Early Rehabilitation for Tetraplegia

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

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson

Introduction

Rehabilitation plays an important role in maximising functional recovery for individuals with tetraplegia following a spinal cord injury. Rehabilitation starts in the intensive care unit and continues across multiple hospital and rehabilitation units. Ensuring patients are involved in decision-making during their rehabilitation journey supports their engagement with treatment, and greater patient involvement has been associated with better rehabilitation outcomes. This article outlines various rehabilitation interventions for individuals with tetraplegia, focusing on early functional mobility skills, such as sitting, rolling and transferring from lying to sitting.

The Importance of Thorough Assessment

A comprehensive assessment provides information on personal treatment goals, specific neurological level, the person's socioeconomic circumstances and roles, and the person's physical attributes, comorbidities, impairments, and function. If you would like to learn more about spinal cord injury assessment, please see Spinal Cord Injury Assessment Guiding Principles.

Creating a Rehabilitation Path

Establishing a rehabilitation path or plan for an individual with a spinal cord injury is an essential part of the rehabilitation process. It is important to set meaningful and motivational goals and possibilities that reflect the person's circumstances. Preventive strategies for skin, muscle and joint complications should also be developed, such as stretches, relaxation techniques, positioning, splinting, etc.

The plan should also address specific complications related to spinal cord injury, such as postural hypotension or autonomic dysreflexia. In addition, it should include patient and caregiver education about spinal cord injury, possible functional outcomes, complications and prevention strategies, and introduce the healthcare team and each team member's role.

Clinical note on stretching and positioning/splinting: Stretching and positioning are widely used and recommended treatments. For example, in their clinical practice guideline, Roquilly et al. suggest that "stretching should be performed for at least 20 min per zone and be completed by a posture orthosis and by bed or chair positioning to prevent and correct predictable deformities". It is worth noting, however, that high-quality evidence supporting stretching for the prevention or correction of contractures is lacking. A Cochrane review found that stretch, as typically provided by therapists, does not produce clinically important effects on joint mobility in people with neurological or non-neurological conditions.

Early Rehabilitation for Individuals with C4 Complete Tetraplegia

Early mobilisation: provide the patient with an appropriate wheelchair, with armrests supporting the elbows to prevent shoulder subluxation.

Clinical significance: when assisting the patient to change positions by reclining or tilting the wheelchair, it is important to prevent the patient's elbows from sliding back, as this can cause anterior subluxation or impingement of the shoulders.

Abdominal binders: apply an abdominal binder before sitting the patient in the wheelchair to help reduce the risk of postural hypotension. The abdominal binder should be tight enough to provide support but not feel uncomfortable. It should not cover the lower ribs but should be placed around the lower torso.

Clinical significance: using an abdominal binder may improve seated lung volume, peak expiratory flow, reduce dyspnoea, increase voice volume, and facilitate coughing. A recent clinical practice guideline makes a weak recommendation for abdominal binders to improve lung volumes, based on very low certainty evidence; the binder is only effective while in situ, with no lasting effect once removed.

Neck muscle strengthening: maintain neck mobility and incorporate a neck muscle strengthening programme. Neck mobility and strength are important for posture, using a chin-controlled wheelchair, assisting with eating, rolling, typing, balance and transfers, and, to a certain extent, pressure relief.

Clinical significance: isometric neck strengthening can be introduced when a patient is in a neck brace or in traction. After this point, strengthening and mobilisation are typically possible. Always check neck precautions before starting these exercises.

Assistive devices: assistive technology (AT) may improve independence and functional ability for people with tetraplegia and can be a valuable part of a rehabilitation programme. It can increase a person's control over their immediate environment, allowing them to use their phone or computer, turn on lights, open doors, watch television, etc. Gaze-tracking technology and voice activation are available on many cellular and computer devices. Using computer technology provides patients with access to information on the internet, a method of communication, and participation in education, work, and leisure. However, the evidence on the benefits of AT, and on long-term adherence, is mixed.

Therapeutic interventions: include teaching the patient to assist when rolling, using their head, neck and shoulder protraction and retraction, and maintaining the patient's shoulder and shoulder girdle range of motion, especially if the upper trapezius is overactive. Work on long sitting with arm support to increase shoulder strength and teach compensatory strategies of elbow extension with shoulder external rotation to facilitate sitting. Relaxation, stretches and trick elbow extension can also be taught to prevent contractures and enhance function.

If you would like more information on therapeutic interventions in a spinal cord injury, please read Therapeutic Interventions for Spinal Cord Injury. You can also learn about trick elbow extension in Wendy Oelofse's course on Upper Limb Management in Upper Tetraplegia.

Pressure relief in the wheelchair: some patients may be able to learn to do their own pressure relief if they have at least a grade two biceps and deltoid.

Early Rehabilitation for C5,C6, and C7 Complete Tetraplegia

Preparatory phase: if there is a period of prolonged bed rest, start working on function and specific impairments. This involves strengthening and increasing the endurance of the neck, arms, diaphragm, and accessory muscles, and maintaining and improving shoulder girdle range of motion. Teach trick elbow extension and tenodesis grip, using adaptive equipment, such as a boxing glove splint, to improve the tenodesis grip, and work on hand-to-mouth feeding. Teach the patient to reach the bell for pressure relief or arm positioning, and to ask for splints to be donned and doffed. It is also important to perform chest clearance.

If you would like to better understand tenodesis grip and trick elbow extension, please read Upper Limb Management in Lower Tetraplegia and Central Cord Syndrome.

Mobilising into the wheelchair: explain the steps and what to expect when mobilising for the first time. This includes

• the choice of transfer technique (hoist vs transfer board)
• the positioning of the hoist or the wheelchair
• the use of wheelchair brakes
• the functional skills that will allow the patient to become independent

Discuss with the patient the possibilities of feeling helpless, losing their balance, or experiencing postural hypotension. It is important to indicate the expected sitting time and ensure the patient is not left in the wheelchair longer than planned; make sure the team knows how to assist the patient back to bed and speak with the team if you cannot return on time to transfer the patient back to bed.

Use the correct transfer technique from day one:

• prepare transfer equipment
• apply an abdominal binder if needed
• sit the patient up
• monitor vital signs throughout the procedure

Working on Functional Skills

General rule: break each action down into smaller components and work on impairments in functional ways.

Long sitting balance and protective extension: the components needed to accomplish this task include neck strength, hamstring mobility, throwing the arms backwards and forwards, elbow extension, and shoulder mobility. Position yourself behind the patient, with the mirror in front of the patient, and gradually remove your support while continuing to guard the patient to prevent them from falling backwards. Include the following steps and instructions:

• "put your hands on your knees"
• "throw your hands behind you and catch yourself"
• "push yourself forward and put your hands on your knees again"

Clinical significance: if the patient cannot sit for long due to shortened hamstrings or neural tension, this activity can be completed in short sitting.

Rolling: the components needed to accomplish this task include neck mobility and strength, lifting the arm without flexing the elbows, and protraction of the shoulder. To roll to the right:

• start by bending the patient's left leg; the therapist can assist with moving the leg to the right
• the patient throws their arms left and right to gain momentum
• they then throw both arms in the direction of movement (i.e. to the right), lift their head and flex their neck

As this movement involves neck flexion, breathing out during rolling assists with task execution. Progress the task by crossing the patient's ankles (left foot over the right when rolling to the right) instead of bending the knee, and finally, teach this task with the legs uncrossed.

Sitting up from supine: the task of sitting up from supine can be accomplished in two ways depending on the patient's ability and the environment.

Option #1: transition from supine into a semi-recline position on the elbows (reversed puppy) and use elbow extension to achieve full sitting.

Option #2: transition to prone on the elbows (puppy position) and walk on the elbows into sitting.

The components needed to accomplish this task include:

• neck range of motion and strength
• shoulder range of motion, strength, and stability
• the ability to get into prone and to weight shift in prone on the elbows
• the ability to straighten the elbows when in a semi-recline position
• the ability to maintain balance in sitting

Option #1: the patient lifts their head, flexes their neck, pulls their elbows back and transitions onto their elbows. You can assist by placing your knee or a wedge under the patient's back. The patient practises getting their elbows back to increase their range of motion. Gradually remove your knee or the wedge so the patient bears more weight onto their shoulders. Next, the patient shifts their weight onto one shoulder, straightens the opposite arm first and sits up.

Exercises that help prepare the patient for this task:

• neck flexion in supine
• weight shifts in a semi-recline position on the elbows
• weight bearing on one elbow and throwing the other arm backwards and in diagonal plane
• push-ups in a semi-recline position on the elbows

Option #2: the patient rolls into prone on their elbows. They then shift their weight onto one forearm and lift their shoulder to straighten the elbow. The patient continues to push until they come to a long sitting position with arm support.

Exercises that help prepare the patient for this task:

• push-ups in prone on the elbows
• crawling forward and back on the elbows
• weight shifting in prone on the elbows

Pressure relief in the wheelchair: initially, the patient must ask or guide another person to do pressure relief, either by leaning forward or from side to side. The level of independence in performing wheelchair pressure relief varies depending on the level of spinal cord injury:

• patients with a C7 spinal cord injury should be able to push up on the wheels or armrests
• patients with a C6 spinal cord injury should be able to push up on the wheels or armrests after learning how to lock the elbow in extension
• patients with a C5 spinal cord injury should be able to hook their arm and lean from side to side or lean forward and push themselves back up

Transferring to the wheelchair using a sliding board: the components needed to accomplish this task include balance in long and short sitting, good protective extension, ability to lock the elbows in extension, sufficient shoulder stability and strength, and the ability to manoeuvre the legs on and off the bed/plinth:

• start with the patient weight shifting in long sitting
• use maximum assistance first and slowly reduce the amount of aid as the patient progresses with the skill
• position a sliding board under the patient's upper thigh
• the patient shifts their weight as they slide along the transfer board
• assist by placing the patient's feet on the footrest and help reposition the patient in the wheelchair
• remove the sliding board

Standing activities: may help manage postural hypotension and spasticity. They may also support the patient psychologically as they adjust to their condition. Standing can be accomplished on a tilt table or in parallel bars with lower limb orthoses for leg stability. Tilt tables and parallel bars place less demand on a patient's shoulder than a standing frame (unless you have an electronic one with a hoist), so they are recommended for individuals with a weak shoulder girdle.

"The rehabilitation journey for a person with acute tetraplegia is multifaceted. It requires a personalised approach, ongoing education, and a focus on functional goals to maximise independence and improve their quality of life. "

Resources

• Understanding Spinal Cord Injury. What you should know about spinal cord injury and recovery

• Spinal Cord Injury Resources
• Exercises For Quadriplegia: How to Get Started with Rehabilitation for Paralysis Recovery