Cervical (neck) injuries usually result in four limb paralysis. This is referred to as Tetraplegia or Quadriplegia. Injuries above the C-4 level may require a ventilator or electrical implant for the person to breathe. This is because the diaphragm is controlled by spinal nerves exiting at the upper level of the neck. The well documented horse riding accident of Christopher Reeve (Superman) resulted in a 'complete' spinal cord injury above C3 and he required a mechanical ventilator via a hole in his throat to breathe. Incomplete tetraplegic injuries are also possible.

HISTORY:

34 year old female (TM) from Hong Kong who was travelling in Northern Territory and had an Motor Vehicle Accident January 2013. She sustained fractures of the bones in the neck, spinal cord injury resulting in tetraplegia, and burns to the underarms and legs. She had surgery in Adelaide to repair and fuse the neck bones, and take pressure off the spinal cord, and skin grafts for her burns. She spent several months in hospital and then in an Adelaide Rehabilitation Centre.

In April 2014 she underwent nerve and tendon transfer surgery in Melbourne with the aim to improve the function of her arms. TM was then referred to us for follow up with aims to improve the function of her arms, in particular:

• improve strength of left tenodesis grip
• achieving new movement of finger and thumb opening and closing
• achieving new movement of straightening right elbow

Other goals of therapy included:

• improving sitting balance and ability to transfer from bed to wheelchair with use of a slide board
• set up at home of a bike with electrical stimulation to the legs maintain cardiovascular fitness
• maintain respiratory / chest health through monitoring and set up with a cough assist machine
• Maintain or improve range of movement in all joints

EXAMINATION:

TM had muscle tightness and stiffness particularly in her right shoulder and both hands and wrists. She found it very difficult to use her right arm / hand functionally as she was unable to straighten her elbow, and had severe weakness though out the arm. She had some function in her left hand however, her grip was weak, resulting in difficulty picking up small/fine objects. She required a lifting machine for all transfers and an electric wheelchair to get around.

TREATMENT:

TM attends twice weekly for stretches and mobilisation of upper and lower limb joints, and practice of sitting balance. TM has been set up with a daily home exercise program following a nerve and tendon transfer protocol. These exercises are frequently reviewed and progressed as able. TM has also been set up with and electrical stimulation bike at home for her legs to maintain cardiovascular fitness.

OUTCOME:

TM has made significant improvement in the strength of her left hand tenodesis grip, and ability to now open her fingers post nerve transfer, which has enabled her to be able to pick up small/fine objects. TM has also made improvements in her right arm; she has improved the range of movement in the shoulder and hands, and is now able to straighten her elbow actively and is beginning to be able to open and close her hand making the right arm more functional. She eventually hopes to be able to use her improved arm function to be able to prepare some light meals independently in the kitchen with aids. TM is hoping to continue to improve the function of her right arm as the strength improves, and would like to continue to work on her sitting balance and transfers without the lifting machine.