Upper Limb Management in Lower Tetraplegia and Central Cord Syndrome

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Introduction[edit | edit source]

Upper limb function is a key element in regaining autonomy for patients with a cervical spinal cord injury. A conservative treatment may transition into a surgical pathway, and treatment strategy is based on the type of damage present (upper vs lower motor neuron). It includes positioning, splinting, passive and active range of motion, functional training, and training with adaptive equipment with aim to offer the best possible benefit to the individual patient.[1]Prevention must be considered when treatment strategies are selected. Claw hands, contractures, or inadequate closing or opening of the fingers may occur as a result of lower level cervical spinal cord injury.[1]This article will discuss upper limb function with lower level cervical spinal cord injury and its impact on the patient's functional abilities.

C6 Tetraplegia[edit | edit source]

  1. Innervated upper limb muscles
    • Deltoid, biceps, brachialis, brachioradialis (C5 level)
    • Pectoralis (clavicular head only)
    • Supinator
    • Radial wrist extensors (extensor carpi radialis longus and/or brevis)
  2. No elbow extension
  3. No active movements of fingers or thumbs
  4. Functional impact
    • Unable to raise arms above shoulder level without external rotation
    • Potential for tenodesis grip
    • Able to extend wrist, rotate and adduct the shoulder[2]
    • Improved weight bearing through the upper limbs due to the function of latissimus dorsi and pectoralis

Goals for upper limb(UL) management:

  • To prevent upper limb secondary complications, including development of contractures and deformities. [3]
  • To assist with function: optimise independence with activities of daily living (ADLs), including eating, dressing, meal prep, grooming, bladder and bowel programme.[4]
  • To gain community integration through learning transfers with assistance and independent wheelchair propulsion[3]

Factors effecting outcomes:[4]

  • Patient's motivation
  • Patient's physique
  • Patient's psychosocial status
  • Complications of spinal cord injury

Prevention of Development of UL Deformities[edit | edit source]

Prevention of Contracture in the Fingers[edit | edit source]

A boxing glove:[2]

  • Maintains range of motion
  • Prevents contractures in the fingers
  • Encourages correct positioning for the tenodesis grasp
  • Has a positive effect on oedema management

Prevention of Contracture in the Elbow[edit | edit source]

  • Teach the patient to maintain elbow extension while flexing the shoulders during functional tasks of mat activities and bed mobility
  • Teach the patient to contract the anterior deltoid and the upper fibres of the pectoralis major and relax the biceps
  • Teach the patient to lock the elbow by externally rotating the shoulders, extending the elbow and the wrist, and supinating the forearm.

Prevention of Development of UL Pain[edit | edit source]

Risk factors:

  • Female more often than male[5]
  • Age over 40[5]
  • Less than 1 year since the spinal cord injury[5]
  • Higher body mass index (BMI)[6]
  • The use of a manual wheelchair
  • Risks associated with a spinal cord injury at the cervical level:
    • upper extremity immobilisation
    • upper extremity reduction in the range of motion in the acute phase
    • muscle shortening and shoulder capsule tightness
    • impaired muscle strength from weakness
    • spasticity

"Pain in the upper extremities of SCI patients is an incapacitating condition."[5] It interfere with all patient's activities: transfer skills, pressure relief and wheelchair mobility. Prevention and early management of upper limb pain should be addressed at every level of rehabilitation of a person with tetraplegia.

The following are examples of therapeutic interventions aiming for upper limb pain reduction:[5]

  • increasing patient and caregiver's knowledge related to upper limb biomechanics
  • implementing appropriate daily live activity techniques, including wheelchair propulsion
  • avoiding overuse and weight-bearing
  • designing a balanced muscle fitness program for upper extremity
  • establishing a nutritional orientation with weight control focus
  • postural optimisation in the appropriate wheelchair
  • evaluating the indication for adaptive devices and environmental changes

Assisting with Function[edit | edit source]

Tenodesis Grip [7][edit | edit source]

  • Contracture in the flexor pollicis longus and extrinsic finger flexor muscles
  • Active wrist extension passively pulls the fingers and thumb into flexion
  • Objects can be passively held between the thumb and index finger or in the palm of the hand

C7 Tetraplegia[edit | edit source]

  1. Innervated upper limb muscles
    • All muscles at C6 level
    • Pectoralis (sternal head)
    • Triceps
    • Pronator teres
    • Flexor carpi radialis (wrist flexor)
    • Extensor digitorum communis (finger extensor)
  2. Weak fingers and/or thumb extension may be present
  3. No fingers and thumb flexion
  4. Functional impact
    • Able to lift arms above shoulder level
    • Potential for tenodesis grip
    • Strong scapular stability[2]
    • Presence of moderate grasp[2]


Goals for upper limb(UL) management:

  • To prevent upper limb secondary complications, including development of contractures and deformities. [3]
  • To assist with function: optimise independence with activities of daily living (ADLs), including eating, dressing, meal prep, grooming, bladder and bowel programme[4]
  • To gain community integration through independent transfers without sliding board [8] and independent wheelchair propulsion[3]

C8 Tetraplegia[edit | edit source]

  1. Innervated upper limb muscles
    1. All muscles at C7 level
    2. Ulnar wrist extensor
    3. Finger flexors
    4. Thumb flexors
  2. May have finger and/or thumb flexors
  3. No intrinsics
  4. No thumb abduction
  5. Functional impact
    1. Limited grip function. An active hand can develop with flexors force at least 3-4/5[9]
    2. Use of enlarged, thick and soft grasps for daily activities [9]
    3. No fine motor control
    4. Deformities of the hand may develop due to hand muscle imbalance (clawed hand)


Goals for upper limb(UL) management:

  • To prevent upper limb secondary complications, including development of contractures and deformities. [3]
  • To assist with function: optimise independence with activities of daily living (ADLs), including eating, dressing, meal prep, grooming, bladder and bowel programme. [4]
  • To gain community integration through independent transfers without sliding board [8], advanced wheelchair skills[8], and driving with adaptations.[8]

Central Cord Syndrome[edit | edit source]

Upper Limb Splinting[edit | edit source]

Short opponens

  • Almost exclusively custom-made
  • Facilitates tenodesis by opposing the thumb and preventing thumb overstretching during functional tasks.
  • Worn as needed to increase function
  • Facilitates tenodesis for individuals with wrist extension 3-5/5 and digitise 0-2/5
  • Recommended for individuals with C6, C7-8 SCI


Wrist splint (Futuro splint):

  • Prefabricated wrist splints are preferred
  • Worn during the day to increase functional activity participation
  • Dorsal varieties and a U-Cuff are favourite options
  • The primary wrist splint goal is to prevent overstretching of the wrist extensors, and adding a universal cuff provides a stable base for ADLs
  • Clinical Practice Guidelines: for daytime use for individuals with elbow flexion 3-5/5, and wrist and hand 0-3/5
  • Most commonly used in a C5 SCI (73% of patients) and C4 (40% of patients)


Metacarpal-Phalangeal (MCP) blocking splint

  • Custom-made splint
  • Prevents hyperextension deformity of the MCP joints
  • Prevent MCP hyperextension during functional hand tasks.
  • Recommended for patients with C7-8 SCI if intrinsic hand weakness is present


More informations on UL splinting in tetraplegia you can find here.

Exercise Therapy[edit | edit source]

Strengthening Exercises[edit | edit source]

According to the literature,[10][11] [12] strengthening exercises in a form of arm ergometry, resistance training, use of mobile arm supports, or virtual reality improve the overall performance of functional daily activities in individuals with a spinal cord injury. Exercise therapy is an effective tool to improve functional outcomes in patients with tetraplegia when it is conducted according to the three principles of training.

Three principles of training:[10]

  • Overload (the most important)
    • system or tissue must be challenged with an intensity, duration and frequency of exercise
    • the outcome depends on patient's motivation, feedback received (augmented feedback [13]), and structure of practice (task specificity and goal-orientated practice)
  • Specificity
    • training effect is limited to the system and tissues involved in the activity
  • Reversibility
    • gains are quickly lost when the overload is removed

Examples of exercise therapy applied in therapy programs for patients with tetraplegia:[10]

  • Virtual Reality: offers repetitive practice, feedback about performance and motivation [14]
  • Use of robotics to increase therapy intensity

Functional Passive Range of Motion (FPROM)[edit | edit source]

Patients with lower tetraplegia presents with:[15]

  • Limitations in forearm pronation
  • Limitations in elbow extension or elbow hyperextension. Elbow hyperextension was present in one-third of patients participating in the study [15]
  • Increased shoulder extension
  • Increased wrist extension

According to research [15]shoulder horizontal adduction and elbow extension were associated with functional performance.

Goal for FPROM:

  1. To develop long term plans for passive range of motion exercises to optimise functional abilities

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Bersch I, Krebs J, Fridén J. A Prediction Model for Various Treatment Pathways of Upper Extremity in Tetraplegia. Front Rehabil Sci. 2022 Jun 30;3:889577.
  2. ↑ 2.0 2.1 2.2 2.3 Oelofse W. Upper Limb Management in Lower Tetraplegia  - Occupational Therapy Course. Plus 2022
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Arsh A, Anwar Z, Zeb A, Ilyas SM. Effectiveness of occupational therapy in improving activities of daily living performance in complete cervical tetraplegic patients; A quasi experimental study. Pak J Med Sci. 2020 Jan-Feb;36(2):96-99.
  4. ↑ 4.0 4.1 4.2 4.3 Yarkony GM, Roth EJ, Heinemann AW, Lovell L. Rehabilitation outcomes in C6 tetraplegia. Paraplegia. 1988 Jun;26(3):177-85.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Barbetta DC, Lopes AC, Chagas FN, Soares PT, Casaro FM, Poletto MF, de Carvalho Paiva Ribeiro YH, Ogashawara TO. Predictors of musculoskeletal pain in the upper extremities of individuals with spinal cord injury. Spinal Cord. 2016 Feb;54(2):145-9.
  6. ↑ Dyson-Hudson TA, Kirshblum SC. Shoulder pain in chronic spinal cord injury, Part I: Epidemiology, etiology, and pathomechanics. J Spinal Cord Med. 2004;27(1):4-17.
  7. ↑ Harvey LA, Herbert RD. Muscle stretching for treatment and prevention of contracture in people with spinal cord injury. Spinal Cord. 2002 Jan;40(1):1-9.
  8. ↑ 8.0 8.1 8.2 8.3 Rodríguez-Mendoza B, Santiago-Tovar PA, Guerrero-Godinez MA, García-Vences E. Rehabilitation Therapies in Spinal Cord Injury Patients. Paraplegia. 2020 Jun 17.
  9. ↑ 9.0 9.1 Suszek-Corradetti M. Rehabilitation path for patients with spinal cord injury from critical condition to optimal independence in everyday life on the example of the activities of the Montecatone Rehabilitation Institute in Italy. Archives of Physiotherapy & Global Researches. 2020 Jul 1;24(2).
  10. ↑ 10.0 10.1 10.2 Kloosterman MG, Snoek GJ, Jannink MJ. Systematic review of the effects of exercise therapy on the upper extremity of patients with spinal-cord injury. Spinal Cord. 2009 Mar;47(3):196-203.
  11. ↑ Atkins MS, Baumgarten JM, Yasuda YL, Adkins R, Waters RL, Leung P, Requejo P. Mobile arm supports: evidence-based benefits and criteria for use. J Spinal Cord Med. 2008;31(4):388-93.
  12. ↑ DiCarlo SE. Effect of arm ergometry training on wheelchair propulsion endurance of individuals with quadriplegia. Phys Ther. 1988 Jan;68(1):40-4.
  13. ↑ van Dijk H, Jannink MJ, Hermens HJ. Effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients: a systematic review of randomized controlled trials. J Rehabil Med. 2005 Jul;37(4):202-11.
  14. ↑ Palaniappan SM, Suresh S, Haddad JM, Duerstock BS. Adaptive Virtual Reality Exergame for Individualized Rehabilitation for Persons with Spinal Cord Injury. InEuropean Conference on Computer Vision 2020 Aug 23 (pp. 518-535). Springer, Cham.
  15. ↑ 15.0 15.1 15.2 Frye SK, Geigle PR, York HS, Sweatman WM. Functional passive range of motion of individuals with chronic cervical spinal cord injury. The Journal of Spinal Cord Medicine. 2020 Mar 3;43(2):257-63.
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