Upper Limb Preservation in Spinal Cord Injury

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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

Risk factors in upper limb pain

• Changing in primary upper limb function from manipulation to weight bearing for mobility
• Repetitive use of upper limb for the same activities throughout the day
• Patient's obesity

Overuse injuries include:

• shoulder pain (30-60% of clients with paraplegia and tetraplegia)
• carpal tunnel syndrome (40-66% of patients with SCI)
• Median nerve damage

assess the patient's function, ergonomics, equipment, and level of pain as part of a periodic health review. At a minimum, evaluation should include home, work, and school environments and the means of transportation. Every environment should be built or modified, when possible, in a manner consistent with ADA standards.

Early and appropriately aggressive treatment for the acute pain associated with acute musculoskeletal injuries may prevent the development of chronic pain. Therefore, acute pain should be identified and controlled as early as possible following acute musculoskeletal injury.

Transfers

Evidence exists that transfers can lead to upper limb injury. In a transfer, the shoulders must not only support the weight of the body, as in a vertical weight relief raise, but also must shift the trunk mass between the outreached hands. Pressure during transfers has been shown to be 2.5 times greater than that recorded when the shoulder is not bearing weight

extremes of wrist motion should be avoided, particularly maximum extension when weight bearing during transfers. Awareness of extreme wrist posture is also important during vocational and avocational activities. This recommendation, which is based on ergonomic studies and research measuring pressure in the carpal canal in various positions, defines extreme positions as those near the limits of motion of the joint.

Whenever possible, the transfer surfaces should be either at equal height or downhill, as uphill transfers are known to increase forces in the upper limb. Consider adaptive bath equipment, such as roll-in shower chairs, and other adjustable height transfer surfaces that can be used for multiple tasks, such as bathing and bowel and bladder care, to be part of a prevention program.

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.

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