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

Strengthening of the proximal muscles of the upper limb provides stability that makes arm and hand possible. The principles of strengthening follows principles of strengthening for able-bodied population: progressive increases in resistance aims to increase muscle strength of innervated muscles. Active assisted, gravity eliminated exercises. When strengthening partially innervated muscle attention must be given to fatigue

scapular mobility is important as poor scapular positioning can contribute to neck and shoulder pain and loss of stability of the shoulder

The correct and early diagnosis of possible malfunctions and subsequent intervention, whether with Neuromuscular Electrical Stimulation, physical therapy exercises and the practice of physical activity, are essential for the good prognosis of the patient.

Spinal cord injury patients are strictly dependent on their upper limbs to perform daily activities. Whether for wheelchair propul- sion, body support or weight transfer. These patients use their upper limbs as supporting joints; as such, this daily requirement causes a chronic overload on the shoulder girdle, aggravated by the muscular weakness due to spinal injury itself

The main complaint of these patients is shoulder pain, whose etiology is multifactorial. The most affected structures are the supraspinatus tendon, bursae and the acromioclavicular joint. Mainpathologiesoftheshoulderincludebursitis,rotator cuff rupture, tendinopathies, anterior instability, osteoarthrosis and osteoporosis of the acromioclavicular joint. Tendinopathies and decreased acromioclavicular space are caused by mechanisms that have not yet been explained of change in blood supply in these areas

he elbow is a relevant joint as it is responsible for the movement of the forearm and hand. Patients with spinal injuries with clinical and physical alterations in this joint become totally dependent. The prevalence of pain and injury to the elbows is reported in 5% to 16% of the literature. Many factors are capable of triggering elbow pain, among them ulnar mononeuropathy by nerve compression resulting in cubital tunnel syndrome – prevalent in 22%-45% of spinal cord injuries – osteoarthritis, lateral epicondylitis and olecranon bursitis. The etiology of pain in these cases is described as a compilation of inflammatory, degenerative and hypertrophied processes resulting from the manifestation of the organism to protect against joint injuries by increasing its load. Overload during transfers and in wheelchair use is the cause of the main clinical and anatomical changes, similarly to the shoulder. In one of the reviewed studies, we found that alterations commonly present as decreased active range of motion (ROM) and muscle and osteocartilaginous alterations (Figure 2b and 2c).

Hands are essential elements in planning, coordinating and ex- ecuting daily activities with objects. After spinal cord injury there are ruptures and reorganizations of neuronal circuits in cervical vertebrae that lead to impairment of the upper extremities.

the connection between the supraspinal centers and the muscles is lost, leading to paralysis of the upper limb and loss of movement, which results in the loss of independence. Lesions between C1-C4 result in loss of complete motor function of the upper limbs, while in C5 there is loss of function from the elbow to the distal end and in C6 only paralysis of the hands.11

In most cases, the patient has a certain degree of muscle strength that allows the positioning of the hand in space through shoulder and arm movements, but the hand grip function is compromised. Neuromuscular Electrical Stimulation (NMES) acts on the paralyzed muscles of the spinal cord injury and promotes rapid muscle fatigue, favoring joint movements and preventing joint stiffness.12 This procedure can be used as a rehabilitation tool, enabling the return of movements such as holding and releasing objects. This can provide the return of the individual’s activities and their independence. A research was carried out that evaluated the capacity of NMES with surface electrodes and concluded that it is possible to under- stand the muscles affected by fixed stimulation of an open circuit, in addition to demonstrating positive feedback from patients when exercising simple activities.

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

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

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

Nerve transfers are increasingly utilized for upper limb reconstruction in tetraplegia. We reviewed the literature for results achieved by nerve transfers for elbow extension, wrist control and finger and thumb flexion and extension.

reconstruction of wrist extension and lateral thumb pinch. Higher groups, namely with more innervated muscles below the elbow, offer the possibility of tendon transfers for grasp and release of fingers and thumb. Restoration of elbow extension is possible in injuries at or below C5 level, either by a posterior deltoid or a biceps to triceps transfer

Reconstruction of finger extension by means of tendon transfers in patients with tetraplegia remains difficult.

Nerve transfers for upper limb reconstruction after SCI are not in opposition to tendon transfers, but a complementary technique, as the combination of nerve and tendon transfers may offer the best solution for some of the patients

Brachialis-to-anterior interosseus nerve transfer with an in situ lateral antebrachial cutaneous nerve graft can be used to reconstruct thumb and finger flexion in tetraplegic patients. Combined with supinator-to- posterior interosseous nerve transfer, simultaneous active extension of the fingers can be achieved. Range of motion activities of the elbow, wrist, and fingers were immediately allowed, but full weight-bearing was limited for 2 weeks. Thereafter, active exercises and training were initiated under the guidance of a hand therapist to begin donor muscle activation.7 Once the first evidence of muscle contraction was detected in the recipient muscle(s), physiotherapy was focused on co-contraction exercises, motor education, and strengthening.

Resources

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