The use of electrical stimulation and taping to address shoulder subluxation for a patient with central cord syndrome.

Central cord syndrome (CCS) results from an injury to the central region of the spinal cord. The injury can be caused by varying etiologies, such as trauma, vascular problems, or tumor growth. This syndrome was first described in 1954 by Schneider et al (1) as greater upper-extremity than lower-extremity involvement, bladder dysfunction, and varying sensory loss. The American Spinal Injury Association (ASIA) defined CCS as "a lesion, occurring almost exclusively in the cervical region, that produces sacral sensory sparing and greater weakness in the upper limbs than in the lower limbs." (2)(p19) The typical order of neurological recovery has been reported as return of lower-extremity function, followed by return of bladder function, upper-extremity function, and intrinsic hand function. (1,3)

Hatzakis et al (4) described a case of an individual with disproportionate weakness of the upper extremities after a gunshot wound to the face. The patient's upper-extremity ASIA motor score initially was 0/50, with the patient being able to transfer and ambulate without assistance. The motor score improved alter 5 weeks to 31.5/50, and the individual was able to brush her teeth and groom herself. By week 10, the upper-extremity motor score improved to 40/50, and the individual could manipulate smaller objects with her hands. (4) This case report illustrated the fact that some individuals with CCS have sufficient strength of the lower extremities to stand and walk but pronounced weakness of the upper extremities, limiting their ability to move their shoulders against gravity.

The Paralyzed Veterans of America (PVA) guidelines tot functional outcomes after spinal cord injury (5) do not specifically mention CCS because the expected functional independence outcomes are based on level of complete motor injury. For individuals with incomplete injuries, PVA reported that one half to two thirds experience the level of motor recovery they are likely to achieve during the first year postinjury within the first 2 months after injury. Further, the guidelines indicate that the prognosis is excellent for individuals initially classified as ASIA D community ambulators (defined as walking being the primary mode of mobility in the home and community). (4) Definitions of the ASIA impairment levels are shown in Table 1.

The mechanism of injury with traumatic CCS is usually hyperextension of the cervical spine with compression of the spinal cord. Roth et al (3) retrospectively studied a sample of 81 patients with acute traumatic CCS whose mean length of rehabilitation was 69.6 days (SD=39.2). They found that patients with normal leg muscle force on admission, younger patients, and those who experienced upper- or lower-extremity neurologic motor recovery during rehabilitation demonstrated the greatest improvement in their ability to complete activities of daily living (ADL). (3) Penrod et al (6) did a retrospective study (N=51) to determine if age was a significant predictor of functional recovery in patients with acute, traumatic CCS. Their result indicated that 97% (29 of 30) of the younger patients (less than 50 years of age) were ambulatory compared with 41% (7 of 17) of older patients. A larger proportion of younger patients also were able to achieve independence in self-care and bowel and bladder function. The researchers concluded that prognosis for functional recovery in patients with acute traumatic CCS should consider the patient's age. (6) Similarly, Bridle et al (7) examined long-term function in patients with CCS and reported improvements in ambulation and bowel and bladder function. The subjects compensated for poor hand function with adaptive equipment to perform ADL. (7) Although the literature reports upper-extremity weakness after CCS, the occurrence of shoulder subluxation is not described.

Kohlmeyer et al (8) examined the use of an orthosis to address shoulder subluxation and to facilitate use of the upper extremity in functional activity for patients with CCS and brachial plexus injury. They described an orthosis fabricated to provide proximal shoulder stability and allow mobility distal to the shoulder when a patient has distal upper-extremity function. The patients they reported on had elbow flexion of less than muscle grade 2. Their orthosis provided elbow flexion assist, which improved their ability to perform ADL. The orthosis described provides passive support of the shoulder with the use of a figure-eight shoulder harness placed under each axilla. They reported benefits of improved arm swing and balance during gait and reduction in shoulder subluxation as measured by palpation. The authors did not report measurement of subluxation. They only described a decrease in shoulder subluxation by palpation when the patients were wearing the orthosis. They also did not specify whether the subluxation was inferior or anterior. I question whether this support would correct anterior subluxation, because it provides no support anterior to the humerus.

In my experience working with patients with CCS, bilateral shoulder subluxation occurs frequently due to upper-extremity weakness. It has been difficult to support the subluxated shoulder to facilitate improved glenohumeral alignment without restricting the use of the entire arm when using a sling. Often the patients are able to stand and walk, which places their upper extremities in a dependent position without having the shoulder force to hold the humeral head in the proper position. Figure-eight slings, which support the elbow and hand and have straps behind the shoulder and back, have been used for shoulder subluxation of patients with hemiplegia. (9) In my opinion, using figure-eight slings bilaterally with patients with CCS interferes with a patient's ability to use the upper extremities to assist with balance, and they keep both upper extremities in a prolonged position of shoulder medial (internal) rotation and adduction. Another problem with a sling is that it is removed when attempting exercises, which leaves the glenohumeral joint unsupported.

An intervention is needed that would provide support only at the shoulder and lessen the shoulder subluxation while allowing mobility distal to the shoulder. The literature describes weakness of the upper extremities but not shoulder subluxation associated with CCS or intervention to address it. (3,4,6-8) Descriptions of interventions for shoulder subluxation due to weakness following cerebrovascular accident (CVA), however, have been reported. (10,11)

Shoulder taping is one intervention that has been used in the management of shoulder subluxation in patients who have had a CVA. Taping (or strapping) is the use of tape applied to the body to provide structural support. Morin and Bravo (12) examined the use of taping and a sling to reduce shoulder subluxation of patients with hemiplegia as measured by radiography. Fifteen subjects with CVA and palpable subluxation received taping and wore a sling over a 5-day period. The time between CVA and start of intervention for subluxation averaged 71.2 days. The authors concluded that taping alone was not more effective than a sling, but the combination of both was most effective, with an 86% reduction in shoulder subluxation. Three days after removing the supports, however, the improvement relative to the initial subluxation was only 1.5 mm. Ancliffe (13) examined the effects of shoulder taping to delay the onset of pain in the shoulders of patients with hemiplegia. The subjects were selected within 48 hours of admission to the hospital if they had a diagnosis of CVA, no history of shoulder pain, and no movement in the affected upper extremity. The experimental group (n=4) received taping of the shoulder on the hemiplegic side, whereas a control group (n=4) received no taping. The subjects who were taped had a mean of 21 days (SD=2.4) before onset of pain as compared with a mean of 5.5 (SD=2.89) pain-free days for the control group. (13) Despite the longer pain-free period of subjects who were taped, all subjects did experience pain. This study did not examine the effect of the tape on the shoulder joint alignment.

Two studies examined the use of taping to provide structural support for patients with orthopedic injuries. Host (14) used tape to hold the scapula in proper alignment for a patient with anterior impingement syndrome. Tape was applied every 4 days. The tape was discontinued when the patient could flex and abduct the arm and perform the home exercise program without pain. Host proposed that scapular taping should be used as an adjunctive form of therapy in an attempt to attain a more favorable scapular alignment. Shamus and Shamus (15) used taping for the management of patients with acromioclavicular joint sprains. The patients were able to discontinue the use of a sling without any increase in symptoms. Both articles illustrate the use of tape to achieve improved structural support with reported benefits of reduced pain.

Electrical stimulation (ES) is another intervention approach with research support for the reduction of shoulder subluxation in patients with CVA. (16-19) Faghri et al, (16) Baker and Parker, (17) and Linnet al (18) used ES targeting the supraspinatus and posterior deltoid muscles to reduce shoulder subluxatiou over 6 weeks, 6 weeks, and 4 weeks, respectively. All authors reported reduction in shoulder subluxation in an experimental group compared with a control group. Chantraine et al (19) also reported reduction in shoulder subluxation in an experimental group, but did not mention where the electrodes were placed. The ranges of parameters reported in these studies were a frequency of 12 to 40 Hz and pulse width of 300 to 350 microseconds, with the goal of achieving a tetanized contraction that visibly lessened the shoulder subluxation. The amount of ES increased to 6 or 7 hours, and the average time of the studies was 6 weeks.

Because taping and ES have effectively addressed shoulder subluxation in patients with CVA, I used them with a patient with shoulder subluxation associated with CCS. I believed that the tape could provide improved positioning support at the shoulders without restricting antigravity movement distal to the shoulder and that improved positioning of the glenohumeral joint might facilitate strengthening of the shoulder muscles. I also believed that ES might further enhance the strengthening of the shoulder muscles that hold the humerus in the proper position. The purpose of this case report is to describe the use of ES and shoulder taping as one component of a rehabilitation program for a patient with CCS and shoulder subluxation.

Case Description

History

The patient was a 29-year-old man who was admitted to an acute care hospital after being hit by a car while riding a bicycle. Loss of consciousness was questionable. A computed tomographic scan of the cervical spine on the day of admission revealed a C3 burst fracture with minimal retropulsion into spinal canal, a C4 split through fracture of the vertebral body and lamina, a C5 lamina and spinous process fracture, and a C6 lamina fracture. The patient was started on a spinal cord injury protocol with methylprednisolone on the day of admission and placed on halo immobilization. Prior to his injury, the patient lived in an apartment with his wife and was employed at a grocery store where he restocked products. The patient wanted to be able to return to his prior level of function.

Examination

The patient began inpatient acute rehabilitation 9 days after his admission to the hospital. The examination and subsequent testing were performed by the same physical therapist. The examination revealed the following impairments: muscle weakness of the upper extremities with resultant decreased functional range of motion (Tab. 2) and palpable shoulder subluxation that was greater on the right side (1.5 cm) than on the left side (1.0 cm). The subluxation measurement was obtained with the patient in a standing position with arms resting at his side. The therapist palpated the acromion and humeral head anteriorly and used a tape measure (with markings every millimeter) to record the space between the landmarks. The patient also had visible anterior subluxation of the humerus relative to the acromion bilaterally.

This was a retrospective case report, and I did not estimate the reliability of measurements obtained for this patient. Boyd and Torrance (20) did examine the reliability of data obtained with 3 clinical measures of shoulder subluxation. The 3 methods tested were: using the finger's breadth by noting how many fingers can be placed between the acromion and humerus, using a caliper to measure the subacromial space, and using a Plexiglas jig to measure the distance between the acromion and a dot on the olecranon when the shoulder is supported and unsupported and recording the difference. The caliper method involved marking a point on the acromion and measuring the subacromial space (in centimeters). The participants in the study had shoulder subluxation following a CVA. The mean time since onset of CVA was 22 months. Four senior occupational therapists with experience in stroke rehabilitation measured the patients' shoulder subluxation. The researchers concluded that if the same person does the measurement, the measurements obtained with the caliper or fingerbreadth method are reliable (intraclass correlation coefficient [ICC]=.73 for caliper method, ICC=.77 for linger-breadth method). They also concluded that the caliper method is the best of the 3 measures for clinical research because it has the ability to detect smaller differences in subluxation than the finger method. (20) Although a caliper was not used in this case, the same concept of measuring the subacroinial space (in centimeters) was used.

Prevost et al (21) examined a tridimensional (3-D) radiographic method to compare measurements of shoulder subluxation using clinical methods and radiological techniques. They reported a Pearson product moment correlation coefficient of .75 between the subluxation measurements obtained with 3-D method and anthropometric measurements. The authropometric method used a sliding caliper (in millimeters) to measure the distance separating the acromial angle and lateral epicondyle of the humerus. They reported that the high level of precision and reliability of data obtained with the 3-D measure indirectly validates all the measurement techniques examined.

Sensation was intact when tested for light touch and pinprick; however, the patient described intermittent tingling irritation in the arms. The manual muscle test (MMT) was performed by the same physical therapist using the grading system of Kendall el al. (22) Wadsworth et al, (23) using Pearson product moment correlation coefficients, estimated intrarater reliability of MMT scores tot shoulder abduction, hip flexion, and knee flexion to be .98, .74, and .63 respectively. The individuals were inpatients receiving physical therapy, and they had a minimum of fair strength in the muscles tested. The patients' ASIA level of impairment was D.

The patient's ASIA motor scores are shown in Table 3. and Table 4 for his functional limitations. Level of assistance for mobility was graded using the Functional Independence Measure (FIM) (24) by the therapist, who completed FIM certification. The patient's FIM scores are shown in Table 4. Heinemann et al (25) reported, based on their Rasch analysis, that the FIM could be used to construct interval measurements from the ordinal data for each of the patient groups studied, including patients with spinal cord dysfunction. They reported variation in item difficulty across groups, reflecting the unique impact of different impairments. They concluded that this variation across groups supports the construe! validity of dam obtained with the FIM. (25)

Diagnosis/Prognosis

The diagnosis provided by the physical therapist was determined using the Guide to Physical Therapist Practice. (26) The diagnosis was impaired motor function, peripheral nerve integrity, and sensory integrity associated with a nonprogressive disorder of the spinal cord. The goals were set that, after 5 or 6 weeks of inpatient acute rehabilitation, the patient would reach modified independence with transfers, bed mobility, ambulation, and stair management. The patient would be able to perform ADL with minimal assistance.

The plan of care was developed to include therapeutic exercise to address the bilateral upper-extremity weakness; functional training with transfers, bed mobility, gait, and stairs; and balance training to adjust to the halo brace and impaired upper-extremity function. The patient was young and motivated and tolerated physical therapy sessions with little to no rest periods.

Interventions

The patient's therapy consisted of 1 1/2 hours of physical therapy and occupational therapy Monday through Friday and a half hour of each on Saturday. Occupational therapy focused on feeding, grooming, bathing, dressing activities, and fine motor control of the upper extremities. An occupational therapist provided a lapboard for the patient's wheelchair to support both extremities. The patient used 2 figure-eight slings initially during any standing or ambulatory activities. Mobility training included transfer training to different-height surfaces and getting in and out of a car with the halo brace. Bed mobility focused on the ability to sit from a supine position, which was difficult due to upper-extremity weakness and the weight of the halo brace. Ambulation training started on level surfaces with progression to unlevel surfaces, outdoor terrain and stairs. Standing balance activities focused on the patient's ability to adjust to the halo brace when standing and walking. Table 4 shows the progression of the patient's functional abilities.

The specific therapeutic exercise interventions for upper-extremity weakness consisted of passive range of motion and active-assisted exercises with progression to active and then resisted exercises as tolerated. The repetitions of exercises started at 2 sets of 10 repetitions, working up to 2 sets of 15 repetitions. The patient initially performed active-assisted exercises for both shoulders in gravity-eliminated positions using a powder board. By week 4, the patient was performing active-assisted shoulder exercises against gravity on the right side and resisted exercises on the left side. For elbow strengthening, the patient began with active-assisted exercise in gravity-eliminated positions on the right side and active exercises on the left side against gravity. By week 2, the patient performed elbow exercises against gravity and tolerated resistance on the left side. Table 5 shows the progression of upper-extremity strengthening exercises.

Two interventions selected to address shoulder subluxation were ES and shoulder taping. These interventions were chosen to avoid restricting movement below the shoulder. Electrical stimulation was initiated at the end of week 1 on the right shoulder using the EMS +2 Neuromuscular Stimulator. * Four electrodes were used: 1 channel to the anterior and middle deltoid muscles and 1 channel to the supraspinatus muscle (Fig. 1). The literature about patients with stroke reported using ES on the supraspinatus and posterior deltoid muscles in an attempt to decrease shoulder subluxation. (16-19) I selected the middle deltoid muscle to achieve superior movement of the humerus. I chose the anterior deltoid muscle instead of the posterior deltoid muscle to pull the humerus in a posterior direction because I observed the patient's humerus to be in an anterior position. Hall et al (27) reported that of the 20 individuals with a CVA and shoulder subluxation, 7 also had an anterior subluxation. I selected the supraspinatus muscle because it pulls the humeral head superiorly and is recommended in patients with stroke. (17,18)

[FIGURE 1 OMITTED]

The patient was positioned in a seated position with the arm supported on the lap tray. The waveform was biphasic alternating current. The settings were 60 Hz for frequency and 250 microseconds for pulse rate. The literature about patients with stroke reported the use of 10 to 40 Hz with the goal of creating a tetanized contraction that lessens shoulder subluxation. (16-19) I chose a higher frequency of 60 Hz, adjusting the frequency to create a contraction that visibly lessened the subluxation. My concern about fatiguing these muscles at this frequency was addressed by limiting the time of the ES to 2 half-hour sessions compared with research with patients with stroke who had ES for 6 to 7 hours a day. The pulse width selected (250 microseconds) was slightly less than the range reported in the literature about patients with stroke (300-350 microseconds). The on/off cycle started at 10 seconds on and 20 seconds off, which is similar to the on/off cycle (15 seconds on/15 seconds off) used in the study by Linn et al. (18) Electrical stimulation was not used on the left side because of the patient's ability to actively reduce the amount of subluxation.

The initial ES sessions were performed during physical therapy sessions to ensure patient tolerance, observe possible fatigue, and adjust parameters if needed. The first intervention session was 10 seconds on and 20 seconds off, intensity 2 for 10 minutes. The humeral head visibly reduced, moving superiorly and posteriorly. The patient had no complaint of shoulder pain and tolerated 10 minutes of stimulation without muscle fatigue. By the end of the first week of daily ES, the patient was tolerating 2 half-hour sessions with 20 seconds on and 10 seconds off. However, the patient reported fatigue pain at the deltoid muscle insertion site and requested having ES sessions every other day. The intervention was then modified to every other day for 2 half-hour sessions. The patient did not complain about fatigue again. There are other ways to address the chance of fatigue with ES. Scott and Binder-Macleod (28) suggested that combining train types (interpulse intervals) may be a useful strategy to offset the rapid fatigue that people with neurological dysfunction, such as spinal cord injury, experience when using ES.

By the fourth session of ES, the patient and his wife were instructed to perform ES outside of therapy sessions. The on/off cycle was progressed over the course of the intervention to 30 seconds on and 10 seconds off by week 4 (see Tab. 6 for the progression). I decided to continue the ES because of the presence of shoulder subluxation.

Shoulder taping was initiated on both shoulders at the beginning of week 2. The patient had intact sensation al the shoulders and said he was not allergic to tape. He was instructed to ask a nurse or therapist to remove the tape if it became uncomfortable. The tape was placed over the self-adhesive electrodes on the right shoulder. The tape completely covered the electrodes, which, in my opinion, facilitated consistent contact to the skin. The first layer of tape was Cover-roll stretch ([dagger]) followed by Leukotape P. ([double dagger]) Two straps were used. The first strap was anchored near the deltoid muscle insertion site, pulling up following the middle deltoid muscle and ending over the acromion. The second strap followed the anterior deltoid muscle and ended over the posterior border of the acromion (Fig. 2).

[FIGURE 2 OMITTED]

The taping was difficult due to the placement of the halo vest. Longer straps are typically used to achieve a better anchor, but adaptation to the halo vest precluded their use. The tape was anchored as high as possible. The shorter length of the tape might have affected its ability to hold the shoulder. I taped both shoulders and repeated it every 3 to 4 days, which was the frequency used in the studies by Ancliffe (13) and Shamus and Shamus. (15) The skin was examined after each removal of the tape for any changes in skin integrity. The taping of the left shoulder was discontinued at week 6, and right shoulder taping was discontinued at the beginning of week 7, when the patient was able to actively reduce the shoulder subluxation and it was not possible to measure (Tab. 7). The shoulder subluxation measurements were taken weekly by another physical therapist who had 8 years of experience managing patients with CVA. The tape was removed prior to the measurement, and the shoulders were retaped after the measurement.

The patient was discharged from the inpatient rehabilitation level of care during week 5 of the ES intervention. The patient's status at the time of discharge, as indicated by his FIM scores, is shown in Table 4. I recommended that the patient continue with the ES 2 to 3 times a day for a half-hour session each, every other day. The patient continued with outpatient occupational therapy to address upper-extremity force and function secondary to requiring minimal assistance with ADL. The ES was monitored by the physical therapist for electrode placement and to answer any questions from the family or patient. Weekly measurement of shoulder subluxation continued until week 10. At this point, I decided to stop measuring because of the palpable reduction of the shoulder subluxation (0.3 cm on the right side and 0.2 cm on the left side at rest and no space to measure when the patient actively reduced the shoulder). The subacromial space also was diminished and difficult to measure. I recommended that the patient resume physical therapy when the halo vest was removed to assess any range of motion or postural issues as a result of prolonged immobilization.

Outcomes

The patient received ES for 8 weeks to the right shoulder with taping. The initial shoulder subluxation measurement on the right at rest was 1.5 cm. At the conclusion of ES and taping, the subluxation measurement at rest was 0.3 cm, with an improvement of 1.2 cm. The left shoulder received taping only. The initial subluxation measurement on the left at rest was 1.0 cm. At the conclusion of taping, the subluxation measurement at rest was 0.5 cm (week 7). The final measurement was 0.2 cm (week 10), with an improvement of 0.8 cm. Table 7 shows all measurements of shoulder subluxation.

Bilateral slings were initially used during any standing activities. The left sling was eliminated during week 3, and the right sling was eliminated during week 5 based on the patient's ability to actively lessen the amount of shoulder subluxation. The patient was able to actively reduce the subluxation until the space between the landmarks was unmeasureable by week 6 on the left and week 7 on the right. The patient's MMT grades of both upper extremities improved over the course of rehabilitation (Tab. 2). His upper-extremity ASIA motor score at discharge improved to 48/50 (Tab. 3).

Discussion

The use of ES and shoulder taping in conjunction with the rest of the rehabilitation program may have played a role in the reduction of the patient's shoulder subluxation. Reduction was visible during the ES sessions. Electrical stimulation has been shown to reduce shoulder subluxation in patients with CVA, (16-19) so the ES applied to the right shoulder could have contributed to the decrease in shoulder subluxation. I would have liked to increase the time to more than half-hour sessions, as some researchers (16-19) have reported; however, the patient had sonic discomfort at the deltoid muscle insertion site, and the amount of time and frequency were modified as a result.

Initially, ambulation and standing activities were performed with both shoulders taped and with slings. Morin and Bravo (12) have reported strapping plus the use of slings resulted in 86% reduction of shoulder subluxations in the patients with CVA they studied. Their duration of the use of tape and a sling was short (5 days), which may have contributed to the return of the subluxation after discontinuing the tape and sling. (12) The use of tape in this case was longer (4 weeks). The patient also had a lapboard when sitting in the wheelchair to provide support to the upper extremities. The slings were discontinued as soon as possible to allow the use of his distal muscle force for balance when standing and walking. The patient initially had antigravity movement of the left elbow, which would provide balance support during ambulation. The patient was also able to assist with ADL due to antigravity strength of the wrist and fingers on the left. The slings were discontinued when the patient was able to actively lessen the amount of shoulder subluxation.

The patient was young and had good lower-extremity muscle force initially, which Roth et al (3) reported were 2 factors indicative of potential for the greatest improvement. Furthermore, Penrod et al (6) concluded that a higher proportion of younger patients (under 50 years of age) also were able to achieve independence. The patient's improvement in the ASIA upper-extremity motor score was similar to the improvements that Hatzakis et al (4) described.

The time period over which the patient received the interventions is consistent with the 2-month period that the PVA guidelines indicate people with incomplete injuries will have significant recovery. (5) I believe, however, that the tape improved the position of the glenohumeral joint, which would optimize the exercises being performed. The tape provided 24-hour support, which a sling would not because slings are not worn in bed or during exercise.

This case report has limitations. One of the limitations is not knowing if the interventions selected or spontaneous recovery contributed to the improvements seen. It is also important to note that by using multiple strategies (ES, taping, sling), the contribution of each is not known. I believed that use of a sling initially was important to protect the shoulder joint because ES and taping have not been reported for use with shoulder subluxation related to CCS. The long-term reduction of shoulder subluxation is not known because the patient did not receive therapy when the halo brace was removed.

The measurement of the shoulder subluxation could have been more precise. A single radiographic measurement would have been the preferred method of measuring subluxation had this been a prospective case report. Prevost et al (21) suggested that a measurement using one x-ray film is sufficient for a clinical study of shoulder subluxation in patients with hemiplegia.

I believe this case report might foster further research examining the use of ES and shoulder taping to determine their effectiveness in the management of shoulder subluxation in patients with CCS. This case also highlights the difficulty of supporting the subluxated shoulders without impeding distal function when antigravity movement is present at the elbow and below.

Table 1.
American Spinal Injury Association (ASIA) Impairment Levels (2)

ASIA
Impairment
Level          Definition

A=complete     No sensory or motor function is preserved in the
                 sacral segments S4-S5.

B=incomplete   Sensory but not motor function is preserved below the
                 neurological level and includes the sacral segments
                 S4-S5.

C=incomplete   Motor function is preserved below the neurological
                 level, and more than half of key muscles below
                 the neurological level have a muscle grade less
                 than 3.

D=incomplete   Motor function is preserved below the neurological
                 level, and at least half of key muscles below the
                 neurological level have a muscle grade greater
                 than or equal to 3.

E=normal       Sensory and motor function are normal.

Table 2.
Manual Muscle Testing of Upper Extremities

                    Right Upper Extremity

Muscle              Initial   Week 2   Week 4   Week 5

Anterior deltoid    1         2-       3-       3-
Middle deltoid      1         2-       3        3
Posterior deltoid   2-        3+       3+       4
Pectoralis major    2-        3+       3-       3-
Biceps              2-        2+       4        4+
Brachioradialis     2-        3-       4        4+
Triceps             2-        3        5        5
Wrist flexors       2-        2+       3+       3+
Wrist extensors     2-        3        4        4
Finger flexors      3         4        5        5
Finger extensors    2-        3-       3/3+     3

                    Left Upper Extremity

Muscle              Initial   Week 2   Week 4   Week 5

Anterior deltoid    1         3        3        3+
Middle deltoid      2+        3        3+       4
Posterior deltoid   2-        4+       4+       4+
Pectoralis major    2-        2+       4        4
Biceps              3+        4        5        5
Brachioradialis     4         4        4+       5
Triceps             2-        4        5        5
Wrist flexors       4+        4+       5        5
Wrist extensors     4+        5        5        5
Finger flexors      3+        5        5        5
Finger extensors    3+        4+       4+       5

Table 3.
American Spinal Injury Association (ASIA) Motor Scores

                    Admission   Discharge
                    Score       Score

Upper limb          26/50       48/50
Lower limb          50/50       50/50
Total motor score   76/100      98/100

Table 4.
Functional Independence Measure (FIM) Scores (a)

FIM Category         Initial  Week 2  Week 3  Week 4  Week 5  Discharge

Grooming             1        2       2       3       4       4
Upper-body dressing  1        1       2       3       4       6
Bathing              1        1       2       3       3       3
Lower-body dressing  1        2       2       4       5       6
Bed transfers        1        4       4       4       5       6
Ambulation           4        4       5       5       5       6
Stairs               1        4       4       5       5       6

(a) 1=total assistance, 2=maximal assistance, 3=moderate
assistance, 4=minimal assistance, 5=supervision, 6=modified
independence, 7=complete independence.

Table 5.
Exercise Progression

           Week 1                    Week 2

Shoulder   Bilateral: powder board   Right: powder board
             active-assisted           without skate, active
             exercises with skate    Left: antigravity

Elbow      Right: powder board       Right: antigravity
             active-assisted         Left: antigravity,
           Left: antigravity           resisted

Wrist      Right: active-assisted,   Right: antigravity,
             antigravity               active
           Left: antigravity         Left: antigravity,
                                       resisted

           Week 4                    Week 5

Shoulder   Right: active-assisted,   Right: active-assisted,
             antigravity               antigravity
           Left: antigravity,        Left: antigravity,
             resisted                  resisted

Elbow      Bilateral: antigravity,   Bilateral: antigravity,
             resisted                  resisted

Wrist      Bilateral: antigravity,   Bilateral: antigravity,
             resisted                  resisted

Table 6.
Electrical Stimulation Progression

                On/Off Cycle (s)   Time (min)

Weeks 1-2
Session 1       10/20              10
Session 2       10/15              15
Session 3       15/10              20
Session 4 (a)   15/10              30/30 (b)
Session 5       20/10              30/30

Week 3
Session 1       20/10              30/30
Session 2       25/10              30/30
Session 3       25/10              30/30
Session 4       25/10              30/30

Week 4
Session 1       25/10              30/30
Session 2       30/10              30/30
Session 3       30/10              30/30
Session 4       30/10              30/30

Week 5
Session 1       30/10              30/30
Session 2       30/10              30/30
Session 3       30/10              30/30

(a) The patient continued with electrical stimulation outside
of therapy sessions with spouse assisting with the setup for
the electrical stimulation.

(b) 30/30 designates 30-minute sessions 2 times in 1 day.

Table 7.
Shoulder Subluxation Measurements (in Centimeters) (a)

                 Week

                 2           3     4     5     6     7     8     10

Right shoulder
  At rest        1.5         1.4   1.3   0.8   0.6   0.6   0.4   0.3
  Active         Not taken   1.0   0.9   0.9   0.9    *     *     *

Left shoulder
  At rest        1.0         1.0   0.8   0.8   0.7   0.5   0.2   0.2
  Active         Not taken   0.7   0.5   0.5    *     *     *     *

(a) Asterisk indicates unable to measure
due to inability to palpate subluxation.

* Rehabilicare, 1811 Old High way 8, New Brighton, MN 55112.

([dagger]) Beiersdorf AG, Hamburg, Germany.

([double dagger]) Beiersdorf Co Ltd, Bangkok, Thailand.

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C Peterson, PT, MPT, is Physical Therapist, Clinician III, Marianjoy Rehabilitation Hospital, 26 W 171 Roosevelt Rd, Wheaton, IL 60187 (USA) ([e-mail]).

This work was approved by the Marianjoy Rehabilitation Hospital Institutional Review Board.

This article was received June 16, 2003, and was accepted December 21, 2003.