Spinal Cord Injury

Traumatic spinal cord injuries
Getachew Azeze(BSc, MPT)

Objectives
• Understand the causes, clinical manifestations, and

possible complications of SCI
• Differentiate between complete and incomplete types of
SCI
• Discuss the various levels of SCI
• Identify patient problems based on the examination
• Establish evidence based physiotherapy managment
Introduction
• Spinal cord injuries (SCI) occurs when the SC is damaged as
a result of trauma, disease processes, vascular compromise,
or congenital neural tube defect
• Resulting in a change in the normal motor, sensory or

autonomic function
• The clinical manifestations depending on the extent and

location of the damage to the SC
• Paralysis of the muscles below the level of the injury can lead
to limited and altered mobility, self-care, and ability to
participate in valued social activities
04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 3
RAPY STUDENTS
Demography and etiology
• SCI is a relatively low-incidence, high-cost injury that

results in tremendous change in an individual’s life.
• Can be divided in to two etiological categories
1. Traumatic is the most frequent cause of injury in adult
populations
• Causes: MVA s (38%), falls (30.5%), violence (13.5%), and
sports-related injuries (9%)
• Falls are the most common cause of SCI in older adults
2. Nontraumatic damage in adult populations generally
results from disease or pathological influence
Demography and etiology …..
• Incomplete tetraplegia (45%) is the most common

neurological category, followed by incomplete paraplegia
(21.3%), complete paraplegia (20%), and complete
tetraplegia (13.3%)
• Factors that influence life expectancy are ;

• Age at onset
• level
• Extent of neurological injury

RAPY STUDENTS
Classification
1. Tetraplegia: refers to impairment or loss motor and/or sensory

function as a result of damage to the cervical segment of SC
• All four extremities and trunk, including the respiratory muscles is
affected
2. Paraplegia : refers to impairment or loss of motor and/or

sensory function as a result of damage to the thoracic, lumbar, or
sacral segments of the SC
• All or part of the trunk and both LEs

RAPY STUDENTS
Anatomy
RAPY STUDENTS
Main ascending and descending tracts
The primary descending tracts
The primary ascending tracts
• The dorsal column (conveys • The lateral CS (voluntary mov,t)
proprioception, vibratory • Anterior CS (voluntary mov,t of
sensation, deep touch, and axial muscles)
discriminative touch) • Medial vestibulospinal
• Anterolateral system, (positioning of head and neck)
consisting of the spinothalamic, • Lateral and medial vestibulospinal
spinoreticular, and spinotectal (posture and balance)
tracts ( pain, temperature, and • Lateral and medial reticulospinal
crude touch) (posture, balance, automatic gait
• The dorsal and ventral related movements)
spinocerebellar tracts (conveys • Rubrospinal (movement of limbs)
unconscious proprioception)
RAPY STUDENTS
RAPY STUDENTS
RAPY STUDENTS
Mechanisms of the injury
• Compression , penetrating injury, and hyperextension or

hyperflexion forces
• Cervical flexion and rotation
• Cervical hyperflexion : frequently severs the anterior

spinal artery and results in an incomplete ACS
• Cervical hyperextension injuries

• Compression injuries
Clinical syndrome
1. Brown squared syndrome

2. Anterior cord syndrome
3. Posterior cord syndrome
4. Central cord syndrome

RAPY STUDENTS
Brown Sequard syndrome
• Hemi section of the spinal cord damage

(in 1% to 4% )
• Caused by penetration wounds
• Asymmetrical
• Achieve good functional gains during
inpatient rehabilitation
• The prognosis for recovery is good

RAPY STUDENTS
• The prognosis is extremely poor for return of
bowel and bladder function, hand function,
and ambulation
RAPY STUDENTS
Central cord syndrome
• The most common SCI syndrome(9%)
• In adults 45 to 50 yrs. of age, hyperextension injuries is
the most common cause during a low impact accident
or injury
• Younger patients are more likely to have a flexion-
compression injury during a high impact accident or
injury, causing fracture or disc herniation
• More severe neurological involvement of the UEs than
of the LEs
• Sensory impairment are less severe than motor deficits
• Patients with CCS typically recover the ability to
ambulate
RAPY STUDENTS
Central cord syndrome …
• Although the prognosis for

functional recovery is good f , the
pattern of recovery is such that
intrinsic hand function is the last
thing to return
• Most people will recover some

level of ambulatory function, and
over half will experience
spontaneous voiding and bladder
emptying

RAPY STUDENTS
RAPY STUDENTS
Cauda equina and conus medullaris syndrome
• Individuals with cauda equina injuries exhibit areflexic bowel

and bladder and saddle anesthesia.
• LE paralysis and paresis is variable, depending on the extent
of the injury to the cauda equina.
• CE lesions are LMN injuries.
• Conus medullaris syndrome occurs when the very distal
portion of the SC is damaged.
• Often results in a mixture of LMN and UMN damage

RAPY STUDENTS
Clinical presentation……..
• Spinal shock : is the loss of muscle tone and spinal reflexes
below the level of a severe spinal cord lesion
• It is characterized initially by an absence of all reflex activity
and impairment of autonomic regulation, resulting in
hypotension and loss of control of sweating and piloerection
(goose bumps).
• In addition to the loss of DTRs, there is a loss of the

bulbocavernosus reflex, cremasteric reflex, Babinski response,
and a delayed plantar response
One of the first indicator of resolving spinal shock is

the presence of +ve bulbo cavernosus reflex
Clinical presentation …..
• Sensory and motor impairments
• Depend on specific features of lesion(i.e. NL and completeness
of the lesion)
• Cardiovascular impairment
• Impaired temperature control
• Pulmonary impairment
• Bowel and bladder impairment
• Sexual dysfunction
• Pain

RAPY STUDENTS
Complications
• Contracture • DVT
• Heterotopic ossification • Osteoporosis
• Osteoporosis and skeletal fracture • Respiratory compromise
• Pressure ulcer • Bowel and bladder dysfunction
• Autonomic dysreflexia • Sexual dysfunction
• Pain • Spasticity
• Postural hypotension

RAPY STUDENTS
Prognosis
 The potential for recovery from SCI is directly related to :
The neurological level of lesion and
Completeness of the injury.
Preservation of pinprick sensation at 4 months after injury in
the LEs or sacral region is associated with a good prognosis for
motor recovery at 1 year after injury.
Medical intervention
Fracture stabilization /Immobilization

Medication
Surgery if indicated
Physiotherapy examination
Before beginning the initial examination;
• The patient must be suﬃciently stable and
• Aware of any precautions (Spinal instability, orthotic devices,

concomitant injuries, and need for medical support (e.g., ventilator))
may preclude certain movements or positions.
1. Sensory and motor function
2. Respiratory function
• Diaphragm and intercostal muscles strength
• Normally, the epigastric region should rise and the chest wall expands during
inhalation while in supine
• Contractions of the sternocleidomastoids and scalene or paradoxical breathing
patterns indicate weakness or lack of innervation of the diaphragm or intercostal
muscles
• RR, Maximum chest expansion , Vital capacity

• Abdominal muscle function: impairs the ability cough and clear the air way
• Cough functions: can be categorized into three
I. Functional cough is loud and forceful, and the patient is able to generate two
or more coughs with one exhalation
II. A weak functional cough is soft, and the patient is only able to generate one
per exhalation. The patient can clear small amounts of secretions and clear the
throat.
III. A nonfunctional cough is not a true cough; it is a clearing of the throat and
has no expulsive force.
• Assistance is needed to clear secretions from the airway
Physiotherapy examination……
3. Integument
4. PROM
5. Early mobility skills

RAPY STUDENTS
Physiotherapy early interventions
• The application of interventions is dependent on :

• The medical stability of the patient
• Stability of healing fracture and surgical sites
• Status of other injuries that may have occurred during the
initial event that caused the SCI
• Clearance from the surgeon

RAPY STUDENTS
Physiotherapy interventions……
• Respiratory management
• Primary goals: improved ventilation, increased
effectiveness of cough, and prevention of chest tightness
and ineffective substitute breathing pattern
• Respiratory muscle training
• Diagrammatic breathing
• Inspiratory muscle training; improve pulmonary function , reduce
dyspnea , improve cough function
• Expiratory muscle training ; assist pulmonary function
• Glossopharyngeal breathing
• Abdominal binder
• Manual stretching

RAPY STUDENTS
Physiotherapy interventions…
• Skin care
• Positioning
• Consistent and effective pressure relief
• Skin inspection
• Patient education
• Strength and ROM
• Mobility intervention
• Education

RAPY STUDENTS
Assisted cough using abdominal thrust

maneuver to clear secretions
Inspiratory muscle trainers
RAPY STUDENTS
Patient extends the wrist, which causes

the shortened long finger flexors to passively
flex, allowing a grasp Intrinsic-plus splint

RAPY STUDENTS
Active rehabilitation
• The overarching goal of rehabilitation is for the patient to become as
independent as possible and to achieve the functional mobility
necessary for everyday life, work, and recreation.
• Independent mobility can be achieved
1. uses new movement strategies to compensate for neuromuscular
impairments (compensation)
2. Uses the neuromuscular system to accomplish the task with a movement
pattern similar to that before the injury(recovery of function)
• Compensation refers to use of an alternative or new movement strategy,

or technology to compensate for NM deficits to accomplish a daily task.
• Recovery of function refers to the restoration of the NM system so that
the motor task is performed in a similar manner as it was before the SCI

RAPY STUDENTS
• As much as greater patient mobility is now allowed, more

complete testing of muscle strength, ROM, and functional skills
can be performed

RAPY STUDENTS
Aerobic capacity and endurance
1. Aerobic capacity and endurance

2. Integumentary integrity
3. Mental function
4. Motor function/sensory integrity
5. Pain
6. ROM
7. Reflex
8. Assistive technology
9. Balance
10. Gait
11. Community ,social and civic life

RAPY STUDENTS
Physiotherapy intervention
• Strengthening exercise
• Cardiovascular/endurance training
• Bed mobility skills
• Rolling
• Transitioning Supine to/From Sitting
• Prone on elbows
• Supine on elbows
• Walking on elbows to assume long sitting
• Coming Straight to Long Sitting From Supine
• Transfer
• Locomotor rehabilitation
• Patient related education

RAPY STUDENTS
Rolling from supine to prone using UE momentum and
crossing the ankles

RAPY STUDENTS
B
A
Transitioning from prone (A) to prone on elbows (B) with
shoulders initially abducted and weight shifting
RAPY STUDENTS
A B C
Patient transitioning from supine (A) to supine-on-elbows (B) by stabilizing

hands under pelvis, forcefully pulling up by contracting the biceps, weight
shifting side to side, and placing elbows farther underneath the shoulder joints
(C)

RAPY STUDENTS
Factors that aﬀect functional outcomes
• Motor level
• Age
• Concomitant injury
• Preexisting health conditions
• Secondary complications
• Body type
• Psychosocial support
ISNCSCI / ASIA Examination
Getachew A.
Objectives
Be familiar with how the ISNCSCI/ASIA exam is performed
Be able to define/determine the following:
• Sensory level
• Motor level
• Neurological level of injury
• Completeness of injury
• AIS Classification
Be able to determine ASIA impairment scale classification using
practice cases
04/24/2024 Neurological rehabilitation for third year phyiotherapy student 43

s
ISNCSCI / ASIA Examination
• American Spinal Injury Association (ASIA) had created the International
Standards of Neurological Classification of Spinal Cord Injury(ISNCSCI)
 The ISNCSCI ; purposes
 Provides a standardized examination method to determine the extent of
motor and sensory function loss after a SCI.
 It promotes better communication between and among professionals
 Provides guidance for establishing the prognosis and
 An important tool for clinical research trials

s
ASIA Examination
• Includes
 Sensory level
 Motor level
 Neurological level of injury (NLI)
 Complete vs. Incomplete injury
 Sacral sparing
 Zone of Partial Preservation (complete injuries)

s
Sensory examination
• Sensory level is the most caudal level with normal light touch and pinprick
sensation
 Sensory level is determined by testing the patient’s sensitivity to light touch and
pinprick on the both side of the body at key dermatomes for key sensory points
28 key dermatomes

Test light touch and pinprick
Face is used as control
Three point scale:
• 0 = absent
• 1 = impaired
• 2 = normal
• NT = not tested

s
Light Touch Sensory Scoring
• Use cotton tip applicator

• Stroke across skin moving over a distance that does not exceed 1 cm
• For C6-C8 use dorsal surface of proximal phalanx
• Chest and abdomen points should be tested in the midclavicular line

s
pinprick scoring
• Clean safety pin

• Use consistent pressure in each dermatome
• Poke one time only, not repeated
Patient “feeling” PP but unable to differentiate sharp

and dull is simply sensing pressure
PP sensation is ABSENT.

s
Sensory Testing—perianal area
• S4/5 dermatome represents the most caudal aspect of the spinal

cord
• S4/5 is tested for both PP and LT
• Deep anal pressure: on digital rectal exam patient is asked to

report sensory awareness. Recorded as “present” or “absent”.

s
Determining sensory level
• Determined for right side and left side

• Defined as the level where sensory function is normal on
both sides of the body
• Lowest level where you have “2’s” with all above levels
being “2’s

s
Motor Examination
Motor level is the most caudal segment of the SC with normal

motor function bilaterally
10 key muscle groups

 Other muscles may be clinically important but do not contribute
to motor scores
 Examine in rostral to caudal sequence (Don’t Skip Around!)
Tested in supine position
• Necessary during acute period, allows for comparison later on.
6 point scale (0-5) - MMT
• Only whole numbers, no plus/minus (for research purposes)
04/24/2024 Neurological rehabilitation for third year phyiotherapy students 51

Motor examination
Upper Extremities: Lower Extremities

• C5 = Elbow Flexors • L2 = Hip Flexors
• C6 = Wrist Extensors • L3 = Knee Extensors
• C7 = Elbow Extensors • L4 = Ankle Dorsiflexors
• C8 = Finger Flexors • L5 = Long Toe Extensors
• T1 = Finger Abductors • S1 = Ankle Plantarflexors

s
Motor testing
Test each of the ten key muscles

Record numeric values only (for research and test-taking purposes).
Voluntary anal contraction: contraction of EAS around examiners finger;
graded as “present” or “absent”
Pain and deconditioning may cause patient to grade 4/5; can grade this as
5*
Score “NT” if patient not fully testable due to pain, spasticity, uncontrolled
clonus, fracture
Contractures:
• What do we do???
NT if contracture limits > 50% ROM

s
Motor score
• Level at which strength is at least 3/5 with all levels above being
5/5
• Scored for each side, overall score is last normal for both.
• Sensory level is in a region that cannot be tested (C2-4, T2-L1,
S3-5)
• Motor level is designated as being the same as the sensory level.
If can’t test motor, then motor level is same

as sensory level

s
Neurological level of injury (NLI)
• The neurological level of injury is the most caudal level of the
SC with normal motor and sensory function on both sides of the
body
 Motor ≥3/5 with levels above being 5/5

 Sensory intact bilaterally for LT and PP with all sensation above
intact
 If there is no key muscle for a segment that has sensory intact
(C2-4, T2-L1, S3-5), the sensory level defines the motor level
and the NLI

s
s
Complete Injuries, Incomplete Injuries,
and Zone of Partial Preservation
• The ISNCSCI defines a complete injury as having no sensory or motor
function in the lowest sacral segments (S4 and S5), with no sacral
sparing.
• Sacral sparing is determined by sensory function at S4–5 dermatome,
ability to feel deep anal pressure, or voluntary anal sphincter contraction.
• An incomplete injury is classified as having motor and/or sensory
function below the neurological level that includes sensory and/or motor
function at S4 and S5, with presence of sacral sparing(perineal
sensation).
• If an individual has motor and/or sensory function below the neurological
level but does not have sacral sparing, then the areas of intact motor
and/or sensory function below the neurological level are termed zones of
partial preservation.

RAPY STUDENTS
American Spinal Injury Association scale for spinal cord injury
(ASIA impairment scale)
ASIA Complete: No sensory or motor function preserved in the sacral segments of S4-S5
A
ASIA Sensory incomplete : Motor deficit without sensory loss below the neurological
B level, including the sacral segments of S4-S5 (light touch, pin sensation or deep anal
pressure at S4-S5), and there is no protected motor function from three levels
below the motor level at each half of the body
ASIA Motor incomplete: Motor function is preserved below the neurological level and
C more than half of the muscles below this level have strength lower than 3/5 (0, 1 or
2)
ASIA Motor incomplete: Motor function is preserved below the neurological level and at
D least half of the muscles (half or more) below this level have strength higher than
3/5
ASIA Normal : Sensory and motor function in all segments are normal and in patients
E with pre-existing deficits there is "E'' degree of ASIA.

RAPY STUDENTS
Complete vs. incomplete
• Complete = NO sacral sparing
• “NOON sign”
• Incomplete = ANY sacral sparing
Sacral sparing
 Light touch sensation at S4/5
 Pinprick at S4/5
 Deep anal pressure
 Voluntary anal contraction
Zone of Partial Preservation
 All segments below NLI with preservation of sensory or motor findings in complete SCI

s
s
Quiz
1. Anterior cord syndrome(1 Pt) ?
2. Brown cord syndrome (1 pt.)?
3. List to ascending tracts of spinal cord (1pt) at least three
4. Define tetraplegia (1 pt.)
5. write factors which determine the prognosis of SCI(1 pt) at lease four

Spinal Cord Injury

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Spinal Cord Injury

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Traumatic spinal cord injuries

Getachew Azeze(BSc, MPT)

• Understand the causes, clinical manifestations, and

• Resulting in a change in the normal motor, sensory or

• The clinical manifestations depending on the extent and

• SCI is a relatively low-incidence, high-cost injury that

• Incomplete tetraplegia (45%) is the most common

• Factors that influence life expectancy are ;

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 5

1. Tetraplegia: refers to impairment or loss motor and/or sensory

2. Paraplegia : refers to impairment or loss of motor and/or

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 6

• Compression , penetrating injury, and hyperextension or

• Cervical flexion and rotation

• Cervical hyperflexion : frequently severs the anterior

• Cervical hyperextension injuries

1. Brown squared syndrome

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 13

• Hemi section of the spinal cord damage

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 14

• Although the prognosis for

• Most people will recover some

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 17

• Individuals with cauda equina injuries exhibit areflexic bowel

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 19

• In addition to the loss of DTRs, there is a loss of the

One of the first indicator of resolving spinal shock is

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 21

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 22

Fracture stabilization /Immobilization

• The patient must be suﬃciently stable and

• Aware of any precautions (Spinal instability, orthotic devices,

• RR, Maximum chest expansion , Vital capacity

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 27

• The application of interventions is dependent on :

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 28

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 29

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 30

Assisted cough using abdominal thrust

Patient extends the wrist, which causes

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 32

• Compensation refers to use of an alternative or new movement strategy,

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 33

• As much as greater patient mobility is now allowed, more

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 34

1. Aerobic capacity and endurance

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 35

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 36

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 37

Patient transitioning from supine (A) to supine-on-elbows (B) by stabilizing

04/24/2024 NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHE 39

04/24/2024 Neurological rehabilitation for third year phyiotherapy student 43

04/24/2024 Neurological rehabilitation for third year phyiotherapy student 44

04/24/2024 Neurological rehabilitation for third year phyiotherapy student 45

28 key dermatomes

04/24/2024 Neurological rehabilitation for third year phyiotherapy student 46

• Use cotton tip applicator

04/24/2024 Neurological rehabilitation for third year phyiotherapy student 47

• Clean safety pin

Patient “feeling” PP but unable to differentiate sharp

04/24/2024 Neurological rehabilitation for third year phyiotherapy student 48

• S4/5 dermatome represents the most caudal aspect of the spinal

• Deep anal pressure: on digital rectal exam patient is asked to