Positioning and General Management of Upper Limbs in Spinal Cord Injury

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Introduction[edit | edit source]

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.[1][2]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. [2]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.

Maintaining Range of motion[edit | edit source]

Upper Limb Positioning[edit | edit source]

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 [3][edit | edit source]

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[edit | edit source]

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[edit | edit source]

Stretching[edit | edit source]

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.[4] 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. [4] 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[edit | edit source]

scapular retraction, your shoulder external rotation, your diagonal extension or abduction, and your serratus anteriors.

Tenodesis Grasp[edit | edit source]

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"[3]

Neuroprosthesis[5]

Precautions[edit | edit source]

Upper Limb Spasticity Management[edit | edit source]

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.[6][7]

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 [6]
  • Difficulty with hygiene [6]
  • Pressure ulcers [6]
  • Poor cosmesis negatively impacting self-esteem and body image [6]


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[edit | edit source]

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".[2] [8]

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. [9]

Passive movement

  • Joint-by-joint passive range should be performed
  • Stretching to be performed slowly
  • Intensity for passive movement to become therapeutic is unknown[10]
  • According to Harvey et al,[4] 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)[11]
  • Hippotherapy [12]
  • Prolonged standing [13]
  • 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."[14]

Upper Limb Reconstruction in Tetraplegia[edit | edit source]

Surgery can improve upper limb function for individuals with C5-C8 spinal cord injury

Resources[edit | edit source]

or

  1. numbered list
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References[edit | edit source]

  1. ↑ Reinholdt C, Fridén J. Selective release of the digital extensor hood to reduce intrinsic tightness in tetraplegia. Journal of Plastic Surgery and Hand Surgery. 2011 Apr 1;45(2):83-9.
  2. ↑ 2.0 2.1 2.2 Saxena A, Sehgal S, Jangra MK. Effectiveness of Neurodynamic Mobilization versus Conventional Therapy on Spasticity Reduction and Upper Limb Function in Tetraplegic Patients. Asian Spine J. 2021 Aug;15(4):498-503.
  3. ↑ 3.0 3.1 Oelofse W. Positioning and General Management of Spinal Cord Injury - Occupational Therapy Course. Plus 2022
  4. ↑ 4.0 4.1 4.2 Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. J Physiother. 2017 Apr;63(2):67-75.
  5. ↑ Marquez-Chin C, Popovic MR. Functional electrical stimulation therapy for restoration of motor function after spinal cord injury and stroke: a review. Biomedical engineering online. 2020 Dec;19(1):1-25.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Barnham IJ, Alahmadi S, Spillane B, Pick A, Lamyman M. Surgical interventions in adult upper limb spasticity management: a systematic review. Hand Surgery and Rehabilitation. 2022 Apr 28.
  7. ↑ Hashemi M, Sturbois-Nachef N, Keenan MA, Winston P. Surgical Approaches to Upper Limb Spasticity in Adult Patients: A Literature Review. Front Rehabil Sci. 2021 Aug 31;2:709969.
  8. ↑ Castilho J, Ferreira LAB, Pereira WM, Neto HP, Morelli JGDS, Brandalize D, Kerppers II, Oliveira CS. Analysis of electromyographic activity in spastic biceps brachii muscle following neural mobilization. J Bodyw Mov Ther. 2012 Jul;16(3):364-368.
  9. ↑ Mirecki MR, Callahan S, Condon KM, Field-Fote EC. Acceptability and impact on spasticity of a single session of upper extremity vibration in individuals with tetraplegia. Spinal Cord Series and Cases. 2022 Feb 5;8(1):1-6.
  10. ↑ Dunn J, Wangdell J. Improving upper limb function. Rehabilitation in Spinal Cord Injuries. 2020 Feb 1:372.
  11. ↑ Li S, Xue S, Li Z, Liu X. Effect of baclofen combined with neural facilitation technique on the reduction of muscular spasm in patients with spinal cord injury. Neural Regeneration Research,2007;2(8):510-512
  12. ↑ Lechner HE, Feldhaus S, Gudmundsen L, Hegemann D, Michel D, Zäch GA, Knecht H. The short-term effect of hippotherapy on spasticity in patients with spinal cord injury. Spinal Cord. 2003 Sep;41(9):502-5.
  13. ↑ Shields RK, Dudley-Javoroski S. Monitoring standing wheelchair use after spinal cord injury: a case report. Disabil Rehabil. 2005 Feb 4;27(3):142-6.
  14. ↑ Davis R. Spasticity following spinal cord injury. Clinical Orthopaedics and Related Research®. 1975 Oct 1;112:66-75.
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