Use of Modalities in Upper Limb Management in Tetraplegia

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

Introduction

A wide range of therapeutic modalities addressing upper limb function in patients with tetraplegia is available in spinal cord injury rehabilitation.

Vibration

Muscle vibration is a technique that has potential to reduce muscle tone and spasticity in individuals with neurological disorders. Direct effect of muscle vibrations include an increase in corticospinal excitability and inhibition of neuronal activity in the antagonistic muscle. The use of focal vibration as a modality in spinal cord injury facilitates a contraction of the agonist muscle. Isometric contraction in triceps brachii were induced with the application of vibratory stimuli at 80 Hz on the muscle.

Three motor effects achieved through muscle vibration are as follow:

1. Sustained contraction of the vibrated muscle via tonic vibration reflex
2. Depression of the motor neurones innervating the antagonistic muscles via reciprocal inhibition or antagonistic inhibition
3. Suppression of the monosynaptic stretch reflexes of the vibrated muscle while being vibrated.

The sustained effect of vibration remains under investigation. According to Laessøe et al. , lower limb spasticity was reduced up to 3 hours following vibratory stimulation at 100 Hz.

Two different vibration frequencies can be chosen and applied directly to the muscle or tendon: high frequency and low frequency vibration.

High Frequency Vibration

• Frequency of 100 - 200 Hz and
• Amplitude of 1 – 2 mA.
• Produce facilitation of muscle contraction through a tonic vibration reflex.
• The effect is brief after application

Low Frequency Vibration

• 5 -50 Hz
• Inhibitory effect on muscle through its activation of spindle secondary endings and the Golgi tendon organs.

General Precautions

• Heat generation at the point of application when high amplitude is used can cause skin damage
• Stable health conditions (stable spine, no fractures)

Potential concerns related to use of vibration therapy

• Increased the risk of thrombosis
• Tissue damage from acute or severe edema
• Increased cardiac issue
• Dislodgement of a thrombus
• Increased damage from peripheral vascular disease
• Effects to spinal stimulators
• Skin injury from friction

You can read more about self-applied vibration here.

Surface Stimulation

Two the most commonly used forms of surface stimulation are:

• Transcutaneous Electrical Nerve Stimulation (TENS)
• Functional Electrical Stimulation(FES).

TENS

This type of stimulation delivers high-frequency (50–150 Hz) and low-intensity (below motor threshold) surface electrical current decreased spasticity due to the use of this modality. For instance, TENS has recently reduced spasticity in SCI patients and the effects outlasted up to several hours after treatment [34]. This is because TENS activates sensory nerves that in turn may activate inhibitory interneurons that will inhibit the spastic muscle activity [34]. More specifically, these anti-spastic effects are due to the release of gamma-aminobutyric acid (GABA) that acts as inhibitory neurotransmitters, achieving similar anti-spastic effects to those of baclofen [32], which is a first-line treatment for spasticity, especially in adults who suffered a SCI [35]. Results of spasticity treatment using TENS seem to improve when combined with physical therapy [36]. Given its low cost, lack of adverse event effects, and ease to use, TENS seems to be a very good solution to treat spasticity after SCI. Moreover, since TENS alleviates pain and fatigue and can be used for periods of several hours, it seems to be appropriate for the beginning of the rehabilitation after SCI, when training is not very intensive.

FES

Goals:

1. To prevent lower limb muscle atrophy,
2. To increase muscle strength,
3. To increase endurance
4. To improve cardiovascular fitness

The FES training can produce the following metabolic benefits:

• Increases in lean muscle mass
• Increases in capillary number
• Decreases in adipose tissue

Other benefits include lowering the blood glucose and insulin levels, improvement in muscles size, strength, and composition, improved fatigue resistance and oxidative capacities, proportional increases in fiber area and capillary number.

FES can be used as a modality in the treatment of the upper limb in person with tetraplegia to:

• Replace function (i.e., as an orthotic device)
• Retrain function (i.e., as a therapeutic device)

Retraining function

• Short-term treatment modality
• The patient is expected to regain voluntary function
• Kapadia et al.described a protocol for transcutaneous FES to retrain reaching and grasping in individuals with spinal cord injury:
  • Upper extremity retraining program is designed based on the level and extent of injury
  • The patient with upper tetraplegia will start with retraining proximal function followed by distal function training
  • The patient with lower tetraplegia will retrain distal function from the beginning
  • The patient with little to no voluntary movement at the wrist and fingers can perform simple tasks while being stimulated with the FES
  • The number of repetitions is based on each of the participant’s strength and endurance
  • 30–45 min out of 1-h session patient performs activities of daily living with FES
  • The following parameters are used: balanced, biphasic, current regulated electrical pulse, pulse amplitude from 8 to 50 mA , pulse width 250 μs; and pulse frequency 40 Hz
  • During the session, therapist guides the patient's hand to make the movement functional
  • Typical FES session is conducted for 45–60 min, 3–5 days a week, for 8–16 weeks, for a total of about 40 sessions

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