Occupational therapy for people with spinal cord injuries

This resource is for clinicians, particularly occupational therapists, working with people with spinal cord injuries (SCI).

Clinicians can find more information and guidance here to:

• assess the needs of a person with an SCI
• make recommendations for equipment and home modifications to assist them.

Some information referenced is specific to NSW, however the majority should also be applicable in other states and territories.

This information is mainly for clinicians who occasionally work with patients with an SCI, to assist them with navigating options. The list of equipment and home modifications is not exhaustive.

Background

An Overview of Occupational Therapy Intervention for Adults with Spinal Cord Injury was last released in 2013. The resource has been updated in 2021 by occupational therapists with expertise working with people with spinal cord injury from Royal North Shore Hospital, Royal Rehab, Prince of Wales Hospital and NSW Spinal Outreach Service.

Evidence

Data for this resource were drawn from a literature search, guideline review and consensus expert opinion of the working party.

Literature search

A rapid review of Medline was conducted in September 2020. Key search terms included: spinal cord injuries OR paraplegia OR quadriplegia and occupational therapy or physical Therapy. Snowball searches were conducted from the reference lists of key articles.

Additional searches were completed of the OT seeker and PEDro evidence databases.

Guideline review

Guidelines for SCI care are produced by different SCI services. Spinal Cord Injury Rehabilitation Evidence (SCIRE) and Consortium for Spinal Cord Medicine (Paralyzed Veterans of America) have developed clinical guidelines that informed this work.

Further information

• The International Spinal Cord Society has developed learning modules on SCI management for all disciplines. The occupational therapy module focuses on developing OT skills specific to SCI, and includes videos, case studies and interactive activities.
  International Spinal Cord Society. elearnSCI.org. International Spinal Cord Society. 2012 [cited 21 March 2021].
• The SCIRE Project Version 6.0 ‘reviews, evaluates, and translates existing research knowledge into a clear and concise format to inform health professionals and other stakeholders of best rehabilitation practices following SCI’.
  Spinal Cord Injury Research Evidence Team. The SCIRE Project. Vancouver: Spinal Cord Injury Research Evidence Team; 2020 [cited 21 March 2021].

Some people with a spinal cord injury (SCI) will have the ability to achieve a high level of functional independence. Others may be limited by their physical ability but will be able to achieve a level of independence through directing their care and by using assistive technology options.

A person’s neurological level should not be viewed as strictly predictive but rather as indicative of potential function. There are many factors that have an impact on an individual’s functional performance.

Factors that affect functional performance

• Neurological level (tetraplegia or paraplegia)
• Degree of impairment (expressed as complete or incomplete, or using the American Spinal Injury Association International Standards for Neurological Classification of Spinal Cord Injury score)¹
• Age at time of injury and years since injury
• Other injuries or medical conditions, for example fractures, nerve injuries, cardiac disease, arthritis
• Physique (body proportion and weight distribution)
• Cognition and motivation (impact of traumatic brain injury)
• Mental illness, for example depression, schizophrenia, personality disorder
• Drug and alcohol abuse
• Social supports
• Cultural expectations
• Financial resources
• Environmental factors.

Changes with ageing

A person’s functional status may change as they age with an SCI. Musculoskeletal changes associated with ageing have a greater impact on people with an SCI and their level of independence than on the able-bodied population. Musculoskeletal problems with overuse syndromes are common.

See Potential levels of functional independence and equipment needs for further information about the expected functional outcomes and equipment requirements for people with different levels of spinal cord injury.

1. The American Spinal Injury Association. International Standards for Neurological Classification of SCI (ISNCSCI) Worksheet [Internet]. 2019 revision. Richmond, VA, USA: The American Spinal Injury Association; 2019 [cited 20 Oct 2021].

A person with a spinal cord injury (SCI) is at risk of developing a pressure injury due to impaired sensation and muscular atrophy. Other factors include reduced vascular supply, dependent oedema, heat and moisture.

Occupational therapy intervention to assist with skin management should take place when the person with an SCI:

• has intact skin, however the clinician has identified that they have a high-risk profile
• is on bed rest with a pressure injury
• has recently had a pressure injury and their skin has healed.

The occupational therapy intervention should be part of a multidisciplinary team review.

Occupational therapy review

When the person with an SCI has intact skin but has a high risk of developing a pressure injury, the occupational therapist should:

• provide education about skin care management and causes of pressure injuries such as pressure care equipment, mobility and regular pressure relieving, microclimate, positioning, shearing risks and clothing
• review equipment, posture, quality of transfers and functional ability as below.

When the person with an SCI is on bed rest with a pressure injury the occupational therapist should:

• inspect their skin
• discuss possible causes of the pressure injury
• examine their equipment
• organise an appropriate mattress
• provide advice about positioning and bed mobility
• gather information about their daily routine including how functional activities are performed
• consider care needs – to facilitate bed rest and to prepare for gradual return to seating when skin has healed
• explore ways in which the person can continue in their life roles e.g. access to alternative technology to support work whilst on bed rest.

When the pressure injury has healed and the person with an SCI is able to start a gradual return to seating protocol, the occupational therapist should consider the following.

Pressure redistribution and relief

• Do seating surfaces provide the person with adequate pressure redistribution?
  • Consider wheelchair cushions, toileting and showering equipment and car cushions.
• Is their method of weight shifting safe and effective for pressure relief?
  • Consider ability to lean forward, side lean or use tilt in space function and to sustain that position for sufficient time to ensure adequate offloading.

Seating

• Does the person have a symmetrical sitting posture?
  • For example, someone with a pelvic obliquity may bear more weight (and more pressure) on one ischial tuberosity than on the other.

Equipment

• Does it meet the person’s needs?
• Does it fit them well?
• Is it well maintained?
  • Consider wheelchair and cushion, mobile shower commode, mattress, hoist and sling, car and exercise equipment.

Mattress

• Does it provide the person with adequate pressure relief and redistribution?
• Does the mattress offer enough support so that they are not resting on the bed frame (bottoming out)?

Transfers

• Does the person clear all surfaces well during all transfers?
• Are their transfers level or downhill?
• If transferred with a hoist, does the person shear in the sling during transfers?
• Is the edge of the sling in contact with the healed skin?

Skin

• Can the person check his or her own skin?
  • Long-handled mirrors or assistive technology, such as a web cam, can assist. Alternatively, ensure that a carer performs regular skin checks.
  • Is the person aware of the importance of wearing soft footwear and seamless breathable clothing to avoid pressure on skin (e.g. to avoid zips, large buckles, belts, jeans, hard leather shoes)?

Function

• Has the person’s level of functioning declined?
  • Transfers, ability to pressure relieve, bed mobility and shoulder integrity.

When assessing seating and sleeping surfaces it may be useful to use a system to measure the pressure between the person and his or her seat or mattress (interface pressure). This may require the use of a pressure mapping device or a referral to a seating clinic.

Further information

Clinical guidelines or information

• Agency for Clinical Innovation. Pressure Injury Toolkit for Spinal Cord Injury and Spina Bifida. Sydney: Agency for Clinical Innovation; 2021 [cited 5 March 2021].
• Carville, K. Wound Care Manual. 7^th ed. Osborne Park. WA: Silver Chain Nursing Association Incorporated; 2017.
• Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: Clinical Practice Guidelines for Health Care professionals. 2nd ed. Washington DC: Paralyzed Veterans of America; 2014 [cited 5 March 2021].
• Haesler, E (Ed.). Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The international guideline. 3rd E. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pacific Pressure Injury Alliance. 2019.
  This is an international consensus document developed by the National Pressure Injury Advisory Panel (US), European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance (including Australian Wound Management Association).
  The Quick Reference Guide can be downloaded for free from the website. Hard copies of the Clinical Guidelines and Quick Reference Guide can be purchased.
• Houghton PE, Campbell KE and CPG Panel. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A Resource Handbook for Clinicians. Toronto: Ontario Neurotrauma Foundation; 2013 [cited 20 March 2021].
  These guidelines are FREE and at 300+ pages are very comprehensive!
• Swanson T, Asimus M, McGuiness, B (Editors). Wound Management for the Advanced Practitioner. Melbourne: IP Communications; 2014.

Consumer resources

• Agency for Clinical Innovation. Pressure Injury Toolkit for Spinal Cord Injury and Spina Bifida: Resources for Consumers and Carers. Sydney: Agency for Clinical Innovation; 2021 [cited 21 March 2021].
• Consortium for Spinal Cord Medicine. Pressure Ulcers: What You Should Know A guide for People with Spinal Cord Injury. Washington DC: Paralyzed Veterans of America; 2002 [cited 20 March 2021].
• Model Systems Knowledge Translation Center. Skin Care and Pressure Sores (set of 6). Arlington: Model Systems Knowledge Translation Center; 2009 [cited 20 March 2021].
• Queensland Spinal Cord Injuries Service. Skin Care: Return to Sitting after a Skin Breakdown. Woolloongabba: Queensland Spinal Injuries Service; 2020 [cited 20 March 2021].

Bedroom equipment

Beds Mattresses

Lifting and transferring equipment

Hoists Transfer boards

Wheelchairs and cushions

Wheelchairs and cushions

Hygiene equipment

Mobile shower commodes Other showering equipment

Assistive technology

Computers Environmental control Emergency call systems

Upper limb

Splinting Tetraplegic hand clinic

Other equipment

Personal care Home management

Motorised height adjustable beds

A motorised height adjustable bed, sometimes called a profiling bed, enables a person with a spinal cord injury (SCI) to:

• reposition and to change the height of the bed so that their transfers in and out of bed are level or downhill
• preserve shoulder function by eliminating the use of equipment that brings the arms above shoulder height, such as monkey bars.

Motorisation of the bed also assists support workers who provide services to a person with an SCI.

Individual characteristics that impact on selection of bedroom equipment

• Height and weight
• Bed mobility: Can the person change position independently?
• Method of transferring into bed: Can the person transfer independently or is a hoist required?
• Upper limb function: ability to operate controls
• Flexibility: presence of internal fixation hardware (e.g. screws, plates etc.) in a person’s spine may restrict movement
• Sleeping alone or with partner.

Other considerations

Environment

• Where will the bed be located?
• How will the bed be installed in the room? (Can the bed be dismantled to fit through doorways and corridors?)

Compatibility with other equipment

• Mattress (length and width) and hoist (mobile floor hoist: consider under bed clearance and lifting range; powered ceiling hoist: consider location of ceiling track).

Geographic location

• What are the options for repairs and maintenance?
• What support is available in rural areas?

Care requirements

• Does the person require hoisting or assistance with turns or personal care activities?

Features to consider

Hi-lo function

• Assists a person to achieve safe functional transfers between the bed and wheelchair or commode.
• Enables the bed to be adjusted to a safe working height for carers.

Elevating head raise

• Enables independent adjustment of position.

Knee break

• Helps prevent a person from sliding down the bed and possibly shearing their skin, especially if the foot of the bed is raised so that the knees are bent prior to elevating the head raise.

Vascular leg raise (electric or mechanical)

• Enables a person with oedema to elevate their legs fully, rather than just bending at the knees.

Under bed clearance

• Must be sufficient to enable a mobile floor hoist access for transfers.

Castor size

• Affects manoeuvrability of the bed. A bed moves more easily with larger castors.

Central locking brakes

• Make it easier to unlock the brakes if the bed needs to be moved frequently.

Width of the bed

• Can influence the ease of completion of personal care tasks and bed mobility.
• Some electric beds are available in king single, double, queen and king sizes.
• Queen and king size beds usually have the option of a central split that would enable independent operation of the elevating head raise on each side.
• Larger stature people who need extra width to turn are usually prescribed king single beds.
• Consider space and carer requirements if scripting a wider bed. A second bed that sits alongside the other bed is an alternative to a wider bed.

Bed sections vary in length

• May influence the comfort of the person.
• Review their anthropometrics, pain and flexibility.

Bed extensions

• Available with some beds and are either fitted in the middle or at the foot end of the bed.
• Review person anthropometrics, pain and flexibility when considering either option for bed extensions.

Attachment sites

• Consider if a person requires an overnight drinking system, night call system, environmental control system or side rails.

Bed controls

• Can be customised so that they can be operated with any switch, and in some cases through an environmental control system.
• Switches that can interface with a scanning bed controller include sip and puff, joystick, rocker and toggle.

Side rails

• Full length, or clamp on, assist with bed mobility and safety.

Further information

Clinical guidelines and information

• Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals [pdf]. 2^nd Ed. Washington DC: Paralyzed Veterans of America; 2014 [cited 5 March 2021].

Clinical practice tool

• Queensland Spinal Cord Injuries Service. Mattress Selection, Trial, Assessment and Evaluation [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2018 [cited 5 March 2021].

Clinical rationale

Pressure care mattresses (support surfaces) are designed to reduce the interface pressure through increasing the body surface area or alternating the area in contact with the support surface.

Main types of mattresses

Reactive (constant low pressure, static, pressure redistributing) support surface

• Powered or non-powered
• Has the ability to change its load distribution properties in response to a pressure load
• Moulds to the person’s shape through immersion and envelopment in order to redistribute body weight over a larger contact area
• Interface pressure remains constant while the person remains in one position but is redistributed over a wider surface area.

Active (alternating pressure, pressure relieving) support surface

• Produces alternating pressure through mechanical means regardless of the pressure load
• Achieved through alternation of air pressure in support surface air cells on a programmed cycle time
• Mechanism continually changes the part of the body experiencing higher pressure loads.

Individual characteristics

• Pressure injury history
• Level of injury including sensory and motor function
• Height and weight
• Bed mobility: Can the person change position independently?
• Method of transferring into bed: Can the person transfer independently or is a hoist required?
• Continence management
• Pain
• Spasm.

Assessment

An adequate trial of at least a week is essential in determining the suitability of a mattress.

If the trial occurs in hospital, ensure that conditions at home are simulated e.g. turns or no turns overnight.

Once a mattress has been selected for trial:

1. The person should lie on it for an hour or two.
2. Undertake a thorough skin check prior to sleeping on it overnight.

Considerations when assessing the suitability of a mattress

Skin

• Has skin integrity been maintained?
  • Pink or red skin over bony prominences indicates that the mattress is not effective.
• Does the person bottom out?
  • Assess by doing a hand check under the lowest point of the body on the mattress when the person is lying and sitting to check for mattress compression.
• Does the mattress control friction and shear?

Comfort

• Is it comfortable?
• Was there any effect on sleeping patterns?

Function

• Is functional status maintained? (e.g. bed mobility, ability to dress and self-catheterise)

Transfers

• What is the impact on transfers?
• Is the surface stable enough to maintain safe transfers?
• Does the floor to top of mattress height interfere with transferring ability?

Moisture

• Does the mattress control moisture and temperature?

Noise and power source

• If there is a pump, can the person tolerate the noise of the pump?
• Is there a reliable power source? Consider use of uninterrupted power supply in remote areas.

Partner

• Is the mattress type and height compatible with partner’s sleeping arrangements?

Carers

• Is there any impact on carers?

Further information

Clinical guidelines and information

• Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals [pdf]. 2^nd Ed. Washington DC: Paralyzed Veterans of America; 2014 [cited 5 March 2021].

Clinical practice tool

• Queensland Spinal Cord Injuries Service. Mattress Selection, Trial, Assessment and Evaluation [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2018 [cited 5 March 2021].

Clinical rationale

A mobile floor or powered ceiling hoist may be required:

• when a person is unable to transfer due to level of injury or function, increasing age, decrease in upper limb strength, shoulder overuse injuries, carer limitation, increased weight, frailty (of person or carer) and presence of pressure injuries
• to decrease human cost and increase quality of life for the user
• to help preserve upper limb function and reduce the risk of developing shoulder overuse injuries by reducing the number of transfers that a person performs each day
• as a substitute for care or to maintain independence – some people with low level paraplegia can transfer themselves independently using a ceiling hoist. It is essential that they can insert and remove the sling or body support system safely without damage to their skin.

Individual characteristics

The type of hoist and sling required is dependent on the following.

• Level of injury or function
• Age
• Height and weight
• Skin integrity
• Pain and spasm
• Falls history
• Psychosocial needs
• Ability to comply with usage
• Personal comfort and positioning when using hoist
• A standing hoist or transfer aid may be appropriate for people who are medically cleared to weight bear.

Other considerations

Environment

• Is there sufficient circulation space in the area where transfers take place?
• Is there clearance for a mobile hoist under the bed?
• Is there clearance for a mobile hoist around equipment (e.g. power wheelchair) ?
• Is there height clearance for all transfers?
• Is the mobile hoist able to be manoeuvred easily on floor surfaces where transfers take place?
• Is the hoist suitable for all transfers, including picking a person up from the floor?
• Can the ceiling structure support a ceiling hoist if this is being considered? A structural engineer will need to complete an assessment of the ceiling.

Carers

• Is care available?
• What are the workplace health and safety requirements?
• What is the carer feedback when trialling a hoist?

Cost

• Cost and available funding.

Options commonly prescribed

Hoists

• Mobile hoist with standard yolk or pivot frame attachment
• Standing hoist if able to weight bear
• Ceiling mounted or free-standing gantry
• Vehicle – driver or passenger
• Safe working limit will vary along with hoist size and type.

Slings

• Type of sling determined by hoist used; general purpose slings with or without head support are generally used.
• Various sizes are available.

Fabrics

• Generally polyester, nylon or mesh are used.

Custom slings

• Alternatives and modifications to regular commercial slings:
  • Use of silk or sheepskin sleeves inserted over the leg sections of the sling to minimise cutting or rubbing of the skin.
  • The addition of extra handles to assist a carer to position the person in the wheelchair.
  • Parachute silk sling – for people with fragile skin or whose carers have difficulty inserting or removing a sling. It must not be left in situ whilst the person is in their wheelchair, and handles may need to be added to assist with positioning them in the wheelchair. Size may vary from conventional slings.
  • Made-to-measure custom sling.

Further information

Clinical guidelines and information

• Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals [pdf]. Washington DC: Paralyzed Veterans of America; 2015 [cited 21 March 2021].

Clinical practice tool

• Queensland Spinal Cord Injuries Service. Mobile Floor Hoist and Sling: Pre-Trial Assessment [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].
• Queensland Spinal Cord Injuries Service. Mobile Floor Hoist and Sling Trial Evaluation [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].

Consumer resource

• Queensland Spinal Cord Injuries Service. Looking After Your Hoist and Slings [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].

The transfer board is a simple device designed to assist a person in transferring with or without assistance to and from a wheelchair, bed, mobile shower commode or vehicle.

When using a transfer board, the person should not slide across it, rather they should do one or more lifts (with full clearance of their body off the board surface) across the board until in the final position.

People who carry out independent transfers should, where possible during the transfer:

• complete level transfers
• avoid positions of impingement (arm internally rotated, forward flexed and abducted)
• avoid placing either hand on a flat surface when a hand grip (fingers draped over and grasping the edge of the transfer surface) or closed fist can be used
• vary the technique used and the arm that leads.

Clinical rationale

A transfer board may be used:

• when a person is unable to lift themselves in a single movement from one place to another
• to protect skin integrity by avoiding contact with the wheel
• to preserve shoulder function by reducing the amount of force required for lateral movement thereby lessening the chance of injury or exacerbation of pain
• for transfers over longer distances, for example into a car.

Main types

Over-wheel transfer board

• A perspex board with a cut-out that enables it to fit around the wheel of the wheelchair and a plastic cover that sits above the wheel.
• Helps prevent the user from sitting directly on the wheel during a transfer.

Curved transfer board

• A board that curves around the wheel that is an alternative design to the over-wheel slider.
• Available in a variety of lengths and widths to suit a range of users.

Straight transfer board

• A long wooden or perspex board.
• Used for transfers on and off a commode, in and out of a car and, possibly, from a bed to/from a power wheelchair.
• Note: Ensure that the person’s weight is compatible with the safe working limit of the transfer board.

Other options

Sheepskin sliding mat

• Can be used to transfer a person in/out of a vehicle when they are physically unable to assist.
• When using this equipment two assistants are required to ensure a safe transfer.

Satin or silk cover

• Can be fitted to a straight transfer board to provide greater skin protection during commode transfers.

Folded slide sheet or a slide sheet tube

• Can help facilitate transfers with a transfer board.

Pillowcases

• Can be used to reduce ‘sticking’ to a board when transferring from a wet commode.

Further information

Clinical guidelines and information

• Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals [pdf]. Washington DC: Paralyzed Veterans of America; 2015 [cited 21 March 2021].

Clinical practice tool

• Queensland Spinal Cord Injuries Service. Mobile Floor Hoist and Sling: Pre-Trial Assessment [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].
• Queensland Spinal Cord Injuries Service. Mobile Floor Hoist and Sling Trial Evaluation [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].

Consumer resource

• Queensland Spinal Cord Injuries Service. Looking After Your Hoist and Slings [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].

Clinical guidelines and information

• EnableNSW and Lifetime Care and Support Authority. Guidelines for the prescription of a seated wheelchair or mobility scooter for people with a traumatic brain injury or spinal cord injury. Sydney: EnableNSW and LTCSA; 2011 [cited 22 December 2020].
• Agency for Clinical Innovation. Spinal Seating Professional Development Program. Sydney: Agency for Clinical Innovation; 2018 [cited 20 March 2021].

Clinical practice tools

• Dalhousie University. Wheelchair Skills Program. Halifax: Dalhousie University; 2020 [cited 20 March 2021].
• Northwest Regional Spinal Cord Injury System. SCI Empowerment Project Videos: Wheelchair Skills Video Series (21 videos). Encino: Craig H. Neilsen Foundation; 2021 [cited 14 March 2021].
• Agency for Clinical Innovation. Spinal Cord Injury Network Resources. Sydney: Agency for Clinical Innovation; (undated) [cited 20 March 2021].
  Various cushion user guides. Go to ‘Spinal Seating’ subcategory.
• Agency for Clinical Innovation. Spinal Seating Professional Development Program. Sydney: Agency for Clinical Innovation; 2018 [cited 20 March 2021].

For information about NSW spinal seating services

• Agency for Clinical Innovation. Spinal Cord Injury Network Resources. Go to ‘Spinal Seating’ subcategory. [cited 20 March 2021]

Clinical rationale

A mobile shower commode may be used:

• for showering and toileting, and can facilitate independence in intimate hygiene tasks such menstrual management
• to reduce the risk of a shoulder overuse injury associated with multiple transfers each day – by using a mobile shower commode rather than transferring on and off the toilet and on and off a shower chair each day a person can reduce the number of transfers that they do from seven to three
• to promote carer workplace health and safety when assisting a person who is dependent in self-care.

Individual characteristics

• Method of transferring
• Length of time taken with toileting and showering
• Level of independence with toileting routine
• Pressure relieving method
• Propulsion method
• Skin integrity
• Travel requirements
• Posture – whether they require support
• Medical history e.g. postural hypotension.

Features to consider

Commode seats

• Important to maintain good pressure care
• Seat is designed to distribute as much pressure through the greater trochanters and thighs as possible whilst the ischial tuberosities 'float' in the aperture and therefore remain free from pressure
• Note: Accommodation will need to be made if there is a history of greater trochanters pressure injuries
• Double foam-layered seat with foam wrapped around the inside edge of the aperture is also recommended for enhanced pressure care
• Consultation assessment with the supplier is recommended for custom commode seats, with the involvement of an experienced occupational therapist
• If a custom commode seat does not provide adequate pressure care, cushions can be added to the seat, such as an air-filled commode cushion or a padded gel cushion.

Other features

• Folding frame for ease of transport
• Fixed frame for greater stability
• Self-propulsion (two large rear wheels) for independent mobility; large rear wheels can also assist a carer to push the commode
• Attendant propulsion (four small castors) when a person is unable to propel themselves, or for use in small space if assistance is available to move the commode
• Tilt-in-space to help manage postural hypotension, for pressure management or to stabilise posture. This is usually required by people with a high-level injury
• Custom-made pressure reducing foam seat with vinyl hand-made cover to help maintain skin integrity; the seams are underneath the seat, reducing the risk of damage to the skin
• Smaller aperture (distance from IT to IT + 50mm) located towards the rear of the seat (50mm from the back of the seat) recommended to promote neutral position of pelvis, to help prevent pelvic rotation and to reduce pressure around the coccyx area
• Extended aperture to accommodate male genitalia
• Additional padding around aperture to help maintain skin integrity
• Cut-outs (full at front or rear, or partial at sides) for ease of access for bowel care and showering
• Seat-to-back support angle (usually 3°) can be increased to 5° or 7° to enhance posture or to accommodate spasm; can be ordered with angle adjustment
• Padded backrest may be required for greater comfort or pressure management
• Higher back rest or removable backrest extension (one and two strap extensions available) for people with higher level injuries
• Head supports for those with little or no head control
• Arm supports (e.g. troughs) for upper limb positioning and protection
• Push handles at the rear of the backrest may assist a person to maintain balance by hooking an elbow over the handle
• Foot plate angle and orientation can be adjusted to accommodate musculature changes and lower limb position
• Elevating leg supports with calf support for management of oedema
• Padded leg supports for improved pressure management of lower limbs
• Shortened leg supports for those with short limbs
• Anti-tip bars to enhance safety
• Pan and pan carrier if person unable to access the toilet or travels.

Further information

Clinical practice tools

• Queensland Spinal Cord Injuries Service. Mobile Shower Commode Assessment and Prescription Tool for Therapists [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].
• Queensland Spinal Cord Injuries Service. Assistive Technology: Shower commodes. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021]. Handmade commode seat pdfs in various configurations

Clinical rationale

A mobile shower commode is usually recommended for hygiene tasks. However, there are circumstances where alternative equipment may be considered for a person who does sideways transfers or walks. These include:

• living in temporary accommodation
• travel.

The absence of shoulder pathology is essential. The increased risk of shoulder overuse injuries should be considered when prescribing this equipment.

Options

• Padded transfer bench for use in shower recess or over bath
• Shower chair or stool with or without arm supports and a padded seat or cushion
• Bath board – consider whether cushion or padding is required for pressure management
• Padded toilet seat
• Low profile commode cushions e.g. air or gel
• Portable toilet seat cushions
• Shower trolley
• Padded over toilet aid.

Further information

Clinical practice tools

• Queensland Spinal Cord Injuries Service. Mobile Shower Commode Assessment and Prescription Tool for Therapists [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021].
• Queensland Spinal Cord Injuries Service. Assistive Technology: Shower commodes. Woolloongabba: Queensland Spinal Cord Injuries Service; 2017 [cited 5 March 2021]. Handmade commode seat pdfs in various configurations.

Many commercial items of technology can be adapted for people with spinal cord injuries. Computer equipment commonly used by people with a spinal cord injury include: modified mouse (for example a trackball), on-screen keyboard, voice-activated software, tablet and smart phone.

Further information

Clinical guidelines and information

• Ability House: Technology for Independence
  An interactive website with technology options for operation of appliances at home [cited 21 July 2020]
• Ability Technology [cited 21 July 2020]
• Joy Zabala [cited 21 March 2021]

Clinical practice tools

• Queensland Spinal Cord Injuries Service. Environmental Control System Assessment Tool [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2020 [cited 5 March 2021].

Product options and suppliers

• Assistive Technology Australia [cited 21 July 2020]
• TAD [cited 2 December 2020]
• Technical Solutions Australia [cited 21 July 2020]
  A supplier who provides technical support.

Support and follow up

• Ability Technology: Solutions [cited 21 July 2020]
• Australian Rehabilitation & Assistive Technology Association (ARATA) [cited 21 July 2020]
• KWSM Group: Smart Assistive Technology Support [cited 8 August 2020]
• Life Access: Occupational Therapists Specialising in Electronic Assistive Technology [cited 21 July 2020]
• Life Tech: Assisted Technology and Assessment Trial [21 July 2020]
  For practical solutions to everyday activities.
• Northcott: Technology [cited 21 July 2020]
  Computer assistive technology services
• Sargood on Collaroy [cited 21 July 2020]
• TAFE NSW Digital [cited 21 July 2020]
  Courses that support students with a disability to learn computer skills in NSW.
• Technical Solutions Australia [cited 21 July 2020]
  A supplier who provides technical support

Clinical rationale

Environmental control systems (ECSs) aim to increase the level of independence in the home environment. Domestic appliances are controlled using a single switch or a voice command input into the ECS, which sends an output command to the appliance to operate. Devices controlled may include lamps, lights, air conditioners, heaters, televisions, videos, stereos, doors, windows and blinds, beds, computers, and telephones.

Options

• There are many types of ECSs on the market. Some options have specifically been designed for people living with a disability. These should be trialled before purchase to ensure they meet the individual needs of the person. Ensure that the ECS trialled in the clinical setting is compatible with their home environment.
• Various switch options exist, including systems that are activated through a person’s power wheelchair.
• Other options have been designed for the mass market and are available ‘off the shelf’. These are controlled through a hub, a smart device and/or via voice control. Compatible smart appliances can then be added to this system to provide greater control over the home environment, such as smart globes, smart door locks, video intercom, doors, air conditioners and thermostats.
• The number and type of devices that a person wants to operate will determine whether they require a simple or more complex ECS.

Assessment

Joy Zabala, an educator, has developed the SETT framework  to use when considering a person’s assistive technology requirements. Understanding a person’s abilities and requirements is essential before considering appropriate assistive technology.

• Student/Self – information relating specifically to the person who will be using the technology.
  • What is the functional area of concern?
  • What does the person need to be able to do that is difficult or impossible to do independently currently?
• Environment – information related to anything or anyone in places where the technology is expected to be used.
  • What are the supports and barriers in the person’s usual environments?
• Task – information about what happens in the environment.
  • What are the specific things that the person needs to do to be actively involved in their environment?
• Tools – devices, services and strategies that are needed to help a person successfully participate in their environment.
  • What needs to be included when developing a system of assistive technology tools for a [person] with these needs and abilities, doing these tasks in these environments?¹

Further information

Clinical guidelines and information

• Ability House: Technology for Independence
  An interactive website with technology options for operation of appliances at home. [cited 21 July 2020]
• Ability Technology [cited 21 July 2020]
• Joy Zabala [cited 21 March 2021]

Clinical practice tools

• Queensland Spinal Cord Injuries Service. Environmental Control System Assessment Tool [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2020 [cited 5 March 2021].

Product options and suppliers

• Assistive Technology Australia [cited 21 July 2020]
• TAD [cited 2 December 2020]
• Technical Solutions Australia [cited 21 July 2020]
  A supplier who provides technical support.

Support and follow up

• Ability Technology: Solutions [cited 21 July 2020]
• Australian Rehabilitation & Assistive Technology Association (ARATA) [cited 21 July 2020]
• KWSM Group: Smart Assistive Technology Support [cited 8 August 2020]
• Life Access: Occupational Therapists Specialising in Electronic Assistive Technology [cited 21 July 2020]
• Life Tech: Assisted Technology and Assessment Trial [21 July 2020]
  For practical solutions to everyday activities.
• Northcott: Technology [cited 21 July 2020]
  Computer assistive technology services
• Sargood on Collaroy [cited 21 July 2020]
• TAFE NSW Digital [cited 21 July 2020]
  Courses that support students with a disability to learn computer skills in NSW.
• Technical Solutions Australia [cited 21 July 2020]
  A supplier who provides technical support

Clinical rationale

An emergency call system provides a person with a system where they can call for assistance at any time, helping to alleviate any anxiety when alone and encouraging independence.

Some people prefer to use a mobile phone for this purpose although there will be situations when a mobile phone cannot be used.

With the development of smart technology, a person is now able to better access technology through voice access to alert family, carers, friends, or emergency services in an emergency even if their device is not within close proximity. Smart devices such as watches can also include accelerometers that are able to detect a person falling and alert family, carers, friends and/or emergency services.

Options

• There are monitored and non-monitored types.
• The transmitter can often be adapted to suit the individual needs of a person, depending on their level of injury. For example, at least one company can provide sip and/or puff and large switch adaptions.
• If the transmitter requires individual specifications, it is suggested that an occupational therapist liaise with the manufacturer and an organisation, such as Technical Aid to the Disabled, or a specialised technology company, such as Technical Solutions.
• People in rural areas may require additional customisation to offer longer range or consider the use of satellite phones or personal locator beacons.

Further information

Clinical guidelines and information

• Ability House: Technology for Independence
  An interactive website with technology options for operation of appliances at home. [cited 21 July 2020]
• Ability Technology [cited 21 July 2020]
• Joy Zabala [cited 21 March 2021]

Clinical practice tools

• Queensland Spinal Cord Injuries Service. Environmental Control System Assessment Tool [pdf]. Woolloongabba: Queensland Spinal Cord Injuries Service; 2020 [cited 5 March 2021].

Product options and suppliers

• Assistive Technology Australia [cited 21 July 2020]
• TAD [cited 2 December 2020]
• Technical Solutions Australia [cited 21 July 2020]
  A supplier who provides technical support.

Support and follow up

• Ability Technology: Solutions [cited 21 July 2020]
• Australian Rehabilitation & Assistive Technology Association (ARATA) [cited 21 July 2020]
• KWSM Group: Smart Assistive Technology Support [cited 8 August 2020]
• Life Access: Occupational Therapists Specialising in Electronic Assistive Technology [cited 21 July 2020]
• Life Tech: Assisted Technology and Assessment Trial [21 July 2020]
  For practical solutions to everyday activities.
• Northcott: Technology [cited 21 July 2020]
  Computer assistive technology services
• Sargood on Collaroy [cited 21 July 2020]
• TAFE NSW Digital [cited 21 July 2020]
  Courses that support students with a disability to learn computer skills in NSW.
• Technical Solutions Australia [cited 21 July 2020]
  A supplier who provides technical support

Clinical rationale

The provision of upper limb splints and orthotics is common practice in spinal injury units to maintain range of movement.

Upper limb orthotic devices, for example splints or kinaesthetic tape, are a well-accepted therapy for the management of spinal cord injury, particularly in the acute phase of injury. ^1,2 They are generally used to minimise or prevent contractures, spasticity and pain through immobilisation, protection and support of the joints, as well as soft tissue.^1-3 Joint and muscle contractures can severely impact independence for people experiencing spinal cord injury. For example, elbow flexion contractures greater than 25 degrees significantly affect a person ’s ability to transfer and complete depression lifts for pressure relief.^4-6 Although orthoses are widely used, few studies have investigated the efficacy of splinting for the management of upper limb function following spinal cord injury.⁷

Not all people are discharged with an upper limb splint and instead may be discharged with a passive range of movement program. Most people need to be assessed on an individual basis and reviewed if there are any changes in their hand, for example if contractures start to develop.

Splints commonly prescribed

• In most cases people with a C4 lesion and above will have a resting hand splint at night. This splint is designed to prevent contractures and maintain cosmesis. It places the hand in a position of rest or function. It is also often worn by people at night with C5 and C6 lesions.
• For most people with a C5 lesion, who have weak or no active wrist extension, a wrist cock-up brace is used during the day to stabilise the wrist and thus increase function. These can be commercially available splints or a custom-made leather or thermoplastic splint.
• People with a C7 lesion often require a metacarpophalangeal blocking splint (anti-claw) to prevent hyper extension of the metacarpophalangeal joints resulting from poor intrinsic function. The splint is worn during the day. These splints are custom made using a thermoplastic material.
• Thermoplastic writing and typing splints may be prescribed. Contact a spinal unit to request a pattern. A range of splints are also commercially available if required.
• Wheelchair gloves or push mitts prevent skin breakdown and may be essential for effective wheelchair propulsion. These can be padded bicycle gloves, or commercially available wheelchair gloves from health product suppliers. A person with tetraplegia may find that commercial supplied gloves are not suitable however as the thumb position can affect a tenodesis grasp. Individual assessment is essential.

Further information

Clinical guidelines and information

• Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals [pdf]. Washington DC: Paralyzed Veterans of America; 2015 [cited 21 March 2021].

Consumer resource

• Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function: What YOU Should Know - A Guide for People with Spinal Cord Injury [pdf]. Washington DC: Paralyzed Veterans of America; 2008 [cited 21 March 2021].

1. Curtin M. Development of a tetraplegic hand assessment and splinting protocol. Paraplegia. 1994 Mar;32(3):159-69. DOI: 10.1038/sc.1994.29
2. Krajnik SR, Bridle MJ. Hand splinting in quadriplegia: current practice. Am J Occup Ther. 1992 Feb;46(2):149-56. DOI: 10.5014/ajot.46.2.149.
3. Paternostro-Sluga T, Stieger M. Hand Splints in Rehabilitation. Crit Rev Phys Rehabil Med. 2004 01/01;16:233-56. DOI: 10.1615/CritRevPhysRehabilMed.v16.i4.10.
4. Bryden AM, Kilgore KL, Lind BB, et al. Triceps denervation as a predictor of elbow flexion contractures in C5 and C6 tetraplegia. Arch Phys Med Rehabil. 2004 2004/11/01/;85(11):1880-5. DOI: 10.1016/j.apmr.2004.01.042.
5. Dalyan M, Sherman A, Cardenas DD. Factors associated with contractures in acute spinal cord injury. SSpinal Cord. 1998 Jun;36(6):405-8. DOI: 10.1038/sj.sc.3100620.
6. Grover J, Gellman H, Waters RL. The effect of a flexion contracture of the elbow on the ability to transfer in patients who have quadriplegia at the sixth cervical level. J Bone Joint Surg Am. 1996 Sep;78(9):1397-400. doi: 10.2106/00004623-199609000-00016.
7. Spinal Cord Injury Research Evidence Team. The SCIRE Project. Orthoses [Internet]. Vancouver: Spinal Cord Injury Research Evidence Team; 2020 [cited 5 March 2021].

Review of the upper limb for people with a tetraplegic injury can be done through the tetraplegic hand clinic at Royal North Shore Hospital. This clinic is held monthly with the aim of assessing the person for potential surgical intervention, that is nerve or tendon transfers, to enhance upper limb and hand function. It is not limited to people who had their acute management at Royal North Shore Hospital.

Contact details

Physiotherapist & NSW Tetraplegic Hand Clinic Coordinator
Spinal Cord Injuries Unit
Royal North Shore Hospital
Pacific Hwy, St Leonards NSW 2065
Tel: 02 9463 2731

Further information

Clinical guidelines and information

• Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals [pdf]. Washington DC: Paralyzed Veterans of America; 2015 [cited 21 March 2021].

Consumer resource

• Consortium for Spinal Cord Medicine. Preservation of Upper Limb Function: What YOU Should Know - A Guide for People with Spinal Cord Injury [pdf]. Washington DC: Paralyzed Veterans of America; 2008 [cited 21 March 2021].

Clinical rationale

Provision of equipment to use during personal care activities will assist a person with a spinal cord injury to increase their participation and independence.

To maximise the independence of a person with a spinal cord injury when completing personal care tasks, their home may need to be modified to meet their needs. See home modifications section.

Options

Feeding

• Angled cutlery
• Ringed cutlery
• Cutlery with built up handles
• Cutlery inserted into palmar bands
• Plates with built up sides
• Non-slip mats
• Lightweight mugs
• Drink bottle with handles
• Drinking systems attached to wheelchair.

Dressing

• Dressing sticks
• Loops sewn onto clothing
• Adaptable clothing.

Grooming

• Toothbrush in palmar band
• Shaver in pouch with palmar band.

Note: This list is not exhaustive.

Further information

Product options and suppliers

• Assistive Technology Australia [cited 23 July 2020]

Clinical rationale

There are many commercially available products that facilitate independence in the performance of home management tasks. The products are especially useful for those people with tetraplegia who have limited hand function. Consider the impact of pain and fatigue on a person’s ability to complete home management tasks.

Options

Meal preparation

• Chopping board with or without attached knife, spikes or peeler
• Large-handled knives or utensils
• Jar key
• Jar or bottle openers
• Kettle tippers
• Electric can opener
• Kitchen or perching stool
• Traymobile or stable table to transport items or carry hot items to reduce the risk of burns on lower limbs.

Cleaning

• Reaching aids
• Long-handled dustpans and brooms.

Washing

• Front-loading washing machine or dryer
• Lowered clothesline.

Other

• Built-up pens and utensils.

Note: This list is not exhaustive.

Further information

Product options and suppliers

• Assistive Technology Australia [cited 23 July 2020]

The home visit process is different for everyone, depending on need, housing situation prior to injury, compensation status and funding avenues available. It can also be difficult to ascertain the expected functional level upon discharge for people with an incomplete lesion.

For people with a complete spinal cord lesion, where the anticipated functional outcome can be anticipated with a reasonable degree of certainty, the home visit process can be started at an earlier time in their rehabilitation.

Further information

Clinical guidelines and information

• Home Modification Information Clearinghouse: Home Modification Resources [cited 22 December 2020]
• Standards Australia Limited. AS 1428.1-2021 Design for Access and Mobility, Part 1: General Requirements for Access – New Building Work. Sydney: Standards Australia Limited. 2021.
• Standards Australia. AS 1428.2-1992 Design for Access and Mobility, Part 2: Enhanced and Additional Requirements – Buildings and Facilities. Sydney: Standards Australia. 1992.

Clinical practice tools

• Home Modifications Australia (MOD.A) [cited 22 December 2020]
  There is a membership fee for full access to information on website.

There are several services available that provide vocational counselling, rehabilitation and work retraining, and assistance with finding employment.

Further information

Clinical guidelines and information

• Australian Department of Social Services: Job Access [cited 1 July 2020]
  For information and advice about employment of people with a disability including potential support for equipment and workplace modification.

Consumer resources

• University of Sydney: AgHealth Australia – Projects – health and well-being [cited 10 Oct 2020]
• AgrAbility: The Toolbox – Assistive Technology Database [cited 1 July 2020]
  Assistive technology solutions for farmers, ranchers and other agricultural workers (USA) with a disability.

Recreation and leisure activities assist people to not only pursue their individual talents, abilities and interests but also to develop many important relationships and social networks in the broader community.

Further information

Consumer resources

• Australian Government Civil Aviation Safety Authority. Travellers with a disability. [cited 5 March 2021].
• Master Locks Access Key [cited 21 March 2021].
• Royal Rehab.The d-Ability. [cited 5 March 2021]
  Leisure, arts, sports and lifestyle web guide.
• Spinal Cord Injuries Australia: Resource Hub
  An online collection of books, reports, papers, articles, factsheets, websites, forums and videos. See ‘Leisure’ and ‘Recreation’ sections. [cited 24 July 2020].

Product options and suppliers

• Assistive Technology Australia: Product Search [cited 24 July 2020]
  Enter ‘Recreation’ or ‘Leisure’ into the Product Search.

Return to driving Vehicle modification Public transport

Further information

Clinical guidelines and information

• Austroads: Assessing Fitness to Drive. [cited 7 March 2021].
• Transport for NSW: Assessing fitness to drive – information for health professionals. [cited 7 March 2021].
• Transport for NSW: Driving with a disability. [cited 7 March 2021].
• Transport for NSW: Mobility Parking Scheme. [cited 21 March 2021].

Consumer resources

• Transport NSW: Planning an Accessible Trip. [cited 7 March 2021].

To find a driver-trained occupational therapist

• Occupational Therapy Australia: Find an OT [cited 7 March 2021].

To return to driving following a spinal cord injury the person may require medical clearance and may be required to undergo further assessment.

The return to driving process

1. Notify Transport for NSW
   • A licensed driver has a legal obligation to notify Transport for NSW of a spinal cord injury as it can affect their ability to drive.
2. Medical clearance
   • A NSW Fitness to Drive Medical Assessment form must be completed by a medical specialist or general practitioner.
   • There are two potential outcomes: the medical specialist may provide clearance for return to driving with no further assessment required or may recommend a driving assessment with a driver-trained occupational therapist.
   • The person’s licence is temporarily replaced with a learner licence during the period of assessment and/or lessons and driving test.
3. Driving assessment
   • The driving assessment will consist of an off-road and on-road component and will determine the need for vehicle modification and driving lessons.
   • The driver-trained occupational therapist will advise the Transport for NSW of the assessment outcome.
4. Test with Transport for NSW 
   • The test with Transport for NSW is undertaken with the recommended modifications that can be completed in a driving assessor’s car.
5. Modification
   • The recommended modifications will need to be installed into the person’s vehicle.
6. Return to driving
   • Once deemed appropriate, the person can return to driving and their licence will be updated with conditions specific to their needs and vehicle modifications.
   • The person may also be eligible for an Australian Disability Parking Permit.

Considerations

• Method of getting in and out of the vehicle
• Funding for assessment and lessons
• Stowing the wheelchair
• Potential side effects of medications
• Pressure injury prevention.

A person must consider whether they will be a driver and/or passenger prior to organising vehicle modifications. It is best to seek the support of a driver-trained occupational therapist to script vehicle modifications if travelling as a passenger in a wheelchair. Modifications must be undertaken by an appropriately-qualified person who can provide the certification required by Transport for NSW on completion.

Considerations

• Method of getting in and out of the vehicle
• Funding for modifications
• Stowing of the wheelchair
• Restraints
• Whether the person will drive from wheelchair or car seat
• Other users of the vehicle
• Age of current vehicle
• Type of vehicle selected
• Insurance.

In NSW most public transport services are accessible.

Considerations

• Access to public transport
• Width of wheelchair
• Safe working limit of ramps
• Accessibility of the station
• Technology (using Trip Planner, Google Maps, etc.)
• Places to sit.

Consumer resources

• Spinal Cord Injuries Australia: Resource Hub
  An online collection of books, reports, papers, articles, factsheets, websites, forums and videos. See ‘Parenting’ section. [cited 24 July 2020]
• Queensland Health. Queensland Spinal Cord Injuries Service: Health and Wellness. [cited 24 July 2020]
  See Parenting Babies and Toddlers - A Practical Guide to Equipment That Can Help Parents with SCI. Brisbane: Queensland Health; 2014.
• TAD [cited 24 July 2020]
  For unique solutions for parenting equipment.

Product options and suppliers

• Assistive Technology Australia: Product Search [cited 24 July 2020]
  Enter ‘Parenting’ into the Product Search.

The information in this section has been adapted from the Consortium for Spinal Cord Medicine and Insurance and Care NSW (icare) publications.^1,2 It is neither exhaustive nor prescriptive, and refers to complete injuries, rather than incomplete injuries.

As every person with a spinal cord injury will have different factors contributing to their functional requirements, they must be individually assessed. It is essential that each person is assessed in their own environment or in a replica of it.

Furthermore, the person is likely to require additional assistive technology for other activities and participation in life roles depending on their individual preferences and lifestyle choices.

Tables

C1-4

C5

C6

C7-8

T1-9

T10-L1

L2-S5

For more information

• Consortium for Spinal Cord Medicine. Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health Care Professionals. Washington DC: Paralyzed Veterans of America; 1999 [cited 3 September 2020].
• Lukersmith, S (Ed.). Guidance on the Support Needs for Adults with Spinal Cord Injury [pdf]. 3rd ed. Sydney: icare (Insurance and Care NSW); 2017. [cited 13 August 2020].

1. Consortium for Spinal Cord Medicine. Outcomes following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health Care Professionals [Internet]. Washington DC: Paralyzed Veterans of America; 1999 [cited 3 September 2020].
2. Lukersmith, S (Ed.). Guidance on the support needs for adults with spinal cord injury. 3rd ed. Sydney: icare (Insurance and Care NSW); 2017. [cited 13 August 2020].

Transfers and moving around

Self-care

Domestic life

Transfers and moving around

Self-care

Domestic life

Transfers and moving around

Self-care

Domestic life

Transfers and moving around

Self-care

Domestic life

Transfers and moving around

Self-care

Domestic life

Transfers and moving around

Self-care

Domestic life

Transfers and moving around

Self-care

Domestic life