The Journal of Spinal Cord Medicine

ISSN: 1079-0268 (Print) 2045-7723 (Online) Journal homepage: https://www.tandfonline.com/loi/yscm20

Functional passive range of motion of individuals

with chronic cervical spinal cord injury

Sara Kate Frye, Paula Richley Geigle, Henry S. York & W. Mark Sweatman

To cite this article: Sara Kate Frye, Paula Richley Geigle, Henry S. York & W. Mark Sweatman
(2019): Functional passive range of motion of individuals with chronic cervical spinal cord injury,
The Journal of Spinal Cord Medicine, DOI: 10.1080/10790268.2019.1622239

To link to this article: https://doi.org/10.1080/10790268.2019.1622239

Published online: 13 Jun 2019.

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Research Article
Functional passive range of motion of
individuals with chronic cervical spinal
cord injury
Sara Kate Frye1, Paula Richley Geigle1,2, Henry S. York1,2, W. Mark Sweatman3
1
University of Maryland Rehabilitation & Orthopaedic Institute, Baltimore, Maryland, USA, 2Department of
Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA, 3Crawford Research Institute at
Shepherd Center, Atlanta, Georgia, USA

Objective: Functional passive range of motion (PROM) requirements for individuals with cervical spinal cord
injury (SCI) are clinically accepted despite limited evidence defining the specific PROM needed to perform
functional tasks. The objective of this investigation was to better define the minimum PROM needed for
individuals with cervical SCI to achieve optimal functional ability, and as a secondary outcome gather self-
reported standardized functional data via the Spinal Cord Independence Measure-III (SCIM-III), and the
Spinal Cord Injury Functional Index (SCI-FI).
Design: Observational cohort.
Setting: 128-bed rehabilitation hospital with inpatient and outpatient spinal cord injury rehabilitation programs.
Participants: A convenience sample of 29 community-dwelling individuals with chronic (greater than one year)
tetraplegic SCI (C5-8) who use a wheelchair for mobility.
Interventions: None.
Outcome measures: Therapist goniometric measurement of upper and lower extremity PROM, and participant
completion of a demographic questionnaire and two functional self-report measures (SCIM-III and SCI-FI)
were completed.
Results: Compared to the general population, differences observed in our study participants included limitations
in forearm pronation and elbow extension and increased shoulder extension and wrist extension (likely related to
prop sitting). Elbow hyperextension was noted in one-third of the participants. Limitations in straight leg raise, hip
flexion, abduction, and internal rotation, in combination with increased hip external rotation suggested these
individuals with cervical SCI potentially completed activities of daily living (ADLs) in frog-sitting, rather than
long-sitting. Ankle plantarflexion contractures were found in many participants. Shoulder horizontal
adduction, elbow extension, hip flexion, knee flexion, ankle plantarflexion, and forefoot eversion ROM were
associated with functional performance.
Conclusion: Based on our results healthcare providers should work with individuals with cervical SCI to develop
long term PROM plans to optimize functional abilities.
Keywords: Cervical spinal cord injury, Tetraplegia, Range of motion, Spinal cord injury, Upper extremity, Occupational therapy, Physical therapy, Rehabilitation,
Contracture

Introduction activities based on knowledge gained from clinical

There is limited evidence defining the minimum passive experience, which can vary widely. For example, clini-
range of motion (PROM) requirements needed by indi- cians may question the minimum amount of hip
viduals with cervical spinal cord injury (SCI) to perform flexion required to successfully complete lower body
functional tasks. Currently, clinicians must rely on an dressing in long sitting, or the degree to which elbow
understanding of functional PROM needed to complete joint restriction impacts the ability to lock the elbow
in extension for transfers. In the current healthcare
Correspondence to: Sara Kate Frye, University of Maryland Rehabilitation & environment, clinicians must prioritize limited treatment
Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD 21207, USA. Ph:
410-448-6302. Email: [email protected] time to obtain the optimal client outcomes. Better

© The Academy of Spinal Cord Injury Professionals, Inc. 2019

DOI 10.1080/10790268.2019.1622239 The Journal of Spinal Cord Medicine 2019 1
Sara Kate Frye et al. Functional passive range of motion of individuals

understanding of the PROM needed to perform func- Mateo et al. hypothesized limited active ROM observed
tional skills will inform clinicians how to effectively allo- during overhead reaching could be caused by shoulder
cate treatment time. joint ankyloses or shoulder pain.14
No empirical data exist to guide practitioner under- Harvey and Herbert published a guide on common
standing what range of motion (ROM) is required for contractures in SCI and positional strategies for preven-
individuals with cervical SCI to optimize functional out- tion.12 They proposed that individuals with C5 injuries
comes. The normative PROM for individuals with SCI and above are at highest risk for contracture but ident-
values currently taught and clinically utilized originated ified risks for all levels of SCI. Common areas for
from non-SCI population data.1 However, PROM limit- upper extremity were hypothesized to be shoulder
ations are prevalent and observed in 9-70% of individ- flexion/abduction/external rotation, elbow extension,
uals with SCI with the most common limitations forearm pronation/supination, wrist flexion, MCP
occurring at the shoulder, elbow, and ankle.2–12 flexion, IP extension and thumb abduction. Common
Multiple factors are associated with PROM limitations lower extremity limitations were hip extension/adduc-
including: an extended acute care hospitalization, con- tion, hip flexion with knee extension, knee extension,
current traumatic brain injury (TBI), spasticity, hetero- and ankle dorsiflexion.
topic ossification (HO), shoulder pain, and age.2–11
Diong et al. measured PROM within 35 days of SCI Methods
and 1 year later using a subjective 4-point scale and This study examined PROM in a convenience sample of
found an 11–43% contracture incidence after 1 year, 29 individuals with cervical SCI. Individuals with C5-8
most commonly affecting the ankle, wrist, and SCI who demonstrated some functional use of their
shoulder.2 Eriks-Hoogland et al. reported 70% of indi- upper limbs and relied on a wheelchair for their daily
viduals with tetraplegia and 29% of those with paraple- mobility were eligible to participate. Participants were
gia experienced limited shoulder PROM during recruited via outpatient clinics, adapted sports pro-
inpatient rehabilitation, and at one year after injury.3 grams, and support groups at a 132-bed freestanding
External rotation deficits were most likely to develop rehabilitation facility with comprehensive inpatient
during inpatient rehabilitation and shoulder flexion def- and outpatient SCI programs. In this pilot study partici-
icits developed after discharge. Increased age, tetraple- pants completed a demographic questionnaire, the
gia, spasticity of elbow extensors, longer duration Spinal Cord Independence Measure-III (SCIM-III),
between injury and start of active rehabilitation, and and the Spinal Cord Injury Functional Index (SCI-
the presence of shoulder pain was associated with FI).15,16 The SCIM-III is an established scale developed
decreased shoulder PROM. to address the ability of individuals with SCI to perform
In a sample of 43 individuals with tetraplegia, Bryden basic activities of daily living. The SCI-FI is a newer
et al. demonstrated that 46% of individuals with C5 SCI instrument that allows the individual to rate their per-
and 63% of those with C6 SCI lacked full elbow exten- formance on specific tasks related to daily life. The
sion, indicating individuals with denervated triceps are paper and pencil forms of both these instruments were
at serious risk for development of elbow contractures.4 used. Because the paper and pencil form of the SCI-FI
Salisbury et al. described 41 people with tetraplegia who is not easily assessed in aggregate, the subsection
lost shoulder flexion, abduction, and external rotation scores were used for this project. Passive ROM was
(at 90° abduction) ROM and experienced concurrent measured according to the guidelines published in
shoulder pain; individuals with a history of previous Bandy and Reese’s Joint Range of Motion and Muscle
shoulder injuries were at a higher risk for developing Length Testing textbook once for each of the move-
shoulder ROM deficits.5 Dalyan et al. studied 482 inpati- ments found in Tables 1 and 2. The participants were
ents and found 9% developed contractures during inpati- tested in supine by one of two skilled clinicians with
ent rehabilitation that were most commonly associated over ten years of clinical experience in SCI.17 The two
with pressure ulcers, spasticity and concurrent TBI.6 clinician ROM measurements demonstrated inter-rater
Research showing the functional implications of ROM reliability within 5 degrees for all study measurements
limitations is also limited. Eriks-Hoogland et al. reported on two subjects with SCI who were not participants in
an association between shoulder pain and reduced the study. For the purposes of this study elbow and
shoulder PROM and a tetraplegia diagnosis in a 5-year knee hyperextension is listed as a positive value, and
longitudinal study of 225 individuals with SCI but the limitations in extension are documented as a negative
functional implications of these limitations were not ana- value (degrees lacked from full extension or 0°). For
lyzed.13 After a literature review of 18 kinematic studies, any motion where the participant was unable to reach

2 The Journal of Spinal Cord Medicine 2019

 Sara Kate Frye et al. Functional passive range of motion of individuals

Table 1 Upper extremity passive range of motion means and ranges by level of injury (absolute values).

Motion General Population SCI Range C5 C6 C7-8

Shoulder Extension 60 72.4 44–95 72.21 73.04 71.61

Shoulder Flexion 165 155.33 88–185 148.79 156.15 159.22
Shoulder Abduction 170 175.41 71–201 169.07 173.38 183.28
Shoulder Horizontal Adduction 120 122.57 94–142 113.43 125.04 126.11
Shoulder External Rotation (Humerus abducted to 90) 90 82.16 32–107 81.79 80.15 79.38
Shoulder External Rotation (Humerus Adducted) 90 85.60 41–119 82.29 85.85 87.83
Shoulder Internal Rotation 70 70.05 22–99 79.07 67.35 66.94
Elbow Extension 0 −6.21 −64-30 −11.14 −0.54 −10.56
Elbow Flexion 140 144.02 124–155 147.64 143.54 141.89
Forearm Pronation 80 65.86 −31-92 51.71 69.15 72.11
Forearm Supination 80 80.38 −5-114 84.86 82.42 73.94
Wrist Extension 70 79.14 40–110 75.79 79.12 81.78
Wrist Flexion 80 81.21 40–110 84.57 78.50 82.50
Wrist Radial Deviation 20 19.84 −10-41 18.50 19.88 20.83
Wrist Ulnar Deviation 30 30.86 2–57 29.21 29.96 31.17

the neutral, or starting position, the value was listed as a American. Time since injury varied from 1.17 to 40
negative. years with a mean of 11.64 years. Injury cause was trau-
Statement of ethics. We certify that all applicable insti- matic for 27 participants and non-traumatic for 2. The
tutional and governmental regulations concerning the participants’ International Standards for Neurological
ethical use of human volunteers were followed during Classification of Spinal Cord Injury (ISNCSCI) classifi-
this research. cation are listed in Table 3. All but one participant self-
Data analysis. All data were entered in to Microsoft reported spasticity, and all but 3 stated spasticity medi-
Excel for storage and management, then exported to cation was used. Mobility characteristics included
SPSS version 22 for analyses. Analyses included descrip- twelve manual wheelchair and 17 power wheelchair
tive statistics, bivariate correlations, and independent users. Twenty-one participants reported completing
means t-tests with statistical significance set at P ≤ home ROM exercises including passive, active, and
0.05. Bivariate correlations relied on Spearman Rho active assist completed at an average of 3.41 times per
coefficients due to the ordinal nature of the variables. week with 17 responding self ROM comprised their
entire home ROM exercise. Twenty-one individuals
Results also completed strengthening exercises on a regular
Demographic data. 30 participants were enrolled, 27 basis with an average frequency of 3.33 times per week.
men and 2 women completed the study; one participant ROM analysis: Absolute ROM assessment revealed
withdrew prior to ROM evaluation and was not notable differences between individuals with cervical
included in the analysis. Ages ranged from 21 to 64 SCI and the general population normative data
(mean 42.3) years. The participants’ racial distribution (Tables 1 and 2). Upper Limb: Shoulder extension
included 14 Black, 13 White, 1 Hispanic, and 1 Native was greater in this study population than the general

Table 2 Lower extremity passive range of motion means and ranges by level of injury (absolute values).

Motion General Population SCI Range C5 C6 C7-8

Straight Leg Raise 100 76.52 35–112 64.71 77.69 84.00

Hip Extension 20 −8.34 −36-20 −8.43 −0.50 −6.28
Hip Flexion 120 110.09 61–142 97.29 114.38 113.83
Hip Abduction 45 32.07 3–90 34.00 28.42 35.83
Hip Adduction 25 23.07 10–41 24.43 20.27 26.06
Hip External Rotation 40 50.07 17–78 46.57 51.81 52.61
Hip Internal Rotation 45 30.64 6–64 30.14 28.81 33.67
Knee Extension 0 −5.84 −25-0 3.50 4.73 9.28
Knee Flexion 140 131.55 92–152 123.57 133.38 135.11
Ankle Dorsiflexion 20 −11.88 −34-18 −10.21 −9.69 −9.67
Ankle Plantar Flexion 50 43.91 18–72 46.07 46.58 38.39
Foot Inversion 35 25.10 0–40 23.79 26.46 24.17
Foot Eversion 20 17.07 −10-30 17.64 16.27 17.78

The Journal of Spinal Cord Medicine 2019 3

Sara Kate Frye et al. Functional passive range of motion of individuals

Table 3 Demographics by level of injury and AIS classification.

Level C5 C6 C7 C8 Total

AIS A 4 4 2 0 8
AIS B 0 2 2 0 4
AIS C 3 6 4 1 14
AIS D 0 1 0 0 1
Total 7 13 8 1 29

C5 C6 C7/8 Total

Age (years) 46.0 ± 15.25 40.85 ± 12.39 40.78 ± 11.10 42.01 ± 12.46
Male (%) 85.71% 100% 88.89% 93.1%
Time since injury (years) 13.42 ± 12.39 7.35 ± 6.83 16.48 ± 13.21 11.65 ± 10.92

able-bodied population. Elbow extension limitations ulnar deviation was associated with lower body
were prevalent, but of those who could achieve full bathing (P = 0.035). Lower limb: The most significant
extension, hyperextension was observed in 10 partici- lower extremity correlations arose from hip and knee
pants. Wrist extension was greater in the sample popu- flexion, where greater PROM was associated with
lation than the general population. Lower Limb: improved performance in ADLs and mobility as
Straight leg raise (SLR) hip flexion, abduction, and measured by the SCIM-III, as well as a large majority
internal rotation fell short of the documented ranges of the subtests (see Table 4). Interestingly, hip and
for the able-bodied population. Ankle plantarflexion knee flexion ROM increased with lower injury levels
contractures were ubiquitous with the mean being over (Table 2). Additional associations included both straight
10 degrees less than neutral and 23 participants unable leg raise, (P = 0.037) and forefoot inversion (P = 0.049)
to achieve a neutral position in one or both ankles. with SCIM-III Grooming.
The relationship between PROM and function. A T-tests examined differences between individuals who
Spearman’s Rho correlation examined the relationship were independent in ADLs compared to those not inde-
between functional skills and PROM (P ≤ 0.05). pendent in ADLs as defined by requiring no assistance
Upper limb: Shoulder horizontal adduction displayed a for items 1–4 on the SCIM-III ADL subsection.
significant association with the most functional tasks Significantly higher PROM for shoulder horizontal
(Table 4). Significant associations were found between adduction, hip flexion, hip internal rotation, and knee
horizontal adduction and overall ADL and mobility flexion were seen for individuals who are independent
status as measured by the SCIM-III and the SCI-FI sub- in their ADLs.
sections, as well as the SCIM-III feeding, dressing, and T-tests also determined the existing PROM differ-
bathing domains. Elbow extension was associated with ences between manual and power wheelchair users.
overall SCIM-III scores and the lower body bathing Significant differences were seen for shoulder horizontal
subtest. Shoulder flexion was associated with SCIM- adduction, wrist ulnar deviation, hip flexion, and knee
III Feeding (P = 0.029), and shoulder abduction was flexion, and power wheelchair users exhibited greater
associated with SCIM-III grooming (P = 0.046). Wrist limitations than manual wheelchair users.

Table 4 Spearman’s rho correlation coefficients and associated P values.

Shoulder horizontal Elbow Hip Knee Ankle Forefoot

adduction extension flexion flexion Plantarflexion Eversion

SCIM-III total 0.496** −0.388* 0.292 0.462* −0.275 0.332

SCIM-III mobility 0.610*** −0.277 0.368* 0.508** −0.315 0.180
SCIM-III ADL 0.574** −0.233 0.541** 0.593** −0.380* 0.309
SCIM-III feeding 0.491** −0.234 0.325 0.429* −0.103 0.201
SCIM-III grooming 0.471* −0.262 0.418** 0.394* −0.315 0.165
SCIM-III upper body bathing 0.435* −0.268 0.469* 0.457* −0.122 0.172
SCIM-III lower body bathing 0.288 −0.367* 0.610*** 0.477** −0.436* 0.434*
SCIM-III upper body dressing 0.412* −0.083 0.542** 0.501** −0.359 0.190
SCIM-III lower body dressing 0.298 −0.035 0.454* 0.487** −0.367* 0.372*

*P < 0.050, ** P < 0.010, *** P < 0.001.

4 The Journal of Spinal Cord Medicine 2019

 Sara Kate Frye et al. Functional passive range of motion of individuals

Discussion continuously bear weight through the wrist for function.

This is the first study to describe typical PROM in Indeed, wrist extension hypermobility was highest in the
people with cervical SCI. Contractures were prevalent subset of individuals with C6-8 levels of injury who
among the study participants, even though the sample demonstrated greater independence and participation
consisted of active community-dwelling individuals in daily transfers and other mobility tasks than individ-
with the majority engaging in regular strength and uals with higher injuries. The association between ulnar
ROM exercises. We measured PROM using standar- deviation and LB bathing may be incidental, but
dized methods in supine to minimize the confounding perhaps ulnar deviation increases for individuals with
effect of compensatory positions and ROM in adjacent tetraplegia completing lower body tasks as they press
joints that some individuals use during functional activi- through their wrist which has stronger innervation at
ties. One inherent limitation of goniometry is that only a the radial side at the C6 level of injury.
single joint can be measured at a time; however, kin- Anecdotal clinical experience recommends an indi-
ematic studies that simultaneously track multiple joints vidual with cervical SCI requires a straight leg raise
using skin markers have demonstrated that a variety of (SLR) of 120 degrees to complete long sitting activities
joint movements can be utilized to perform a given func- of daily living (ADLs). The actual SLR measured in
tional task. This apparent limitation may be an advan- the study population measured much less at 76.52
tage in isolating joint ROM and is more widely degrees. SLR does increase with lower level of injury
available in clinical practice. Many of the subjects and more functional mobility, but this finding, in con-
demonstrated independence with ADLs and functional junction with concomitant hip external rotation hyper-
mobility despite PROM limitations. mobility suggests individuals with SCI are not
Adapting to cervical SCI and maximizing function completing ADLs in long sitting, but rather using a
can strain joints. Shoulder hyperextension is required frog-sitting posture. Hip flexion, abduction, and internal
for “prop-sitting,” to position the upper limb behind rotation also fell short of the recommended required
the torso for sitting stability. Elbow hypermobility/ ranges. It is possible these motions may not be essential
hyperextension may be linked to locking out the to completing ADLs.
elbows for prop-sitting and transfers. Interestingly, The association of hip PROM with ADL perform-
eight participants with elbow extension limitations ance with tabletop tasks highlights the importance of
were able to achieve independence in transfers. pelvic position upon function. The pelvis serves as the
Horizontal adduction contributes greatly to performing base of stability for ADL performance. Limitations in
ADL functions as the ability to reach the arm across the hip mobility can lead to sub-optimal pelvic positioning,
body impacts all areas of ADL performance. There is a sacral sitting, a kyphotic posture, and forward head pos-
resultant increase in horizontal adduction with lower ition can limit active reach at the shoulder and func-
level injuries as pectoralis innervation increases. tional use of the upper limb. In our client population,
Increases in shoulder flexion with feeding and shoulder hip flexion limitations were prominent and observed in
abduction with grooming are likely associated with the 24 of the participants. To counteract this ROM loss,
need to reach forward to the mouth and laterally to daily prone positioning is required to support optimal
the face and head for these tasks, respectively. pelvic alignment. Standing frame use could also
Forearm pronation and supination is critical for ADL stretch the pelvis, knee, and ankle for those who are
performance as these motions position the hand in an medically able to tolerate standing. Neutral or close to
optimal position for bimanual or tenodesis-based neutral pelvic alignment, or a stable base, is needed to
tasks. In addition, limited forearm mobility puts an complete functional activities. The association between
increased burden on shoulder muscles as shoulder forefoot inversion and grooming may be incidental or
abduction substitutes for forearm rotation which may may further support the need for a stable sitting
contribute to the high incidence of shoulder pain in indi- posture for tabletop activities. Foot flat positioning
viduals with SCI.18 It is important to remember the offers an assist to a neutrally positioned pelvis to
musculature required for forearm movement is not provide a stable platform for upper body activities.
innervated at higher levels of cervical SCI and, as Plantarflexion contractures were prevalent, but some
expected, the amount of pronation increased as the individuals with tight plantarflexion in supine may be
level of SCI moved caudally. able to achieve foot flat in their wheelchair when the
Wrist extension hypermobility appears related to the knee is flexed which may be why the functional impact
tendency for individuals with cervical SCI to of this limitation is not observed.

The Journal of Spinal Cord Medicine 2019 5

Sara Kate Frye et al. Functional passive range of motion of individuals

Clinicians who work with individuals with tetraplegia physical attributes necessary to achieve optimal func-
should educate individuals and their caregivers to con- tion. Finally, longitudinal investigation of how ROM
stantly monitor ROM limitations and their impact on and function change over time could guide more effec-
functionRegular outpatient therapy maintenance evalu- tive ROM re-education and intervention. Such a study
ations may prevent ROM limitations and guide individ- might incorporate kinematic analysis and examine
uals with cervical SCI to develop a sustainable plan to differences in how exercise impacts ROM when it is
maintain their flexibility and resultant function. A completed independently, with caregiver assistance,
recent Cochrane review indicates that stretching may using rehabilitation technology, or in an outpatient
not improve ROM limitations so positional strategies setting with a skilled therapist.
and activity modifications should be emphasized
during therapy sessions.19 Regular seating system evalu- Conclusion
ations are also recommended to accommodate any This observational study identified significant ROM
ROM limitations that may develop over time. differences in individuals with cervical SCI when com-
Clinicians are encouraged to assess ROM during pared to the general population and associated these
seating evaluations and prescribe home exercise and with their self-reported performance of functional
ROM programs as needed and provide appropriate out- tasks. Some of these range of motion differences can
patient clinic referrals to address new or increasing be associated with enhanced functional performance
limitations. [or the residue of optimization], while others may be
Study limitations include the use of a convenience maladaptive. Achievement of optimal function and
sample composed exclusively of participants living in quality of life with cervical SCI requires effective
the community, with no inclusion of individuals residing ROM during rehabilitation and throughout the lifespan
in subacute or long-term care facilities. Furthermore, all
participants held and utilized accessible transportation. Acknowledgements
These two factors may create a cervical SCI subset Thank you, Hayyan Goodin, OTR/L, without your
demonstrating more robust PROM values. All func- diligence and thoroughness in data collection, this
tional skill data utilized self-reported scales which are study could not have been completed. Thank you to
valid clinical tools but in future studies data triangu- Peter H. Gorman, MD MS for playing a key role in
lation by caregiver input is suggested. It is also unclear recruitment and to Leigh Casey, BA for logistical
if our weak to moderate associations between PROM support.
and the self-reported ADL activities were impacted by
a small pilot study cohort. Disclaimer statements
Future research recommendations include expanding Financial support This work was unsupported.
the range of motion and function investigation scope.
One suggestion is to include multiple geographic areas Conflicts of interest None.
to provide more data from each injury level and facili-
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