Therapeutic Interventions for Spinal Cord Injury

Introduction[edit | edit source]

Spinal cord injury has a significant impact on the quality of life, life expectancy and economic burden, with considerable costs associated with primary care and loss of income. While the most obvious consequence of spinal cord injury is paralysis, there are much wider consequences for many body functions including bladder, bowel, respiratory, cardiovascular and sexual function as well as social, financial and psychological implications. [1]

Individuals with quadriplegia rank recovery of arm and hand function as a priority, while individuals with paraplegia rate recovery of sexual function as most important, when measured against recovery of bladder/bowel function, eradicating autonomic dysreflexia, improving gait and trunk stability, regaining normal sensation and eliminating chronic pain. [2]

A wide range of therapeutic interventions addressing these and other important priorities such as the recovery of cardiovascular performance, muscular properties, and reducing spasticity are utilised in spinal cord injury Rehabilitation. Physiotherapists treat an array of different problems related to spinal cord injury and these involve many body systems, even though the underlying pathology is neurological in nature. This section provides a brief overview of some of the therapeutic approaches and the principles of physiotherapy rehabilitation for individuals with a spinal cord injury and the evidence underpinning the effectiveness of commonly used physiotherapy interventions. [1]

Spasticity & Contracture Management[edit | edit source]

Positioning[edit | edit source]

Patients should be given individualised positioning and early mobilisation management plans as soon as possible after a neurological impairment to prevent complications and to regain function. It is based on reducing the effects of gravity on alpha motor neuron and consequently inhibiting muscle tone. Relaxation achieved by this technique is not permanent and unless motor learning or central program adaptation is actualised it is reversible. Hence, modifications in a number of systems are required for this treatment to be effective. The effects of muscle tone on autogenic inhibition, reciprocal innervation, labyrinthic or somatosensory effects and cerebellar regulation can be affected. It should be kept in mind that active participation of the patient is required for the changes in the CNS to occur and motor learning to take place. Positioning is used widely to prevent the development of contracture and to discourage unwanted reflex activity. After a spinal cord injury, muscles can be affected in various ways, causing pain, spasticity, and problems with speed and range of motion. One way to minimise these effects is to properly support, position, and align the body. Proper positioning can be useful to minimise or prevent pain and stiffness that are commonly present post-impairment. It can also regain movement that was lost, or limit future problems with movement. In addition, proper positioning has been shown to increase awareness and protection of the weaker side of the body.

Stretching[edit | edit source]

The presence of increased tone can ultimately lead to joint contracture and changes in muscle length. When we look at the use of stretch to normalise tone and maintain soft tissue length we employ a slow, prolonged stretch to maintain or prevent loss of range of motion. While the effects are not entirely clear the prolonged stretch produces inhibition of muscle responses which may help in reducing hypertonus, e.g. Bobath's NeuroDevelopmental Technique, Inhibitory Splinting and Casting Technique. It appears to have an influence on both the neural components of muscle, via the Golgi Tendon Organs and Muscle Spindles, and the structural components in the long term, via the number and length of sarcomeres.

  • Muscle Immobilised Short Position = Loss of Sacromeres and Increased Stiffness related to an increase in connective tissue
  • Muscle Immobilised in Lengthened Position = Increase Sacromeres

Studies in mice show that a stretch of 30 mins daily will prevent the loss of sarcomeres in the connective tissue of an immobilised muscle, although the timescale in humans may not relate directly. Stretching may be achieved through a number of methods which include;

Manual Stretching[edit | edit source]

Prolonged manual stretch may be applied manually, using the effect of body weight and gravity or mechanically, using machine or splints. Stretch should provide sufficient force to overcome hypertonicity and passively lengthen the muscle. Unlikely to provide sufficient stretch to cause a change in a joint that already has contracture.

Weight Bearing[edit | edit source]

Weight-bearing has been reported to reduce contracture in the lower limb through the use of Tilt-tables, and standing frames through a prolonged stretch. Angles are key to ensure the knees remain extended during the prolonged stretch as the force exerted on the knee can be quite high. Some research also challenges the assumption of the benefits of prolonged standing.

Splinting[edit | edit source]

Splints and casts are external devices “Splints and casts are external devices designed to apply, distribute or remove forces to or from the body in a controlled manner to perform one or both basic functions of control of body motion and alteration or prevention in the shape of body tissue.”Splinting can be used to produce low-force, long-duration stretching although there is a dearth of evidence to support this. A wide range of splints have been used to influence swelling, resting posture, spasticity, active and passive ROM.

Serial Casting[edit | edit source]

Serial casting is a common technique that is used and most effective in managing spasticity related contracture. Serial casting is a specialised technique to provide increased range of joint motion. The process involves a joint or joints that are tight which are immobilised with a semi-rigid, well-padded cast. Serial casting involves repeated applications of casts, typically every one to two weeks as the range of motion is restored. The duration of the stretch to reduce both spasticity and to prevent contracture are not yet clear from the research and require further research to determine the most appropriate technique and duration to produce the required effect.

Vibration[edit | edit source]

Muscle vibration has been used as a technique to reduce muscle tone and spasticity in individuals with neurological conditions. Vibrations of the muscle are thought to increase corticospinal excitability as well as inhibitory neuronal activity in the antagonistic muscle. Three motor effects achieved through muscle vibration have been identified;

  1. Sustained contraction of the vibrated muscle via tonic vibration reflex
  2. Depression of the motor neurones innervating the antagonistic muscles via reciprocal inhibition or antagonistic inhibition
  3. Suppression of the monosynaptic stretch reflexes of the vibrated muscle while being vibrated.

Questions still remain as to whether vibration has any sustained effect on the muscle. Muscle Vibration is generally applied to directly to the chosen muscle or tendon and may be applied in two ways;

High Frequency[edit | edit source]

The high-frequency vibration is driven from a vibrator that optimally operates at a frequency of 100 - 200 Hz and at an amplitude of 1 – 2 mA. This type of vibration produce facilitation of muscle contraction through what is known as tonic vibration reflex. This facilitatory effect sustained for a brief time after application. Therefore it can be used for stimulating muscles whose primary function is one of tonic holding.

Low Frequency[edit | edit source]

The low-frequency stimulation occurring between 5 -50 Hz has an inhibitory effect on muscle through its activation of spindle secondary endings and the Golgi tendon organs.

While Vibration has the potential as a good treatment technique there is still limited evidence on its effectiveness the therapist must be aware of the precautions that must be considered when using it as a treatment option including heat generation at the point of application that has the potential for skin damage, particularly at high amplitude. Further studies are needed in the future well-designed trials with a bigger sample size to determine the most effective frequency, amplitude and duration of vibration application in the neurorehabilitation[3].

Mobility[edit | edit source]

Bed Mobility & Transfers[edit | edit source]

Understanding the way people with spinal cord injury move and knowledge of the optimal levels of motor function that people can expect to attain is essential for effective skill training. Motor skills that people with tetraplegia and paraplegia have the potential to attain are:

  1. Rolling
  2. Moving from supine to long sitting
  3. Unsupported sitting
  4. Lifting vertically
  5. Transferring

These skills are best broken down into subtasks which are the critical steps to performing the motor skill. Some people with paraplegia master more difficult transfers such as vertical transfers from the floor to wheelchair. Vertical transfers are useful because they enable people to get off the floor following a fall and they allow flexibility for leisure and work activities.

Wheelchair Training[edit | edit source]

Effective training of wheelchair skills in rehabilitation and community settings is key to increasing participation by individuals with spinal cord injury and may also reduce the incidence of pain and chronic overuse injuries. In terms of the International Classification of Function, wheelchair skills are Activities. The purpose of these activities is to overcome barriers in the environment and to thereby permit the wheelchair user to fulfil their desired role in society (Participation). Other potential benefits of wheelchair-skills training for wheelchair users and caregivers include fewer acute and overuse injuries, an improved sense of wellbeing (through self-esteem, self-efficacy, confidence and personal control, the sense of becoming newly enabled, empowered and having accomplished something of worth), improved development (of children) and having fun. [4]

One key factor that determines the type of wheelchair mobility that people with spinal cord injury (SCI) use is level of injury:

C1-C4 tetraplegia
  • mobilise in a chin-control, sip and puff or head array power wheelchair
  • use attendant operated manual wheelchairs that have been specifically set-up for their needs
  • are unable to self propel a manual wheelchair
C5 tetraplegia
  • mobilise in a hand-control power wheelchair
  • can propel a manual wheelchair on flat smooth surfaces with the assistance of adaptive equipment such as plastic push rims and textured gloves, however this is not their main form of mobility
  • are dependent on an attendant for propelling a manual wheelchair on uneven surfaces and slopes
C6-C8 tetraplegia
  • mobilise independently in a manual wheelchair over most surfaces and terrains with varying degrees of skill
  • may find the assistance of adaptive equipment such as plastic push rims and textured gloves useful
  • mobilise in a hand-control power wheelchair as an alternate form of mobility
thoracic paraplegia
  • mobilise in a manual wheelchair with varying degrees of skill
  • use power mobility if they are not functional in a manual wheelchair due to impairments such as poor cardiovascular fitness and shoulder pain

Mobilising in a power or manual wheelchair requires skill and practice. People with SCI need close supervision/assistance when initially learning to mobilise in a wheelchair, to be taught to propel the wheelchair with long slow strokes, gripping the handrim as little as possible (unless slowing down) and letting the wheelchair glide; and to be safe and competent at mobilising over different terrains in a wheelchair.

Key wheelchair skills include:

  • Wheelchair handling ( folding, into/out-of car)
  • Pushing forwards and backwards
  • Turning
  • Negotiating slopes
  • Wheelstand
  • Curbs, steps and escalators
  • Uneven ground
  • Transfers
  • Pressure relief techniques

Refer to the Wheelchair Service Provision Category further information on wheelchair provision and training.

Gait Training[edit | edit source]

The ability to walk independently is a prerequisite for most daily activities. The capacity to walk in a community setting requires the ability to walk at speeds that enable an individual to cross the street in the time allotted by pedestrian lights, to step on and off a moving walkway, in and out of automatic doors, walk around furniture, under and over objects and negotiate kerbs. A walking velocity of 1.1 - 1.5 m/s is considered to be fast enough to function as a pedestrian in different environmental and social contexts. The major requirements for successful walking include; [5]

  • Support of body mass by lower limbs
  • Propulsion of the body in the intended direction
  • The production of a basic locomotor rhythm
  • Dynamic balance control of the moving body
  • Flexibility, i.e. the ability to adapt the movement to changing environmental demands and goals.

Walking dysfunction is common in individuals with an incomplete spinal cord injury, arising not only from the impairments associated with the spinal cord lesion but also from secondary cardiovascular and musculoskeletal consequences of disuse and physical inactivity. Muscle weakness and paralysis, poor motor control and soft tissue contracture are major contributors to walking dysfunction post spinal cord injury.

Overground Training[edit | edit source]

Treadmill Training[edit | edit source]

The incentive to provide a challenging environment, in which there is an opportunity to practise repetitively the missing components of gait, has underpinned another task-specific activity. This involves using a treadmill for gait re-training and also for improvements in cardiovascular function. A harness can be used for individuals with significant functional limitations, and this also offers the opportunity to grade the amount of body weight support provided. Therapists help to facilitate alternating stepping and weight-bearing, and as many as three therapists may be required to assist with the complete gait cycle. It has been suggested that treadmill training can support Gait Re-education as it allows a complete practice of the full gait cycle, with an opportunity for improvements in speed and endurance, which optimises cardiovascular fitness.

Task-specific training on a treadmill has also been shown to induce expansion of subcortical and cortical locomotion areas in individuals following stroke and spinal cord injury. It can result in an increase in cadence and a shortening of step length as compared to overground walking.

Upper Limb Management[edit | edit source]

Key muscles are innervated at each level of spinal cord injury and it is these muscles that determine the optimal level of upper limb function that individuals with a complete spinal cord injury can achieve.

Upper Limb Function Post Spinal Cord Injury
Level of Lesion Upper Limb Function
C4 Tetraplegia No Upper Limb Function
C5 Tetraplegia Perform Simple Hand to Mouth Activities
C6 Tetraplegia Tendonesis Grip
C7 Tetraplegia Tendonesis Grip
C8 Tetraplegia Active Grasp and Release

Understanding the way individuals with tetraplegia use their upper limbs and hands functionally is essential for effective management which includes:

  • Prevention and treatment of contracture
  • Prevention and treatment of musculoskeletal pain
  • Management of the shoulder
  • Improving strength and skill
  • Promoting and preserving a tenodesis grip when appropriate
  • Management of hand swelling
  • Awareness of the potential for tendon transfers or electrical stimulation

Robotics[edit | edit source]

Over the past decade, robotics technologies are more commonly incorporated into the daily treatment schedule of many individuals post spinal cord injury. These interventions hold greater promise than simply replicating traditional therapy because they allow therapists an unprecedented ability to specify and monitor movement features such as speed, direction, amplitude, and joint coordination patterns and to introduce controlled perturbations into therapy.

Rehabilitation robotics is a field of research dedicated to understanding and augmenting rehabilitation through the application of robotic devices. Rehabilitation robotics includes the development of robotic devices tailored for assisting different sensorimotor functions (e.g. arm, hand, leg, ankle, development of different schemes of assisting therapeutic training, and assessment of sensorimotor performance). Rehabilitation using robotics is generally well-tolerated, and has been found to be an effective adjunct to therapy in individuals with motor impairments as a result of a spinal cord injury.

Robotic devices provide safe, intensive and task-oriented rehabilitation allowing;

  1. precisely controllable assistance or resistance during movements
  2. objective and quantifiable measures of subject performance
  3. good repeatability
  4. increased training motivation through the use of interactive biofeedback

You can read more about Robotic Rehabilitation for the Lower Extremity and Upper Extremity Rehabilitation using Robotics on Physiopedia.

Physical Activity & Exercise[edit | edit source]

Strength Training[edit | edit source]

Strength training is generally defined as training where the resistance against which a muscle generates force is progressively increased over time. [6] The maximal weight or resistance a person can lift or move to complete the movement is defined as One Repetition Maximum (1 RM). Prescriptions of repetitions vary depending on prior experience of strength training and co-morbidities. Progressive resistance training is the most common form of strength training. It is thought to be most effective when it incorporates resistance, is appropriately progressed based on etc individuals capacity and the mode of training is similar to the task in which strength gains are required

It is more challenging to apply the principles of progressive resistance training to partially paralysed muscles because it is difficult to apply resistance when a muscle is unable to move through full range against gravity, which is a greater problem for weak and very weak muscles more than it is for muscles that are closer to normal strength. When partially paralysed muscles are strong enough to move through range against gravity the principles of progressive resistance training can be more easily followed. When partially paralysed muscles are not strong enough to move against gravity, training occurs in a gravity eliminated plane. Resistance can be added manually or by rotating the plane of movement away from the horizontal.

One example of an effective dosage of progressive resistance training is:

  • 1 - 3 sets of 8 - 12 Repetitions with a rest of 1-3 minutes between sets
  • A load corresponding to 8 - 12 Repetition Maximum (60-70% of 1RM)
  • 2-3 times a week

Muscle hypertrophy and increased strength, along with the changes in body composition, the hormonal and nervous systems, have a positive impact on the daily activities of living and functional independence of the individuals with a spinal cord injury.

Read more about Strength Training in Spinal Cord Injury

Cardiovascular Training[edit | edit source]

Cardiovascular training involves the use of oxygen to meet the energy demands of the body’s muscles during exercise. It is associated with longer duration exercise during a given session of training, often at a consistent pace. Regular cardiovascular training has been shown to improve cardiovascular function, aerobic capacity and exercise tolerance in individuals with a spinal cord injury, often resulting in improved independence in activities of daily living.

Assessment of cardiovascular fitness is essential for physiotherapists to directly determine training or conditioning intensities required to elicit improvements in cardiovascular and cardiometabolic health. Tests may include:

  • Peak Oxygen Consumption Tests
  • Submaximal Exercise Tests
  • Field Exercise Tests

Use of regular cardiovascular capacity testing during spinal cord injury rehabilitation allows us to monitor the impact of rehabilitation interventions on an individual level, Incremental arm ergometry with small increments per stage is the most relevant means of assessment for peak cardiovascular capacity for individuals with a spinal cord injury, Use of the submaximal wheelchair ergometer test is preferable to use for the assessment of daily life functioning, Systematic reporting on test termination, peak outcomes criteria and adverse events is key to enhance comparability of results. [7]

Response to cardiovascular fitness training is significantly influenced by the type of spinal cord injury including neurological level, level of completeness and extent of the injury. Those with an incomplete level of injury, particularly those who can ambulate and have some lower limb use during exercise, respond to exercise in a similar way to able-bodied individuals. While those with a complete cervical level injury or upper thoracic level injury have a significantly different response as a result of reliance on upper limb exercise, lower limb paralysis and most importantly loss of supraspinal sympathetic nervous control, which adversely affect cardiac output and arterio-venous oxygen; the two components of VO2 Peak.[8][9]

Safe and effective exercise prescription requires careful consideration for the target individual's health status, baseline fitness, goals and exercise preferences. When considering exercise prescription in an individual with a spinal cord injury you should also consider their neurolgical level of injury, and the implications it may have the type of exercise available and the modifcations required to support their participation including trunk stability and balance, and use of strapping, gripping aids and assistive devices.[10] 

Read more about Cardiovascular Training in Spinal Cord Injury

Respiratory Management[edit | edit source]

Impaired respiratory function is common following spinal cord injury and is primarily determined by neurological level of injury. Paralysis or partial paralysis of key muscles has a marked impact on respiratory function and typical respiratory complications include hypoventilation, atelectasis, secretion retention and pneumonia.

level muscles affected implication
C1-3 tetraplegia
  • paralysis scalenes and diaphragm
  • mechanical ventilation via a tracheostomy
C4 tetraplegia
  • partial paralysis diaphragm and scalenes
  • total paralysis of the intercostal and abdominal muscles
  • breathe independently but may require initial periods of mechanical ventilation immediately after injury
  • vital capacity is typically less than 1/3 of predicted and cough is ineffective
C5-8 tetraplegia
  • partial paralysis of the scalenes and pectoralis
  • paralysed intercostal and abdominal muscles
  • altered breathing mechanics and increased work of breathing
  • vital capacity is typically between 1/3 and 1/2 of predicted and cough is poor
Thoracic paraplegia
  • partially paralysed intercostal and abdominal muscles
  • vital capacity is closer to normal and cough strength is dependent on the degree of paralysis of the intercostal and abdominal muscles

See more about the assessment of respiratory function.

Physiotherapy interventions aim to remove secretions and increase ventilation, these interventions include:

  • Assisted cough
  • Percussion and vibration
  • Postural drainage
  • Suctioning
  • Positioning
  • Breathing exercises
  • Incentive spriometry
  • Inspiratory muscle training
  • CPAP, BiPAP and IPPB

Pain Management[edit | edit source]

Pain is a common complication of spinal cord injury that can affect performance of motor tasks and may impact participation in family life, work, and leisure activities.

Acute or chronic nociceptive pain can be visceral or musculoskeletal:

  • Visceral pain may arise from trauma, disease or inflammation of the viscera, for example headache secondary to dysreflexia.
  • Musculoskeletal pain may arise from trauma, disease or inflammation of the musculoskeletal system, common problems include: back or neck pain, shoulder pain, and pain associated with overuse.

Neuropathic pain can occur above, at or below the level of injury:

  • Above-level neuropathic pain is not exclusive to SCI and may occur secondary to complex regional pain syndromes or peripheral nerve injury (e.g. carpal tunnel syndrome).
  • At-level neuropathic pain may occur secondary to trauma to the spinal cord or nerve roots and presents as a band of burning, electric or shooting pain in dermatomes close to the level of injury.
  • Below-level neuropathic pain also occurs secondary to trauma to the spinal cord and presents as diffuse burning, electric or shooting pain below the level of injury.

A thorough pain assessment should be performed and interventions may include:

  • physical modalities such as TENS, heat, and cold
  • soft tissue techniques such as massage
  • specific strengthening and stretching exercises
  • graded exercise or activity programmes
  • hydrotherapy
  • education on activity pacing
  • education on posture
  • education to minimise risk of overuse injuries
  • retraining of transfers and wheelchair skills
  • ergonomic review of seating and equipment

Electrotherapy[edit | edit source]

Modern electrotherapy practice needs to be evidence-based and used appropriately. Used at the right place, at the right time for the right reason, it has a phenomenal capacity to do good. Used unwisely, it will either do no good at all or worse still, make matters worse. The skill of electrotherapy is to make the appropriate clinical decision as to which modality to use and when.

Transcutaneous Electrical Nerve Stimulation[edit | edit source]

Transcutaneous Electrical Nerve Stimulation (TENS) is a method of electrical stimulation which primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the opioid system. The different methods of applying TENS relate to these different physiological mechanisms. The effectiveness of TENS varies with the clinical pain being treated, but research would suggest that when used ‘well’ it provides significantly greater pain relief than a placebo intervention. In the clinical context, it is most commonly assumed to refer to the use of electrical stimulation with the specific intention of providing symptomatic pain relief.

You can read more about Transcutaneous Electrical Nerve Stimulation (TENS) on Physiopedia.

Functional Electrical Stimulation[edit | edit source]

Functional Electrical Stimulation (FES), is an assistive technology that can be used to aid the recovery of muscle function post spinal cord injury. FES uses electrical pulses to stimulate motor neurons or denervated muscle fibers directly to elicit a contraction during functional activity in a weakened or paralysed limb. [11] FES has an extensive history for its treatment of orthopaedic and neurological conditions. [12] It has been used since the mid 1960’s, traditionally to aid mobility through activation of tibialis anterior to help dorsiflex the foot throughout the gait cycle in individuals with foot drop and more recently it has been considered as a promising treatment modality for upper-limb recovery. [12] 

Read more about the use of Functional Electrical Stimulation Cycling for Spinal Cord Injury on Physiopedia. 

Biofeedback[edit | edit source]

Biofeedback is the technique of using equipment to reveal to human beings some of their internal physiological events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals. [13] The ultimate purpose is that the patient gets to know his own body signs and that he can control them consciously. In the first instance using biofeedback equipment, afterwards even without. [14]

Further, neuromuscular training or biofeedback therapy is an instrument-based learning process that is based on “operant conditioning” techniques. The governing principle is that any behaviour - be it a complex manoeuvre such as eating or a simple task such as muscle contraction-when reinforced its likelihood of being repeated and perfected increases several-fold. [15]

You can read more about Biofeedback on Physiopedia.

Pharmacological Management[edit | edit source]

The symptoms of spinal cord injury that are managed with pharmacological interventions target: pain, spasticity and inflammation[16]. Controlling these symptoms can help limit further complications such as autonomic dysreflexia, initiate tissue repair, and help patients and physical therapists preserve or restore function[17].  The physiotherapist must be aware of how to enhance rehabilitation by capitalising on the therapeutic benefit of medications and considering adverse effects that may impact the plan of care. Some of the common drugs used in the treatment of spinal cord injuries include opioids, benzodiazepines, second generation antiepileptics, skeletal muscle relaxants, and glucocorticoids.

Many of these drugs have adverse side effects that impact therapy. Of note are the drugs that threaten the safety of physical therapy, such as dizziness seen in benzodiazepines and skeletal muscle relaxants[18], which could result in falls and injury. Lethargy and drowsiness are common side effects[18], impacting the patient’s engagement level during the therapy session, thus limiting the effectiveness of any intervention requiring the patient's active participation. Coordinating appointments to avoid peak adverse effects while ensuring the optimal positive effects of the drug will require careful collaboration between the physical therapist, patient, and physician. As the patient’s drug regimen becomes more standardised and understood, predicting the optimal timing for appointments will be easier. Of special note is the addictive nature of opioids. Because physical therapists will be seeing the patient more than the prescribing physician, it is important to monitor for signs of addiction or abuse and take appropriate action.

Read more about the Pharmacological Management of Spinal Cord Injuries

References[edit | edit source]

  1. 1.0 1.1 Harvey LA. Physiotherapy Rehabilitation for People with Spinal Cord Injuries. Journal of Physiotherapy. 2016 Jan 1;62(1):4-11.
  2. Thuret S, Moon LD, Gage FH. Therapeutic Interventions after Spinal Cord Injury. Nature Reviews Neuroscience. 2006 Aug;7(8):628.
  3. Murillo N et al (2014). Focal vibration in neurorehabilitation. Eur J Phys Rehabil Med. Apr;50(2):231-42.
  4. Kirby RL, Smith C, Parker K, McAllister M, Boyce J, Rushton PW, Routhier F, Best KL, Mortenson B, Brandt A. The Wheelchair Skills Program Manual. Published electronically at Dalhousie University, Halifax, Nova Scotia, Canada.
  5. Forssberg H (1982) Spinal locomotion functions and descending control. In Brain Stem Control of Spinal Mechanisms (eds B Sjolund, A Bjorklund), Elsevier Biomedical Press,New York.
  6. Liu C, Latham NK. Progressive Resistance Strength Training for Improving Physical Function in Older Adults (Cochrane Review). Cochrane Database Syst Rev 2009; (3): CD002759.
  7. Eerden S, Dekker R, Hettinga FJ. Maximal and submaximal aerobic tests for wheelchair-dependent persons with spinal cord injury: a systematic review to summarize and identify useful applications for clinical rehabilitation. Disability and rehabilitation. 2018 Feb 27;40(5):497-521.
  8. Harvey, Lisa. (2008). Chapter 12: Cardiovascular Fitness Training. In Management of Spinal Cord Injuries: A Guide for Physiotherapists. London: Elsevier
  9. Goosey-Tolfrey, Vicky and Price, Mike. (2010). Chapter 3: Physiology of Wheelchair Sport. In Wheelchair Sport: A Complete Guide for Athletes, Coaches and Teachers. London: Elsevier
  10. Goosey-Tolfrey, Vicky and Price, Mike. (2010). Chapter 3: Physiology of Wheelchair Sport. In Wheelchair Sport: A Complete Guide for Athletes, Coaches and Teachers. London: Elsevier
  11. Berkelmans R. FES Cycling. Journal of Automatic Control. 2008;18(2):73-6
  12. 12.0 12.1 Martin R, Sadowsky C, Obst K, Meyer B, McDonald J. Functional Electrical Stimulation in Spinal Cord Injury: from Theory to Practice. Topics in Spinal Cord Injury Rehabilitation. 2012 Jan 1;18(1):28-33
  13. Basmajian J. (1989), Biofeedback: Principles and Practices for Clinicians, Williams and Wilkins (level 4)
  14. Biofeedback Vereniging Nederland (2012), What is biofeedback?, geraadpleegd op 1/05/2013, (level 4),
  15. Satish S.C. Rao, DYSSYNERGIC DEFECATION and BIOFEEDBACK THERAPY, Gastroenterology Clinics of North America, Volume 37, Issue 3, Pages 569-586, September 2009 (level 2A)fckLR
  16. Fehlings M, Singh A, Tetreault L, Kalsi-Ryan S, Nouri A. Global prevalence and incidence of traumatic spinal cord injury. Clinical Epidemiology. 2014:309. doi:10.2147/clep.s68889
  17. Noller CM, Groah SL, Nash MS. Inflammatory Stress Effects on Health and Function After Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation. 2017;23(3):207-217. doi:10.1310/sci2303-207
  18. 18.0 18.1 Ciccone CD. Davis's Drug Guide for Rehabilitation Professionals. Philadelphia: F.A. Davis; 2013.