Upper Limb Management in Lower Tetraplegia and Central Cord Syndrome

Original Editor - Ewa Jaraczewska based on the course by Wendy Oelofse

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

Introduction

Upper limb function is vital for individuals with cervical spinal cord injury (SCI) to regain autonomy. There are conservative management options and surgical pathways available to enhance upper limb function. Conservative treatment includes positioning, splinting, passive and active range of motion, functional training, and training with adaptive equipment. Prevention must be considered when treatment strategies are selected. Claw hand, contractures or inadequate closing or opening of the fingers may occur with lower-level cervical spinal cord injury. The treatment strategy depends on the type of damage present (upper vs lower motor neuron). This article will discuss upper limb function with lower-level cervical spinal cord injury and its impact on an individual's functional abilities.

C6 Tetraplegia

1. Innervated upper limb muscles in C6 spinal cord injury are:
   • Deltoid, biceps, brachialis, brachioradialis (C5 level)
   • Pectoralis (clavicular head only)
   • Supinator
   • Radial wrist extensors (extensor carpi radialis longus and/or brevis)
2. No elbow extension
3. No active movements of the fingers or thumbs
4. Functional impact:
   • Unable to raise arms above shoulder level without external rotation
   • Potential for tenodesis grip
   • Able to extend the wrist, rotate and adduct the shoulder
   • Improved weight bearing through the upper limbs due to the function of latissimus dorsi and pectoralis

Goals for upper limb management:

• To prevent secondary complications in the upper limb, including the development of contractures and deformities
• To assist with function: i.e. optimise independence with activities of daily living (ADLs), including eating, dressing, meal preparation, grooming, bladder and bowel programme
• To gain community integration by learning transfers with assistance and independent wheelchair propulsion

Factors effecting outcomes:

• Patient's motivation
• Patient's physique
• Patient's psychosocial status
• Complications of spinal cord injury

Prevention of the Development of Upper Limb Deformities

Prevention of Contracture in the Fingers

Boxing glove:

• Maintains range of motion
• Prevents contractures in the fingers
• Encourages correct positioning for a tenodesis grasp
• Has a positive effect on oedema management

Prevention of Contracture in the Elbow

• Teach the patient to maintain elbow extension while flexing the shoulders during functional tasks, such as mat activities and bed mobility
• Teach the patient to contract the anterior deltoid and the upper fibres of the pectoralis major and to relax the biceps
• Teach the patient to lock the elbow by externally rotating the shoulders, extending the elbow and the wrist, and supinating the forearm

Prevention of the Development of Upper Limb Pain

Risk factors:

• Females are affected more often than males
• Age over 40 years
• Less than 1 year since the spinal cord injury
• Higher body mass index (BMI)
• Using a manual wheelchair
• Risks associated with a spinal cord injury at the cervical level:
  • Upper extremity immobilisation
  • Upper extremity reduction in range of motion in the acute phase
  • Muscle shortening and shoulder capsule tightness
  • Impaired muscle strength from weakness
  • Spasticity

"Pain in the upper extremities of SCI patients is an incapacitating condition." It interferes with all patient activities, including transfer skills, pressure relief and wheelchair mobility. Prevention and early management of upper limb pain in persons with tetraplegia should be addressed at every stage of rehabilitation.

The following are examples of therapeutic interventions that aim to reduce upper limb pain:

• Increasing patient/caregiver knowledge of upper limb biomechanics
• Implementing appropriate techniques for activities of daily living, including wheelchair propulsion
• Avoiding overuse and weight-bearing through the upper limbs
• Designing a balanced muscle fitness programme for the upper extremity
• Establishing a nutritional approach which focuses on weight control
• Postural optimisation in the appropriate wheelchair
• Evaluating indications for adaptive devices and environmental changes

Assisting with Function

Tenodesis grasp.

Tenodesis Grasp

• Requires contracture in flexor pollicis longus and the extrinsic finger flexor muscles
• Active wrist extension passively pulls the fingers and thumb into flexion
• Objects can be passively held between the thumb and index finger or in the palm

Methods to encourage/develop a good tenodesis grasp

• Perform passive range of motion (PROM) exercises daily
• The sequence for PROM exercises is: wrist down (flexed) and fingers opened (extended); fingers closed (flexed) when wrist comes up (extends)

• Achieve and preserve mild tension in the long finger flexors without overstretching or shortening the extensors
• Maintain the webspace
• A thumb opponens splint (see below) may be prescribed to increase tenodesis grasp as it helps to maintain proper thumb position

Tenodesis splint: an orthotic device that spinal cord injury patients can wear over their hand and forearm. It helps guide grasp and release movements, providing the extra support individuals may need to perform tasks independently.

C7 Tetraplegia

1. Innervated upper limb muscles in C7 spinal cord injury:
   • All muscles innervated at C6
   • Pectoralis (clavicular and sternal head)
   • Triceps
   • Pronator teres
   • Flexor carpi radialis (wrist flexor)
   • Extensor digitorum communis (finger extensor)
2. Strong wrist extension
3. Extensor digitorium muscle allows extension of digits
4. Some finger flexor muscle are intact
5. Functional impact
   • Able to lift arms above shoulder level
   • Potential for tenodesis grip
   • Strong scapular stability
   • Presence of moderate grasp

*Please note that there is some variation given in the literature on innervation. Another source indicates that a person with a C7 spinal cord injury may have weak finger and/or thumb extension, but no finger or thumb flexion.

Goals for upper limb management:

• To prevent secondary complications of the upper limb, including the development of contractures and deformities.
• To assist with function: e.g. optimise independence with ADLs, including eating, dressing, meal preparation, grooming, bladder and bowel programme
• To gain community integration through independent transfers without a sliding board and independent wheelchair propulsion

C8 Tetraplegia

1. Innervated upper limb muscles in C8 spinal cord injury:
   1. All muscles at the C7 level
   2. Extensor carpi ulnaris
   3. Flexor digitorum profundus and flexor digitoum superficialis
   4. Flexor pollicis longus and brevis
2. May have finger and/or thumb flexors
3. No intrinsics
4. No thumb abduction
5. Functional impact:
   1. Limited grip function - an "active hand" is possible if there is flexor force of at least 3-4/5
   2. Use of enlarged, thick and soft grasps for daily activities
   3. No fine motor control
   4. Deformities of the hand may develop due to hand muscle imbalances (claw hand)

Goals for upper limb management:

• To prevent secondary complications of the upper limb, including the development of contractures and deformities.
• To assist with function: optimise independence with ADLs, including eating, dressing, meal preparation, grooming, bladder and bowel programme.
• To gain community integration through independent transfers without a sliding board, advanced wheelchair skills, and driving with adaptations.

Incomplete Spinal Cord Injuries

Incomplete Spinal Cord Injury

The term "incomplete spinal cord injury" is used when there is "preservation of any sensory and/or motor function below the neurological level that includes the lowest sacral segments S4–5 (i.e., presence of “sacral sparing”)."

Goals for upper limb management

• Prevent complications
• Improve function

General Guidelines for upper limb management in incomplete spinal cord injury

• Complete a comprehensive baseline assessment
  • Individual muscle testing
  • Movement analysis for detection of compensatory strategies

• Continuously assess and reassess to align treatment aims with strategies

Treatment strategies for upper limb management

• Upper limb positioning
• Early out-of-bed mobilisation
• Activities in an upright position using a tilt table or standing frame
• Stimulate/encourage more normal movement patterns: therapist-directed activities, hand-over-hand guidance

Central Cord Syndrome, Anterior Cord Syndrome, Brown-Sequard Syndrome

Central Cord Syndrome

"Central cord syndrome (CCS) is the most common of the clinical syndromes, often seen in individuals with underlying cervical spondylosis who sustain a hyperextension injury (most commonly from a fall), and may occur with or without fracture and dislocations. This clinically will present as an incomplete injury with greater weakness in the upper limbs than in the lower limbs."

Pathophysiology

• Forward fall with striking the chin and the neck extending backwards
• High velocity of trauma
• Cervical spine subluxation
• Cervical spine fracture

Symptoms

• Significant strength impairments in the upper and lower extremities - these deficits are greater in the upper than the lower extremities
• Sensory deficits below the level of injury (frequent, but not always)
• Pain and temperature sensations are typically affected
• Light touch sensation impaired
• "Cape-like" sensory impairment across the upper back and down the posterior upper extremities
• Neck pain at the site of spinal cord impingement
• Increased muscle tone and spasticity in the upper and lower limbs
• Shoulder pain and/or shoulder subluxation
• Hand oedema
• Joint contractures of the upper limbs

Treatment strategies for upper limb management

• Varies based on the level of injury. For example, a rehabilitation programme for an individual with a C5 central cord syndrome would need to focus on poor proximal stability at the shoulder and the elbow. Treatment strategies for a person with a C8 central cord syndrome should focus on regaining a functional hand and preventing the development of hand deformities.
• Spasticity management
• Upper limb pain management
• Upper limb positioning strategies in sitting, standing and during ambulation

Upper Limb Splinting

Short opponens

• Almost exclusively custom-made
• Facilitates tenodesis by opposing the thumb and preventing thumb overstretching during functional tasks
• Worn as needed to increase function
• Facilitates tenodesis grip for individuals with wrist extension 3-5/5 and digits 0-2/5
• Recommended for individuals with C6, C7, C8 spinal cord injuries

Wrist splint (Futuro splint):

• Prefabricated wrist splints are preferred
• Worn during the day to increase functional activity participation
• Dorsal varieties and a universal cuff (U-Cuff) are preferred options
• The primary goal of a wrist splint is to prevent overstretching of the wrist extensors; adding a universal cuff provides a stable base for ADLs
• Clinical Practice Guidelines: for daytime use for individuals with elbow flexion 3-5/5, and wrist and hand 0-3/5
• Most commonly used in a C5 (73% of patients) and C4 (40% of patients) spinal cord injuries

Metacarpophalangeal (MCP) blocking splint

• Custom-made splint
• Prevents hyperextension deformity of the MCP joints
• Prevents MCP hyperextension during functional hand tasks
• Recommended for patients with C7, C8 spinal cord injury if intrinsic hand weakness is present

More information on upper limb splinting in tetraplegia is available here.

Exercise Therapy

Strengthening Exercises

According to the literature, strengthening exercises such as arm ergometry, resistance training, the use of mobile arm supports, or virtual reality improves the overall performance of functional daily activities in individuals with a spinal cord injury. Exercise therapy effectively improves functional outcomes in patients with tetraplegia when conducted according to the following three training principles.

Three principles of training:

• Overload (the most important)
  • The intensity, duration and frequency of exercise must challenge system or tissue
  • The outcome depends on the patient's motivation and feedback received (augmented feedback), and structure of practice (task specificity and goal-orientated practice)
• Specificity
  • The training effect is limited to the system and tissues involved in the activity
• Reversibility
  • Gains are quickly lost when the overload is removed

Examples of exercise therapy applied in rehabilitation programmes for patients with tetraplegia:

• Virtual Reality: offers repetitive practice, feedback about performance and motivation
• Use of robotics to increase therapy intensity

Functional Passive Range of Motion (FPROM)

Patients with lower tetraplegia present have been found to present with:

• Limitations in forearm pronation
• Limitations in elbow extension or elbow hyperextension - a study by Frye et al. found that one-third of study participants with chronic (i.e. time of injury was more than one year ago) C5 to C8 spinal cord injuries had elbow hyperextension
• Increased shoulder extension
• Increased wrist extension

Frye et al. also note that shoulder horizontal adduction and elbow extension are associated with functional performance.

The goal of FPROM:

1. To develop long-term plans for passive range of motion exercises to optimise functional abilities

Resources

• Web-based teaching and educational resource for medical and paramedical professionals involved in SCI Management: https://www.elearnsci.org/pages.aspx?id=16&page=Who_are_we
• International Standards for Neurological Classification of Spinal Cord Injury: Revised 2019