Upper Limb Preservation in Spinal Cord Injury

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (20.12.2022)

Original Editor - User Name

Top Contributors - Ewa Jaraczewska, Jess Bell and Tarina van der Stockt  

Introduction

Mechanical upper limb problems including pain, weakness from overuse, range of motion limitation or contracture are common complications present in patients with a spinal cord injury (SCI). Interdisciplinary team assessment is needed to identify risk factors leading to mechanical upper extremity problems. Periodic health review of a person with a spinal cord injury can provide information that helps to diagnose and treat these problems. This article offers strategies to preserve upper limb and prevent pain with activities of daily living in clients with spinal cord injury.

Risk Factors Assessment

The primary risk factor in upper limb injuries in clients with spinal cord injury is related to changing in primary upper limb function from manipulation to weight bearing for mobility. Additional risk factors in patients with spinal cord injuries include:

• Repetitive use of upper limb
• New medical problems
• Weight gain
• Changes in medical status

Overuse injuries include:

• Shoulder pain (30-60% of clients with paraplegia and tetraplegia)
• Carpal tunnel syndrome (40-66% of patients with SCI)
• Median nerve neuropathy (78% of wheelchair users)
• Ulnar nerve entrapment at both the wrist and elbow
• Tendinitis
• Osteoarthritis
• Lateral epicondylitis
• Olecranon bursitis
• Rotator cuff tear
• Shoulder impingement
• Adhesive capsulitis of the glenohumeral joint
• Recurrent shoulder dislocations
• Bicipital tendinitis

Interdisciplinary Team Assessment

Periodic assessment is recommended to gain inside into the patient's new vs old problems and to establish the most effective plan of care. At the minimum this assessment should include  :

• Pain assessment
  • Etiology
  • Intensity
• Functional limitations
  • New medical problems influencing function
  • Weigh gain effecting performance
• Psychosocial adjustment
• Assessment of patient's environment
  • Home, work, or school environment
  • Means of transportation
• Equipment assessment
  • Manual vs power wheelchair
  • Seating system
  • Bathroom equipment

Treatment Plan

Treatment plan should include:

• Early and appropriately aggressive treatment for the acute pain associated with acute musculoskeletal injuries may
• Development of chronic pain prevention program
• Introduction of alternative techniques for activities

Transfers

There is enough evidence suggesting that transfers can lead to upper limb injury in clients with spinal cord injury.This is not only due to the fact that during a transfer, the shoulders must support the weight of the body, but they also must shift the trunk mass between the outreached hands. This activity demands 2.5 times greater pressure than one recorded when the shoulder is not bearing weight position.The forces associated with transfers effect not only shoulders, but the wrists and hands as well.

Shoulders

• support body weight
• shift the trunk mass between hands

Wrist

• Extreme wrist extension causing median nerve compression

Hand

• Flat palm causing increase pressure in the carpal tunnel

Treatment Ideas

• Keep the shoulders open by externally rotating the arm
• Lean forward to take the weight off the buttocks
• Create momentum during transfers
• Choose transfer surfaces that are either at equal heigh or downhill
• Consider roll-in shower chair to decrease the number of transfers throughout the day
• During transfers, place hands in a position to avoid extreme wrist extension, e.g draping over and grasping the transfer surface's edge
• Transfers using closed-fist maneuvers with the wrist in neutral (watch for instability!)
• Transfers should be performed with the wrist extended to preserve tenodesis grip

.

The forces associated with transfers are borne at the wrist and hand. Applying force through an extended wrist and flat palm increases pressure in the carpal canal, thereby compressing the median nerve. A number of studies have documented the association between wrist posture and CTS, with greater flexion and extension linked to injury, more so in the presence of high forces

When possible, the hand should be placed in a position that allows it to avoid extremes of wrist extension (i.e., that allows the fingers to drape over and grasp the edge of the transfer surface). Transfers using closed-fist maneuvers with the wrist in neutral may reduce the pressures in the carpal tunnel; however, the impact on the metacarpal joints is unknown and this may be an unstable position for the wrist. To preserve tenodesis grip for individuals who use tenodesis, transfers should be performed with the wrist extended and the fingers flexed.

Pressure Relief

Whenever possible, the person with a spinal cord injury should perform pressure relief activities by using a combination of techniques, such as forward leaning, side-to-side shifting, and depression-style maneuvers.

Overhead Reach

The association between overhead activity and shoulder pain and injury in the ergonomics literature is strong. A number of studies have found that working above shoulder height increases risk of pain and injury

Task Performance Modification

• overall program of health promotion and a wellness-oriented lifestyle that includes regular activity and/or exercise is important

Environment Modification

A thorough assessment of the environments where routine transfers, activities of daily living, and work are performed is necessary for consumers and clinicians to know when and where to intervene. The environment should be altered and/or equipment provided to minimize overhead activities, reduce forces in the extremities, and reduce the frequency at which activities are completed.

Resources

• bulleted list
• x

or

1. numbered list
2. x