To maintain and increase joint range of motion, muscle flexibility, and muscle strength for the best possible functional outcome, passive and active range of motion (ROM), proprioceptive neuromuscular facilitation (PNF), joint mobilization, prolonged static stretch, and progressive resistive exercises, as well as functional activities, and/or functional electrical stimulation (FES) of the following areas are particularly important. Somatosensory stimulation is a valuable adjunct to massed practice training of hand and upper-extremity function in people with chronic incomplete tetraplegia (Beekhuizen and Field-Fote, 2008). However, range of motion and strengthening of all musculature, even areas with full range and strength, are important since functional outcome depends on the body's response to abnormal demands and its ability to substitute functioning muscles for non-functioning muscles. ROM and strengthening exercises should begin as soon after injury as possible and continue through the acute and functional rehabilitation stages.

1. Shoulders and Neck
   • Normal range in shoulders is needed for upper body dressing.
   • Greater than normal extension and external rotation of the shoulder, together with elbow extension, in the side-lying position, support coming to sit if triceps are non-functional.
   • Muscles used in shoulder flexion and horizontal adduction and in scapular protraction and depression are used for most functional activities and should be strengthened.
   • If the cervical spine is not stable, ROM and strengthening exercises of the shoulder should be performed gently, and not past 90 degrees. ROM exercises of the neck should not be performed until the spine is completely stable.

2. Elbows, Forearms, and Wrists
   • Full elbow extension, wrist extension, forearm supination, and strengthening muscles used in elbow extension are needed for most functional activities, but are critical if triceps are nonfunctional to lock the elbow for transfers and mat activities, and if finger musculature is absent to achieve a tenodesis grasp.
   • Daily ROM exercises, positioning the elbow in extension, and an orthosis are recommended for the elbows and forearms.
   • Positioning the wrist in extension with cock-up splints or hand rolls is recommended to prevent overstretching of the wrist extensors.

3. Fingers
   • Mild tension should be achieved and preserved in the long finger flexors, without overstretching or shortening of the flexors, for tenodesis grasp and release in individuals with C7 or higher quadriplegia and those with C5 or higher lesions, who recover function in one or more levels or who learn to use the hand as a hook.
   • ROM exercises that include finger extension to neutral (with full flexion of the wrist) and full finger flexion (with full extension of the wrist) are recommended.

4. Low Back, Hamstrings, and Hips
   • Mild tension should be achieved and preserved in the low back, without overstretching, to support transfers and mat activities. Overstretching can be caused by sitting with lumbar kyphosis.
   • Hamstring inflexibility can interfere with maintaining low back tension and long-sitting. Hamstring flexibility that permits 110 to 120 degrees of straight leg raise supports low back tension, long-sitting, dressing, transfers, mat activities, and coming to stand from the floor with KAFOs. Hamstring stretching should be performed in the supine position to preserve tension in the lower back, and with caution and straight leg raising not past 60 degrees if the lumbar spine is unstable
   • Hip extension to at least neutral is needed for prone lying, mat and bed activities. Full hip extension is needed if ambulation is a possible functional outcome. Hip ROM exercises should be performed with caution and with hip flexion less than 90 degrees if the lumbar spine is unstable.

5. Ankles
   • Ankle dorsification to at least neutral is needed for wheelchair use to prevent skin breakdown that can result from excessive pressure caused by plantar flexion. Full ankle dorsification is needed if ambulation is possible and for standing stability if the hip extensors are nonfunctional.
   • Stretching of the gastrocnemius and soleus (rather than the foot) should occur, and a downward force should be applied to the heel while the ankle is moved into dorsiflexion.