Spinal Cord Injury Occupational Therapy Reference Guide

ASIA Scale

A – CompleteNo motor or sensory

B – Sensory Incomplete Sensory but no motor function below the specified level

C – Motor IncompleteMotor function is preserved below the specified level with more than half of key muscles with muscle grade LESS than 3

D – Motor IncompleteMotor function is preserved below the specified level with at least half of key muscles with muscle grade MORE than 3

E – Normal

Motor Function


  • +Neck flexion/extension/rotation/lateral flexion
  • +Swallowing
  • No motor function in trunk, upper & lower extremities
  • Ventilator dependent


  • +Respiration/Inspiration(Diaphragm)
  • +Scapular elevation
  • No motor function in trunk, upper, & lower extremities


  • +Shoulder flexion/abduction/extension/rotation
  • +Elbow flexion
  • +Forearm supination
  • +Scapular adduction/abduction
  • No elbow extension, pronation, wrist, or hand movements
  • Paralysis of trunk and lower extremities


  • +Scapular protraction/upward rotation
  • +Shoulder horizontal adduction
  • +Wrist extension (Tenodesis)
  • No wrist flexion, elbow extension, or hand movement
  • Paralysis of trunk and lower extremities


  • +Shoulder internal rotation, adduction, depression
  • +Elbow extension
  • +Forearm pronation
  • +Wrist flexion
  • Paralysis of trunk and lower extremities


  • +Digit extrinsics (FDS, FDP, EDC) with weak grasp


  • Full use of hands
  • Some trunk (upper half) control


  • Full trunk control


  • Partial control of lower extremities
  • Partial paralysis of lower extremities (hips, knees, ankle, foot)
  • Difficulty with bowel & bladder

Assistance Levels

Standing – Total assist from C1 to C6. Some assist at C7. Independent at T1.

Ambulation – Not functional at T1. Functional at T10 (may need some assistance).

Feeding – Total assist from C1 to C4. Set up at C5, but independent with equipment. May require assistance for cutting. Independent at C7.

Grooming – Total assist from C1 to C4. Functional at C5 with assistance. Modified independent at C6. Independent at C7.

Dressing – Total assist from C1 to C5. Modified independent for the upper body. Moderate assistance for the lower body. Independent at T1.

Bathing – Total assist from C1 to C5. Independent for the upper body at C6.  Assistance for lower extremity. Independent at T1.

Bowel & Bladder – Total assist from C1 to C5. At C6 begin training with A/E. Independent at T1.

Bed mobility – Total assist from C1 to C4. Max assist at C5. Min to Mod assistance at C6. May be independent at C7. Independent by T1.

Transfers – Total assist from C1 to C5. Some assist at C6. Independent at T1.

Pressure relief and repositioning – Total assist from C1 to C4. Independent at C5 with adaptive equipment.

Manual wheelchair propulsion – Total assist from C1 to C4. Some assist at C5. Independent indoors at C6. Independent also with level outdoor surfaces at C7. Independent at T1.

Power wheelchair propulsion – Total assist from C1 to C3. Independent at C4.

IADLs – Total assist from C1 to C5. Light meal prep at C6. Independent at C7 for simple meal preparation and light homemaking. Will require assistance at all levels for heavy housecleaning.

Driving – Dependent from C1 to C5. Independent at C6.

Function Goals & Emphasis

C1 – C3

  • ADLS – Dependent
  • Caregiver education for ADLs & Equipment
  • Ventilator supports (suction, battery)
  • Power wheelchair with head support, reclining, pressure relief cushion, transfer board
  • Mouth stick
  • Bathing – Padded, reclining
  • Pressure relief mattress
  • Mechanical lifts
  • Voice/Eye assistive technology
  • Remote doorbell for caregiver assistance


  • Shoulder shrugging to activate switch
  • Ventilator – as required
  • Power wheelchair – Sip and puff, head switches, voice control, pressure relief, head support, transfer board
  • Hydraulic standing table, tilt table
  • Call systems, environmental controls, mouthstick for page-turning & computer use


  • Strengthen biceps
  • Deltoid aid for feeding
  • Potential to self-feed (eccentric contraction of elbow flexors to lower hand)
  • Shoulder abduction to pick-up food
  • Plate guard, place dycem under plate
  • Grooming with some assistance (electric razors, electric toothbrush)
  • Some dressing
  • Dependent with toileting and bathing
  • Typing stick for computer use
  • Wrist cock-up (AM) and Intrinsic plus (PM) splints
  • U-cuff for feeding, long straw, plate guard, mobile arm support


  • Slideboard transfers
  • Power wheelchair with recliner (pressure relief) for most surfaces
  • Manual wheelchair for smooth level surface ONLY, limited use to decrease scapular dysfunction
  • Educate on use of Tenodesis grasp, Tenodesis brace
  • Feeding: Dining with dignity silverware, U-cuff, cutting & opening packages
  • Grooming: Adapted grooming aids, U-cuff, large top toothpaste with rubber bands
  • Dressing: dressing independently (arm & thumb to hook); dependent with lower body dressing
    • Elastic shoelaces, sock aid
  • Bathing: adapted sponges, mitts, long-handle, grab bars, padded chairs
  • Strengthen extensors
  • Passively stretch wrist flexors and extensors with finger flexion
  • Typing stick
  • Driving: adapted hand controls


  • Training with adaptive equipment
  • Weight shifting


  • Built-up handles
  • Dycem (gripping utensils, electric toothbrush, etc.)
  • Strengthening functional muscles


  • Manual wheelchair
  • Trunk control/balance/awareness
  • Hand mirror for skin checks



  • Can live independently
  • Mostly physical therapy


  • Screen for any OT needs

Precautions and Prevention


  • Aspiration, choking
  • Minimize prolonged sitting for certain levels

Autonomic Dysreflexia

  • T4 or higher
  • Signs & symptoms: elevated blood pressure, pounding headache, perspiring, chills, flushed, decreased heart rate. HTN at risk for hemorrhagic CVA.
  • Activate emergency response
  • Help lower blood pressure
  • Sit upright. Remove abdominal binder
  • Lower legs. Remove compression hose
  • Check for catheter tube, full ladder, foot plate, feet crossed

Orthostatic / Postural Hypotension

  • Recline
  • Abdominal binder & compression hose before

Pressure Injuries

  • Due to sensation loss
  • Lack of blood flow (necrosis)
  • Ischial tuberosity, superior aspect of gluteal fold, heels, malleoli, elbows, trochanters, scapulae
  • Educate
  • Padding
  • Float heels
  • Repositioning Q-…
  • Minimize shearing

Bowel & Bladder

  • Risk for infections with catheters
  • Collaborate with nursing
  • Reaching may be difficult for hygiene
  • Lack of sensation may be difficult even with A/E

Clinical Syndromes

Central Cord Hyperextension injury More UE loss (than LE)
Motor Pain , Temperature Proprioception, Light Touch
Brown-Sequard Ipsilateral injury Ipsilateral Loss Contralateral Loss Ipsilateral Loss
Anterior Cord Flexion injury Loss Loss Preserved
Posterior Cord Injury to posterior columns Preserved Preserved Loss, Preserved

cauda-equina diagram

Conus medullaris Sacral cord injury LE loss, Areflexic bowel & bladder
Cauda equina L1 and below