Positioning and General Management of Upper Limbs in Spinal Cord Injury

Original Editor - Ewa Jaraczewska based on the course by Wendy Oelofse

Top Contributors - Ewa Jaraczewska, Jess Bell, Tarina van der Stockt and Naomi O'Reilly  

Introduction

Range of motion (ROM) limitations and joint contracture can significantly limit functional abilities in individuals with a spinal cord injury. Shoulder ROM problems are related to functional limitations and disability, and can affect an individual's perception of health. In addition, persons with tetraplegia can develop upper limb spasticity, which is reported to be one of the most difficult health complications after spinal cord injury.

Complications after spinal cord injury can impact an individual's ability to participate in activities of daily living (ADLs), cause pain, fatigue, and sleep disturbances, and affect safety, leading to contractures, pressure ulcers, infections, and negative self-image. This article will discuss therapeutic strategies for the upper limb, including appropriate positioning, stretching, strengthening, the tenodesis grasp and spasticity management. These strategies can help to maintain upper limb 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 pain
3. To prevent upper limb injury

Positioning in Supine

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

Shoulders

• Open position of shoulders to expand the rib cage and decrease rounding of shoulders
• Some abduction and external rotation of shoulder - can alter position as needed
• In a mid-position or slight protraction (i.e. not in retraction which can damage anterior capsule)
• Scapula pulled together

Elbows

• Extension, but not hyperextension
• With overactive biceps, elbow extension is maintained by using a soft splint, a vacuum splint, or a pillow wrapped around the forearm

Wrist

• Extension or dorsiflexion up to 45 degrees
• The appropriate position is maintained using a splint or pillow

Thumb

• 

  Crucifix position
  Position thumb in opposition to maintain the web space
• Night splint vs hand resting splint at night
• Place a rolled-up towel in the web space to maintain the web space
• Position the hands higher than the shoulders to prevent gravitational swelling

Crucifix Position

• Shoulders are in external rotation
• Use with caution
• Avoid extreme positions and use progression ("serial positioning") to reach end range and avoid putting stress on the tissue

Positioning in Sitting

Poor wheelchair sitting posture in persons with a cervical-level spinal cord injury is often characterised by:

• Rounded shoulders with increased thoracic kyphosis
• Tendency to progress to a 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. These include, but are not limited to:
  • Back rest
  • Seat cushion
  • Arm rest
  • Seat to back angle
  • Foot rest
• Keep arms out to the side
• Provide adequate support for the weight of the upper limb

Upper Limb Stretching and Strengthening Programmes

Stretching

Stretching is a common technique therapists use to treat and prevent contractures. The importance of stretching for joint mobility has yet to be proven clinically. However, some studies indicate that the effects of stretching accumulate over time. It is recommended that regular stretching become part of a home maintenance programme for people with spinal cord injury to potentially achieve clinically important effects on joint mobility. The following upper limb tissues should be included in a stretching programme for persons with upper or lower tetraplegia:

• Upper trapezius muscle
• Pectoralis major muscle
• Long head of biceps
• Capsular stretches to support the shoulder

Strengthening

Patients with tetraplegia depend on their upper limbs to perform activities of daily living, such as transfers and wheelchair propulsion. In addition, good proximal muscle stability (i.e. at the scapula, shoulder) allows for better arm and hand function. Poor scapula position can contribute to neck and shoulder pain and inadequate shoulder stability. Loss of shoulder stability and daily overload of the shoulder girdle in patients with cervical 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 used in individuals without spinal cord injuries can be applied in persons with tetraplegia
• It is important to make a correct and early diagnosis of possible shoulder malfunctions with a subsequent treatment plan
• Progressive increases in resistance to increase muscle strength of innervated muscles
• Start with active assisted, gravity-eliminated exercises
• Observe muscle fatigue when exercising partially innervated muscles, as they require longer recovery time

Examples of Strengthening Exercises

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

Tenodesis Grasp

Tenodesis Grasp

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

General Guidelines

• Daily passive range of motion exercises of the wrist and fingers are required
• Do not overstretch the fingers in extension during passive range of motion exercises
• During weight-bearing tasks or transfers, the fingers should be in flexion
• It is important to retain tendon tightness in the fingers for a future tenodesis grasp
• Family and caregivers should be educated about stretching / over-stretching the fingers and weight bearing during transfers

Characteristics of a Tenodesis Grasp

Position of the wrist and fingers

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

Position of the thumb

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

You can read more about the tenodesis grasp here.

Upper Limb Spasticity Management

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 individuals with a spinal cord injury and associated spasticity:

• Stiffness all-day
• Interference with sleep
• Painful spasms
• A perceived link between spasticity and pain
• Intensification of pain before a spasm
• Muscle contracture
• Difficulty with hygiene
• Pressure ulcers
• Poor cosmesis negatively impacts 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

• Spasticity is influenced considerably by changes in posture and muscle length. Position influences stretch reflex activity. Proper positioning can decrease the presence and intensity of upper limb spasticity in patients with tetraplegia.
• Wheelchair seating system assessment and recommendations directly impact spasticity management through the patient's posture and positioning in the wheelchair.
• Adequate positioning helps reduce fatigue while sitting, thus decreasing 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: A study by Saxena et al. looked at the impact of median nerve neurodynamic mobilisation on individuals with C5-C8 spinal cord injuries. Their protocol was as follows:

• Five sessions per week for four weeks.
• Each session included twelve minutes of mobilisation.
• Patient position: supine, shoulder girdle depressed, glenohumeral joint extended, abducted, and laterally rotated, elbow in extension, forearm in supination, wrist, fingers, and thumb in extension. This position was held and then neural mobilisation performed, with "slow, rhythmic oscillations of wrist flexion and extension."
• Twenty oscillations were performed each minute for 3 minutes; this process was repeated three times in one session, with a 1 minute gap between each attempt.

Self-applied vibration to the upper limb

The current classification of vibration is as follows:

• Stimulation directly applied to a specific muscle or tendon
• Indirect vibration - i.e. stimulation which is not muscle specific and is delivered through the hands by holding a device

The potential effects of upper limb vibration:

• Inhibits H-reflex amplitude
• Increases inhibition on pre-synaptic spinal pathways
• May provide an effective avenue for targeted rehabilitation during conditions of spasticity
• A study by Mirecki et al. found that participants with higher spasticity had decreased spasticity after focal upper extremity vibration. There was, however, "no clear effect on grasp, transport and release function"

Passive movement

• Joint-by-joint passive range should be performed.
• The intensity of passive movement required to achieve therapeutic level is unknown.
• According to Harvey et al., when range of motion is limited, stretching should be done for long periods (from 20 minutes to up to 12 hours). A prolonged stretch can be accomplished 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 or 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 complement tendon transfer techniques. A combination of nerve and tendon transfers may be the best solution for some individuals with tetraplegia. The nerve transfer procedure involves cutting and reconnecting a functional nerve from the above injury zone and reconnecting it to a non-functional nerve, which serves a more important function, from below the injury zone.

• 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-operative therapeutic protocol includes immediate elbow, wrist and finger passive range of motion
  • Weight-bearing activities start two weeks post surgery
  • Active exercises of the donor muscles start two or three weeks post surgery
  • When the recipient's muscles start contracting, physiotherapy intervention must focus on co-contraction exercises, motor education, and a strengthening exercise programme
• Finger 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 are 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 reattaching it at the insertion site of a non-functional muscle. Tendon transfers are performed to restore grasp and release of the fingers, and thumb and elbow extension in persons with a C5 through C8 spinal cord injury. Reconstruction of finger extension through tendon transfers in patients with tetraplegia remains difficult.

The following are examples of tendon transfer procedures in patients with upper or lower tetraplegia:

• No elbow extension
  • Posterior deltoid-to-triceps tendon transfer, or
  • Biceps-to-triceps tendon transfer
• Weak or no grip:
  • With weak or no wrist extension: brachioradialis-to-extensor carpi radialis brevis tendon transfer. Some patients require an additional posterior deltoid transfer to counteract brachioradialis
  • With active wrist extension: brachioradialis-to-flexor pollicis longus transfer

Resources

• Spasticity Following Spinal Cord Injury
• Marquez-Chin C, Popovic MR. Functional electrical stimulation therapy for restoration of motor function after spinal cord injury and stroke: a review. Biomed Eng Online. 2020 May 24;19(1):34.