Physical Therapy Management and Individualized Rehabilitation of Patient with Incomplete Spinal Cord Injury: A Case Report

Background: Incomplete spinal cord injury can present itself very differently depending on the level and severity of the injury. Many factors, such as weight bearing restrictions and co-morbidities, need to be considered when choosing intervention techniques. Thus, the purpose of this case report is to provide an example of successful multi-interventional rehabilitation of a patient with incomplete level spinal cord injury despite complicating secondary factors such as non-weight bearing limitations on his left lower extremity. Case Description: The patient was diagnosed with C4 ASIA C level incomplete spinal cord injury following a motorcycle accident. The patient sustained multiple injuries including ligamentous disruption between C5-C6 at the anterior longitudinal ligament and posterior longitudinal ligament, along with multiple other fractures. He underwent multiple surgeries including anterior cervical disc fusion and closed reduction with external fixation to heal other fractures. He was transferred to an inpatient rehab hospital and later transferred to subacute rehabilitation center for continued rehab. The patient had orders to maintain non-weight bearing status to left lower extremity due to his fractures. Outcomes: This report compared levels of assistance at initial evaluation and discharge. Discussion: This case report supports the multi-interventional rehabilitation approach to incomplete spinal cord injury while considering external factors that complicate patient care such as weight bearing restrictions. It allows clinicians an example of how to abide by restrictions without compromising patient’s ability to meet goals and increase lower extremity strength with incomplete spinal cord injury.