Neuro ICU >Spinal Cord Injuries

Spinal Cord Injuries (SCI)

ASIA Impairment Scale (AIS)

(Roberts et al., 2017)

The AIS is a standardized examination to classify the level of spinal cord injury. It consists “of a myotomal-based motor examination, dermatomal-based sensory examination, and an anorectal examination” (Roberts et al., 2017).

Sensation Assessment: 28 dermatomes are evaluated bilaterally for light touch and pinprick. Graded on a 0 (absent sensation) to 2 (normal sensation) scale.

Motor Assessment: Manual muscle testing is performed for five specific muscle groups in the upper extremities and five specific muscle groups in the lower extremities, which represent major cervical and lumbar myotomes.

  • Upper Extremity: C5 - Elbow flexors; C6 - Wrist extensors; C7 - Elbow extensors; C8 - Finger flexors; T1 - Finger abductors

  • Lower Extremity: L2 - Hip flexors; L3 - Knee extensors; L4 - Ankle dorsiflexors; L5 - Long toe extensors; S1 - Ankle plantar flexors

Complete vs Incomplete Spinal Cord Injury: determination requires the resolution of spinal shock. Spinal shock is a trauma response that can cause the patient to exhibit a period of flaccid paralysis

  • No motor or sensory function is preserved below the level of injury or in the sacral segments S4-S5

  • Sensory function is preserved but not motor function below the level of injury and includes the sacral segments S4-S5.

  • Motor function is preserved below the level of injury and more than 1/2 of key muscles have a muscle grade of less than 3

  • Motor function is preserved below the level of injury and at least 1/2 of the key muscles have a muscle grade of 3 or more

  • Motor and sensory function are normal

Level of Injury and Preserved Musculature

(Hamby, 2024; Shepard Center, 2019)

  • Preserved Muscles: Face & neck muscles

    Preserved Movements: typically able to perform neck and facial movements. Have use of their mouth.

    Patterns of Weakness: Total paralysis.

    Expected Functional Outcomes: Dependent for all ADL. Vent dependent. Incontinent requiring catheter and bowel program; caregiver assist required. Can use electronic activation devices.

  • Preserved Muscles: Neck & trapezius

    Preserved Movements: scapular elevation, retraction, and depression. diaphragm has enough strength for respiration

    Patterns of Weakness: Paralysis of the trunk, UEs, and LEs with ineffective cough

    Expected Functional Outcomes: Dependent for ADL. May be able to breathe without a ventilator. Incontinent requiring catheter and bowel program; caregiver assist required.

  • Preserved Muscles: Biceps, brachialis, brachioradialis, deltoid, infraspinatus, rhomboid, & supinator

    Preserved Movements: potential to perform elbow flexion, supination, external rotation, and shoulder abduction to 90.

    Patterns of Weakness: lacks elbow extension and hand function with total paralysis of the trunk and LEs.

    Expected Functional Outcomes: Mod to Max A for functional mobility. Min to Mod A ADL using adaptive equipment. Bowel & bladder programs are required; the patient may be able to participate.

  • Preserved Muscles: Extensor carpi radialis, Infraspinatus, Latissimus dorsi, Pectoralis major, Pronator teres, Serratus anterior, & Teres minor

    Preserved Movements: Patients have the potential to perform shoulder movement, scapular protraction, Horizontal adduction, Supination, Radial wrist extension, and Tenodesis grasp

    Patterns of Weakness: lacks wrist flexion, elbow extension, & hand function, but has functional tenodesis grasp. Total paralysis of the trunk and LEs.

    Expected Functional Outcomes: Mod A to Independent for ADL using adaptive equipment

  • Preserved Muscles: Above muscles plus Triceps, Pronator quadratus, Extensor carpi ulnaris, Flexor carpi radialis, Flexor digitorum profundus and superficialis, Extensor communis, Thumb muscles, and Lumbricals (partially)

    Preserved Movements: Patients have the potential to perform Elbow extension; Wrist extension and flexion; Finger flexion and extension; Thumb flexion, extension, and abduction; and shoulder movement

    Patterns of Weakness: limited grasp and dexterity with paralysis of the trunk and LEs

    Expected Functional Outcomes: Independent transfers. Independent with ADL using adaptive equipment.

  • Preserved Muscles: Intrinsics, intercostals, erector spinae

    Preserved Movements: UEs intact, potential to ambulate with assistive device

    Patterns of Weakness: paraplegic, limited trunk stability

    Expected Functional Outcomes: Independent for all ADL. May have bowel/bladder issues, but the patient is able to be independent with their toileting programs

  • Preserved Muscles: Intercostals, external obliques, rectus abdominus

    Preserved Movements: trunk stability. May be able to ambulate

    Patterns of Weakness: weak LEs

    Expected Functional Outcomes: Independent for all ADL. May have bowel/bladder issues, but the patient is able to be independent with their toileting programs

  • Preserved Muscles: All trunk muscles, depending on the level some hip, knee, & ankle muscles

    Preserved Movements: trunk stability; partial control of LEs; may be able to ambulate

    Patterns of Weakness: weak LEs

    Expected Functional Outcomes: Independent for all ADL. May have bowel/bladder issues, but the patient is able to be independent with their toileting programs

Common Types of Spinal Cord Injuries

(Hamby, 2024; United Spinal Association, 2022).

    • Loss of all motor function & sensation below level of injury. Typically maintain light touch and proprioception.

    • This is due to damage to or an infarct of the anterior spinal artery

    • One side of the spinal cord is injured resulting in lateral damage.

    • Primary Feature: motor paralysis & loss of deep touch and proprioception on the ipsilateral side of injury and loss of pain, temperature, and touch discrimination on the contralateral side.

    • Seen after burst fractures, epidural abscess, hematoma, or herniated discs at level L2-L4.

    • Primary Feature: Flaccid paralysis without spasticity

    • Typically occurs following fracture subluxations and acute disc herniations

    • More common in older adults due to narrowing of the spinal cord

    • Primary Features: paralysis or weakness and sensory loss that greater in the UEs than the LEs

    • Stroke within the spinal cord resulting in damage at the level of infarct

    • Inflammation across 1 level of the spinal cord damaging the myelin sheath resulting in paralysis below the level of inflammation

    • 1/3 of patients fully recover. 1/3 partially recovery but are left with significant deficits (i.e., spasticity or bowel/bladder issues). 1/3 do not recover.

Complications & Precautions

(Allen & Leslie, 2022; Hamby, 2024; Queensland Health, 2022)

  • Physiological loss or depression of reflexes below the level of injury. Symptoms can last anywhere from 24 hours to 6 weeks.

    Symptoms: areflexia, flaccid bladder/bowel, decreased deep tendon reflexes, & impaired sympathetic functioning.

    • Symptoms of impaired sympathetic functioning: decreased HR, decreased BP, no perspiration below the level of injury, & decreased constriction of the blood vessels

  • The brain is unable to control muscle function below the level of injury resulting in the muscles’ inability to control or stop the messages to “contract and tighten” resulting in an overactive muscle response. Most commonly seen in the flexor immediately after spinal shock, but can switch to the extensors.

    Spasticity can cause:

    • Involuntary muscle contractions or muscle spasms

    • Muscle stiffness or tightness inhibiting ROM

    • Clonus

    • Pain and weakness

    Triggers: Touching or moving the limb, stretching or moving the muscles, and pressure or pain

    Spasticity can help:

    • Maintain muscle bulk

    • Improve circulation

    • Reduce swelling in the extremity

    • Perform particular movements or activities

    Spasticity can:

    • Impede participation in daily tasks (dressing, transfers)

    • Impede ability to properly position the patient in bed, wheelchair, etc.

    • Cause skin breakdown, joint contractures, and/or pain

  • A sudden, exaggerated reflexive increase in blood pressure in response to a noxious stimulus originating below the level of injury — most commonly bladder or bowel distension. 90% of patients with cervical and higher thoracic injuries (above T6) are susceptible.

    Triggers: UTI, distended bladder, clogged Foley catheter, bowel impaction, pressure or pain below the level of injury

    Symptoms: severe headache, hypertension, diaphoresis/flushing above the level of injury, pallor/cold skin below the level of injury, visual disturbances, anxiety, nausea/vomiting, dizziness

  • A drop in blood pressure upon moving from supine to an upright position, caused by loss of sympathetic vasoconstriction below the level of injury. Most common in cervical and high thoracic injuries (above T6). Can cause dizziness, lightheadedness, visual changes, and syncope — and is a direct barrier to upright activity and mobility.

    Symptoms: dizziness, lightheadedness, blurred vision, pallor, nausea, and loss of consciousness in severe cases.

    Therapy implications:

    • Check BP before and after any position change

    • Progress head-of-bed elevation gradually before attempting sitting or transfers

    • Use abdominal binder and compression stockings to support venous return

    • If SBP drops >20 mmHg or patient becomes symptomatic, return to supine and notify nursing

    • Tilt table or reclining wheelchair may be indicated for early upright tolerance

⚠ Autonomic Dysreflexia — Immediate Response

Autonomic dysreflexia is a medical emergency. Act immediately:

  1. Stop therapy and sit the patient upright (elevating the head lowers BP relative to the heart)
  2. Notify nursing immediately
  3. Identify and remove the noxious stimulus — most commonly: check catheter for kinks or obstruction, check for urinary retention, check for bowel impaction, look for skin pressure or pain below the level of injury
  4. Monitor BP every 2–5 minutes until symptoms resolve
  5. If BP remains elevated (>150 mmHg systolic) after stimulus is removed, medical management (antihypertensives) may be required

Do not leave the patient unsupervised during an episode.

Therapy Implications

  • Review VITALS before each session: confirm activity orders, check for active autonomic dysreflexia, orthostatic hypotension risk, and respiratory status (particularly for cervical injuries)

  • Position changes should always be gradual — monitor BP and symptoms with each change

  • Spinal precautions (log roll, no trunk flexion) may be in place — confirm with the team before any mobility

  • Adaptive equipment assessment is a core OT role: tenodesis splints, universal cuffs, mobile arm supports, and environmental control units, depending on level

  • Bowel and bladder programs require caregiver or patient education — begin early

Back to Neuro ICU

References

Allen, K. J., & Leslie, S. W. (2022). Autonomic Dysreflexia. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK482434/

Hamby, J. R. (2024). The nervous system, part 1: Traumatic brain injury, spinal cord injury, and stroke. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 365–448). AOTA Press.

Roberts, T. T., Leonard, G. R., & Cepela, D. J. (2017). Classifications in brief: American Spinal Injury Association (ASIA) Impairment Scale. Clinical Orthopaedics & Related Research, 475(5), 1499–1504. https://doi.org/10.1007/s11999-016-5133-4

Queensland Health. (2022). Spasticity following spinal cord injury (SCI). https://www.health.qld.gov.au/__data/assets/pdf_file/0027/421776/spasm.pdf

Shepard Center. (2019). Understanding Spinal Cord Injury. https://www.spinalinjury101.org/files/20190827/Understanding%20Spinal%20Cord%20Injury%20Booklet.pdf

United Spinal Association. (2022). What is Spinal Cord Injury/Disorder? United Spinal Association. https://unitedspinal.org/what-is-spinal-cord-injury-disorder-scid/