See Part 1
Essentials of Assessment
See Part 1
Rehabilitation Management and Treatments
Available or current treatment guidelines
The Paralyzed Veterans of America (PVA) have sponsored the development of clinical practice guidelines for the management of those with spinal cord injury (SCI). Entitled the Consortium for Spinal Cord Medicine, they are based on literature reviews and expert panel consensus.1-12
The Spinal Cord Injury Rehabilitation Evidence (SCIRE) project is a compilation of the research evidence underlying rehabilitation interventions for people with SCI.13
At different disease stages
- Management of persons with new onset or acute SCI typically takes place in the acute hospital setting.
- Key components of early acute management include immobilization of the spine during transportation and initial hospitalization, monitoring of airway, blood pressure, heart rate, and temperature, and recognition and treatment of associated injuries.1
- Surgical spinal stabilization and decompression may be indicated. Closed or open reduction should be done as soon as feasible with bilateral cervical facet dislocation in incomplete SCI.1
- Anticoagulation for venous thromboembolism (VTE) prophylaxis should be initiated within 72 hours of injury unless contraindicated. In these cases, mechanical VTE prophylaxis should be initiated until it is safe to begin anticoagulation.1,2
- Oxygen saturation and arterial blood gas monitoring should occur in the initial days following injury, in order to monitor for declining oxygen saturation and carbon dioxide retention. This may herald the need for mechanical ventilation. Early tracheostomy may be indicated in high tetraplegia if weaning cannot occur in the acute period.1
- Positioning, range of motion, skin integrity, and bladder and bowel management should be addressed from the onset of hospitalization in order to minimize complications.1
- Neurogenic bladder is initially managed with an indwelling catheter.1 Discontinuation of the indwelling catheter and initiation of timed void can be considered with the emergence of bladder reflexes seen on physical exam (i.e., the bulbocavernosus reflex or the anal wink). Bladder scans can evaluate for incomplete bladder emptying and prompt intermittent catheterization.
- Management of persons with new onset or acute SCI typically takes place the acute inpatient rehabilitation setting, although hospitalization may be needed for medical complications such as urosepsis, pneumonia, or worsening pressure injuries.
- The primary goals during the subacute period are to educate the person and family about SCI, prevent secondary complications, improve function, and prepare the person for integration into the community. Taking into account the neurologic level, completeness of injury, individual factors, and coexisting conditions, functional goals can be established.3 Acute inpatient rehabilitation goals include improving independence with functional mobility, self-care activities and bladder and bowel management.
- Indwelling bladder catheters should be discontinued if still present. Timed voiding trials, or if needed, intermittent catheterization, can be initiated. The goal volume per catheterization should be under 500 mL in order to prevent bladder overdistention and elevated intra-detrusor pressure. Urodynamic studies may be necessary in order to evaluate the underlying bladder dysfunction and for planning long-term bladder management.4
- Goals of a bowel program are complete and regular bowel movements without episodes of incontinence between planned evacuations. An upper motor neuron bowel responds well to nightly suppositories and digital rectal stimulation along with oral stool softeners and pro-kinetic agents. Lower motor neuron bowel management usually requires manual evacuation or enemas.5
- Pressure ulcer prevention includes turning in bed every 2 hours, teaching weight-shifting strategies, and optimizing nutritional status.6
- Autonomic dysfunction can cause significant morbidity and mortality. Orthostatic hypotension can be managed with abdominal binders and elastic bandage wrapping of the lower extremities. Autonomic dysreflexia (AD) is a medical emergency occurring in patients with a level of injury T6 or higher. Signs of AD include blood pressure greater higher than 20 mm Hg above baseline, often with bradycardia, headache, flushing, sweating, and piloerection above the level of injury. Bladder and bowel distention are the most common precipitating factors for AD. Management includes sitting the patient upright, loosening clothing, inspection of the body for noxious stimulants (e.g., pressure ulcer or ingrown toenails), and immediate bladder catheterization. If symptoms persist, a rectal exam should be performed.7 An algorithm for the treatment of AD for both children and adults is available from the Dana and Christopher Reeve Foundation at no expense.14
- Most new venous thromboembolism cases have been found to occur in the first two weeks after injury. The risk for deep venous thrombosis (DVT) is substantially decreased eight weeks following injury. VTE prophylaxis should be administered for at least eight weeks after injury in persons with SCI with limited mobility.2
- Spasticity, a component to upper motor neuron syndrome, may emerge during the subacute phase. Spasticity may assist with function in some patients, such as leg spasticity helping with transfers. Range of motion exercises can help prevent complications related to spasticity.
- The higher the level of SCI, the greater the risk of pulmonary complications. Secretion management and prevention of atelectasis are critical to minimize risk of pneumonia. Weaning from the ventilator may be attempted using progressive ventilator-free breathing, usually once vital capacity is consistently over 1L.8
- Heterotopic ossification, the formation of extraosseus lamellar bone in the soft tissue surrounding peripheral joints, most commonly develops around the anteromedial hip in persons with SCI, usually between 3 and 12 weeks after injury. Treatments include NSAIDS, bisphosphonates, radiation therapy and surgical excision15
- Management of persons with chronic, stable SCI typically takes place in an outpatient setting.
- Periodic genitourinary evaluation is performed to ensure adequate voiding and to prevent complications. Changes in voiding warrants a urinalysis and culture to evaluate for a urinary tract infection. Patients with neurogenic bladder are often colonized and should only be treated if symptomatic. Many surgical options exist, including suprapubic tubes, bladder augmentation and continent and incontinent diversions.4 Intradetrusor botulinum toxin has allowed for increased capacity and improvement in patients with detrusor-sphincter dysynergia.16
- A bowel program should be designed to minimize the occurrence of unplanned or difficult evacuations, to be completed at regular, predictable times within 60 minutes of initiation of the program and to minimize gastrointestinal complications.5
- SCI has been associated with obstructive sleep apnea, and a sleep study should be considered if symptomatic. Pneumococcal and influenza immunization and tobacco cessation counseling are important, as are ongoing measures to prevent cardiovascular disease.8
- Spasticity may impair function and can cause complications such as contractures, pain, or skin breakdown. Generalized spasticity can be treated with oral anti-spasticity medications. Localized spasticity can be treated with chemodenervation, such as botulinum toxin or alcohol injections. The impact of these interventions can be enhanced with skilled rehabilitation interventions such as splinting, stretching, electric stimulation, and other modalities. Intrathecal baclofen pumps may be considered for those whose spasticity is not effectively treated or who cannot tolerate the side effects of oral or injectable medications.
- Persons with SCI are at risk for the development of osteoporosis. Common sites of osteoporosis in a person with chronic SCI are not usually the hip and lumbar spine, but rather the distal femur proximal tibia. These areas are more prone to risk of fracture with minimal trauma.17
- Persons with SCI who use a manual wheelchair as their primary means of mobility are at risk for developing upper limb pain and overuse injuries. Upper limb function, mobility and equipment use should be routinely assessed. Many prevention and treatment options exist.9
- Sexual and reproductive health should be addressed in a supportive, respectful, and nonjudgmental manner.10
- Depression, suicide risk, and substance abuse, which are more common in SCI than in the general public, require careful assessment and appropriate management.11
- Given that persons with SCI typically have decreased physical activity, reduced muscle mass, and increased body fat as compared to those without SCI, they should be screened for diabetes at least every three years.12
- Asymptomatic posttraumatic syringomyelia (PTS) is estimated to occur in about 30% of individuals with SCI, and progressive myelopathy due to PTS may occur in about 5%. Diagnosis is confirmed with magnetic resonance imaging.18
- Pain in a person with SCI can be either nociceptive or neuropathic, similar to other patient populations, and should be treated accordingly. The CanPain SCI Clinical Practice Guidelines recommend provides a tiered approach to neuropathic pain treatments.19
pre-terminal or end of life care
- Unique clinical and ethical issues may need to be addressed with aging and end of life care in persons with SCI.
Coordination of care
A team approach is necessary in the rehabilitation person with SCI. Team meetings and communications are critical for coordination of care. Inclusion of the patient in goal setting is essential.
Patient & family education
Literature focused on education and expected outcomes for persons with SCI is available from the PVA in a series called Consumer Guidelines. For those at risk for AD, special emphasis should be placed on recognizing signs and symptoms. 20 The Yes You Can!: Guide to Self-Care for Persons with Spinal Cord Injury provides educational material on a variety of subjects for newly injury patients.21 The Christopher & Dana Reeve Foundation also offers many consumer-oriented resources.22
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Spinal Cord Injury Medicine is a subspecialty with the American Board of Physical Medicine and Rehabilitation. Physicians specializing in SCI Medicine often function as primary care providers for persons with SCI. Advocacy and education within the health care system is important to ensure optimal care for person with SCI.
Cutting Edge/Emerging and Unique Concepts and Practice
Cutting edge concepts and practice
Research into possible neuroprotective or restorative therapies for acute SCI are ongoing. Recently, the neuroprotective effects of riluzole, an antiglutamatergic sodium channel blocker typically used for amyotrophic lateral sclerosis, has been found to be promising.23
Functional electric stimulation (FES) uses intact neuromuscular systems to provide therapeutic exercise and allow for functional restoration. Many FES devices exist, including those that can restore upper and lower extremity function, trunk control, respiratory muscle function, bladder control and gait.24
Diaphragmatic pacing systems provide electric stimulation to those with intact phrenic nerves and can help some candidates wean off mechanical ventilation.25
Numerous neurostimulation strategies exist, such as spinal cord stimulation and repetitive transcranial magnetic stimulation, that can address pain, autonomic dysregulation and bladder and bowel function.26
Robotic exoskeletons can allow persons with SCI with a variety of levels of injury to safely ambulate or exercise. Feasibility, cost, and setting realistic expectations are important considerations when considering the use of an exoskeleton.27
Gaps in the Evidence-Based Knowledge
There are no precise guidelines regarding the timing of surgical decompression following acute SCI except for cervical SCI. There is growing evidence to support that spinal decompression following cervical injury within 24 hours of injury is associated with positive outcomes, though uniform consensus about specific situations when early surgical intervention is indicated is still lacking.28,29
Evidence for the evaluation and treatment of osteoporosis in the setting of SCI is still evolving. Specific recommendations regarding the type and timing of laboratory and imaging studies to detect bone loss, along with recommendation regarding prevention and treatment will be helpful.30
Persons with SCI are more likely to experience a low serum testosterone earlier than those without SCI. Further research is needed to better understand the risk versus benefits associated with repletion of this low testosterone concentration.31
There is controversy regarding outcomes in body-weight-supported treadmill systems versus over-ground ambulation training.32
- Consortium for Spinal Cord Medicine. Early Acute Management in Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2008.
- Consortium for Spinal Cord Medicine. Prevention of Venous Thromboembolism in Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals 3rd Edition Washington, DC: Paralyzed Veterans of America; 2016.
- Consortium for Spinal Cord Medicine. Outcomes Following Traumatic Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 1999.
- Consortium for Spinal Cord Medicine. Bladder Management for Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2006.
- Consortium for Spinal Cord Medicine. Management of Neurogenic Bowel Dysfunction in Adults After Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2020.
- Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals 2nd Edition. Washington, DC: Paralyzed Veterans of America; 2014.
- Consortium for Spinal Cord Medicine. Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows: Individuals With Spinal Cord Injury Presenting to Health-Care Facilities. Washington, DC: Paralyzed Veterans of America; 2020.
- Consortium for Spinal Cord Medicine. Respiratory Management Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2005.
- Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2005.
- Consortium for Spinal Cord Medicine. Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2010.
- Consortium for Spinal Cord Medicine. Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Washington, DC: Paralyzed Veterans of America; 2020.
- Consortium for Spinal Cord Medicine. Identification and Management of Cardiometabolic Risk after Spinal Cord Injury: Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America; 2018.
- Spinal Cord Injury Rehabilitation Evidence. Available at: http://www.scireproject.com/. Accessed March 27, 2021.
- Christopher and Dana Reeve Foundation AD pamphlets. Available at: https://www.christopherreeve.org/living-with-paralysis/free-resources-and-downloads/wallet-cards. Accessed March 27, 2021.
- Sullivan, M. P., Torres, S. J., Mehta, S., & Ahn, J. (2013). Heterotopic ossification after central nervous system trauma: A current review. Bone & joint research, 2(3), 51–57.
- Linsenmeyer TA. Use of botulinum toxin in individuals with neurogenic detrusor overactivity: state of the art review. J Spinal Cord Med. 2013 Sep;36(5):402-19
- Cirnigliaro CM, Myslinski MJ, La Fountaine MF, Kirshblum SC, Forrest GF, Bauman WA. Bone loss at the distal femur and proximal tibia in persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options. Osteoporos Int. 2017 Mar;28(3):747-765.
- Kim, H. G., Oh, H. S., Kim, T. W., & Park, K. H. (2014). Clinical Features of Post-Traumatic Syringomyelia. Korean journal of neurotrauma, 10(2), 66–69.
- Guy SD, Mehta S, Casalino A, Côté I, Kras-Dupuis A, Moulin DE, Parrent AG, Potter P, Short C, Teasell R, Bradbury CL, Bryce TN, Craven BC, Finnerup NB, Harvey D, Hitzig SL, Lau B, Middleton JW, O’Connell C, Orenczuk S, Siddall PJ, Townson A, Truchon C, Widerström-Noga E, Wolfe D, Loh E. The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: Recommendations for treatment. Spinal Cord. 2016 Aug;54 Suppl 1:S14-23.
- Paralyzed Veterans of America (PVA) Consumer Guides. Available at: .http://pva.org/research-resources/publications/consumer-guides/. Accessed March 30, 2021.
- Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord Injury. Fourth edition. Available at: https://pva-cdnendpoint.azureedge.net/prod/libraries/media/pva/library/publications/yes-you-can_digital.pdf. Accessed March 31, 2021.
- Christopher and Dana Reeve Foundation Consumer Resources. Available at:
http://www.christopherreeve.org/living-with-paralysis. Accessed March 30, 2021.
- Srinivas S, Wali AR, Pham MH. Efficacy of riluzole in the treatment of spinal cord injury: a systematic review of the literature. Neurosurg Focus. 2019 Mar 1;46(3):E6.
- Ho CH, Triolo RJ, Elias AL, Kilgore KL, DiMarco AF, Bogie K, Vette AH, Audu ML, Kobetic R, Chang SR, Chan KM, Dukelow S, Bourbeau DJ, Brose SW, Gustafson KJ, Kiss ZH, Mushahwar VK. Functional electrical stimulation and spinal cord injury. Phys Med Rehabil Clin N Am. 2014 Aug;25(3):631-54
- Dalal K, DiMarco AF. Diaphragmatic pacing in spinal cord injury. Phys Med Rehabil Clin N Am. 2014 Aug;25(3):619-29
- Chari A, Hentall ID, Papadopoulous MC, Pereira EA. Surgical neurostimulation for spinal cord injury. Brain Sci. 2017;7(2):18
- Kandilakis C, Sasso-Lance E. Exoskeletons for personal use after spinal cord injury. Archives of Physical Medicine and Rehabilitation. 2021;102(2):331-337
- Liu JM, Long XH, Zhou Y, Peng HW, Liu ZL, Huang SH. Is urgent decompression superior to delayed surgery for traumatic spinal cord injury? A meta-analysis. World Neurosurg. 2016 Dec
- Mattiassich G, Gollwistzer M, Gaderer F, et al. Functional outcomes in individuals undergoing very early (<5h) and early (5-25h) surgical decompression in traumatic cervical spinal cord injury: analysis of neurologic improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma. 2017 Dec 15;34(24):3362-3371.
- Battaglino, R. A., Lazzari, A. A., Garshick, E., & Morse, L. R. (2012). Spinal cord injury-induced osteoporosis: pathogenesis and emerging therapies. Current osteoporosis reports, 10(4), 278–285.
- Bauman, W. A., La Fountaine, M. F., & Spungen, A. M. (2014). Age-related prevalence of low testosterone in men with spinal cord injury. The journal of spinal cord medicine, 37(1), 32–39.
- Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial. Clin Rehabil. 2015 Jan;29(1):42-9
Original Version of the Topic
Argyrios Stampas, MD, Joel E Frontera MD. SCI Traumatic: Part 2. 8/7/2012.
Previous Revision(s) of the Topic
Argyrios Stampas, MD, Joel E Frontera MD. SCI Traumatic: Part 2. 5/5/2016.
Scott Campea, MD
Nothing to Disclose
Hetal Patel, MD
Nothing to Disclose