ACUTE PHASE I

     During the first phase of rehabilitation, also known as the acute phase, the newly injured SCI patient is usually:

• Immobilized in traction or in a halo brace or body jacket
• Confined to bed while waiting for or recovering from surgery to stabilize the spine
• Prohibited from flexing, extending, and rotating the spine
• Under close medical care
• Needful of great care, both emotionally and physically

     Occupational therapy should begin within the first 48 hours of admission with an initial evaluation. Immediately after the initial evaluation:

1. A daily range of motion program should be begun, with active and active-assisted ROM of all joints within strength, ability, and tolerance levels
   • Muscle reeducation techniques to wrists and elbows should be used when indicated
   • Progressive resistive exercises to wrists may be done
   • Patients should be encouraged to do self-care activities, such as feeding, writing, hygiene, etc.

2. Total body positioning should be evaluated and instruction to the staff, patient, and family members should be given if necessary.
   • In supine, the patient's shoulders should be externally rotated and abducted to 90 degrees, the elbows flexed, the palms facing the ceiling, and a pillow placed under the forearms
     • In patients with tetraplegia, the upper extremities should be intermittently positioned in 80 degrees of shoulder abduction, external rotation with scapular depression, and full elbow extension to alleviate pain in the shoulders and ROM limitations
     • In patients with injuries at the C5 level, the forearm should be positioned in forearm pronation to prevent supination contractures
   • In side lying:
     • A pillow should be placed in a vertical position under the thoracic region of the trunk
     • The upper extremity under the patient should be placed in 100 degrees of shoulder flexion
     • The elbow should be flexed or extended with the palm facing the ceiling
     • The upper extremity on top of the patient should be placed in pillows in front of the patient

3. Hand splinting needs should be initiated with the selection, fabrication, and fitting of the appropriate splint style. Dorsal, rather than ventral splints should be used to allow maximum sensation when the hand is resting on a surface
   • If there is inadequate musculature to support wrist and hands properly for function and/or cosmesis, the wrist should be supported in extension, with the thumb in opposition. This will maintain the thumb web space and allow the fingers to flex naturally
   • If there is at least F+(3+) strength of wrist extension, short opponens splints should be used to maintain the web space and support the thumb in opposition

4. Facilitation of a tenodesis grasp should be begun during range of motion of the hand, particularly for patients with injuries at the C6 and C7 levels. The wrist is maintained in an extended position while the fingers are flexed, and the wrist is flexed while the fingers are extended

5. The patient should be provided with a basic environmental control, such as a television, telephone, and nurse call system, based on the patient's capabilities and needs, to promote the patient's sense of self-control and independence

6. Education of the patient is begun, including the importance of skin management, pressure relief, and daily ROM, and truthful, but encouraging answers to the patient's question regarding prognosis

7. Education of the family is begun, including discussion of anticipated medical equipment, home modifications, and caregiver training should be initiated

8. As the patient becomes medically stable, ADL and light upper extremity strength training should be begun, particularly for patients who are on prolonged bed rest, followed by transfer to a wheelchair and learning to tolerate an upright sitting position