CLINICAL
REVIEW
Spinal Cord Injuries and Exercise
Indexing Metadata/Description
› Title/condition: Spinal Cord Injuries and Exercise
› Synonyms: Chronic spinal cord injuries and exercise; spinal cord injuries and physical
activity; paraplegia and exercise; tetraplegia and exercise
› Anatomical location/body part affected: Vertebrae/spinal cord, autonomic system. In
general, the body parts affected are typically below the level of the spinal cord injury
(SCI)
› Area(s) of specialty: Neurological rehabilitation, orthopedic rehabilitation, pediatric
rehabilitation
› Description
• SCI is classified by motor level and sensory level
–Motor level is defined by the lowest key muscle that has a grade of at least 3 on manual
muscle testing (MMT) provided the key muscles above that level are intact (5 on
MMT)(26)
–Sensory level is the most caudal, normal dermatome for both pinprick and light touch
where 0 = absent, 1= altered (including hyper), and 2= normal(26)
–There can be up to 4 different levels if sensory and motor impairments differ and sides
differ (e.g., angled lesions). Neurological level of injury refers to the lowest segment
with normal sensory and motor function on both sides)(26)
› For more information, see International Standards for Classification of SCI at http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3232636/ for more information
• Cervical SCI lesions cause tetraplegia (quadriplegia) affecting movement of the trunk
and upper and lower extremities. Thoracic, lumbar, and sacral lesions cause paraplegia
affecting movement of the trunk and lower extremities
• Annual incidence of traumatic SCI in North America is reported to be ~40 individuals
per million(27)
• Annual incidence of traumatic SCI in Europe is reported to be ~17.5 individuals per
Author
Rudy Dressendorfer, BScPT, PhD
Cinahl Information Systems, Glendale, CA
Reviewers
Ellenore Palmer, BScPT, MSc
Cinahl Information Systems, Glendale, CA
Andrea Callanen, MPT
Cinahl Information Systems, Glendale, CA
Rehabilitation Operations Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Sharon Richman, MSPT
Cinahl Information Systems, Glendale, CA
February 6, 2015
million(27)
• This Clinical Review focuses on exercise training among adults with chronic SCI. For
additional information, see the following:
–Clinical Review…Spinal Cord Injuries: General Overview; Item Number: T708579
–Clinical Review…Spinal Cord Injuries: Physiological Changes; Item Number:
T708639
–Clinical Review…Spinal Cord Injuries: Complete-MotorComplete Injuries; Item
Number: T708641
–Please see Clinical Review…Spinal Cord Injury: Incomplete Injuries; Item Number:
T708640
–Please see Clinical Review…Spinal Cord Injury: Cervical Lesions; Item Number:
T708642
–Please see Clinical Review…Central Cord Syndrome; Item Number:T708779
› ICD-9 codes
• 767.4 injury to spine and spinal cord due to birth trauma
• 806.0 closed fracture of cervical vertebra with spinal cord injury
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–806.00 closed fracture of C1-C4 level with unspecified spinal cord injury
–806.01 closed fracture of C1-C4 level with complete lesion of cord
–806.02 closed fracture of C1-C4 level with anterior cord syndrome
–806.03 closed fracture of C1-C4 level with central cord syndrome
–806.04 closed fracture of C1-C4 level with other specified spinal cord injury
–806.05 closed fracture of C5-C7 level with unspecified spinal cord injury
–806.06 closed fracture of C5-C7 level with complete lesion of cord
–806.07 closed fracture of C5-C7 level with anterior cord syndrome
–806.08 closed fracture of C5-C7 level with central cord syndrome
–806.09 closed fracture of C5-C7 level with other specified spinal cord injury
• 806.1 open fracture of cervical vertebra with spinal cord injury
–806.10 open fracture of C1-C4 level with unspecified spinal cord injury
–806.11 open fracture of C1-C4 level with complete lesion of cord
–806.12 open fracture of C1-C4 level with anterior cord syndrome
–806.13 open fracture of C1-C4 level with central cord syndrome
–806.14 open fracture of C1-C4 level with other specified spinal cord injury
–806.15 open fracture of C5-C7 level with unspecified spinal cord injury
–806.16 open fracture of C5-C7 level with complete lesion of cord
–806.17 open fracture of C5-C7 level with anterior cord syndrome
–806.18 open fracture of C5-C7 level with central cord syndrome
–806.19 open fracture of C5-C7 level with other specified spinal cord injury
• 806.2 closed fracture of dorsal vertebra with spinal cord injury
–806.20 closed fracture of T1-T6 level with unspecified spinal cord injury
–806.21 closed fracture of T1-T6 level with complete lesion of cord
–806.22 closed fracture of T1-T6 level with anterior cord syndrome
–806.23 closed fracture of T1-T6 level with central cord syndrome
–806.24 closed fracture of T1-T6 level with other specified spinal cord injury
–806.25 closed fracture of T7-T12 level with unspecified spinal cord injury
–806.26 closed fracture of T7-T12 level with complete lesion of cord
–806.27 closed fracture of T7-T12 level with anterior cord syndrome
–806.28 closed fracture of T7-T12 level with central cord syndrome
–806.29 closed fracture of T7-T12 level with other specified spinal cord injury
• 806.3 open fracture of dorsal vertebra with spinal cord injury
–806.30 open fracture of T1-T6 level with unspecified spinal cord injury
–806.31 open fracture of T1-T6 level with complete lesion of cord
–806.32 open fracture of T1-T6 level with anterior cord syndrome
–806.33 open fracture of T1-T6 level with central cord syndrome
–806.34 open fracture of T1-T6 level with other specified spinal cord injury
–806.35 open fracture of T7-T12 level with unspecified spinal cord injury
–806.36 open fracture of T7-T12 level with complete lesion of cord
–806.37 open fracture of T7-T12 level with anterior cord syndrome
–806.38 open fracture of T7-T12 level with central cord syndrome
–806.39 open fracture of T7-T12 level with other specified spinal cord injury
• 806.4 closed fracture of lumbar spine with spinal cord injury
• 806.5 open fracture of lumbar spine with spinal cord injury
• 806.6 closed fracture of sacrum and coccyx with spinal cord injury
–806.60 closed fracture of sacrum and coccyx with unspecified spinal cord injury
–806.61 closed fracture of sacrum and coccyx with complete cauda equina lesion
–806.62 closed fracture of sacrum and coccyx with other cauda equina injury
–806.69 closed facture of sacrum and coccyx with other spinal cord injury
• 806.7 open fracture of sacrum and coccyx with spinal cord injury
–806.70 open fracture of sacrum and coccyx with unspecified spinal cord injury
–806.71 open fracture of sacrum and coccyx with complete cauda equina lesion
–806.72 open fracture of sacrum and coccyx with other cauda equina injury
–806.79 open fracture of sacrum and coccyx with other spinal cord injury
• 806.8 closed fracture of unspecified vertebra with spinal cord injury
• 806.9 open fracture of unspecified vertebra with spinal cord injury
• 907.2 late effect of spinal cord injury
• 907.3 late effect of injury to nerve root(s), spinal plexus(es), and other nerves of trunk
• 952 spinal cord injury without evidence of spinal bone injury
–952.0 cervical spinal cord injury without evidence of spinal bone injury
- 952.00 C1-C4 level spinal cord injury, unspecified
- 952.01 C1-C4 level with complete lesion of spinal cord
- 952.02 C1-C4 level with anterior cord syndrome
- 952.03 C1-C4 level with central cord syndrome
- 952.04 C1-C4 level with other specified spinal cord injury
- 952.05 C5-C7 level spinal cord injury, unspecified
- 952.06 C5-C7 level with complete lesion of spinal cord
- 952.07 C5-C7 level with anterior cord syndrome
- 952.08 C5-C7 level with central cord syndrome
- 952.09 C5-C7 level with other specified spinal cord injury
–952.1 dorsal (thoracic) spinal cord injury without evidence of spinal bone injury
- 952.10 T1-T6 level spinal cord injury, unspecified
- 952.11 T1-T6 level with complete lesion of spinal cord
- 952.12 T1-T6 level with anterior cord syndrome
- 952.13 T1-T6 level with central cord syndrome
- 952.14 T1-T6 level with other specified spinal cord injury
- 952.15 T7-T12 level spinal cord injury, unspecified
- 952.16 T7-T12 level with complete lesion of spinal cord
- 952.17 T7-T12 level with anterior cord syndrome
- 952.18 T7-T12 level with central cord syndrome
- 952.19 T7-T12 level with other specified spinal cord injury
• 952.2 lumbar spinal cord injury without spinal bone injury
• 952.3 sacral spinal cord injury without spinal bone injury
• 952.4 cauda equina spinal cord injury without spinal bone injury
• 952.8 multiple sites of spinal cord injury without spinal bone injury
• 952.9 unspecified site of spinal cord injury without spinal bone injury
› ICD-10 codes
• P11.5 birth injury to spine and spinal cord
• S14 injury of nerves and spinal cord at neck level
–S14.0 concussion and edema of cervical spinal cord
–S14.1 other and unspecified injuries of cervical spinal cord
–S14.2 injury of nerve root of cervical spine
• S24 injury of nerves and spinal cord at thorax level
–S24.0 concussion and edema of thoracic spinal cord
–S24.1 other and unspecified injuries of thoracic spinal cord
–S24.2 injury of nerve root of thoracic spine
• S34 injury of nerves and lumbar spinal cord at abdomen, lower back and pelvis level
–S34.0 concussion and edema of lumbar spinal cord
–S34.1 other injury of lumbar spinal cord
–S34.2 injury of nerve root of lumbar and sacral spine
–S34.3 injury of cauda equina
• T06.0 injuries of brain and cranial nerves with injuries of nerves and spinal cord at neck level
• T09.3 injury of spinal cord, level unspecified
• T09.4 injury of unspecified nerve, spinal nerve root and plexus of trunk
• T91.3 sequelae of injury of spinal cord
› G-Codes
• Mobility G-code set
–G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8979, Mobility: walking & moving around functional limitation; projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end
reporting
• Changing & Maintaining Body Position G-code set
–G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end
reporting
• Carrying, Moving & Handling Objects G-code set
–G8984, Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8985, Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end
reporting
• Self Care G-code set
–G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals
–G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at
discharge or to end reporting
–G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting
• Other PT/OT Primary G-code set
–G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end
reporting
• Other PT/OT Subsequent G-code set
–G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
–G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to
end reporting
›.
G-code Modifier
Impairment Limitation Restriction
CH
0 percent impaired, limited or restricted
CI
At least 1 percent but less than 20 percent impaired, limited or restricted
CJ
At least 20 percent but less than 40 percent impaired, limited or restricted
CK
At least 40 percent but less than 60 percent impaired, limited or restricted
CL
At least 60 percent but less than 80 percent impaired, limited or restricted
CM
At least 80 percent but less than 100 percent impaired, limited or restricted
CN
100 percent impaired, limited or restricted
Source: http://www.cms.gov
.
› Reimbursement: No specific issues or information have been identified regarding reimbursement for therapy, which will
depend on insurance contract coverage. Some treatment interventions may be considered investigational and not covered by
the third-party payor/insurance
› Presentation/signs and symptoms
• Incomplete or complete paraplegia or quadriplegia
• Most patients will present unassisted in a wheelchair. Some may have limited self-mobility, while others may ambulate
with an assistive device
• Reduced exercise capacity
Causes, Pathogenesis, & Complications
› Causes
• Trauma such as in motor vehicle or motorboat accidents, falls, and sports(1)
–Often involve acceleration-deceleration forces
–Traumatic spinal hyperextension, hyperflexion, axial loading, deformation, compression, and/or rotation
• Stab injury or gunshot wound
• Nontraumatic SCI is disease dependent. Causes include:(1)
–Infection
–Inflammation (e.g., transverse myelitis, syringomyelitis)
–Malignancy
–Vascular insufficiency/hemorrhage
–Motor nerve disease
–Degeneration of spine (e.g., spinal stenosis)
–Spina bifida
–Primary tumor
–Pathological fracture
› Pathogenesis
• High-level thoracic and cervical lesions are associated with problems of autonomic dysreflexia (AD)(6)
• The most common issues raised by patients with SCI seen in primary care are related to disability and secondary
complications (see below)(2)
• Mobility limitations contribute to hypokinesis. Impaired cardiovascular, respiratory, autonomic, and musculoskeletal
systems as a result of SCI impact the patient’s ability to perform physical activity and an optimal level of daily exercise.
These factors combined together increase the individual’s risk of developing cardiovascular disease, diabetes, cancer,
osteoporosis, and depression. Regular exercise would reduce the risk of these comorbidities that can have a dramatic
negative effect on the overall quality of life in patients with SCI(1,2)
› Complications (1,2)
• Pain
• Muscle: muscle spasms, spasticity, clonus
• Bowel and/or bladder: dysfunction, incontinence, urinary tract infection (UTI)
• Renal: kidney stones, pyelonephritis, failure
• Cardiovascular: blood pressure (BP) dysregulation, atherosclerosis, deep vein thrombosis (DVT)
• Bone: osteoporosis, fragility fractures
• Skin: thinning, pressure ulcers
• Pulmonary: respiratory muscle weakness, pneumothorax, pneumonia
• Behavioral: depression
• Sexual dysfunction and reproductive health issues
Overall Contraindications/Precautions
› Document clearance for exercise testing and training in physician’s referral form, along with any special precautions and
parameters for monitoring vital signs
› Consult physician regarding relative (i.e., depending on severity) contraindications, including:(6)
• ADsigns include:
–Elevated BP
–Pounding headache
–Bradycardia
–Profuse sweating
–Piloerection (goose bumps), usually above the level of the lesion but can be below
–Cardiac arrhythmias, atrial fibrillation, premature ventricular contractions, and atrioventricular conduction abnormalities
–Flushing of the skin, especially in the face, neck, and shoulders, or possibly below the level of lesion
–Blurred vision
–Appearance of floaters (spots in the visual field)
–Congestion of mucous membranes
–Anxiety
• Cardiovascular comorbidity
• Osteoporosis with increased fracture risk
• Presence of DVT: obtain orders from physician before resuming exercise
• Orthostatic hypotension
› Take additional special precautions as may be needed by patients who will exercise at home and in other unsupervised
settings
Examination
› Contraindications/precautions to examination
• History taking and examination procedures will vary depending on the patient’s SCI level and functional capacity, as well
as current complications that require modification of methods used
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness: Document cause and date of SCI, including level of lesion. Document the
extent of sensory and motor function based on the American Spinal Injury Association (ASIA) Impairment Scale. Also
document patient’s recovery and rehabilitation course to this point
–Course of treatment
- Medical management: Who are the members of the patient’s medical team? What complications has the patient
experienced since the date of SCI, and how are these currently being treated?
- Medications for current illness/injury: Determine what medications clinician has prescribed; are they being taken?
- Common medications after SCI include corticosteroids for swelling, tizanidine and baclofen for spasticity, and
gabapentin for chronic pain(7)
- Experimental drugs that inhibit Rho GTPase activity and promote spinal axon regeneration are under investigation(7)
- Diagnostic tests completed: Usual tests for this condition include imaging studies such as x-rays, magnetic resonance
imaging (MRI), and computerized tomography (CT) scans, nerve conduction tests, myelography, electro- and
echocardiograms, and pulmonary function tests
- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative
therapies (e.g., acupuncture) and whether or not they help
- Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and
what specific treatments were helpful or not helpful
–Aggravating/easing factors: Identify what symptoms are being aggravated or eased by specific activity, positions, and
movement. What is the duration of the symptoms?
–Body chart: Use body chart to document location and nature of symptoms
–Nature of symptoms: Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,
numbness, tingling). Radicular, mechanical, and referred pain is not uncommon after SCI. (For patients with shoulder
pain, see Clinical Review…Shoulder Pain: Wheelchair User; Accession Number; Item Number: T708462)
–Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and
at the moment (specifically address if pain is present now and how much). Consider Wheelchair User’s Shoulder Pain
Index, as indicated(8)
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of wakings/night
–Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/
or symptoms that could be indicative of a need to refer to physician (e.g., spasticity, dizziness, bowel/bladder/sexual
dysfunction, respiratory distress, saddle anesthesia)
–Respiratory status: Document respiratory status (e.g., need for ventilator, supplemental oxygen), status of respiratory
muscles especially diaphragm. In higher functioning patients, document the results of formal exercise tests (e.g., arm
ergometry, wheelchair ergometry, body-weight-supported (BWS) treadmill exercise tests)
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe ____________________________
• Medical history
–Past medical history
- Previous history of same/similar diagnosis:Document rehabilitation history since SCI, fitness and activity limitations
pre and postinjury
- Comorbid diagnoses: Ask patient about other problems, including diabetes, cancer, heart disease, complications of
pregnancy, osteoporosis, psychiatric disorders, orthopedic disorders, etc.
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask patient about other symptoms he or she may be experiencing
• Social/occupational history
–Patient's goals: Document what the patient hopes to accomplish with therapy and in general
–Vocation/avocation and associated repetitive behaviors, if any: Is the patient back to work? Does the patient
participate or desire to participate in recreational or competitive sports?
–Functional limitations/assistance with ADLs/adaptive equipment: How well does the patient negotiate obstacles in the
home/work environment?
–Living environment: Document stairs, number of floors in home, with whom patient lives, caregivers, etc. Identify if
there are barriers to independence in the home; any modifications necessary, such as widening doorways for a wheelchair
or assistive device?
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Anthropometric characteristics: Document height, weight, and body mass index (BMI)
–Overweight/obesity may negatively impact health and well-being in chronic SCI(9)
• Arousal, attention, cognition(including memory, problem solving)
–Assess if the patient is alert and oriented x 4. Does the patient exhibit signs of poor mood, anger, or anxiety?
–Further cognitive testing may be indicated if patient has also suffered a traumatic brain injury (TBI) or has a comorbidity
involving cognitive deficits such as dementia, attention deficit disorder (ADD), or learning disability
• Assistive and adaptive devices: Document assistive devices currently in use. Assess if these devices appropriate, in
good condition, and being used properly? Are additional assistive/adaptive devices indicated? Document the use of any
pressure-relieving cushions or mattresses and in what condition they are in
• Balance: Evaluate static and dynamic balance in sitting and standing using the Berg Balance Scale (BBS) or Pediatric
Balance Scale (PBS). The Modified Functional Reach Test can also be used
–Document whether postural reactions and righting reactions to perturbations are impaired or intact
–Does the patient use compensatory upper extremity strategies to sustain posture against gravity? If so, do these strategies
prevent the patient from using his or her hands for instrumental ADLs?
• Cardiorespiratory function and endurance
–Document vital signs at rest and during mobility
–Patients with SCI level above T4 may have impaired sympathetic innervation to the heart, which can reduce cardiac
output, maximal heart rate (HR), BP, and distribution of regional blood flow, increasing the risk of orthostatic and
exercise-related systolic hypotension(16)
–Assess exertion with the Borg Rating of Perceived Exertion (RPE) Scale
–Assess endurance with appropriate cardiorespiratory measure (e.g., gait, upper extremity cycle ergometer, wheelchair
mobility for set time or distance)
–Respiratory muscle status(17)
- Patients with injuries above C4 require ventilator support for respiration
- It is important that the clinician assess which muscles of respiration have been impacted by SCI
- Monitor for signs and symptoms of atelectasis or infection (e.g., increased temperature, change in respiratory rate,
shortness of breath, increased HR, anxiety, and increased volume or change in consistency of secretions)
- Forceful expiration and cough may be affected in patients with SCI depending on the lesion level
- Document respiration pattern and any accessory muscle use
- Document need for artificial ventilation/oxygen
- Document cough ability and need for support during coughing
–Maximal or symptom-limited graded exercise testing (GXT) on a cycle (arm or leg) ergometer may be indicated for
high-functioning patients to assess HR and BP responses and to determine peak oxygen uptake (VO2peak) for the aerobic
exercise prescription(13)
• Circulation
–Assess bilateral peripheral pulses
–Assess for any signs and symptoms of DVT
• Cranial/peripheral nerve integrity
–Assess cranial nerves if patient has a history of TBI
• Ergonomics/body mechanics: Assess for alterations in body mechanics with functional mobility that impair the patient’s
ability to conserve energy and achieve optional postural alignment
• Functional mobility (including transfers, etc.)
–Complete a functional assessment of basic mobility, including bed mobility, wheelchair mobility, and transfers
–Assessment measures to consider include the FIM, WeeFIM, and the Spinal Cord Independence Measure (SCIM), Version
III(10)
• Gait/locomotion: Assess gait as indicated
–Patients with incomplete paraplegia or complete SCI level at T12 or below can often regain the ability to ambulate in the
community with the use of an assistive device(2)
–For ambulatory patients, outcome measures to consider are the Timed Up & Go (TUG) test, Walking Index for Spinal
Cord Injury (WISCI), Version II,(12)10-meter walktest (10MWT), and 6-minute walk for distance test (6MWT)(11)
• Joint integrity and mobility: Assess bilateral upper and lower extremity joints for mobility using the Parris Stoddard
Scale. Note any joint crepitus, symptomatic pain, or hyper- or hypomobility
• Motor function (motor control/tone/learning)
–Assess muscles for abnormal tone and spasticityusing the Modified Ashworth Scale or Spinal Cord Assessment Tool for
Spasticity (SCATS)
–The Patient Reported Impact of Spasticity Measure (PRISM)can also be used(25)
–Motor control assessment is appropriate when there is abnormal tone, lack of coordinated movement, or patient cannot
follow instructions for MMT. Note the patient’s ability to isolate muscle groups in a gravity-eliminated or antigravity
position. Note ability to modulate reflexes, especially in patients with incomplete SCI (e.g.,the ability to suppress plantar
reflex)
• Muscle strength
–Assess bilateral upper and lower extremity muscle strength and trunk strength using MMT; however, do not use MMT for
muscles with contractures or spasticity
• Observation/inspection/palpation
–Assess skin integrity, particularly over bony prominences, and document characteristics of any decubiti/pressure ulcers
(e.g., stage, size, location, depth, exudate). Will existing decubiti interfere with the patient’s ability to exercise? Observe
ability to weight shift while seated in wheelchair
• Posture: Complete a postural assessment in sitting on flat surface and in patient’s wheelchair. Assess patient’s standing
posture and note any asymmetry or abnormalities
• Range of motion: Document bilateral upper and lower extremity active and passive ROM. Document muscle flexibility for
the following: hamstrings, iliopsoas, quadriceps, gastrocsoleus, biceps, triceps, and wrist flexors/extensors
• Reflex testing: Evaluate bilateral upper and lower deep tendon reflexes and assess for Babinski reflex
• Self-care/activities of daily living (objective testing): Refer to occupational therapist (OT) for complete evaluation of
patient’s ability to perform ADLs and self-care
–Patients with injury at the C1-C4 level are usually dependent for ADLs but can verbalize what needs to be done(17)
–Patients with injury at C6-C7 level may be able to feed and dress themselves with adaptive equipment and setup(17)
–Patients with C8-S1 injuries have the ability to be independent with self-care with adaptive equipment (depending on the
level)(17)
• Sensory testing
–Sharp-dull discrimination and light touch sensation must be evaluated
–Optional sensory testing includes joint movement appreciation, joint position sense, deep pressure, deep pain, and
temperature(26)
–Please refer to the physician’s report for information regarding sensation in the anal area
• Special tests specific to diagnosis
–American Spinal Injury Association (ASIA) Impairment Scale(21)
–Autonomic Standards Assessment Form(ASAF), Second Version(22)
- The Autonomic Standards Committee of ASIA and the International Spinal Cord Society (ISCoS) developed the ASAF,
an autonomic nervous system assessment tool, to be included as part of the clinical evaluation of individuals with SCI.
In 2012, the tool’s second version was updated
–WISCI, Version II(12)
–Medical Outcomes Study 36-Item Short Form (SF-36) or SF-12(23)
–Needs Assessment Checklist (NAC)(24)
- Created for patients with SCI to evaluate 9 functional mobility and disability categories: ADLs, bladder management,
bowel management, skin management, mobility, community, wheelchair and equipment, psychosocial issues, and
discharge coordination
–SCIM, Version III(10)
- Assesses 17 skills and encompasses 3 areas of function: mobility, self-management, and respiration and sphincter
management
• Wheelchair mobility
–Evaluate wheelchair mobility and skills
–The SmartWheel(18,19)
- An assessment device that can be attached to the majority of standard wheelchairs
- Device records amount of force put forth with every push, length and ease of every push, and push frequency
- Data collected may be utilized as objective outcome data or for reimbursement
–The SmartWheel Users’ Group (SWUG)(18,19)
- Created a standard clinical protocol
- The clinician evaluates the patient in the following areas with the SmartWheel:
- Propelling a wheelchair over smooth tile
- Propelling a wheelchair over carpet
- Propelling a wheelchair up a ramp which acts in accordance with the Americans with Disabilities Act
- Performing a figure 8 on smooth tile
- Identified 4 parameters that are of great consequence in clinical setting
- Average peak resultant force, velocity, push frequency, and stroke length
- Group felt that each patient should complete a wheelchair velocity assessment first; minimum velocity for safe
community propulsion must be attained (reportedly 1.06 m/s)
–Velocity and push frequency may be determined without use of a SmartWheel through the following method:(18)
- Plot out a 10-m path and record type of surface
- Patient begins at first line and propels over finish line
- Clinician counts number of pushes required to cross line
- Velocity (m/s) = 10 m divided by time to complete 10 m (in seconds)
- Push frequency (contacts per second) = number of pushes in 10m divided by time to complete 10 m (in seconds)
–Wheelchair Skills Test
Assessment/Plan of Care
› Contraindications/precautions
• Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The summary
below is meant to serve as a guide, not to replace orders from a physician or a clinic’s specific protocols
• Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard to
modalities. Rehabilitation professionals should always use their professional judgment
• Patients with this diagnosis are at risk for falls; follow facility protocols for fall prevention and post fall prevention
instructions at bedside, if inpatient. Ensure that patient and family/caregivers are aware of the potential for falls
and educated about fall prevention strategies. Discharge criteria should include independence with fall prevention
strategies
–In a 2013 study in the United States that assessed fall risk in individuals with SCI, at least 1 fall-related injury (FRI)
occurring in the previous 12 months was reported by ~20% of the 515 adults with chronic SCI and of ambulatory status.
Poor balance, decreased gait speed, pain medication abuse, and minimal daily exercise were associated with an increased
risk of FRI(20)
› Diagnosis/need for treatment: Chronic SCI/prescription for personal exercise program to improve functional capacity and
well-being and to reduce health risks associated with physical inactivity
› Rule out: Medical conditions associated with paralysis (e.g., Guillain-Barré syndrome, amyotrophic lateral sclerosis [ALS],
multiple sclerosis [MS], peripheral neuropathy)
› Prognosis
• A year or more after SCI (considered long-term or chronic SCI), patients with incomplete tetraplegia or paraplegia often
regain at least grade 3/5 strength in the affected muscles, and their functional capacity may further improve with exercise
training(1)
• Most patients with incomplete paraplegia regain the ability to ambulate in the community, while patients with complete
paraplegia rely primarily on the use of a wheelchair(2)
• There is strong evidence that supervised exercise programs can improve the functional capacity of individuals with a wide
range of SCI levels(3)
• Exercise in the SCI population is associated with health promotion and prevention of chronic diseases, including
osteoporosis, atherosclerosis, diabetes, and obesity(4)
• Secondary health conditions and illness associated with the need for hospitalization can increase the morbidity and
mortality rates of individuals with SCI(14)
› Referral to other disciplines
• Physiatrist
• Wound care specialist
• Social worker or case manager
• Resource educational specialist
• OT
• Orthotist
• Recreation therapist
• Behavioral therapist and/or clinical psychologist
• SCI support groups
• Vocationalrehabilitaiton specialist
› Other considerations
• Exercise interventions may also improve mood and reduce depression in the SCI population(5)
› Treatment summary
• Based on a 2012 systematic review, researchers concluded that the quality of the studies regarding exercise and SCI is not
good enough to make firm conclusions regarding the benefits and efficacy of exercise in patients with SCI(31)
–240 studies published between 2001 and 2011 were reviewed; 57 studies were included in the final review
–Studies typically were low in quality of methodology and primarily evaluated outcome related to the Body Function and
Body Structures of the World Health Organization International Classification of Functional Disability and Health (ICF)
–Researchers concluded that future studies need to have better methodological designs and include outcome measures that
focus on the “Activities” and “Participation” component of the ICFto truly assess the potential positive effects of exercise
on health and functional mobility in patients with SCI
• Guidelines for physical activity for persons with SCI were recently developed by a panel of physicians and exercise
physiologists(29)
–To optimize physical fitness and well-being, persons with SCI should, at minimum:
- Do 20 minutes of cardiovascular exercise twice a week
- Do strength training of the major muscle groups (3 sets of 8-10 repetitions per exercise) twice a week
• Based on a 2011 systematic review, evidence supports that exercise, performed 2-3 times per week at moderate-to-vigorous
intensity, increases physical capacity and muscular strength in the individuals with SCIhowever, there isinsufficient
evidence to make a conclusion about the effects of exercise on body composition or functional performance(3)
–This review included English-language studies published prior to March 2010 that evaluated the effects of exercise
intervention on at least one of the four main components of physical fitness (physical capacity, muscular strength, body
composition, and functional performance)
–166 studies were identified and 82 studies were included for review (69 studies addressing the effects of exercise on
patients with chronic SCI and 13 studies on the effects of exercise on patients with acute SCI)
–Most studies were of low quality; however, the evidence was consistent that exercise is effective in improving some
aspects of physical fitness for individuals with acute and chronic SCI of all injury levels
–Researchers concluded that exercise programs can be performed safely by people of all SCI levels
• Ergometer training in patients with SCI was reported to increase workload performance during the beginning phase of
training; however, outcome measures leveled off after week 4(30)
–Based on a study conducted in Italy that included 21 participants, all in the subacute phase of SCI
–6 weeks of training, 5 days/week, 90 min/day
–Training included cranking ergometer, wheelchair ergometer, and pulley work
–Outcome measures included parameters of workload level on ergometer and hematologic and hormonal studies
–Authors recommended that following 4 weeks of rehabilitative training for strengthening and aerobic endurance a patient
should be transferred to an independent maintenance program
• Upper extremity strengthening exercise may improve upper extremity strength and function and decrease pain in people
with thoracic SCI(32)
–Based on a research study conducted in Spain that included 15 people with SCI who participated in 8 weeks of upper
extremity strengthening
• Respiratory muscle endurance training (RMET)can reduce the perception of exertional dyspnea and thus improve exercise
performance in athletes with SCI(15)
–Based on a study conducted in France that included 9 endurance athletes (7 individuals with SCI impairment levels
between T4-L1 and 2 individuals with post-poliosyndrome)
–Evaluations took place at 3 intervals with 1-month intervals between each evaluation
–Participants performed their standard individual weekly exercise training program between the first 2 evaluations
–During the second and third training intervals, patients continued with the same program plus 5 additional respiratory
muscle endurance training sessions
–Evaluations included lung function tests, respiratory muscle strength and endurance tests, ventilation, dyspnea, a maximal
incremental arm cranking test, and a field test (simulated competition)
–Lung function variables and maximal inspiratory strength did not improve significantly, however, maximal expiratory
muscle strength and respiratory endurance increased following the intervention period
–During the arm crank test, exercise duration and maximal power output increased slightly while ventilation and dyspnea
remained the same
–During the field test, exercise time and ventilation were unchanged, but dyspnea levels decreased
–Researchers concluded that RMET can improve respiratory muscle function, reduce the perception of dyspnea, and mildly
improve exercise performance in SCI athletes
• Sports and recreational activities awareness
–Individuals who participate in sports and recreational activities and have a SCI above the level of T8 are at increased
risk for dehydration and hypothermia due to impaired thermoregulation. Impaired sweating, venous pooling, and lack of
shiver response all affect the body’s ability to thermoregulate(28)
–Competitive athletes may intentionally induce ADknown as “boosting,” in an attempt to increase their peak HR, peak
BP, and maximal oxygen uptake for a competitive advantage. An athlete may use various means to induce AD. including
intentionally distending their bladder by clamping a Foleycatheteror pinching oneself with a device in a leg that does not
have sensation. The International Paralympic Committee banned “boosting” from the Paralympics(28)
• Please see Clinical Review…Gait Training, Robotic-Assisted; Item Number: T709290 for details on the benefits of
locomotor training with robotic assistance and/or functional electrical stimulation (FES) in individuals with SCI
.
Problem
Goal
Intervention
Expected Progression
Limited knowledge on
exercising with SCI
Increase patient
knowledge
Patient education
_
_
Verbal instruction
and demonstration of
exercise modalities
consistent with the
patient’s ability
Skin breakdown,
pressure ulcers
_
Prevent/ promote
healing of decubiti
Therapeutic strategies N/A
_
_
Positioning schedule as
indicated
_
_
Pressure-relieving
equipment as indicated
_
_
Refer back to physician
as indicated
Decreased ROM/
contractures
Improve ROM/
contracture
management
Therapeutic exercise
_
_
Implement a
ROM/stretching
and contracture
management program
_
_
Refer to orthotist as
indicated for dynamic
splinting
Decreased functional
aerobic endurance and
strength
Improve endurance and Therapeutic exercise
strength (as able)
_
_
Implement aerobic
and strengthening
program as indicated
and appropriate
_
_
(See Treatment
summary, above)
N/A
Home Program
Provide specific
exercise prescription
Provide
recommendations for
home management
of pain and skin
breakdown as indicated
Progress each unique
Provide
patient as indicated and recommendations for
appropriate
home management of
ROM/contractures as
indicated
Progression of strength
typically moves from
gravity-eliminated
active assisted ROM
initially to resisted antigravity therapeutic
exercise and functional
aerobic activities
Implement a program
for home that includes
endurance and
strengthening activities
as indicated
Spasticity
Spasticity management Therapeutic strategies N/A
_
_
Interventions to
normalize muscle tone
as appropriate (e.g.,
weight-bearing, joint
loading, proprioceptive
neuromuscular training,
vibration)
_
_
Refer back to physician
as indicated for medical
management
_
_
Strategies to prevent
contracture formation
Respiratory limitations
_
_
Decreased endurance
due to exertional
dyspnea and
cardiovascular
compromise
Assist in respiratory
strategies
_
_
Improve endurance
Therapeutic strategies Improved endurance
_
and tolerance of
_
measured activities
Interventions centered
around improving
respiratory muscle
capacity as appropriate
_
_
Monitor vital signs
_
_
Refer to respiratory
therapist as indicated
Implement a program
for home that includes
endurance activities as
indicated
Decreased functional
mobility including gait
Improve functional
mobility
Functional training
Progress each unique
_
patient as indicated and
_
appropriate
Implement gait training
or FES-assisted training
as indicated
_
Implement a program
for home that includes
functional tasks as
indicated
Impaired ADL
Improve ADLs
Functional training
_
_
Implement functional
training as indicated
by medical status and
current ability
_
_
Refer to OT as
indicated
Provide
recommendations for
home management of
spasticity as indicated
Progress each unique
Implement a program
patient as indicated and for home that includes
appropriate
functional tasks as
indicated
Incontinence
Independent in bowel/
bladder programs
Functional training
Progress each unique
Implement a home
_
patient as indicated and program for bowel and
_
appropriate
bladder management
Implement bowel/
bladder program as
indicated by medical
status and current
ability
_
_
Refer to OT and/or
nursing as indicated
_
Coordinate scheduling
of therapy/exercise
training with bowel and
bladder program
Decreased sensation
with increased risk for
decubiti
Prevent pressure
ulcers/assist in healing
existing ulcers
_
_
Implement strategies to
compensate for sensory
loss
Therapeutic strategies N/A
_
_
Skin inspections with
mirror as able
_
_
Provide pressurerelieving devices
_
_
Positioning
scheduleWeight shifting
strategies
_
_
Patient education
_
_
Ensure adequate
nutrition
_
_
Refer to wound care
specialist per facility’s
protocol
Provide
recommendations for
home around managing
pressure sores/reduced
sensation as indicated
Therapeutic strategies Progress each unique
_
patient as indicated and
_
appropriate
Interventions to
improve coordination
Implement a program
for home that includes
balance/coordination
tasks as indicated
Decreased coordination Improve coordination
Decreased balance
Improve balance
Therapeutic strategies Progress each unique
_
patient as indicated and
_
appropriate
Interventions to
improve balance
reactions in sit and
stance
Implement a program
for home that includes
balance/coordination
tasks as indicated
.
Desired Outcomes/Outcome Measures
› Desired outcomes
• Management of pressure sores
• Independent with bowel and bladder management
• Decreased pain
• Increased patient knowledge about exercise
• Spasticity management
• Improved functional aerobic endurance
• Improved flexibility and ROM
• Improved strength
• Improved ADLs
• Improved mobility
• Improved functional endurance
• Improved balance
› Outcome measures
• VAS
• Increased patient knowledge about exercise and physical activity
• FIM, WeeFIM, SCIM Version III
• TUG test, 10MWT, 6MWT
• WISCI, Version II
• NAC
• Modified Ashworth Scale or SCATS
• PRISM
• Goniometry
• MMT
• SF-36, SF-12
• SWUG, SmartWheel
• BBS, PBS
Maintenance or Prevention
› Patients should follow the guidelines, home program, and any recommendations provided by their clinician. It is important
that patients attend all follow-up appointments with their multidisciplinary care team
› DVT prevention
• Please see Clinical Review…Deep Vein Thrombosis: Exercise; Item Number: T708457 for specific details
› Pressure sore prevention
› Patients need to follow the guidelines provided by their healthcare team. This may require the patient to perform scheduled
pressure relief
› Please see Clinical Review…Pressure Ulcer: Prevention; Item Number: T708780
› UTI prevention
• Follow the guidelines and any bowel/bladder program provided by the patient’s healthcare team. These will include the
following: regular voiding, bowel regimen, adequate hydration, and proper catheterization technique
› AD prevention
• Please see Clinical Review…Autonomic Dysreflexia in Adults; Item Number: T708491 for more information on this
condition
› Pneumonia prevention
• Follow the guidelines provided by the healthcare team. These may include the following: incentive spirometry, deep
breathing and coughing, and inspiratory muscle training
Patient Education
› Patients should consult with their exercise provider about the quality of information obtained on Web sites before
self-implementation
› Spinal Cord Injury Network, “Exercise and Spinal Cord Injury,” http://www.themiamiproject.org/document.doc?id=290
› Christopher & Dana Reeve Foundation, http://www.christopherreeve.org/site/c.ddJFKRNoFiG/b.4048063/k.C5D5/
Christopher_Reeve_Spinal_Cord_Injury_and_Paralysis_Foundation
› National Institute of Neurological Disorders and Stroke, http://www.ninds.nih.gov/
› Paralyzed Veterans of America, http://www.pva.org
› U.S. Department of Education, Office of Special Education and Rehabilitative Services, http://www.ed.gov/about/offices/list/
osers
› FacingDisability, a Website that assists with connecting families who have loved ones with SCI, http://
www.facingdisability.com
Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
RV Published review of the literature
RU Published research utilization report
QI Published quality improvement report
L Legislation
C Case histories, case studies
PGR Published government report
G Published guidelines
PFR Published funded report
PP Policies, procedures, protocols
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation
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