Rehabilitation Protocol for Spinal Cord Injury

Timing of Rehabilitation Initiation

The American College of Anaesthesia recommends starting rehabilitation immediately upon medical stability in the ICU, even before transfer to a dedicated rehabilitation unit 1, 2

Perform stretching exercises for at least 20 minutes per anatomical zone to maintain joint amplitudes and prevent contractures 2, 3
Apply simple posture orthoses, including elbow extension, flexion-torsion of metacarpophalangeal joints, and opening of thumb-index commissure 2, 3
Position patient correctly in bed and chair to prevent predictable deformities 2, 3
Focus on strengthening existing musculature from the earliest phase 2, 3

Implement early mobilization as soon as spine is stabilized, visual and tactile checks of all at-risk areas at least once daily, repositioning every 2-4 hours with pressure zone checks, use discharge tools to avoid interosseous contact, and utilize high-level prevention supports 1, 2

Remove indwelling catheter as soon as patient is medically stable to minimize urological risks 1, 2, 4
Initiate intermittent urinary catheterization once daily diuresis volume is adequate, as this is the reference method that reduces urinary tract infections, urolithiasis, and increases continence probability 1, 2, 4
Use a micturition calendar to adapt frequency and schedule of catheterization 1, 4
Do not treat asymptomatic bacteriuria with antibiotics, as this creates antimicrobial resistance 4

Position patient in semi-recumbent or recumbent position rather than sitting when possible, as this is better tolerated due to gravity effects on abdominal contents and inspiratory capacity 3
Consider abdominal contention belt to increase tolerance of spontaneous ventilation, particularly in sitting position 3
For upper cervical injuries or complete injuries, anticipate potential need for tracheostomy if vital capacity is reduced by >50% 3
Perform tracheostomy after 7 days if anterior cervical surgical approach was used; earlier timing possible with posterior approach 3

Introduce multimodal analgesia during surgical management, combining non-opioid analgesics, antihyperalgesic drugs, and opioids to prevent prolonged pain 2, 3
For neuropathic pain, initiate oral gabapentinoid treatment for more than 6 months 2, 3
Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 2, 3

Ensure rehabilitation centers have the equivalent of 2.5 full-time physiotherapists per 15 patients 1, 2

Do not delay removal of indwelling catheters, as prolonged use increases urological complications 1, 2, 4
Do not treat asymptomatic bacteriuria or rely on pyuria, urine odor, or cloudiness alone to diagnose UTI in catheterized patients 4
Do not delay rehabilitation until transfer to a dedicated rehabilitation unit; begin in the ICU as soon as medically stable 1, 2
Do not neglect pressure ulcer prevention measures, as prevalence can reach 26% with sacrum, heels, and ischium being most affected 1, 2