Positioning and General Management of Upper Limbs in Spinal Cord Injury

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Introduction

Range of motion (ROM) limitations and joints contracture can significantly limit functional abilities in patients with a spinal cord injury. Shoulder ROM problems are related to functional limitations, disability, and perceived health. In addition patients with tetraplegia can suffer from upper limb spasticity which is reported to be one of the most difficult health complications after SCI.These complications include restriction in activities of daily living (ADLs), pain and fatigue, sleep disturbance, and safety, leading to the development of contractures, pressure ulcers, infections, and negative self-image. This article will discuss therapeutic strategies including appropriate positioning, stretching, strengthening, the tenodesis grasp and spasticity management which can help to maintain range of motion and facilitate function.

Upper Limb Positioning

Goals:

1. To increase and/or maintain range of motion
2. To prevent and/or decrease upper limb (UL) pain
3. To prevent UL injury

Positioning in Supine

The following are recommended positions for the upper limb when a person with tetraplegia is in bed:

Shoulders

• Crucifix position with shoulders in external rotation. Avoid extreme position and use progression ("serial positioning) to reach end range and eliminate stressing the tissue

• In open position
• Some shoulder abduction and external rotation, with positions alteration as needed
• Shoulders in a mid-position or in slight protraction
• Scapula "pulled back"

Elbows

• Extension, but not hyperextension.
• With overactive biceps maintain extension of the elbow using a soft splint, a vacuum splint, or a pillow wrapped around the forearm.

Wrist

• Extension or dorsiflexion up to 45 degrees
• Appropriate position maintained using the splint, or the pillow

Thumb

• Position in the opposition to maintain the web space
• Night splint vs hand resting splint at night, or
• Rolled-up towel placed in the web space to maintain the web space.
• Position the hands higher than the shoulders to prevent gravitational swelling

Positioning in Sitting

A wheelchair sitting posture of a person with cervical level spinal cord injury is often characterised by:

• rounded shoulders with increased thoracic kyphosis
• tendency to progress to more slouched posture throughout the day
• forward head posture
• reliance on the upper extremities to maintain balance

Recommended posture improvement strategies:

• wheelchair seating system adaptations
• arms out to the side
• adequate support for the weight of the upper limb

Upper Limb Stretching and Strengthening Programs

Stretching

Stretching is a common technique used by therapists to treat and prevent contractures. The importance of stretch on the joint mobility has not been proven clinically, however some studies indicate that the effects of stretch accumulates over time. It is recommended that the regular stretching should become a home maintenance program for people with spinal cord injury to demonstrate clinically important effects on joint mobility. Stretching the following tissues should be included into upper limb treatment plan for a person with upper and lower tetraplegia:

• Upper trapezius muscle
• The pectoralis major muscle
• The long head of the biceps
• Capsular stretches to support the shoulder

Strengthening

Patients with tetraplegia depends on their upper limbs to perform activities of daily living which include transfers and wheelchair propulsion. In addition good proximal muscle stability (scapula, shoulder) allows for better arm and hand function. On the other hand, poor scapula position can contribute to neck and shoulder pain and inadequate stability of the shoulder. Loss of shoulder stability and overload of the shoulder girdle due to daily requirements placed upon upper limbs in patients with cervial spinal cord injury, cause shoulder, elbow and hand pathologies.

The most common shoulder pathologies include:

• Bursitis
• Rotator cuff rupture
• Tendinopathies
• Anterior instability
• Osteoarthrosis
• Osteoporosis of the acromioclavicular joint.

Clinical and physical alteration in the elbow joint:

• Ulnar neuropathy by nerve compression resulting in cubital tunnel syndrome
• Osteoarthritis
• Lateral epicondylitis
• Olecranon bursitis
• Decreased range of motion

General Principles for Strengthening Exercises

• The same principles as the principles of strengthening for able-bodied population
• The correct and early diagnosis of possible shoulder malfunctions with subsequent treatment plan
• Progressive increases in resistance to increase muscle strength of innervated muscles
• Starting with active assisted, gravity eliminated exercises
• Observe muscle fatigue when exercising partially innervated muscles as they require longer recovery time

Strengthening exercise program examples

• Scapular retraction
• Shoulder external rotation
• Shoulder diagonal extension or abduction
• Serratus anteriors strengthening exercises

Tenodesis Grasp

Individuals with " C6 and C7 tetraplegia use a tenodesis grasp to compensate for weak or absent active finger movement in order to manipulate objects during the daily activities." The function of grasp is achieved by actively extending the wrist followed by closing the fingers and flexing a thumb until the index finger is touched.

General Guidelines

• Daily passive range of motion of the wrist and fingers is required
• Do not overstretch the fingers in extension during passive range of motion exercises
• Family and caregiver education about stretching and weight bearing
• During weight-bearing tasks or transfers the fingers are in flexion
• Retain tendon tightness in the fingers for a future tenodesis grasp

Characteristic of Tenodesis Grasp

Position of wrist and fingers

• With active movement of the wrist extension, there is passive flexion of the fingers. With the wrist flexion, the fingers extend to release an object.

Position of thumb

• Thumb in: helps to develop a lateral pinch
• Pulp-to-pulp pinch when the thumb touches the pulps of your fingers

You can read more about tenodesis grasp here.

Upper Limb Spasticity Management

A typical patterns of upper limb spasticity include shoulder adduction and internal rotation, elbow flexion, forearm pronation, wrist flexion, thumb flexion, adduction and first webspace tightness, and finger flexion.

The following negative experiences were reported by patients with a spinal cord injury in relation to presence of spasticity:

• Stiffness all day
• Interference with sleep
• Painful spasms
• Perceived link between spasticity and pain
• Intensification of pain before a spasm
• Muscle contracture
• Difficulty with hygiene
• Pressure ulcers
• Poor cosmesis negatively impacting self-esteem and body image

Goals for spasticity management:

1. To diminish spasticity
2. To allow voluntary movements
3. To improve the ability to independently perform ADLs (transfers, dressing, and toileting)

Therapeutic Strategies

Positioning

• Posture influences reflexes
• Wheelchair seating system
• Fatigue can increase spasticity

Neurodynamic mobilisation

Neurodynamic mobilisation is a"group of techniques that aim to place the neuraxis in tension and stretch it with appropriate mobilisation through certain postures, along with the application of slow, rhythmic movements of the joints intended to reach the peripheral nerves and the spinal cord".

Example: Median nerve neurodynamic mbilisation

• Patient position: supine, shoulder girdle depressed, the glenohumeral joint extended, abducted, and laterally rotated; the elbow in extension, the forearm in supination, and the wrist, fingers, and thumb in extension
• Twelve minutes during each session; sessions were conducted five times each week for four weeks
• Slow, rhythmic oscillations of wrist flexion and extension
• Twenty oscillations were performed each minute for 3 minutes; the process was performed thrice during the same session, with a 1-minute interval between consecutive attempts

Self-applied vibration to the upper limb

Participants with higher spasticity demonstrated decreased spasticity after focal UE vibration, although there was no clear effect on grasp, transport and release function.

Passive movement

• Joint-by-joint passive range should be performed
• Stretching to be performed slowly
• Intensity for passive movement to become therapeutic is unknown
• According to Harvey et al, when range of motion is limited, stretching should be done for a long periods of time (from 20 minutes to up to 12 hours). A prolonged stretch can be accomplish with splint use

Other treatment interventions

• Neurodevelopmental Therapy (NDT)
• Hippotherapy
• Prolonged standing
• Electrical stimulation (patterned electrical stimulation (PES) or patterned neuromuscular stimulation (PNS), functional electrical stimulation (FES) and transcutaneous electrical nerve stimulation (TENS)
  • "Electrical stimulation applied to individual muscles may produce a short term decrease in spasticity. There is also some concern that long-term use of electrical stimulation may increase spasticity."

Upper Limb Reconstruction in Tetraplegia

Reconstruction surgeries can improve upper limb function for individuals with upper and lower tetraplegia. The two types of reconstructive procedures are nerve transfers and tendon transfers. The following examples represent an incomplete list of currently available procedures.

Nerve transfers

Nerve transfers are complementary to tendon transfers techniques. A combination of nerve and tendon transfers are often the best solution for some of the patients with tetraplegia. Nerve transfer procedure involve cutting and reconnecting functional nerve from the above injury zone and reconnecting it to a nonfunctional nerve from below injury zone which serves a more important function.

• Thumb and finger flexion reconstruction with brachialis-to-anterior interosseus nerve transfer with an in situ lateral antebrachial cutaneous nerve graft
• Active extension of the fingers with supinator-to- posterior interosseous nerve transfer complements brachialis-to-anterior interosseus nerve transfer
  • Post-op therapeutic protocol include immediate elbow, wrist and fingers passive range of motion
  • Weight bearing activities started two weeks post surgery
  • Active exercises of donor muscles started two-three weeks post surgery
  • When recipient muscles started contracting, physiotherapy intervention focused on co-contraction exercises, motor education, and strengthening exercise program
• Fingers pinch and grasp with musculocutaneous to median nerve transfer

Benefits of nerve transfer procedures:

• Restore muscle groups without altering their biomechanics
• Do not require prolonged immobilisation
• Potential reconstructions available when no tendon transfer options exist
• Offer a greater than 1:1 functional exchange: sacrificing one simple function can potentially restore multiple functions

Tendon Transfers

Tendon transfers are the most commonly accepted intervention for restoring hand function in persons with tetraplegia. The procedure includes cutting the distal end of a functional muscle and its reattachment at the insertion site of a nonfunctional muscle. Tendon transfers are performed to restore a grasp and release of fingers and thumb, and elbow extension in patients with a C5 and below spinal cord injury. Reconstruction of finger extension by means of tendon transfers in patients with tetraplegia remains difficult.

The following examples represent tendon transfers procedures in patients with upper and lower tetraplegia:

Resources

• Spasticity Following Spinal Cord Injury
• Functional electrical stimulation therapy for restoration of motor function after spinal cord injury and stroke: a review