Physical Therapy for Spinal Accessory Nerve Injury Complicated by Adhesive Capsulitis.

This case illustrates the responsibility of a physical therapist to perform a comprehensive orthopedic and neurologic examination of not only the involved structures but adjacent areas as well.

Spinal accessory nerve injury is documented in the literature as a complication of various surgical procedures or trauma. Surgical procedures contributing to iatrogenic spinal accessory nerve injury are carotid endarterectomy, biopsy of the cervical lymph nodes,[1] radical neck dissection for the treatment of neck and head tumors,[2] and surgical procedures in the posterior triangle.[3]

The spinal accessory nerve arises superficially from a series of filaments located behind the root filaments of the vagus nerve and from the lateral surface of the medulla and upper cervical spinal cord and leaves the cranial cavity through the jugular foramen.[4] The spinal accessory nerve leaves the jugular foramen and passes laterally and backward, either posterior or anterior to the internal jugular vein, then descends obliquely to the upper part of the sternocleidomastoid muscle.[5] At this location, the spinal accessory nerve is vulnerable to injury during surgical procedures. It pierces the deep surface of the sternocleidomastoid muscle, giving off branches for its innervation. It then runs along the deep surface of the sternocleidomastoid muscle to emerge at its posterior border just above the midpoint of the length of the muscle. The nerve then crosses the posterior triangle of the neck on the anterior surface of the levator scapulae and rhomboid muscles. In this region, the nerve is covered only by subcutaneous fat and skin. From the posterior part of the posterior triangle, the nerve descends on the anterior surface of the trapezius muscle, giving off branches to the trapezius muscle[6] (Fig. 1).

[Figure 1 ILLUSTRATION OMITTED]

In addition to spinal motor distribution to the sternocleidomastoid and trapezius muscles, the spinal accessory nerve provides laryngeal and cranial innervation. Therefore, compression in the jugular foramen can affect the spinal accessory nerve, causing dysphagia, hoarseness, and dysarthria. This combination of clinical findings may indicate involvement of cranial nerves IX, X, and XI (the so-called jugular foramen syndrome or Jackson syndrome), whereas involvement of the spinal accessory nerve proximal to the sternocleidomastoid muscle would affect the sternocleidomastoid and trapezius muscles.[4] Distal compression (as in the posterior triangle) would involve the trapezius musculature alone.[4]

Nakamichi and Tachibana[1] provided only general exercise recommendations for treatment of spinal accessory nerve injury. We believe that spinal accessory nerve injury may lead to decreased mobility in the involved shoulder and may contribute to adhesive capsulitis. The purpose of this case report is to demonstrate specific physical therapy interventions, including proximal scapular stabilization exercise, proprioceptive neuromuscular facilitation (PNF), neuromuscular electrical stimulation (NMES), shoulder strengthening exercises with Thera-Band,(*) and pool exercises for a patient with spinal accessory nerve injury complicated by adhesive capsulitis.

Case Description

Patient History and Systems Review

The patient was a 67-year-old woman who was referred for physical therapy 2 weeks after left shoulder manipulation for adhesive capsulitis and 11 weeks after a left carotid endarterectomy. Her cardiologist referred her to an orthopedic surgeon approximately 1 month after the endarterectomy with complications of left proximal clavicular pain and limited range of motion of the left shoulder. The orthopedic surgeon diagnosed adhesive capsulitis.

The patient reported that her shoulder stiffness began 2 days after her neck surgery. Her past medical history also included a right carotid endarterectomy 2 months prior to the left endarterectomy, hypertension for which she was taking spironolactone (25 mg twice daily), a C2 fixation after a motor vehicle accident 8 years previously, and the resection of a right parotid tumor 13 years before. The patient had no previous injury to the left shoulder. She underwent radiography prior to the manipulation, which revealed a normal joint relationship of the left shoulder.

The patient was a retired orthopedic registered nurse who reported that she was unable to lift her left arm high enough to wash her left axilla until after the manipulation, when her shoulder abduction improved to 45 degrees. She said that she also had difficulty with overhead reaching, doing dishes, washing and styling her hair, dressing with the left upper extremity, and holding her 4-month-old grandchild. Her recreational activities were also affected because she was unable to complete her swimming routine due to left shoulder pain and limited motion. Her goals were to regain mobility of her left shoulder to return to her previous levels of activities of daily living, which included swimming, holding her infant grandchild, and hanging clothes on the line.

Examination: Tests and Measures

Pain and posture. The patient reported constant anterior clavicular pain, which she rated 3 on a visual analog scale with 0 indicating no pain and 10 indicating the worst possible pain.[7] She had a notable depression and forward translation of the left shoulder, with atrophy in the left anterior supraclavicular region and left trapezius muscle (Fig. 2). The left scapula was protracted, abducted, and rotated clockwise with increased distance of 9.0 cm from the inferior angle to the T8 spinous process as compared with 7.0 cm on the right. This was measured by the therapist (KH) 2 times for accuracy using a standard metric ruler.

[Figure 2 ILLUSTRATION OMITTED]

Joint integrity, mobility, and range of motion. Initially, the patient had 120 degrees of active left shoulder flexion, and active abduction was limited to 60 degrees. The therapist (KH) collected all data using a goniometer. Riddle et al[8] concluded that measurements of passive range of motion in flexion and abduction are most reliable when the same physical therapist takes the measurements with either a large or small goniometer. The measurements were repeated by 2 additional therapists, who found comparable results for range of motion in the shoulder joint. With lateral (external) rotation, the patient could fully reach behind her head with her hand, with compensation of left shoulder girdle elevation. She had full medial (internal) rotation in the hand-behind-back position and full passive range of motion of the glenohumeral joint with manual scapular stabilization of the examiner's left hand over the lateral inferior aspect of the left scapula. She reported anterior shoulder pain, which she rated as 4 on a scale of 0 to 10 at the end-range of active and passive movements in all directions. Cervical active range of motion was symmetrically limited to 25 degrees of lateral flexion and 35 degrees of cervical rotation due to left-sided weakness and right-sided muscle tightness. She had no limitation of cervical flexion and extension, and she did not report pain with cervical motion testing.

Muscle performance. Strength testing[9] of the left upper extremity revealed 1/5 strength of the left upper trapezius muscle, 2+/5 strength of the left middle trapezius muscle, 2-/5 strength of the left lower trapezius muscle, and 1/5 strength of the left sternocleidomastoid muscle, with minimal contraction noted. The patient had 2+/5 strength of the middle and anterior deltoid muscles and 5/5 strength throughout the rest of her left shoulder and both elbows, wrists, and hands. Right lower trapezius muscle strength was 3+/5, middle trapezius muscle strength was 4/5, and upper trapezius and sternocleidomastoid muscle strength was 5/5. Further testing showed that the left upper and lower trapezius muscles could be stimulated to contraction with NMES with the electrodes placed over the motor points.[10]

To assess the reliability of the measurements, 3 physical therapists with 5, 13, and 25 years of experience repeated the manual muscle testing and measurements of range of motion. They reported data for range of motion within 5 degrees and consistent scores for manual muscle testing.

Cranial nerve integrity. The patient had no dysphagia, dysarthria, or hoarseness, indicating that the spinal accessory nerve was not affected in the jugular foramen.

Evaluation

Evaluation of the examination findings indicated spinal accessory nerve involvement, because the spinal accessory nerve provides motor innervation to the trapezius and sternocleidomastoid muscles, which were weak on the left side. The patient's history and examination findings prompted the physical therapist (KH) to try to identify the most probable causes of this clinical picture. Sweeney and Wilbourn[11] described multiple cases of spinal accessory nerve palsy following carotid endarterectomy. In case reports of a similar nature,[1,12] the authors reported recovery of function in an average of 6 to 12 months. Based on prior cases and the fact that the left trapezius and sternocleidomastoid muscle contraction occurred with NMES and manual muscle testing, we believed that the patient's postsurgical complications would improve to premorbid levels within this time frame. The plan to restore function included the use of NMES to improve muscle performance, range of motion exercises to reduce restrictions, and clinical and home exercise programs to improve physical tasks and activity levels. The referring orthopedic physician was contacted regarding the physical therapy examination, and he agreed to the recommended course of treatment. He stated that he would see the patient as scheduled, 4 weeks after the date of referral.

Intervention

A physical therapy program was initiated 11 weeks after the left carotid endarterectomy. It included outpatient treatment sessions 2 times a week for 3 weeks (Tab. 1), followed by appointments at 16, 18, 22, and 30 weeks after surgery, for a total of 10 physical therapy sessions. The patient was provided with written and illustrated home exercise program instructions (Tabs. 2 and 3) and a chart to help her record daily exercise performance. Treatment goals were to maintain the range of motion obtained by manipulation and to strengthen the muscles affected by the spinal accessory nerve injury.

[TABULAR DATA 1-2 NOT REPRODUCIBLE IN ASCII]

Table 3. Stretching and Strengthening Home Exercises

Exercise            Description

AAROM:(a)           Patient, in a supine position, holds both ends
shoulder            of a cane or dowel rod in a pronated position
elevation           and slowly elevates the arms overhead as far as
with wand           possible, leading with the uninvolved side, and
                    holds for 2-5 seconds, then returns to a
                    resting position.

Scapular            In a prone-on-elbows position, the patient's
stabilization       elbows are directly under the shoulders and
with opposite       thoracic spine in a slightly elevated, neutral
shoulder            position, with the cervical spine in a neutral
elevation           position. The goal is to maintain a neutral
                    thoracic position, contracting the involved
                    scapular and shoulder stabilizers while
                    elevating the uninvolved shoulder into a fully
                    flexed position overhead with elbow extension.
                    Patient maintains the elevation for 2-5
                    seconds, returns to a bilateral prone-on-elbows
                    position, then repeats the movement.

Wall slides         Patient stands facing a wall and slides the
                    affected arm up the wall with the palm facing
                    the patient for elevation and with the palm
                    facing away for abduction. Patient holds the
                    stretch for 2-5 seconds, then repeats the
                    movement.

Cervical            To work the involved sternocleidomastoid
PNF(b)              muscle, patient extends with contralateral
                    rotation and moves in a diagonal pattern into
                    cervical flexion with ipsilateral rotation.
                    Movement should be slow and held in a
                    flexed/ipsilaterally rotated position for 2 to
                    5 seconds and then repeated. Patient starts in
                    a standing position and progresses to a supine
                    position.

Standing            Patient, in a standing position, places
scapular PNF        Thera-Band(c) under the contralateral foot and
                    holds in ipsilateral hand. Patient pulls
                    scapula from position of anterior depression
                    into a position of posterior elevation. Patient
                    progresses from yellow to blue Thera-Band.

Resisted shoulder   Patient, in a standing position, places blue
forward flexion     Thera-Band under the ipsilateral foot and pulls
and abduction       from 0 to 90 degrees into shoulder flexion and
                    abduction.

Shoulder shrugs     Patient, in a standing position, places blue
                    Thera-Band under the ipsilateral foot and, with
                    shoulder adducted to side, elevates shoulder.

Lower trapezius     Patient is positioned prone for manual muscle
muscle              testing of the lower trapezius muscle.[9]
strengthening       Patient pulls blue Thera-Band (tied to table
                    leg) into scaption.(d)

(a) AAROM = active assistive range of motion.

(b) PNF = proprioceptive neuromuscular facilitation.

(c) The Hygenic Corp, 1245 Home Ave, Akron, OH 44310.

(d) Scaption is defined as active elevation (170 [degrees]-180 [degrees]) through the plane of the scapula (30 [degrees]-40 [degrees] of forward flexion), sometimes called "neutral elevation" (Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1997:186).

During the first treatment session, the patient was given a shoulder sling to support and elevate the left shoulder girdle to improve symmetry and was instructed in its use. With the patient positioned supine, the physical therapist performed passive range of motion and manual mobilization of the left glenohumeral joint. Manual stabilization of the lateral inferior angle of the left scapula was provided by the therapist's right hand. With the patient in a right side-lying position, the left scapula was mobilized by the physical therapist into adduction. The physical therapist educated the patient in wand exercises into shoulder elevation, abduction, and lateral rotation. She did 3 sets of 10 repetitions and was asked to continue these exercises at home.

The patient was then positioned in right side lying, and NMES was used with biphasic pulses in burst mode applied via electrodes over the motor points[10] of the left upper and lower trapezius muscles. Neuromuscular electrical stimulation[13] was used to prevent trapezius muscle atrophy initially (sessions 1 and 2) and then to reeducate the scapular muscles in conjunction with scapular PNF exercises (sessions 3-6). A frequency of 50 pulses per second was used, with an "on time" of 10 seconds and an "off time" of 50 seconds,[14] and the intensity was set for an observable muscle co-contraction. McConnell tape was applied over protective tape from the posterior-lateral left acromion diagonally across the back and ended just lateral to the thoracic spinous process T10.[15] After passive range of motion and NMES in the first 2 sessions, McConnell taping and manual scapular stabilization were used with active range of motion to 90 degrees of shoulder elevation into abduction. At session 3, the patient began cervical PNF.[16] For the treatment, the patient was positioned supine with her head off the table and shoulders even with the table's edge. The therapist passively guided the patient's head from cervical extension and right rotation into cervical flexion and left rotation. Treatment progressed in sessions 4, 5, and 6 by adding active range of motion during PNF and manually resisted isometric exercises of the sternocleidomastoid muscle.

In the next 5 sessions, the same regimen was followed, with progressions as described in Table 1. The home program progressed from passive support of a sling and passive range of motion exercises of the shoulder through active assistive to resistive exercises. A general strengthening program for the left upper quadran[17] emphasized improvement of proximal shoulder stability in a gravity eliminated to standing progression. The patient began a pool program of bilateral shoulder horizontal abduction and breaststroke simulation during ambulation after her first 6 sessions (4 weeks after initiation of physical therapy and 15 weeks following left endarterectomy). Her goal was to resume the pool exercises that she had done before her left carotid endarterectomy.

Outcome

During the final session, 6 months after the onset of symptoms, the patient had nearly full strength, with a return of function of her left shoulder with improved glenohumeral and scapular position (Fig. 3). She was able to hold her infant grandchild, hang clothes on the line, dress without difficulty, wash and style her hair, and place objects into upper cabinets and on shelves with either arm. She documented her exercise program on a chart indicating exercises, repetitions, and time. Passive mobility remained unchanged, using full range of motion in the left glenohumeral joint. In standing, she had active left shoulder forward flexion to within 10 degrees of right shoulder forward flexion. Although abduction improved from 60 degrees to 150 degrees with active range of motion and fully with passive range of motion, weakness of the lower trapezius muscle appeared to limit her active range of motion of left shoulder abduction to 150 degrees. Thus, the final home program consisted of lower trapezius muscle strengthening exercise and continued scapular stabilization exercise (Tabs. 2 and 3). All cervical ranges of motion improved bilaterally (45 [degrees] of rotation and 35 [degrees] of lateral flexion). Left anterior deltoid muscle strength improved to 5/5, upper trapezius and middle deltoid muscle strength improved to 4+/5, left middle trapezius muscle strength improved to 4/5, and left lower trapezius muscle strength improved to 3-/5 (as compared with 3+/5 right lower trapezius muscle strength with manual muscle testing). The sternocleidomastoid muscle improved from 1/5 (Fig. 4) to 4+/5, with evidence of visible muscle contraction (Tab. 4, Fig. 5).

[Figures 3-5 ILLUSTRATION OMITTED]

Table 4. Initial and Final Active Range of Motion (AROM) and Manual Muscle Testing (MMT) Data

                           Initial           Final
Movement/Muscle            AROM/MMT         AROM/MMT

Left shoulder
  Flexion                120 [degrees]    160 [degrees]
  Abduction               60 [degrees]    150 [degrees]

Bilateral cervical
  Lateral flexion         25 [degrees]     35 [degrees]
  Rotation                35 [degrees]     45 [degrees]

Left side
  Upper trapezius        1/5             4+/5
  Middle trapezius      2+/5              4/5
  Lower trapezius       2-/5             3-/5
  Middle deltoid        2+/5             4+/5
  Anterior deltoid      2+/5              5/5
  Sternocleidomastoid    1/5             4+/5

The distance between the spinous process of T8 and the left inferior angle decreased to 7 cm, as it was on the right side, although the left scapula was approximately 1 cm higher than the right scapula. Finally, the patient performed a lift test on a pulley system where she was asked to do 10 repetitions of shoulder shrugs with a maximum load established with the uninvolved extremity. This test was not conducted at the initial evaluation due to lack of sufficient muscle strength in the affected extremity. At the exit evaluation, the maximum lift on the right was 49.9 kg (110 lb) for 2 sets of 10 repetitions. The patient was able to lift 49.9 kg 7 times for the first set and 9 times for the second set on the involved extremity.

Discussion

Our physical therapy program deviated from traditional treatment for adhesive capsulitis. After manipulation by the orthopedic surgeon, we concentrated more on proximal stability, muscle re-education, stimulation, and strengthening than on heat modalities and range of motion. The patient's posture, past medical history, and symptoms suggested a spinal accessory nerve injury. She responded to muscle stimulation distal to the nerve injury, and posture and function improved in less than 6 months, which suggests accessory nerve neurapraxia. The 2 other classifications of nerve injury are axonotmesis (interruption of the axon with subsequent Wallerian degeneration; connective tissue of the nerves remains intact) and neurotmesis (complete transection of the nerve).[18]

Studies[12,19] have demonstrated full recovery from spinal accessory nerve palsy in about 1 year. Our patient showed marked improvement in quality of motion and posture in 5 months following the exercise program, which further suggests postsurgical neurapraxia. Without physical therapy, the patient probably would have recovered in 6 to 12 months, as suggested in the literature. The fact that our patient's limitations improved following upper trunk stabilization exercise (postexercise findings of proximal weakness due to a probable compression or stretch injury to the spinal accessory nerve following a left carotid endarterectomy) emphasizes the need for a complete evaluation. We believe that the complete evaluation, including not only the involved area but the entire upper quadrant, contributed to finding the source of the shoulder pain and limitation. If the adhesive capsulitis had been caused secondary to trauma, immobilization, or systemic disease, we would have changed the course of the treatment.[20] This evaluation includes use of observation skills, complete cervical and thoracic assessment, integration of findings with medical history, and basic neurologic examination as outlined in the American Physical Therapy Association's Guide to Physical Therapist Practice.[21] This case illustrates the responsibility of a physical therapist to perform a comprehensive orthopedic and neurologic examination of not only the involved structures but adjacent areas as well.

(*) The Hygenic Corp, 1245 Home Ave, Akron, OH 44310.

References

[1] Nakamichi KI, Tachibana S. Iatrogenic injury of the spinal accessory nerve. J Bone Joint Surg Am. 1998;80:1616-1621.

[2] Short SO, Kaplan JN, Laramore GE, Cummings CW. Shoulder pain and function after neck dissection with or without preservation of the spinal accessory nerve. Am J Surg. 1984;148:478-482.

[3] Gordon SL, Graham WP III, Black JT, Miller SH. Accessory nerve function after surgical procedures in the posterior triangle. Arch Surg. 1977; 112:264-268.

[4] Chusid JG. Correlative Neuroanatomy and Functional Neurology. 19th ed. Los Altos, Calif: Lange; 1985.

[5] Aboujaoude J, Alnot J-Y, Oberlin C. The spinal accessory nerve (n. accessorius), I: anatomical study. Rev Chir Orthop Reparatrice Appar Mot. 1994;80:291-296.

[6] Vandeweyer E, Goldschmidt D, de Fontaine S. Traumatic spinal accessory nerve palsy. J Reconstr Microsurg. 1998;14:259-261.

[7] Kremer E, Atkinson JH, Ignelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain. 1981;10; 241-248.

[8] Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting: shoulder measurements. Phys Ther. 1987;67:668-673.

[9] Kendall FP, McCready EK, Geise PG. Muscles: Testing and Function. 4th ed. Baltimore, Md: Williams & Wilkins; 1993.

[10] Watkins AL. A Manual of Electrotherapy. 3rd ed. Philadelphia, Pa: Lea & Febiger; 1972.

[11] Sweeney PJ, Wilbourn AJ. Spinal accessory (11th) nerve palsy following carotid endarterectomy. Neurology. 1992;42:674-675.

[12] Mariani PP, Santoriello P, Maresca G. Spontaneous accessory nerve palsy. J Shoulder Elbow Surg. 1998;46:545-546.

[13] Hayes KW. Manual for Physical Agents. 4th ed. East Norwalk, Conn: Appleton & Lange; 1993.

[14] Snyder-Mackler L, Robinson AJ. Clinical Electrophysiology. Baltimore, Md: Williams & Wilkins; 1989.

[15] Host HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther. 1995;75:803-812.

[16] Voss DE, Ionta MK, Myers BJ. Proprioceptive Neuromuscular Facilitation. Philadelphia, Pa: Harper & Row; 1985.

[17] Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. 2nd ed. Philadelphia, Pa: FA Davis Co; 1990.

[18] Umphred DA. Neurological Rehabilitation. 2nd ed. St Louis, Mo: Mosby; 1990.

[19] Ogino T, Sugawara M, Minami A, et al. Accessory nerve injury: conservative or surgical treatment? Journal of Hand Surgery. 1991;16: 531-536.

[20] Richardson JK, Iglarsh ZA. Clinical Orthopaedic Physical Therapy. Philadelphia, Pa: WB Saunders Co; 1994.

[21] Guide to Physical Therapist Practice. Rev ed. Alexandria, Va: American Physical Therapy Association; 1999.

T Laska, PT, PTMGR, is Instructor of Physical Therapy, Wheeling Jesuit University, and Staff Physical Therapist, Ohio Valley Medical Center, Wheeling, WVa. Address all correspondence to Mr Laska at Department of Physical Therapy, Wheeling Jesuit University, 316 Washington Ave, Wheeling, WV 26003 (USA) ([e-mail]).

K Hannig, PT, MPT, is Staff Physical Therapist, Ohio Valley Medical Center.

Both authors provided writing, data analysis, and project management. Mr Laska and Richard Lambie, PT, provided concept/project design. Ms Hannig provided data collection. The authors acknowledge the support and assistance of Mr Lambie, Mark Dutton, PT, Robert W Galbreath, PhD, and Maureen McKenna, PT, PhD, in the preparation of the manuscript.

This project was approved by the Ohio Valley Medical Center Committee for the Protection of Human Subjects.

This work was presented at the Combined Sections Meeting of the American Physical Therapy Association; February 14-18, 2001; San Antonio, Tex.

This article was submitted December 31, 1999, and was accepted September 4, 2000.