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Early Rehabilitation for Incomplete Spinal Cord Injury

Original Editor - Ewa Jaraczewska based on the course by Melanie Harding

Top Contributors - Ewa Jaraczewska and Jess Bell

Introduction

Recent advances in emergency medical care have significantly altered spinal cord injury (SCI) outcomes. There is also a growing number of people with incomplete spinal cord injuries. In incomplete spinal cord injuries, some neurological function remains. These injuries present unique challenges and opportunities for recovery.

Effective early rehabilitation for incomplete spinal cord injuries requires a comprehensive assessment, including muscle strength, sensory function, spasticity, and functional movement potential, alongside targeted interventions to maximise recovery and function.

This article provides an overview of types of incomplete spinal cord injuries and introduces practical approaches to managing common complications like muscle imbalance and spasticity. It also explores specific gait training techniques for patients with incomplete spinal cord injuries.

Definition of Incomplete Spinal Cord Injuries

In incomplete spinal cord injuries, some motor or sensory function is preserved below the level of injury.

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), commonly referred to as the ASIA Exam, was developed by the American Spinal Injury Association (ASIA).[1] The ASIA exam has three parts: (1) a myotomal-based motor examination, (2) a dermatomal-based sensory examination, and (3) an anorectal examination. After completing all three parts, the patient's injury grade and level are established.

Spinal cord injuries are classified as neurologically “complete” or “incomplete” based on whether or not there is sacral sparing.  Sacral sparing is "the presence of sensory or motor function in the most caudal sacral segments (i.e. preservation of light touch or pinprick sensation at the S4-5 dermatome, DAP [deep anal pressure] or voluntary anal sphincter contraction)."[2]

The International Standards for Neurological Classification of Spinal Cord Injury[2] has five categories: ASIA Impairment Scale (AIS) A, B, C, D and E. Injuries classified as AIS A are complete spinal cord injuries. AIS B, C and D are incomplete spinal cord injuries. Individuals classified as AIS E have normal sensory and motor functions.

AIS B = sensory incomplete: sensory but not motor function is preserved below the neurological level, including sacral segments S4-S5. No motor function is preserved more than three levels below the neurological level on either side of the body.

AIS C = motor incomplete: motor function is preserved below the neurological level, and more than half of the key muscle functions below the neurological level of injury have a muscle grade of less than 3.

AIS D = motor incomplete: motor function is preserved below the neurological level, and at least half of the key muscle functions below the neurological level of injury have a muscle grade of 3 or more.

If you would like to learn more about the ASIA Exam, please see: American Spinal Injury Association (ASIA) Impairment Scale.

Types of Incomplete Spinal Cord Injuries

Incomplete spinal cord injuries are usually described based on which part of the spinal cord is affected (e.g. front, centre, rear, or side).

Central cord syndrome, anterior cord syndrome and Brown-Séquard syndrome.
Anterior Cord Syndrome

In anterior cord syndrome, the anterior two-thirds of the spinal cord are impacted. Anterior cord syndrome is usually caused by occlusion of the anterior spinal artery (ASA) or hyperflexion injuries that cause compression fractures. Depending on the level of ischaemia, individuals with anterior cord syndrome experience varying degrees of motor loss and dissociated sensory loss. This means that pain and temperature are affected more than light touch. Proprioception is relatively or completely spared. Individuals with anterior cord syndrome have a high risk of developing autonomic dysreflexia, movement and sexual impairments, neuropathic pain, bladder and bowel dysfunction, and severe spasticity. Individuals may recover 10-20% of their motor function, but coordination and strength deficits typically persist.[3]

Central Cord Syndrome

Central cord syndrome is the most common type of incomplete injury.[3] It is often caused by a hyperextension injury of the cervical spine,[4] and affects the central portion of the spinal cord. This causes sensory and motor loss below the injury. Usually, there is more loss of function in the upper limbs than in the lower limbs. Age plays an important role in recovery, with younger patients tending to experience greater recovery than older patients.[5]

Brown-Séquard Syndrome

Brown-Séquard syndrome is a rare condition that affects one side of the spinal cord, creating an asymmetrical injury. It is most common in the cervical or thoracic spine and can have both traumatic and non-traumatic causes.[6] Brown-Séquard syndrome causes a loss of motor function and light touch on one side and a loss of pain and temperature sensation on the opposite side below the level of the lesion. 75% of patients with Brown-Séquard syndrome can ambulate at the time of discharge.[3]

Posterior Cord Syndrome
Posterior cord syndrome.

Posterior cord syndrome is the rarest form of incomplete spinal cord injury. Individuals with posterior cord syndrome have intact motor function, pain, and temperature sensation, but proprioception, light touch, kinaesthesia and vibration below the level of the lesion are impacted. Gait is sometimes difficult due to decreased proprioception.[3]

Treatment Principles for Incomplete Spinal Cord Injury

When treating individuals with incomplete spinal cord injury, rehabilitation professionals must complete an accurate and comprehensive assessment. This helps to ensure that the rehabilitation programme will meet each patient's needs. Regular reassessment is essential. During rehabilitation, we must aim to prevent or reduce the risk of complications[7] and ensure patients become as functionally independent as possible, using their abilities and spared function. People with incomplete spinal cord injuries usually learn to adapt how they do things based on what sparing they have. Where possible, it's important to explore gait options, but ensure that gait is functional.[3]

Spasticity Management

Individuals with incomplete spinal cord injuries often develop spasticity, which can range from mild to severe. Spasticity can affect a person's quality of life and their ability to perform activities of daily living.[3] [7] Regular assessment is essential to ensure that the management plan is adapted according to a patient's evolving needs and response to treatment. Patients should be taught to use spasticity where appropriate rather than fight it (e.g. for gait training, bed mobility, transfers, etc).[3] However, if spasticity is not optimally managed, patients are at risk of pain, contractures, and pressure injuries. These complications can impact their overall outcomes.[7]

Spasticity management is multifactorial. The frontline treatment is medication for moderate to severe spasticity.[8] Patients must be taught to identify triggers and self-management techniques. Rehabilitation techniques also play an important role. It is important to note that this is an evolving field, and further research on rehabilitation for spasticity in spinal cord injury is required.[9] Rehabilitation techniques may include positioning, splinting, range of motion exercises, stretching, passive standing or weight-bearing exercises, and functional electrical stimulation-cycling.[8][10][11] Other modalities may include bracing, taping, and casting to maintain or optimise proper muscle fibre length. It's important to note that modalities such as cryotherapy and thermotherapy show no long-term benefit for spasticity reduction in persons with spinal cord injuries, but transcutaneous electrical neuromuscular stimulation (TENS) may effectively reduce spasticity-related pain.[12]

If you would like to read about proactive spasticity management in spinal cord injury, please refer to Spasticity Management in Spinal Cord Injury.

Muscle Imbalance Management

Muscle imbalance is a common issue following spinal cord injury, and can cause secondary complications, including overuse injuries and scoliosis. Rehabilitation interventions focus on strengthening or facilitating weaker muscles, stretching stronger muscles, and protecting the joints, particularly those with decreased proprioception.[3]

Strengthening interventions focus on both unaffected and partially paralysed muscles. Strength training can be enhanced through the use of electrical stimulation. For muscles with Grade 2 strength, high repetitions of isometric or through-range contractions can be beneficial. For muscles with Grade 3 and 4 strength, progressive resistance training can be introduced. Task-specific training can be combined with progressive resistance training as well.[13]

If you would like to learn more about strengthening and the physiotherapy management of individuals through all stages of their rehabilitation journey, please see: Physiotherapy Management of Individuals with Spinal Cord Injury.

Gait Training

Walking recovery is a main goal for many individuals with incomplete spinal cord injury.[14] However, the prognosis for walking recovery depends on many factors, including (1) injury type and level, (2) upper and lower muscle strength, (3) lumbar spine and lower extremity range of motion, (4) proprioception, and (5) balance.[3]

AIS Grade and Gait Recovery

The neurological level of injury and the severity of the lesion are the most relevant prognostic factors for gait recovery in spinal cord injury patients.

For patients with AIS B spinal cord injury, ambulation recovery is considered to be about 33%. Preservation of pinprick sensation is a favourable prognostic factor compared to preservation of light touch only, as it indicates less extensive damage to the spinothalamic tracts and posterior column.[15]

The overall rate of walking recovery for individuals with AIS C spinal cord injury is around 75%. Patients with low thoracic or lumbar lesions demonstrate greater recovery, but most walk with braces and assistive devices. Older age is a negative prognostic factor for walking recovery. 30-40% of patients aged over 50 years at the time of injury can ambulate, compared to 80-90% of patients aged less than 50 years.[15]

Patients with AIS D spinal cord injury have a very good prognosis for walking one year after injury.[15][16]

Lower Extremity Motor Score and Gait Recovery

The lower extremity motor score (LEMS), obtained during the ASIA assessment, is considered a good predictor of walking recovery for individuals with incomplete paraplegia and tetraplegia.[15]

Scivoletto et al.[15] found that all patients with incomplete paraplegia with an initial lower extremity motor score of ≥10 points ambulated in 1 year. 70% of patients with an initial motor score between 1 and 9 ambulated at 1 year, and all patients with an initial hip flexor or knee extensor Grade ≥2 ambulated in the community at 1 year.[15]

In the same study, Scivoletto et al.[15] found that 63% of patients with incomplete tetraplegia with an initial lower extremity motor score of ≥10 points ambulated by 1 year. 21% of patients with an initial lower extremity motor score between 1 and 9 ambulated by 1 year. They also found that patients with higher motor scores are more likely to become community or household ambulators. There is also a strong link between upper extremity strength and the ability to ambulate, as upper limb strength facilitates the use of assistive devices during walking.[15]

The motor score of a specific muscle can also help predict walking ability.[15] For example, Scivoletto et al.[15] found that all patients with an initial quadriceps strength of at least Grade 2/5, which increased at least 3/5 in at least one quadriceps by 2 months post-injury were able to walk independently in the community with or without assistive devices and braces (i.e. functional ambulation). However, only 25% of individuals who did not reach at least 3/5 quadriceps strength within 2 months of injury were able to achieve functional ambulation.[15]

Gait Assessment Tools

Key outcome measures for gait assessment and reassessment for individuals with incomplete spinal cord injury are the 10-metre walk test or the six-minute walk test.

Treatment Strategies for Gait Recovery

It is crucial to initiate gait training as soon as possible after injury.[3] Early intervention can involve using assistive devices or robotic systems that support the patient while they practise walking. Early mobilisation is associated with better long-term functional independence.

Early rehabilitation gait training strategies for patients with incomplete spinal cord injury include physiotherapy, treadmill training, overground training, body weight-supported gait training, robot-assisted gait training (RAGT), and exoskeletons. [17][18] Visual compensation and weighting of the lower limbs can be useful during walking activities for individuals with impaired proprioception. Assistive technology is effective in compensating for muscle weakness and balance impairment.[3]

If you would like to read more about the compensatory approach to gait training, please see: Introduction to Gait Rehabilitation in Spinal Cord Injury.

For clinical practice guidelines on how to improve locomotor function for individuals who are at least six months post-injury, please see: Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury.

Community Reintegration

Facilitating community reintegration for individuals with incomplete spinal cord injury requires a comprehensive understanding of their unique challenges and strengths. These challenges may be personal, environmental, psychological or social.

Personal: various personal factors can impact how an individual reintegrates into the community after spinal cord injury. Educational level, necessary adaptations, willingness, skills and motivation can all affect a person's return to work and reintegration into the community.[3] Effective bladder and bowel management is also essential - individuals with poor bladder and bowel management report greater difficulty creating new social relationships.[19]

If you would like to read more about bowel and bladder management in spinal cord injury, please see: Bladder Considerations with Spinal Cord Injury and Bowel Considerations with Spinal Cord Injury.

Environmental: accessibility issues in homes and public spaces can hinder mobility and participation in community activities.[20]

Psychological: feelings of isolation, grief, or anxiety can all impact how well a person reintegrates into the community.[21]

Social: unfavourable perceptions from the community can negatively impact a person's confidence or desire to engage socially. Return to work can be influenced by an employer's willingness to provide necessary work adaptations.[20]

Resources

References

  1. ↑ ASIA and ISCoS International Standards Committee. The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-What's new? Spinal Cord. 2019 Oct;57(10):815-817.
  2. ↑ 2.0 2.1 Burns S, Biering-Sørensen F, Donovan W, Graves D, Jha A, Johansen M, Jet al. International Standards for Neurological Classification of Spinal Cord Injury, Revised 2011. Top Spinal Cord Inj Rehabil 2012;18(1):85-99.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Harding M. Early Rehabilitation for Incomplete Spinal Cord Injury Course. Plus, 2025.
  4. ↑ Ameer MA, Tessler J, Munakomi S, et al. Central Cord Syndrome. [Updated 2023 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441932/
  5. ↑ Foo D. Spinal cord injury in forty-four patients with cervical spondylosis. Paraplegia. 1986 Oct;24(5):301-6.
  6. ↑ Shams S, Davidson CL, Arain A. Brown-Séquard Syndrome. [Updated 2024 Feb 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538135/
  7. ↑ 7.0 7.1 7.2 Rayegani SM, Tavanaei R, Oraee-Yazdani S. Principles of Rehabilitation Strategies in Spinal Cord Injury. InParaplegia-New Insights 2023 Mar 21. IntechOpen.
  8. ↑ 8.0 8.1 Glinsky JV, Harvey LA. Physiotherapy management of people with spinal cord injuries: an update. J Physiother. 2024 Oct;70(4):256-264.
  9. ↑ Barbosa PHFA, Glinsky JV, Fachin-Martins E, Harvey LA. Physiotherapy interventions for the treatment of spasticity in people with spinal cord injury: a systematic review. Spinal Cord. 2021 Mar;59(3):236-247.
  10. ↑ Australian and New Zealand Clinical Practice Guidelines. Available from: https://sciptguide.com/ (accessed 10 February 2025).
  11. ↑ Alashram AR, Annino G, Mercuri NB. Changes in spasticity following functional electrical stimulation cycling in patients with spinal cord injury: A systematic review. J Spinal Cord Med. 2022 Jan;45(1):10-23.
  12. ↑ Billington ZJ, Henke AM, Gater DR Jr. Spasticity Management after Spinal Cord Injury: The Here and Now. J Pers Med. 2022 May 17;12(5):808.
  13. ↑ Glinsky JV, Harvey LA. Physiotherapy management of people with spinal cord injuries: an update. J Physiother. 2024 Oct;70(4):256-264.
  14. ↑ Scivoletto G, Di Donna V. Prediction of walking recovery after spinal cord injury. Brain Res Bull. 2009 Jan 15;78(1):43-51.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 Scivoletto G, Tamburella F, Laurenza L, Torre M, Molinari M. Who is going to walk? A review of the factors influencing walking recovery after spinal cord injury. Front Hum Neurosci. 2014 Mar 13;8:141.
  16. ↑ Van Middendorp JJ, Hosman AJ, Donders AR, Pouw MH, Ditunno JF Jr, Curt A, Geurts AC, Van de Meent H; EM-SCI Study Group. A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study. Lancet. 2011 Mar 19;377(9770):1004-10.
  17. ↑ Patathong T, Klaewkasikum K, Woratanarat P, Rattanasiri S, Anothaisintawee T, Woratanarat T, Thakkinstian A. The efficacy of gait rehabilitation for the treatment of incomplete spinal cord injury: a systematic review and network meta-analysis. J Orthop Surg Res. 2023 Jan 23;18(1):60.
  18. ↑ La Rosa G, Avola M, Di Gregorio T, Calabrò RS, Onesta MP. Gait Recovery in Spinal Cord Injury: A Systematic Review with Metanalysis Involving New Rehabilitative Technologies. Brain Sci. 2023 Apr 22;13(5):703.
  19. ↑ Hicken BL, Putzke JD, Richards JS. Bladder management and quality of life after spinal cord injury. Am J Phys Med Rehabil. 2001 Dec;80(12):916-22.
  20. ↑ 20.0 20.1 Mohan M, Deb R. Barriers and Facilitators during Community Reintegration of People with Spinal Cord Injury: A Qualitative Study. J Caring Sci. 2023 Dec 30;13(1):44-53.
  21. ↑ Atobatele KO, Olaleye OA, Fatoye FA, Hamzat TK. Relationships Between Community Reintegration and Clinical and Psychosocial Attributes in Individuals With Spinal Cord Injury in a Nigerian City. Top Spinal Cord Inj Rehabil. 2018 Fall;24(4):306-314.
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