Retraining mobility in a patient following spinal cord infarction: a case report.
Abstract: This case report presents the physiotherapy management and mobility retraining of an 81-year-old woman with a non-traumatic incomplete spinal cord injury, secondary to spinal cord infarction. There is little evidence to direct mobility retraining following spinal cord infarction and non-traumatic incomplete spinal cord injury, so a functionally based approach to retraining mobility was employed. Initially, wheelchair-bound and hoist transferring, Mary regained limited independence with mobility, walking with a frame and assistance of one person, over 11 weeks of inpatient rehabilitation. The use of predictive tools for determining likely length of stay, functional outcome and therefore discharge destination, and consideration of an early-supported discharge approach may have assisted Mary to make similar long-term functional gains following a shorter hospital admission. Ongoing research is required to establish optimal mobility retraining intervention for patients following spinal cord infarction and non-traumatic incomplete spinal cord injury. McGregor L, Hale L. (2010): Retraining Mobility in a patient following spinal cord infarction: a case report. New Zealand Journal of Physiotherapy 38(3): 98-105.

Key words: Spinal cord diseases, physiotherapy, mobility limitation, locomotion.
Article Type: Case study
Subject: Walking (Physiological aspects)
Spinal cord injuries (Diagnosis)
Spinal cord injuries (Care and treatment)
Spinal cord injuries (Case studies)
Physical therapy (Health aspects)
Physical therapy (Case studies)
Therapeutics, Physiological (Health aspects)
Therapeutics, Physiological (Case studies)
Authors: McGregor, Lesley
Hale, Leigh
Pub Date: 11/01/2010
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: Nov, 2010 Source Volume: 38 Source Issue: 3
Geographic: Geographic Code: 90ASI Asia
Accession Number: 263880353
Full Text: INTRODUCTION

Spinal cord infarction (SC infarction), or spinal cord stroke, is a rare form of non-traumatic incomplete spinal cord lesion, accounting for 1-1.2% of all strokes (Hogan 2006, Novy et al 2006). Annual incidence internationally is estimated at 12 in 100,000 (Hogan 2006). The low incidence results in a dearth of literature pertaining to all aspects of the condition. Aetiology, natural history and prognosis are therefore difficult to define (Cheshire et al 1996, Hogan 2006). The studies summarised in Table 1 highlight the diverse aetiology of SC infarction. The most common causes appear to be related to aortic pathology, although cryptogenic aetiology is also common.

SC infarction is marked by an acute onset (minutes to hours), heralded by sudden, severe, sometimes radicular, back pain (at the level of infarction), bilateral limb weakness, paraesthesia, sensory loss, loss of sphincter control with hesitancy and difficulty voiding bladder and bowel (Cheshire et al 1996, Hogan 2006, Masson et al 2004, Novy et al 2006).

Functional outcome is influenced by the neurological level and completeness of injury, and degree of neurological recovery (McKinley et al 2006). Other influencing factors include the patient's age; presence and degree of spasticity, contracture, pain; co-existing medical conditions; amount of rehabilitation; expertise of rehabilitation professionals involved and psychosocial factors (motivation, social support, financial resources) (McKinley et al 2006, Masson et al 2004, Salvador de la Barrera et al 2001). There is widespread agreement that motor preservation is a good indicator of functional outcome (McKinley et al 2006, Salvador de la Barrera et al 2001). The absence of motor ability at admission has been shown to correlate negatively with functional outcome and, if still present at one month, has been linked with poor prognosis (McKinley et al 2006, Salvador de la Barrera et al 2001). Outcomes vary considerably between studies with 9-54% of patients post-SC infarction regaining assisted mobility and 5-26% regaining independent mobility (Cheshire et al 1996, Masson et al 2004, Salvador de la Barrera et al 2001). Burns et al (1997) reported that out of 105 people with incomplete tetraplegia following acute traumatic cervical spinal cord injury, only 40% of those with an American Spinal Injury Association (ASIA) (Maynard et al 1997) classification of C, over the age of 50 years, acquired the ability to walk 61 metres by discharge, as compared to 90% of those younger than 50 years. Patients classified as ASIA A/B were significantly more likely to be wheelchair dependent (Salvador de la Barrera et al 2001) and very few people with this level of disability achieved functional mobility (Dobkin et al 2007). Patients classified as ASIA C/D were likely to regain functional mobility (Dobkin et al 2007, McKinley et al 2006, Salvador de la Barrera et al 2001). Community ambulation was most often achieved in patients with L3 (or lower) injury (McKinley et al 2006) and usually achieved by six months post-injury (Dobkin et al 2007). Recovery of mobility is of top-priority for patients following incomplete spinal cord injury (ISCI) ranked as equally important to bowel and bladder concerns (Patrick et al 2003).

As SC infarction is a rare condition, studies to date have focused primarily on aetiology, diagnosis, medical and pharmaceutical management, and prognosis. There is a paucity of evidence for physiotherapy assessment and treatment of patients with SC infarction. The purpose of this case report is to describe the inpatient physiotherapy assessment and treatment of mobility limitation in an elderly patient following SC infarction, and to consider the outcomes in terms of length of stay, functional independence and quality of life. Ethical approval was gained from the relevant New Zealand Ethics Committee (CEN/07/15/EXP), and written informed consent was obtained from Mary (pseudonym).

CASE REPORT

History

Mary, an 81-year-old lady, presented with a two-week history of new onset thoracic back pain and loss of strength and sensation from her feet to her saddle region.

On admission, lower limb muscle strength was reduced to 4/5 on the Medical Research Council scale for all major lower limb muscle groups (Medical Research Council 1942). Ankle reflexes were absent bilaterally; sensation was reduced distal to the level of T7/8. Mary's past medical history was unremarkable. Magnetic resonance imaging (MRI) findings revealed spinal cord oedema and suspected infarction at the C7-T10 level. Vasculitis resulting in SC infarction was diagnosed. Five days of high-dose, intravenous methyl prednisolone was commenced, followed by ongoing oral prednisone. Mary transferred to the rehabilitation unit three weeks after admission, having made little functional progress despite regular physiotherapy intervention.

Baseline Physiotherapy Assessment

On initial rehabilitation assessment, Mary presented as low in mood, frustrated and fearful of movement. Previously, Mary lived alone and functioned at a high level. Her goal was to return home, even if wheelchair or housebound, although she wished to walk short distances with a frame.

The ASIA Standard Neurological Classification of Spinal Cord Injury and ASIA Impairment Scale (ASIA-IS) incorporates the assessment of key myotomes and sensory points within dermatomes to determine neurological, motor and sensory levels of impairment, and assign an associated classification grade (A-D), in patients following spinal cord damage (Maynard et al 1997). Table 2 depicts the results of the motor assessment at admission to the rehabilitation unit, 21 days after infarction. Sensory assessment was unchanged from admission. Mary was classified "ASIA D Incomplete" (Maynard et al 1997). (See Appendix 1).

Mary's knee reflexes were brisk, ankle reflexes absent, and the Babinski sign present. Proprioception was unaffected according to the scoring system proposed by Lincoln et al (1998). Muscle tone and passive range of motion were normal as assessed by the Tardieu Scale (Tardieu et al 1954). Mary was doubly incontinent and a urinary catheter remained in situ. She was in pain from superficial friction blisters on both buttocks and a right malleolal ulcer.

Mary needed the assistance of two people with bed mobility. Static and dynamic sitting balance was limited. Mary could slide transfer with three assistants but anxiety with this activity was very high; she therefore hoist-transferred for all ward-based activities. She was able, with maximal assistance of four people, to pull-to-stand from a 70 centimetre raised plinth. Exercise tolerance was greatly reduced.

Collaborative Goals

Collaborative physiotherapy goals, outlined in Table 3, progressed throughout the admission according to achievement of previous goals and the need to attain maximal safety and independence for Mary's return home.

Outcome Measures

The Modified Barthel Index (Collin et al 1988) was used as a measure of global functional outcome. Mary's disability was rated by her primary physiotherapist, occupational therapist and nurse upon admission to, and discharge from, the rehabilitation unit. The Modified Barthel Index has good inter-rater agreement (Kendall's coefficient of concordance =0.93) (Collin et al 1988), although this version has not been proven reliable and valid in a population with ISCI.

The Motor Assessment Scale (MAS) (Carr and Shepherd 1985), used to assess motor function in patients with hemiplegia following stroke, was used to assess and measure progress in activity limitations. Although the MAS has not been validated in a population with ISCI it was chosen for the close association between items measured on the MAS and collaborative goals towards the achievement of independence with transfers and ambulation.

The Ten Metre Timed Walk (10MTW) (Wade 1992) was measured at week eight, when Mary was first capable of mobilising ten metres, and reassessed at discharge. Van Hedel et al (2006) advocate the use of timed walking tests to improve responsiveness of outcome measurement associated with mobility post-SC infarction. They reported excellent inter- and intrarater reliability for the 10MTW and later stated that the 10MWT was more responsive than the Walking Index for Spinal Cord Infarction II (WISCI II) in detecting ongoing improvements in walking capacity after three months post-SC infarction (Van Hedel et al 2005, Van Hedel et al 2006).

Treatment

Mary was treated for 11 weeks in the rehabilitation unit. Treatment followed a functional approach and consisted of graduated part-task and wholetask practice of bed mobility, sitting and standing balance, transfers, and mobility including practice of steps. Practice of unsupported sitting balance focused on pelvic and core stability. This included pelvic tilting exercises and maintenance of neutral pelvis with trunk extension, trunk rotation and reaching activities with increasing multidirectional limits of stability.

Standing practice commenced from a high (70cm) support surface, with maximal upper limb support and assistance of four people. This progressed to standing with aids (gutter frame, frame, crutches) and one or two person assistance. The support surface was progressively lowered to the height of Mary's wheelchair (50cm). Verbal and visual feedback was used to train self-control of foot position. Standing balance activities included pelvic tilting and control of neutral pelvic position in standing, head and trunk rotations and small, self-initiated upper limb movements.

Transfer practice commenced with sliding transfers and progressed to standing transfers using a gutter frame, frame, and finally crutches. Mary learnt to step on the spot and move her mobility aid forwards and backwards without stepping, then with stepping, before progressing to turning and transferring. This process was repeated for each mobility aid progression and formed the basis of initial mobility training. Verbal and visual feedback were used to train self-monitoring of foot position.

Mobility practice commenced with a gutter frame and progressed to a frame, then crutches with assistance of one to two people. Turning practice and endurance work were included. Steps practice involved step-ups with bilateral rails. Step height was gradually increased from 8cm to 15cm. When Mary could perform 11 consecutive step-ups, she began practising a flight of steps with bilateral rails and assistance of two people. Self-initiated visual feedback was encouraged to ensure correct foot placement.

Mary participated in a therapy assistant-supervised bed mobility and strengthening exercise programme (Table 4) on alternate days, three days per week. The number of repetitions for each exercise was increased as Mary's strength increased. Fatigue management (timetabled rest periods) was important to enable Mary to engage in all rehabilitative and social activities of importance to her. In addition to physiotherapy, Mary was attending occupational therapy sessions where the focus was on personal care management.

RESULTS

On discharge, Mary could get in to and out of an electric bed independently, using the controls to assist her in to a sitting position. She was able to stand transfer with an assistant, using a frame or crutches. Her poor sensation and balance continued to limit independence with standing mobility tasks. Mary mobilised independently using a self-propelling wheelchair or, with a frame and assistance of one, could walk a maximum of 20 metres indoors. She was able to slowly ascend and descend a flight of steps with assistance of two people but required frequent rests. Her confidence with movement was greatly increased but she remained at a high risk of falls. Modified Barthel Index scores increased from 3/20 on admission to 13/20 on discharge. Table 5 shows an increase of nine points in MAS scores from 19/48 on admission to 28/48 on discharge. Mary achieved a 94 second reduction in 10MWT results over the final four weeks of admission, increasing her walking velocity from 0.07[ms.sup.-1] to 0.19[ms.sup.-1].

Mary was discharged 97 days post infarction, with follow-up arranged via the community rehabilitation team.

DISCUSSION

Mary did not achieve independent ambulation, but she did achieve her goal of discharging to her own home. Despite improvements across all outcome measures, overall ability as described by these measures still falls well below that required for independent functional ability. The relatively poor level of functional mobility attained on discharge supports reports of previous studies documenting functional recovery following SC infarction (Burns et al 1997, McKinley et al 2006, Masson et al 2004, Salvador de la Barrera et al 2001). Although Mary was classified as "ASIA D Incomplete" and had fair retention of motor control, she was elderly, showed no improvement in sensory loss and struggled with significant pain, negatively impacting on her ability to practice functional tasks (Burns et al 1997, McKinley et al 2006, Masson et al 2004, Salvador de la Barrera et al 2001). Her levels of motivation may have been negatively affected by her initial fear of movement (McKinley et al 2006). Mary's achievement of her goal is attributable in part to her determination, her excellent social support system, and her access to the financial resource required to maintain her independence at home; all of which McKinley et al (2006) highlight as being important determinants of overall prognosis.

Mary's length of stay fell five weeks over the average length of stay for this rehabilitation facility. Mary was able to transfer with assistance of one in just under eight weeks and was independently wheelchair mobile in just over six weeks. Gains made over her final three weeks of admission included the ability to get in to bed independently, mobilise with a frame and assistance of one (or crutches and assistance of two) and manage steps with assistance of two. On discharge, Mary primarily relied on her ability to transfer with the assistance of one person, and her ability to self-propel in a wheelchair. Hence, given the absence of 24 hour assistance upon discharge home, Mary made little use of functions gained subsequent to week eight of her rehabilitation admission. This begs the question whether Mary's lengthy stay was justified and whether alternative rehabilitation management may have enabled the requisite functional gains to be made over a shorter period of time. Could discharge outcome have been predicted and planned for from the outset and could this have assisted in managing the length of her rehabilitation admission?

Functional Independence Measure-Function Related Groups (FIM-FRGs) describe the most reasonable outcomes and length of stay for patients based on their clinical characteristics (Bates and Stineman 2000). Patients are grouped according to their expected rehabilitation length of stay, functional outcomes and likelihood of discharge to home (Bates and Stineman 2000). Each module first assigns patients to one of 20 distinct impairments based on their primary diagnosis (relevant to rehabilitation referral) (Bates and Stineman 2000). Following this, patients are grouped according to severity of initial disability based on FIM scores, and according to age (Bates and Stineman 2000). The FIM-FRGs assignments distinguish between patients expected to have different rehabilitation outcomes and total costs of care (length of stay) (Bates and Stineman 2000). Its predictions have been shown to be stable over time (Bates and Stineman 2000). As such, patients' functional recovery can be predicted at the outset of rehabilitation and this prediction can be used to refer them to the most appropriate setting, at the appropriate time (Bates and Stineman 2000). Early discharge planning is promoted based on predicated, risk-adjusted outcomes and the necessity for unexpected increases in length of stay is minimised (Bates and Stineman 2000). In the United States of America, FIM-FRGs and similar allied systems have been used to triage patients to various levels of rehabilitation service and/or continuing care facilities, making best (most equitable) use of limited financial resources (Bates and Stineman 2000). The nine (Stroke) FIM-FRG assignments fall into three bands: lower, middle and upper designating patients as severely, moderately and mildly disabled respectively (Bates and Stineman 2000) (See Table 6). The lower band of patients are the most disabled: young patients with extreme physical disability, older patients with severe physical and cognitive disability and older patients with extreme physical disability but less severe cognitive disability (Bates and Stineman 2000). Middle band patients include those, regardless of age or cognition, who have varying degrees of moderate physical disability (Bates and Stineman 2000). Those in ST-7 included patients with cognitive disability as well (Bates and Stineman 2000). The upper band of patients included those with minimal to no cognitive disability, and mild physical disability (Bates and Stineman 2000). Mary fell into the lower level of FIM-FRGs. As such, her mean length of stay could be anticipated to be around 28 days, and it could be expected that her level of eventual functional independence would be limited.

As such, and given all the existing evidence to suggest caution in functional outcome prediction for Mary, planning for an early supported discharge to home could have begun from the outset of the rehabilitation admission. Although it is acknowledged that these observations are based on Mary's diagnosis of a stroke but as the stroke was in the spinal cord, and thus did not alter cognitive function, these predictions may not hold true in this case. There is good evidence to support the fact that early supported discharge, with access to robust community follow-up, can assist patients in making further gains (Early Supported Discharge Trialists 2000, 2005, Langhorne and Holmqvist 2007). Given the structure of the community rehabilitation team at the time however, the requisite level of community input could not have been guaranteed. There is no available literature to direct physiotherapy approaches to mobility retraining in patients following SC infarction. The literature pertaining to mobility retraining in patients following non-traumatic ISCI is also sparse. Growing evidence exists to suggest that body-weight supported treadmill training (BWSTT) may be effective in retraining independent mobility following ISCI, resulting in improvements in over-ground walking, gait parameters and endurance (Behrman and Harkema 2000, Behrman et al 2005, Gardner et al 1998, Hornby et al 2005, Protas et al 2001). These single case reports, case series reports and pilot studies provide only low quality evidence in support of BWSTT and commonly involved subjects with chronic ISCI. Dobkin et al (2006, 2007) recently conducted a multi-centre, single-blinded, randomised controlled spinal cord injury locomotor trial. The results suggest that there is no significant difference in mobility outcome following acute ISCI between patients participating in 12 weeks equal time over-ground training as compared with BWSTT (Dobkin et al 2006, Dobkin et al 2007). BWSTT has the added disadvantage of requiring specific, expensive equipment. Although the rehabilitation unit does not currently have access to the necessary facilities for BWSTT, the inclusion of this treatment approach may have facilitated earlier recovery of mobility, particularly given Mary's anxiety levels pertaining to practicing mobility tasks and the security associated with mobility retraining using BWSTT.

Mary experienced considerable pain associated with pressure sores and a malleolal ulcer. She displayed significant fear of movement when practicing functional movements, leading to movement avoidance. Further investigation and management of these issues may have assisted Mary to engage in rehabilitation, and may have facilitated earlier and greater functional gains. Retrospectively, the inclusion of a self-report measure of confidence with movement or fear of falling may have more objectively tracked changes in movement-related fear. The Activities-specific Balance Confidence Scale (Powell and Myers 1995) and the Modified Falls Efficacy Scale (Hill et al 1996), commonly used for the purpose of self-report assessment of fear of falling and confidence with specified movements and activities, are more suited to community-dwelling adults. The tasks incorporated represent a much higher level of independent activity than corresponds to Mary in this case (Hill et al 1996, Powell and Myers 1995). It is apparent that similar measures are required, assessing lower-level functional activities, for patients in inpatient or residential care settings, thereby eliminating the inherent floor effect common to currently available measures. A balance outcome measure was not included as Mary could not stand unsupported.

Eighteen months on, Mary remains at home. Following six months of community rehabilitation input she transfers and mobilises independently with a frame indoors. She has, however experienced multiple falls with five Emergency Department attendances and a fractured tibia/fibula requiring intermedullary nailing and flap repair with a subsequent 36 day admission.

CONCLUSION

A function-based approach to mobility retraining enabled Mary to achieve assisted ambulation indoors and discharge home, an outcome superior to the generally poor outcomes purported in the literature for elderly patients with this condition. Tools such as FIM-FRGs exist to predict likely outcomes, length of stay and costs associated with rehabilitation admissions. The use of such tools can assist in making informed and equitable decisions regarding rehabilitation. Mary's lengthy admission may be justified given the achievement and maintenance of her goal to return home. The use of a tool such as FIM-FRGs may have facilitated achievement of similar goals through alternative channels such as early supported discharge. Early-supported discharge, in the presence of a robust community rehabilitation team may assist in achieving similar functional outcomes with reduced length of hospital admission. BWSTT and interventions addressing pain and fear may have facilitated an earlier recovery of mobility. There is inadequate evidence to determine best evidence-informed management of mobility retraining following SC infarction or non-traumatic ISCI. The rarity of SC infarction renders high-powered, randomised controlled trials largely impossible, hence further randomised controlled trials are required to investigate current, common management strategies for addressing mobility limitations in the non-traumatic, ISCI population as a whole. Furthermore, careful, consistent reporting of case-by-case management of patients following SC infarction will assist in developing guidelines for physiotherapy management of this population.

KEY POINTS

* Spinal cord infarction (or spinal cord stroke) is a rare form of non-traumatic incomplete spinal cord injury. The low incidence of spinal cord infarction makes it difficult to study the effectiveness of physiotherapy interventions through robust randomised controlled trials.

* There is thus little empirical evidence in existence to guide physiotherapy assessment and mobility retraining intervention following non-traumatic incomplete spinal cord injury.

* Careful, consistent reporting of case-by-case management of patients following spinal cord infarction will assist in developing guidelines for physiotherapy management of this population.

* Tools such as FIM-FRGs exist to predict likely outcomes, length of stay and costs associated with rehabilitation admissions. The use of such tools can assist in making informed and equitable decisions regarding rehabilitation.

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Lesley McGregor, BPhty

Senior Physiotherapist

Therapies

Hutt Valley District Health Board

Wellington

Assoc Prof Leigh Hale, PhD; MSc (Physio) (WITS), BSc (Physio) (UCT)

Senior Lecturer

School of Physiotherapy

University of Otago

Dunedin

ADDRESS FOR CORRESPONDENCE

Lesley McGregor, 70 Spinnaker Drive, Whitby, Porirua. Phone: (04) 234 8418, Mobile: (027) 542 3602, Fax (work): (04) 570 9361. Email: lesley.mcgregor@gmail.com
Table 1: The varied aetiology of spinal cord infarction

                Suggested cause

                                                       Cardiac
                                                       Arrest/
                                                     Hypovolemic
                Idiopathic   Aortic *   Spinal TIA      Shock

Cheshire et         3           19          3             4
al (1996)         (6.8%)     (43.2%)      (6.8%)       (9.1%)
n = 44

Salvador de         13          12                        4
la Barrera et    (36.1%)     (33.3%)                   (11.1%)
al (2001)
n = 36

Masson et           17          8
al (2004)        (60.7%)     (28.6%)
n = 28

Novy et al          20          1
(2006)#           (74%)       (3.7%)
n = 27

                Suggested cause

                                                         Arterial
                          Arteriosclerosis/            Hypotension/
                Anaemia       Embolism         AVM     Insufficiency

Cheshire et        1              1             3
al (1996)       (2.3%)         (2.3%)         (6.8%)
n = 44

Salvador de                       7
la Barrera et                  (19.4%)
al (2001)
n = 36

Masson et
al (2004)
n = 28

Novy et al                                                   3
(2006)#                                                   (11.1%)
n = 27

                Suggested cause

                 Arterial
                Occlusion
                ([dagger])    Other **

Cheshire et                    10
al (1996)                    (22.7%)
n = 44

Salvador de
la Barrera et
al (2001)
n = 36

Masson et           21          1
al (2004)         (7.1%)     (3.6%)
n = 28

Novy et al          3
(2006)#          (11.1%)
n = 27

This table provides a summary of findings from these studies and is
not intended as an inter-study comparison. Percentages may not
total 100 due to rounding. Abbreviations: AVM: Arteriovenous
malformation; TIA: Transient ischaemic attack.

* Aortic refers to aortic aneurysm rupture +/- surgical repair,
aortic dissection, thoracic and abdominal aortic aneurysms, aortic
thrombosis and aortic atherosclerosis.

([dagger]) Arterial occlusion includes that associated with
mechanical factors such as disk prolapse/herniation, cervical
osteophytosis/spondylosis (or hypertrophic degenerative changes of
the vertebral column), mechanical tension on spinal/radicular
arteries (associated with spinal mobility, spinal disease and
infarct-triggering movements).

** Other causes previously associated with spinal cord infarction
include haematomyelia, epidural haematoma, cervical spondylosis,
celiac plexus block, coagulopathy (hypercoagulability), sickle cell
disease, polycythemia, vasculitis, systemic lupus erythema,
collagen and elastin disorders, decompression sickness,
angiography, sympathectomy, gastrectomy, therapeutic embolisation
of renal and spinal arteries, aortic and spinal surgeries (or any
invasive procedure with a risk of compromise to spinal
circulation), and a thoracic stab wound (Cheshire et al 1996,
Masson et al 2004, Salvador de la Barrera et al 2001).

(#) It should be noted that 27 patients out of a total 72 patients
with acute myelopathy were selected and patients with aetiology
suggestive of compressive, traumatic, infectious or inflammatory
causes were excluded.

Table 2: Muscle strength assessment at rehabilitation admission
and discharge (Medical Research Council scale) ([section])

                          Rehabilitation         Rehabilitation
                             Admission              Discharge
                             Week One             Week Eleven
Muscle Strength
(Total Score = 5)         Left      Right        Left      Right

Rectus Abdominus                      2                      3
Hip Extension              2          2           3          4
Hip Flexion                2          3           4          4
Hip Abduction              3          3           4          4
Hip Adduction              4          4           4          4
Knee Extension             3          3           4          4
Knee Flexion               3          4           4          4
Ankle Dorsiflexion         3          3           4          4
Ankle Plantarflexion       4          4           4          4
Toe Extension              4          4           4          4
Toe Flexion                4          4           5          5

Grade       Medical Research Council Scale Definition

0                          No movement
1         Palpable contraction, but no visible movement
2           Movement but only with gravity eliminated
3                    Movement against gravity
4          Movement against resistance, but weaker than
                            other side
5                          Normal power

([dagger]) For scoring, please refer to Wade DT (1992):
Measurement in Neurological Rehabilitation.
Oxford: Oxford University Press, p53.

Table 3: Physiotherapy goals over the course of 11-week inpatient
rehabilitation admission

Week One                            Week Two

To move from lying to sitting       To move from sitting
on the edge of the bed safely       to standing safely and
and independently within            independently, from a 50cm
three weeks.                        high bed/chair, using a frame,
                                    within four weeks.

To sit unsupported safely and       To stand transfer between the
independently at the edge of        bed and the wheelchair, using
the bed, feet flat on the floor,    a frame, with assistance of one
no upper limb support, within       person, within three weeks.
three weeks.

Week Eight                          Week Ten

To mobilise safely and              To move from sitting
independently up to the toilet      to standing safely and
and back with a frame, within       independently from wheelchair
two weeks.                          or bed with crutches, within
                                    two weeks.

To ascend/descend ten
steps with bilateral rails and
assistance of one person
safely, within two weeks.

Table 4: Treatment: Therapy assistant-supervised strengthening
exercise programme

Exercise: three times per week             Muscle Groups Targeted

1. Supine knee bends + knee to chest           --Knee flexors
   lifts                                       --Hip flexors
Two sets of Ave repetitions each leg *          --Abdominals

2. Supine bridging                              --Abdominals
Two sets of Ave repetitions *                 --Hip extensors

3. Side lying leg lifts                         --Abdominals
Two sets of five repetitions each leg *       --Hip abductors
                                              --Hip adductors

4. Static quadriceps                          --Knee extensors
Two sets of five repetitions each leg *

5. Inner range quadriceps over a             --Knee extensors,
   wedge                                        inner range
Two sets of five repetitions each leg *

6. Straight leg raises                        --Knee extensors
Two sets of five repetitions each leg *        --Hip flexors
                                                --Abdominals

7. Ankle pumps                              --Ankle dorsiflexors
Two sets of five repetitions each leg *    --Ankle plantarflexors

* The number of repetitions for each exercise was increased as
Mary's strength increased.

Table 5: Motor Assessment Scale (MAS) scores on rehabilitation
admission and discharge

                                 Rehabilitation
Functional ability                 Admission      Rehabilitation
(Total score = 6) ([section])        Score        Discharge Score

Supine[R] Side lying onto              0                 1
Intact Side

Supine[R] Sitting Over                 1                 2
Side of Bed

Balanced Sitting                       1                 4

Sitting[R] Standing                    0                 2

Walking                                0                 2

Upper Arm Function                     5                 5

Hand Movements                         6                 6

Advanced Hand                          6                 6
Movements

TOTAL (48)                             19               28

([section]) For a full description of scoring, please refer
to Wade DT (1992): Measurement in Neurological Rehabilitation.
Oxford: Oxford University Press, p157-162.

Table 6: Functional Independence Measure-Function
Related Groups (FIM-FRGs)

          Function Related    Motor FIM Score     Cognitive FIM Score
Band        Group (FRG)      (Total score = 91)   (Total score = 35)

Upper           ST-9               74-91                 31-35
Upper           ST-8               63-73                 31-35
Middle          ST-7                >62                  5-30
Middle          ST-6               56-62                  --
Middle          ST-5               49-55                  --
Middle          ST-4               38-48                  --
Lower           ST-3               13-37                 18-35
Lower           ST-2               13-37                 5-17
Lower           ST-1               13-37

                     Mean Length of
Band      Age (yr)    Stay (days)

Upper        --           8.9
Upper        --           11.5
Middle       --           13.0
Middle       --           15.1
Middle       --           18.1
Middle       --           23.1
Lower       >74           28.5
Lower       >74           26.6
Lower      16-74          32.0
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