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 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.

Interventions

• 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 manoeuvres 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

Shoulder Elevation

The compression of the supraspinatus tendon can occur when humerothoracic elevations reaches 30-60 degrees angles. The mechanics during these angles of shoulder movement helps to predict the tendon compression risk. Research shows, that individuals with cervical level of spinal cord injury use 30-60 degrees of shoulder elevation on their dominant and non-dominant sides frequently throughout the day. One example of upper limb use is wheelchair propulsion when humeral elevation reaches 25 to 55 degrees when measurement is completed at a self-selected speed. Another studyindicates that humeral elevation occurs five times more often in wheelchair users than in person without spinal cord injury.

Glenohumeral and scapulothoracic kinematics effect subacromial proximities. There is a linear relationship between reduced scapular external rotation, posterior tilt and thoracic kyphosis in individuals with SCI during overhead reaching activity. 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 risk of shoulder pain and injury in clients with spinal cord injury.

Interventions

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

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

Manual Wheelchair Mobility

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

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

• The choice of the wheelchair
  • Type
  • Position of the rear axle
  • Seat position
  • Tire 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 tends to develop "a protective short-term wheelchair propulsion biomechanical response" , that includes decrease glenohumeral flexion/extension and reduction in scapular angles.
  • Increases in wheelchair propulsion speed increases the load on the upper limb muscles and joints

Interventions

Personal Factors

• Include body-weight maintenance program
• Strengthening program should target shoulder adductors to decrease the likelihood of shoulder pain development

The choice of the wheelchair

• Select a light-weight, customised wheelchair
• Position the rear axle as far forward as possible without compromising the stability of the user. When the hand is placed at the top dead-center 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 lower position, but without compromising upper limb position. Too much shoulder abduction will increase risk for shoulder impingement
• Inflate the tires properly to decrease the friction between the tire and the floor

Biomechanics during wheelchair propulsion

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

Task 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 barrier types when accessing outdoor environment. They include slopes, cross-slopes, curbs, and various ground types.

Interventions

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

Tasks

Interventions

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

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.