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

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)
  • Shoulder pain: 71% , wrist pain 51%, hand pain 43%, and elbow pain 35%
• 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
  • Interface between age and length of time from SCI onset
  • Upper extremity (UE) joint ROM and muscle strength limitations or imbalances
  • Exercise capacity and tolerance for the physical demands of ADL
  • Body mass and composition

• Previous UE injury or disease history

• 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
• 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. The upper limb is forced to produce the following activities during transfers:

Shoulders

• Support body weight
• Shift the trunk mass between hands

Wrist

• Positioned in extreme wrist extension

Hand

• Palm stays flat

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

Treatment Ideas

• Keep the shoulders open by externally rotating the arm
• 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 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!)
• To preserve tenodesis grip the wrist should be extended and the fingers flexed during transfers
• Lead with the arm experiencing the pain when possible during transfers

Pressure Relief

All patients with spinal cord injury should complete training on how to perform a regular repositioning movements to off-load the pressure around the ischial tuberosity and sacral regions. The type of repositioning movements include vertical push-ups, lateral and forward leans. The frequency recommendation for effective pressure relief is every 15–30 minutes. However, research has shown that patients' compliance with these recommendations is poor. Push-up pressure relief are usually held for less than 20 seconds, which is not adequate to achieve tissue reperfusion. Overall the effectiveness of the vertical push-up and lateral leans weight shifts was low.

Leaning forward should be the most frequently recommended method to relieve pressure. According to research, a 40° forward lean leads to decrease muscle and soft tissue deformation at the ischial tuberosity, when a 45° forward lean produces the largest decreases in maximum pressure. Leaning forward can be completed by leaning with the elbows on the knees, on a table, or supported by the back of another chair. Such a position when stable and secure can be maintained for prolonged periods of time.

The benefits of lean forward pressure relief:

• Preserves the shoulders
• Allows for more time to replenish the blood supply to the area
• Position can be kept for extended time.

The disadvantage of lean forward pressure relief:

• May be difficult for person with arthritis
• May be hard to achieve for an obese person

Overhead Reach

Humeral elevation is a critical motion for individuals who use a manual wheelchair given that, in a typical day, wheelchair users reach overhead 5 times more often than able-bodied controls.

Maximal elevation was reduced in SCI with increased thoracic kyphosis. Medium to large effect sizes were found at each elevation angle, with reduced scapular external rotation, posterior tilt, and increased thoracic kyphosis for those with SCI. The linear relationship occurred later and within a significantly (P = .02) smaller range of humeral elevation in SCI. Altered movement coordination, including a diminished linear association of scapular upward rotation and humeral elevation (scapulohumeral rhythm), is found with reduced maximal elevation and increased thoracic kyphosis during overhead reaching tasks in those with acute SCI.

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

Try and avoid reaching overhead - When reaching overhead, the shoulder is normally positioned in internal rotation which closes up the shoulder joint which can lead to pain

Reaching overhead is sometimes required during transfers and when reaching for objects that are placed above shoulder level.

We general do not encourage the use of overhead bars/monkey chains.

• When an overhead reach is necessary for certain transfers (such as into a car or truck), minimize internal rotation of the arm.
• Modify the environments where items are stored overhead.

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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