Management of the Upper Limb in the Sub Acute Phase

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Introduction 

It is accepted that the central nervous system is capable of reorganization, especially in the incomplete spinal cord injury because there is largely intact local spinal cord circuitry and some partially interconnected fibres. [1] 

Within spinal cord injury, reorganization is thought to occur at two levels;

  1. in pre-existing circuits by synaptic plasticity or
  2. in new circuits through sprouting or anatomical reorganization (anatomical plasticity). [1]

Traditional approaches to improving arm and hand function in people with tetraplegia generally is;

  1. strengthening of innervated muscles,
  2. education of compensatory or substitution strategies and movement patterns and
  3. translation into daily activities.

As soon as possible individuals should be encouraged and trained to use their hands in daily activities to recapture control over their life. The fundamental concept of motor learning is the assumption that practice of task-specific movements causes plastic changes in the central nervous system and that increased frequency and duration of training are associated to improvements in performance. [2] There are several principles underlying the facilitation of neural plasticity and functional recovery such as intense activity and repeated practice.  

Strengthening of Remaining Innervated Muscles

Strengthening of the proximal muscles of the upper limb provides stability that makes arm and hand function possible. The principles of strengthening are the same as for the able-bodied population; progressive increases in resistance aiming to increase muscle strength of innervated muscles. [3] Fatigue must be addressed when strengthening partially innervated muscles  as the muscle requires longer recovery time than a fully innervated muscle. FES can be used for treatment to strengthen weak muscles, improve hand posture/tenodesis, and guiding motor relearning. [4] Studies using massed practice and/or FES have demonstrated potential for both neural and functional improvements in people with tetraplegia. [5][6]

Education of Movement Patterns

In order to complete daily activities, the person with tetraplegia has to relearn many movement patterns. Essential to this his learning how to move and position their upper limb despite lack of critical functions such as elbow extension, finger and thumb movement. Compensatory strategies are movement patterns resulting from the adaptation of remaining muscles. An example of this is a person with tetraplegia learning to externally rotate the shoulder lifting the arm above the head to allow for the elbow to remain straight compensating for loss of elbow extension. In contrast, substitution is where functions are replaced or substituted by orthoses or assistive devices e.g. use of a universal cuff to hold eating utensils, typing peg (Figure XX).

Compensatory Strategies

In the initial stage of rehabilitation, the person with spinal cord injury is unable to perform common tasks due to lack of skills. The learning process has similarities to an able-bodied person learning an unfamiliar sport, thus motor skill learning is a useful treatment technique in rehabilitation. Effective motor task training should be well structured, intense and incorporate practice that is task and context specific. [7] Feedback of the motor performance is essential to ensure correct motor patterns are reinforced. Complex tasks can be broken down in smaller sub-tasks and trained individually in a similar but simpler approach, before putting it all together. [8]

Despite lack of active grip in the hand, those with active wrist extension are able to perform several compensatory strategies, such as tenodesis grasp, and can develop great skills in daily activities. [9] A well-balanced tenodesis function facilitates the opportunity for several adapted grips (Figure XX). 

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References

  1. 1.0 1.1 Raineteau O, Schwab ME. Plasticity of motor systems after incomplete spinal cord injury. Nature Reviews Neuroscience. 2001;2(4):263.
  2. Carr JH, Shepherd RB. Movement science : foundations for physical therapy in rehabilitation.2nd ed. Gaithersburg, Md.: Aspen Publishers; 2000.
  3. Field-Fote E. Spinal cord injury rehabilitation.FA Davis; 2009.
  4. Bryden AM, Peljovich AE, Hoyen HA, Nemunaitis G, Kilgore KL, Keith MW. Surgical restoration of arm and hand function in people with tetraplegia. Top Spinal Cord Inj Rehabil. 2012;18(1):43-49.
  5. Beekhuizen KS, Field-Fote EC. Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal cord injury. Neurorehabilitation and neural repair. 2005;19(1):33-45.
  6. Hoffman LR, Field-Fote EC. Functional and corticomotor changes in individuals with tetraplegia following unimanual or bimanual massed practice training with somatosensory stimulation: a pilot study. Journal of Neurologic Physical Therapy. 2010;34(4):193-201.
  7. Shumway-Cook A, Woollacott MH. Motor control : translating research into clinical practice.4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.
  8. Carr JH, Shepherd RB. Neurological rehabilitation : optimizing motor performance.2nd ed. Edinburgh ; New York: Churchill Livingstone; 2010.
  9. Harvey LA, Batty J, Jones R, Crosbie J. Hand function of C6 and C7 tetraplegics 1 - 16 years following injury. Spinal cord. 2001;39(1):37-43.