Upper Limb Preservation in Spinal Cord Injury

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

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

Introduction

Mechanical upper limb problems, including pain, weakness from overuse, range of motion limitations or contracture, are common complications in persons with spinal cord injuries (SCI). An interdisciplinary team assessment is needed to identify risk factors leading to mechanical upper extremity problems. A periodic health review of a person with a spinal cord injury can provide information to help diagnose and treat these problems. This article explores strategies to preserve the upper limb and prevent pain with activities of daily living in clients with spinal cord injuries.

Risk Factors Assessment

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

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

Overuse injuries include:

• Shoulder pain (present in 30-60% of clients with paraplegia and tetraplegia)
  • Shoulder pain: 71%; wrist pain: 51%; hand pain: 43%; and elbow pain: 35%
• Carpal tunnel syndrome (present in 40-66% of persons with spinal cord injury)
• Median nerve neuropathy (present in 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 insight into a client's new vs old problems and establish the most effective care plan. At the minimum, this assessment should include the following:

• Pain assessment
  • Aetiology
  • Intensity
• Functional limitations
  • New medical problems influencing function
  • The interface between age and length of time from spinal cord injury onset
  • Upper extremity joint range of motion and muscle strength limitations or imbalances
  • Exercise capacity and tolerance for the physical demands of activities of daily living
  • Body mass and composition

• Previous upper extremity injury or disease history

• Psychosocial adjustment
• Assessment of the client's environment
  • Home, work, or school environment
  • Means of transportation
• Equipment assessment
  • Manual vs power wheelchair
  • Seating system
  • Bathroom equipment

Treatment Plan

A treatment plan should include the following:

• Early and appropriate treatment for pain associated with acute musculoskeletal injuries
• Development of a chronic pain prevention programme
• Introduction of alternative techniques for activities

Transfers

There is evidence suggesting that transfers can lead to upper limb injury in clients with spinal cord injuries. This is because, during a transfer, the shoulders must support the body's weight and shift the trunk mass between the outreached hands. This activity demands 2.5 times more pressure than when the shoulder is not bearing weight. The forces associated with transfers affect the shoulders, wrists, and hands:

• Shoulders:
  • Support body weight
  • Shift the trunk mass between hands

• Wrists:
  • Positioned in extreme wrist extension

• Hands:
  • Palms stay flat

These demands can lead to shoulder pain, increased pressure in the carpal tunnel and median nerve compression.

Interventions

• Keep the shoulders open by externally rotating arms
• Lean forward to take the weight off the buttocks
• Create momentum during transfers
• Complete transfers in stages when using a transfer board
• Choose transfer surfaces that are either at equal height or downhill
• Consider a roll-in shower chair/commode to decrease the number of transfers throughout the day
• During transfers, place hands in a position that avoids extreme wrist extension, e.g. draping over and grasping the transfer surface's edge
• Transfer using a closed-fist with the wrist in neutral (but watch for instability!)
  • Please note, to preserve a tenodesis grip, the wrist should be extended, and the fingers flexed during transfers
• Lead with the arm experiencing pain when possible during transfers

Pressure Relief

All persons with spinal cord injury should complete regular repositioning training. Repositioning movements reduce the pressure around the ischial tuberosity and sacral regions.

Repositioning movements include vertical push-ups and lateral and forward leans. Repositioning movements should be performed every 15-30 minutes for adequate pressure relief. However, research has shown that patients' compliance with these recommendations is poor. Push-up pressure relief is usually held for less than 20 seconds, which is inadequate to achieve tissue reperfusion. It has been found that, overall, the effectiveness of the vertical push-up and lateral lean weight shifts is low.

Safe forward lean for pressure relief

According to research, forward leans should be the most frequently recommended method to relieve pressure. A 40° forward lean leads to decreased muscle and soft tissue deformation at the ischial tuberosity, while a 45° forward lean produces the most significant decrease in maximum pressure. A forwards lean can be achieved by leaning with the elbows on the knees, on a table, or supported by the back of another chair. This position can be maintained for prolonged periods when stable and secure.

Advantages of lean forward pressure relief:

• Preserves the shoulders
• Allows for more time to replenish the blood supply to the area
• The position can be maintained for an extended time

Disadvantages of lean forward pressure relief:

• May be difficult for a person with arthritis
• May be hard to achieve for a person with obesity

Shoulder

Shoulder Elevation

Compression of the supraspinatus tendon is most likely to occur at 30-60 degrees of humerothoracic elevation. Research shows that individuals with a cervical spinal cord injury are frequently in 30-60 degrees of shoulder elevation. For example, during wheelchair propulsion at a self-selected speed, humeral elevation reaches 25-55 degrees. Finley et al. also report that humeral elevation occurs five times more often in wheelchair users than in persons without spinal cord injuries.

Glenohumeral and scapulothoracic kinematics affect subacromial proximities. During overhead-reaching activities, there is a linear relationship between reduced scapular external rotation, posterior tilt and thoracic kyphosis in individuals with spinal cord injury. In addition, the degree of maximal elevation in patients with spinal cord injury decreases as thoracic kyphosis increases. As a result, all tasks that require above-shoulder height movement can increase the risk of shoulder pain and injury in clients with spinal cord injuries.

Interventions

• Try to avoid reaching overhead
• Avoid using overhead bars/monkey chains
• Assess for appropriate wheelchair seating and positioning to prevent or reduce a patient's thoracic kyphosis

• When an overhead reach is necessary for car transfers, minimise internal rotation of the arm
• Modify environments where items are stored overhead

Manual Wheelchair Mobility

As mentioned, shoulder pain and injury among wheelchair users are common. Shoulder forces during manual wheelchair propulsion can be affected by multiple factors. However, one study showed that personal factors, including a person's body weight, were the primary demographic variable that affected shoulder forces. Other factors include:

• Personal factors
  • Shoulder muscle weakness, specifically shoulder adductors, leads to compensatory muscle patterns

• The choice of wheelchair
  • Type
  • Position of the rear axle
  • Seat position
  • Tyre pressure
• Biomechanics during wheelchair propulsion
  • "Peak shoulder joint loading occurs when the arm is extended and internally rotated, which may leave the shoulder at risk for injury"
  • To maintain independence with wheelchair propulsion, persons with spinal cord injury tend to develop "a protective short-term wheelchair propulsion biomechanical response", including decreased glenohumeral flexion/extension and reduced scapular angles
  • Increases in wheelchair propulsion speed increase the load on the upper limb muscles and joints

Optimal upper limb position during wheelchair propulsion

Interventions

Personal factors

• Include a body-weight maintenance programme
• A strengthening programme should target the shoulder adductors to decrease the likelihood that shoulder pain will develop

The choice of the wheelchair

• Select a light-weight, customised wheelchair
• Position the rear axle as far forward as possible without compromising the user's stability
  • When the hand is placed at the top-dead-centre position on the push rim, the angle between the upper arm and forearm should fall between 100 and 120 degrees
• Adjust the wheelchair seat to a lower position without compromising the upper limb position; too much shoulder abduction will increase the risk of shoulder impingement
• Inflate the tyres properly to decrease the friction between the tyre and the floor

Biomechanics during wheelchair propulsion

• Use long, smooth strokes that limit impact on the push rim
• Allow the hand to drift down naturally, keeping it below the push rim when not in contact with that part of the wheelchair

Tasks and Environment Modification

Environment

"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." Wendy Oelofse

Manual wheelchair users face different barriers when accessing outdoor environments. They include slopes, cross-slopes, curbs, and various ground types.

Interventions

• Complete a thorough assessment of the client’s environment (school, work, home, outdoors)
• Reduce forces in the extremities
• Reduce the frequency at which difficult-to-perform activities are completed
• Modify the home environment
  • For example, transfer overhead cabinets to a lower location and modify a home to ensure that transfers are level

Tasks

Interventions

• Avoid activities that involve raising the arm above shoulder height
• Use adaptive equipment (e.g. a reacher)
• Keep frequently used items within easy reach
• Incorporate overall health promotion and a wellness-oriented lifestyle programme

Resources

• Lawrence RL, Braman JP, Ludewig PM. Shoulder kinematics impact subacromial proximities: a review of the literature. Braz J Phys Ther. 2020 May-Jun;24(3):219-230.
• Slowik JS, Requejo PS, Mulroy SJ, Neptune RR. The influence of wheelchair propulsion hand pattern on upper extremity muscle power and stress. J Biomech. 2016 Jun 14;49(9):1554-1561.