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. This article provides an overview of most commonly used modalities in the treatment of clients with upper and lower tetraplegia.

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
• Unstable health conditions (unstable spine, 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

Goals:

1. To reduce spasticity
2. To alleviates pain
3. To reduce muscle fatigue

The following are the mechanisms of TENS:

• It activates sensory nerves
• Sensory nerves activate inhibitory interneurons
• Spastic muscle activity is inhibited
• It may involve the stimulation of large diameter afferent fibers

Treatment Protocols Examples

Spasticity management:

• High-frequency of 50–150 Hz surface electrical current
• Low-intensity (below motor threshold) surface electrical current

Neuropathic pain management:

• High frequency of 80 Hz
• Time for one session was 45 minuts
• Two sessions per day for 8 weeks
• Adverse effects can be present: rash and local tingling sensation
• Possibility of relapse of neuropathic pain

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)

Replacing function

• A specific movement facilitation (neuroprosthesis)
• Neuroprosthesis components include electrical stimulator, stimulation delivering electrodes, sensors for user or automatic control of the stimulation, and ian orthosis that provides additional assistance to perform the desired movement

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
• According to Anderson and her colleagues

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