RANGE OF MOTION

Moving the muscles and joints through their normal range of motions will be a critical part of your daily care. Range of motion prevents contracture and spasticity. Upper level quadriplegics must practice passive range of motion daily if possible with a caregiver. For quadriplegics with some arm and hand function, a host of active range of motion exercises can strengthen and preserve function.

Contractures result from a loss in the extensibility of ligaments, muscles and joints. They can result in permanently bent or straightened arms or legs, drooping feet and wrists, curled fingers, etc. Spasticity that forces our appendages to flex exacerbates potential deformity. Spasms (sudden involuntary tightening or contraction of a muscle) tend to increase when range of motion exercise is neglected.  

Quadriplegics are prone to developing:

• elbow flexion contractures due to triceps paralysis, as we are frequently sitting with elbows in flexion on the armrests of wheelchairs and lie with elbows flexed
• knee flexion contractures from using wheelchairs, which can lead to hip flexion and abduction contractures
• Contracture of the wrists, ankles, fingers and toes.

Physical therapy helps with spasticity as well as contracture. Spasticity and spasms are caused by an increase in muscle “tone". Muscle tone is the level of resistance to movement. Spasticity makes your arms and legs heavy and difficult to move. When spasticity is severe it can be very difficult to bend a limb at all.            

If you don’t move a joint through its full range of motion regularly, contracture is inevitable. The flexibility of a joint—how far it will move in any direction—is referred to as “range of motion” (ROM). To prevent contracture, you must practice ROM exercises every day, or as often as directed by your SCI healthcare provider. In rehab you will be trained on how to instruct others to do ROM for you. 

Make sure you are being moved slowly, gently, and smoothly. Avoid fast or jerky motions. Caregivers should support the area near the joint and move your body part with the other hand. Each joint should be moved as far it will go, to the point where you feel some resistance, but not to where it hurts. Stretching exercises should be held for 20–30 seconds and repeated 2–5 times.  

Passive ROM  

• Shoulder Flexion and Extension: Have your caregiver stand at your side while you are seated. With one hand, they will hold onto your forearm, and with the other, hold onto and stabilize the elbow joint. Keeping your elbow straight, have them move your whole arm slowly up above your head, then back down. Alternatively, this exercise can be done with you lying down.
   
•  Shoulder Abduction: While seated, have your caregiver stand behind you and place one hand on your forearm and use the other to stabilize the elbow. Have them move the arm upwards slowly, palm facing up once they go above shoulder height. They will bring your arm above your head, and then slowly lower it back down.

•  Elbow Flexion and Extension: In the same position, have your caregiver place one hand on your wrist and the other on your upper arm. Next they’ll slowly bend the elbow until your hand is touching your shoulder, then fully extend and straighten the arm down.

  

• Wrist and Hand Flexion and Extension: With one hand, your caregiver will hold onto and support your wrist. With the other hand, have them curl your fingers into your palm and slowly stretch your wrist back. Next, they’ll allow the wrist to drop and the fingers to straighten. 
   
•  Hip and Knee Flexion: While lying face up have your caregiver place one hand underneath your knee and use the other to stabilize your heel. Have them lift the knee, bending it towards the chest. Make sure they keep your foot and knee in a straight line with your hip.

• Hip Abduction: While lying face up, have your caregiver stand at your side and place one hand underneath your knee and use the other to stabilize your heel. They’ll keep your knee straight, and slowly move your leg toward them until it is at a 45-degree angle (approximately) with the other leg, before slowly returning the leg to its original position.
   
•  Leg Rises: While lying flat on your back with your legs straight, have your caregiver stabilize the knee and raise the leg to a straight position. They may place your ankle on their shoulder while kneeling slightly on your bed if possible, holding for a 10 -20 count at the apex of the rise.

• Ankle Rotation: With your knee straight, stabilize the ankle with one hand and place the other around the foot. Slowly turn the foot inward and outward.
   
•  Heel Flexion: Lying flat on your back with your legs straight out, have your caregiver grab the heel, resting the bottom of your foot against the inside of their forearm, and place their other hand on your shin. They’ll pull down on your heel and bend the top of your foot towards your knee.

• Toe Flexion and Extension: Have your caregiver stabilize your foot just below the toes with one hand. With the other, they’ll grasp your toes and slowly move them forward and backward.
   
• Finger Flexion and Extension: Have your caregiver hold your wrist in a neutral position, not bent back or forward. Bend and straighten each finger and joint separately.

 

Wrist Flicks: Move the hand forward so that the palm moves towards the inner arm and makes a 90° angle. Then, move the hand back in the opposite direction.           

Hand Flips: Hold the arm out so that it is straight and the back of the hand is facing up. With one hand, hold on to the elbow and with the other, flip the hand so that the palm faces up.

Spine Twists: Lie on your back with knees together and bent. After, tilt the knees towards one side and then the other. 

Foot Claps: Lying down, the legs should be straight. Pull one to the side, creating separation between the feet until there’s slight resistance. Then, bring your feet back together.   

Active Exercise 

Keeping the muscles we still have control of in good shape is important, even if it’s just our neck. Accidently decreasing your neck range is possible, if you repetitively turn to one side more than the other to access devices by mouth as quadriplegics often do. Stretching daily can help.

 Neck Range of Motion Exercises  

Chin Tucks: Lying on your back, glide your head back and tuck in your chin. Do not tilt the head up or down. Hold 5 seconds.  

 

Neck Side bending: Slowly tilt your head toward one shoulder, then slowly repeat to the opposite side while keeping your face straight ahead.  

Neck Rotation: Slowly turn your head to look over one shoulder, then slowly repeat to opposite side.    

 Isometric Flexion: Have a caregiver use light pressure with their fingers against your forehead, and resist with your neck muscles to keep your head in the upright position. 

Isometric Side Bending: Have a caregiver use light pressure with their fingers against the side of your head (above the ear), and resist with your neck muscles to keep your head in the upright position. 

          

Strengthen Arm/Hand Function (lower injuries) 

For quadriplegics who have some arm and hand function, try the following for strengthening our upper extremities:           

Shoulder Rolls: Shrug your shoulders and slowly move them in circular motions backward for 30 seconds. Quadriplegics who use manual wheelchairs tend to already roll their shoulders forward a lot when pushing their wheelchairs.           

Arm Circles: Spread your arms out to your sides so that they are aligned with your shoulders and slowly make large circles forward and backward for 30 seconds.           

Cross-Body Shoulder Stretch: Pull one arm across your body and bend your other arm to hold it in place. Pull the arm further across your body until you feel the stretch (but no pain) and then hold for 30 seconds. Then, repeat with the other arm.             

Overhead Triceps Stretch: Raise one arm and bend your elbow so that your hand is behind your head or back. Use the other arm to press down on the elbow until you feel the stretch and then hold for 30 seconds. Repeat with the other arm.             

Wall-Chest Stretch: Position yourself next to a wall or in a doorway. Hold your arm out to the side and then place the palm and inner arm against the wall or doorway with your elbow slightly bent. Gently lean forward or rotate your body to the opposite side until you feel the stretch (without pain) and then hold for 30 seconds. Repeat with the other side.           

Wrist Flexion & Extension Stretch: Raise one arm out in front of you. With your other arm, push the back of the palm down so that your hand and forearm form a 90° angle facing the floor. Hold for 30 seconds and then press the palm upwards and back so that this time, the fingers face the ceiling. Hold for 30 seconds and then repeat with the other wrist.           

Interlocked Fingers Stretch: Bring your hands together and interlock your fingers. Then, straighten your arms out in front of you and twist your wrists so that the backs of your hands are facing you. Hold for 30 seconds.           

Wheelchair Pushups: Put your hands on the armrests and straighten your arms to lift yourself up slightly from the seat and hold yourself up with your arms straight for 10 seconds.          

Triceps Extensions: Hold any sort of weight with both of your hands and raise it over your head. Slowly lower behind your head so that your elbows are bending. Then, lift it back up so that your arms are straight again.