Spinal cord injury (SCI) causes severe disability and secondary complications with an associated high burden of care. The estimated annual global incidence is 40 to 80 cases per million population. Up to 90% of these cases have traumatic causes, although the proportion of nontraumatic SCI appears to be growing. Most individuals with SCI are males (78%) and the overall average age at injury is 43. Males are the most at risk in young adulthood (20–29 years) and older age (70+ years). Females are the most at risk in adolescence (15–19) and at older age starting in their 60 s. Studies report male-to-female ratios of about 2:1 among adults. Many of the consequences associated with SCI do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social, and policy environments.
Common associated conditions experienced in persons with SCI are neurogenic bladder, bowel and sexual dysfunction, neuropathic and musculoskeletal pain, spasticity, pressure injury (PI), orthostatic hypotension, autonomic dysreflexia (AD), respiratory insufficiency, and metabolic and cardiovascular disorders. The top three most frequently reported secondary complications are urinary tract infection (UTI), AD, and PI with incidences of 62%, 43%, and 41%, respectively.
Within the first year after discharge from inpatient acute rehabilitation, persons with SCI develop on average two to three distinct SCI-related complications. As there are an increasing number of aging persons with SCI, cardiometabolic disorders and obesity have become conditions that need to be monitored closely. Preventive measures should be considered after SCI since they may influence cardiovascular health as well as subjective well-being. Prevention of secondary conditions is also important since such conditions affect health, “self-management,” and quality of life (QoL) as persons with SCI age.
Many individuals with SCI live in rural areas without rehabilitation services and must travel hours to see an SCI specialist. There is also a lack of providers in the community who have knowledge and experience treating persons with SCI. These barriers can lead to delays in diagnosis and treatment of secondary complications and may ultimately impede the patient’s ability to reintegrate back into the community.
Barriers to self-management in persons with SCI include physical limitations, secondary complications, lack of accessibility, caregiver burnout, and lack of funding. Persons with SCI also frequently have extensive needs for disposable supplies and durable medical equipment (DME) and additional needs to document their disabilities for varying purposes (e.g. obtaining disability benefits and disabled parking permits, leave from school/work, documentation of service/emotional support animals, need to fly with medical equipment). These issues present significant challenges for individuals with SCI when they are reintegrating into their community.
In 2016 an international panel of leaders in SCI and telehealth coined the term “telespinalcordinjury” or “teleSCI” at the International Spinal Cord Society (ISCoS) Annual Meeting in Austria. Technological solutions and performing rehabilitation visits via telehealth can mitigate barriers by reducing or eliminating burdens such as the time it takes to travel, the need for caregiver support to travel, and the costs of transportation itself. The following sections describe teleSCI applied for persons with SCIs throughout the continuum of care.
TeleSCI allows for low-cost and wide-reaching solutions in providing specialized consultation and therapy to persons with SCI living in rural areas and/or who have transportation difficulties. Various forms of technology can be used, ranging from smartphones or tablets that allow for basic audio and visual access to the patient, their caregivers, and their environment to more specialized peripheral devices that allow measurements of vital signs, or more sophisticated examination of limb movements, skin condition, speech, facial expressions, mood, and gait. This is of particular importance for people with SCI that reside in rural areas, whose access to medical services may be limited. The successful integration of teleSCI into traditional in-person health care practices can bridge the discrepancy of quality of care between rural and urban areas, and address issues of lengthy travel and costs that have adverse effects on QoL.
Historically, most studies of telerehabilitation used in the population of people with SCI have been conducted via telephone, videoconferencing, web-based portal platforms, or data messaging devices. In the United States, the Veterans Health Administration (VHA) was an early adopter of videoconferencing, especially for mental health treatment. Today, different telerehabilitation devices are in daily use in many countries around the world, and these telerehabilitation models can reduce the distance needed to consult with SCI specialists. Nevertheless, transportation to local health centers with access to the tools remains a barrier in some places where people do not have adequate internet at their homes or access to a cell phone. In the United States, the VHA has also tried to minimize the “digital divide” —the gap in those who have access to digital devices and the internet and those who do not—by providing tablets and internet access to veterans who are not able to afford devices of their own.
One of the first reports of using teleSCI was in 1999, when telerehabilitation was demonstrated to successfully manage PI. In 2001, Philips et al. compared the standard of care between inpatient care and the use of supporting care using telephone and videoconference. The results showed improved health-related outcomes for patients in the telephone and video group. The European “Thrive” teleSCI project showed no difference in the occurrence of clinical complications when telerehabilitation was used, but there was a higher improvement of functional scores in persons who participated in telerehabilitation interventions.
A number of studies have examined the feasibility and efficacy of care delivery via telerehabilitation to the SCI population. Utilizing and integrating telerehabilitation into treatment practices may offer a unique and low-cost alternative to traditional on-site medical care. Telerehabilitation interventions have also achieved high satisfaction scores for care in persons with SCI and may decrease the rates of rehospitalization after hospital discharge. However, despite these benefits and the fact that telerehabilitation has been available for decades, telerehabilitation is still not considered standard of care for this group of people.
Incorporating TeleSCI Into a Rehabilitation Practice
Successful implementation of teleSCI requires consideration of several environmental and logistical factors. First, the availability of a private area to conduct the teleSCI visit must be confirmed, as well as access to usable teleconferencing platforms that work with commercially available products (i.e., smartphones and tablets). Effective telehealth visits mirror in-person clinical encounters by being well lit, with the provider centered on the screen, and through efforts to make eye contact by looking directly into the camera to facilitate rapport.
Using TeleSCI for Acute Assessment and Management
Acute care of persons with SCI starts at the scene of an accident if a person sustains a traumatic SCI or at least in the emergency department (ED) when patients arrive with symptoms of SCI. First responders and/or providers in the ED in remote areas may not be familiar with managing persons with acute SCI. Furthermore, an SCI specialist will most likely not be available on-site for the majority of the hospitals in the world to assist critical care providers to manage these patients. Acute care management of SCI involves accurate neurological examination to determine the degree of injury, management of hemodynamic instability and respiratory insufficiency, bladder management, and surgical interventions. While telemedicine is used for acute stroke management, as of yet, teleSCI has not been used routinely for acute SCI care. However, like telemedicine for stroke, it should be possible to use teleSCI to assist with diagnosing and managing persons with acute SCI who are in an ED or in an ICU. Video consultation with acute care facilities is also an appropriate way for rehabilitation facilities to ensure patient stability prior to admission, evaluate for PI, and confirm presumed level and degree of injury. Remote collaboration between different specialists can also be performed between departments and wards during an inpatient stay, and teleSCI can be used for planning the rehabilitation stay for patients needing readmission.
Prognosis and Ongoing Research Studies
After acute SCI, patients should have a neurological examination based upon the International Standards for the Neurological Classification of SCI ( Fig. 3.1 ). In order to facilitate assessment with teleSCI, it is beneficial for patients to have a copy of their neurological examination and to know what date it was performed. After injury, many patients are interested to hear about their prognosis and ongoing clinical trials, and this baseline examination can assist physicians in counseling. With proper assistance, lighting, and positioning of the patient for examination, a repeat neurological examination can also be performed to assess recovery of function. Some physicians may use teleSCI on an ongoing basis to discuss prognosis and neurological recovery with individuals with SCI; however, video-based teleSCI is preferred, which will allow for visualization of the patient’s facial expression and reaction to what is being discussed.
TeleSCI in Inpatient Rehabilitation
During inpatient rehabilitation, teleSCI can serve many useful purposes. As shown during the COVID-19 pandemic, it can be used to minimize spreading infections during group meetings between patients and allow providers to see patients without gowning and entering their rooms. TeleSCI can also be used for team conferences across facilities, and it can allow specialists from another facility to see a patient. It has been shown to be useful to use an app to perform a home visit prior to discharge for a patient. It has also been successfully utilized for wheelchair clinics and can effectively be used to allow community-based providers to learn about the needs of the individual with SCI when they return home.
TeleSCI Outpatient Management Applications
Providers with limited experience in working with the SCI population may have inaccurate preconceived notions about the capability of their patients to utilize telehealth platforms, especially if they have not previously interacted with the patient. To avoid these pitfalls, providers should ask patients about their current usage of a smartphone or tablet. Patients who can access the internet for news or emails have a 28 sufficient skill level to use teleSCI services.
In longer term planning for patients with upper-limb mobility impairments, consider recommending accessibility features present on most devices such as voice command, or referring to occupational therapy to identify appropriate adaptive equipment to facilitate independence. During times of crisis where these options may not be feasible, assess if a caregiver is available and capable of facilitating a teleSCI visit. When setting expectations for the visit, traditional guidance is to recommend parameters (i.e., being dressed and seated upright vs. in bed and ready for a skin examination) to ensure a positive experience. However, for providers who are unfamiliar with the nuances of the SCI population, flexibility is needed. For example, laying prone is typically not allowed in noninjured patients but may be medically required for a patient with a recent muscle flap to the sacrum.
TeleSCI can be used to manage nearly every secondary condition after SCI. In a recent teleSCI program using FaceTime via iPad, different topics were discussed (general/routine SCI follow-up [63%], genitourinary [12%], pain [8%], spasticity [7%], PI [5%], and other uncommon SCI concerns [5%]). Moreover, persons with chronic SCI who present to an ED with acute medical issues could be seen by a specialist in SCI to assist with management of SCI-related problems.
Pressure Injury Management
As already noted, PI management via teleSCI was one of the first areas where video was used to manage secondary conditions seen in persons with SCI. With teleSCI being performed with the patient in his or her home, patients do not need to travel and thus avoid the risk of the PI worsening. Furthermore, weight shift techniques can be reviewed via teleSCI. Using video, a provider can observe a patient’s methods of weight shift such as tilt-in-space and recline in a power wheelchair, or in a manual wheelchair user, lateral- or forward-lean or full push-up pressure reliefs, and counseling can be provided to correct inadequate weight shifts. More information regarding PI management can be found in Chapter 11 .
Neurogenic Bladder, Bowel, and Sexual Dysfunction
Management of neurogenic bladder via teleSCI should be considered, since assessing and recommending interventions for this condition does not necessarily require physical examination. While initial education is often completed during inpatient rehabilitation, ongoing education of patients and caregivers is often needed, and use of teleSCI can spare a patient office visits to complete this. Detailed history taking and counseling are critical for effective bladder management. This knowledge can be conveyed by teleSCI, either by videoconferencing or by telephone. It is recommended that practitioners use the International Standards for the Assessment of Autonomic Function after SCI to ensure the degree of anticipated versus reported voluntary control of sacral autonomic function is adequately documented ( Fig. 3.2 ). Using the autonomic standards as a basis, history on methods of bladder management (including management strategy, frequency of intermittent catheterization if used, and history of incontinence) can be easily obtained using teleSCI. Patients can also be given a urinal to record urination volume in conjunction with residual volumes obtained through catheterizations, and this can be reported to the provider as appropriate. Bladder medication management can also be provided via teleSCI, including monitoring for adverse effects.
UTIs can be managed either with telephone calls or video-based visits as patients do not need to be seen in person for the providers to obtain a history of symptoms of UTI, such as presence of fever and/or chills, increase in spasms, malaise, abdominal discomfort, increases in incontinence, and/or pain on urination. Color, smell, and clarity of urine can be either verbally described by the patients or urine can be visualized using video. Urine sample can be brought to the patient’s general physician or local laboratory. However, if urodynamic examination is indicated, the patient will need to see a urologist or a urotherapist in-person.
For bowel management, history is important in guiding providers to manage a patient’s bowel function. Using teleSCI, a provider can obtain a detailed history, including frequency and timing of bowel movements, stool consistency, bowel medications being used, diet, fluid intake, and can actually visualize how a bowel program is being done. TeleSCI can also prompt the examiner to visualize whether the patient is using a commode for their bowel program or whether the bowel program is being done in the bed. Based on the history, medications and bowel program may be adjusted. Hemorrhoids can be diagnosed remotely based on history (e.g., periodic rectal bleeding, blood on stool) and visualization of external hemorrhoids via video or photo. If a patient may need a colostomy, counseling about colostomy and its risks and benefits can be provided via teleSCI, including connecting a peer with colostomy with the patient for peer advice. However, there are some occasions when a person with SCI may need an in-person visit, such as rectal examination and radiological imaging. As with bladder management, ongoing education of patient and caregiver is easily facilitated with teleSCI.
Queries about neurogenic sexual function should also be made in conjunction with bladder and bowel function and sexual education can be performed via teleSCI. Chapter 16, Chapter 17 provide complete discussion on neurogenic bladder and bowel, and sexual dysfunction.
Cardiovascular Autonomic Conditions After SCI
AD can be evaluated and managed via teleSCI, as blood pressure measurement and associated symptoms are most critical in managing AD. However, in this case, patients will need to have necessary medications, as well as blood pressure monitors at home, and be able to use them. A diary of blood pressure measurements and pulses over several days with recording of time of the day, associated symptoms, and what activities the patient was doing at the time will be helpful in determining the potential cause of AD and establishing a treatment plan. Similarly, neurogenic orthostatic hypotension can be managed remotely. Depending on the blood pressure measurement and the time of the day when the patient is experiencing hypotension, blood pressure medications like midodrine, fludrocortisone, and/or pseudoephedrine may be prescribed and adjusted remotely.
Pain management, especially for patients with neuropathic pain, usually does not require new physical examination. As pain medications for neuropathic pain are titrated, this can often be done remotely. Moreover, observation of persons with SCI in their home environments can often reveal nuances that can contribute to their pain. In many areas, it is possible for medications to be refilled online so that patients needing regular refills do not need to attend in-person clinic visits just for medication refills.
For those patients who are having musculoskeletal pain, such as shoulder and upper extremity pain—a common secondary condition in persons with SCI—a limited but still worthwhile examination can be done via teleSCI. Using video, a provider can ask the patient to move their upper extremities to see active range of motion (AROM) of shoulders, elbows, and wrists. A modified impingement test and painful arc test can also be done by asking the patient to flex his arm forward and abducting the arm above the shoulder level respectively, and possible rotator cuff tendonitis can be diagnosed. If a caregiver is available at home or if a patient is with a physical therapist, they may also be able to maneuver the patient’s limb to see if pain is induced with passive range of motion and at what degree of range of motion. If probable diagnosis of musculoskeletal pain such as rotator cuff tendonitis, elbow bursitis, or de Quervain’s tenosynovitis can be determined via teleSCI, conservative treatment such as medications and therapy interventions can be ordered remotely; however, if a patient needs a steroid injection or an imaging study, the patient will need in-person visits.
Utilizing teleSCI for chronic opioid management in patients with severe pain can also be considered. Screening for compliance with treatment, monitoring of pain symptoms, determining risk for opioid use disorder, and opioid medication refill can all be done via audio or audiovisual methods. Urine toxicology screen can also be done locally by the patients or could be taken from a visiting nurse provider. Similarly, opioid weaning can be performed via teleSCI.
Spasticity assessment that can be conducted via telerehabilitation has been described. A caregiver can be coached to perform passive range of motion and to feel for the degree of resistance through the range of motion. Providers can also ask the patients themselves to demonstrate AROM, and the effect of spasticity on the activities of daily living (ADLs) can be also be observed by asking the patients to perform different ADLs. Spasticity management by teleSCI can also be performed to increase or decrease medications. If an individual is on baclofen or another medication, for instance, and lives a distance from a health care provider, tapering the medication by a small dosage and reevaluation in a couple of weeks may be much more beneficial than driving a long distance to an in-person visit. Since most antispasticity medications are oral, teleSCI can be a great adjunct to care. Clearly, if patients need interventions, such as botulinum toxin injection or nerve blocks, or have an intrathecal baclofen pump, then in-person visits will be required.
While the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) is highest in the first few weeks of acute SCI, patients with chronic SCI can remain at a higher risk for DVT and PE throughout their life. Thus a patient may report a new asymmetrical swollen leg via teleSCI. In this case, we recommend the patient is directed to go to the nearest ED for further diagnosis and treatment, in light of the risk of PE. Additionally, it is recommended that the telerehabilitation provider always err on the side of caution, and patients with SCI should always be told to seek emergency care immediately with any chest pain and/or shortness of breath. Still, patients with DVT and/or PE who may need to be on chronic anticoagulation medication can also be managed with teleSCI.
Osteoporosis and Fractures
Osteoporosis is another common complication, and leads to pathological fractures in over half of those with chronic SCI. Persons with SCI may not immediately notice that they may have sustained pathological fractures due to reduced or lack of sensation. While fractures after falling from a wheelchair or from a traumatic event may be obvious, many patients also sustain fractures from low-force impact such as during transfers, range of motion, and ADLs. Patients may notice swelling, redness, and/or bruising of a limb days after the fracture as they may not feel pain from the fracture. With teleSCI, the location of the swelling and associated redness/bruise can be visualized, and the patient can be directed to seek care if appropriate in an ED or told to return to their rehabilitation or general health provider for further follow-up.
Common dermatological conditions that are seen in persons with SCI are acne, seborrheic dermatitis, tinea cruris, ingrown toenail, onychomycosis, folliculitis, and drug-induced cutaneous reactions. Except for a severe ingrown toenail that may need surgical intervention, all of these dermatological conditions can be visualized and treated conservatively via teleSCI.
Telerehabilitation has been utilized to evaluate the maintenance of functional status after rehabilitation, upon discharge to home. Moreover, store and forward telerehabilitation has been utilized after discharge in India to evaluate the patient’s status after discharge from acute SCI rehabilitation and to provide and evaluate postdischarge exercise programs. While it is well recognized that home-based exercise programs are effective in improving physical activity and endurance in people with SCI, there are few published studies of teletherapy for persons with SCI. Some use web-based or virtual games (Nintendo Wii), while in 2014, the first teletherapy videoconferencing program was described by Van Straaten. A 12-week exercise program for rotator cuff and scapular stabilization was designed with physical therapists supervising with personal computers. The exercise program showed reduction in pain and improvement in muscle strength in serratus anterior and scapular retractors and in function based on Shoulder Rating Questionnaire (SRQ) and the Disabilities of the Arm, Shoulder, and Hand (DASH) Index.
Gait can also be assessed via teleSCI. Many persons with SCI also use standing frames at home, which are impossible to bring to an in-person visit. TeleSCI will allow therapists and providers to visualize the patients in their standing frames at home and confirm that the patients are in a good position in their standing frames.
For persons with SCI, tele–occupational therapy can allow visualization of the layout of patients’ residences and the condition of DME being used, especially if a person with SCI has more than one piece of DME, such as an electric wheelchair and a manual wheelchair, and may not be able to bring in all their DME to the in-person consultation. The general condition of other DME, such as hospital beds, commodes, and shower benches, can also be visualized with video and if they are in disrepair, then the need for replacement can be documented.
Ambulant Rehabilitation Team
Some hospitals have ambulatory rehabilitation teams or home care teams that can travel from the rehabilitation hospital to the consumer’s home, or to community locations such as assistive aid offices together with the consumer. The Ambulant Rehabilitation Team (ART) can consist of occupational therapists, physical therapists, wound nurses, and/or social workers, amongst other personnel. With this intervention, team members can meet with the local care providers in the consumer’s home to discuss and figure out appropriate solutions to increase activity and participation for the consumer. The ART members can also participate in meetings with the municipality care providers and their leaders or in meeting at the assistive aid offices if there are particular concerns that need to be followed up. However, most of these meetings can be performed via teleSCI, giving the ART members more time to spend with the consumers, instead of in their cars.
Persons with traumatic SCI have a higher prevalence of cardiovascular disease (CVD) and an increased odds of chronic obesity (odds ratio [OR] = 4.05), heart disease (OR = 2.7), hypertension (OR = 2), and diabetes (OR = 1.7), compared with individuals with other traumatic injuries. CVD has become one of the leading causes of death (35%–46%), and the mortality rate due to CVD is 228% higher in persons with SCI than among those without. Hetz et al. found that persons with SCI who considered themselves overweight had more secondary complications, such as fatigue, pain, upper extremity overuse injuries, as well as lower QoL and more depressive symptoms compared with those who did not consider themselves overweight. Barriers to weight management in persons with SCI include lack of established guidelines for weight management specific to SCI, limited wheelchair accessible options to engage in physical activity, difficulties with receiving group counseling, and lack of staffing with expertise in both SCI and nutrition.
Telenutrition (TN) may provide a promising way to address barriers for nutrition management for persons with SCI. In a Veterans Affairs setting, persons with SCI participated in a multidisciplinary CVD risk reduction program. The program consisted of case managers frequently contacting the participants on the telephone and in-person visits by a dietitian, physical therapist, and exercise physiologist. Significant improvements were seen in weight reduction, reduction in plasma insulin levels, and in total cholesterol/high-density lipoprotein (HDL) ratios. In a pilot program using FaceTime, TN was also found to potentially increase healthy eating behaviors in persons with SCI.
SCI can affect an individual’s psychological well-being and compound their physical impairments. Mood disorders that affect QoL are common after SCI. Depression has been estimated at 28% in US veterans with SCI as compared with 22% in civilians with SCI. Cognitive behavioral therapy (CBT) is a well-established psychological intervention to treat depression and has demonstrated a positive impact on various psychological concerns including depression within the SCI population. Telepsychology (TP) for prevention and treatment of psychological disorders with CBT offers many unique physical and psychosocial advantages, such as reduced stress, stigma, inconvenience of travel, and scheduling difficulty, over an in-person appointment with an SCI specialist.
Dorstyn et al. published a systematic review on applications of TP in SCI with a total of 272 participants. The majority of the studies were nonrandomized and uncontrolled, and most of the studies used telephone, with only one using a video format. The telephone counseling studies showed “moderate to large, but non-significant, short-term treatment effects.” Psychotherapy has been also offered by telephone and videoconferencing. The major advantage to teleSCI is overcoming the physical barriers, that is, accessibility, transportation, distance and resources, and delivering specialized SCI care directly to the individual in a private and convenient manner. TP can reduce barriers to care as well as facilitate compliance with interventions to reduce depressive symptomology, mitigate secondary associated symptoms (anxiety), and improve QoL in persons with SCI.
In-person and telephone-based peer support for persons with SCI is feasible and effective in increasing life satisfaction, resource awareness and service usage, as well as improving self-management. Although there are no research studies published on the efficacy of peer support conducted via video, peer support is already being conducted via different available platforms.
Developing a Telehealth System of Care
An important concept in SCI care is development of a system of care. As such, it is important for teleSCI to be a part of the SCI system of care from prevention through lifelong follow-up.
In the United States, a Hub and Spoke model of telerehabilitation delivery is utilized in the VA. Patients travel to a local health center (spoke) for remote communication with more specialized providers at their assigned SCI center (hub). Although this model dramatically reduces the distance needed to consult with SCI specialists, transportation to “spoke” sites remains a barrier because of the need to travel and reliance on a supporter; thus teleSCI is often used for communications between specialists at the spoke and generalists at the sites. Similar models are present in other countries and rehabilitation systems.
After acute inpatient rehabilitation and in the case of shortening of length of stay, home-based postrehabilitation programs by a multidisciplinary team may be beneficial and are frequently provided. The postrehabilitation team can consist of a physiatrist, a visiting nurse, a physical therapist, an occupational therapist, a speech pathologist, a psychologist, a social worker, and/or a case manager. An SCI specialist can coordinate care with the multidisciplinary team via teleSCI by giving guidance on stretching/strengthening, transfer training and ambulation training at home, appropriate DME, supplies, and answering any medical questions that the team members may have. A video visit can be performed when the multidisciplinary team members are visiting the patient at their home. Ongoing education of the patient and their family/caregivers can occur during these video visits.
Aging with SCI
Persons with SCI may experience accelerated aging as compared to their able-bodied peers. The decline in function and/or independence or with potential loss of caregivers that comes with aging makes teleSCI more valuable. With aging, persons with SCI may experience new neurological decline, more musculoskeletal pain, diminished bladder function, worsening constipation, more fragile skin, and diminution of immune function. Depression also has been reported to be more severe for older persons with SCI and for those with longer duration of injury. Persons aging with SCI have increasing needs for assistance as their family members/caregivers age. Therefore attention should be paid not only to the persons with SCI but also to aging family members/caregivers, and teleSCI can be used to address these medical and psychosocial issues on a regular basis. TeleSCI is a valuable way to minimize the burden on the family/caregivers by decreasing the need to assist the patient to get ready for an in-person appointment, the need to provide transportation, and the time spent at an in-person visit. In addition, both older persons with SCI and their older caregivers may experience challenges with using technology and may require additional support and training with devices to be used for teleSCI.
Different platforms and technological devices may be used by persons with SCI for teleSCI. For example, the European “THRIVE” project used a dedicated videoconferencing platform comprising a central unit (set-top box), webcam, microphone, remote controller, and multiple cables, and the system was powered by software designed specifically for people with limited manual dexterity. Now that smartphones have become ubiquitous (in 2019, 76% of people in advanced economies and 45% of people in emerging economies owned a smartphone ), using more mobile and portable devices like smartphones may be more effective and practical for persons with SCI. However, for some persons with cervical SCI with impaired hand function, smartphones may be too small and challenging, if not impossible to use. In that case, larger tablet devices can be an option.
For users who have impaired hand function, specialized accessory equipment may be required. Individuals with higher-level cervical injuries (C1–C4) and with very limited or no use of upper extremity function may be unable to access the touchscreen interface of a tablet device. To address this concern, patients can use adaptive equipment such as mouth stick styluses ( Fig. 3.3 ). A mounting bracket with a rotating arm is also useful for providing stability and flexibility in positioning a tablet device ( Fig. 3.4 ). A wheelchair mount is helpful for enabling individuals with high-level injuries that have limited mobility and upper extremity function to access a tablet from the wheelchair. For individuals with injuries at or above C7 level with limited hand function, the use of an adapted stylus such as the ball top or t-shaped stylus ( Fig. 3.5 ) or a u-cuff ( Fig. 3.6 ) can provide access to a tablet’s touchscreen. Occupational therapists, special educators, and/or speech therapists can be consulted to assist with training patients on the use of tablet devices and their accessories. Most devices have built-in voice control options that are useful for individuals with limited upper extremity function.