Spinal cord injury physiotherapy guidelines: key updates & clinical insights
New guidelines from Australia and New Zealand are charting a clearer course for physiotherapy in spinal cord injury (SCI) care. Here’s what’s new and what it means for clinicians, students, and families eager to optimise rehabilitation.
Why new SCI physio guidelines matter
For the first time, Australia and New Zealand have comprehensive clinical practice guidelines specifically for physiotherapy management in SCI. Until now, there was no nationally consistent, evidence-based advice for physios treating people with spinal cord injuries. These guidelines – developed by leading experts and people with SCI over three years – answer 100 important clinical questions with either evidence-based recommendations or consensus statements. In total, the panel issued 14 evidence-backed recommendations and 80+ consensus opinion statements, each labelled as strong or weak, and either for or against an intervention.
In short: The guidelines distil the latest research and expert experience into practical advice on what works (and what doesn’t) in SCI rehab. They cover everything from strengthening partially paralysed muscles to clearing lung secretions, managing spasticity, preventing shoulder injuries, improving fitness, and more. For clinicians, this means clearer direction in treatment planning. For patients and families, it means more transparency and confidence about the rehab strategies being used.
Multidisciplinary, lifelong care as a foundation
A strong theme is holistic, continuous care. The guidelines affirm that a person with a new SCI should be managed in a specialised SCI unit by a multidisciplinary team (including physiotherapists) from the very start.
Early involvement is critical: if the person has respiratory muscle weakness (a common issue in cervical or high thoracic injuries), a physio should assess them within 24 hours of hospital admission. Physiotherapy isn’t a one-off burst during acute rehab – the panel emphasises that people with SCI should continue to have access to physiotherapy throughout their lives as needed.
Families and patients can expect ongoing support, with periodic physio check-ups and interventions even years post-injury to address new issues or goals. Importantly, all therapy should be delivered by qualified professionals and tailored to the individual’s needs.
The guidelines remind clinicians to educate patients on the risks and benefits of interventions and always practise person-centred care. This includes empowering people with SCI in their own rehab – involving them in setting goals and giving them copies of personalised exercise programmes for home.
Breathing easier: respiratory health recommendations
Because SCI can profoundly affect breathing, respiratory physiotherapy features prominently. The guidelines offer steps to improve lung function and cough effectiveness:
Respiratory muscle training (RMT): For people with weakened breathing muscles, targeted exercises (like using inspiratory muscle trainers) may help increase respiratory strength.
Abdominal binder: Wearing an abdominal binder while sitting is advised to boost lung volumes in those with paralysed or weak abdominal muscles.
Positioning for lung volume: Positioning a patient flat on their back (supine) rather than upright can temporarily improve lung volumes in people with SCI who have abdominal muscle paralysis.
Air stacking and deep breathing: Breath-stacking and deep-breathing exercises may help improve lung capacity.
Cough and secretion clearance: Postural drainage and assisted coughing are strongly supported. Cough assist devices can be used where available, ideally combined with manual cough techniques for maximum effect.
Regaining movement: strength and skill training
The guidelines reinforce that strength can be improved even in the context of SCI.
Strength training for partially paralysed muscles: For muscles that still have some function, resistance training is recommended. Targeted exercise can improve voluntary muscle strength even in weak or partially innervated muscles.
FES combined with exercise: Combining functional electrical stimulation with voluntary exercise is encouraged. FES cycling can help maintain muscle bulk and cardiovascular fitness.
Practice functional skills: The guidelines strongly endorse motor skills training – practising the actual tasks needed for independence, including transfers, sitting balance, wheelchair skills, standing and walking where appropriate.
Know when not to walk: Where there is no voluntary movement in the lower limbs, gait training will not restore functional walking. In these cases, therapy time is better spent on wheelchair skills and upper limb strengthening to maximise independence.
Managing spasticity and contractures
Muscle spasticity and joint contractures are common after SCI.
Stretching and splinting: Long-duration stretching, splints and serial casting may help maintain joint range or treat contractures. Passive range of motion exercises remain important to prevent stiffness.
Reducing spasticity: Passive movements are not effective for reducing spasticity. More functional approaches, such as standing in frames and FES cycling, may help manage tone.
Preventing pain and protecting shoulders
Shoulder care: The guidelines stress education to avoid shoulder overuse and recommend shoulder strengthening exercises to prevent pain and injury.
Pain relief: TENS (transcutaneous electrical nerve stimulation) may help reduce pain. Massage therapy can also be used as an adjunct.
Preventing subluxation: For people with tetraplegia, arm supports and slings are strongly recommended to prevent shoulder subluxation.
Boosting fitness and cardiovascular health
Adapted aerobic exercise: Upper-body aerobic exercise such as arm cranking, hand cycling or circuit training can improve cardiovascular fitness.
FES-assisted exercise and sports: Using FES cycling to engage paralysed muscles, as well as encouraging participation in sports, are strongly supported.
Everyday mobility: Wheelchair propulsion can also be used as a form of exercise to improve endurance and fitness.
Strong vs weak recommendations
Strong recommendations mean the panel is very confident in the benefits versus risks. These are the “definitely do this” or “definitely avoid this” actions.
Weak recommendations mean the intervention probably has more benefit than harm, but there is more uncertainty or it may depend on individual circumstances.
Strong recommendations form the backbone of standard care, while weak ones encourage clinicians to use their judgement and tailor decisions to each person’s needs.
Final thoughts
These guidelines provide clarity and confidence for clinicians to deliver evidence-informed care while supporting patients and families to understand the rationale behind rehabilitation choices. They highlight that physiotherapy after SCI is not one-size-fits-all – it is a collaborative, lifelong process.
By following the guidelines, therapists can prioritise interventions that truly make a difference, avoid those unlikely to help, and empower people with SCI to achieve the best possible outcomes.
Sources:
1. Glinsky, J. V., Harvey, L. A., & the Australian and New Zealand Physiotherapy Clinical Practice Guidelines Consortium. (2022). Australian and New Zealand clinical practice guideline for the physiotherapy management of people with spinal cord injury (Version 1.2). John Walsh Centre for Rehabilitation Research & The Kolling Institute. https://www.sciptguide.com/wp-content/uploads/2024/11/SCI-SCIPT-CPG-V1.2.pdf
Trudinger, M. (2024, June 3). Finding consensus: guiding physiotherapy for people with spinal cord injury. InMotion (Australian Physiotherapy Association). https://australian.physio/inmotion/finding-consensus-guiding-physiotherapy-people-spinal-cord-injury
Glinsky, J. V., & Harvey, L. A. (2024). Physiotherapy management of people with spinal cord injuries: An update. Journal of Physiotherapy, 70(X), xx–xx. https://www.sciencedirect.com/science/article/pii/S1836955324001024
World Physiotherapy. (2023). Australian and New Zealand clinical practice guidelines for physiotherapy management of people with spinal cord injury [Conference proceeding]. World Physiotherapy Congress. https://world.physio/congress-proceeding/australian-and-new-zealand-clinical-practice-guidelines-physiotherapy-0