The deciding rule
Rank them, then checkPut the six in the order you would see them and press Check my order. Two of these are genuine emergencies and the order between them is arguable — but one of them is a breathing problem, and breathing does not wait for an argument.
Red flags that end the session
New or worsening weakness or a rising sensory level. Sudden hypertension with bradycardia in a T6-or-above patient. Unilateral calf swelling, or new dyspnoea and desaturation. Fever with a swollen, warm joint or a new pressure injury. A sudden drop in vital capacity or a weakening cough after cervical injury. High fever with rebound spasticity and confusion in a patient with a baclofen pump. New saddle anaesthesia with urinary retention. Any of these is an SBAR call now, not a note for the morning team.
The harder half of rehabilitationChronic sorrow — recurring waves of grief triggered by milestones, anniversaries, a friend’s wedding, a child’s first steps — is a normal response to a permanent loss, not a failure of coping. Depression runs at roughly a fifth to a third of patients after stroke, spinal cord injury, amputation and progressive neurological disease, and it is undertreated because staff mistake it for realism. Screen with the PHQ-9, ask directly about suicidal thinking, and treat it: untreated depression is the strongest predictor of failed rehabilitation participation. Teach in short chunks at a fifth-to-eighth-grade reading level, use teach-back (“show me how you would do your catheterisation tonight”), and build an action plan the patient writes in their own words.
Prevention, system by system
Six pairs to makeChoose a complication on the left and the routine that prevents it on the right. Each correct pair unlocks the numbers you are expected to know.
One deliberate exceptionIn a patient with a C6 injury who relies on tenodesis, the finger flexors are deliberately allowed to tighten a little, because that tightness is what closes the hand when the wrist extends. Follow the therapist’s hand-positioning plan rather than stretching them out — this is the one place where a contracture is the goal.
Investigate or dose?
A sudden increase in spasticity is a symptom, not a diagnosisIn a patient whose sensation is absent, escalating tone may be the only way the body can report a urinary tract infection, a full bladder, an impacted rectum, a developing pressure injury, an ingrown toenail, a fracture or an acute abdomen. Investigate the change before you increase the dose.
| Drug | How it works | What you monitor |
|---|
| Baclofen | GABA-B agonist — the workhorse; oral doses titrated slowly | Sedation and weakness. Abrupt intrathecal withdrawal is an emergency: high fever, rebound spasticity far worse than baseline, altered mental status, rhabdomyolysis, death. It mimics sepsis and malignant hyperthermia. |
| Tizanidine | Alpha-2 agonist | Sedation and a drop in blood pressure — warn about orthostasis; check liver enzymes. |
| Dantrolene | Works at the muscle rather than the cord | Dose-related hepatotoxicity — baseline and serial liver function tests are mandatory. |
| Diazepam | Helps nocturnal spasms | Falls, sedation and dependence, particularly in older adults. |
| Botulinum toxin | Targets one focal problem muscle | No systemic sedation — the reason to choose it when the problem is one muscle, not the whole limb. |
Spasticity is not purely an enemy. A degree of tone helps with transfers, standing and venous return, and preserves muscle bulk. It becomes a target only when it interferes with function, positioning, sleep, hygiene or skin — and first-line management is daily stretching, positioning, weight-bearing, cold, and removal of noxious triggers.