Unit 3 - SCI: Compensatory Treatment Strategies for Upright and Wheelchair Mobility

Sit-to-stand (STS) or stand-to-sit task following an incomplete spinal cord injury (iSCI) refers to…

the controlled and coordinated movement of transitioning from a seated position to an upright standing position or vice-versa, despite partial impairment of motor and/or sensory function below the level of injury

Sit-to-Stand: Why It Matters in iSCI

• Foundation for mobility & independence

  • toileting, ADLs, bed transfers, getting in and out of a wheelchair, or in and out of a vehicle

• Involves strength, coordination, and postural control

• Challenging in iSCI due to motor/sensory deficits

• Key goal in neurorehabilitation

Use in Function

Sit to Stand

Crucial transitional movement

• demands a complex combination of lower extremity strength, interlimb coordination,
  and postural control, all of which can be disrupted in incomplete spinal cord injuries due
  to impaired motor output and altered sensation

• crucial role in transfers to and from various heights

• Practicing and improving this skill can reduce injury risk and improve confidence in community mobility

• preventing pressure sores

• supports functional independence, whether it's for dressing, toileting, or simply engaging socially at eye level

Use in Function

Standing Balance

• Access to items above wheelchair height

• Transfers to various heights

• Assists in preventing LE contractures

• Assists in preventing pressure sores

• Functional independence

Connection to Body Structure and Function Domain of ICF

• Impaired movement initiation

  • struggle to activate the correct motor pathways to begin the transition from sitting to standing, especially in cases of incomplete lesions where motor signals are partially disrupted

• Loss of LE motor recruitment

  • decreased ability to activate key muscle groups like the quadriceps, gluteals, and plantar flexors

• Reduced muscle strength/power of LE

  • upward momentum required for standing is compromised

• Restricted ROM

  • can mechanically limit the ability to move through the full sit to stand arc

• Hypertonicity (spasticity, rigidity)

  • can create resistance to voluntary movement, disrupt timing, and increase fall risk during transitional movements

• Impaired movement coordination

  • affects the smooth sequencing of muscle activation needed for balanced and symmetrical standing

• Abnormal postural alignment

  • posterior pelvic tilt, trunk asymmetry, or forward head posture can shift the center of mass, making it much more difficult to initiate or complete the sit to stand phase without compensatory strategies or assistance

Part to Whole Tasks

Sit to Stand

• Flexion momentum

• Momentum transfer

• Extension

• Stabilization

Part to Whole Tasks

Standing Balance

• Body alignment

  • affects the center of mass and joint loading

• Muscle tone

  • helps maintain postural readiness

• Postural tone

  • the baseline level of activation and anti-gravity muscles that support upright posture

• Muscle strength

  • provides the force needed to make postural adjustments and respond to perturbations

Four Mechanical Phases of Sit to Stand

Four Mechanical Phases of Sit to Stand

Flexion Momentum

• begins with forward trunk flexion, shifting the center of mass anteriorly over the base of support

• requires adequate trunk control and momentum generation

Four Mechanical Phases of Sit to Stand

Momentum Transfer

• the most critical and unstable moment when the body transitions from sitting to lifting off the seat

• The center of mass moves vertically as weight is transferred to the lower limbs

• Timing and control are key here to avoid loss of balance or reliance on compensatory strategies

Four Mechanical Phases of Sit to Stand

Extension

• the hips, knees, and ankles extend to bring the body to an upright standing position

• This requires significant lower extremity strength and coordination

Four Mechanical Phases of Sit to Stand

Stabilization

• the body must stabilize itself to prevent falls

• This is where standing balance becomes crucial, especially in individuals with spinal cord injury

• Transitioning from sit to stand naturally leads us to standing balance, which itself is a composite task influenced by several underlying factors

Recovery/Compensation

• recovery is often the primary goal, especially when there is residual motor function and the potential for regaining volitional control.

• compensation involves adopting new movement patterns or using assistive devices to accomplish the task when full recovery is not possible

  • more common in the complete spinal cord injury population, where the neurological damage limits potential for motor return

  • may include the use of assistive devices, bracing, body weight support systems, or modified techniques such as momentum based stands, or using upper extremity support to substitute function

Neuroanatomy Refresher – SCI Levels & Functional Potential

C1-C7

• Key Functional Muscles: Limited UE

• Standing Potential: Dependent standing (tilt-table)

Neuroanatomy Refresher – SCI Levels & Functional Potential

T1-T6

• Key Functional Muscles: Full UE, partial trunk

• Standing Potential: Standing frame, KAFO use

Neuroanatomy Refresher – SCI Levels & Functional Potential

T7-T12

• Key Functional Muscles: Improved trunk control

• Standing Potential: Orthotic-supported STS possible

Neuroanatomy Refresher – SCI Levels & Functional Potential

L1-L5

• Key Functional Muscles: Hip flexion to ankle

• Standing Potential: Potential for STS with AFOs or canes

Neuroanatomy Refresher – SCI Levels & Functional Potential

S1-S5

• Key Functional Muscles: Foot/ankle function

• Standing Potential: Near-normal STS, minor aids

Sit-to-Stand in Complete SCI

Key Characteristics

• No voluntary movement below lesion

• Use of compensatory strategies, orthotics, and assistive tech

Sit-to-Stand in Complete SCI

Approaches: T6-T12

Standing frames, KAFOs + parallel bars

Sit-to-Stand in Complete SCI

Approaches: L1-L5

KAFOs with AD, possible reciprocal gait orthosis

Sit-to-Stand in Complete SCI

Approaches: Focus

Weight-bearing, safety, cardiovascular conditioning

Sit-to-Stand in Incomplete SCI

Key Characteristics

• Partial preservation of motor/sensory function

• Recovery-based strategies prioritized

Sit-to-Stand in Incomplete SCI

Approaches

• Use of task-specific training: repetition, cueing, neuroplasticity

• PNF, functional electrical stimulation (FES), BWSTT

• Adaptive support based on ASIA grade (C, D most responsive)

Level-Specific Interventions & Equipment

T6-T12 Complete

• Intervention: Tilt table → Standing frame → KAFOs + AD

• Equipment: Parallel bars, KAFOs

Level-Specific Interventions & Equipment

L1-L5 Complete

• Intervention: Progressive upright training, AD

• Equipment: KAFOs, walker/canes

Level-Specific Interventions & Equipment

Incomplete (any level)

• Intervention: Task-specific STS, FES

• Equipment: Bioness, LiteGait, standard rehab tools

Clinical Pearls and Decision Making

• Use recovery when possible, compensate when necessary

• Always assess: strength, endurance, spasticity, posture, motivation

• Prioritize upright positioning early for multiple system benefits

• Customize based on neurological level, ASIA score, and goals

• Emphasize safety, support, progression, and education

Importance of Tone Management in Sit-to-Stand

• Muscle tone affects initiation and control

• Hypertonicity can resist movement

  • may have difficulty bending forward, weight shifting, or extending the hips and knees smoothly

• Hypotonia can impair posture and initiation

  • often struggle with trunk control, pelvic alignment, and sufficient muscle activation to even initiate the movement

  • transitions may look slow, unstable, or incomplete

• Goals: Normalize tone to optimize performance

Positioning and Postural Adjustments

• Align trunk and pelvis

  • upright and aligned

  • neutral to slightly anterior tilt

• Feet flat, knees at ~90°

  • stable base and promotes active loading of the lower extremities

  • supports effective momentum generation and prevents overreliance on the upper extremities for pushing up

• Symmetrical weight-bearing

• Neutral pelvis reduces extensor tone

Poor posture setup

posterior pelvic tilt, feet tucked under the chair, or asymmetrical posture, can trigger abnormal tone patterns, increase effort, and reduce movement efficiency

Facilitation and Inhibition Techniques

Inhibition

• Prolonged stretch

  • reduce hypertonicity

  • allows the muscle spindle to adapt and quiet down its response

• Gentle, slow movement

  • slow rocking or passive range

  • reduce excitatory input to the nervous system, promoting relaxation and smoother movements

Facilitation and Inhibition Techniques

Facilitation

• Tapping

  • over a muscle belly can help engage the muscle right before movement, especially in the quadriceps or glutes prior to standing

• Quick stretch

  • uses the stretch reflex to initiate a more robust response

• Vibration

  • can increase excitability in low-toned muscles and help prepare them for activity

Tone Management Interventions

Weight Shifting & Rocking

• Lateral and anterior shifts

  • help normalize tone, encourage equal loading, and increase body awareness

  • teach patients how to initiate movement using their base of support.

• Rhythmic rocking reduces tone

  • forward and back motion in the seated position, especially in neutral pelvic tilt

  • calming to the nervous system and prepares patients for the forward momentum needed in order to sit-to-stand

Tone Management Interventions

Standing with Support

Promotes postural extension

• upper extremity support on a plinth, table, or in parallel bars to allow them to engage postural muscles without bearing full weight independently

• can facilitate extensor activation while reducing the fear of falling or collapsing

Tone Management Interventions

Deep Pressure & Massage

• Calms hypertonicity

• Increases body awareness

• applied to the joints through weight bearing, and can inhibit spasticity and provide proprioceptive feedback

• slow and firm strokes, can reduce muscle guarding and relax hypertonic regions before or after standing tasks

Tone Management Interventions

ROM Exercises

Active and passive ROM to maintain length and reduce tone

• maintaining mobility, but engaging motor pathways, and can reduce tone through reciprocal inhibition

Tone Management Interventions

Therapeutic Tapping

• can facilitate activation during transitions

• Used just before or during movement, it helps the nervous system find the target muscles more effectively

Tone Management Interventions

Reflex Inhibition Patterns

• Bobath or NDT-based postures to reduce abnormal reflex activity can help reset muscle tone

• This may involve head and limb positioning that counteracts typical flexor or extensor patterns

Tone Management Interventions

Breathing + Exhalation Timing

Encourages relaxation during transition

• with movement incorporating exhalation with effort, such as during the forward trunk lean or lift phase of sit-to-stand, can help reduce holding patterns and tone

• rhythmically promotes relaxation and reduces rigidity. It also supports coordinated movement

Assistive Devices and Aids

• Splints and orthotics: Stabilize joints, reduce spasticity

  • Ankle foot orthoses can prevent foot drop or ankle inversion, ensuring a more stable base for rising

  • Hand or elbow splints may be used to inhibit flexor tone in upper limbs during transfers

• Positioning aids: Wedges, bolsters

  • adjust pelvic positioning, reduce abnormal reflexes, and increase comfort

  • A slight anterior wedge can promote forward trunk lean and reduce extensor tone

  • Lateral supports can prevent asymmetrical posture that may reinforce tone imbalances

• Chairs with armrests and firm seats assist with safety

  • ensures better mechanical advantage and reduces compensatory movement

Sit-to-stand lifts or standing frames

• may be used to gradually build tolerance for upright posture and weight bearing

• These can reduce fear and physical strain while supporting tone normalization

Neuromuscular Re-education and Functional Practice

• Practice functional sit-to-stand with facilitation

• Task-specific repetition builds neuroplasticity

  • improves timing, sequence, and control

• Use mirrors or feedback for alignment

  • improve alignment, awareness, and motor control

• Integrate into daily tasks

Safety, Body Mechanics & Hand Placement

• PT body mechanics: Wide base, stay close

  • wide base of support with one foot slightly forward

  • back straight and your hips down, not bending at the waist

  • Stay close to the patient's center of mass. This gives you better control and leverage

• Hand placement:

  • At scapula/pelvis—not pulling arms or under axilla

  • Cue trunk lean, foot placement

• Avoid excessive force or pulling

• Always position yourself slightly to the side and in front of the patient during the transfer.

• Use a gait belt for added safety, especially in early practice or with patients that are at high fall risk

• Cue the patient to lean forward to bring their center of mass over their base of support

Gait Training for SCI

Prognosis

• Neurological return in the first 6 to 9 months postinjury, with greatest return within first 3 months

• Clinical Prediction Rule (CPR) of walking indoor for at least 10 meters:

  • Age ≤ 65 years

    • Age 65 or over has a weighted coefficient of negative 10, while younger than 65 has a weighted coefficient of 0.

  • Motor score L3 (knee extensor)

  • Motor score S1 (plantar flexor)

    • multiplied by 2

  • Light touch score of L3

  • Light touch score of S1

    • multiplied by 5

• the highest possible total score of 40

Compensatory-Based Approach for Gait Training

• Motor complete lesions (ASIA Impairment Scale A or B)

• Nonphysiological walking

  • does not involve muscles below the level of the lesion

• Uses assistive device, bracing, and/or technology to walk

Compensatory-Based Approach for Gait Training

Focus of rehabilitation

• Strengthen both upper extremities and trunk

• Stretch the hip to allow hip extension

• Prevent contractures in knees and ankles

Compensatory-Based Approach for Gait Training

Precautions

• Orthopedic precautions

• Pressure injuries and skin abrasions from bracing

• Injury from falls

Compensatory-Based Approach for Gait Training

Benefits

• Therapeutic exercise

• Skill or mobility

• Benefits of standing:

  • Circulation and cardiovascular health

  • Skin integrity

  • Bowel and bladder function

  • Sleep

  • Sense of well-being

  • Bone health

Compensatory-Based Approach for Gait Training

Challenges

• Time-consuming

• Energy-consuming

• Equipment cost

• Less time for functional training

• Potential for falls

• Excessive stress on upper extremities

• Donning and doffing

To Walk or Not to Walk?

challenges of walking with braces and assistive devices, particularly the high energy expenditure, Individuals with SCI often choose to use wheelchair as the primary mode of mobility

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: C8 or higher

Functional ambulation not feasible

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: T1-T9

(+) Fully innervated upper extremities, Walking for exercise, forearm crutches or walker, KAFOs, HKAFOs, RGOs

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: T10-L1

(+) trunk musculature, Home and limited distances in the community, KAFOs, HKAFOs

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: L2

(+) hip flexion for swing phase, forearm crutches or walker, KAFOs, floor-reaction AFOs

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: L3

(+) quadriceps for knee control during stance, forearm crutches or walker, AFOs with plantarflexion stop and dorsiflexion assist, floor-reaction AFOs

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: L4

(+) dorsiflexion; still with hip extensor and abductor weakness, independent community ambulation; forearm crutches or canes, AFO with dorsiflexion stops

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: L5

(+) limited stability of subtalar joint and foot; independent community ambulation, Standard canes, AFOs with dorsiflexion stops

Potential for Ambulation for Motor Complete SCI (AIS A and B)

Potential for Independence in Ambulation: S1

(+) plantarflexion; Community ambulation; no assistive devices

Requirements for Compensatory-Based Approach for Gait Training

• Full hip hyperextension

  • to be able to hang on their wide ligament during a parastance position

• No knee flexor contractures or plantar flexor contractures

• Good strength in shoulder depressors and triceps

• Pain-free weight-bearing BUE

• Low levels of spasticity or well-controlled spasticity

• Good trunk control

  • required to maintain static and dynamic balance during walking to allow for the advancement of assistive devices and the lower extremities

• Dynamic balance in standing

• No secondary complications from SCI such as obesity, pressure injuries, heterotopic bone formation at the hips or deformity, osteoporosis

• Cardiovascular endurance

• Highly motivated

Considerations for Orthotic Prescription

• Orthosis meets biomechanical needs

  • Patient’s voluntary motor function, muscle tone, range of motion, kinematics

• Adjustability

• Weight

• Potential damage to patient’s skin

• Expected trajectory

• Durability

• Ease of donning and doffing

• Cosmesis

• Cost

• Impact on other functional activities

Parallel Bars Activities

• Balanced Standing Strategies

  • Pelvis forward

  • Extension movement at hips

    • Y ligament restricts hip extension, so the hips are more stable in a hyperextension position

  • Head-hips relationship: retracting shoulder blades, throwing head back

• Weight shifting

  • needed in order for the patient to move the assistive device or the limb

• Push-ups

  • improve the ability of the patient to lift the body off the floor.

  • This is performed using elbow extension and scapular depression and protraction while tucking the head

Nonphysiological Walking (AIS A or B)

Four-point gait pattern

• slow, safe, and requiring less energy.

• It uses the latissimus dorsi, quadratus lumborum, or abdominal musculatures, if innervated for hip hiking to swing the limb forward

• Balanced standing posture

• One crutch advanced

• Lift leg by elevating pelvis, head tucked down and away from swing leg

• Leg swings forward

• Balanced standing posture

• The other leg advanced

Nonphysiological Walking (AIS A or B)

Swing-through

• Balanced standing posture

• Crutches ahead

• Lifting pelvis and legs by extending elbows, depressing and protracting scapulae and tucking head

• Torso and legs swing forward

• Heels strike

• Balanced posture regained

Nonphysiological Walking (AIS A or B)

Progressions

Stepping backward, stepping to the side, increasing walking distance

Advanced Skills

negotiating obstacles, ascending and descending ramps, curbs and stairs, and standing from the floor for fall recovery

Advanced Skills: Ramps

• To ascend, keep crutches well forward and angle body so that pelvis is well forward to prevent jackknifing.

• To descend, step past the crutches

Advanced Skills: Curbs and Stairs

• To ascend, face curb or stairs, place crutches on curb or step, tuck head, extend elbows and depress scapula, swing legs forward and step on curb or step.

• To descend, face forward, bring tips of crutches on top of curb or step close to edge, lean on crutches, tuck head, extend elbows and depress scapula, swing legs forward and step off the curb or step

Advanced Skills: Stand from Floor

Falling Safely

• Throw crutches laterally and posteriorly

• Break the fall by landing on palms, not hold arms rigid

• Practice fall over a short distance or restrained falling

• Progress to build distance or falling unrestrained

Advanced Skills: Stand from Floor

Person gets in prone position, orthotic knees locked in extension, move to plantigrade (tuck head down and lift pelvis high), walks hands back, grasp crutch with one hand, then grasp the other crutch with the free hand, reposition cuff, push self up to position to a standing position.

Compensatory Walking Systems

• Implantable FES System

• External FES System

• Neuromuscular Electrical Stimulation

• Robotic/exoskeleton devices

• Neuromodulation for gait training with epidural electrical stimulation

• Transcutaneous spinal cord stimulation

Compensatory Walking Systems

FES system, either implantable or external

applied to key muscle groups while performing a functional task

Compensatory Walking Systems

Neuromuscular electrical stimulation

• similar to an FES

• produces muscle contraction, but not functional movement

Compensatory Walking Systems

Epidural stimulation

• an implantable neural stimulator in the spinal cord

• It sends impulse to the dorsal afferent and has been found to improve function in motor complete SCI's once the stimulation is combined with the task-specific activity

• not approved by FDA for clinical use yet

Compensatory Walking Systems

Transcutaneous spinal cord stimulator

non-invasive, it also stimulates the dorsal afferent of the spinal cord and showed promising results

Manual vs Power

Client Considerations

• Function

• Cognitive status

• Safety

• Pain

• Orthopedic limitations

• Strength and endurance

• Sensation

Manual vs Power

Equipment Considerations

• Compatibility with seating & accessories

• Mobility-related ADLs (MRADLs)

• Environment

• Speed

• Size

• Accessibility

• Transportation

• Cost vs. Funding

Wheelchair use

Wheelchair use

C4 or higher complete

• lack the motor control and strength to propel a manual wheelchair, and therefore require the use of a power wheelchair for mobility

• These individuals will control the wheelchair by chin movements, sip and puff, or head array

Wheelchair use

C5 complete

• commonly use power wheelchairs controlled by hand movements.

• However, they may be able to propel a manual wheelchair for limited distances indoors or on level ground

Wheelchair use

C6 complete

choose not to use a powered wheelchair and can propel a manual wheelchair household and community distances

Wheelchair use

C7 and lower complete

typically solely use a manual wheelchair

Sequence of Evaluation: Custom Power Wheelchair

1. Postural support and seating needs

   1. most appropriate back, cushion, and positioning product, you must take into consideration the individual's sitting posture, and skeletal deformities, level of balance and trunk strength

2. Selection of input device (drive controls/switches)

3. Essential controller functions

4. Selection of powered mobility base

Seating Systems Considerations

• Sitting posture

• Skeletal deformities

• Contractures

• Spasticity

• Level of balance

• Trunk strength

• Vertical tolerance

• Stability for operation of input device

• Need for positional changes

• Need for intermittent catheterization

Powered Seating System Functions: Tilt

change of orientation in space; maintains angles at hips, knees, and ankles

Powered Seating System Functions: Recline

change of orientation by opening seat-to-back angle

Additional Powered Seating System Options

• Power seat elevator and standing features

  • can improve the user's independence by increasing access to higher spaces, reducing the risk of repetitive strain injuries from reaching overhead, and facilitate improved social participation by promoting eye-level interaction

• Elevating leg rests

  • can be a benefit to prevent contracture and improve posture and comfort

• Power seat standing

  • can also promote bone health, improve circulation, and reduce the risk of pressure sores

    

Back Supports

General purpose backrest

• Limited contour

• Limited adjustability

• Used for comfort with limited additional postural needs

Back Supports

Lateral support (contoured) backrest

• Moderate to significant contour

• May have adjustment options

• Designed for keeping upright/midline posture

Back Supports

Custom needs backrest

• Body shape is unique

• Positioning needs are not met by off the shelf back rest

Four Classes of Cushions

Foam PROS

• Least expensive

• Comes in different densities

• Lightweight

• Don’t deflate or leak

  

Four Classes of Cushions

Foam CONS

• Compress and deteriorates over time

• Damaged by light/moisture

Four Classes of Cushions

Gel/Fluid PROS

• Provides good pressure relief

• Can assist with heat retention

• Minimize shear forces

  

Four Classes of Cushions

Gel/Fluid CONS

• Heavy

• Can freeze

• Can puncture

• Can change over time as gel breaks down

Four Classes of Cushions

Air PROS

• Best for pressure relief

• Lightweight

• Adjustable

  

Four Classes of Cushions

Air CONS

• Poor stability with transfers and alignment

• Can puncture

• Inflation must be monitored

Four Classes of Cushions

Hybrid PROS

• Can be a mixture of foam, gel, and/or air.

• May provide more adjustability and support to address specific needs.

• Can be adapted over time

  

Positioning Products

• Lateral thigh supports (hip guides)

• Adductor pads (distal lateral thigh supports)

• Medial thigh supports (abduction pommel)

• Lower leg and foot supports

• Lateral trunk supports

• Head supports

• Anterior trunk support

• Upper extremity supports (tray)

Controller Functions

Proportional

speed and control is proportional to the input given

• Standard Joystick

• Mini-Joysticks

• Touch pads

• Finger Steering

Controller Functions

Non-Proportional

on/off operation, specific direction and speed, typically pre-set

• Proximity and fiber optic

• Mechanical switch systems

• Head Arrays

• Sip & Puff

• Single Switch Scanners