C7 complete and below (including paraplegia of all levels)

Key muscles:

  • Triceps: (straighten your elbow)
  • Intercostals / rib muscles: (help with breathing and with steadying the trunk) – In injuries between T1 and T12, the lower the level of the injury, the more rib muscles are working. In injuries below T12 all these muscles are working.
  • Abdominal muscles (help with coughing, steadying the trunk and moving it forwards) – In injuries above T8 there is usually no abdominal muscles function. Below T8, there is wide variation in the amount of abdominal muscle function at each level of injury.
  • Back Extensors (help with steadying the trunk and moving it backwards) – working at the lower levels of injury.

Triceps function allows you to catch and hold a position leaning forward, even if your elbows are bent. You can also push up from a bent elbow position which means you can lean forward and balance much more easily as well as transfer up and down between different heights. Triceps also makes rolling much easier because you can use your arms in an extended position and get enough momentum to roll your body over to the side.

Lifting and holding objects is possible even without the ability to move your fingers. You will be able to use your wrist extensors (bend the wrist back) to form a tenodesis grasp. This compensatory movement will allow you to pick up and hold items in your hand even though the muscles that move your fingers are not working. The muscles for hand movement will be working at the levels just below C7 (C8 and T1).

For people with paraplegia, the lower the level of injury, the more trunk muscles will be working. This will allow you to maintain your balance and move from one position to another much more easily.
Using your head and shoulders to help with balance and moving is still very important, even though you may have some trunk muscles to assist. Good posture in your wheelchair is essential if you want to be able to function independently and to preserve your long term health.

Balance strategies:

You can learn to maintain your body position when you are in a sitting position by moving your head and arms. When you are sitting without support for your trunk, you will need to use a series of movements back and forth to keep your balance unless you put your hands down to lean on. If your trunk muscles are working, you can use these to help stabilise you.

You can learn to perform tasks using your arms while you are sitting up and you can learn to throw your head and arms backwards and catch yourself to lean on your hands. This is called propping.

When you are sitting in your wheelchair, with your trunk supported you will have more balance. If you have paraplegia, you will be able to learn how to hold on to your wheelchair with one hand while you reach to do things with your other hand. If you have quadriplegia then you can learn how to hold onto your wheelchair using your wrist or your elbow. Many people also lean down and rest their chest on their knees when they want to use two hands to perform a task down at ground level.

Performing two handed tasks while sitting up can be a challenge but learning how to counter balance the weight of your arms by leaning your head back can help. Practice in your wheelchair by loosening your chest strap. Explore how changes in your head and arm position can shift your weight. Make sure you have someone spotting you.

Moving on the bed:

You will be able to learn to move on the bed independently.

You will be able to learn how to roll using your head and arms to get momentum and how to get up and lean on to your elbow and move around to get into a sitting position. You can also learn how to move your elbows underneath your body while you are lying on your back and push down through your arms to get up into a sitting position.

You can learn how to sit in a bent forward position called long sitting (with your legs out in front of you on the bed). Then you can learn to move from this bent forward position to a leaning back position, by throwing your head and arms back and landing in the prop position.

Once you have learned to prop, then you can learn to move forward from the prop position and use your arms to push down on the bed to lift your bottom. A special lifting and twisting technique means you can move your bottom across the bed. Maintaining balance on one arm and moving your legs with the other is another important part of moving across the bed.

Some people use a mechanical bed that has features that assist them with getting into an upright sitting position and balance while they are sitting up.


Some people with injuries below C7 use a hoist for their daily transfers on and off the bed. This can reduce strain on your arms and can also be quicker and safer than trying to perform multiple repetitions of the other transfers discussed here. You may find other problems like shoulder pain, spasms, and ill health impact on your ability to perform other transfers safely and you need to consider using a hoist for some transfers.

If you are able to balance and prop in a short sitting position (with your legs down over the edge of the bed) and you are able to lift and move your bottom across the bed, then you can learn to perform a slide board transfer with assistance. You will need to be able to keep your balance while you push down on your arms to get some lift of your bottom. Moving across the slide board requires a specific technique of lift and twist and is difficult to master in the short sitting position. Balance and timing are the key features of this skill, not just strength!

Many people are able to learn to perform this transfer without a slide board. This lift transfer requires very good balance and an ability to lift your bottom in the short sitting position. Some people use a legs up technique to get on and off the bed. This helps with balance but can place additional strain on your shoulders and may put you at risk of damaging your skin from friction.

Once you have mastered the basic lift transfer then getting on and off a variety of things becomes possible: couch, hand cycle, car, the floor, shower bench and toilet to name a few. Transferring up or down a height difference can be difficult, even with triceps function. Good technique and careful practise is crucial to ensure you don’t injure yourself when learning these more advanced transfers.

Many people are able to learn how to transfer into a car; some people are able to get themselves and their wheelchair in the car independently although there are also many people who need assistance. Many people perform a lift transfer into the car and many other people need to use a slide board.

Equipment to get around:

Many people use a manual wheelchair full time. You can learn to use your wheelchair independently in a variety of situations. Some people need help to negotiate slopes, gutters and soft terrain like grass.

Some people use motorised wheels on their manual chair to be able to push their chair independently in more situations. The wheels magnify the force of pushing, making it easier to push with weak muscles. These wheels are called power assist technology. There are also many people who use both a manual and power wheelchair.

Power wheelchairs can cover up to 25 kms per day but they will not get you everywhere you need to go. People who use power chairs travel in a modified vehicle that transports them sitting in their wheelchair. Some vehicles have lowered floors to drive the chair straight in, others have ramps and some have hydraulic hoists that can lift you and the chair up into the vehicle.

Many people are able to drive. They use hand controls to allow them to operate the vehicle. Many people who drive are able to transfer into their car and also get their wheelchair into the car as well. Others use a hoist fitted on the roof of the car to pick up and store their wheelchair while they drive to their destination. (This saves the strenuous task of taking the wheelchair apart and putting it into the car piece by piece). Some people who drive remain in their wheelchair and drive a customised vehicle that allows them to wheel up to the driving position where they dock their wheelchair into place.

Equipment to exercise:

You can learn to use straps, foam blocks and your wheelchair to position yourself to use your body weight for stretch. You may need assistance to move into some of the positions but should be able to remain in the stretch without someone helping. This will help you maintain flexibility in your body which can help reduce pain and spasm.

You can use rubber tubing (Theraband) to perform strengthening exercises for your arms. Take care not to use a band that is too strong as this can cause shoulder blade winging and can lead to shoulder pain. Ask for an assessment from a physiotherapist or exercise physiologist to make sure you are using the correct technique and that you are performing the best exercises for you. You can also use a variety of gym machines and other strengthening equipment although you will need to pay particular attention to your balance and posture when performing exercise.

Many people do not undertake regular exercise for fitness and face the future problems of a sedentary life. You can use an arm crank machine, a hand cycle, a wheelchair roller, your manual wheelchair and a variety of other methods to perform fitness training. Choose a form of exercise that you enjoy and that you can do with your family and friends – everyone does better when they have moral support to exercise!

FES cycling is another option that is effective for providing cardio-vascular exercise. The cycling equipment requires expert knowledge to set up and trial, it is also very expensive.