Physiotherapy plays a critical role in both the acute and long-term management of spinal cord injury (SCI). Interventions are highly individualised, depending on the level of injury, extent of neurological involvement, and personal goals. Physiotherapists work as part of a broader rehabilitation team to maximise function, minimise complications, and support meaningful participation in life.
Phases of Physiotherapy Intervention
Acute Stage Interventions (Early Rehabilitation)
In the early stages following a SCI, often while a person is still in hospital, physiotherapy focuses on preventing complications and supporting vital body functions. Core priorities include:
- Respiratory Management: Chest physiotherapy helps maintain lung function and prevent respiratory complications, which can affect up to 80% of individuals with high-level SCI in the acute stage.
- Positioning and Movement: Repositioning and supported movement reduce the risk of pressure injuries and prevent contractures.
- Passive Range of Motion (ROM): To maintain joint mobility and reduce stiffness, especially in motor deficit affected limbs.
- Education: Supporting the person and their family with information on injury implications, positioning, respiratory care, and self-management.
Subacute to Ongoing Rehabilitation
As recovery progresses, physiotherapy shifts toward functional restoration:
- Strength and Functional Retraining: Enhancing available voluntary movement and promoting independence.
- Wheelchair Skills and Transfer Training: Safe and efficient movement between bed, chair, into a car etc.
- Balance and Coordination: Developing core stability and dynamic balance for seated and standing tasks.
- Gait Retraining: Includes use of parallel bars, bodyweight-supported treadmill training (BWSTT), and robotic or orthotic supports.
- Pain and Spasticity Management: Through stretching and positioning, among other techniques.
- Hydrotherapy: Utilised to facilitate movement in a gravity-reduced environment, promoting confidence and joint motion.
Physiotherapists collaborate closely with occupational therapists, psychologists, speech therapists, and medical specialists to provide an integrated, multidisciplinary rehabilitation program. Through multidisciplinary collaboration assistive technologies and environmental supports can be trialled and prescribed. This can include items such as wheelchairs, orthoses and mobility aids, as well as environmental modifications and community reintegration programs.
Key Physiotherapy Interventions and Evidence
Strengthening and Functional Electrical Stimulation (FES)
Muscle strengthening is essential in SCI rehabilitation. The choice of method depends on the level and severity of injury, and the capacity of individual muscle groups.
- Progressive resistance training has been shown to improve voluntary strength and physical capacity in both paraplegia and tetraplegia.
- FES is a commonly utilised adjunct to strength training. This intervention uses low-level electrical pulses to activate paralysed muscles, aiming to enhance the progression of strength.
Evidence:
One study found that combining progressive resistance training with FES increased strength in muscles with good residual function. Another reported up to a two-fold increase in oxygen uptake with FES cycling, highlighting its value for both muscle hypertrophy and cardiovascular health.
Task-Specific Training and Neuroplasticity
Task-specific training is a vital complement to strengthening and functional recovery. It replicates everyday movements (e.g. reaching, standing, stepping), which are more meaningful and effective for promoting neuroplastic changes.
Neuroplasticity is a buzz word in the neurological rehabilitation community and refers to the ability of the brain and spinal cord to adapt and rewire in response to repeated, goal-oriented activity. Repetition, progressive difficulty, and function-focused exercises strengthen new neural pathways and support recovery hence your physiotherapist will design an exercise program which involves high volume, purposeful exercises.
Evidence:
Once study researched the affect of task specific training on improving functional independence, assessed with the “Spinal Cord Independence Measure”. After a training period of just 6 weeks a statistically significant change was seen using this outcome measure with marked improvements in the domain of self care and outdoor mobilisation.
Respiratory Physiotherapy
Respiratory dysfunction is especially significant in cervical or upper thoracic SCI due to impaired diaphragm and intercostal muscle function.
Key interventions:
- Airway Clearance: Percussion, vibration, suctioning
- Assisted Coughing: Manual or mechanical support for effective clearing of secretions
- Breathing Exercises: Including diaphragmatic and glossopharyngeal techniques
- Incentive Spirometry: Strengthens respiratory muscles and promotes lung expansion
- Positioning: Considered the gold standard for optimising airway drainage and ventilation.
Balance and Transfer Training
Improving postural control and balance is fundamental for seated and standing function. This area of physiotherapy is especially important for reducing falls and improving safety during transfers.
Interventions:
- Transfer Training: Bed, toilet, car, and floor-to-chair techniques
- Wheelchair Propulsion Skills
- Reactive and Anticipatory Balance Tasks
- Indoor/Outdoor Navigation
- Pressure Relief Education: Essential to prevent pressure injuries in those with sensory loss
- Virtual Reality Training
Range of Motion (ROM) and Spasticity Management
After SCI, joints can stiffen and muscles may become spastic, making movement more difficult and sometimes painful.
Interventions:
- Passive and Active ROM Exercises: Maintain joint flexibility and prevent contractures
- Stretching Routines: May reduce spasticity and improve comfort
- Splinting or Serial Casting: Used for specific contractures and most common for upper limb concerns.
- Weight-bearing and Vibration Therapy: Can reduce muscle tone and promote more normal movement patterns. This can be performed with the use of equipment such as the tilt table.
- Education: Particularly important in regard to spasticity management; there are times in which we can use the presence of spasticity to our advantage and it is key to understand how to manage both triggers and in which situations spasticity can be used to maximise movement.
Clinical Bottom Line
The above is not an exhaustive list of interventions for spinal cord injury but rather acts as an introduction into key concepts of the rehabilitation process.
Due to the nuances present in spinal cord injury it is important that we carefully curate our programs on a case by case basis. By analysing the needs of the individual we can begin to build upon ideas in each of the above domains to ensure we are productive and beneficial with our rehabilitation.