Examqo › Examqo library › Physical medicine and rehabilitation › Spinal cord injury
Functional outcomes by spinal cord injury level and respiratory function
In complete injury, each level adds a muscle that changes function: C6 allows a tenodesis grasp, C7 (triceps) is the "level of independence" for wheelchair life, and below C4 the patient usually breathes without a ventilator.
Why it matters in the exam
The exam presents a patient with a complete injury at a given level and asks what they are expected to do: breathe alone, push a manual wheelchair, transfer alone from bed to chair, eat, drive or walk. C1–C3: ventilator dependence (or diaphragm pacing), a power wheelchair controlled by head, chin or sip-and-puff, and full dependence for care. C4: usually weaned from the ventilator, power wheelchair, dependent for daily activities. C5: elbow flexion — eating with devices, a power wheelchair with hand control and a manual wheelchair for short distances, assisted transfers.
C6: wrist extension — tenodesis grasp (wrist extension closes the fingers), a manual wheelchair with adapted rims, transfers with a sliding board, driving an adapted car and partial independence in bathing and dressing. C7: triceps — independent transfers, manual wheelchair and independent living in most daily activities. C8–T1: hand function — full independence at wheelchair level. T2–T9: full independence; standing with devices for exercise. T10–L1: household walking possible with long orthoses and crutches. L2 and below: community walking with short orthoses (AFO) and crutches or canes, depending on hip and knee strength.
Breathing: the diaphragm is supplied by the phrenic nerve (C3–C5). Diaphragm pacing requires an intact phrenic nerve and intact motor neurons, so it does not suit an injury that destroys the C3–C5 nuclei. Tetraplegia has a restrictive pattern: vital capacity (VC), total lung capacity (TLC), functional residual capacity (FRC) and expiratory reserve volume (ERV) fall, but residual volume (RV) rises, because the expiratory muscles are paralysed. VC is larger supine than sitting (the abdomen pushes the diaphragm up), and an abdominal binder improves it when sitting. Cough is weak — assisted (manual) cough is taught and a mechanical insufflation-exsufflation device is used.
Key points
- C4 and below — usually no ventilator.
- C6 — tenodesis and a manual wheelchair.
- C7 — independent transfers.
- L2 and below — community walking with devices.
- Tetraplegia: VC falls, RV rises; VC better supine.
Summary table
| Level | New muscle | Expected function |
|---|---|---|
| C1–C3 | — | Ventilator or diaphragm pacing; head-controlled power wheelchair |
| C4 | Diaphragm | No ventilator; power wheelchair; dependent for daily activities |
| C5 | Elbow flexors | Eating with devices; hand-controlled power wheelchair |
| C6 | Wrist extensors | Tenodesis; manual wheelchair; sliding-board transfers; adapted driving |
| C7 | Elbow extensors | Independent transfers; independent living in most activities |
| T10–L1 and below | Trunk and leg muscles by level | Household walking with devices; from L2 down — community walking |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Physical medicine and rehabilitation.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- PVA Consortium for Spinal Cord Medicine: Outcomes Following Traumatic Spinal Cord Injury — clinical practice guidelines for health-care professionals, 1999 — Expected outcomes by level
- PVA Consortium for Spinal Cord Medicine: Respiratory Management Following Spinal Cord Injury, 2005 — Ventilation, cough and diaphragm pacing
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.