Paraplegia Protocol

Objectives
1. Assist patient with spinal cord injury (SCI) below level Tl to achieve the maximal level
offunctional independence and to prepare for rehabilitation or discharge.
II. Educate and orient patient and family on precautions and discharge treatment programs,
with emphasis on maintenance of functional independence.
III. Investigate home situation and coordinate treatment and discharge planning with other
disciplines involved.
Admission/Evaluation
1. Areas to evaluate (Spinal Cord Injury Evaluation form follows protocol.)
A. Range of motion. Evaluate passive and active range of motion of upper and lower
extremities.
B. Manual muscle test. Test and specifically grade strength of upper and lower ex-
tremities.
C. Functional ability. Evaluate balance, coming to sit, bed mobility, weight shift, ability
to achieve pressure relief, and preparation for stance, if indicated.
D. Posture. Evaluate posture in supine and sitting.
E. Neurological
1. Evaluate sensation, including gross evaluation of upper extremity sensation and
dermatomal evaluation of lower extremity and trunk.
2. Examine proprioception, kinesthetic sensation, changes in muscle tone, reflexes,
and movement abnormalities.
3. Begin ongoing assessment of functional level.
F. Assess need for involvement of other ancillary services.
II. Precautions during evaluation
A. Log roll patient only until physician indicates that patient is stable.
B. Avoid manual muscle test of trunk unless approved by physician.
C. Joint pain, limitation ofmotion, swelling, or heat around major weight-bearingjoints
may indicate heterotrophic ossification or deep vein thrombosis and may require the
attention of a physician.
D. Re-evaluate patient weekly to assess the extent of neurological injury or change in
status. Frequency of re-evaluation should be reconsidered when patient is out of
neurological intensive care unit or offbed rest.
Treatment/Goals
1. Frequency. Patient should be seen a minimum of one time per day.
II. Treatment techniques and goals
A. Patient is restricted to bed and is pain-free.
Treatment: Begin progressive resistive exercises to upper extremities with weights
or therapeutic exercises while in supine.
Goals: Increase upper extremity strength; improve function for bed mobility, weight
shift, pressure relief, and preparation for coming to sit.
B. Patient is cleared by physician for out-of-bed activity.
1. Treatment: Begin sitting and upright activities in wheelchair to increase
tolerance for upright position. Progress to sitting activities on the edge ofthe mat.
Goals: Increase tolerance for upright position; improve balance in sitting.
2. Treatment:
a. Aggressively strengthen upper extremities, lower extremities, and trunk.
b. Increase upper extremity strength and endurance with transfers, mobility
skills, balance activities, weight shifting, pressure relief, and preparation for
coming to stand.
Goals: Increase upper extremity and trunk strength and balance for effective
functional ability, protection of skin/soft tissue, and development of inde-
pendence.
3. Treatment: Begin muscle re-education at level appropriate to deficit.
Goal: Obtain as much muscle return as possible to assist in previously listed
functional abilities.
4. Treatment: Gently stretch lower extremity muscle groups. Instruct patient in
selfrange of motion.
Goal: Achieve full muscle length, particularly in gastrocnemius and hamstring
muscles, to effectively carry out above-stated functional activities.
5. Treatment:
a. Teach weight shifting and rolling.
b. Progress to balance in long sitting and wheelchair pushups.
Goal: Achieve independent weight shifting, rolling, and long sitting.
6. Treatment: Initiate transfer training and assist with obtaining proper equipment.
Goal: Ensure safe, independent wheelchair,
toilet, and tub transfers.
7. Treatment: Instruct patient in wheelchair management, mobility, and safety.
a. Include instruction in operation of wheelchair parts and mobility on level
surfaces and ramps, and introduction to technique for wheelies.
b. Progress to negotiating curbs and various surfaces.
Goal: Maneuver wheelchair independently and safely in household and com-
munity.
8. Treatment: Assess wheelchair needs if patient is not going to rehabilitation
setting.
Goal: Obtain a wheelchair specifically suited to the needs of each patient.


9. Treatment: Assess patient for reciprocating brace, long leg braces, or orthotic
devices and begin gait training with equipment if patient is not going to
rehabilitation setting.
Goal: Achieve functional or physiological ambulation through the use of braces.
10. Treatment: Develop skin-care program, educate patient on pressure areas and
how to relieve them.
Goals: Prevent skin breakdown; educate patient and family on magnitude of
problem; promote effective preventive measures.
C. Patient is cleared by physician for more extensive rehabilitation.
1. Treatment: Progress to transfer training to and from uneven surfaces (for
example, to floor or car), with emphasis on safety and balance.
2. Treatment: Progress to independent negotiation of architectural barriers:
bedroom, bathroom, curbs, heavy doors, stairs ifable, and community ambulation
if applicable.
3. Treatment: Begin ambulation activities ifindicated by level ofspinal cord injury.
4. Treatment: Work on full hamstring and lower extremity stretching, establish
patient independence in selfrange of motion program.
Goal: Achieve maximal level of functional independence.
III. Precautions during treatment
A. Orthostatic hypotension may be common during initial sitting trials.
B. Autonomic dysreflexia may be present in patients with SCI at level T6 and above.
1. Symptoms include severe headaches, sweating, red blotchy skin, and behavioral
changes.
2. Symptoms may occur rapidly and are caused by any painful condition (for
example, kinked urinary catheter, bowel impaction, severe urinary tract infec-
tion, or malposition of extremities).
3. Treat patient by quickly dropping blood pressure (sit up rapidly), and look for
causes.
4. Autonomic dysreflexia may be a life-threatening situation because a sudden rise
in blood pressure may be sufficient to cause a CVA.
C. Consistently evaluate skin for onset of skin breakdown, and be prepared to initiate
treatmentJpositioning changes immediately.
D. Clear all activities with physician ifthere is any doubt about appropriateness for the
patient.
E. Harrington rod stabilization between T3 and L5 may be performed to provide
distraction or compression.
1. Ifrods are attached to pelvis, do not flex hips above 90°.
2. Do not rotate trunk in any case.
3. All patients should have body jacket or cast prior to beginning work in sitting.
IV. Equipment. Each patient has individual needs, but most will require a wheelchair and  shower chair.

V. General considerations
A. Advise physician to order abdominal binder or corset for lower body support to
improve respiratory efficiency.
B. Recommend changes in seating system to correct for asymmetrical postures.
C. Provide vascular support to lower extremities during standing or sitting activities to
avoid hypotension.
D. Always recommend a rehabilitation consult.
E. Consult occupational therapy regarding adaptive equipment.
F. Consider the effects of the following factors on patient recovery and compliance:
1. Financial status
2. Home or post-discharge situation
3. Motivation and cognition, family support, and patient expectations
4. Availability of needed braces and equipment
5. Luque rods (L-Rods) are used for stability only, no treatment restrictions exist.
Discharge
1. Evaluation
A. Coordinate discharge planning with occupational therapy, nursing, and social services.
B. Determine which goals have been reached and patient's status at discharge as
compared to onset of disability.
C. Evaluate patient progress, with emphasis on specific muscle grades, neurological
fmdings, and functional abilities.
II. Follow-up plan/referral
A. Arrange for home-health physical therapy or outpatient physical therapy.
B. Refer patient to support groups, community resources, and vocational resources.
III. Home program
A. Include upper extremity, trunk, and lower extremity strengthening and stretching,
with emphasis on maintaining gross mobility skills.
B. Provide skin-care program to educate patient on the importance of pressure relief
over bony prominences.
C. Identify resource center for equipment and maintenance needs.
Patient Example
Patient is a 30-year-old female who presents with TI0 paraplegia sustained in a
motor vehicle accident. Patient exhibits no functional sensory or motor function below
the level of her injury. Patient has been stabilized vvith rods from T8 to Ll and is
cleared to begin out-of-bed activities by her physician.
Goal: (l week) Patient will tolerate upright sitting to 90° in a wheelchair for 30
to 45 minutes three times a day and upright sitting on a mat for
15 minutes at a time.