Early Rehabilitation for Paraplegia

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

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson

Introduction

Rehabilitation plays a crucial role in optimising functional outcomes for individuals with paraplegia. Many factors can influence rehabilitation outcomes, including the severity and level of injury, age, gender, and the presence of medical complications. Early intervention is essential, setting the foundation for successful community reintegration. This article provides a general overview of expected function in individuals with paraplegia depending on their level of injury. It looks at factors that can influence outcomes and provides guidance on early mobility interventions.

Functional Outcomes in Complete Paraplegia

"Paraplegia is loss of the ability to move or feel the legs and lower part of the body, usually because of a severe injury to the spine".

The level of injury determines the function of individuals with complete paraplegia. Paraplegia is associated with spinal cord injuries at the thoracic, lumbar or sacral spine levels. Individuals with complete spinal cord injuries from T1 and below have full upper limb function. For more information on types of spinal cord injury (complete vs incomplete) and the ASIA scale, please see: American Spinal Injury Association (ASIA) Impairment Scale.

Complete spinal cord injuries at T1-T6 result in total motor and sensory loss of the lower limbs, weak abdominal muscles, poor trunk stability, loss of bladder and bowel control, and problems with coughing and deep breathing. Patients with spinal cord injuries at T6-T12 present with the same lower limb impairment as patients with T1-T6 injuries, but their trunk control is preserved. People with this injury level have little or no voluntary control of their bowel or bladder. Individuals with injuries at L1-L5 have varying control of their leg muscles and little or no voluntary control of their bowel or bladder. Incomplete paraplegia becomes more common in people with injuries at L3 and below. Bowel and bladder function may be affected in these patients. Patients with sacral injuries present with plantar flexion and toe flexion weakness and a loss of bladder and bowel control.

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

Factors Influencing Functional Outcomes in Paraplegia

Various factors influence functional outcomes after spinal cord injury. The severity and level of injury are key predictors of neurologic and functional outcomes. The aetiology of a spinal cord injury (e.g. traumatic, non-traumatic, degenerative, metastatic) influences functional recovery as do patient-specific factors, such as age, gender, comorbidities and being overweight or obese. For instance, being older tends to have a negative impact on function while men tend to do better functionally than women at the time of discharge from rehabilitation. Increased weight can impact how well a person can use their upper limbs during transfers or wheelchair propulsion. Increased weight has also been associated with increased respiratory dysfunction. Other factors that impact function include a patient's level of motivation, their goals and denial or acceptance of their injury, and the skills of the therapist. It is important to remember that social determinants of health (i.e. the economic, environmental, and social conditions in which we are born, develop, live, earn, and age) also impact outcomes.

If you would like to read more about prognosis and outcomes in spinal cord injury, please see: Prognosis and Goal Setting in Spinal Cord Injury.

Spinal Cord Injury Complications and Functional Outcomes

Spinal cord injury can cause other conditions or issues. Rehabilitation programmes aim to prevent and address many complications. Remember that "prevention is always better than cure".

It is important that range of motion is maintained for optimal function. We need good shoulder and wrist range of motion for transfers and bed mobility. We need sufficient hip extension for gait / standing and flexion for sitting. Ankle range of motion is important for foot position on the wheelchair footplate and for standing.

Muscle imbalances and inadequate strength, endurance and joint stability of the upper limbs and innervated muscles can impact functional outcomes. Lower extremity muscle strength is a key determinant of functional walking performance in individuals with paraplegia.

Over 50% of individuals with T1-T6 spinal cord injuries and 34.5% of individuals with T7-T12 spinal cord injuries experience respiratory complications. In addition to this, spinal cord injuries and chest trauma (e.g. rib fractures, pulmonary contusions or lacerations, pleural effusion and pneumohaemothorax) often occur together. These traumatic injuries can cause abdominal weakness and pain on activity for at least six weeks post-injury, potentially affecting early mobility, including bed mobility and transfer training.

Individuals who spend prolonged periods in bed or in a wheelchair are at risk of pressure injuries. Areas most at risk for wheelchair users are the ischial tuberosities, buttocks, coccyx, and upper thighs. Treatment for pressure injuries in these areas involves offloading the affected area through bed rest. This can, however, have negative psychosocial consequences.

Autonomic disruption and spasticity can also significantly impact functional outcomes. If you would like to learn more about these complications, please see: Autonomic Nervous System and Spinal Cord Injury and Spasticity Management in Spinal Cord Injury.

Functional Activities for Individuals with Paraplegia

General Guidance

When starting rehabilitation, we need to complete a thorough assessment, establishing a patient's functional capabilities and personal circumstances, including their roles, and home and work environments. After identifying potential barriers and available resources, it is important to establish patient-centred goals. Goal setting should be collaborative, involving the patient and the multidisciplinary team.

Early mobilisation is crucial - we should start teaching the correct transfer techniques from day one. An abdominal binder may be needed to manage postural hypotension.

A structured sitting programme should be implemented to enhance sitting endurance. It should incorporate appropriate pressure relief techniques and education. Additionally, early wheelchair mobility training is vital as it helps to improve balance, upper limb strength, and overall endurance. Throughout this process, the focus remains on maximising independence while considering the patient's unique circumstances and co-morbidities.

Bed Mobility

The components of bed mobility training include sitting balance, rolling from side to side, and sitting up.

Sitting Balance

Individuals with T1-T9 spinal cord injuries have impaired abdominal muscle function. Individuals with T1-T4 spinal cord injuries have no rectus abdominis function. Individuals with T5 spinal cord injuries have partial rectus abdominis function. People with T12 injuries have full function of their rectus abdominis and those with L1-L2 spinal cord injuries also have full function of their internal and external obliques and partial function of their iliopsoas and quadratus lumborum.

During sitting balance activities, patients with upper thoracic spinal cord injuries may use non-postural muscles such as the latissimus dorsi and the lower part of the trapezius to restore sitting balance.

Sitting balance training can include long or short (high) sitting. Training should include the following elements:

• protective extension and static balance
• reaching for the floor without falling (helps to overcome the fear of falling)

• lifting, shifting and moving the lower limbs (once sitting balance is achieved)
• lower limb passive range of motion exercises (performed by the patient)
• dressing during occupational therapy sessions

Long sitting balance exercise

Short sitting balance exercise

Rolling

Being able to roll independently allows individuals with spinal cord injuries to perform functional activities, including pressure relief, transferring to a sitting position, dressing, and changing positions in bed. Exercises to help facilitate rolling include: head lifts in supine, side-to-side rocking, and gentle hamstring stretches.

To train rolling:

• teach the patient to use momentum and swing their arms to the left and right, lift their head and protract their top shoulder
• you can facilitate this by teaching or assisting the patient to bend one knee (opposite to the direction of movement) or cross the ankles (the leg away from the direction of movement should be on the top)

Sitting Up

The ability to transition to sitting for individuals with paraplegia requires adequate upper limb and trunk strength and hip and trunk mobility. Exercises to help facilitate sitting up include: head lifts in supine, reverse push-ups, and vertical lifting.

Arm positioning for reverse push-up exercise.

To perform a reverse push-up, the patient lies supine. They are supported on their forearms with their arms slightly to the side and back. The patient lifts the upper part of their body off the bed by pushing down with their hands and straightening their elbows to reach a semi-recline position. This exercise focuses on lifting and lowering the body.

The vertical lifting exercise relies on the patient's arm strength. The patient lies supine. They lift their chest and trunk by flexing their elbows, sliding the elbows back, and then extending the elbows. This pushes them into a long sitting position with their arms behind their trunk. To lower their body, the patient flexes their elbows and lowers their chest and trunk, returning to the supine position. This exercise focuses on lifting and lowering the upper body as many times as possible.

Individuals with paraplegia can learn to transition to a sitting position from side lying or supine. Training should cover the following elements:

• rolling from supine to side-lying
• lifting the trunk off the bed by pushing through one or both upper limbs
• straightening the upper limbs and transferring the centre of gravity over the hips

Sitting up from supine

Transfers

People with paraplegia must learn to transfer to different surfaces. A rehabilitation programme should cover transfer training to and from the bed, wheelchair, car, bus or train, toilet, commode, shower chair, and floor.

To transfer safely, individuals with paraplegia will need relevant skills and knowledge, adequate upper limb strength, mobility and stability, balance and protective extension, and they must not be afraid of leaning forward.

Exercises to help patients transfer independently include upper limb strengthening exercises (e.g. push-ups, benches, quadruped kneeling, kneeling), mobility and stability exercises (small benches), balance and protective extension and split-level transfers. Breaking up the movement into small parts can help (e.g. hopping on the plinth, hopping from side to side on the plinth and lifting the legs up).

If you would like to learn general training tips for level and ground transfers, please see: Wheelchair Skills Training - Transfers.

Weight shifting in preparation for transfers

Gait

There are several prerequisites for individuals with paraplegia to begin gait training. They must have good upper limb strength and endurance to ensure that they can manage assistive devices. They need adequate hip and lumbar extension to enable standing balance. Ankle dorsiflexion is also necessary to allow the hips to move into enough extension to achieve standing balance.

Early implementation of standing activities through tilt tables, standing frames, or parallel bars can be beneficial for motivated patients, as it helps them understand the challenges ahead and sets realistic expectations. The energy demands of walking with orthoses and crutches are substantial.

The choice of gait pattern (e.g. swing-to, swing-through or reciprocal gait) depends on the level of injury. While crutches are often preferred, patients with limited hip flexor length may require more support, such as a rollator or walking frame.

It is necessary to take into account the financial impact of gait training. Mobility devices can be costly and they typically complement rather than replace the need for a wheelchair, especially in the early stages of rehabilitation.

For a detailed discussion of walking recovery after spinal cord injury, please see this optional article: Introduction to Gait Rehabilitation in Spinal Cord Injury.

Community Reintegration

Societal or community reintegration is a multifaceted issue for individuals with spinal cord injury. They may experience a wide range of activity limitations and participation restrictions, which can impact their community reintegration.

Continence

If bowel and bladder regimes are not established and a person is incontinent / having regular accidents, they may not feel confident reintegrating into society. It is, therefore, essential to establish effective bowel and bladder programmes.

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

Community Mobility

It can be challenging for individuals with spinal cord injuries to mobilise in the community. Community mobility is impacted by various community, personal, and environmental factors.

Community factors include the quality of the mobility device, availability of wheelchairs, and community accessibility. Ferretti et al. note that "significant effort should be made to provide and maintain the wheelchair as a facilitator to participation (.....), (and) enhance wheelchair services. A person's ability to get in and out of cars and / or drive independently can also be vital for work and community participation. Several factors must be considered before individuals with spinal cord injury return to driving. There are specific legal requirements that must be met. A car must be converted to hand controls and it must be automatic. It also must be an appropriate height for wheelchair-to-car transfers and be able to transport a wheelchair.

Personal factors, such as personal self-efficacy and self-esteem, can significantly impact community participation. Wheelchair skills are important for community access and should be a key focus of a rehabilitation programme. Rehabilitation should focus on speed (i.e. how fast the individual can push their wheelchair or walk), safety, and negotiating various terrains. It is also important to explore various sports for people with disabilities and equipment adaptations to ensure a person with paraplegia can participate in preferred sports and hobbies.

Environmental factors are the conditions in which a person lives. These factors can influence how a person with paraplegia is able to reintegrate into the community. All spaces, including homes, workplaces, public spaces, and public transport, need to be accessible. We need to determine if there are barriers to a person accessing their home, workplace, school or community. Are specific adaptations, such as ramps, required? We also need to consider the natural environment. How will the terrain, climate, and temperature impact mobility? Are roads and other surfaces smooth or uneven? Are there steep slopes that a person needs to navigate? Other key considerations include resource availability and social support. Will the person have access to necessary adaptive equipment and support services, or are there barriers to accessing equipment, information and other healthcare services? Rehabilitation professionals must consider these factors in discharge planning.

Resources

• Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord Injury