Spinal Cord Injury Wheelchair Prescription & Autonomic Dysreflexia

T12 (low thoracic) lesion
- Nearly full activation of trunk musculature ➔ “pretty good amount of core engagement.”
- All musculature above the lesion is intact ➔ full strength and coordination of both upper extremities (UE).
- Primary loss = lower-extremity motor/sensory function; ambulation is not feasible.
T6 (mid-thoracic) lesion
- Anything above T6 remains intact; anything below = impaired/absent.
- T6 is well above the autonomic “splanchnic outflow” level, so the sympathetic nervous system is disrupted ➔ risk for autonomic dysreflexia (AD).

OT Goal: provide the least-restrictive device that maximizes preserved abilities and fosters long-term functional goals.
Device must challenge but not limit the client. On exams, choose the answer that keeps the most function intact.

Client profile: T12, complete injury, intact core + full UE strength.
- Power chair ↓ UE engagement, ↓ cardiovascular demand, ↑ device weight/cost.
- Recommendation ➔ Manual wheelchair to capitalize on UE strength and cardiorespiratory benefits.

Reclining chairs indicated when the user lacks:
- Adequate core control for upright sitting OR
- Ability to perform independent pressure relief via UE/triceps extension.
Client (T12) has both core control & triceps strength ➔ standard manual chair suffices.

If the client can:
- Sit upright without external support
- Propel with UEs
  …then pick a standard manual option.
Only add recline/tilt/power if there is a clear clinical justification (poor trunk, high fatigue, progressive disease, etc.).

Feature	Autonomic Dysreflexia	Orthostatic Hypotension
Typical Level	Lesions at T6 & above	Any level, but common in high SCI
BP change	\uparrow BP (severe hypertension)	\downarrow BP
Key Symptom	Pounding headache, flushing, sweating above lesion	Dizziness, light-headedness
Trigger	Noxious stimulus below lesion (e.g., kinked catheter)	Upright postural change
First OT Action	Sit upright to lower BP; remove stimulus	Recline / Trendelenburg to raise BP

AD: Reflex sympathetic surge below lesion raises peripheral vascular resistance + BP. Baroreceptors trigger vagal response above lesion (bradycardia & headache) but descending inhibitory control cannot pass through lesion.
OH: Failure of sympathetic vasoconstriction on standing ➔ venous pooling, ↓ preload, ↓ cardiac output.

Recognize: pounding headache in T6 client = red flag for AD.
Immediate positioning:
- Keep/bring client upright in wheelchair or high-Fowler’s in bed.
- Do NOT use Trendelenburg (would worsen \uparrow BP).
Search & remove noxious trigger:
- Check catheter tubing for kinks/occlusion.
- Inspect clothing, abdominal binders, shoes for pressure spots.
- Perform bladder/bowel assessment if trained/appropriate.
Activate medical team: press nurse call button, monitor vitals.
Continue OT only after BP stabilizes.

Trendelenburg (legs > heart) raises venous return ➔ raises BP. Use for OH (low BP), not for AD.
For AD use upright posture to leverage gravity and lower BP:
\text{Vertical posture} \Rightarrow \downarrow venous return \Rightarrow \downarrow BP

Therapist guiding student: “Think orthostatic = low BP, Trendelenburg helps; AD = high BP, Trendelenburg harms.”
Costco garlic bread side-comment (humor) = irrelevant to clinical decision but highlights informal learning setting.

Choosing an overpowered chair may decrease independence, physical fitness, and long-term outcomes.
Mismanaging AD could be fatal; rapid recognition and appropriate response are critical competencies for OTs.