Spinal cord injuries can cause paralysis, sensory loss, and autonomic dysfunction below the level of injury. There are two main types - complete lesions with no preserved function below the injury, and incomplete lesions with some preserved sensation or motor function. Complications include neurogenic bladder, spasticity, autonomic dysreflexia, pressure ulcers, and orthostatic hypotension. Early rehabilitation is important to prevent further issues and maximize recovery of function.

1. Spinal Cord Injury
Partial or complete disruption of spinal cord resulting in
paralysis, sensory loss, altered autonomic and reflex activities.
A report by: Kenneth Pierre M. Lopez

2. Complete Lesion Incomplete Lesion
• A lesion to the spinal cord • A lesion to the spinal cord
where there is no with incomplete damage
preserved motor or to the cord. There may be
sensory function below scattered motor function,
the level of lesion sensory function or both
below the level of lesion
Introduction :
2 General Classifications

3. SCI COMMON TERMINOLOGY

4. • Cauda Equina Injuries: a term • Neurectomy: A surgical removal
used to describe injuries that of a segment of a nerve in order to
occur below the L1 level of the decrease spasticity and improve
spine (LMN) function
• Dermatome: Designated sensory • Neurologic level: the lowest
areas based on spinal segment segment of the spinal cord with
innervation intact strenth and sensation.
• Myelotomy: A surgical procedure Muscle groups at this level must
that severs certain tracts within receive a grade of 3
the spinal cord in order to • Paraplegia: a term used to
decrease spasticity and improve describe injuries that occur at the
function level of the thoracic lumber or
• Myotome: Designated motor sacral spine
areas based on spinal segment
innervation

5. • Rhizotomy: a surgical resection of the sensory
component of a spinal nerve in order to decrease
spasticity and improve function
• Tenotomy: a surgical release of a tendon in order to
decrease spasticity and improve function
• Zone of preservation: a term used to describe poor or
trace motor or sensory function up to three levels
below the neurologic level of injury

6. EPIDEMIOLOGY/ETIOLOGY

7. • Incidence of SCI is lowest for persons under the age of 15 and highest
for persons 16-30 years of age.
• 80% of all SCI occurs in males
• Motor Vehicular Accidents = 48%
• Falls = 16% (most common in pts over 45)
• Sports Injuries = 16%
• Violence = 14% (most common in urban communities)
• Quadriplegia = 55%
• Complete = 49%
• Incomplete = 51%
• Paraplegia = 45%
• Complete = 62%
• Incomplete = 38%
• Spinal Areas of greatest frequency of injury: C5, C7, T12 and L1

8. ANATOMY OF THE SPINAL CORD

9. • Gross Anatomy
• Sagittal Diameter: 7-12 mm
• Cervical Enlargement: C3-T2 level
• Lumbar Enlargement: T10-T12 level
• Length: approximately 45cm. From foramen magnum to
L1-L2 vertebrae
• Vascular Supply
• 1 anterior spinal artery which supplies the anterior 2/3 of
the cord
• 2 posterior spinal arteries which supply the posterior 1/3 of
the cord
• Both anterior and posterior arteries receive reinforcement
from the Radicular Artery
• Spinal vertebral venous plexus to the azygous vein

10. • Internal Anatomy
• Gray Matter – neuronal cell bodies & synapses
• Anterior Horn – motor neurons
• Posterior Horn – sensory neurons
• White Matter – ascending & descending fiber
pathways
• Ascending – relays sensory information to
the brain
• Descending – relays motor information down
to the cord

13. ASCENDING TRACTS
Consists of axons that conduct action potentials or
impulses towards the brain (afferent)

14. • Pain and
Temperature
• Lateral Spinothalamic Tract –
Main Pathway
• Ventral Spinothalamic Tract
• Both tracts cross to the
contralateral side of the cord
about 2-3 cord levels above as it
travels up the cerebral cortex
(Area 3,1,2)
• Lesion of this tract presents with
loss of contralateral pain &
temperature below the level of
injury

15. • Proprioception and
Stereognosis
• Posterior Column – ascends up
the spinal cord and crosses to the
contralateral side at the level of
the medulla to the cerebral cortex
(Area 3,1,2)
• Fasciculus Cuneatus – laterally
located; UE proprioception
• Fasciculus Gracilis – medially
located; LE proprioception
• Lesion of Posterior Column:
Loss of ipsilateral proprioception
& stereognosis below the level of
injury

16. • Lateral & Anterior Spinothalamic Tracts
• Pain & temperature sensation and crude touch
• Dorsal Column
• Fine touch, proprioception, two-point discrimination
• Dorsal & Ventral Spinocerebellar Tracts
• Proprioceptive and exteroceptive stimuli for movement
and position sense
• Spinoreticular Tract
• Deep and chronic pain
Summary Ascending Tracts

17. DESCENDING TRACTS
Consists of axons that conduct action potentials or
impulses away from the brain (efferent)

18. • Lateral Corticospinal Tract – main pathway
• Ventral Corticospinal Tract
• Both tracts decussate from the cerebral cortex (area 4,6) at
the level of the medulla as it descends to the cord
ipsilaterally
• Lesion of corticospinal tract: loss of ipsilateral motor
function below the level of injury
Motor Pathway

19. • Rubrospinal Tract
• Serves as motor junction
• For large muscle movement & fine motor control
• Facilitates flexion & inhibits extension of upper extremities
• Reticulospinal Tract
• For modulation of sensory transmission esp. pain; spinal
reflexes
• Tectospinal Tract
• For reflex head turning
• Mediate reflex postural movements of the head in response
to visual & auditory stimuli
• Medial Longitudinal Fissure
• For coordination of head and eye movements
Summary Descending Tracts

20. • Anterior Corticospinal (Direct Pyramidal Tract)
• Pathway for control of voluntary motion
• Conduct voluntary motor impulses from the precentral
gyrus to the motor centers of the cord.
• Lateral Corticospinal (Crossed Pyramidal Tract)
• Pathway for control of voluntary motion
• Provides fine motor control of limbs and digits
• Vestibulospinal Tract
• For postural reflexes
• Facilitates extensor muscle tone & equilibrium
• Spino-olivary Tract
• Proprioception from muscles & tendons and cutaneous
impulses to the olivary nucleus
Summary Descending Tracts

21. CLASSIFICATION

22. • Lesion level indicates most distal uninvolved
nerve root segment with normal function;
muscles must have a grade of at least 3+/5 or fair
+ function
• Tertraplegia (quadreplegia): injury occurs
between C1 and C8, involves all extremities and
trunk
• Paraplegia: injury occurs between T1 and T12-
L1; involves both lower extremities and trunk
(varying levels)
UMN Injury

23. Upper Motor Neuron (UMN) vs. Lower Motor Neuron (LMN) Syndrome
UMN syndrome LMN Syndrome
Type of Paralysis Spastic Paresis Flaccid Paralysis
Atrophy No (Disuse) Atrophy Severe Atrophy
Deep Tendon Reflex Increase Absent DTR
Pathological Reflex Positive Babinski Sign Absent
Superficial Reflex Absent Present
Fasciculation and Absent Could be
Fibrillation Present

24. • A= complete: no motor or sensory function is preserved in the sacral
segments S4-S5
• B= incomplete: sensory but not motor function is preserved below the
neurological level and includes the sacral segments S4-S5
• C= incomplete: motor functional is preserved below the neurological
level, and most key muscles below the neurological level have a
muscle grade <3
• D= incomplete: motor function is preserved below the neurological
level, and most key muscles below the neurological level have a
muscle grade of ≤3
• E= normal: motor and sensory function in normal
American Spinal Injury Association

26. SPECIFIC INCOMPLETE LESIONS

28. • An incomplete lesion that results from compression and
damage to the anterior part of the spinal cord or anterior
spinal artery. The mechanism of injury is usually cervical
flexion. There is loss of motor function and pain and
temperature sense below the lesion due to damage of the
corticospinal and spinothalamic tracts
Anterior Cord Syndrome

29. • A relatively rare syndrome that is caused by compression of
the posterior spinal artery and is characterized by loss of
pain perception, proprioception, two point discrimination,
and stereognosis. Motor function is preserved.
Posterior Cord Syndrome

31. • An incomplete lesion usually caused by a stab wound, which
produces hemisection of the spinal cord. There is paralysis
and loss of vibratory and position sense on the same side as
the lesion due to the damage to the CST and dorsal columns.
There is a loss of pain and temp sense on the opposite side
of the lesion from damage to the lateral spinothalamic tract.
Brown Sequard Syndrome

32. • An incomplete lesion that results from compression and
damage to the central portion of the spinal cord. The
mechanism of injury is usually cervical hyperextension that
damages the spinothalamic tract, CST and dorsal columns.
The upper extremities present with greater involvement than
the lower extremities and greater motor deficits exist as
compared to sensory deficits.
Central Cord Syndrome

33. • An incomplete lesion that results from compression and damage to the
central portion of the spinal cord. The mechanism of injury is usually
cervical hyperextension that damages the spinothalamic tract, CST,
and dorsal columns. The upper extremities present with greater
involvement than the lower extremities and greater motor deficits exist
as compared to sensory deficits
Cauda Equina Injuries

34. • sparing of tracts to sacral segments with preservation
of perianal sensation, rectal sphincter tone or active
toe flexion.
Sacral Sparing

35. WHAT TO EXAMINE
Things to watch out for in a patient with SCI

36. • Vital Signs
• Respiratory function: action of diaphragm,
respiratory muscles, intercostals; chest expansion
breathing pattern, cough, vital capacity; respiratory
insufficiency or failure occurs in lesion above C4
(phrenic nerve, C3-5 innervation for diaphragm)
Examine

37. • Skin condition, integrity: check areas of high
pressure
• Muscle tone and DTRs
• Sensation/Spinal cord level of injury: check to see if
sensory level corresponds to motor level of
innervation (may differ in incomplete lesions)
Examine

38. • Muscle Strength (MMT)/spinal cord level of
injury: lowest segmental level of innervation
includes muscle strength present at a fair +
grade (3+/5); use caution when doing MMT in
acute phase with spinal immobilization.
• Functional status: full functional assessment
possible only when patient is cleared for
activity and active rehabilitation
Examine

39. STANDARDIZED TESTS AND
MEASURES
For examination of patients with spinal cord
injury

40. • FIM/FAM (functional independence and
functional assessment measures)
• Wheelchair skills test provides for
measurement of functional and
wheelchair management skills for the
patient who uses the wheelchair for
primary mobility
Functional Tests

41. COMMON COMPLICATIONS IN
SCI AND THEIR INTERVENTIONS

42. • Spinal shock: A physiologic response that occurs
between 30 and 60 minutes after trauma to the spinal
cord and can last up to several weeks. Spinal shock
presents with total flaccid paralysis and loss of all
reflexes below the level of injury.
• Neurogenic Bladder: the bladder empties reflexively
for a patient with an injury above the level of S2. the
sacral reflex arc remains intact.
• Nonreflexive Bladder: the bladder is flaccid as a
result of a cauda equina or conus medullaris lesion.
The sacral reflex arc is damaged.

43. • Can occasionally be useful to a patient with a SCI however more often
serves to interfere with functional activities. Spasticity can be
enhanced by both internal and external sources such as stress, decubiti,
urinary tract infections, bowel or bladder obstruction, temperature
changes or touch.
• Increased involuntary contraction of muscle groups, increased tonic
stretch reflexes, excessive deep tendon reflexes.
• Treatment: medications are usually administered in an attempt to
reduce the degree of spasticity (Dantrium, Baclofen, Lioresal).
Aggressive treatment includes rhizotomies, myelotomies, and other
surgical intervention. Physical therapy intervention includes
positioning, aquatic therapy, weight bearing, FES, ROM, resting
splints and inhibitive casting.
Spasticity

44. • (hyperreflexia): an emergency situation in which a noxious stimulus
precipitates a pathological autonomic reflex with symptoms of
paraoxysmal hypertension, bradycardia, headache, diaphoresis,
flushing, diplopia, or convulsions; examine for irritating stimuli; treat
as a medical emergency, elevate head, check and empty catheter first.
• Treatment: the first reaction to this medical crisis is to transfer the
patient to a sitting position and then immediately check the catheter for
blockage. The bowel should also be checked for impaction. A patient
should remain in sitting position. Lying a patient down is
contraindicated and will only assist to further elevate blood pressure.
The patient should be examined for any other irritating stimuli. If the
cause remains unknown the patient should receive immediate medical
intervention.
Autonomic Dysreflexia

45. • Abnormal bone growth in soft tissues; examine for early changes-
soft tissue swelling, pain, erythema, generally near large joint; late
changes- calcification, initial signs of ankylosis
• Treatment: Drug intervention usually involves diphosphates that
inhibit ectopic bone formation. Physical therapy and surgery are
often incorporated into treatment. Physical therapy must focus on
maintaining functional range of motion and allowing the patient the
most independent functional outcome possible.
Heterotopic Bone Formation

46. • Results from the formation of a blood clot that becomes dislodged
and is termed an embolus. This is considered a serious medical
condition since the embolus may obstruct a selected artery. A
pateint with a spinal cord injury has a greater risk of developing a
DVT due to the absence or decrease in the normal pumping action
by active contractions of muscles in the lower extremities.
• Treatment: once a DVT is suspected there should be no active or
passive movement performed to the involved lower extremity. Bed
rest and anticoagulant drug therapy are usually indicated. Surgical
procedures can be performed if necessary.
Deep Vein Thrombosis

47. • Occurs due to a loss of sympathetic control of vasoconstriction in
combination with absent or severely reduced muscle tone. Venous
pooling is fairly common during the early stages of rehab. A
decrease in systolic blood pressure greater than 20mmHG after
moving from supine to sitting is typically indicative of this.
• Treatment: Monitoring vital signs assists with minimizing the
effects of orthostatic hypotension. The use of elastic stockings, ace
wraps to the lower extremities, and abdominal binders are common.
Gradual progression to a vertical position using a tilt table is often
indicated. During intervention may be indicated in order to increase
blood pressure
Orthostatic Hypotension

48. • Caused by sustained pressure, friction, and/or shearing to a surface.
The most common areas susceptible to pressure ulcers are the
coccyx, sacrum, ischium, trochanters, elbows, buttocks, malleoli,
scapulae, and prominent vertebrae. Pressure ulcers require
immediate medical intervention and can often significantly delay
the rehab process.
• Prevention is of greatest importance. A patient should change
position frequently, maintain proper skin care, sit on an appropriate
cushion, consistently weight shift, and maintain proper nutrition
and hydration. Surgical intervention is often necessary with
advanced pressure ulcers.
Pressure Ulcers

49. PHYSICAL THERAPY GOALS,
OUTCOMES AND
INTERVENTIONS

51. • Deep breathing exercises, strengthening
exercises to respiratory muscles; assisted
coughing, respiratory hygiene (postural
drainage, percussion, vibration, suctioning)
as needed to keep airway clear; abdominal
support
Improve Respiratory
Capacity

52. • Prevent contracture: PROM,
positioning, splinting, selective
stretching to preserve function
(tenodesis grasp)
Maintain ROM

53. • Free of pressure ulcers and other injury
positioning program, pressure relieving
devices (cushion, ankleboots) patient
education: pressure relief activities
(pushups) and skin inspection; provide
prompt treatment of pressure sores
Maintain Skin Integrity

54. • Strengthen all remaining innervated
muscles use selective strengthening during
acute phase to reduce stress on spinal
segments; resistive training to hypertrophy
muscles
Improve Strength

55. • Tilt table, wheelchair, use of abdominal
binder, elastic lower extremity wraps to
decrease venous pooling; examine for
signs and symptoms of orthostatic
hypotension (light headedness, syncope,
mental or visual blurring, sense of
weakness
Reorient Patient to
Vertical Position

56. • Emphasis on independent rolling and
bed mobility assumption of sitting,
transfers, sit-to-stand, and ambulation
as indicated
• Tolerance, postural control, symmetry,
and standing balance as indicated
Promote early return of
ADLs

57. APPROPRIATE WHEELCHAIR
PRESCRIPTION

58. • Pt with high cervical lesions (C1-C4) require electric
wheelchair with tilt-in space seating or reclining seat back;
microswitch or puff and sip control, portable respirator may
be attached
• Pt with cervical lesions, shoulder function, elbow flexion
(C5): can use a manual chair with propulsion aids
independent for short distances on smooth flat surfaces; may
choose electric wheelchair for distances and energy
conservation

59. • C6: manual wheelchair with friction surface hand
rims; independent
• C7: same for C6, but with increased propulsion
• Patients with hand function C8-T1 and below:
manual wheelchair, standard hand rims
• Significant changes in lighter, more durable,
sports-oriented chairs

60. PROMOTE WHEELCHAIR
SKILLS/INDEPENDENCE

61. • management of wheelchair parts,
turns, propulsion, all surfaces
indoors and outdoors, safe fall out
of and return to wheelchair.

62. APPROPRIATE ORTHOTIC
PRESCRIPTION/AMBULATION
TRAINING

63. • Pt’s with midthoracic lesions (T6-9): supervised
ambulation for short distances (physiological,
limited household ambulatory); requires bilateral
knee-ankle-foot orthoses and crutches, swing-to
gait pattern; requires assistance; may prefer
standing devices/ standing wheelchairs for
physiological standing

64. • Pt’s with high lumbar lesions (T12-L3); can be
independent in ambulation all surfaces and stairs;
using a swing-through or four-point gait pattern
and bilateral KAFOs and gait orthoses with
walker with or without FES system. Typically
independent house hold ambulators; wheelchair
use for community ambulation

65. • Patients with low lumbar lesions (L4-5); can
crutches or canes. Typically independent
community ambulators; may still use wheelchair
for activities with high-endurance requirements.
• High rate of rejection of orthoses/ambulation in
favor of wheelchair mobility and energy
conservation

66. IMPROVE CARDIOVASCULAR
ENDURANCE

67. • Methods: arm crank ergometry; functional
electrical stimulation- leg cycle ergometry hybrid:
arm crank ergometry and functional electrical
stimulation- leg cycle ergometry wheelchair
propulsion
• Precautions: individuals with tetraplegia and high-
lesion paraplegia experience blunted tachycardia,
lack of pressure response, and very low VO2 peak,
substantially higher variability of most responses

68. • Trunk stabilization and skin protection important
• Vascular support may be needed (elastic stockings, abdominal binder).
• Absolute contraindications to exercise testing and training of
individuals with SCI (from American College of Sports Medicine,
ACSM)
• Autonomic dysreflexia
• Sever or infected skin on weight-bearing surfaces
• Symptomatic hypotension
• Urinary Tract Infection
• Uncontrolled Spasticity or Pain
• Unstable Fracture
• Uncontrolled hot and humid environments
• Insufficient ROM to perform exercise task

69. TREADMILL TRAINING USING
BWS

70. • (Body Weight Support)
• Indications: incomplete cervical/thoracic injuries (ASIA
levels B,C and D)
• Promotes spinal cord learning/activation of spinal
locomotor pools
• Uses body harness to support weight; variable levels of
loading from 40% decreasing to 10% to full loading
• Early training: therapists assist with foot placement
• High Frequency (4days/week): moderate duration (30
minutes); typically for 8-12 weeks
Treadmill Training Using
BWS

71. PROMOTE MAXIMUM MOBILITY

72. • In home and community environment; assist patient in
community reintegration; ordering of proper equipment,
home modification.
• Provide psychological and emotional support, encourage
socialization and motivation
• Reorient and reassure
• Promote independent problem solving, self-direction
• Provide patient and family education. Focus on strategies to
prevent skin breakdown, and maintain ROM, strength, and
function
Promote Maximum
Mobility

73. • References:
• PTEXAM the complete study
guide Scott M. Gilles 2011
• IQ PT/OT Reveiwer 2010
• NPTE – Mark Dutton 2010
• NPTE Review & Study Guide
Sullivan & Siegelman 2011
• Physical Rehabilitation 5th Edition
:Susan O’Sullivan
• Physical Medicine &
Rehabilitation :Braddom
• Clinical Neuroanatomy : Richard
Snell
• Clinical Neuroanatomy made
ridiculously simple: Stephen
Goldberg
Thank You!