Length of Stay in SCI Rehabilitation

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Author: Dominik Zbogar | Reviewer: Giorgio Scivoletto | Published: 30 April 2025 | Updated: ~

Key Points

    • The length of stay (LOS) in spinal cord injury (SCI) inpatient rehabilitation varies widely between countries, from 41 days in USA to 135 in Switzerland.
    • Between countries, LOS varies due to cultural, economic, and health infrastructure factors.
    • Within a country, LOS varies depending on the severity/level of injury, age, complications and pre-existing conditions, and functional goals.
    • Inpatient SCI rehab LOS has been decreasing over decades for reasons including advancements in medical and surgical care, technology and equipment, changing injury characteristics and demographics, changes in healthcare policy and insurance, changes in rehab practice and increased focus on community-based (outpatient) care.

How long people receive inpatient rehabilitation for spinal cord injury (SCI) is called rehabilitation length of stay (LOS). Rehabilitation is often part of the care pathway for a SCI patient. From initial injury to discharge into the community, the care pathway typically involves acute care, rehabilitation and discharge into the community, each addressing different aspects of recovery. Progression through the care pathway is not always seamless. For example, the interval before rehabilitation can involve more than one acute facility, or a patient may be readmitted to acute care while in rehabilitation.

Acute care

This period of early health care after a major injury or illness includes both emergency services in the community (like ambulance and paramedic services) and treatment at an acute care hospital. During this time, serious and urgent health problems are addressed to stabilize the patient.

Average acute care LOS

USA

30 days in the 1970s to 19 days since 2015

Canada

Between 25-37 days depending on injury severity/level

Rehabilitation

When a person is medically stable, most people leave acute care and are transferred to a “rehabilitation center” or “rehabilitation hospital”, where they focus on recovering and developing the skills for living with an SCI long-term. In some cases, the acute and rehabilitation services are in the same hospital. In other cases, the rehabilitation hospital is a separate centre.

Inpatient rehabilitation

Inpatient rehabilitation involves staying at a rehabilitation centre and receiving full-day programming.

Outpatient rehabilitation

Outpatient rehabilitation has individuals living in the community and visiting the rehabilitation centre for regular services. This phase can continue for several months, focusing on further functional improvements, community reintegration, and vocational training.

Community

Returning to community living after an SCI involves planning for suitable living arrangements after rehabilitation and for a possible return to previous activities. Some return home while others may go to a long-term or transitional care facility. This is done with support from the whole health team and may be led by a social worker or discharge planner.

Refer to our article on Understanding Rehabilitation for more information!

The LOS for SCI rehabilitation varies significantly between countries due to differences in healthcare systems, insurance models, resource availability, economic factors, cultural and social factors, and adaptation of evidence-based rehabilitation practices. These factors are discussed in detail in the next sections.

In this section, we show rehab LOS values for select countries around the world since 2010. The LOS is counted in average days (unless we indicate otherwise). Text descriptions provide details about subgroups while images provide a summary value.

North America

United States (2020 – 2023)

41 days (median)

Canada (2021)

  • Traumatic SCI:
  • Non-traumatic SCI
    • Complete tetraplegia: 95
    • Incomplete tetraplegia: 67
    • Complete paraplegia: 70
    • Incomplete paraplegia 55

Europe

Germany (2013­­­­­­­­ – 2016)

57.7

Italy (1996 – 2020)

  • With complications: 180.4 (93)
  • Without complications: 154.5 (85)

Norway (2012 – 2016)

120

Switzerland (2013 – 2014)

135 (median)

Middle East

Saudi Arabia (2009 – 2014)

  • Traumatic SCI: 85
  • Non-traumatic SCI: 64

Asia

China (2010 – 2019)

113.5

Australia (2010 – 2011)

130 (median)

In the USA the median rehabilitation LOS has decreased from 91 days in 1972-1979 to 41 days in 2020-2023.

This decrease over the years is a trend also seen in other high-income countries (HIC). This decrease in LOS for inpatient SCI rehabilitation may be due to a combination of several factors reflecting both the evolution of care practices and the economic realities of healthcare delivery:

Advancements in medical and surgical care

Early surgical intervention, better acute care, and improved stabilization techniques post-injury may allow for quicker transitions from acute care to rehabilitation or community settings. This is supported by studies showing that early surgery may lead to shorter LOS in acute care, which could impact how soon patients are admitted to rehabilitation.

Changes in healthcare policy and funding

Economic incentives in healthcare systems, particularly in HICs, have pushed for shorter hospital stays to manage costs. Insurance policies and healthcare reforms often aim to reduce LOS to lower expenditure, which has influenced rehabilitation practices.

Changes in rehabilitation practices

Intensity of rehabilitation and not just LOS can influence outcomes. In the US for example, some rehab facilities have a three-hour rule where at least three hours of intensive rehab therapy per day, at least five days a week. This has led to a focus on maximizing therapy within a shorter period, thereby reducing LOS while still aiming for similar or better outcomes. Rehabilitation methods have evolved, emphasizing more intensive, shorter-duration therapies that aim to achieve functional gains more quickly. This includes the use of early, intensive physical therapy, occupational therapy, and other modalities that can lead to earlier discharges.

Technological and equipment advances

The availability of advanced assistive devices, home adaptations, and technology for home use allows individuals with SCI to manage more aspects of their care at home, reducing the need for extended inpatient stays.

Increased focus on community-based rehabilitation

There is a growing trend towards discharging patients to community settings earlier for continued rehabilitation, supported by home health services, outpatient programs, or community-based rehabilitation centers. This shift is partly due to evidence showing that community integration and social participation can be maintained or even enhanced with earlier discharge.

Changes in demographic and injury characteristics

Changes in the demographics of those injured, and the level and severity of SCI may also play a role. An increase in SCI among older people may increase rehab periods. Conversely, a trend towards more effective complication prevention could lead to shorter rehabilitation periods. Also, a trend towards incomplete SCI could lead to shorter rehabilitation periods. However, this trend towards incomplete SCI is not always reflected in a reduction of LOS as a sizeable subset of those with incomplete tetraplegia suffer from central cord syndrome which has very poor independence recovery.

The next section provides more information on these demographic factors.

Severity of injury

  • Complete SCI (no sensory or motor function below the level of injury) typically requires longer stays.
  • Incomplete SCI (some preserved function below the level of injury) may involve shorter stays, but this varies widely depending on the extent of motor and sensory recovery.

Level of injury

  • Higher-level injuries (cervical injuries) tend to result in more significant functional impairments, leading to longer stays.
  • Lower-level injuries (thoracic or lumbar injuries) may require less rehabilitation time, though patients still need extensive care for functional independence.

Refer to our article on SCI Basics for more information!

Complications

Patients who develop complications like pressure ulcers, respiratory issues, or infections often experience prolonged rehabilitation stays but without any improvement in independence. Also, medical complications in rehabilitation are a predictor of rehospitalization in the period after rehabilitation discharge.

Age and pre-existing conditions

Older patients or those with pre-existing health conditions may require longer rehabilitation. The increased age of patients can often mean that caregivers are older and are themselves unable to assist their partner, complicating discharge planning.

Functional goals

Rehabilitation LOS can be extended or shortened based on the patient’s ability to achieve specific functional milestones, such as regaining mobility, independence in self-care, or achieving vocational goals.

Early versus late decompression surgery

Early surgery is associated with a small decrease in acute care LOS. However, there is no association between early surgery and rehabilitation LOS. More research is needed to support the finding as the 2 studies on this topic had very imprecise estimates.

Early versus late admission to rehab

Research has shown that SCI patients without effective rehabilitation in the six months following injury had a significantly longer length of stay in rehabilitation (as well as a notably lower percent increase in motor recovery from admission to discharge). Additionally, it has been shown that early rehabilitation is effective in accelerating and promoting improvement in activities of daily living.

Barriers to discharge

Sometimes, individuals remain in the rehabilitation setting after their rehabilitation goals have been met and even when they are deemed ready for discharge. For example, family deliberations, procurement of supported care or services, provision of required equipment, need for residential care, a lack of accessible housing or a requirement for home modifications can all result in an extended stay in rehabilitation. Architectural barriers in heritage buildings and neighbourhoods in old European cities can be a significant barrier to discharge that the North American reader may not have considered.

Specialized centres of care

When patients have access to specialized centres of care there is a decrease in mortality and LOS. However, relatively few specialized SCI rehabilitation centers exist globally and they are generally concentrated in high-income countries. Examples include the acute care centres and rehabilitation units that are part of the Spinal Cord ­Injury Model Systems in USA and the Rick Hansen Spinal Cord Injury Registry in Canada. The global lack of specialist rehabilitation skills in low-income countries can result in inadequate initial management of SCI cases at the receiving hospital and a rapid development of secondary complications, ultimately contributing to a longer length of hospital stay and potentially poorer functional outcomes or even death.

Healthcare models

LOS can be influenced by the healthcare models. In one study from 2005 comparing USA, Canada and Italy, it was found that LOS in USA was influenced by third party payer requirements for discharge where patients are discharged as soon as they achieve a minimally acceptable level of mobility. In contrast, for Italy and Canada, length of stay in rehabilitation was based primarily on patients achieving the highest level of independence feasible. Today, 20 years later, while the health care systems in many countries are intended to allow continued rehabilitation (inpatient or outpatient) until patients reach a mobility plateau or maximal mobility independence, there is tremendous financial pressure to discharge patients as quickly as possible.

Healthcare differences between HICs and LMICs

While there is much variability even within HICs and low- and middle-income countries (LMICs), the health care infrastructure in HICs supports a more structured and systematic approach to SCI rehabilitation with clear protocols for early intervention, which can reduce LOS. In many LMICs, the infrastructure might be less developed, leading to inefficiencies in care delivery. Additionally, insurance coverage and health policies in HICs often allow for longer recovery times in rehabilitation settings, while in LMICs, financial constraints might force earlier discharge.

HICs tend to have better resources in terms of advanced medical equipment, trained personnel, and ongoing support services post-discharge, which can facilitate quicker rehabilitation and shorter hospital stays. In LMICs, economic conditions can directly impact LOS as lack of funding and constraints in resources mean that rehabilitation might be slower or less effective due to a lack of necessary equipment, like robotic rehabilitation devices, trained staff, and lack of systems for post-discharge care, including home care services, community support, and outpatient rehabilitation, which could reduce the need for prolonged inpatient stays. Environmental factors like access to transportation for follow-up care or the availability of accessible living environments also play a role.

Cultural attitudes towards disability and rehabilitation can influence LOS. In some LMICs, there may be cultural barriers to accepting or seeking out rehabilitation services, which could prolong hospital stays. Social factors include lower awareness of SCI care, which might delay initial treatment and extend the rehabilitation period.

The evidence for how LOS affects individual functional improvement at discharge is mixed. Some studies report a longer LOS is associated with increased functional improvement while others report the opposite.

Longer LOS may allow for additional opportunities for interdisciplinary treatments, patient education, and discharge planning to support transitions in care and reduce risk of re-hospitalization. However, LOS alone does not account for the intensity and quality of rehabilitation. In a hypothetical situation, patients recover their motor function faster and finish their rehabilitation program sooner if the therapy intensity is increased. Also, other factors such as psychological support, and community reintegration efforts play critical roles in long-term outcomes for SCI patients​. Time in an inpatient rehabilitation hospital can be disruptive to patients and adjusting sooner to routine at home, say as an outpatient, can accelerate community reintegration efforts.

Note too, that those with the most severe injuries tend to have the longest LOS in rehabilitation, yet their outcomes are often worse than those with shorter LOS and less severe injuries. It would be incorrect to assume then that longer LOS results in worse outcomes. Instead, consider the context of injury/demographic factors (as discussed in the previous sections) when looking at LOS values.

Ideally, the appropriate rehabilitation LOS for any person is determined by collaborative decision-making between the rehabilitation team, the patient, and their family. The ultimate goal is functional independence and quality of life improvement, even if rehabilitation continues in an outpatient or community-based setting.

In reality, rehabilitation LOS is impacted by the many factors discussed in this article. Factors specific to the patient include injury severity, age, medical complications, pre-existing conditions, and their individual recovery progress. Factors beyond the individual patient are those determined by the healthcare system and include how long it takes to be admitted to rehab, barriers to being discharged from rehab, specialized centres of care, and healthcare models. Insurance systems, and economics/resource availability especially play a role in the differences seen between HICs and LMICs. Finally, socio-cultural factors can also play a role, with lower awareness of SCI care or cultural barriers to accepting or seeking out rehabilitation services resulting in delayed initial treatment and extend the rehabilitation period.

Over the decades, rehab LOS has been decreasing. Reasons for this include advancements in surgical care and technologies, changes in rehab practices, increased focus on community-based rehabilitation, less severe injuries and complications, and economic/healthcare system pressures.

Parts of this page have been adapted from the SCIRE Professional “Rehabilitation Practices” Module. Available from: scireproject.com/evidence/rehabilitation-practices/sci-rehabilitation-outcomes/rehabilitation-length-of-stay/

Evidence for “The SCI care pathway” is based on:

Burns, A. S., Santos, A., Cheng, C. L., Chan, E., Fallah, N., Atkins, D., Dvorak, M. F., Ho, C., Ahn, H., Paquet, J., Kwon, B. K., & Noonan, V. K. (2017). Understanding Length of Stay after Spinal Cord Injury: Insights and Limitations from the Access to Care and Timing Project. Journal of Neurotrauma, 34(20), 2910. https://doi.org/10.1089/NEU.2016.4935

NSCISC. (2024). Traumatic Spinal Cord Injury Facts and Figures at a Glance. https://bpb-us-w2.wpmucdn.com/sites.uab.edu/dist/f/392/files/2024/06/Facts_and_Figures_2024_Final.pdf

Praxis Spinal Cord Institute. (2022). Rick Hansen Spinal Cord injury Registry: A look at Spinal Cord Injury in Canada in 2022. https://praxisinstitute.org/wp-content/uploads/2024/10/Praxis-Registry-Annual-Report-2022.pdf

Evidence for “Typical rehab LOS around the world” is based on:

National Spinal Cord Injury Statistical Center. (2023, August). 2023 Annual Statistical Report for the Spinal Cord Injury Model Systems. University of Alabama at Birmingham. https://bpb-us-w2.wpmucdn.com/sites.uab.edu/dist/f/392/files/2024/06/9.4_SAS_System_Output.pdf

Noonan, V. K. (2023). A Look at Spinal Cord Injury in Canada: Rick Hansen Spinal Cord Injury Registry (RHSCIR) – 2021 SCI Data Summary. Topics in Spinal Cord Injury Rehabilitation, 29(Supplement), 165–170. https://doi.org/10.46292/SCI23-00031SPonfick 2017

Scivoletto, G., Marcella, M., Floriana, P., Federica, T., & Marco, M. (2020). Impact of complications at admission to rehabilitation on the functional status of patients with spinal cord lesion. Spinal Cord 2020 58:12, 58(12), 1282–1290. https://doi.org/10.1038/s41393-020-0501-zHalvorsen 2018

Franceschini, M., Bonavita, J., Cecconi, L., Ferro, S., Pagliacci, M. C., Ferro, S., Bellentani, M., Franceschini, M., Cavina, A., Biggeri, A., Cecconi, L., De Iure, F., Gordini, G., Redaelli, T., Actis, M. V., Del Popolo, G., Bertagnoni, G., Avesani, R., & Falabella, V. (2020). Traumatic spinal cord injury in Italy 20 years later: current epidemiological trend and early predictors of rehabilitation outcome. Spinal Cord 2020 58:7, 58(7), 768–777. https://doi.org/10.1038/s41393-020-0421-y

Mahmoud, H., Qannam, H., Zbogar, D., & Mortenson, B. (2017). Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: Time to rehabilitation admission, length of stay and functional independence. Spinal Cord, 55(5), 509. https://doi.org/10.1038/SC.2016.165

Zhang, Z., Wang, F., & Wu, Y. (2020). Factors affecting length of stay in hospital of patients with traumatic spinal cord injury in China. Journal of Rehabilitation Medicine, 52(11), 1–5. https://doi.org/10.2340/16501977-2761

Tovell, A., & Harrison, J. (2018). Spinal Cord Injury, Australia, 2010-2011. Injury research and statistics series no. 80. Cat. no. INJCAT 156.

Evidence for “How has rehab LOS changed over the years” is based on:

National Spinal Cord Injury Statistical Center. (2023, August). 2023 Annual Statistical Report for the Spinal Cord Injury Model Systems. University of Alabama at Birmingham. https://bpb-us-w2.wpmucdn.com/sites.uab.edu/dist/f/392/files/2024/06/9.4_SAS_System_Output.pdf

Fehlings, M. G., Hachem, L. D., Tetreault, L. A., Skelly, A. C., Dettori, J. R., Brodt, E. D., Stabler-Morris, S., Redick, B. J., Evaniew, N., Martin, A. R., Davies, B., Farahbakhsh, F., Guest, J. D., Graves, D., Korupolu, R., McKenna, S. L., & Kwon, B. K. (2024). Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update. Global Spine Journal, 14(3 Suppl), 38S. https://doi.org/10.1177/21925682231197404

Mac-Thiong, J. M., Feldman, D. E., Thompson, C., Bourassa-Moreau, E., & Parent, S. (2012). Does Timing of Surgery Affect Hospitalization Costs and Length of Stay for Acute Care following a Traumatic Spinal Cord Injury? Https://Home.Liebertpub.Com/Neu, 29(18), 2816–2822. https://doi.org/10.1089/NEU.2012.2503

Bryden, A. M., & Gran, B. (2024). Seeking sufficient and appropriate care during the first year after spinal cord injury: a qualitative study. Spinal Cord 2024 62:5, 62(5), 241–248. https://doi.org/10.1038/s41393-024-00974-x

Burns, A. S., Santos, A., Cheng, C. L., Chan, E., Fallah, N., Atkins, D., Dvorak, M. F., Ho, C., Ahn, H., Paquet, J., Kwon, B. K., & Noonan, V. K. (2017). Understanding Length of Stay after Spinal Cord Injury: Insights and Limitations from the Access to Care and Timing Project. Journal of Neurotrauma, 34(20), 2910. https://doi.org/10.1089/NEU.2016.4935

Forrest, G., Reppel, A., Kodsi, M., Smith, J., & Enix, D. (2019). Inpatient rehabilitation facilities: The 3-hour rule. Medicine, 98(37), e17096. https://doi.org/10.1097/MD.0000000000017096

Kao, Y. H., Chen, Y., Deutsch, A., Wen, H., & Tseng, T. S. (2021). Rehabilitation length of stay and functional improvement among patients with traumatic spinal cord injury. Spinal Cord 2021 60:3, 60(3), 237–244. https://doi.org/10.1038/s41393-021-00686-6

Lamontagne, M. E., Gagnon, C., Allaire, A. S., & Noreau, L. (2013). Effect of rehabilitation length of stay on outcomes in individuals with traumatic brain injury or spinal cord injury: a systematic review protocol. Systematic Reviews, 2, 59. https://doi.org/10.1186/2046-4053-2-59

Truchon, C., Fallah, N., Santos, A., Vachon, J., Noonan, V. K., & Cheng, C. L. (2017). Impact of Therapy on Recovery during Rehabilitation in Patients with Traumatic Spinal Cord Injury. Journal of Neurotrauma, 34(20), 2901. https://doi.org/10.1089/NEU.2016.4932

Morone, G., Pirrera, A., Iannone, A., & Giansanti, D. (2023). Development and Use of Assistive Technologies in Spinal Cord Injury: A Narrative Review of Reviews on the Evolution, Opportunities, and Bottlenecks of Their Integration in the Health Domain. Healthcare, 11(11), 1646. https://doi.org/10.3390/HEALTHCARE11111646

Baehr, L. A., Kaimal, G., Hiremath, S. V., Trost, Z., & Finley, M. (2022). Staying active after rehab: Physical activity perspectives with a spinal cord injury beyond functional gains. PLoS ONE, 17(3), e0265807. https://doi.org/10.1371/JOURNAL.PONE.0265807

Kendall, M. B., Amsters, D., Schuurs, S., Borg, D. N., Pershouse, K., & Kuipers, P. (2022). Longitudinal effects of time since injury and age at injury on outcomes of people with spinal cord injury in Queensland, Australia. Spinal Cord, 60(12), 1087. https://doi.org/10.1038/S41393-022-00824-8

Nas, K., Yazmalar, L., Şah, V., Aydin, A., & Öneş, K. (2015). Rehabilitation of spinal cord injuries. World Journal of Orthopedics, 6(1), 8. https://doi.org/10.5312/WJO.V6.I1.8

Scivoletto, Giorgio. (2025) personal communication

Evidence for “Injury/demographic factors influencing rehab LOS” is based on:

Chan, S. S. S., & Chan, A. P. S. (2005). Rehabilitation outcomes following traumatic spinal cord injury in a tertiary spinal cord injury centre: a comparison with an international standard. Spinal Cord 2005 43:8, 43(8), 489–498. https://doi.org/10.1038/sj.sc.3101743

DeVivo, M. J., Kartus, P. L., Stover, S. L., & Fine, P. R. (1990). Benefits of early admission to an organised spinal cord injury care system. Paraplegia, 28(9), 545–555. https://doi.org/10.1038/SC.1990.74

Tooth, L., McKenna, K., & Geraghty, T. (2003). Rehabilitation outcomes in traumatic spinal cord injury in Australia: functional status, length of stay and discharge setting. Spinal Cord 2003 41:4, 41(4), 220–230. https://doi.org/10.1038/sj.sc.3101433

Whiteneck, G., Gassaway, J., Dijkers, M., Backus, D., Charlifue, S., Chen, D., Hammond, F., Hsieh, C. H., & Smout, R. J. (2011). Inpatient treatment time across disciplines in spinal cord injury rehabilitation. The Journal of Spinal Cord Medicine, 34(2), 133. https://doi.org/10.1179/107902611X12971826988011

Whiteneck, G., Gassaway, J., Dijkers, M. P., Heinemann, A. W., & Kreider, S. E. D. (2012). Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: The SCIRehab Project. The Journal of Spinal Cord Medicine, 35(6), 484. https://doi.org/10.1179/2045772312Y.0000000057

Dejong, G., Tian, W., Hsieh, C. H., Junn, C., Karam, C., Ballard, P. H., Smout, R. J., Horn, S. D., Zanca, J. M., Heinemann, A. W., Hammond, F. M., & Backus, D. (2013). Rehospitalization in the First Year of Traumatic Spinal Cord Injury After Discharge From Medical Rehabilitation. Archives of Physical Medicine and Rehabilitation, 94(4), S87–S97. https://doi.org/10.1016/J.APMR.2012.10.037

Scivoletto, Giorgio (2025). personal communication

Evidence for “Healthcare system factors determining rehab LOS” is based on:

Fehlings, M. G., Hachem, L. D., Tetreault, L. A., Skelly, A. C., Dettori, J. R., Brodt, E. D., Stabler-Morris, S., Redick, B. J., Evaniew, N., Martin, A. R., Davies, B., Farahbakhsh, F., Guest, J. D., Graves, D., Korupolu, R., McKenna, S. L., & Kwon, B. K. (2024). Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update. Global Spine Journal, 14(3 Suppl), 38S. https://doi.org/10.1177/21925682231197404

Ter Wengel, P. V., De Gendt, E. E. A., Martin, E., Adegeest, C. Y., Stolwijk-Swuste, J. M., Fehlings, M. G., Oner, F. C., & Vandertop, W. P. (2022). Impact of Surgical Timing on Motor Level Lowering in Motor Complete Traumatic Spinal Cord Injury Patients. Https://Home.Liebertpub.Com/Neu, 39(9–10), 651–657. https://doi.org/10.1089/NEU.2021.0428

Wilson, J. R., Singh, A., Craven, C., Verrier, M. C., Drew, B., Ahn, H., Ford, M., & Fehlings, M. G. (2012). Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study. Spinal Cord 2012 50:11, 50(11), 840–843. https://doi.org/10.1038/sc.2012.59

Janssen, T. W. J., Van Oers, C. A. J. M., Van Der Woude, L. H. V., & Hollander, A. P. (1994). Physical strain in daily life of wheelchair users with spinal cord injuries. Medicine and Science in Sports and Exercise, 26(6), 661–670. https://doi.org/10.1249/00005768-199406000-00002

Scivoletto, G., Morganti, B., & Molinari, M. (2005). Early versus delayed inpatient spinal cord injury rehabilitation: An Italian study. Archives of Physical Medicine and Rehabilitation, 86(3), 512–516. https://doi.org/10.1016/J.APMR.2004.05.021

Sumida, M., Fujimoto, M., Tokuhiro, A., Tominaga, T., Magara, A., & Uchida, R. (2001). Early rehabilitation effect for traumatic spinal cord injury. Archives of Physical Medicine and Rehabilitation, 82(3), 391–395. https://doi.org/10.1053/APMR.2001.19780

Burns, A. S., Marino, R. J., Kalsi-Ryan, S., Middleton, J. W., Tetreault, L. A., Dettori, J. R., Mihalovich, K. E., & Fehlings, M. G. (2017). Type and Timing of Rehabilitation Following Acute and Subacute Spinal Cord Injury: A Systematic Review. Global Spine Journal, 7(3 Suppl), 175S. https://doi.org/10.1177/2192568217703084

Scivoletto, Giorgio (2025). Personal communication

Parent, S., Barchi, S., LeBreton, M., Casha, S., & Fehlings, M. G. (2011). The Impact of Specialized Centers of Care for Spinal Cord Injury on Length of Stay, Complications, and Mortality: A Systematic Review of the Literature. Journal of Neurotrauma, 28(8), 1363. https://doi.org/10.1089/NEU.2009.1151

Arejan, R. H., Azadmanjir, Z., Ghodsi, Z., Dehghan, H. R., Sharif-Alhoseini, M., Tabary, M., Khaleghi-Nekou, M., Naghdi, K., Vaccaro, A. R., Zafarghandi, M. R., & Rahimi-Movaghar, V. (2022). How Can Policymakers be Encouraged to Support People With Spinal Cord Injury—Scoping Review. Global Spine Journal, 12(4), 732–741. https://doi.org/10.1177/21925682211005406/ASSET/IMAGES/LARGE/10.1177_21925682211005406-FIG3.JPEG

O’Connell, C., Armstrong, J., De la Cerna-Luna, R., Ganvir, S., & Arnillas Brigneti, P. (2024). Perspective of the World Rehabilitation Alliance: Global Strategies to Strengthen Spinal Cord Injury Rehabilitation Services in Health Systems. Healthcare 2024, Vol. 12, Page 2313, 12(22), 2313. https://doi.org/10.3390/HEALTHCARE12222313

Ditunno, P. L., Patrick, M., Stineman, M., Morganti, B., Townson, A. F., & Ditunno, J. F. (2005). Cross-cultural differences in preference for recovery of mobility among spinal cord injury rehabilitation professionals. Spinal Cord 2006 44:9, 44(9), 567–575. https://doi.org/10.1038/sj.sc.3101876Abedi 2022

Reinhardt, J. D., Mansmann, U., Fellinghauer, B. A. G., Strobl, R., Grill, E., Von Elm, E., & Stucki, G. (2011). Functioning and disability in people living with spinal cord injury in high-and low-resourced countries: A comparative analysis of 14 countries. International Journal of Public Health, 56(3), 341–352. https://doi.org/10.1007/S00038-010-0222-8/METRICS

Ronca, E., Scheel-Sailer, A., Eriks-Hoogland, I., Brach, M., Debecker, I., & Gemperli, A. (2020). Factors influencing specialized health care utilization by individuals with spinal cord injury: a cross-sectional survey. Spinal Cord 2020 59:4, 59(4), 381–388. https://doi.org/10.1038/s41393-020-00581-6Beauregard 2012

Marchesini, N., Rubiano, A. M., Sala, F., Demetriades, A. K., & Alves, O. L. (2022). Secondary damage management of acute traumatic spinal cord injury in low and middle-income countries: A survey on a global scale (Part III). Brain & Spine, 2, 101694. https://doi.org/10.1016/J.BAS.2022.101694

Øderud, T. (2014). Surviving spinal cord injury in low income countries. African Journal of Disability, 3(2), 80. https://doi.org/10.4102/AJOD.V3I2.80

Chanbour, H., Chen, J. W., Ehtesham, S. A., Ivey, C., Pandey, A. K., Dewan, M. C., & Zuckerman, S. L. (2022). Time to Surgery in Spinal Trauma: A Meta-Analysis of the World’s Literature Comparing High-Income Countries to Low-Middle Income Countries. World Neurosurgery, 167, e268–e282. https://doi.org/10.1016/J.WNEU.2022.07.140

Evidence for “Socio-Cultural factors determining rehab LOS” is based on:

Alves, M. A., Pilusa, S., & Mashola, M. K. (2023). The prevalence and profile of spinal cord injury in public healthcare rehabilitation units in Gauteng, South Africa. Spinal Cord Series and Cases, 9(1), 15. https://doi.org/10.1038/S41394-023-00571-9

Øderud, T. (2014). Surviving spinal cord injury in low income countries. African Journal of Disability, 3(2), 80. https://doi.org/10.4102/AJOD.V3I2.80

Evidence for “Does greater rehab LOS improve outcomes?” is based on:

Abdul-Sattar, A. B. (2014). Predictors of functional outcome in patients with traumatic spinal cord injury after inpatient rehabilitation: In Saudi Arabia. NeuroRehabilitation, 35(2), 341–347. https://doi.org/10.3233/NRE-141111

Kao, Y. H., Chen, Y., Deutsch, A., Wen, H., & Tseng, T. S. (2021). Rehabilitation length of stay and functional improvement among patients with traumatic spinal cord injury. Spinal Cord 2021 60:3, 60(3), 237–244. https://doi.org/10.1038/s41393-021-00686-6

Morrison, S. A., & Stanwyck, D. J. (1999). The Effect of Shorter Lengths of Stay on Functional Outcomes of Spinal Cord Injury Rehabilitation. Topics in Spinal Cord Injury Rehabilitation, 4(4), 44–55. https://doi.org/10.1310/LG0X-1X2Y-CV2Y-RUR9

Warschausky, S., Kay, J. B., & Kewman, D. G. (2001). Hierarchical linear modeling of FIM instrument growth curve characteristics after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 82(3), 329–334. https://doi.org/10.1053/apmr.2001.21510

Herzer, K. R., Chen, Y., Heinemann, A. W., & González-Fernández, M. (2016). Association Between Time-to-Rehabilitation and Outcomes Following Traumatic Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 97(10), 1620. https://doi.org/10.1016/J.APMR.2016.05.009

Sumida, M., Fujimoto, M., Tokuhiro, A., Tominaga, T., Magara, A., & Uchida, R. (2001). Early rehabilitation effect for traumatic spinal cord injury. Archives of Physical Medicine and Rehabilitation, 82(3), 391–395. https://doi.org/10.1053/APMR.2001.19780

Cohen, J. T., Marino, R. J., Sacco, P., & Terrin, N. (2012). Association between the Functional Independence Measure following spinal cord injury and long-term outcomes. Spinal Cord 2012 50:10, 50(10), 728–733. https://doi.org/10.1038/sc.2012.50

Truchon, C., Fallah, N., Santos, A., Vachon, J., Noonan, V. K., & Cheng, C. L. (2017). Impact of Therapy on Recovery during Rehabilitation in Patients with Traumatic Spinal Cord Injury. Journal of Neurotrauma, 34(20), 2901. https://doi.org/10.1089/NEU.2016.4932

Image credits

  1. The Blue Marble (remastered)NASA/Apollo 17 Crew, Public Domain
  2. BlankMap-World. Canuckguy (talk) and many others (see File history), Public domain, via Wikimedia Commons. Modified by SCIRE.
  3. Graph of Median LOS in the USA ©SCIRE, CC BY-NC 4.0
  4. GF Strong hallway ©SCIRE, CC BY-NC 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Working With a Primary Care Provider

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Author: Kelsey Zhao | Reviewer: James Milligan | Published: 19 March 2025 | Updated: ~

SCIRE would like to acknowledge the staff at Spinal Cord Injury BC who contributed invaluable knowledge and experience to the development of this article.

Key Points

  • Primary care providers (PCPs) help manage your health over a lifetime. They can diagnose and treat common health concerns and coordinate specialist health care.
  • See your PCP whenever you have a concern about your health and discuss the possibility of annual check-ups.
  • In this article, we provide a thorough guide to preparing for an appointment with a PCP after spinal cord injury.
  • Health checklists can help you and your PCP make sure routine tests and screenings are done.
  • There are many online resources and local organizations your PCP can consult to learn more about providing care to people with spinal cord injury.

Primary care providers (PCPs) take care of the day-to-day health of people at all stages of life. They are often the first contact when someone has a non-emergency health concern. This person is often a family doctor, but the role can also be filled by a nurse practitioner, physician assistant. They play a central role in the care team for people with spinal cord injury (SCI) and you will maintain a relationship with your PCP for many years. The responsibilities of a PCP include:

  • Diagnose and treat common health conditions.
  • Encourage and provide advice for a healthy lifestyle.
  • Conduct preventative screenings, tests, and checks.
  • Refer more complex or specific problems to specialists or programs.
  • Coordinate the care you receive from specialists, programs, etc.

People with SCI should see a PCP whenever there is a health concern that needs to be addressed. Due to complex health issues, people with SCI should discuss with their PCP whether an annual physical check-up would be suitable.

If you have a health concern and do not have or cannot reach a PCP, consider virtual health services, telehealth services, and walk-in clinics. If you need immediate care, please visit an urgent care/treatment centre. If your condition is severe or life-threatening, go to your nearest Emergency Room or call your regional emergency phone number.

If you do not have a PCP, find out if there is a community or government registry that will put you on a waitlist to find one.

Go to an urgent care/urgent treatment centre if…

  • You need immediate care, and you cannot get an appointment with your PCP soon enough (for example, an infection or pressure injury that will get worse with time).

Go to the emergency room or call your regional emergency number if…

  • Your condition is getting worse very quickly.
  • You condition is life-threatening.
  • You have autonomic dysreflexia that is not responding well to treatment.
  • The problem is time-sensitive, and you cannot get an appointment with your PCP soon enough and there is no urgent care centre nearby.

Appointments with PCPs are often short in time. This guide offers recommendations to help make the most of your appointment. Most PCPs do not have many patients with SCI and are not familiar with SCI-related health care needs. Although people with SCI should not be responsible for educating others on SCI, being on top of your own needs is important. Becoming an expert in your own health can help you work with your PCP as a team and keep you healthy.

Write down what you want to address in the appointment

  • Current health concerns. Gather information to try and understand the problem, what may be causing it, and possible solutions
  • Questions you have about your health or potential treatments/therapies
  • Prescriptions that need to be refilled
  • Forms and referrals that need to be filled out and signed. For referrals to programs, check that you meet the eligibility requirements. If a referral letter is required, it may speed things along to present an initial draft of the letter to your PCP.

It is possible that all you concerns cannot be addressed in a single appointment. Set priorities by keeping in mind which concerns you want addressed as soon as possible and which ones can wait for another appointment.

Bring up to date medical and health information

Make sure your PCP is up to date on your medical history. For your own records, it can be helpful to keep a folder for your personal medical and health information. This could be a physical folder or a digital one. These records may include:

  • A health journal: Keep a journal of ongoing health concerns, the symptoms you are experiencing, and your day-to-day activities. This gives your doctor more information to better understand and address the issue (for example, if you are experiencing persistent urinary tract infections, a bladder journal might help you find the root cause). The SCI Health Toolkit App is a free, easy-to-use tool designed to help you track and monitor health changes, and walk you through health checks.
  • Medications: Note the name of the medication, the dose and when a refill is needed. Free apps like the Medisafe App can help you keep track of your medications.
  • Other treatments or supplements: Include any over-the-counter medication, vitamins, and natural remedies that you are taking. Note any alternative medicine treatments you are using.
  • Tests screenings: Keep track of routine tests/screening and when the next one should be scheduled. Keep a record of test results and imaging results if available.

Accessibility

If this is your first appointment with your PCP since your injury, you may need to phone or visit their office to ask about accessibility.

Building accessibility

  • Accessible parking
  • Accessible routes into and throughout the building
  • Automatic power doorways

Medical equipment accessibility

  • Adjustable height accessible exam table
  • Transfer and lift equipment
  • Wheelchair accessible scales

Scheduling flexibility

  • Appointments later in the day
  • Appointments scheduled around other health-related commitments like physiotherapy or a bowel routine.
  • Longer appointments to accommodate complex health issues, transfers, skin inspections etc.
  • Virtual or telephone appointments for certain concerns.

Physical Exams

There are many screenings, tests, and checks that require an in-person procedure where your body is examined by looking, feeling, using medical tools, or taking a sample of cells. You may also be required to transfer for the procedure. Being prepared and informed for these procedures can make your experience safer and more comfortable. Some tips to keep in mind:

Equipment for exams

  • If accessible equipment like an adjustable exam table is not available, bring a caregiver, friend, or family who can help you transfer safely and stay at the side of the table to prevent falls.
  • If accessible equipment is required for the procedure, you or your PCP may need to reach out to get the procedure done at another clinic or hospital that has the equipment.

Health complications during exams

  • Before starting, have a conversation with your PCP about issues that might come up during the procedure and how to address them.
  • For people with an injury above T6, a procedure below the injury can trigger autonomic dysreflexia (AD). Inform your PCP about the triggers, symptoms and how to manage your AD. Consider measuring blood pressure before and after the procedure to monitor for AD.
  • Depending on your bowel and bladder dysfunction, accidents may happen during procedures. Empty the bowel bladder before an exam of the pelvic region and let your PCP know if you may have an accident during the procedure.
  • If you experience muscle spasms that could affect the procedure, discuss triggers and how to manage spasticity with your PCP.

If a physical exam is not necessary, virtual appointments and phone appointments with your PCP may be a suitable option.

Refer to our articles on Autonomic Dysreflexia, Urinary Tract Infections, and Spasticity for more information!

Practical Tips

    • Ask if a note can be added to your profile about physical disability and use of mobility aid(s) so that staff knows to book you in an accessible exam room.
    • Make sure everyone who provides health care to you sends notes, images, and results to your PCP, who is responsible for coordinating your care.
    • Be aware of other services in the community (such as labs, imaging centres, and specialist offices) that have accessible equipment.
    • Wallet cards are small cards available for free that provide basic information on common SCI complications: autonomic dysreflexia, urinary tract infections, and pressure injuries. Keep them on you to give to your PCP at an appointment or to first responders and paramedics in an emergency. Wallet cards can be printed at home or mailed from livingwithsci.ca/wallet-information-cards.

  • Request a “standing order” for laboratory tests done often like bloodwork and urine tests so that you don’t need to make an appointment every time.
  • Request clean empty urine containers for when you need to test for urinary tract infection. You may need to explain to your PCP that urinary tract infections are common for people with SCI.
People with SCI have a higher risk for antibiotic resistance. Avoid using antibiotics to prevent UTI or to treat unspecific symptoms that could be caused by something else. Inappropriate use of antibiotics can lead to infections with antibiotic resistant bacteria, that cannot be treated with common medications.

During the appointment

  • Take notes or ask if you can record the appointment so you do not have to worry about remembering everything your PCP says and follow up with tasks as needed.
  • Ask questions or ask for more information if you are unsure or don’t understand something.
  • If you are nervous, bring a caregiver/friend/family member who can help take notes and help advocate for your needs.

Reach out to other people with SCI/peer support programs

Attending peer programs or calling a help line run by SCI organizations can connect you with someone who can help you prepare for the appointment. Often, another person with SCI will have had similar health issues and can provide advice on how to address it with your PCP. There may also be people or programs that can help you prepare documents or do research.

SCI-specific health checks

Checklists made for people with SCI can help keep you and your PCP on top of routine exams and tests. They can also help you find the language to ask and talk about health issues.

The American Spinal Injury Association (ASIA) has checklists for people with SCI.

If your PCP is interested in more in-depth information, case studies, advice, and guidelines for these checklists and SCI-specific care, they can check out the Primary Care Article series from ASIA’s peer-reviewed journal. For brief overviews on managing common SCI complications in primary care, they can visit the Primary Care section on the SCIRE Professional website.

Visit SCIRE Professional for more information on Primary Care for SCI

Standard health checks

PCPs should also do the same general health checks and routine screenings that they would for any other patient. The College of Family Physicians of Canada provides Preventative Care Checklists.

Sexual and reproductive health care

Both the public and some health professionals can have the misconception that people with physical disabilities are not sexually active, at risk for sexually transmitted infections (STIs), interested in sexual activity, or interested in having kids. Initiate a conversation with your PCP if you have questions or concerns about sexual health (challenges with sexual activity, contraception, sexually transmitted diseases), reproductive health (fertility, pregnancy, family planning), or menstruation/menopause.

If your PCP is interested in learning more to better care for people with SCI and people with disabilities, there are many resources they can consult. See a selection of free resources below:

Online resources

American Spinal Injury Association (ASIA) – SCI Healthcare Resources for Primary Care Providers

asia-spinalinjury.org/primary-care

Online hub providing a variety of resources for family physicians caring for patients with spinal cord injury from guides to make a health facility accessible, to SCI care information, to patient education materials.

Americans with Disabilities Act (ADA) – Access to Medical Care for Individuals With Mobility Disabilities

ada.gov/resources/medical-care-mobility

Online guide to making a health care facility accessible to people with mobility disabilities. Includes answers to commonly asked questions.

Spinal Cord Injury Research Evidence (SCIRE) Professional – Primary Care

scireproject.com/primary-care

SCIRE Professional provides systematic reviews of spinal cord injury (SCI) research, to allow researchers and health professionals to guide their practice based on current best evidence. This includes a section specifically for primary care providers.

Spinal Cord Injury Research Evidence (SCIRE) Community

community.scireproject.com

SCIRE Community provides free information about spinal cord injury research that is written in everyday language.

Model Systems Knowledge Translation Center (MSKTC) – Spinal Cord Injury Factsheets

msktc.org/sci/factsheets

Online factsheets providing information on the changes that come with living with spinal cord injury.

International Spinal Cord Society (ISCoS) – Global Education Initiative

elearnsci.org

Online learning module for health care providers on rehabilitation and management for SCI.

Connect with SCI organizations and specialists

Local non-profit SCI organizations, rehabilitation centres, and SCI centres can be excellent resources for region-specific information and advice. Regular communication with SCI-related specialists can also be helpful for both coordinating care and sharing knowledge.

Primary care providers have an invaluable role in the care team for people with SCI. They provide diagnoses, treatments, advice, referrals to specialist services, and conduct preventative screenings and tests.

Being prepared for your appointment and staying on top of your health concerns can go a long way in helping your PCP address your concerns. Work together with your PCP to figure out the best way to coordinate your appointments, find solutions for accessibility, and address your health concerns.

There are many free resources available to help people with SCI stay on top of their health and help PCPs provide care to their patients with SCI.

 

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page have been adapted from the SCIRE Professional “Primary Care and SCI” Section: Available from: scireproject.com/primary-care

Evidence for “What is a primary care provider?” is based on:

Holland, K. (2023, June 29). Types of Doctors: PCP vs. Family Doctor vs. Internist. https://www.healthline.com/find-care/articles/primary-care-doctors/types-of-doctors#internist

McColl, M. A., Aiken, A., McColl, A., Sakakibara, B., & Smith, K. (2012). Primary care of people with spinal cord injury: scoping review. Canadian Family Physician Medecin de Famille Canadien, 58(11), 1207–1216, e626-35.

Evidence for “When should I see my primary care provider?” is based on:

McColl, M. A., Aiken, A., McColl, A., Sakakibara, B., & Smith, K. (2012). Primary care of people with spinal cord injury: scoping review. Canadian Family Physician Medecin de Famille Canadien, 58(11), 1207–1216, e626-35.

Evidence for “How do I prepare for an appointment?” is based on:

How to Prepare for a Doctor’s Appointment | National Institute on Aging. (2020, February 3). NIH National Institue on Aging. https://www.nia.nih.gov/health/medical-care-and-appointments/how-prepare-doctors-appointment

Making the Most of Your Appointment | HealthLink BC. (2022, November 14). Healthlink BC. https://www.healthlinkbc.ca/health-topics/making-most-your-appointment

Access to Medical Care for Individuals with Mobility Disabilities | ADA.gov. (2020, June 26). https://www.ada.gov/resources/medical-care-mobility/

Phelan, S. T., & Unser, C. (2020, March 13). Eight tips to improve outpatient visits for spinal cord injury patients. https://www.contemporaryobgyn.net/view/eight-tips-improve-outpatient-visits-spinal-cord-injury-patients

Evidence for “What should I ask my primary care provider to check?” is based on:

Hough, S., Cordes, C. C., Goetz, L. L., Kuemmel, A., Lieberman, J. A., Mona, L. R., Tepper, M. S., & Varghese, J. G. (2020). A Primary Care Provider’s Guide to Sexual Health for Individuals With Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation, 26(3), 144–151. https://doi.org/10.46292/sci2603-144

Image credits

  1. Doctor smiling ©SCIRE, CC BY-NC 4.0
  2. Ambulance by Dahlia nur aini, the Noun Project
  3. Question by Yunita Bela, the Noun Project
  4. Automatic doorway ©SCIRE, CC BY-NC 4.0
  5. Accessible parking ©SCIRE, CC BY-NC 4.0
  6. Adjustable-height exam table by S. Department of Justice (Disability Rights Section)
  7. Autonomic Dysreflexia Wallet Card by Spinal Cord Injury BC
  8. Notes by Qadeer Hussain, the Noun Project
  9. Checklist by Anggara Putra, the Noun Project

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Quality of Life With SCI

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Author: Kelsey Zhao | Reviewer: Rachel Abel | Published: 26 February 2025 | Updated: ~

Key Points

  • A good quality of life (QoL) is not uncommon for people with SCI. There is no relationship between injury level or severity and QoL.
  • Involvement in the community through work, school, volunteer work, and social activities is associated with higher QoL.
  • Social support from family, friends, peers, and the community is associated with higher QoL.
  • The frequency of medical complications and how much they interfere with life reduces QoL.
  • QoL can be impacted by the accessibility of the community, work, and home environments.

A woman on a wheelchair having a conversation with another woman sitting at the table

Quality of life (QoL) measures the different parts of an individual’s life to try and paint a picture of how well they are doing and how satisfied they are with their life. This might include things that an outsider could measure, like housing, income, employment, and health status. This can also include things that are based on an individual’s own values and aspirations, like whether they are satisfied with their current life and whether they feel their wants and needs are fulfilled.

QoL can be difficult to measure since individuals have different values and expectations for life. These values, expectations, and priorities can also change over an individual’s lifetime. Assessments used in research will not always accurately reflect how an individual weights different life components. QoL scores can also be influenced by regional differences in cultural values, access to care, and the accessibility of the surrounding environment.

Contrary to popular belief, people with SCI generally have good QoL. On average, people with SCI score lower on QoL tests than the general population. However, a lower average does not mean that all people with SCI see their QoL as low, or that all people with SCI will have a lower score than people who do not have an SCI. In studies of people with cervical SCIs, the majority of participants felt that their QoL is average or better than average.

Most studies find little to no relationship between level of injury, injury severity, and QoL. Rather, higher QoL is limited by the physical and social barriers that prevent people from accessing community, activities, and employment.

Sam Sullivan speaking with Simon in libraryEmployment

Numerous studies show that work is strongly related to higher QoL for people with SCI. This is true whether the person is working full-time, part-time, or in an unpaid position.

In a study that looked at the QoL of people with SCI in six different countries, employment was one of the only factors found to be associated with higher QoL regardless of location. One large study also found that satisfaction with life increased over time for people who were employed or students.

Is it hard to find suitable work with SCI?

Differences in age, injury, work experience, and what is defined as work make it hard to pin down an exact number, but research estimates that about 35% of people with SCI are employed. The low rates of employment are likely due to a mix of personal and environmental factors.

Physical and health limitations

After an SCI, job opportunities can be limited by physical impairments and health. For example, someone might not be able to return to the work they did before their injury because it is too physically demanding. Health complications related to SCI like pain and fatigue, and managing care routines can also limit energy and time, making it more difficult to work.

Workplace environment

That said, people with SCI are often underemployed even when they want to and are able to work. Finding suitable work can be difficult because of issues like lack of transportation, inaccessible workplaces, fear of losing financial or health benefits, and employer discrimination towards people with disabilities. This is extremely concerning because of the connection between work and QoL. There is evidence that workplace support and accommodations increase employment for people with physical disabilities.

Local rehabilitation programs or SCI peer programs may have services to help people with SCI reach work and career goals.

Community involvement

One study found that people with SCI felt they had a greater sense of community than the general population. Community involvement can include recreational activities, hobbies, and positions in community organizations and can contribute to a higher QoL.

Social support

Social support refers to one’s relationships with other people, and the interactions, support, and care provided by this network of people, including family members, friends, and peer community. There is consistent evidence that more social support is linked to higher QoL in people with SCI.
Social interaction and participation in social activities are also linked to higher QoL. In some studies, it has the highest positive impact on life satisfaction of all factors. Marriage/having a partner is found to either improve or have no effect on QoL.

Independence

Independence in personal care and transportation is associated with higher QoL. One large study found that life satisfaction increased over the years for people with SCI who lived independently.

Psychological factors

Feeling like you have control over your life was related to higher QoL in several studies. Research has also shown strong associations between symptoms of depression and anxiety and lower quality of life. The connection between QoL and psychological factors highlight the importance of mental health support and treatment in SCI rehabilitation.

Health complications

Having an SCI usually comes with additional health complications over one’s lifetime. These conditions can be directly or indirectly related to the SCI and could include:

Read our articles on the areas listed here and many other Topics!

The more health complications disrupt regular life, the greater the impact on QoL. For example, more frequent UTIs are associated with lower QoL as they limit daily activities and increase experiences of spasticity. How much pain interferes with life is also related to QoL. One study found that over a 2-year period, if pain interfered less with life over time, QoL increased, and vice versa. Pain also contributes to higher rates of mental health conditions for people with SCI, which are commonly associated with lower QoL.

Further, the more health conditions one experiences at once, the more QoL decreases. There is some evidence that when there are no health complications, the average QoL for people with SCI is similar to the average QoL of non-SCI populations.

Since community involvement and access to services is so important to QoL for people with SCI, access to the community environment can have a big effect on health and QoL. Many of the factors that hinder access can be improved by changing policies, practices, and the physical environment.

Community Access

Although accessibility features are required in many public places, what is accessible for one person may not be for another. The environment outside and inside can still be inaccessible to people with SCI for many reasons. Things like unmaintained sidewalks; physical barriers in parks, beaches, and swimming pools; a lack of adjustable equipment in a health care centre; and obstacles inside and outside of buildings, can prevent people with SCI from participating in the community and accessing health care. This lack of access to community spaces and resources can have a negative impact on QoL.

Housing Access

Not having suitable housing with adaptations for SCI can have a negative impact on QoL. Living in a home that hinders one’s ability to do daily activities or participate in activities can be very stressful. The inaccessible homes of family and friends can also affect QoL.

Read our article on Housing After SCI for more information!

Transportation Access

A lack of accessible transportation can lower QoL by blocking access to community resources, health care, and activities, especially for people in living in rural or remote areas. Owning a private adapted vehicle may be too expensive, not suited to one’s particular needs, or not available in the area. Public transportation like buses and trains are not always available or equipped to accommodate people with SCI.

Read our article on Adapted Driving for more information!

Regardless of injury level and severity, many people with SCI report that they have a good quality of life. QoL can be difficult to measure because everyone has their own priorities, values, and expectations for what they consider to be a good life.

Involvement in the community through work, school, volunteer work, and social activities are some of the factors that are most strongly related to higher QoL. Social support from family, friends, peers, and the community are also important for QoL.

The disruption caused by frequent and problematic medical complications can lower QoL. Seek medical care from a health professional if pain, fatigue, spasticity, bowel/bladder problems etc. are having a big negative impact on your daily life.

 

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page have been adapted from the SCIRE Professional “Work and Employment” Module:

Escorpizo R, Smith EM, Finger ME, Miller WC (2018). Work and Employment Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, Sproule S, Querée M, Benton B editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0. p 1- 35.
Available from: scireproject.com/evidence/work-and-employment/

Evidence for “What is quality of life?” is based on:

Hammell, K. W. (2004). Exploring quality of life following high spinal cord injury: a review and critique. Spinal Cord, 42(9), 491–502. https://doi.org/10.1038/sj.sc.3101636

Sakakibara, B. M., Hitzig, S. L., Miller, W. C., & Eng, J. J. (2012). An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life. Spinal Cord, 50(8), 570–578. https://doi.org/10.1038/sc.2012.19

Theofilou, P. (2013). Quality of Life: Definition and Measurement. Europe’s Journal of Psychology, 9(1), 150–162. https://doi.org/10.5964/ejop.v9i1.337

Tate, D., & Forchheimer, M. (2014). Review of Cross-Cultural Issues Related to Quality of Life After Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation, 20(3), 181–190. https://doi.org/10.1310/sci2003-181

Evidence for “Does spinal cord injury impact quality of life?” is based on:

Hill, M. R., Noonan, V. K., Sakakibara, B. M., & Miller, W. C. (2010). Quality of life instruments and definitions in individuals with spinal cord injury: a systematic review. Spinal Cord, 48(6), 438–450. https://doi.org/10.1038/sc.2009.164

Sakakibara, B. M., Hitzig, S. L., Miller, W. C., & Eng, J. J. (2012). An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life. Spinal Cord, 50(8), 570–578. https://doi.org/10.1038/sc.2012.19

Hammell, K. W. (2004). Exploring quality of life following high spinal cord injury: a review and critique. Spinal Cord, 42(9), 491–502. https://doi.org/10.1038/sj.sc.3101636

McColl, M. A., Arnold, R., Charlifue, S., Glass, C., Savic, G., & Frankel, H. (2003). Aging, spinal cord injury, and quality of life: structural relationships11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Archives of Physical Medicine and Rehabilitation, 84(8), 1137–1144. https://doi.org/10.1016/S0003-9993(03)00138-2

Olkin, R. (2022). Conceptualizing disability: Three models of disability. American Psychological Association. https://www.apa.org/ed/precollege/psychology-teacher-network/introductory-psychology/disability-models

Evidence for “What can increase quality of life for people with SCI?” is based on:

Lakhani, A., Parekh, S., Watling, D. P., Grimbeek, P., Duncan, R., Charlifue, S., & Kendall, E. (2022). Access and engagement with places in the community, and the quality of life among people with spinal cord damage. The Journal of Spinal Cord Medicine, 45(4), 522–530. https://doi.org/10.1080/10790268.2020.1860867

Geyh, S., Ballert, C., Sinnott, A., Charlifue, S., Catz, A., D’Andrea Greve, J. M., & Post, M. W. M. (2013). Quality of life after spinal cord injury: a comparison across six countries. Spinal Cord, 51(4), 322–326. https://doi.org/10.1038/sc.2012.128

Chen, Y., Anderson, C. J., Vogel, L. C., Chlan, K. M., Betz, R. R., & McDonald, C. M. (2008). Change in Life Satisfaction of Adults With Pediatric-Onset Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 89(12), 2285–2292. https://doi.org/10.1016/j.apmr.2008.06.008

Nevala, N., Pehkonen, I., Koskela, I., Ruusuvuori, J., & Anttila, H. (2015). Workplace Accommodation Among Persons with Disabilities: A Systematic Review of Its Effectiveness and Barriers or Facilitators. Journal of Occupational Rehabilitation, 25(2), 432–448. https://doi.org/10.1007/s10926-014-9548-z

Ottomanelli, L., & Lind, L. (2009). Review of Critical Factors Related to Employment After Spinal Cord Injury: Implications for Research and Vocational Services. The Journal of Spinal Cord Medicine, 32(5), 503–531. https://doi.org/10.1080/10790268.2009.11754553

Trenaman, L., Miller, W. C., Querée, M., & Escorpizo, R. (2015). Modifiable and non-modifiable factors associated with employment outcomes following spinal cord injury: A systematic review. The Journal of Spinal Cord Medicine, 38(4), 422–431. https://doi.org/10.1179/2045772315Y.0000000031

Migliorini, C. E., New, P. W., & Tonge, B. J. (2011). Quality of life in adults with spinal cord injury living in the community. Spinal Cord, 49(3), 365–370. https://doi.org/10.1038/sc.2010.102

Helgeson, V. S. (2003). Social support and quality of life. Quality of Life Research, 12(1suppl), 25–31. https://doi.org/10.1023/A:1023509117524

Kashif, M., Jones, S., Darain, H., Iram, H., Raqib, A., & Butt, A. A. (2019). Factors influencing the community integration of patients following traumatic spinal cord injury: a systematic review. JPMA. The Journal of the Pakistan Medical Association, 69(9), 1337–1343.

Müller, R., Peter, C., Cieza, A., & Geyh, S. (2012). The role of social support and social skills in people with spinal cord injury—a systematic review of the literature. Spinal Cord, 50(2), 94–106. https://doi.org/10.1038/sc.2011.116

Chang, F.-H., Wang, Y.-H., Jang, Y., & Wang, C.-W. (2012). Factors Associated With Quality of Life Among People With Spinal Cord Injury: Application of the International Classification of Functioning, Disability and Health Model. Archives of Physical Medicine and Rehabilitation, 93(12), 2264–2270. https://doi.org/10.1016/j.apmr.2012.06.008

Jörgensen, S., Iwarsson, S., & Lexell, J. (2017). Secondary Health Conditions, Activity Limitations, and Life Satisfaction in Older Adults With Long‐Term Spinal Cord Injury. PM&R, 9(4), 356–366. https://doi.org/10.1016/j.pmrj.2016.09.004

van Leeuwen, C. M. C., Kraaijeveld, S., Lindeman, E., & Post, M. W. M. (2012). Associations between psychological factors and quality of life ratings in persons with spinal cord injury: a systematic review. Spinal Cord, 50(3), 174–187. https://doi.org/10.1038/sc.2011.120

García-Rudolph, A., Cegarra, B., Opisso, E., Tormos, J. M., & Saurí, J. (2021). Relationships Between Functionality, Depression, and Anxiety With Community Integration and Quality of Life in Chronic Traumatic Spinal Cord Injury. American Journal of Physical Medicine & Rehabilitation, 100(9), 840–850. https://doi.org/10.1097/PHM.0000000000001773

Parker, M. A., Ichikawa, J. K., Bombardier, C. H., & Hammond, F. M. (2022). Association Between Anxiety Symptoms, Depression Symptoms, and Life Satisfaction Among Individuals 1 Year After Spinal Cord Injury: Findings From the SCIRehab Project. Archives of Rehabilitation Research and Clinical Translation, 4(3), 100211. https://doi.org/10.1016/j.arrct.2022.100211

Evidence for “What can decrease quality of life for people with SCI?” is based on:

Andresen, S. R., Biering-Sørensen, F., Hagen, E. M., Nielsen, J. F., Bach, F. W., & Finnerup, N. B. (2016). Pain, spasticity and quality of life in individuals with traumatic spinal cord injury in Denmark. Spinal Cord, 54(11), 973–979. https://doi.org/10.1038/sc.2016.46

Ataoğlu, E., Tiftik, T., Kara, M., Tunç, H., Ersöz, M., & Akkuş, S. (2013). Effects of chronic pain on quality of life and depression in patients with spinal cord injury. Spinal Cord, 51(1), 23–26. https://doi.org/10.1038/sc.2012.51

Kemp, B., Tsukerman, D., Kahan, J., & Adkins, R. (2014). Predicting Psychosocial Outcomes Using a Brief Measure of Quality of Life in a Sample of People with Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation, 20(3), 191–196. https://doi.org/10.1310/sci2003-191

Putzke, J. D., Richards, S. J., Hicken, B. L., & DeVivo, M. J. (2002). Interference due to pain following spinal cord injury: important predictors and impact on quality of life. Pain, 100(3), 231–242. https://doi.org/10.1016/S0304-3959(02)00069-6

Vogel, L. C., Krajci, K. A., & Anderson, C. J. (2002). Adults With Pediatric-Onset Spinal Cord Injury: Part 2: Musculoskeletal And Neurological Complications. The Journal of Spinal Cord Medicine, 25(2), 117–123. https://doi.org/10.1080/10790268.2002.11753611

Theisen, K. M., Mann, R., Roth, J. D., Pariser, J. J., Stoffel, J. T., Lenherr, S. M., Myers, J. B., Welk, B., & Elliott, S. P. (2020). Frequency of patient-reported UTIs is associated with poor quality of life after spinal cord injury: a prospective observational study. Spinal Cord, 58(12), 1274–1281. https://doi.org/10.1038/s41393-020-0481-z

Piatt, J. A., Nagata, S., Zahl, M., Li, J., & Rosenbluth, J. P. (2016). Problematic secondary health conditions among adults with spinal cord injury and its impact on social participation and daily life. The Journal of Spinal Cord Medicine, 39(6), 693–698. https://doi.org/10.1080/10790268.2015.1123845

Wijesuriya, N., Tran, Y., Middleton, J., & Craig, A. (2012). Impact of Fatigue on the Health-Related Quality of Life in Persons With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 93(2), 319–324. https://doi.org/10.1016/j.apmr.2011.09.008

Peterson, M. D., Meade, M. A., Lin, P., Kamdar, N., Rodriguez, G., Krause, J. S., & Mahmoudi, E. (2022). Psychological morbidity following spinal cord injury and among those without spinal cord injury: the impact of chronic centralized and neuropathic pain. Spinal Cord, 60(2), 163–169. https://doi.org/10.1038/s41393-021-00731-4

Wollaars, M. M., Post, M. W. M., van Asbeck, F. W. A., & Brand, N. (2007). Spinal Cord Injury Pain: The Influence of Psychologic Factors and Impact on Quality of Life. The Clinical Journal of Pain, 23(5), 383–391. https://doi.org/10.1097/AJP.0b013e31804463e5

Rivers, C. S., Fallah, N., Noonan, V. K., Whitehurst, D. G., Schwartz, C. E., Finkelstein, J. A., Craven, B. C., Ethans, K., O’Connell, C., Truchon, B. C., Ho, C., Linassi, A. G., Short, C., Tsai, E., Drew, B., Ahn, H., Dvorak, M. F., Paquet, J., Fehlings, M. G., & Noreau, L. (2018). Health Conditions: Effect on Function, Health-Related Quality of Life, and Life Satisfaction After Traumatic Spinal Cord Injury. A Prospective Observational Registry Cohort Study. Archives of Physical Medicine and Rehabilitation, 99(3), 443–451. https://doi.org/10.1016/j.apmr.2017.06.012

Burke, D., Lennon, O., & Fullen, B. M. (2018). Quality of life after spinal cord injury: The impact of pain. European Journal of Pain, 22(9), 1662–1672. https://doi.org/10.1002/ejp.1248

Evidence for “How does accessibility impact quality of life?” is based on:

Gurung, S., Jenkins, H.-T., Chaudhury, H., & Ben Mortenson, W. (2023). Modifiable Sociostructural and Environmental Factors That Impact the Health and Quality of Life of People With Spinal Cord Injury: A Scoping Review. Topics in Spinal Cord Injury Rehabilitation, 29(1), 42–53. https://doi.org/10.46292/sci21-00056

 

Image credits

  1. Two people sitting outside ©SCIRE, CC BY-NC 4.0
  2. Sam Sullivan https://samsullivan.ca/photo-gallery/
  3. Mother in wheelchair with child ©SCIRE, CC BY-NC 4.0
  4. Elderly man in wheelchair cityscape ©SCIRE, CC BY-NC 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Thumbnail image. Text: SCIRE Community Stories, Sam Sullivan: A conversation about everything. Image: B&W portrait of Sam on black background.

Community Stories: Sam Sullivan

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Authors: Dominik Zbogar, Kelsey Zhao, Sarah Yada Seto | Published: 27 November 2024

 

A Conversation About Everything

We spoke with Sam Sullivan, former mayor, city councillor, and MLA, non-profit creator, spinal cord injury survivor, salon host, proud Vancouverite, and possible advocate, about… everything.

INJURY

I was skiing when I broke my neck. I had just turned 19, living in Vancouver. I went on a run that was steep and ended up going quite fast and then crashing. Somewhere in the whole thing I felt my neck break. I experienced it as feeling my body was expanding, the size of the universe. I experienced it as a sound like multiple sirens going off, very loud noises going very broadly. Then, I experienced my body going into a fetal position but when I opened my eyes my arms were up here. I said to myself, “You broke your neck – don’t move.” Eventually, people went down and got a piece of plywood to carry me off the mountain. They took me down, sort of bouncing, which is probably where more damage came.

REHAB

Initially, I was quite strong in that I was interested in experiences. “Wow, I’ve never broken my neck before. This is interesting. I’m going to live this one and really, really embrace it, and see how it goes.” But then, over time, eventually you get worn down and you say, “Okay, I’ve had this experience, I think I’m ready for the next thing. Why don’t we just get over this one here and move on?” And that’s when it all sinks in. This is not a light thing.

There are some panicky moments where you really need someone to be there, though sometimes you need to be able to reflect as well. I would say visitors should ask the person they’re visiting, “What can I do? What do you need from me? How can I help?” You should be saying to me, “We’re going to get through this one, we’re going to figure out how to get you better.” I think there is no real advantage in saying too early to someone who hasn’t accepted it, “Hey, you know, maybe you should just get used to this and whatever”. There are medical people and other people who should say those messages. That’s one of the takeaways from my experience.

METAMORPHOSIS

It was lucky that I was able to stay at GF Strong [Rehab Centre] for quite a while; I think it was over a year from injury to being discharged. It was only in those last couple of months that I actually learned how to get in and out of bed. It took quite a long time because of my injury. After leaving rehab I was with my parents in my family home, but realized I was going downward, becoming suicidal. I needed to get out of the house. Eventually, I went into the only place I could: a paraplegic lodge – a type of social housing. I had to keep my blinds closed because I couldn’t open them myself, and I couldn’t sleep with open blinds with so much light outside. That did not contribute to my emotional well-being to be in the dark room all the time. There I dealt with suicidal thoughts and contemplations.

Eventually I went through a very real scenario where I rehearsed a dry run in my mind.

“The key in what happened there – and only in retrospect can I understand it – I killed the old Sam.”

A gun blast, blood, brains, dripping down the wall, the smell of the gun. That was a very powerful moment. Then eventually, after a while I felt very calm, deep in thought. My thinking process went, “Okay, this is good, I think I can handle that. But it certainly would be great if I could somehow donate my body to someone who probably was in worse shape than me; who would it be?” Some people would be thrilled to get what I had. I dwelled on that for a while, then I thought, “What about me?” What if I was to take this mortal body on and see what I could do with it? Eventually, I thought yeah, that could be interesting.

The key in what happened there – and only in retrospect can I understand it – is I killed the old Sam. And I always refer to him in the third person. At that point, I killed the hopes, dreams, aspirations, and all the baggage of the previous me. Then I was able to say, “Okay, let’s start from scratch.”

REBUILDING

After this I was faced with the question, “What do I do with my life?” I ended up purchasing motivational literature, a book called How to Get Control of Your Time and Your Life and things like that. I’d go through all the exercises and try to figure things out and that was very helpful.

One day I did all my morning things, got up, and went down to the bank to cash my welfare check. I got there and the bank manager was just closing the door because this was in the days when banks closed at three o’clock in the afternoon. I realized, “Oh my god”, I only got out at the same time everybody else is going home. Now I have to go home and start getting undressed to get ready for bed.

So, I did things like to-do lists and time analysis. The very first thing I did was analyze getting up in the morning – I would lift up my leg, put it on, put my sock on the other leg, put my sock on, put it down, then the other leg again, and then put my shoe on. Well, what if I put my sock and my shoe on at the same time and I didn’t have my legs going up and down? Then I would celebrate how much time I’d just saved, you know, 4 minutes times 80 years. Wow, that means I’ve just now come up with 12 weeks!

It seems to me that I never had a point in my life where I was not solving a problem or looking at my next to-do list. I have a tendency towards depression but find if I’m constantly solving problems, it prevents the dark part from arising. In fact, I would use my disappointment at not ticking a box on my to-do list to cultivate anger or frustration or negative emotions and channel them to a desire for forward motion.

This all happened over a period of time I call the Seven Lean Years. And now I had my model: ticking boxes on to-do lists, time analysis, channeling emotions, moving ahead, kill the old Sam. Those are the fundamental pieces that had to be done and informed what happened in my life moving forward.

NONPROFIT

The key was figuring out what I want to do. “Okay, I really don’t know what I want to do with my life, what did I used to do when no one paid me and when no one forced me into doing something?” I was going skiing. I was playing in a band. I wanted to start a little business and these sorts of things. Once you have a good idea of the directions you want to go, then your mind will organize things as they come to you. And you will pick out and grab the right things that will help move you forward.

The most important thing was me discovering this model of setting up nonprofit societies. This was an accidental discovery; I volunteered and got involved in some fundraiser and I asked, “how do you get one of these funding systems going?” Well, you have to have a nonprofit society, and then you apply. That was quite a revelation. So, the Tetra Society was probably the most important innovation. The purpose of it was to recruit people like engineers to work with clients and build custom-made assistive devices to help them. I was the executive director, I had a board, it was a lot of administrative work, but I was able to raise money. We called ourselves “Tetra”, we all had “tetraplegia”, and there were actually four of us. Everybody was on welfare. We looked into an engineer’s hourly rate, it was around 400 bucks an hour, and all of us made 396 per month on welfare, I remember that. Whoa, that’s not a very sustainable model if for one hour of an engineer’s time, it cost us an entire month! So, I wrote a letter to an engineer’s magazine – maybe there was a retired person or company that is willing to help? A guy (Paul Cermak) answers that he just took early retirement, and says, “My wife wants me out of the house, can you give me something to do?” The very first thing he did was fix my fridge: My grandmother had given me a fridge, and the freezer was on the top, and I had to pull it down. When I tried to put something in, it would flop back up with the spring. I just couldn’t figure out a way getting my elbow on there to hold it down. So he came over, looked at me struggling with this, got a clothes hanger from the closet, bent it and hooked it around the drawer handle. Then I pulled it down and the hook came around a little tray. And it was open, just like that, within minutes he revolutionized my diet.

“What did I used to do when no one paid me and no one forced me into doing something?”

I wanted to go skiing again but because I was so uncomfortable when I get cold, I thought what else can I do? I heard a guy talking about ultralight airplane flying and I thought that’d give me the challenge I needed. I found a plane and the Disabled Ultra Lighters of Vancouver Society was born. We did that for a while and were successful; we got people flying. Then the company went bankrupt. There was a fundamental flaw in the whole program: you have to get people out to these remote places.

 

So then, we went into sailing through Rick Hansen; he had this sailboat gifted from Margaret Thatcher. We found the old sailboat in a farmer’s field somewhere. And Rick said, if you can use it, I need somebody to actually do something with it. So, we fixed it up. That became the Disabled Sailing Association of British Columbia.

But we still wanted to do hiking. So we had the BC Mobility Opportunity Society – BCMOS (I wasn’t very good at naming that one) to be more about getting out there. We originally used a big golf cart. I remember we were not welcomed by environmentalists when we would come crashing through the bush with this big vehicle-tank, so we came up with another solution with a one wheeled vehicle, which I had drawn out on a napkin. I gave the drawing to Paul Cermak (the first Tetra volunteer) and then he designed and put one together using an old lounge chair, a wheelbarrow wheel, you know, just stuff he found. And that enabled me to go out to the forest and people would be able to take me around. So that’s how those things, the societies happened.

You know, I wish everybody could have their own society so they would be able to then have control and agency. Because I was doing all the work, recruiting the engineers, fundraising and all, I had really great access to all this stuff. So even when I was on welfare, I was sailing, going hiking, doing all these things. I do regret that for most people I was never able to do with TETRA what I wanted to do, which was that everybody gets access, just like I had, right away. We always ended up with a long form filling process.

NO ADVOCATE?

I’ve never thought of myself as an advocate. What I wanted to do was fix my own life. I would say, “I want to go sailing, I want to go flying. How do I do that?” I realized I was good at fundraising. I’ve never thought of myself as such, but people would say, “Well, you sure know how to fundraise!” And so in a way, I guess I was raising money for other people too. I wasn’t saying, “Hey, I want to go sailing”, and I don’t say “Hey, I want to create a program where all sorts of people go sailing.” In fact, regarding sailing, the first thing I did is go to the Royal Vancouver Yacht Club, and I said, “You know, we have people from your club who have injured themselves or their son has injured themselves. We want you guys to be able to continue even if you have a bad accident. Look at it as we’re what you do for any of your members or their family who end up in a situation where they can’t go on the regular yachts. Look at it as an insurance payment because you might end up like this and you would like to have access to sailboats”. You have to be a bit clever with how you frame it.

So, about advocacy, that’s not where I was coming from. I was coming from a personal level. I always wanted to stay in a position where we’re doing this for ourselves; we had little boards, and all our boards were disabled people. All of them were on welfare. That was strategic in many ways. When we had able-bodied people with money on the board, they would get freaked out when you’re taking a quadriplegic on his own out in the ocean. “What? I’ve got assets, I have a home! I’m not going to get sued, we can’t be doing that, you need to get more processes, etc.” They’re really getting in the way of our fun or what we are trying to accomplish. And so we realized, okay, if all of our board members were quadriplegics on welfare, who’s going to sue us? Go ahead, they’re going to take my wheelchair?

Well, maybe I should say that I did advocacy because I was always pushing for wheelchairs in transit. I came in as mayor, as the city councillor, with a stick. I didn’t come with my hand out. I said, “I’ve worked myself into this position where you need my vote, and I am now with agency. I’m not asking for anything from you, I’m telling you that this is the way we need to go. We need 100% transit accessibility and we need more taxis.”

THE MAYOR

I’ve always had two areas that were really important for me. One is drug addiction and overdose. The other is housing. They are the two areas that I failed the most spectacularly at, as you can tell with where the city is today. In my own defense, I analyzed those to be the two problems that seemed like there was no way out of. I chose them, and I said, “These issues are the most important, and we need to start moving on them.” So at least I can say I was accurate in analyzing them as impossible to solve.

Regarding housing affordability, my experience of it was that everybody was anti-density. For disabled people, to have compact, vibrant, diverse neighborhoods – it’s much easier to make those accessible. People don’t have to drive everywhere, and transit is much more possible. Everybody who lived in their little single-family home hated density. All the people who were looking out for the future of the city loved density, but there were very few of them. I said, “Wow, this is so important, and it’s the right thing to do.” I’ve always been attracted to the right thing to do that everybody thinks is wrong.

“I came in as mayor, as the city councillor, with a stick. I didn’t come with my hand out."

My assumption was that all the bureaucracy comes from the top, risk-averse leadership that didn’t want to lose the election. I said, I’m going to be different, I’m going to say, “Go for it.” I would ask for forgiveness, not permission, in addressing the housing issue. But I found out when I came in and pushed for density, the city council said “Density is good! We want it”. I was stunned to discover on numerous occasions that the bureaucracy is internally generated. People given the option of getting right into the job or creating bureaucracy around the job will naturally default to bureaucracy. To see all the internal machinery, all the bureaucracy that ended up going around it, that tries to not do density, “Oh my God, this is gonna be a nightmare!” So that was a real shock for me. Because I thought all I had to do was say, “We are the political leader, we got elected. We want density, call it EcoDensity, eco for eco-logical and eco-nomic. We want to address house prices and environmental issues.” And yet that didn’t do it. That was a powerful lesson that I wish I knew before then.

Proudest Achievement

The most exhilarating thing for me was being able to get out of bed by myself at GF Strong. What a miracle to be able to do that. Those are the moments. I’m supposed to say flying the flag, or the Olympics. But while those are interesting, wonderful things, there wasn’t a sense that I did anything useful. I happened to be there when a flag needed to be flown. I tried not to fly the flag, I said, “Give it to Gordon Campbell, give it to the mayor of Whistler. I’m busy, I don’t want to go to the Olympics and twirl a flag.” It certainly was interesting and fun to do, but I wouldn’t call it an achievement.

Regarding the drug addiction issue, when I first got elected I used to go out with this group, ‘Shame the John’ in East Vancouver. I would go out with them and they’d walk around the street and try to shame the johns, which is shaming prostitutes in a way. I was totally new to this and didn’t really know anything about it. And I said, “Wow, these women are prostituting themselves, what’s going on? Well, they are forced to because they’re drug addicted. Why don’t they just not do drugs anymore?”

Taking a step back, I remember when I was in GF Strong, of this moral issue around disability. I see the history of disability where originally it was seen as a moral issue caused by your sins or the sins of your fathers or bad karma, and it was somehow your fault. Then we moved into the medical model, “you need to be fixed, we need a doctor to look after you. And you need to be on a ward in a hospital.” And then, one day somebody said, “Excuse me, I’m not sick, I’m disabled, it is a totally different thing, you know”. This is not a short-term problem you fix it’s a long-term problem you manage. And that insight moved us along to a community model of disability. Agency, you know, you just need to give people the support they need and get out of the way.

When I heard about the prostitutes, people said, “I guess they just didn’t want it enough [to get out].” Where have I heard this? I remember in GF Strong, somebody said, “Well, the guy in the next bed, he got better because he really wanted to get better.” And what about Sam? “Well, I guess he just didn’t want to, he didn’t have that same sort of willpower.” Oh, wow. So, this disability is still a moral issue. It’s about willpower and desire?

If we think of drug addiction like the disability problem, then we still have one foot in the moral model and another in the medical model. We need to move past that and see it as people who need the supports. Then they can get on with their lives. You know, in the 90s, Switzerland solved their overdose problem and their street disorder problem with their four pillars approach. And here, we are still today, stupidly doing stupid things, and not emulating other countries that have solved the problem.

THE PUBLIC SALON

When I retired from City Hall – or as my mother helpfully reminds me, was thrown out of City Hall – I found myself asking again, “What am I going to do with my life?” I went back to my standard question, “What is it that I do when no one pays me?” And so, I developed this thing called a Private Salon. We would put these little private dinners together, and invite a real scattering of different people that were very different from each other. We’d come together for dinner and just share; it was very interesting for me. I loved to do it and Lynn, my wife, loved doing it. We asked ourselves, “is there a way to turn this into a job somehow as I had done originally with my injury?” So we said, let’s have a Public Salon. It was hard when you scale up from a little dinner to a theater, but it was still fun.

We were able to put on the Public Salons for about four or five years, having received a million dollars from a foundation in California. We tried to raise additional money to bolster that, but eventually we ran out. We had to try to make it profitable on its own, but it wasn’t designed for fundraising, it was designed for giving me pleasure. Fundraising would be a real challenge. So, we had to totally revolutionize it a couple years ago. What I do now is bring in an international speaker, that’s the star, and then have local responders who give them questions, comments, critiques, etc. So that’s the new model and it seems to be working. I brought in a former chief planner of the World Bank, Alain Bertaud, and a recent Think-Tank Salon included experts on addiction and mental health. In a way, I’m still on those two issues of prices and addiction, now attacking them from outside, not from the inside as mayor.

MAKING A DIFFERENCE

Advice for those living with a disability

It’s hard to just say, “Set goals.” You also have to know why. You have to get to that point to where you find out why you want to do what you want to do. But I know for sure that setting goals was a revolutionary thing for me. Also, just recognizing that life is very precious. Recognize what a miracle it is and how we are the luckiest people ever in history, even myself as a quadriplegic. I would rather be me as a quadriplegic than someone living more than a few 100 years ago. People today don’t grasp how difficult life was then in every aspect. To have what we have today is just so miraculous, and so beautiful.

I can’t say it comes from any enlightenment really, that I decided I’m going to help the world and I want to solve everybody’s problems. But when it turned out that way, I certainly wasn’t disappointed about it. I was happy that I could make a difference for some people. I wouldn’t recommend to people that they should decide to save the world or whatever. I think you should put your own mask on first before you put it on others. Remember, all of that was me being self-absorbed. I wanted to go sailing. I would have rather just been given a whole bunch of money, and then I could buy a sailboat.

But, we had to do it the hard way because I was on welfare, and the genius of our civic society is you can’t do it unless you do it for others too, so I needed lots of involvement. Then I realized this is fantastic. At one point in the beginning, I was going sailing, buying sailboats, going in regattas, etc. And then at a later point, I was the only one not going sailing, I was filling out forms and fighting bureaucratic battles. I then recognized that it was so important. When people asked me, “Why are you doing this, all this bureaucratic work and lobbying? The only answer I can give is “I’m doing it for Sam. The 19 year old kid, suicidal and sitting in a dark room where the blinds don’t open.” I wanted to reach people who were like me.

Image Credits
  1. Mount Seymour | Mt. Seymour
  2. Rick Hansen’s Boat | Rick Hansen Foundation
  3. Trail rider | The Disability Foundation
  4. Sailing | Jean-Edouard de Marenches
  5. Mayor | Shaw Cablesystems
  6. Olympics Closing Ceremonies | The Canadian Press | Paul Chiasson
  7. Public Salon | Sarah Murray

Non-traumatic Spinal Cord Injury

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Author: Dominik Zbogar, Kelsey Zhao | Reviewer: Peter New | Published: 17 September 2024 | Updated: ~

Key Points

  • NTSCI can be broken down into three major categories: congenital, genetic, and acquired which accounts for the large majority of cases.
  • Rates of NTSCI vary widely worldwide and much information is lacking. Developed countries tend to have a higher proportion of cases caused by degenerative conditions and tumours. Developing countries tend to have a higher proportion of NTSCI acquired from infection.
  • Those with NTSCI are more likely to be older, female, have paraplegia and have an incomplete injury when compared to those with traumatic SCI.
  • Much of NTSCI rehabilitation is similar to traumatic SCI rehabilitation, though the rehabilitation stay is shorter.

Spinal cord injuries (SCI) can have traumatic or non-traumatic causes. Traumatic SCIs are caused by external forces in events such as car accidents and falls. Non-traumatic spinal cord injuries (NTSCI) occur without an external physical force and are typically caused by an underlying health condition.

Causes of NTSCI can be divided into three major categories: congenital, genetic, and most commonly – acquired.

Congenital (present at birth)

Congenital NTSCIs are developmental defects, malformations, and abnormalities affecting the spinal cord which are present at birth. An infant can have one congenital condition, or multiple conditions at the same time. For example, Type 2 Chiari malformations almost always occurs in association with myelomeningocele, a severe form of spina bifida

Spinal dysraphism

Myelomeningocele is the most severe type of spina bifida as the spinal cord itself protrudes through the opening of the unfused portion of the spinal column.2

Spinal dysraphism is a defect in the development of the neural tube (an early form of the brain and spine) where the canal that houses the spinal cord does not completely close and causes damage to the spinal cord and nerves. A well know type of spinal dysraphism is spina bifida.

Chiari malformations

Chiari malformations are a condition where a part of the brain known as the cerebellum is pushed into the space where the brain connects to the spinal cord.

Skeletal malformations

Skeletal malformations include any deformities or abnormalities in the development of bones or ligaments that affects the spine. These malformations can put the person at higher risk of spine instability which can cause pressure on the spinal cord that can result in NTSCI.

Congenital syringomyelia

Congenital syringomyelia is the formation of a fluid-filled sac, known as a cyst or syrinx, in the spinal cord. This often occurs in association with spina bifida or Chiari malformations, but can also happen on its own, spontaneously.

Genetic

A genetic NTSCI comes from an abnormality in a person’s genes that affects the spinal cord. This abnormaility can be inherited from one’s parents or be a spontaneous mutation that occurred during development. The effects of this genetic abnormality can be present at birth or show up later in life. Most genetic NTSCIs lead to loss of movement and/or sensation from the degeneration of nerve cells.

Some examples of genetic NTSCI types include hereditary spastic paraplegia, spinocerebellar ataxias (e.g. Freidrich’s ataxia), adrenomyeloneuropathies, leukodystrophies, and spinal muscular atrophy.

Acquired

Acquired conditions include the most common causes of NTSCI, such as degenerative spinal cord conditions, tumours, and vascular problems. This is a diverse category and the conditions become more common in older age.

Degenerative

Degenerative NTSCIs include any condition that causes damage to the spinal cord through the degeneration of its bone or ligaments. For example, spondylosis is a condition where there is an abnormal and painful degeneration in the bones and cartilage of the neck that can lead to loss of control or sensation over parts of the body.

Metabolic

Metabolism is the processes in the body that turns food into energy and the components that make up and maintain the body. Nutrient deficiencies like vitamin B12 and folate deficiency, or diseases that affect the maintenance of bone like osteoporosis and Piaget’s disease, can cause degeneration or damage to the spinal cord.

Vascular

Vascular causes of NTSCI refer to spinal cord damage caused by problems with the vessels that carry blood through the body. For example, if a blood vessel bursts and bleeds, if there are issues with abnormal connections between vessels, or if the blood supply is blocked, the spinal cord could be damaged. These issues can happen anywhere in the body and can cause NTSCI when they happen in the spinal cord.

Inflammatory or auto-immune

Inflammatory and auto-immune conditions involve immune system activity that damages the spinal cord through swelling (inflammation) or direct attack on healthy cells (auto-immune). The immune system is normally responsible for protecting us from viruses, bacteria, and other orgamisms but different conditions can cause overactive or innapropriate immune reactions. Examples include transverse myelitis and multiple sclerosis.

Spinal tumors may be (left to right) intramedullary, intradural-extramedullary, or extradural.5

Tumors and masses

Benign or malignant tumours can cause a NTSCI if the growth of the mass puts pressure on the spinal cord or interferes with the blood supply.

Infection

The spinal cord can be infected by bacteria, viruses or other organisms. Infections can put pressure on the spinal cord due to an abcess (pocket of infection) or interfere with the blood supply.

Other

Other uncommon causes of NTSCI include damage to the spinal cord due to radiation exposure and exposure to toxic substances. Amyotrophic lateral sclerosis and primary lateral sclerosis are both rare degenerative diseases that affect the motor neurons which are the nerve cells involved in the control and coordination of movement.

Are Multiple Sclerosis and ALS types of NTSCI?

Multiple sclerosis (MS) is an auto-immune disease where the immune system attacks the protective covering (myelin) of nerve fibers in the central nervous system, which is made up of the brain and spinal cord. Amyotrophic lateral sclerosis (ALS) is a progressive nervous system disease that affects nerve cells in the brain and spinal cord. Because lesions can occur not only in the spinal cord but in the brain too, categorizing them is a challenge. Some studies include MS and ALS with their SCI sample while others choose to exclude these conditions.

TSCI = traumatic spinal cord injury; NTSCI = non-traumatic spinal cord injury

Although NTSCI still affects males more overall, the proportion of females with NTSCI is higher relative to traumatic SCI. NTSCI is also more likely to affect older people.

The numbers by cause

The incidence of NTSCIs varies depending on the cause and the health services in the country where you live. Although there are many gaps in the research data, existing studies provide an idea how different NTSCI causes are distributed.

Congenital & Genetic

  • In the few studies that recorded cases of congenital causes of NTSCI, spina bifida and other congenital conditions cause between 1 to 6% of cases. Overall, congenital and genetic NTSCI make up a very small proportion of NTSCI.

Acquired

  • Malignant and benign tumours are common causes of NTSCI globally. Studies from all over the world since 1975 report that tumours are the cause of 14-44% of NTSCI cases
  • Degenerative conditions of the spine are a very common cause of NTSCI in high-income developed countries. The percentage of NTSCI cases caused by degenerative conditions ranges from 13 to 62%. Many of these conditions become more prevalent with age.
  • In the regions of Sub-Saharan Africa and South Asia, tuberculosis has been reported to cause 15 to 30 % of NTSCI cases. Tuberculosis is an infectious disease caused by bacteria that typically attacks the lungs but can also damage other parts of the body like the spine and brain.
  • Other causes of NTSCI commonly reported in research include inflammatory/auto-immune conditions, vascular conditions, and infections.

Pediatric SCI

Traumatic injury is the most common cause of SCI in adults, while non-traumatic causes are more common in children. The most common non-traumatic causes of pediatric SCI include congenital anomalies, spinal cord tumors, infections, and vascular malformations. Common traumatic causes of pediatric SCIs include motor vehicle accidents, falls, sports-related injuries and iatrogenic harm.

Visit SCIRE Professional for more information on Pediatric SCI.

Where in the World?

An estimated 20.6 million individuals live with SCI globally. It appears that the incidence of NTSCI is increasing due to the ageing population in many countries. Indeed, in some countries the incidence of NTSCI is now higher than that of traumatic SCI.

There is a general lack of information about incidence and types of NTSCI worldwide. That said, developed countries tend to have a higher proportion of cases caused by degenerative conditions (32%) and from tumours (25%) in Western Europe. Developing countries, in comparison, tend to have a higher proportion of NTSCI acquired from infection, particularly tuberculosis and HIV, though tumours are also reported as a major cause. There are many gaps in tracking the global rates of NTSCI.

The onset of NTSCI may be slow and gradual and be related to a progressive condition or a complication from another medical event. Onset can range from minutes to months depending on the cause of injury.

Compared to traumatic SCI, those with NTSCI:

TSCI = traumatic spinal cord injury; NTSCI = non-traumatic spinal cord injury

  • are more likely to have paraplegia
  • are more likely to have an incomplete injury
  • spend less time in rehabilitation and have reduced hospital charges
  • have similar discharge destinations.

“Invisible” disability

Compared to people with traumatic SCI, people with NTSCI are more likely to have regained some walking ability when they are discharged from rehabilitation. People with SCI who can walk may face unique physical and psychosocial challenges. The use of mobility devices for walking likes canes and walkers might cause more fatigue and/or pain then a wheelchair. The absence of a wheelchair as a clear indicator of disability can result in misunderstanding and judgement from others due to lack of awareness about people with SCI who can walk. Some feel that they exist in a “grey zone” where they are neither fully abled nor disabled and experience “invisible” challenges.

Some examples of challenges include:

  • Misunderstanding from others about the severity of their injury and the impairments they live with.
  • Feeling out of place in SCI programs or in the SCI community, especially when the program or space is not built with people who can walk in mind (e.g., no places to sit).
  • Unwanted attention and scrutiny when in public or in social situations due to an abnormal gait or assistive devices.
  • Lack of empathy from others when they pass as not disabled (e.g., “Can you hurry up? Why are you so slow?”).

There is a need for more programs and services that are welcoming to and consider the needs of people with SCI who can walk. If you or someone you know is struggling with finding community and services as a person with SCI who can walk, it can be helpful to talk to health professionals or peers with similar injuries and experiences. Peer support has been proven to improve adjustment to life after injury and general wellbeing through social/emotional support and sharing knowledge. If pain or fatigue with walking are a problem, it may also be beneficial to consider the intermittent use of wheeled mobility devices.

Read our article on SCI Basics for more information about types of SCI!

Rehabilitation common to all types of SCI

Most of the rehabilitation process will be similar between traumatic and NTSCI while treatment of the underlying conditions that cause NTSCI will vary. Rehabilitation common to both traumatic SCI and NTSCI includes:

  • Education about the SCI and the related medical problems that need to be managed.
  • Complication management and prevention: In people with all types of SCI, complications like urinary tract infection, pneumonia, pressure ulcers, spasticity and neuropathic pain are common and managed in rehabilitation. Prevention and education are essential to minimize complications.
  • Physical and occupational therapy: Physical therapists work with patients to regain mobility, strength, and coordination. Occupational therapists focus on helping patients adapt to their new circumstances, relearn daily living skills, and regain independence. Both are critical essential to rehabilitation after SCI.
  • Assistive devices: Mobility aids, adaptive equipment, assistive technologies, and other supports like cushions and mattresses can significantly improve the quality of life for people with SCIs. These devices help with mobility, communication, daily tasks, and prevent complications like pressure ulcers.
  • Pain management: Chronic pain is a common issue in that can be managed with medications, nerve blocks, or other interventions to alleviate discomfort.
  • Bladder and bowel training: Medical treatments can be used to treat bladder and bowel problems. Training also includes learning how to manage your bladder and bowel care after rehabilitation.
  • Psychological support: Psychological support and counseling can help individuals and their families navigate the challenging emotional aspects of coping with SCI.
  • Community reintegration: In preparation for leaving rehabilitation, the health team should provide support in finding local resources and services, managing finances, returning to regular life activities, and adapting the home for SCI.

Read our article on Understanding Rehabilitation for more information!

Read our articles on the areas listed here and many other Topics!

Rehabilitation unique to non-traumatic SCI

Predicting recovery

NTSCI presents unique rehabilitation challenges. Given that those with NTSCI tend to be older, there is an increased likelihood of chronic conditions such as arthritis, diabetes, cardiovascular disease, obesity, and other conditions. These comorbidities can negatively impact rehabilitation and recovery.

Predicting rehabilitation outcomes after injury is particularly difficult in those with a progressive NTSCI, where the condition underlying the SCI leads to a deterioration over time compared to those with a non-progressive cause of NTSCI. The cause of NTSCI is an important predictor of outcomes, length of stay, and survival.

Considering the older age of many people with NTSCI, the various possible chronic health conditions that they may have, and that many NTSCI are incomplete, it can be very hard to predict the recovery from NTSCI. Making comparisons with traumatic SCI is also very hard for the same reasons.

Access to rehabilitation services

People with NTSCI have improved recovery outcomes when they are treated in a spinal-specific rehabilitation unit rather than in general rehabilitation. Clinicians agree that that a spinal rehabilitation unit that specializes in NTSCI is the ideal setting for treatment. However, there is a tendency for spinal rehabilitation units to give preference to traumatic SCI when admitting clients as NTSCI is considered less urgent and they may exclude older patients or those with metastatic cancer presumably referring them to gerontology and oncology units, respectively.

Concurrent treatment

Depending on the cause of the NTSCI, some people will undergo treatments for the underlying condition at the same time as rehabilitation. This could include surgeries, radiation therapy and chemotherapy for tumours, immunosuppressant medications for auto-immune conditions, antibiotics for bacterial infections, etc. The rehabilitation unit needs to be aware of these treatments for safety and to optimally plan treatments and rehabilitation therapy. Some treatments for underlying conditions can be draining and negatively impact rehabilitation if therapy is scheduled soon after.

Diagnosis of underlying cause

There is also a possibility for people with NTSCI to be admitted to rehabilitation without a diagnosis or with an incorrect diagnosis of the underlying condition. In these situations, rehabilitation clinicians and therapists may end up being involved in determining the correct diagnosis.

The many different types of NTSCI can be grouped into three categories: congenital, genetic, and acquired. Each will have their unique presentation and treatment needs. That said, the large majority of NTSCIs result from acquired conditions. In developed countries, most acquired NTSCIs are degenerative conditions and tumors, while developing countries tend to have a higher proportion from infection.

Those with NTSCI are more likely to be older, female, have paraplegia and have an incomplete injury when compared to those with traumatic SCI.

Much of NTSCI rehabilitation is similar to traumatic SCI rehabilitation, though the rehabilitation stay is shorter and less costly.

 

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page have been adapted from the SCIRE Professional “Rehabilitation Practices” Module available from: scireproject.com/evidence/rehabilitation-practices/factors-affecting-rehabilitation-outcomes/traumatic-vs-non-traumatic-sci/

Evidence for “What causes non-traumatic SCI?” is based on:

Molinares DM, Gater DR, Daniel S, Pontee NL. Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management. J Pers Med. 2022 Nov 8;12(11):1872.

New PW, Reeves RK, Smith É, Eriks-Hoogland I, Gupta A, Scivoletto G, et al. International retrospective comparison of inpatient rehabilitation for patients with spinal cord dysfunction: Differences according to etiology presented in part to the international spinal cord society, September 2-5, 2012, London, United Kingdom. Arch Phys Med Rehabil. 2016 Mar 1;97(3):380–5.

New PW, Marshall R. International Spinal Cord Injury Data Sets for non-traumatic spinal cord injury. Spinal Cord. 2014 Feb 8;52(2):123–32.

Klimo P, Rao G, Brockmeyer D. Congenital Anomalies of the Cervical Spine. Neurosurg Clin N Am. 2007 Jul;18(3):463–78.

Hart DJ. Syringomyelia. Encyclopedia of the Neurological Sciences. 2014 Jan 1;378–81.

Kuo DT, Tadi P. Cervical Spondylosis. In: StatPearls. StatPearls Publishing; 2023.

Evidence for “Who gets non-traumatic SCI?” is based on:

Cosar SNS, Yemisci OU, Oztop P, Cetin N, Sarifakioglu B, Yalbuzdag SA, et al. Demographic characteristics after traumatic and non-traumatic spinal cord injury: a retrospective comparison study. Spinal Cord 2010 48:12. 2010 May 4;48(12):862–6.

McCaughey EJ, Purcell M, McLean AN, Fraser MH, Bewick A, Borotkanics RJ, et al. Changing demographics of spinal cord injury over a 20-year period: a longitudinal population-based study in Scotland. Spinal Cord. 2016 Apr 13;54(4):270–6.

New PW, Cripps RA, Bonne Lee B. Global maps of non-traumatic spinal cord injury epidemiology: towards a living data repository. Spinal Cord 2013 52:2. 2013 Jan 15;52(2):97–109.

Niemi-Nikkola V, Koskinen E, Väärälä E, Kauppila AM, Kallinen M, Vainionpää A. Incidence of Acquired Nontraumatic Spinal Cord Injury in Finland: A 4-Year Prospective Multicenter Study. Arch Phys Med Rehabil. 2021 Jan;102(1):44–9.

Smith É, Fitzpatrick P, Lyons F, Morris S, Synnott K. Epidemiology of non-traumatic spinal cord injury in Ireland – a prospective population-based study. J Spinal Cord Med. 2022;45(1):76–81.

Choi Y, Leigh JH, Jeon J, Lee GJ, Shin HI, Bang MS. Trends in the Incidence and Etiology of Non-Traumatic Spinal Cord Injury in Korea: A Nationwide Population-Based Study From 2007 to 2020. J Korean Med Sci. 2023 May 5;38(18).

Cunha NSC, Malvea A, Sadat S, Ibrahim GM, Fehlings MG. Pediatric Spinal Cord Injury: A Review. Children. 2023 Sep 1;10(9).

Jain NB, Ayers GD, Peterson EN, Harris MB, Morse L, O’Connor KC, et al. Traumatic Spinal Cord Injury in the United States, 1993–2012. JAMA. 2015 Jun 6;313(22):2236

DeVivo MJ, Vogel LC. Epidemiology of spinal cord injury in children and adolescents. J Spinal Cord Med. 2004;27 Suppl 1.

Safdarian M, Trinka E, Rahimi-Movaghar V, Thomschewski A, Aali A, Abady GG, et al. Global, regional, and national burden of spinal cord injury, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2023 Nov 1;22(11):1026–47.

New PW, Epi MC, Biering-Sørensen F. Review of the History of Non-traumatic Spinal Cord Dysfunction. Top Spinal Cord Inj Rehabil. 2017 Sep 1;23(4):285.

Kennedy P, Hasson L. An audit of demographics and rehabilitation outcomes in non-traumatic spinal cord injury. Spinal Cord 2016 54:11. 2016 Mar 22;54(11):1020–4.

Evidence for “How does non-traumatic SCI present?” is based on:

New PW, Marshall R. International Spinal Cord Injury Data Sets for non-traumatic spinal cord injury. Spinal Cord. 2014 Feb 8;52(2):123–32.

New PW, Cripps RA, Bonne Lee B. Global maps of non-traumatic spinal cord injury epidemiology: towards a living data repository. Spinal Cord 2013 52:2. 2013 Jan 15;52(2):97–109.

McKinley WO, Seel RT, Gadi RK, Tewksbury MA. Nontraumatic vs. traumatic spinal cord injury : A rehabilitation outcome comparison. Am J Phys Med Rehabil. 2001;80(9):693–9.

Citterio A, Franceschini M, Spizzichino L, Reggio A, Rossi B, Stampacchia G. Nontraumatic spinal cord injury: An Italian survey. Arch Phys Med Rehabil. 2004 Sep 1;85(9):1483–7.

Dionne A, Richard-Denis A, Lim • Victor, Mac-Thiong JM. Factors associated with discharge destination following inpatient functional rehabilitation in patients with traumatic spinal cord injury. Spinal Cord. 2021;59:642–8.

Franceschini M, Bonavita J, Cecconi L, Ferro S, Pagliacci MC, Ferro S, et al. Traumatic spinal cord injury in Italy 20 years later: current epidemiological trend and early predictors of rehabilitation outcome. Spinal Cord 2020 58:7. 2020 Jan 29;58(7):768–77.

Halvorsen A, Pettersen AL, Nilsen SM, Halle KK, Schaanning EE, Rekand T. Non-traumatic spinal cord injury in Norway 2012–2016: analysis from a national registry and comparison with traumatic spinal cord injury. Spinal Cord. 2019 Apr 14;57(4):324–30.

McKinley WO, Conti-Wyneken AR, Vokac CW, Cifu DX. Rehabilitative functional outcome of patients with neoplastic spinal cord compression. Arch Phys Med Rehabil [Internet]. 1996 Sep 1;77(9):892–5.

Jeawon M, Hase B, Miller S, Eng J, Bundon A, Chaudhury H, et al. Exploring the Quality of Life of People with Incomplete Spinal Cord Injury Who Can Ambulate. Disabilities. 2023 Oct 6;3(4):455–76.

Jeawon M, Hase B, Miller S, Eng JJ, Bundon A, Chaudhury H, et al. Understanding the experiences, needs, and strengths of people with incomplete spinal cord injury who can ambulate. Disabil Rehabil. 2024 Jan 30;46(3):546–55.

Evidence for “How is non-traumatic SCI treated?” is based on:

New PW. Non-traumatic spinal cord injury: what is the ideal setting for rehabilitation? Australian Health Review. 2006;30(3):353.

New PW, Eriks-Hoogland I, Scivoletto G, Reeves RK, Townson A, Marshall R, et al. Important Clinical Rehabilitation Principles Unique to People with Non-traumatic Spinal Cord Dysfunction. Top Spinal Cord Inj Rehabil. 2017 Oct;23(4):299–312.

Image credits

  1. Baby by Nick Abrams
  2. Different types of spina bifida by Centers for Disease Control and Prevention, Public Domain
  3. DNA by Adrien Coquet
  4. old man by Gan Khoon Lay
  5. Spinal Tumors Illustration by Thom Graves, CMI; used with permission of Weill Cornell Medicine Neurological Surgery.
  6. The Blue Marble (remastered) NASA/Apollo 17 Crew, Public Domain
  7. TSCI/NTSCI 1 ©SCIRE
  8. TSCI/NTSCI 2 ©SCIRE

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Abdominal Binders Infographic: A Guide

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Author: Kelsey Zhao | Reviewers: GF Strong OTs and PTs | Published: 11 June 2024 | Updated: ~

For more information on abdominal binders, visit: community.scireproject.com/topic/abdominal-binders/

thumbnail with text: SCIRE Community Stories | Ainsley, Dan & Caleb on Nerve Transfer Surgery

Community Stories: Experiences of Nerve Transfer Surgery

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Authors: Kelsey Zhao, Dominik Zbogar | Published: 14 May 2024

Nerve transfer surgery can restore movement to the paralyzed arm or hand of someone with a high-level spinal cord injury (SCI), by connecting a healthy nerve to the nerve of the paralyzed muscle.

There is much about nerve transfers that we don’t know but we can construct a nuanced view from the diverse experiences of people who have done the procedure. Ainsley, Dan, and Caleb graciously recount their experiences with nerve transfer surgeries, the obstacles they encountered, and the insights they have gleaned, for our readers.

Refer to our article on Nerve Transfer Surgery for more information!

Introducing…

Ainsley is 17 and plans on doing a Bachelor of Arts at the University of British Columbia after graduating high school this year!

SCI level: C5-C6 complete

Dan is 37 and a full-time student at Douglas College in Recreation Therapy! He enjoys cooking and has a dog.

SCI level: C5-C6 complete

Caleb is 35 and likes to spend his time outdoors and doing sports like scuba diving, whitewater kayaking and sitskiing!

SCI level: C5 complete

Nerve transfer options

Choosing to have surgery can be a tough decision. There are pros and cons to every procedure and a million factors to consider. 

Ainsley opted to have three nerve transfers on each arm: supinator nerve to posterior interosseous nerve (PIN) for hand opening, brachialis nerve to anterior interosseous nerve (AIN)/flexor digitorum superficialis (FDS) for hand closing, and teres minor nerve (with some deltoid) to triceps for elbow extension. Ainsley’s surgical team was able to do her surgeries 6 months after her SCI, during a holiday break from school. Keeping in mind that nerve transfers are not always successful, the nerves were carefully selected to make sure tendon transfers could be done as backups. This precaution paid off when the right-side hand closing nerve transfer didn’t work out.

Dan had two nerve transfers on each arm for finger extension and finger flexion. Unlike Caleb and Ainsley who had nerve transfers done only a few months after injury, Dan had been living with SCI for 5 years when he did the surgeries. Nerve transfer is not always possible for a chronic injury because the muscle might be too deteriorated to recover. However, it can still be an option if electrodiagnostic tests show that there is still activity in the muscle and nerve. Dan said, “they did a test to see whether my nerves were still viable, and they were.”

Caleb had three nerve transfers on both arms 5 months after his cervical SCI: supinator nerve to PIN for finger extension, brachialis nerve to AIN for finger flexion, and deltoid to triceps for elbow extension. In the first few months after his SCI, but before the nerve transfer surgeries, he had recovered good wrist function, but his fingers and triceps were not improving. At that point, he was told what the probability of getting hand function back was and decided that doing the nerve transfers was the best option. Caleb said, “Even if it works out slightly, it will still be better than not doing it”.

Recovery: the good and the bad

Although the evidence so far shows that nerve transfer surgery rarely causes any lasting harms, the general risks that accompany any surgical procedure do exist, and the recovery period can be challenging. Negative experiences do exist alongside the overall success of the procedure.

Ainsley had her nerve transfer surgeries while recovering from SCI at a rehabilitation centre. She stayed at the centre for a few days after the surgery but went home for the holiday season, then returned to continue rehabilitation. After the surgery, there was no cast, splint, or movement restrictions, but the incisions were quite large and painful for the first few days. Over time, the pain became more manageable with pain medication and the stitches dissolved, but it took two or three months before the incision scars stopped bothering her completely. For the first couple of weeks, Ainsley needed a lot of assistance with everyday tasks and had to be careful with big movements like getting dressed.

Because Ainsley used a power wheelchair, she was able to move around after the surgery like before, but she imagines it would be challenging for someone in a manual chair. Pain and loss of strength after surgery could make pushing a manual wheelchair difficult.

This was very true for Dan. After his nerve transfer surgery, he lost some muscle strength in his left hand and arm. He was still strong enough to push his chair but not to stop. As a result, he went from strictly using a manual chair to using a power wheelchair for about 10 months. The rest of Dan’s recovery did not go so smoothly either. He explains, “in my left arm, when I moved my arm in a certain way, I would get a twang. It felt like I hit my funny bone but times 100. It was really bad and that lasted about two weeks. I also had some numbness in my left thumb all the way down to my palm. I still have numbness but it’s mostly the tip of my thumb so it’s better.” On top of everything, Dan was living at home and not at a rehabilitation centre when he had his surgeries. He came to realize post-surgery that he did not have all the necessary supports in place to accommodate the temporary losses in function. Reflecting on these struggles, he suspects that since people with chronic SCI don’t get nerve transfers often, there is less awareness of how much the surgery can affect their functional abilities.

Like Ainsley, Caleb was living and recovering at a rehabilitation facility up until when his nerve transfer surgeries were done, and was able to extend his stay a bit to include the first few days of his surgical recovery. He had pain for one day after the nerve transfers were done, followed by the normal aches of surgery. Caleb was still pretty weak from his SCI accident, but he did not feel any difference in strength from before to after the surgery. All in all, nothing unexpected.

What stuck out the most to Caleb about recovery was the amount of time he spent imagining movements (visualization exercises) while no movement was actually happening! Coming from a big sports background, he understood what it meant to visualize actions and the benefits of the exercise. Even so, before the first signs of movement showed up, Caleb had moments where he thought, “Oh man, this is just not doing anything. Will it ever happen?”.

Good to have a back up plan

Around a year and a half after Ainsley’s nerve transfer surgeries, her hand closing was improved and strong in the left, but her right hand produced only a flicker of movement. With her surgeons, it was determined that her right hand was not improving further so Ainsley went ahead with Plan B – a tendon transfer for the thumb to index finger pinch grip. Ainsley describes the tendon transfer recovery as “hard” compared to nerve transfer because “I was in a cast and not allowed to move for 6 weeks”. In contrast, she was able to move around immediately after nerve transfer surgery with pain medications. That said, the tendon transfer was a success!

Where they are at today

Ainsley is now 2 years after the nerve transfers and has gained the ability to fully open both hands. On the left, her restored hand closing from nerve transfer is very strong and she can pick things up. The right-hand pinch gained from the tendon transfer is functional and continues to build strength. All these improvements in her fingers and hands mean that Ainsley can use her cell phone with finger gestures, scratch an itch, adjust her hair, and hold and use things like cutlery, a toothbrush, makeup, and bank cards. The triceps nerve transfer has recovered to the point where she can now extend both arms against gravity. These days, Ainsley is getting ready to hit the road in a custom hand control vehicle, something that would not have been possible if not for the triceps surgeries that improved her strength enough to turn a steering wheel. Hopeful for the future, Ainsley says that she is “still improving everyday”.

Dan is coming up on 3 years after the nerve transfers. Although his grip is not strong, it is strong enough that he can use and squeeze the brakes on the new e-bike attachment for his wheelchair, which he would not have been able to do without the nerve transfer. Being able to extend his fingers has made it much easier to open his hand to grasp things and move them around. He has more function in his hands then before, but he still has not recovered some of the strength he lost after the surgeries. Dan described how “Before the surgery I could lift a full backpack of groceries off of the back of my chair now I have difficulty if there’s any weight in my bag.” That said, he is still waiting to see how much he improves, explaining, “…it’s coming, it’s just not there yet. I think they say the plateau is four years for this surgery…”, referencing experts who say that improvements for nerve transfers typically reach their peak at around 4 years.

Even though Caleb is only 1 year and 3 months after the nerve transfer and still has a long way to go, he is already happy with the improvements. “Going from zero movement in my fingers to now, it’s kind of huge”. The first big impact the nerve transfers had in Caleb’s day-to-day life was probably around four months in, when he was able to open his hand to grab his toothbrush without any kind of assistance. He can now grab a toothbrush or pop can and hold on to it without a problem. His triceps progress has been harder to pin down. There is some movement in his left arm and a small amount in his right arm but he wonders if that would have come back naturally after SCI regardless of the nerve transfers. Whether or not the improvements came from the nerve transfers or from natural recovery, it has been a big help for Caleb’s mobility and being able to shift and transfer.

It is clear that the functions gained and the rate of recovery for nerve transfer surgeries can vary widely. However, what determines the success and speed of recovery after surgery is still an area of active research.

Advice and recommendations

There is a sense of excitement about nerve transfer surgeries and their potential for helping patients with SCI. The procedure has had many successes but so much research remains to be done to improve outcomes. Reflecting on their own journeys, Ainsley, Dan, and Caleb offered some words of advice on nerve transfers for both the clinicians who make them happen and the people who will need them in the future.

Ainsley encourages others to advocate for their treatment options. She and her family found a specific nerve transfer that they believed would be a good option for her, and worked closely with the surgical team. The results were good and Ainsley tells us that since then, that surgical team has had many successes with that same procedure on other people. Overall Ainsley believes that the surgery was “very much worth it. The benefits outweigh the cons, and I was very lucky that I had great surgeons”. Ainsley and her dad also strongly recommend considering tendon transfers as a backup for nerve transfers.

Dan offered some words of caution as a nerve transfer recipient with chronic SCI. He felt like he went into the surgery with rose-coloured glasses on, only to discover that the recovery was not seamless and there were many unforeseen obstacles. Having lived with an SCI for many years, Dan says, “…there were so many things that I had learned how to do in those five years that all of a sudden, I wasn’t able to do.” and he thinks the doctors did not realize these adaptations would be impacted by the surgery. He had the impression that he would “be able to do everything you could do before”, but in reality, he lost some abilities for a while, including being able to transfer and use a manual wheelchair.

Considering his rehabilitation, Dan wonders if more could be done at home. For example, he heard of other people who did a lot of functional electrical stimulation (FES) for their nerve transfer rehabilitation and proposed, “You can set up somebody to do FES by themselves on their arms, right?… The client can be shown how to do it… and do it at home.” On the other hand, Ainsley had the chance to try FES but found that even when working with an occupational therapist, it was too difficult to correctly place the electrodes. That said, rehabilitation is specific to the individual and what doesn’t work for one person might work for another!

Dan also suggested that rehabilitation after surgery could be more structured, “like a program that you do after the surgery, then for the next three months after”.

Having spoken with Dan about this before, Caleb agrees that following a program would be useful. He thinks his occupational and physical therapy team did a great job but a clear step-by-step handbook or video outlining the exercises and the braces used would be nice. While Caleb did exercises in rehabilitation, some videos of him were recorded for him to refer back to but he thinks it would also be beneficial to see someone demonstrate the exercises, like a guide.

When asked what he would say to someone considering nerve transfer, Caleb admits, “Because mine went so well, when I talk to people, I’m like yeah it went really good. It’s gonna be all benefit…”. Still, he recognizes that it does not go that well for everyone, adding that “it would be awesome to have this larger compilation of all the things that went well and didn’t go well (for different people), so that way, people could really see the options…”

All in all, we can see that every experience with nerve transfer surgery will be different; every person will encounter unique obstacles, surprises, and benefits. Even with all the research papers and educational resources, nothing can portray an experience in full colour quite like a conversation with a person who has been through it.

 

Videos of Ainsley, Dan, and Caleb demonstrating some of the movements and functions they have gained in rehabilitation after nerve transfer surgery.

Ainsley demonstrating functional recovery of hand opening and closing by using a fork to eat.
Ainsley demonstrating functional recovery of triceps shoulder extensions by reaching up to adjust a wall thermostat.
Dan demonstrating functional recovery of hand opening and closing by driving and squeezing the brakes on an e-bike wheelchair attachment.
Dan demonstrating functional recovery of hand opening and closing by opening and closing the lid on a jar.
Caleb demonstrating an elbow extension exercise for triceps nerve transfer rehabiliation.
Caleb demonstrating a hand opening exercise for supinator to PIN nerve transfer rehabilitation.

Abstract schematic of Nerve Transfer Surgery

Nerve Transfer Surgery

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Author: Kelsey Zhao | Reviewer: Michael Berger, Christopher Doherty | Published: 23 January 2024 | Updated: ~

Key Points

  • Nerve transfer surgeries in SCI aim to restore some movement to the arm or hand by connecting a healthy nerve to the nerve of a paralyzed muscle.
  • This surgery is most commonly used to improve finger and thumb movement for people with cervical SCIs.
  • Depending on the type of injury, some nerve transfers are time-sensitive and must be done within 6 months, while others can be done years after the injury.
  • Experts recommend at least two years of physical and occupational therapy after a nerve transfer to rehabilitate the muscles.
  • Although the current evidence is limited, nerve transfers are a promising treatment for improving an individual’s independence and quality of life.

Spinal cord injury (SCI) disrupts the nerve pathways that send signals between the brain and muscles. This disruption can lead to loss of muscle strength and movement.

Nerve transfer surgery aims to restore some movement to a paralyzed muscle by connecting a nearby functional nerve from above the SCI to the non-functional nerve of the paralyzed muscle. The paralyzed muscle and its non-functional nerve are called the recipient. The functional nerve transferred to the recipient is called the donor. The donor nerve used is expendable (i.e. removing the nerve does not cause any significant loss of movement) or taken from an area where there is more than one muscle that performs the same movement. Over time and with rehabilitation, the healthy cells of the functional nerve will use the non-functional nerve as a scaffold to grow towards the paralyzed muscle. This creates a new pathway for signals to travel between the brain and the muscle.

simple diagram showing how the donor nerve is attached to the recipient nerve to re-innervate a paralyzed muscle in nerve transfer surgery

Nerve transfers involve the transfer of a functional donor nerve to a non-functional recipient nerve to create a new signal pathway to a paralyzed muscle.1

Since the success of nerve transfer techniques were demonstrated in other nerve injuries, like brachial plexus injury, they are now being applied to SCI. Nerve transfers are usually done after a cervical SCI to regain movement in the upper limbs. Some functions commonly targeted in nerve transfers include elbow extension, wrist extension, finger extension, finger flexion, and finger extension.

Table 1: Common nerve transfer surgeries and the donor/recipient nerves that can be used to restore each muscle function.2-5

Function
Donor
Recipient
 

Teres minor nerveTriceps nerve
Teres minor and motor portion of posterior division of axillary nerveTriceps nerve
Motor portion of posterior division of axillary nerveTriceps nerve
Fascicle of anterior division of axillary nerveTriceps nerve
 

Supinator nerveECRB (Extensor carpi radialis brevis) nerve
 

Supinator nervePIN (Posterior interosseous nerve)
 

Brachialis nerveAIN (Anterior interosseous nerve)
ECRB nerveAIN
Supinator nerveAIN
Fascicle to pronator teres nerveFDS (Flexor digitorum superficialis) nerve

Although wrist extension (bend wrist up) and wrist flexion (bend wrist down) can be targeted with nerve transfer, wrist movement is often reconstructed with tendon transfers instead. Learn more about tendon transfers in the How do nerve transfers compare to tendon transfers? section below.

Improved movement in the arms and hands can increase an individual’s independence and confidence in many areas of life, including daily activities, mobility, and socializing.

This YouTube video explains the basics of nerve transfer and tendon transfer surgeries, and the differences between the two. This video was created by Neramy Ganesan, a graduate of the University of Toronto MSc Biomedical Communications Program, with the help of content expert Dr. Jana Dengler at Sunnybrook Health Sciences Centre. Please see the end credits in the video for more details.6

Level of injury

Silhouette of a human bust overlayed with the spine and brachial plexus nerves. Spinal levels C2-C7 are labelled to show which spinal cord injury levels are potentially eligible for nerve transfer surgery.

Nerve transfers are usually done on cervical spinal cord injuries levels C5-C7.7

Nerve transfers are typically used to improve arm and hand function for people with higher level spinal cord injuries between C5 and C7. Keep in mind that since nerve transfers are a surgical treatment targeting movement, suitability is based on the level of muscle function. For example, someone with an incomplete SCI whose overall level of injury is C3, but C5 for muscle function, is more likely to be eligible for nerve transfer than someone whose level of injury is C3 for both sensory and muscle function.

Recent studies have shown some success with nerve transfers in injury levels up to C2, but more recovery of movement is associated with lower levels of cervical injury. Consideration for nerve transfer surgery in levels above C5 is made on a case-by-case basis, depending on what donor nerves are available.

Refer to our articles on Spinal Cord Anatomy and Spinal Cord Injury Basics for more information!

Nerve function and time since injury

Two types of neurons make up the nerve pathways that send movement signals to and from the brain and the muscles.

The ideal timing for how long after SCI a nerve transfer can be performed depends on whether the upper or the lower motor neurons in the nerve pathway of the paralyzed muscle are damaged. Which motor neurons are damaged is different for nerve pathways that exit the spinal cord (out to the muscle) at the level of injury and nerve pathways that exit below the level of injury.

Motor neurons at the level of injury

Often, both lower and upper motor neurons are damaged at and around the level of injury. The loss of a functional nerve in the muscle causes it to degenerate and atrophy (waste away). The muscle atrophy becomes irreversible 12-18 months after the injury, at which point a nerve transfer would be unable to restore any movement to the muscle. In this case, a nerve transfer should be done around 6 months after SCI, so that the donor nerve cells can reach the paralyzed muscle before the degeneration becomes irreversible.

Motor neurons below the level of injury

Below the SCI, often the upper motor neuron is damaged but the lower motor neuron that connects the muscle to the spinal cord is still intact. The nerve in the muscle is still functional, but you cannot control it because the connection to the brain is disrupted. The muscle is maintained by the activity of the functional nerve’s connection to the spinal cord so degeneration occurs more slowly. In this case, a nerve transfer may be possible for years after the injury, but patient selection is more specific and surgery outcomes are less predictable.

Diagram showing how a nerve transfer surgery can be time sensitive or not depending on whether there is an upper motor neuron injury or lower motor neuron injury.

The timing of nerve transfer after spinal cord injury depends on whether the nerve that connects to the muscle is damaged. If it is, the muscle will degenerate more quickly, and nerve transfer should be considered earlier.8

Other considerations

Some other factors to consider when deciding whether to do a nerve transfer surgery include:

  • Caregiver availability for the period after surgery when you will need extra support with daily activities.
  • Emotional/psychological supports.
  • Personal goals for function or recovery. Speak to your health care provider to determine whether a nerve transfer is suitable for your goals.
  • Transportation to the clinic or hospital for diagnostic testing, the surgery, and rehabilitation.
  • Other injuries in the arms, hands, or wrists or other neurological conditions that could increase the risk of complications in surgery and/or rehabilitation.
  • General considerations for surgery (e.g., open wounds, infection, high blood pressure, diabetes, heart and lung problems, extreme obesity, mental health).
  • SCI considerations for surgery (e.g., pressure sores, joint stiffness, spasticity, autonomic dysreflexia).
Illustration of the timeline for a time-sensitive nerve transfer after cervical spinal cord injury.

A timeline of the process for time-sensitive nerve transfer for a cervical spinal cord injury where the lower motor neuron of the recipient muscle is injured.9

Before surgery

The irreversible degeneration of muscle needs to be balanced with giving the nerves time to heal from the SCI. However, after 6 months, the probability of nerves recovering on their own becomes much less likely. The timing and type of nerve transfer ultimately depend on the nature of the SCI and what nerves are affected by the injury.

Suitability for nerve transfer is determined through physical examinations of muscle function and electrodiagnostic testing. Physical examination looks at the stability, strength and range of motion (how far you can move a limb in different directions) of the muscles and joints.

Electrodiagnostic tests may include the following:

Electromyography (EMG)

Electromyography measures the activity of nerves in a muscle by inserting a small needle electrode (similar to acupuncture) into the muscle tissue.

Nerve Conduction Studies

Nerve conduction studies measure the strength and speed of the signals travelling through a nerve by sending electrical pulses from a device and measuring with electrodes.

The combination of results from electrodiagnostic tests and physical exams is used to identify nerves and muscles that are functional /non-functional and figure out which muscles and nerves should be used in the nerve transfer. The tests could also determine if there is a possibility that the muscles will recover on their own and not require surgery. The results can also help to estimate what your timeline for surgery might look like.

During surgery

General anesthesia is given before the surgery. Electrical stimulation can be used to make sure the right nerves are being cut. Once the identities of the nerves are confirmed, the healthy nerve is cut and stitched to the cut end of the damaged nerve.

After surgery

In the 1-2 weeks following surgery, activity will be restricted to allow your skin and nerves to heal. After the period of rest, you can return to regular activity and begin intensive physical/occupational therapy. Even though the nerve transfer reconnects the pathway from the paralyzed muscle to the brain/spinal cord, it is not like plugging two extension cords together and having the current run through instantly. Attaching the two nerves allows the recipient nerve to act as a scaffold for the cells of the donor nerve to grow through, towards the muscle. This process can take months or years depending on the distance to the muscle because nerve cells grow at approximately 1mm per day.

Rehabilitation

After healing, you undergo intense physical therapy and occupational therapy to recover and maintain the muscle’s range of motion and strength, and to relearn how to move the muscle with the new nerve pathway. This rehabilitation process will teach you how to use the muscle properly and strengthen the muscles with a variety of exercises. Experts recommend that consistent therapy be continued for a minimum of 2 years.

Research on nerve transfers has found that people can continue to experience improvements in function as far as 4 years after the surgery with physical and occupational therapy.

Some activities to rehabilitate muscle function after nerve transfers include:

Early stage (no movement in the muscle yet)
    • Education: Understanding which muscles and nerves are involved in the nerve transfer and how the surgery has changed the way they work.
    • Range of motion: Exercises to maintain how far the muscle can move in different directions. Splints may be used to manage range of motion and spasticity.
    • Donor activation: Physically moving the donor muscle to activate the donor nerve.
    • Visualization: Moving the donor muscle and visualizing moving the recipient muscle. This is an important exercise in early rehabilitation.
    • Donor co-contraction: Moving the donor muscle and having someone else move the recipient muscle at the same time to strengthen the connection between the nerve and the new movement.
After first sign of muscle movement
    • Donor co-contraction: Moving the donor muscle and recipient muscle at the same time to strengthen the nerve connection.
    • Moving only the recipient muscle.
    • Exercises based on real life activities.
    • Doing exercises in water or with assistive devices like slings and prostheses can make movements easier by reducing the effect of gravity.
    • Biofeedback or neuromuscular electrical stimulation (NMES) may be used to promote movement.
Strength and endurance
    • Gradually increased resistance of exercises (adding weights).
    • Gradually increased repetitions of exercises.
    • Incorporating function of muscle into everyday life.

Visualization for muscle rehabilitation

Visualization (also known as mental practice, mental imagery, and motor imagery) is a technique where you consciously and repeatedly imagine performing a movement without actually moving your body. One theory for why this technique works is that visualizing a movement activates areas of the brain that overlap significantly with the areas that activate when physically doing the movement.

Studies of people without SCI and athletes who use visualization when learning new skills have shown that physical movement performance improves. In rehabilitation for neurological disorders, including SCI, evidence from high-quality studies has shown that visualization used in combination with physical therapy has positive effects on muscle movement.

Tendons are rope-like bands that connect your muscles to your bones. In a tendon transfer, the tendon of a healthy muscle with functional nerves is cut and attached to the tendon of a paralyzed muscle. This transfer allows the working muscle to take over the movement of the paralyzed muscle. This is another way that movement can be restored in the arm or hand for someone with tetraplegia.

simple diagram of tendon transfer surgery

Tendon transfers involve using a working muscle to power a paralyzed muscle movement by transferring the tendon of the working muscle to the paralyzed muscle.10

Nerve transfers and tendon transfers can also be used in combination to restore movement. Patients in one study who underwent both nerve transfer and tendon transfer reported no preference because each was beneficial in a different way. Hands with nerve transfers resulted in more natural and dexterous movement, and hands with tendon transfers felt stronger. Each has characteristics that make the procedure more or less suitable for an individual depending on their injury, timing, and recovery goals.

Table 2: Comparison of nerve transfers and tendon transfers

Nerve Transfer
Tendon Transfer
What kind of movement is improved?
More precise, controlled movements that do not require as much strength.Stronger movements that do not require as much precise coordination.
What kind of activities could this surgery help with?
• Using devices like a phone, keyboard, mouse, or touchscreen.
• Social interactions like a handshake or hug
• Eating and drinking independently
• Holding light objects
• Pressure relief movements
• Some self-catheterization steps
• Lifting and holding heavy objects
• Wheelchair pushing and maneuvering
• Eating and drinking independently
• Dressing
• Improved transfers
• Personal hygiene
• Writing
When can I get this surgery?
Depending on your injury, this surgery is usually done around 6 months after SCI, or could be done years later in some cases.Any time after SCI.
How long does healing take?
You can do light activities immediately after surgery while your skin heals.
You can return to normal activities after 2-4 weeks.
Avoid weight-bearing, repetitive, or straining activities for 1 month.
A splint and cast will be used to immobilize your arm for 1-2 months while the tendon heals.
Avoid weight-bearing activities and sports for 2-3 months.
Some centres may start physical/occupational therapy exercises days after surgery, during the immobilization period.
How long will rehabilitation take?
Daily exercises at home and physical/occupational therapy at least once per month for 2 years.Approximately 3 months
Physical/occupational therapy helps you to learn the new movement and makes sure the tendons heal properly.
How long will it take to see movement?
First improvements in movement usually happen between 3 to 12 months, depending on the type of nerve transfer. There are accounts of initial movement recovery as late as 2.5 years after surgery.
Research shows that movement may continue to improve for years after surgery.
Improvements in movement usually occur between 1-3 months after surgery.
Research shows that movement may continue to improve for up to 12 months after surgery.

Like with any other surgery, there is a risk of bleeding, infection, and other complications in the healing process. Some people who get a nerve transfer experience temporary weakness in the wrist after surgery that usually returns to normal strength during recovery. Similarly, there may be areas of numbness that develop that often go away over time. So far, the evidence shows that nerve transfer surgeries are safe, and people rarely experience permanent losses in movement or sensation because of the surgery.

Having to rely on others to carry out normal daily activities for a period after surgery can be challenging. A strong social support system and mental health supports can be helpful for recovery.

Some people feel disappointment and frustration with the slow pace at which improvements are made after a nerve transfer. It is important to set realistic expectations going into a nerve transfer. That said, even small improvements in function can have significant impacts on independence and confidence.

As with any surgery, there is a possibility that the nerve transfer surgery does not work. If a nerve transfer fails to restore any function to a paralyzed muscle after physical and occupational therapy, it may be possible to do a tendon transfer to try and regain that movement.

The reasons why a nerve transfer succeeds or fails are still an ongoing area of research. Expert opinion suggests that timing (i.e. when in the recovery process the surgery takes place), and the frequency and intensity of physical and occupational therapy influence how successful a nerve transfer is.

Future research directions for nerve transfer surgery

Although nerve transfers are available to people with SCI as a treatment option, it is still a relatively new area of ongoing research.

Some of the research underway in the realm of nerve transfer surgery include:

  • Exploring the possible application of nerve transfer techniques on diaphragm paralysis to reduce ventilator dependence.
  • The use of electrical stimulation in combination with nerve transfer to strengthen the nerve connections.
  • Research to better understand what factors may influence the success of a nerve transfer.
  • A multi-centre Canadian study is currently looking at the effect of nerve transfers on functional results like the ability to pick up an object, eat independently, self-catheterize etc.

There is some evidence that a successful nerve transfer surgery in combination with consistent physical/occupational therapy can lead to increases in the movement, control, and strength of a paralyzed muscle. In recent studies, the nerve transfer surgeries performed were 87.5 – 92% successful at recovering some strength. Better outcomes were seen in people with lower levels of cervical SCI, a greater range of motion and strength in the donor muscle, and more activity in the recipient muscle. More research evidence is needed, but experts are hopeful that nerve transfers can improve the ability to do daily activities such as inserting catheters, relieving pressure, holding and releasing items, and eating. That said, there is some limited evidence that reports people who undergo nerve transfers can experience increases in overall independence and quality of life. It is possible to see improvements for many years after the surgery with continued physical/occupational therapy.

Read Caleb, Ainsley, and Dan’s full interviews in the full article: Community Stories – Experiences of Nerve Transfer Surgery.

Caleb: Nerve Transfer Trifecta

Age: 35
Level of Injury: C5 ASIA A
Fun fact: Caleb enjoys scuba diving, whitewater kayaking and sitskiing!

Caleb had three nerve transfers on each arm for finger extension, finger flexion, and elbow extension 5 months after SCI. It has been 1 year and 3 months since his surgery.

Three months after the surgery, Caleb started to see flickers of movement. There was some loss in strength after the surgery, but at the time he was still weak from the accident that caused his SCI. Caleb can now grip a 5lb kettle bell, while his triceps is still at a flicker but continues to recover. Caleb plans to continue building his finger extension and grip strength to improve his chair skills and everyday living activities. He is hoping that with time, his triceps will have the strength to help with transfers. Overall, Caleb says, “I am very impressed with the whole team and happy with the results!”.

Ainsley: Nerve and Tendon Transfers

Age: 17
Level Of Injury: C5-C6 complete
Fun fact: Ainsley plans on doing a Bachelor of Arts at the University of British Columbia after graduating high school this year!

Ainsley had three nerve transfers on each arm for hand opening, hand closing, and elbow extension 6 months after SCI. She is now at 2 years post nerve transfer. Ainsley has also had a tendon transfer on the right side.

After the surgery, Ainsley could move around right away but had to be careful and was on strong pain medications because of the many incisions. Scar management was important to heal the incisions with minimal scarring and avoid complications. After 2-3 months of visualization exercises, Ainsley noticed the first flickers of movement. By 5-6 months she was using her left hand for tasks. Unfortunately, her right hand didn’t progress beyond a flicker, so Ainsley and her team decided to do a tendon transfer for that side. Ainsley found that the recovery for tendon transfer was more difficult because she was in a cast for 1.5 months and not allowed to move. Today, Ainsley can open both hands, pick things up with her left hand, and extend both arms against gravity. She continues to improve every day but recalls that even before the surgery, “I definitely knew that I had to put in the work to make it stronger.”

Dan: Nerve Transfer with a Chronic Injury

Age: 37
Level of Injury: C5-C6 ASIA B
Fun fact: Dan is a full-time student at Douglas College in Recreation Therapy! He enjoys cooking and has a dog.

Dan had nerve transfers on both arms for finger flexion and extension 5 years after his SCI. He’s coming up on 3 years post nerve transfer.

Recalling some of the effects right after the surgery, Dan described numbness, loss of strength, and two weeks of pain when raising his arm that “felt like I hit my funny bone but times 100”. Dan’s recovery from nerve transfer was tough and didn’t line up with the picture the surgeons and doctors painted. Because nerve transfers are done more on acute SCIs than chronic SCIs, he suspects the doctors were not aware of how much the surgery could affect the independence of someone living in the community without the supports that exist in in-patient rehabilitation. There needed to be more preparation to accommodate the losses in function he experienced. Considering his rehabilitation, he says, “…you’re on your own so I think it would be better if there was something more – like a program that you do for three months after the surgery”.

Three years after the surgery, the numbness and pain from right after surgery have improved, but the losses in strength have persisted. Dan says, “I still have difficulty doing some things that I used to do before the surgery, but not too much.” That said, he has gained the ability to open and extend his fingers and has enough grip to squeeze the hand brakes of the electric bike attachment on his wheelchair.

Overall, the research on nerve transfer surgeries suggests that it can improve arm/hand muscle function and independence for people with cervical SCI, and that the procedure is safe. However, this is an invasive procedure, so the evidence is limited because it is usually not possible to have randomization or a control group to experimentally demonstrate the benefits.

Extensive assessments are required to determine whether a nerve transfer could work for you. It is important to keep in mind that it may take years of physical/occupational therapy to see the full results of the treatment. There are also external factors to consider, including if you can take time off work/school for recovery, if you have adequate care and support, if you are mentally well enough to have surgery, and what your personal goals are for function. If you are interested in nerve transfer, speak to your health care provider to determine if it’s the right fit for your goals and your injury.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Nerve and Tendon Transfers to Improve Upper Limb Function in Cervical Spinal Cord Injury (video)

SCIRE Professional “Upper Limb” Module

Evidence for “What is nerve transfer surgery?” is based on:

Ahuja, C. S., Wilson, J. R., Nori, S., Kotter, M. R. N., Druschel, C., Curt, A., & Fehlings, M. G. (2017). Traumatic spinal cord injury. Nature Reviews Disease Primers, 3(1), 17018. https://doi.org/10.1038/nrdp.2017.18

Hill, E. J. R., & Fox, I. K. (2019). Current Best Peripheral Nerve Transfers for Spinal Cord Injury. Plastic & Reconstructive Surgery, 143(1), 184e–198e. https://doi.org/10.1097/PRS.0000000000005173

Evidence for “What can nerve transfers help with?” is based on:

Mahar, M., & Cavalli, V. (2018). Intrinsic mechanisms of neuronal axon regeneration. Nature Reviews Neuroscience, 19(6), 323–337. https://doi.org/10.1038/s41583-018-0001-8

Bazarek, S., & Brown, J. M. (2020). The evolution of nerve transfers for spinal cord injury. Experimental Neurology, 333, 113426. https://doi.org/10.1016/j.expneurol.2020.113426

Bunketorp-Käll, L., Reinholdt, C., Fridén, J., & Wangdell, J. (2017). Essential gains and health after upper-limb tetraplegia surgery identified by the International classification of functioning, disability and health (ICF). Spinal Cord, 55(9), 857–863. https://doi.org/10.1038/sc.2017.36

Evidence for Table 1 is based on:

Bazarek, S., & Brown, J. M. (2020). The evolution of nerve transfers for spinal cord injury. Experimental Neurology, 333, 113426. https://doi.org/10.1016/j.expneurol.2020.113426

Galea, M., Messina, A., Hill, B., Cooper, C., Hahn, J., & van Zyl, N. (2020). Reanimating hand function after spinal cord injury using nerve transfer surgery. Advances in Clinical Neuroscience & Rehabilitation, 20(2), 17–19. https://doi.org/10.47795/CQZF2655

Evidence for “Who is suitable for a nerve transfer?” is based on:

Khalifeh, J. M., Dibble, C. F., Van Voorhis, A., Doering, M., Boyer, M. I., Mahan, M. A., Wilson, T. J., Midha, R., Yang, L. J. S., & Ray, W. Z. (2019a). Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: Systematic review of the literature. Journal of Neurosurgery: Spine, 31(5), 629–640. https://doi.org/10.3171/2019.4.SPINE19173

Dengler, J., Mehra, M., Steeves, J. D., Fox, I. K., Curt, A., Maier, D., Abel, R., Weidner, N., Rupp, R., Vidal, J., Benito, J., Kalke, Y.-B., Curtin, C., Kennedy, C., Miller, A., Novak, C., Ota, D., & Stenson, K. C. (2021). Evaluation of Functional Independence in Cervical Spinal Cord Injury: Implications for Surgery to Restore Upper Limb Function. The Journal of Hand Surgery, 46(7), 621.e1-621.e17. https://doi.org/10.1016/j.jhsa.2020.10.036

Kirshblum, S. C., Burns, S. P., Biering-Sorensen, F., Donovan, W., Graves, D. E., Jha, A., Johansen, M., Jones, L., Krassioukov, A., Mulcahey, M. J., Schmidt-Read, M., & Waring, W. (2011). International standards for neurological classification of spinal cord injury (Revised 2011). The Journal of Spinal Cord Medicine, 34(6), 535–546. https://doi.org/10.1179/204577211X13207446293695

Javeed, S., Dibble, C. F., Greenberg, J. K., Zhang, J. K., Khalifeh, J. M., Park, Y., Wilson, T. J., Zager, E. L., Faraji, A. H., Mahan, M. A., Yang, L. J., Midha, R., Juknis, N., & Ray, W. Z. (2022). Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia. JAMA Netw Open, 5(11), e2243890-. https://doi.org/10.1001/jamanetworkopen.2022.43890

Khalifeh, J. M., Dibble, C. F., Van Voorhis, A., Doering, M., Boyer, M. I., Mahan, M. A., Wilson, T. J., Midha, R., Yang, L. J. S., & Ray, W. Z. (2019b). Nerve transfers in the upper extremity following cervical spinal cord injury. Part 2: Preliminary results of a prospective clinical trial. Journal of Neurosurgery: Spine, 31(5). https://doi.org/10.3171/2019.4.SPINE19399

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet, 394(10198), 565–575. https://doi.org/10.1016/S0140-6736(19)31143-2

Stanley, E. A., Hill, B., McKenzie, D. P., Chapuis, P., Galea, M. P., & N, van Z. (2022). Predicting strength outcomes for upper limb nerve transfer surgery in tetraplegia. J Hand Surg Eur Vol, 47(11), 1114–1120. https://doi.org/10.1177/17531934221113739

Berger, M. J., Dengler, J., Westman, A., Curt, A., Schubert, M., Abel, R., Weidner, N., Röhrich, F., & Fox, I. K. (2023). Nerve transfer after cervical spinal cord injury: Who has a “time sensitive” injury based on electrodiagnostic findings? Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2023.11.003

Bryden, A. M., Hoyen, H. A., Keith, M. W., Mejia, M., Kilgore, K. L., & Nemunaitis, G. A. (2016). Upper Extremity Assessment in Tetraplegia: The Importance of Differentiating Between Upper and Lower Motor Neuron Paralysis. Archives of Physical Medicine and Rehabilitation, 97(6), S97–S104. https://doi.org/10.1016/j.apmr.2015.11.021

Castanov, V., Berger, M., Ritsma, B., Trier, J., & Hendry, J. M. (2021). Optimizing the Timing of Peripheral Nerve Transfers for Functional Re-Animation in Cervical Spinal Cord Injury: A Conceptual Framework. Journal of Neurotrauma, 38(24), 3365–3375. https://doi.org/10.1089/neu.2021.0247

Hill, E. J. R., & Fox, I. K. (2019). Current Best Peripheral Nerve Transfers for Spinal Cord Injury. Plastic & Reconstructive Surgery, 143(1), 184e–198e. https://doi.org/10.1097/PRS.0000000000005173

Jain, N. S., Hill, E. J. R., Zaidman, C. M., Novak, C. B., Hunter, D. A., Juknis, N., Ruvinskaya, R., Kennedy, C. R., Vetter, J., Mackinnon, S. E., & Fox, I. K. (2020). Evaluation for Late Nerve Transfer Surgery in Spinal Cord Injury: Predicting the Degree of Lower Motor Neuron Injury. J Hand Surg Am, 45(2), 95–103. https://doi.org/10.1016/j.jhsa.2019.11.003

Fox, I. K., Novak, C. B., Krauss, E. M., Hoben, G. M., Zaidman, C. M., Ruvinskaya, R., Juknis, N., Winter, A. C., & Mackinnon, S. E. (2018). The Use of Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury. PM&R, 10(11), 1173. https://doi.org/10.1016/j.pmrj.2018.03.013

Evidence for “What is the process for a nerve transfer?” is based on:

Dengler, J., Steeves, J. D., Curt, A., Mehra, M., Novak, C. B., & Fox, I. K. (2022). Spontaneous Motor Recovery after Cervical Spinal Cord Injury: Issues for Nerve Transfer Surgery Decision Making. Spinal Cord, 60(10), 922–927. https://doi.org/10.1038/s41393-022-00834-6

Hill, E. J. R., & Fox, I. K. (2019). Current Best Peripheral Nerve Transfers for Spinal Cord Injury. Plastic & Reconstructive Surgery, 143(1), 184e–198e. https://doi.org/10.1097/PRS.0000000000005173

Kane, N. M., & Oware, A. (2012). Nerve conduction and electromyography studies. Journal of Neurology, 259(7), 1502–1508. https://doi.org/10.1007/s00415-012-6497-3

Berger, M. J., Dengler, J., Westman, A., Curt, A., Schubert, M., Abel, R., Weidner, N., Röhrich, F., & Fox, I. K. (2023). Nerve transfer after cervical spinal cord injury: Who has a “time sensitive” injury based on electrodiagnostic findings? Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2023.11.003

Bersch, I., & Fridén, J. (2020). Upper and lower motor neuron lesions in tetraplegia: implications for surgical nerve transfer to restore hand function. J Appl Physiol (1985), 129(5), 1214–1219. https://doi.org/10.1152/japplphysiol.00529.2020

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet, 394(10198), 565–575. https://doi.org/10.1016/S0140-6736(19)31143-2

Fox, I. K., Miller, A. K., & Curtin, C. M. (2018). Nerve and Tendon Transfer Surgery in Cervical Spinal Cord Injury: Individualized Choices to Optimize Function. Topics in Spinal Cord Injury Rehabilitation, 24(3), 275–287. https://doi.org/10.1310/sci2403-275

Kahn, L. C., Evans, A. G., Hill, E. J. R., & Fox, I. K. (2022). Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury. Spinal Cord Ser Cases, 8(1), 47. https://doi.org/10.1038/s41394-022-00512-y

Aguirre-Güemez, A. V, Mendoza-Muñoz, M., Jiménez-Coello, G., Rhoades-Torres, G. M., Pérez-Zavala, R., Barrera-Ortíz, A., & Quinzaños-Fresnedo, J. (2021). Nerve transfer rehabilitation in tetraplegia: Comprehensive assessment and treatment program to improve upper extremity function before and after nerve transfer surgery, a case report. J Spinal Cord Med, 44(4), 621–626. https://doi.org/10.1080/10790268.2019.1660841

Javeed, S., Dibble, C. F., Greenberg, J. K., Zhang, J. K., Khalifeh, J. M., Park, Y., Wilson, T. J., Zager, E. L., Faraji, A. H., Mahan, M. A., Yang, L. J., Midha, R., Juknis, N., & Ray, W. Z. (2022). Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia. JAMA Netw Open, 5(11), e2243890-. https://doi.org/10.1001/jamanetworkopen.2022.43890

Larocerie-Salgado, J., Chinchalkar, S., Ross, D. C., Gillis, J., Doherty, C. D., & Miller, T. A. (2022). Rehabilitation Following Nerve Transfer Surgery. Techniques in Hand & Upper Extremity Surgery, 26(2), 71–77. https://doi.org/10.1097/BTH.0000000000000359

Opsommer, E., Chevalley, O., & Korogod, N. (2020). Motor imagery for pain and motor function after spinal cord injury: a systematic review. Spinal Cord, 58(3), 262–274. https://doi.org/10.1038/s41393-019-0390-1

Evidence for “How do nerve transfers compare to tendon transfers?” is based on:

Bazarek, S., & Brown, J. M. (2020). The evolution of nerve transfers for spinal cord injury. Experimental Neurology, 333, 113426. https://doi.org/10.1016/j.expneurol.2020.113426

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet, 394(10198), 565–575. https://doi.org/10.1016/S0140-6736(19)31143-2

Evidence for Table 2 is based on:

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet, 394(10198), 565–575. https://doi.org/10.1016/S0140-6736(19)31143-2

Aguirre-Güemez, A. V, Mendoza-Muñoz, M., Jiménez-Coello, G., Rhoades-Torres, G. M., Pérez-Zavala, R., Barrera-Ortíz, A., & Quinzaños-Fresnedo, J. (2021). Nerve transfer rehabilitation in tetraplegia: Comprehensive assessment and treatment program to improve upper extremity function before and after nerve transfer surgery, a case report. J Spinal Cord Med, 44(4), 621–626. https://doi.org/10.1080/10790268.2019.1660841

Kahn, L. C., Evans, A. G., Hill, E. J. R., & Fox, I. K. (2022). Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury. Spinal Cord Ser Cases, 8(1), 47. https://doi.org/10.1038/s41394-022-00512-y

Bunketorp-Käll, L., Reinholdt, C., Fridén, J., & Wangdell, J. (2017). Essential gains and health after upper-limb tetraplegia surgery identified by the International classification of functioning, disability and health (ICF). Spinal Cord, 55(9), 857–863. https://doi.org/10.1038/sc.2017.36

Fox, I. K., Miller, A. K., & Curtin, C. M. (2018). Nerve and Tendon Transfer Surgery in Cervical Spinal Cord Injury: Individualized Choices to Optimize Function. Topics in Spinal Cord Injury Rehabilitation, 24(3), 275–287. https://doi.org/10.1310/sci2403-275

Dunn, J. A., Sinnott, K. A., Rothwell, A. G., Mohammed, K. D., & Simcock, J. W. (2016). Tendon Transfer Surgery for People With Tetraplegia: An Overview. Archives of Physical Medicine and Rehabilitation, 97(6), S75–S80. https://doi.org/10.1016/j.apmr.2016.01.034

Javeed, S., Dibble, C. F., Greenberg, J. K., Zhang, J. K., Khalifeh, J. M., Park, Y., Wilson, T. J., Zager, E. L., Faraji, A. H., Mahan, M. A., Yang, L. J., Midha, R., Juknis, N., & Ray, W. Z. (2022). Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia. JAMA Netw Open, 5(11), e2243890-. https://doi.org/10.1001/jamanetworkopen.2022.43890

Evidence for “What are the risks of nerve transfers?” is based on:

Francoisse, C. A., Russo, S. A., Skladman, R., Kahn, L. C., Kennedy, C., Stenson, K. C., Novak, C. B., & Fox, I. K. (2022). Quantifying Donor Deficits Following Nerve Transfer Surgery in Tetraplegia. J Hand Surg Am, 47(12), 1157–1165. https://doi.org/10.1016/j.jhsa.2022.08.014

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet, 394(10198), 565–575. https://doi.org/10.1016/S0140-6736(19)31143-2

Bertelli, J. A., & Ghizoni, M. F. (2017). Nerve transfers for restoration of finger flexion in patients with tetraplegia. Journal of Neurosurgery: Spine, 26(1), 55–61. https://doi.org/10.3171/2016.5.SPINE151544

Wilson, T. J. (2019). Novel Uses of Nerve Transfers. Neurotherapeutics, 16(1), 26–35. https://doi.org/10.1007/s13311-018-0664-x Khalifeh, J. M., Dibble, C. F., Van Voorhis, A., Doering, M., Boyer, M. I., Mahan, M. A., Wilson, T. J., Midha, R., Yang, L. J. S., & Ray, W. Z. (2019a). Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: Systematic review of the literature. Journal of Neurosurgery: Spine, 31(5), 629–640. https://doi.org/10.3171/2019.4.SPINE19173

Mooney, A., Hewitt, A. E., & Hahn, J. (2021). Nothing to lose: a phenomenological study of upper limb nerve transfer surgery for individuals with tetraplegia. Disabil Rehabil, 43(26), 3748–3756. https://doi.org/10.1080/09638288.2020.1750716

Hill, E. J. R., & Fox, I. K. (2019). Current Best Peripheral Nerve Transfers for Spinal Cord Injury. Plastic & Reconstructive Surgery, 143(1), 184e–198e. https://doi.org/10.1097/PRS.0000000000005173

Evidence for “What are the limitations of nerve transfers?” is based on:

Mooney, A., Hewitt, A. E., & Hahn, J. (2021). Nothing to lose: a phenomenological study of upper limb nerve transfer surgery for individuals with tetraplegia. Disabil Rehabil, 43(26), 3748–3756. https://doi.org/10.1080/09638288.2020.1750716

Hill, E. J. R., & Fox, I. K. (2019). Current Best Peripheral Nerve Transfers for Spinal Cord Injury. Plastic & Reconstructive Surgery, 143(1), 184e–198e. https://doi.org/10.1097/PRS.0000000000005173

Heredia Gutiérrez, A., Cachón Cámara, G. E., González Carranza, V., Torres García, S., & Chico Ponce de León, F. (2020). Phrenic nerve neurotization utilizing half of the spinal accessory nerve to the functional restoration of the paralyzed diaphragm in high spinal cord injury secondary to brain tumor resection. Child’s Nervous System, 36(6), 1307–1310. https://doi.org/10.1007/s00381-019-04490-9

Bazarek, S., & Brown, J. M. (2020). The evolution of nerve transfers for spinal cord injury. Experimental Neurology, 333, 113426. https://doi.org/10.1016/j.expneurol.2020.113426

Evidence for “Are nerve transfers effective?” is based on:

Javeed, S., Dibble, C. F., Greenberg, J. K., Zhang, J. K., Khalifeh, J. M., Park, Y., Wilson, T. J., Zager, E. L., Faraji, A. H., Mahan, M. A., Yang, L. J., Midha, R., Juknis, N., & Ray, W. Z. (2022). Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia. JAMA Netw Open, 5(11), e2243890-. https://doi.org/10.1001/jamanetworkopen.2022.43890

Khalifeh, J. M., Dibble, C. F., Van Voorhis, A., Doering, M., Boyer, M. I., Mahan, M. A., Wilson, T. J., Midha, R., Yang, L. J. S., & Ray, W. Z. (2019b). Nerve transfers in the upper extremity following cervical spinal cord injury. Part 2: Preliminary results of a prospective clinical trial. Journal of Neurosurgery: Spine, 31(5). https://doi.org/10.3171/2019.4.SPINE19399

Stanley, E. A., Hill, B., McKenzie, D. P., Chapuis, P., Galea, M. P., & N, van Z. (2022). Predicting strength outcomes for upper limb nerve transfer surgery in tetraplegia. J Hand Surg Eur Vol, 47(11), 1114–1120. https://doi.org/10.1177/17531934221113739

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet, 394(10198), 565–575. https://doi.org/10.1016/S0140-6736(19)31143-2

Image credits

  1. Nerve Transfer by SCIRE
  2. Elbow Extension by SCIRE
  3. Wrist Extension by SCIRE
  4. Finger Extension by SCIRE
  5. Finger Flexion and Pinch by SCIRE
  6. Nerve and Tendon Transfers to Improve Upper Limb Function in Cervical Spinal Cord Injury (video)
  7. Nerve Transfer Level of Injury by SCIRE
  8. Time Sensitive Nerve Transfers by SCIRE
  9. Nerve Transfer Timeline by SCIRE
  10. Tendon Transfer by SCIRE
  11. Photo provided by participant (Caleb)
  12. Photo provided by participant (Ainsley)
  13. Photo provided by participant (Dan)

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Adapted Sports and Equipment

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Author: Sharon Jang | Reviewer: Courtney Pollock | Published: 18 October 2023 | Updated: ~

Key Points

  • Staying active after SCI has many benefits, but structured workouts may not be for everyone. Sports may be a good alternative to stay physically active.
  • Adapted sports (sometimes called “adaptive sports”) are sports that use modified equipment to allow individuals of all abilities to participate.
  • Participating in adapted sports is a great way to build social connections with others and to become a part of a community.
  • There are a variety of sports that can be played including cycling, court sports, winter sports, and water sports. This article introduces various adapted sports and the required equipment to partake in them.

Staying physically active after SCI is important for your health. There is moderate to strong evidence that physical activity has many benefits after SCI including:

  • Allowing you to perform everyday activities (e.g., shopping, cooking, transferring) with more ease,
  • Improving depression and quality of life,
  • Increasing muscle strength and endurance,
  • Management of blood sugar levels,
  • Helping you to breathe with more ease,
  • Reducing pain and spasticity.

Although going to a gym is one common way to get moving, there are a variety of adapted sports that can also be played. While this article discusses a selection of adapted sports (including handcycling, court sports, winter sports, and water sports), it should be noted that almost any sport can be adapted for participation after SCI.

Refer to our article on Physical Activity for more information!

Adapted sports are sports that can be played with equipment and approaches that are adapted to a person’s physical abilities. Many adapted sports have been altered in one of many ways to promote accessibility. Some of these adaptations include changes to the rules of a game, modifications in the equipment, or specialized equipment to allow you to partake in a sport.

Athlete Classification

There are different levels of adapted sports, ranging from recreational (or just for fun and fitness) to competition. Should you want to become competitive, classifications are used to ensure that competition is equal and fair. Classifications are used to determine which athletes should be grouped together. In adapted sports, classification is based on function (e.g., strength, how many limbs are affected by injury, range of movement, tone/spasticity). This is similar to categorizing by age, gender, or weight in able-bodied sports.

Precautions when trying new sports

While trying out new sports can be fun and exciting, skin health is an important consideration. Trialing new sports is often associated with trying new equipment. When trying new equipment, it is important to check for red marks or pressure spots on your skin including your seat and any area of the body positioned against equipment (e.g., footrest or frame). People will commonly use the cushion from their everyday chair in their sport chair when they first try a sport. However, it is important to remember that although it is the same cushion, you may be sitting in a different position (e.g., seat angle) which will change pressure and potential forces from rubbing. The best approach is like that of trialing a new wheelchair or cushion: frequently check your skin in the early days of your new sport. This means that it is best to start with shorter sessions and work your way up in time once you know that your skin can tolerate the new equipment and positions. In water sports such as kayaking, or in rainy conditions for outdoor sports, make sure to check your skin when you are done since being wet can make the skin more prone to injury.

Additionally, you may want to consider the influence of temperature (extreme hot or cold weather), as temperature regulation may be impaired with an SCI.

Refer to our article on Pressure Injuries for more information!

Handcycles are a type of bicycle that is propelled by the arms instead of the legs. There are different types of handcycles available for all levels of ability. In general, most arm-cycles have alternative handle options for those with limited hand function.

Types of arm cycles

Recumbent cycles

Recumbent arm-cycles are three wheeled bikes that are controlled with the arms while seated in a reclined position. This type of bicycle has support straps to rest the feet in while cycling.

Upright cycles

Upright cycles are similar to recumbent bikes in that the feet are on either side of the front wheel. However, the user is seated in a more upright position when using this bike.

Tandem bikes

A variety of tandem arm bikes are available. Bike models are available to allow riders to either ride beside each other, or one in front of the other. Power-assist versions are also available for those who may have some function in their legs.

Arm cycle add-ons

Instead of buying a separate wheelchair, arm-cycle add-ons are available for manual wheelchair users. These add-ons connect to the front of a manual wheelchair, lifting up the casters. This then allows an individual to propel their wheelchair via an arm cycle. Additionally, power-assist versions are available for those with less upper body strength.

Off-road wheelchairs

If you are looking to go on some trails, an off-road wheelchair may appeal to you. These wheelchairs are used for recreational riding, such as going for a hike, or going fishing. Off-road wheelchairs often have larger, knobbier tires that are meant to withstand the trail, roots, and rocks. Like the arm-cycles, off-road wheelchairs come in a variety of set ups. Some setups may look like a typical manual wheelchair, but with larger wheels. There are also ones that are controlled with push-levers (such as the mountain trike), and powered wheelchairs with more power, suspension, and agility (such as the x5 frontier, and the x8-extreme all-terrain wheelchair).

Wheelchair racing

For those who are interested in competition, wheelchair racing may be an option. Wheelchair race events range from the 100m, 200m, 400m, 800m, 1500m, and 5k distance races in track and field, to marathons. Racing wheelchairs differ from the wheelchairs and cycles listed above in that they typically have two wheels with a third one extended out in front. Ideally, race chairs should be light-weight to enhance performance. When seated, the wheelchair should fit “like a glove”, and there should be little movement in the seat. Unlike arm-cycles, the feet are bent down and kept closer to the body. In addition, specialized rubber gloves are worn to push the rims during races.

Refer to our article on Wheelchair Propulsion Assist Devices for more information!

Tennis

Wheelchair tennis is played on the same court as able-bodied tennis, and with similar rules. One rule difference is that in wheelchair tennis, players are allowed two bounces instead of one, and the second bounce can be anywhere – even out of bounds. Although one can play wheelchair tennis in their day chair, tennis wheelchairs are often preferred during play. These wheelchairs are faster, lighter, more agile, and more stable. The wheels on the wheelchair are also angled (i.e., there is more camber ) to allow for more swift turning. For those with limited hand function, taping the racquet to your hand is common practice, though it can take some time to find the optimal tension for you. Therefore, people with all levels of ability can play wheelchair tennis.

Basketball

Wheelchair basketball is played on a standard basketball court. The wheelchair used for basketball is one with wheels angled to 15-20 degrees and a single rollerblade used for a caster at the back. In addition, there are many strapping options to promote stability and safety, or to hold the body in a certain position. Commonly strapped body parts include the hips, knees, feet and/or ankles. It is common for wheelchair basketball leagues to include able bodied participants at the local level of competition. This allows for more players and teams for great league play.

Rugby

Wheelchair rugby was developed specifically for people with tetraplegia and has grown to include people without SCI but with similar functional abilities (e.g., some impaired arm and hand function in addition to impaired leg function). Wheelchair rugby is played with a volleyball. The goal of the game is to carry the ball over the other team’s goal line. Unlike able-bodied rugby, wheelchair rugby is played indoors on a court. Specialized wheelchairs are used to play wheelchair rugby and can be separated into chairs for offensive players and chairs for defensive players. Offensive wheelchairs are set up for speed and mobility and are distinguished with a front bumper to prevent other chairs from hooking them. Often, offensive chairs are used by players with more function. On the other hand, defensive wheelchairs are set up with a bumper to hook and hold onto other players. Defensive chairs are often used by players with less function. Additional equipment used in rugby include straps and gloves. Straps are used on the waist (to compensate for a lack of core muscles), the thighs (to prevent them from falling to the side or from shifting side to side), and the feet (for comfort). Meanwhile, gloves work to protect the skin, add extra grip when pushing the chair, and to making throwing and catching the ball easier.

Community Voices: Byron

Byron has been playing wheelchair rugby for 17 years. He describes it as “a fast-paced sport. You get to hit things with your wheelchair, and at the same time there is a lot of strategy going on.” He enjoys the sport as he explains, “the physical benefits are a big part of why I enjoy playing wheelchair rugby. The community is amazing – it’s great because every practice is an opportunity to see a bunch of my friends.”

Alpine Skiing

Alpine skiing, also known as downhill skiing, is a sport that individuals with tetraplegia and paraplegia can partake in with the use of sit-skis. In general, sit skis have a bucket-type of seat with an adjustable seat and footrest. To create a smoother ride, sit-skis have additional features such as suspensions and a shock compression system under the seat. The seat and suspension/shock systems are all connected to either a single ski (mono-ski) or a pair of skis (bi-skis). In general, mono-skis require the user to have good upper body strength, and the ability to ski independently. Bi-skis are often used by individuals who may require some assistance. Often, bi-skis are used with an able-bodied individual who skis behind them. Skiers who use a sit-ski can use the typical chairlifts at the mountains and with experience, can access all terrains of ski areas.

Cross Country Skiing

Cross country skiing (which is a type of Nordic skiing) allows individuals with paraplegia and tetraplegia to explore snowy trails. Like the alpine skis, cross country skis consist of a bucket seat that connects to a metal frame, which clips into the skis. Cross country skiers also often use poles while skiing to propel themselves along flatter terrain. If assistance is required, an able-bodied person can help push the ski forward with their ski-pole using an adaptive add-on.

Sledge (Ice) Hockey

Sledge hockey, or para ice hockey is identical to ice hockey but is played while sitting in sledges as opposed to standing on skates.

A sledge consists of a plastic bucket-shaped seat that is connected to a metal frame. This frame is set on two adjustable skate blades, with the blades aligned on the bottom of the seat. The skate blades may be adjusted so that they are further apart for stability (good for new players) or can be moved closer together to allow for more maneuverability and speed. Straps are available to help keep the feet, knees, and hips in place. Players propel themselves in the sledge using two sticks. These sticks are dual ended: one end has a blade for handling the puck, while the other end has a metal pick in it to help players propel themselves across the ice. Typical hockey pads are used for safety during play.

Sailing

Adapted sailing is a sport that people of all abilities can participate in. Common features of adapted sailboats include handguards along the side of the boats, greater deck space due to removed masts, and customized molded seats with back support and belts that pivot. For individuals with reduced function, other available adaptations include electronic controls (such as the use of a joystick), and sip ‘n’ puff technology to steer the boat with breath. Many sailing clubs have power/mechanical lifts dockside to assist with transfers into boats.

Community Voices: Terry

Terry has been involved in adapted sailing since 1994. Terry sails a Matin 16 using sip ‘n puff technology. Sailing is special to Terry as he says he can “finally get out of my chair and be as free as the wind!” As he is unable to play court sports, sailing has provided Terry a competitive outlet.

Kayaking

Kayaks are available for people with all levels of SCI. While individuals with a lower level of injury may use non-adapted kayaks, adaptations are available for comfort and to accommodate those with limited function. Some kayaks may have custom seating with side and abdominal support. These supports are cushioned to protect the skin while kayaking. Stabilizing outriggers are available to increase stability of the boat and to reduce the chances of tipping. For those with limited arm/hand function, there are various adaptations for the paddle including:

  • A back of the hand grip, which places more paddling pressure on the arms instead of the hands.
  • Wrist cuff adaptation, which allows individuals to connect the paddle to their wrists via a cuff.

There are many benefits to staying physically active after SCI and there is a large variety of sports to participate in. Whether you prefer staying on land, floating on water, or being in the snow, most sports have been adapted in some way or another so that all who want to can participate! Prior to trying a sport, talk with your health providers to ensure that you are in a condition to play.

Evidence for “Why be physically active after SCI” is based on:

Martin KA, Latimer AE, Francoeur C, Hanley H. Sustaining exercise motivation and participation among people with spinal cord injuries – Lessons learned from a 9 month intervention. Palaestra 2002;18(1):38-51.

Hicks AL, Martin KA, Ditor DS, Latimer AE, Craven C, Bugaresti J et al. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41(1):34-43.

Latimer AE, Ginis KA, Hicks AL, McCartney N. An examination of the mechanisms of exercise- induced change in psychological well-being among people with spinal cord injury. J Rehabil Res Dev 2004;41(5):643-652.

Martin Ginis KA, Latimer AE, McKechnie K, Ditor DS, Hicks AL, Bugaresti J. Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. REHABIL PSYCHOL 2003;48(3):157-164.

Latimer AE, Martin Ginis KA, Hicks AL. Buffering the effects of stress on well-being among individuals with spinal cord injury: A potential role for exercise. Therapeutic Recreation Journal 2005;39(2):131-138.

Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., et al. (2011). Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Physical Therapy, 91, 305—324.

Jacobs, P. L. (2009). Effects of resistance and endurance training in persons with paraplegia. Medicine & Science in Sports & Exercise, 41, 992-997.

De Groot PC, Hjeltnes N, Heijboer AC, Stal W, Birkeland K. Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord 2003;41(12):673-679.

de Carvalho DC, Martins CL, Cardoso SD, Cliquet A. Improvement of metabolic and cardiorespiratory responses through treadmill gait training with neuromuscular electrical stimulation in quadriplegic subjects. Artif Organs 2006;30(1):56-63.

Information for “What are adapted sports” is based on:

World Para Athletes. (n.d.). What is classification? https://www.paralympic.org/athletics/classification

Information for “What types of cycling and pushing sports are there?” is based on:

World Para Athletes. (n.d.). Para-athletics explained: Wheelchair racing. https://www.paralympic.org/news/para-athletics-explained-wheelchair-racing

Chair Institute. (2019). Best off road all terrain wheelchairs for outdoors review 2020. https://chairinstitute.com/best-wheelchairs-for-outdoors/

Information for “What adapted court sports are available?” is based on:

BC Wheelchair Sports. (n.d.). Wheelchair Tennis.https://www.bcwheelchairsports.com/sites/default/files/images/BCWSA%20Wheelchair%20Tennis%20First%20Introduction%20Manual%20-%20PRINT%20%281%29.pdf

Wheelchair Basketball Canada. (2021). About the sport. https://www.wheelchairbasketball.ca/the-sport/about-the-sport/

Wheelchair Basketball Canada. (2021). Equipment. https://www.wheelchairbasketball.ca/the-sport/equipment/

Wheelchair Rugby Canada. (2018). Rules and equipment. https://wheelchairrugby.ca/rules-equipment/

Information for “What adapted winter sports are available?” is based on:

Canadian Ski Council. (2018). Skiing is for everyone! https://www.skicanada.org/ready/accessible-skiing-information/

XCSkiResorts. (2016). Nordic adaptive sit-skis bring freedom to mobility impaired persons. https://www.xcskiresorts.com/resort-features/2016/9/12/nordic-adaptive-sit-skis-bring-freedom-to-mobility-impaired-persons

BC Hockey Saanichton, BC. (2016). Para Hockey Brochure Guide.https://www.bchockey.net/Files/Sledge%20Hockey%20Brochure.pdf

Information for “What water sports are available?” is based on:

Disabled Sailing Association of British Columbia. (2021). Sip ‘n’ Puff Technology. https://asabc.org/sip-n-puff/

Creating Ability. (2021). Seating systems. https://www.creatingability.com/seating-systems/

Creating Ability. (2021). Paddle adaptations. https://www.creatingability.com/paddle-adaptations/

Image credits

  1. Man on Arm Erg by SCIRE Community
  2. BC Wheelchair Rugby Day 1 293©Melissa Nemeth, CC BY-SA 2.0
  3. Noun Project
  4. Noun Project
  5. Noun Project
  6. Shark ©Sunrise Medical 2021
  7. Replacement parts for Invacare Top End Handcycles ©RehabMart.com, LLC 1998-2021
  8. Van Ram Fun2Go Tandem ©Bike-On.com 2020
  9. Batec Hybrid ©Batec Mobility
  10. Invacare top end crossfire all terrain wheelchair ©Invacare Corporation 2021
  11. Top end preliminator youth racing wheelchair – custom version. ©How I Roll Sports, LLC 2018
  12. Harness Glove ©Harness Designs Wheelchair Gloves
  13. Wheelchair Tennis ©BC Wheelchair Sports
  14. Wigan Warthogs Wheelchair Basketball-2 ©Andrew Spillane, CC BY-ND 2.0
  15. Equipment ©International Wheelchair Rugby Federation 2013-2021
  16. London 2012 Paralympics Wheelchair Rugby (Murderball) ©Sum_of_Marc, CC BY-NC-ND 2.0
  17. Monique-1 Mono Ski ©Enabling Technologies 2021
  18. Dynamique Bi Ski ©Enabling Technologies 2021
  19. Woman using sit ski – photo by northeast passage ©U.S. Forest Service – Pacific Northwest Region, Public Domain Mark 1.0
  20. Sledge Hockey: Italy/Sweden ©Mariska Richters, CC BY-NC-SA 2.0
  21. Terry in Matin 16
  22. Outfitted Kayak ©Creating Ability 2021
  23. Stabilizing Outriggers ©Creating Ability 2021

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.