology Vasomotor disturbance
Spasticity
Maceration
Nutrition (decreased protein)
Infection
Positional change after every 2 hours on bed
Positional change after every 15 mints on wheel chair
 Outlines
• Pressure ulcer

• Vasomotor

• Postural sense

• Muscle length
 Pressure ulcers
• Sacrum
• Trochneters
• Ischial tuberosities
• Knees
• Fibula
• Heel
• 5th MT
• Scapula, occipital in cervical lesion
• Under splint where sensation compromise
 Contribution factor
• Loss of sensation
• Loss of voluntary movement
• Loss of vasomotor control
• 30 classification
• Stirling scale described 4 stages

• Stage 0 pre ulcer stage

– Normal intact skin
– Erythematic
– 48 hours resolve inflammation
• Stage 1
– Permanent without damage to superficial layers
– Congestion not disappear on digital pressure
– Skin color change
• Stage 2
– Abrasion of skin and formation of blisters
– Shallow ulcer without underming adjacent tissue
• Stage 3
– Full thickness skin loss
– Not extending to bone , tendon, joint capsule

• Stage 4
– Full thickness
– Up to bone and deep structure

• Osteomylitis
• Ectopic bone formation
• Septicemia and death
 Prevention of ulcer
• Sir Ludwing Guttmann used to say
• ” Where there is no pressure, there will be no sore”

• Relief with correct positioning

• Age, gender, body build, level of injury, degree of incontinence

and general health

• Smoking
• Anemia
• Diabetes
• Turning the patient
– 2-3hour
– Improve renal function

• If side lying not possible adopt hip flick position

– Not in lower thoracic and lumbar fracture
– Each turn inspect the skin

• Redness that not fade on pressure, bruising , swelling warning sign

• Electrical turning and tilting bed
• Prone in non acute lesion if sacrum pressure ulcer
• Ripple Mattress
• Intact skin should be kept clean with soap
and water

• Dead epithelium collect at feet and palm

due to disuse

• Remove and Emollient into skin

 Do’s and don’ts

• The patient is taught the following list of simple do’s and don’ts when he first
gets out of bed:

• Do relieve pressure in the chair for 1.5–2 minutes every half-hour.

• Do lift the paralysed limbs when transferring.
• Do little lifts when using a transfer board or use a sliding sheet to reduce
friction.

• Do cover the tyre of the rear wheel when transferring whilst undressed.
• Do use a mirror to detect marks, abrasions, blisters and redness on buttocks,
back of legs and malleoli

• Do protect the limbs against excessive cold.

• Do have the bath water ready and not too hot.
 Do’s and don’ts
• Don’t force the transfer board under the bottom, lean over to the side
before placing it.

• Don’t allow the clothes to be pulled to be repositioned.

• Don’t open the hot tap when having a bath in case hot water drips on the
toes.

• Don’t have a hot water bottle in bed.

• Don’t expose the body to strong sunlight; tetraplegic patients must wear a
hat.
• Don’t knock the limbs against any hard object.

• Don’t carry hot drinks on the lap.

• Don’t rest the paralysed limbs on hot water pipes or radiators.

• Don’t sit too close to the fire.

• Don’t leave the legs, particularly the feet, unprotected against car heaters.
 Physical proportion of the patient
• Ease and speed
• Height, weight, arm length
• Below C6
• Intrepid or daring patient have good independence

• Study on physical ability complete below C6

• Extensor carpi radialis present, triceps absent

• Long arms and a short trunk

• Its only subjective impression

• Lean further have transfer ability

• Broader hips…..mechanical disadvantages

• Females have narrow shoulder and broader hips so difficult in transfer
If flex elbow ??????? will strengthen
 Indirect impairments

Autonomic dysreflexia (Hyper-reflexia)

Pathological reflex if lesion above T6 level(sympathetic outflow)

Both complete and incomplete lesion

Afferent below lesion initiate reflex response to increase B.P

Normally impulses stimulate carotid sinus and aorta which
adjust PR so maintain B.P

In SCI no regulation from higher centers so no vasodilatation

Emergency condition
 Indirect impairments

Autonomic dysreflexia (Hyper-reflexia)

Stimulus Bladder distension

Pressure sore
Infection

Symptoms HTN,Bradycardia
Headache,sweating

Treatment Sitting,catheter released

Loose clothing,drugs
 Indirect impairments

Postural hypotension

Heterotrophic ossification

Contracture

DVT

Pain Traumatic pain

Nerve root pain
Musculoskeletal pain
• Paralytic ileus
– Food cannot digested
– Aspiration pneumonia
– Nil by mouth
 Spinal Cord Paralysis Levels
C1-C3
 All daily functions must be totally assisted
 Breathing is dependant on a ventilator
 Motorised wheelchair controlled by sip and puff or chin movements is
required
C4
 Same as C1-C3 except breathing can be done without a ventilator
C5
 Good head, neck, shoulder movements, as well as elbow flexion
 Electric wheelchair, or manual for short distances
C6
 Wrist extension movements are good
 Assistance needed for dressing, and transitions from bed to chair and
car may also need assistance
C7-C8
 All hand movements
 Ability to dress, eat, drive, do transfers, and do upper body washes
 Spinal Cord Paralysis Levels
T1-T4 (paraplegia)
• Normal communication skills
• Help may only be needed for heavy household work or
loading wheelchair into car
T5-T9
• Manual wheelchair for everyday living
• Independent for personal care
T10-L1
• Partial paralysis of lower body
L2-S5
• Some knee, hip and foot movements with possible slow
difficult walking with assistance or aids
• Only heavy home maintenance and hard cleaning will need
assistance
Cervical paraspinal, sternocleidomastoid, neck accessory muscles, partial
innervation of diaphragm

C1 – 3 Levels Expected Functional Outcomes Equipment

Respiratory • Ventilator dependent • 2 ventilators (bedside, portable)
• Inability to clear secretions • Suction equipment
• Generator/battery backup

Bowel Total assist • Padded reclining shower/commode chair

(if roll-in shower available)
Bladder Total assist
Bed Mobility Total assist • Full electric hospital bed with Trendelenburg
feature
• side rails
Transfers Total assist • Transfer board
• Power or mechanical lift with sling

Pressure relief Total assist; may be independent • Power recline and/or tilt W/C
with equipment • W/C pressure-relief cushion
• Postural support and head control devices as
indicated
• Hand splints may be indicated
• Specialty bed or pressure-relief mattress may
be indicated
Eating Total assist
Dressing Total assist
Grooming Total assist
 Cervical paraspinal, sternocleidomastoid, neck accessory muscles, partial
innervation of diaphragm

C1 – 3 Levels Expected Functional Outcomes Equipment

Bathing Total assist • Handheld shower

• Shampoo tray
• Padded reclining shower/commode chair
(if roll-in shower available)
W/C propulsion Manual: Total assist • Power recline and/or tilt W/C with head, chin,
Power: Independent with or breath control
equipment • Manual recliner W/C
• Vent tray
Standing/ Standing: Total assist
Ambulation Ambulation: Not indicated
Communication Total assist to independent, • Mouth stick, high-tech computer access,
depending on work station setup environmental control unit
and equipment availability • Adaptive devices everywhere as indicated

Transportation Total assist • Attendant-operated van (e.g. lift, tie-downs) or

accessible public transportation
Homemaking Total assist
Assist Required • 24-hour attendant care to include
homemaking
• Able to instruct in all aspects of
care
 Further innervation of diaphragm & paraspinal muscles

C4 Level Expected Functional Outcomes Equipment

Respiratory May be able to breathe without a If not ventilator free then same equipment as for
ventilator C1-3

Bowel Total assist • Padded reclining shower/commode chair

(if roll-in shower available)
Bladder Total assist
Bed Mobility Total assist • Full electric hospital bed with Trendelenburg
feature
• side rails
Transfers Total assist • Transfer board
• Power or mechanical lift with sling

Pressure relief Total assist; may be independent • Power recline and/or tilt W/C
with equipment • W/C pressure-relief cushion
• Postural support and head control devices as
indicated
• Hand splints may be indicated
• Specialty bed or pressure-relief mattress may
be indicated
Eating Total assist
Dressing Total assist
Grooming Total assist
 Further innervation of diaphragm & paraspinal muscles

C4 Level Expected Functional Outcomes Equipment

Bathing Total assist • Handheld shower

• Shampoo tray
• Padded reclining shower/commode chair (if
roll-in shower available)
W/C propulsion Manual: Total assist • Power recline and/or tilt W/C with head, chin,
Power: Independent or breath control
• Manual recliner W/C
• Vent tray
Standing/ Standing: Total assist • Tilt table
Ambulation Ambulation: Not indicated • Hydraulic standing table

Communication Total assist to independent, • Mouth stick, high-tech computer access,

depending on work station setup environmental control unit
and equipment availability
Transportation Total assist • Attendant-operated van (e.g. lift, tie-downs) or
accessible public transportation
Homemaking Total assist
Assist Required • 24-hour attendant care to include
homemaking
• Able to instruct in all aspects of
care
Biceps (elbow flexors), deltoids, rhomboids, partial innervation of serratus
anterior (shoulder flexion, extension, & abduction)

C5 Level Expected Functional Outcomes Equipment

Respiratory May require assist to clear secretions

Bowel Total assist • Padded shower/commode chair or transfer

tub bench with commode cutout
Bladder Total assist • Adaptive devices may be indicated (electric
leg bag emptier)
Bed Mobility Some assist • Full electric hospital bed with Trendelenburg
feature
• side rails
Transfers Total assist • Transfer board
• Power or mechanical lift with sling

Pressure relief Independent with equipment • Power recline and/or tilt W/C
• W/C pressure-relief cushion
• Postural support and head control devices as
indicated
• Hand splints may be indicated
• Specialty bed or pressure-relief mattress
may be indicated
Eating Assist for setup, then independent • Long opponens splint
with equipment • Adaptive devices as indicated

Dressing Lower extremity: Total assist • Long opponens splint

Upper extremity: Some assist • Adaptive devices as indicated

Grooming Some to total assist • Long opponens splint

• Adaptive devices as indicated
Biceps (elbow flexors), deltoids, rhomboids, partial innervation of serratus
anterior (shoulder flexion, extension, & abduction)

C5 Level Expected Functional Outcomes Equipment

Bathing Total assist • Handheld shower

• Padded tub transfer bench or
shower/commode chair
W/C propulsion Manual: Independent to some assist • Power recline and/or tilt W/C with arm drive
indoors on noncarpet, level surface; control
some to total assist outdoors • Manual lightweight rigid or folding W/C with
Power: Independent handrim projections

Standing/ Standing: Total assist • Hydraulic standing frame

Ambulation Ambulation: Not indicated
Communication Independent to some assist after • Long opponens splint
setup and equipment availability • Adaptive devices as indicated for page
turning, writing, button pushing
Transportation Independent with highly specialized • Highly specialized modified van with lift
equipment; some assist with
accessible public transportation; total
assist for attendant-operated vehicle
Homemaking Total assist
Assist Required • Personal care: 10 hours/day
• Homecare: 6 hours/day
• Able to instruct in all aspects of care
Wrist extensors

C6 Level Expected Functional Outcomes Equipment

Respiratory May require assist to clear
secretions
Bowel Some to total assist • Padded shower/commode chair or transfer
tub bench with commode cutout
• Adaptive devices as indicated
Bladder Some to total assist with • Adaptive devices may be indicated
equipment; may be independent
with leg bag emptying
Bed Mobility Some assist • Full electric hospital bed
• side rails

Transfers Level: some assist to independent • Transfer board

Uneven: some to total assist • mechanical lift

Pressure relief Independent with equipment • Power recline and/or tilt W/C
and/or adapted techniques • W/C pressure-relief cushion
• Postural support devices
• Pressure-relief mattress or overlay may be
indicated
Eating Assist for setup (cutting), then • Adaptive devices as indicated (e.g. u-cuff,
independent tenodesis splint, adapted utensils, plate guard)

Dressing Lower extremity: some to total • Adaptive devices as indicated (e.g. button
assist hook, loops on zippers, Velcro on shoes)
Upper extremity: independent
Grooming Some assist to independent with • Adaptive devices as indicated (e.g. u-cuff,
equipment adapted handles)
Long opponens splint
Long opponens splint
 Occupational therapy

Taping (Hands splinting) Eating Aid Wheel Chair Propelling

Writing Aid Typing Aids

Wrist extensors

C6 Level Expected Functional Outcomes Equipment

Bathing Lower body: some to total assist • Handheld shower

Upper body: independent • Padded tub transfer bench or
shower/commode chair
• Adaptive devices as indicated
W/C propulsion Manual: Independent indoors; • May require standard upright power or
some to total assist outdoors recline
Power: Independent • Manual lightweight rigid or folding W/C with
modified rims
Standing/ Standing: Total assist • Hydraulic standing frame
Ambulation Ambulation: Not indicated
Communication Independent • Adaptive devices as indicated for page
turning, writing, button pushing
Transportation Independent driving from W/C • Modified van with lift and tie-downs
• Sensitized hand controls

Homemaking Some assist with light meal prep; • Adaptive devices as indicated
total assist for other homemaking
Assist Required • Personal care: 6 hours/day
• Homecare: 4 hours/day
Triceps (elbow extensors), finger flexors

C7 – 8 Levels Expected Functional Outcomes Equipment

Respiratory May require assist to clear secretions

Bowel Some to total assist • Padded shower/commode chair or transfer

tub bench with commode cutout
• Adaptive devices as indicated
Bladder Independent to some assist • Adaptive devices may be indicated

Bed Mobility Independent to some assist • Full electric hospital bed or full to king
standard bed
Transfers Level: independent • May need transfer board
Uneven: independent to some assist
Pressure relief Independent • W/C pressure-relief cushion
• Postural support devices as indicated
• Pressure-relief mattress or overlay may be
indicated
Eating Independent • Adaptive devices as indicated

Dressing Lower extremity: independent to • Adaptive devices as indicated

some assist
Upper extremity: independent
Grooming Independent • Adaptive devices as indicated
Triceps (elbow extensors), finger flexors

C7 – 8 Levels Expected Functional Outcomes Equipment

Bathing Lower body: independent to some • Handheld shower

assist • Padded tub transfer bench or
Upper body: independent shower/commode chair
• Adaptive devices as indicated
W/C propulsion Manual: Independent indoors and • Manual lightweight rigid or folding W/C with
level outdoor terrain; some assist modified rims
uneven terrain
Standing/ Standing: Independent to some • Hydraulic or standard standing frame
Ambulation assist
Ambulation: Not indicated
Communication Independent • Adaptive devices as indicated

Transportation Independent car if independent with • Modified vehicle

transfer and W/C loading/ unloading;
independent driving modified van
from captain’s seat
Homemaking Independent light meal prep and light • Adaptive devices as indicated
housecleaning; some to total assist
for complex meal prep and heavy
housekeeping
Assist Required • Homecare: 2 hours/day
• Personal care: 6 hours/day
T1 – 9 Levels Expected Functional Outcomes Equipment
Respiratory
Bowel Independent • Elevated padded toilet seat or tub bench with
commode cutout
• Adaptive devices as indicated
Bladder Independent
Bed Mobility Independent • Full to king standard bed

Transfers Independent • May need transfer board

Pressure relief Independent • W/C pressure-relief cushion

• Postural support devices as indicated
• Pressure-relief mattress or overlay may be
indicated
Eating Independent
Dressing Independent
Grooming Independent
T1 – 9 Levels Expected Functional Outcomes Equipment
Bathing Independent • Handheld shower
• Padded tub transfer bench or
shower/commode chair

W/C propulsion Independent • Manual lightweight rigid or folding W/C

Standing/ Standing: Independent • Standard standing frame

Ambulation Ambulation: Typically not functional

Communication Independent
Transportation Independent in car, including W/C • Hand controls
loading/unloading

Homemaking Independent complex meal prep and • Adaptive devices as indicated

light housecleaning; some to total
assist for heavy housekeeping

Assist Required • Personal care: 6 hours/day

• Homecare: 2 hours/day
Management
 Management
• Goal of spine trauma care
• Pre-hospital management
• Clinical and neurologic assessment
• Acute spinal cord injury
– type and clinical characteristic
• Common cervical spine fracture and
dislocation
 Goal of spine trauma care
• Protect further injury during evaluation and
management

• Identify spine injury or document absence of

spine injury

• Optimize conditions for maximal neurologic

recovery
 Goal of spine trauma care
• Maintain or restore spinal alignment

• Minimize loss of spinal mobility

• Obtain healed & stable spine

• Facilitate rehabilitation
 Suspected Spinal Injury
• High speed crash
• Unconscious
• Multiple injuries
• Neurological deficit
• Spinal pain/tenderness
 Pre-hospital management

• Protect spine at all times during the

management of patients with multiple injuries

• Up to 15% of spinal injuries have a second

(possibly non adjacent) fracture elsewhere in
the spine

• Ideally, whole spine should be immobilized in

neutral position on a firm surface
• 20% cases can be prevented from further
complications if handle safely
 Assessment
Palpation of neck: pain, obvious deformity,
bleeding, spasm?
Motor testing of upper extremities
Sensory testing of upper extremities
Motor testing of lower extremities
Sensory testing of lower extremities
Reassessment of vital signs
 Continued reassurance of the injured person
 Upper-extremity motor function
testing

A-Bilateral comparison of
grip strength B: Finger abduction/adduction. C:Wrist extension
 Upper-extremity sensory testing

A: Soft brush, repeated over as many B: Sharp pin, repeated

dermatomes over as many dermatomes as possible.
as possible.
 Lower-extremity Motor Function
Testing.

A:“Pushing on the gas pedal” (ankle B: Pulling toes toward the head
plantarflexion). (ankle dorsiflexion).
 Warring Signs
 The presence of shallow, diaphragmatic or absent
respirations, hypotension, or bradycardia is a strong
indication of injury to the spinal cord.
 Another important vital sign to watch carefully in an
injured person with a potential spinal cord injury is body
temperature. Individuals with spinal cord injuries lose
their ability to maintain normal body temperature;
therefore, one may note fluctuations, especially below
the level of the injury.
 Any deterioration in vital signs is indicative of an
emergent situation.
 Management

• After completing the evaluation process and determining that the

person needs to be immobilized, many things need to be
accomplished.
• First, activation of the emergency action plan should be initiated if it
hasn’t already, including notification of the local EMS system.
• A rigid cervical collar should be applied if possible and the patient
should be stabilized by manual means, which should be maintained
throughout the management process.
• Retrieval of the appropriate equipment, including a spine board,
straps, head immobilization device, and airway control devices to
carry out the necessary procedures, is also essential.
• The major goal of managing a suspected injury to the spinal cord is
to maintain a neutral, in line position.
 On-Site Assessment of an
Injured person with a Potential Cervical
Spine Injury

 Determine mechanism of injury if possible.

 Determine level of consciousness of the injured
person if possible.
 Manually stabilize head and neck of injured person.
 Check ABCs. This may require rolling a prone person.
 Activate EMS, manage airway, and begin rescue
breathing or CPR if necessary.
 Perform secondary assessment.
 Continue to monitor vital signs for changes.
 Airway management of the Trauma Victim

• The potential for cervical spine injury makes airway

management more complex in the trauma patient. A
cervical spine injury should be suspected in all injury
mechanisms involving blunt trauma. Patients with injury
above the clavicles are at increased risk, and this is
increased 4-fold if there is a clinically significant head
injury (GCS < 9). Cervical spine injury is often occult, and
secondary injury to the spinal cord must be avoided.
• Immobilization of the cervical spine must be instituted
until a complete clinical and radiological evaluation has
excluded injury
 Airway Assessment

• The fully conscious, talking patient is able to maintain his own airway
and needs no further airway manipulation. However patients' status
may deteriorate at any time, and ABC's must constantly be reassessed.
• The following categories of patients require a definitively secured
airway :
• Apnoea
• Glasgow Coma Scale < 9 or sustained seizure activity.
• Unstable mid-face trauma.
• Airway injuries.
• Large flail segment or respiratory failure.
• High aspiration risk.
• Inability to otherwise maintain an airway or oxygenation.
 Airway Management

• Initially the airway should be cleared of debris, blood

and secretions. It should be opened using the 'chin
lift' or 'jaw thrust' manoeuvres. The 'sniffing the
morning air' position for standard tracheal intubation
flexes the lower cervical spine and extends the
occiput on the atlas. However, studies (2) have shown
that 'jaw thrust' and 'chin lift' both cause distraction
of at least 5mm in a cadaver with C5/6 instability. This
movement was unaffected by use of a rigid collar.
Manual stabilization did however reduce movement.
'sniffing the morning air' position
 Airway Management
continue …
• An oral (Guedel) or nasopharyngeal airway
may be necessary to maintain patency until a
definitive airway is secured. Insertion of an
airway produces minimal disturbance to the
cervical spine. Bag and mask ventilation also
produces a significant degree of movement at
zones of instability.
An oral (Guedel) or nasopharyngeal airway
 On-Site Assessment of an
Injured person with a Potential Cervical
Spine Injury
Manual stabilization of the
cervical
spine. Hands should be on
both sides of the
head with fingers spread to
provide the most
control over head and neck
movements.
Traction is not recommended.
 On-Site Secondary Assessment
Palpation of neck: pain, obvious deformity,
bleeding, spasm?
Motor testing of upper extremities
Sensory testing of upper extremities
Motor testing of lower extremities
Sensory testing of lower extremities
Reassessment of vital signs
 Continued reassurance of the injured person
 Specific equipment required for
spine boarding procedure

long spine board

with handles, rigid cervical collar, head immobilization
device, straps.
Philadelphia hard collar
 Transportation of spinal cord-injured patients

• Emergency Medical Systems (EMS)

• Paramedical staff
• Primary trauma center
• Spinal injury center
 The Log Roll Method
• The log roll can usually be accomplished with five people:
• one at the head, one controlling the board, and the other
• three spaced along the side of the injured person.
• Larger person may require a sixth person.
• The lead rescuer will dictate the position of the other rescuers, keeping in
mind that male tend to carry more of their weight in the chest/shoulder
area and females tend to carry more of their weight in the area of the
pelvis,so stronger rescuers should be positioned accordingly.
• The three along the side of the injured person should position themselves
equally spaced with their knees against the victim’s side.
• To facilitate the roll, the arm of the patient on the side of the direction of
the roll should be carefully raised above the person’s head; the legs of the
person should be straightened with care, if necessary.
• The rescuers at the side should grasp the person on the opposite side,
being sure to place their hands in a position in which they can maintain a
grasp of the person.
 The Log Roll Method
A: Five rescuers; one at the head maintaining
manual stabilization and directing the procedure,
one controlling the spine board, and
three positioned to roll the Person.The rescuer
controlling the spine board ensures that the
straps are out of the way and will not be
trapped under the patient.The hands of the
rescuers rolling the patient are reaching under
the athlete; clothing is not grasped because it
tends to slip during the roll.The knees of the
rescuers rolling the patient will block the patient
from sliding toward the rescuers during
the roll.The arm of the patient on the side of
the direction of the roll is abducted as high as
possible. On command, the patient is carefully
rolled as a unit toward the three rescuers until
the “stop”command is given
 The Log Roll Method
Once the Patient is rolled to
one side, the spine board is
pushed into position against
the patient ,angled upward,
and held firmly in that
position. On command, the
patient is then carefully
rolled back onto the spine
board, which is lowered to
the ground. The patient is
now supine on the spine
board.
 The Straddle Slide Method
• The straddle slide method also incorporates five rescuers:
• one at the head, one controlling the board, and the other
three straddling the victim with a foot on either side
• Extreme care must be taken not to step on or kick the
patient.
• In this method, the patients arms and legs should be
carefully straightened; both arms should be down at the
patient side.
• Each of the three rescuers straddling the person places
their hands under the sides of the injured person at the
shoulders, waist, and knees.
 The Straddle Slide Method
Five rescuers
are involved: one at the head
maintaining manual stabilization
and directing the procedure,
one controlling the spine board,
and
three positioned to lift the
patient .The hands of the
rescuers lifting the patient are
reaching under the patient .;
clothing is not grasped because
it tends to slip during the lift. On
command, the patient is
carefully lifted as a unit until the
“stop "command is given.
 The Injured Person is Found in The Prone
Position
• If the person is found in the prone position, he or she should be log rolled
to the supine position with the neck maintained in a neutral position.
• If the person is found in the supine position, then carefully move the neck
into a neutral position.
• After moving the person, always reassess ABCs and sensory and motor
function.
• Maintain a neutral cervical spine position by stabilizing the head and neck
• The person controlling the head will “lead” the spine boarding process by
directing the other rescuers.
• This person should also maintain communication with the person,
explaining each action and attempting to calm and reassure the injured
person at all times.
 Managing the Prone pateint

A: Lead rescuer initially uses a

crossed-arm technique for manual stabilization. B:One rescuer is positioned opposite the
Once the injured person is rolled to supine, the direction of the roll to help control the
lead rescuer’s arms will have been uncrossed. patient's position and prevent sliding of
the patient and/or the spine board
 Immobilization
• Once the patient is correctly positioned on the
spine board, he or she must be immobilized
effectively.
• A person who is not secured to the spine board is
not considered to be immobilized.
• The head of the injured person should be placed in
an immobilizing device.
• A number of different products are available for
immobilizing the head of an injured person on a
spine board
Head Immobilization Device

Firm blocks on either side of the head

prevent motion in rotation or lateral
flexion. These blocks are easily
adjustable to provide for a tight fit
against different sizes of head or
helmet.
Two straps across the forehead and
chin of the injured person prevent
movement in the direction
of flexion. Instead of straps, strong
tape can be used for this same
purpose.
 The Lift and Transfer
• Once the person is secured to the spine board,
it is safe to lift and transfer the spine board.
• This transfer will most often be directly onto
an ambulance gurney or onto a motorized cart
for transport off the field.
• It is important that the medical staff continue
to work in a coordinated, careful manner
throughout the lift and transfer.
 Physical examination
• Inspection and palpation
– Occiput to Coccyx
– Soft tissue swelling and bruising
– Point of spinal tenderness
– Gap or Step-off
– Spasm of associated muscles

• Neurological assessment
– Motor, sensation and reflexes
– PR

• Do not forget the cranial nerve (C0-C1 injury)

 Neurogenic Shock
• Temporary loss of autonomic function of the
cord at the level of injury
– results from cervical or high thoracic injury

• Presentation
– Flaccid paralysis distal to injury site
– Loss of autonomic function
• hypotension
• vasodilatation
• loss of bladder and bowel control
• loss of thermoregulation
• warm, pink, dry below injury site
• bradycardia
 Comparison of neurogenic and hypovolemic shock

Neurogenic Hypovolemic

Etiology Loss of sympathetic Loss of blood volume

outflow
Blood Hypotension Hypotension
pressure
Heart rate Bradycardia Tachycardia

Skin Warm Cold

temperature

Urine Normal Low

output 198
 Neurologic assessment
• Spinal shock
– Bulbocavernosus reflex

• Complete VS incomplete cord injury

spinal shock
 Neurologic assessment
• American Spinal Injury Association grade
– Grade A – E

• American Spinal Injury Association score

– Motor score (total = 100 points)
• Key muscles : 10 muscles
– Sensory score (total = 112 points)
• Key sensory points : 28 dermatomes
Mechanisms for Neurological Recovery
• 1. Remyelination- neuropraxia (0-3 months)
• 2. Hypertrophy of innervated muscles (3-6
months)
• 3. Peripheral sprouting from intact nerves to
denervated muscle (3-6 months)
• 4. Axonal regeneration (12-18 months)
Mechanisms for Neurological Recovery
• 1. Remyelination- neuropraxia (0-3 months)
• 2. Hypertrophy of innervated muscles (3-6
months)
• 3. Peripheral sprouting from intact nerves to
denervated muscle (3-6 months)
• 4. Axonal regeneration (12-18 months)
 Acute phase

Emergency care
ABC
Mobility safe
Avoid active & passive movement of spine
Strapping spine and cervical collar
Normal anatomic normal position
High dose of steroid (Methylpredinsolone) first 48 hrs
Investigation and diagnosis
Early immobilization
Restoration of vertebral alignment
Catheter inserted
 Acute phase

Fracture stabilization

Skeletal traction

1-Tongs Cervical injuries

12wks

2-halo devices Most commonly used

12wks
 Respiratory assessment

Respiratory rate
Respiratory muscle
Chest expansion Axilla
Xiphoid

2.5-3 inches (6.4-7.6cm)

Breathing pattern
 Respiratory assessment

Cough 3 types

1-Functional
2-Weak functional
3-Non-functional

Vital capacity
Spirometer
 Skin assessment

Visual

Palpation

24hours
 Sensory assessment

Pinprick sensation

Light touch

Not match with motor in incomplete

Tone and deep tendon reflexes

MMT

Functional assessment

Sacral sparing
 Compensatory mechanism
• Elbow locking
• Head and trunk relationship

Applied mechanics
First ..Inertia……wheel chair…
Sliding board…long pushes …..short pushes

2nd Newton ‘s law…Momentum….decrease strength…..speed increase …less

effort

3rd law….Friction…..sliding board…..clothes…..

• Vector…..horizontal….vertical

• Levers
• First
• 2nd
• Third
 Physiotherapy treatment

Respiratory management

1-Deep breathing exercises Diaphragmatic

Assistance
2-Glossopharangeal breathing high level of lesion
gulping pattern

3-Air shift maneuver increase chest expansion

closing glottis after max.inspiration,relaxing the diaphragm and
allowing air to shift from lower to upper thorax.
0.5 –2 inches
 Respiratory management

4-strengthening exercises diaphragm

Weight
5-Assistive coughing

6-Abdominal support

7-Stretching

8-Chest mobility
 Range of motion and positioning

Motion of trunk and hip contraindicated

SLR above 60

Hip flexion (knee & hip flexion) above 90

Prone contraindicated fracture

Respiratory compromise
 Range of motion and positioning

Tetraplegia Head and neck movement contraindicated

Not full ROM
Tightness need
Tetraplegia Tightness of lower trunk muscle
Sitting posture by increase trunk stability
Long flexors for grip

Lengthening Hamstring
Sitting,transfer,lower dressing
Positional splints Wrist and hand
AFO
Sand bags
 Selective strengthening

Early few weeks resistance avoided

Scapular muscles in tetraplegia
Hip and trunk in paraplegia

Bilateral upper extremity activities

PNF
PRE
Tetraplegia Ant.deltoid,sh.extensors,triceps,lower
Trapezius,biceps,pectoralis
Paraplegia Depressors,triceps,lattismus dorsi
Transfer and ambulation
 Orientation to vertical position

Abdominal binder

Sitting

Elevating bed
 Sub acute stage

Skin inspection

Mat activities Strength

Stretching
Balance
Transfer
Stability
Ambulation
Mobility
 Rolling
Pressure relief Dressing
Functional activities Mobility

• Flexion of H & N with rotation supine to prone

• Extension of H & N with rotation prone to supine
• B/L upper limb rocking and rhythmically
• Crossing ankles
• Hip & knee flexed of top lower leg
• Pillow used from supine to prone

PNF pattern
Overhead support
Shoulder retraction and protraction
 Prone on elbow position

For sitting & quadruped position

Scapular strengthening exercises

Weight bearing Joint approximation

Weight shifting

Rhythmic stabilization
Unilateral weight bearing
Push ups
Serratus anterior
 Prone on hands

Paraplegia

Postural alignment

Strong pectoralis and deltoid

Lateral weight shift

 Supine on elbows position

Bed mobility

Achieve long sitting

If abdominal control patient push elbow to adopt this position

Lateral weight shifting

Side to side movement

 Sitting

Both long and short

Essential for dressing,self ROM,transfer,W/C mobility
Tetraplegia need 100 SLR for long sitting
Hamstring tightness cause post.pelvic tilt
Paraplegia no problem with sitting
2 approaches supine on elbows to long sitting
prone on elbows to long sitting
PNF pattern
Sitting push up
Push up blocks
 Quadruped position

Weight bearing to hip and lower trunk

Rocking activities
Approximation----------propriception

Hand movement
Creep movement
Balance activities
 Kneeling

Weight distribution

Mat crutches for ambulation

Quadruped --------------kneeling

Weight shifting
Balance activities
 Transfer

If patient has adequate sitting balance

Tub transfer , wheel chair to bed , bed to w/c , w/c to floor , floor to w/c
Sliding board

2 approaches
90 angle to bed
45 angle to bed
Wheel chair
• All wheelchairs have seven main
components—
• Armrests
• Seating system
• Foot/leg rests
• Frame
• Tires
• Brakes
• Casters (small wheels).
 Wheel chair

Level and extent of injury

Seat depth 1 inches(2.5cm) from popliteal fossa
Symmetrical weight shifting
Floor to seat height 2 inches (5cm)

Back height
Tetraplegia --------up to angle of scapula,axilla free for arm activities
Paraplegia-------lower back support
Seat width 16 inches to 18 inches (40 cm—46cm)
Removable arm rest,detachable leg rests,cushions.
C4 ----------electric w/c
 Wheel chair training

How to use brakes,arm rest and pedals

After 10-15 mints------------15 seconds pressure relief

W/c push ups

Lateral weight shift to relief pressure
 Ambulation of Paraplegia

Functional ambulation
Physiological standing tolerance (tilt table , standing frame)

Who can walk

Strength , ROM, postural alignment , CVS endurance
Abdominal and erector spinae-------------fair or better
Braces restricts ambulation

Hip ROM ----------upright posture

Absence of knee flexor and T.A contracture ----helpful
 Ambulation of Paraplegia

Energy 2-4 times in paraplegia than normal

CVS endurance
Complications reduces the chance of ambulation
Spasticity,bed sore,pain,propriception loss

Orthotic prescription
T9-T12—KAFO
(5-10degree Dorsiflexion to assist hip extension in heel strike)
Elbow crutches
 Gait training
Swing to----- swing through pattern
KAFO
Crutches same distance from toes and heels

Putting orthosis
Sit to stand practice in parallel bars
Trunk balance
Push up
Turning around
Parallel bars----
 Standing from w/c with crutches

Crutches behind chair

Crutch balance

Ambulation activities
 Elevation activities
Ascending stairs backward
Crutch on step to which patient ascends
Head & trunk flexed , shoulder depressed , elbow extension
Create momentum to move

Descending stair forward

Crutch remains on same step
Flexion of head & trunk immediately extension with shoulder
depression & elbow extension
Postural alignment & crutch move
 Long term planning

Transportation
Finance
Live with disability
Education
Exercises
Positioning----lying to sitting----protraction
Rolling---pressure relief---weight exercises
Triceps wt exe---Hamstring stretching---Functional
position
Hiking---lifting---standing---
W/c to bed--------W/c to parallel bar
Resisted exercise------------Wheeling
Hitching and hiking
Stretching