For a patient with SMA to be able to function with their maximal amount of independence, it is important to have as much range of motion possible. As with the majority patients with SMA, my current patient with SMA spends most of his time in his wheelchair. Therefore, he has contractures in his knees and ankles, causing him to lack range of motion in those joints. He also has not used footrests on his wheelchair in many years secondary to limitations with things such as sitting close to a table. This has caused him to have decreased dorsiflexion of both his ankles.
We have begun to work every other week on increasing his range of motion in his knees and ankles by passively stretching him out reclined on a table and re measure once a month to track our progress. We start by stretching out his hamstring by pushing his knees into extension and holding for approximately ten seconds and then relaxing. We repeat this motion about twenty times throughout the treatment. We alternate between knee and ankle passive range of motion. We have found that the most effective way to stretch out his ankles to increase dorsiflexion is to flex his knee and bring his foot towards his bottom, pushing down on his knee to approximate the heel to the table. Some weeks we were able to push into more dorsiflexion that others secondary to increased swelling in his ankles.
Please see the following tables for measurements of PROM knee extension and PROM dorsiflexion.
| PROM L knee extension | PROM R knee extension | |
| 04/19/19 | -18o | -21o |
| 03/13/19 | -20o | -23o |
| 02/12/19 | -23o | -23o |
| 01/15/19 | -23o | -25o |
| 12/18/18 | -23o | -26o |
| 11/20/18 | -21o | -27o |
| 10/30/18 | -27o | -40o |
| PROM L dorsiflexion | PROM R dorsiflexion | |
| 04/19/19 | -30o | -37o |
| 03/13/19 | -30o | -28o |
| 02/12/19 | -26o | -27o |
| 01/15/19 | -29o | -28o |
| 12/18/18 | -25o | -27o |
| 11/20/18 | -19o | -26o |
| 10/30/18 | -34o | -28o |
As you can see, the ankle measurements haven’t improved as much as his knee passive range of motion has. One reason that could be causing this was the amount of swelling this patient was struggling with in his ankles. This patient has recently started taking diuretics, so we may begin to see improvements from this. It is also important to reinforce the importance of wearing compression stockings and properly elevating legs to decrease swelling in lower extremities.
We have discussed continuing some of these stretches that don’t require skilled physical therapy at home since stretching for one hour once every two weeks doesn’t have a huge effect on his joints and muscles. It is important that he keep up with his home exercise program to see the maximum benefits and improve range of motion.
