Date of birth: 23 Sep 1957
Date of accident: 25 Sep 2000
Fell from a bridge (approx. 20 feet)
Level of injury: fracture of C5 on C4
Other injuries: right upper collapse of right lung
Discharge summary
from the Salisbury Health Care, NHS, 15 Apr 2002:
C5 ASIA A, flaccid paralysis
- Motor and sensory systems: C5 level; some signs of biceps activity; can move his shoulders.
- Bowels: can feel when his bowels are full but cannot wait; bowels managed with the help of two carers (suppositories and manual extraction).
- Bladder: suprapubic catheter in Feb. 2001.
- Frequent chest infections.
- Vital capacity is normally between 1.2 and 1.5 litres sitting in the chair.
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Limbs measurements |
Pinprick test |
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14/09/04 |
01/09/05 |
03/09/06 |
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03/05/07 |
12/09/08 |
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Beginning of treatment: 22 Apr 2002.
1. Stability
- Has a better sitting position in his wheelchair since Jan. 2003.
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Can stand in frame for 25 minutes since 5 May 2003.
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27 May 2003: can stand between parallel bars in callipers; felt the weight of his body in his feet for the first time.
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2 June 2003: can stand between parallel bars in callipers for 40 minutes; felt the weight of his body in his hips, knees and feet.
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9 Oct. 2003: when standing in the frame, can feel the pressure of his body at the navel level; between bars, can feel pressure in his buttocks.
2. Mobility
- April 2003: easier to settle Paul in his wheelchair and feels himself that he has a better sitting position in his wheelchair.
- 9 Oct. 2003: on the electric bike, can feel the movements in his hips and abdomen; easier to move Paul in bed.
3. Voluntary motricity
- 24 April 2003: begins to move his left wrist.
- 5 May 2003: begins to move his two wrists simultaneously or separately.
- 20 May 2003: more movement in his shoulders and elbows.
- 3 June 2003: can move his two writs voluntarily; begins to move his right and left thumbs, 1st fingers and hips.
- 8 June 2004: can move his shoulders and elbows (flexion + extension: grade 2); can rub his thighs.
- 8 June 2004: can pull up to one pound with his left forearm.
- 8 June 2004: can move one leg after the other on the treadmill when suspended with a harness.
- 8 June 2004: can push his wheelchair without help.
- 8 June 2004: can lean forwards, hold the position and lean backwards in his wheelchair.
4. Sensory level
- Light touch:
Feels pins and needles, tingling and electricity to touch.
12 June 2003: can feel both feet, lower limbs, stomach and forearms.
Normal feeling to touch in his lower limbs.
9 Oct. 2003: feels tingling, pins and needles and electricity on arms, shoulders, buttocks, lower limbs, and feet.
5 June 2004: tingling and pins and needles on front of forearms, arms, back of his lower limbs and front of calves and feet.
6 Sept. 2004: feels tingling, pins and needles, waves below the injury when touched. - Pressure:
Feels pins and needles, tingling and electricity to pressure.
12 June 2003: can feel both feet.
9 Oct. 2003: can feel light pressure at the tip of his fingers and wrists.
6 Sept. 2004: feels pressure all over his body. - Pain: below the injury
April 2002: feels pain from T3 to T12 in lower back and stomach, buttocks, lower limbs, and feet through pins and needles, tingling and electricity.
12 June 2003: normal feeling in his feel but with a latent period.
9 Oct. 2003: feels immediately when he knocks himself (feet only).
6 Sept. 2004: feels tingling, electricity all over his body below the injury; feels when knocked (bones and muscles). - Hot:
12 June 2003: no feeling.
6 Sept. 2004: feels sometimes warmness (warm water or ambient temperatures) and tingling all over his body below the injury (arms, and down to his nipples, knees, legs and feet). - Cold:
12 June 2003: feels cold in her lower limbs, feet and abdomen.
9 Oct. 2003: normal feeling to cold (cold water and cold temperatures) but not constant. Feels pins and needles, tingling and electricity to cold in the third half of his thighs, knees, back and front of his legs and feet.
Warms himself up next to a heater or with a blanket.
8 June 2004: can feel the cold air from a ventilator on his lower limbs.
8 June 2004: feels cold (water + air) as tingling and pins and needles down to dermatome T4, back and front, on arms and forearms, back of lower limbs, calves and feet. - Water:
12 June 2003: under the shower, can feel water through tingling in his lower limbs.
When having a shower, water triggers spasms. - 9 Oct. 2003: could whistle for the first time since his accident.
- 16 Oct. 2003: sneezed normally for the first time since his accident.
5. Bowels and bladder
- Bowels:
12 June 2003: can feel when empties bowels; normal evacuation.
2 Oct. 2003: slight feeling when suppository is introduced; can feel when empties bowels but not constant.
08/0604: feels when his bowels are full - Bladder:
May 2003: can feel when his bladder is full (abdomen); possibility to clamp the suprapubic catheter for 2 to 3 hours.
8 June 2004: feels when passes water.
6 Sept. 2004: possibility to clamp the catheter during 3 to 4 hours in a go. - Intimate sensations:
30 Sept. 2003: tingling in the glans.
Thermoregulation
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9 Oct. 2003: hot temperatures or physical exercises make his hands, forearms and wrists sweat.
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14 Oct. 2003: back his hands sweat.
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Since Sept. 2003: feels when his feet are cold (inside sensation).
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Since Oct. 2003: feet are warm.
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8 June 2004: no more spasms caused by the hot temperatures: thermoregulation is better.
Her wife informed us that Paul has been classified ASIA B during his last check-up in Salisbury (Feb. 2004)
Last update: 3 Nov. 2008