Upper Limb Function in Spinal Cord Injury: Difference between revisions

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Diverse splinting and taping strategies have been practiced, but no one strategy has yet proven to be superior in providing the desired tenodesis function.<ref>Harvey L. Principles of Conservative Management for a Non-orthotic Tenodesis Grip in Tetraplegics. ''J Hand Ther.'' 1996;9(3):238-242.</ref> Failure to develop tenodesis function generally results in a less functional hand. One of the common presentations is the intrinsic minus (claw hand) (Figure 2).  
Diverse splinting and taping strategies have been practiced, but no one strategy has yet proven to be superior in providing the desired tenodesis function.<ref>Harvey L. Principles of Conservative Management for a Non-orthotic Tenodesis Grip in Tetraplegics. ''J Hand Ther.'' 1996;9(3):238-242.</ref> Failure to develop tenodesis function generally results in a less functional hand. One of the common presentations is the intrinsic minus (claw hand) (Figure 2).  


== Management of the Upper Limb in the Acute Phase ==
The main aim of management of the upper limb in the acute phase is to prevent secondary complications such as swelling and contractures from occurring in addition to developing tenodesis function.  
In the first days following injury, immobilization results in structural changes to the muscle characterized by:
* Shortening of muscles fibre length
* Disorganization and loss of sarcomere
* Increase in connective perimysium
* Accumulation of intramuscular collagenous connected tissue
* Atrophy, increased changes at the myotendinous junction. <ref>Lieber RL, Ward SR. Cellular mechanisms of tissue fibrosis. 4. Structural and functional consequences of skeletal muscle fibrosis. ''Am J Physiol Cell Physiol.'' 2013;305(3):C241-252.</ref><ref>Williams PE, Goldspink G. Connective tissue changes in immobilised muscle. ''J Anat.'' 1984;138 ( Pt 2):343-350.</ref>
Awareness of these structural changes, along with imbalances of joint biomechanics due to paralysis of key muscles is of paramount importance should treatment of the upper limb should commence early following injury to prevent secondary complications.  
=== Diagnosis of Upper and Lower Motor Neuron Damage ===
As discussed above, following a spinal cord injury damage occurs to the upper motor neurons, preserving the lower motor neurons below the level of injury. At the level of the injury, the lower motor neurons are not viable and muscle atrophy from loss of neuromuscular junctions is seen.  Below the level of injury, as the anterior horn cells are viable, the neuromuscular junctions are intact, the muscle is viable and a reflex arc is present. Functional Electrical Stimulation (FES) can be used diagnostically to distinguish between paralyzed muscles with intact versus damaged lower motor neurons with a weak or absent response of a paralyzed muscle recorded at least eight days following injury indicating, with 100% certainty, that the peripheral motor nerve has undergone irrecoverable damage.<sup>7</sup> There is also evidence that lower motor lesions can predict both contracture development and the development of the tenodesis function.<ref name=":0" /> Knowledge of the presence of lower motor neuron damage is also important for those considering nerve transfer surgery. Therefore, there may be value in the use of surface FES to assess tetraplegic upper limbs to determine functional denervation and assist in identifying appropriate interventions for maximizing function in the acute phase.  
=== Oedema Prevention and Treatment ===
Due to the loss of muscle pump activity due to paralysis combined with the dependent position of the upper limb there is reduced capacity for venous and lymphatic return, which, left unmanaged, will result in oedema. The hand can contain up to 50ml of additional fluid before oedema is visible.<sup>8</sup>If this is left and becomes persistent, the proteins in the fluid increases and the oedema becomes viscous and fibrotic.  Untreated, this can result in loss of tenodesis grip due to loss of range of motion especially around the MCP joints (Figure 3). Prevention of oedema is a primary goal of upper limb management and can consist of elevation, activity, orthoses and compression. <sup>9</sup>
Positioning of the hand in elevation, especially in the acute phase assists venous return and reduces arterial hydrostatic pressure.<sup>8</sup> Elevation usually provided by pillows or slings attached to the bed (figure XX) can be used in conjunction with positioning to maintain length and prevent contracture as discussed later in the chapter. 
In sitting, if the individual does not have sufficient movement to activate the muscle pump, the arm needs to be fully supported with a well-fitting armrest or the wrist braced into extension.  Wrist positioning is especially important as extended periods of flexion can obstruct the venous and lymphatic return on the dorsum of the hand and encourage the development of oedema.  
Hand Orthoses have been used to manage the tetraplegic hand for many years.  However, there is variability between clinicians/centres on the purpose, positioning and treatment prescription of orthoses and minimal research on the effectiveness of this intervention.<sup>10</sup> Consensus does however endorse the use of static splinting, either custom-made or off-the-shelf, depending on the need of the patient.  Ideally, static splinting should begin immediately following injury with the aims to
a) facilitate conditions for venous return
b) maintain range of motion of structures of the hand, and
c) encourage slight shortening of the finger flexors for optimal tenodesis function.<sup>11</sup>
Compared to passive or active movements, orthoses aim for low-load prolonged stretch.<sup>12</sup> In the acute phase the primary purpose of the orthosis is to prevent oedema and protect the structures of the hand. Therefore the orthosis should ensure the hand is resting in a position of safety with the wrist extended approximately 20° to maintain length of the finger extensors, MCP’s flexed 70° to maintain MCP collateral ligament length and balance finger flexors/extensors and intrinsics, IP joints of the fingers straight to balance the intrinsics and the thumb CMC joint abducted 30°, MCP and IP joints straight or slightly flexed to position the thumb for opening and key pinch (Figure 6).  To facilitate the transport of fluid to the dorsum of the hand, where the majority of venous return occurs, the orthosis should provide firm volar pressure.  If required additional compression by bandaging or elastic bands over the dorsum of the hand and forearm may be used in conjunction with the orthosis if oedema is problematic.  Ideally, during the bedrest stage the orthosis should be worn for 3 hours on/3 hours off during the 24 hour period.  
Once the patient mobilises and becomes more active the risk of oedema reduces due to use of the muscle pump.  Thus the need for splinting to prevent oedema is decreased and such splints interferes with function.  Thus the aims of splinting changes and should be individually assessed for each patient.  If the hand demonstrates spasticity, stretching of the involved muscles using orthoses overnight is indicated and constant assessment and evaluation of the balance of the hand and positioning is essential.  
=== Spasticity and Contracture ===
Cervical spinal cord injury is commonly associated with hypertonia, which is characterized by spasticity and dystonia that can involve both the upper and lower limb.  Splinting of the upper extremity can be used to prevent soft tissue shortening and contracture.  It has been demonstrated that an elbow flexion contracture greater than 25 degrees has a significant impact on the independence of a person with tetraplegia.<sup>13</sup> Consideration of splints to assist with positioning the elbow in extension for those patients who lack triceps innervation and who have increased tone and spasticity is recommended.<sup>13</sup> Once present, contracture is difficult to reduce, thus emphasis is placed on prevention.<sup>14</sup> Prediction of contracture is an essential task of the therapist, and factors such as innervation pattern, spasticity, pain, oedema and long term position of the body are important to observe and analyse.<sup>15</sup> Prevention is a team approach and can include medication, including pain relief, anti-spasmodics, botulinum toxin, in conjunction to passive movement and regular positioning of the upper limb at end ranges throughout the day.  
=== Passive Movement ===
The rationale and the use of passive movement and stretching is mostly justified by old animal studies.<sup>16</sup> The intensity of passive movements necessary to reach therapeutic benefit is unknown despite a strong clinical confidence in the effect.  However, daily assessment of the upper limb in the acute phase can be combined with passive movements performed by a therapist, providing ongoing monitoring of the limb. Passive movements are important to prevent adhesions of tendons and lubricate joints. Therefore joint-by-joint passive ranging is vital.  Stretching of the joints is performed slowly and joints should never be forced. As it difficult to reduce contractures once developed, stretch is most likely to be effective if started before the onset of contracture thus rehabilitation and treatments of the upper-limb should be initiated as soon as possible after injury.<sup>15</sup> Soft tissues, such as muscles, ligaments and joint capsules, most at risk should be targeted, particularly if contracture is likely to impose functionally important limitations including loss of passive elbow extension (due to tight biceps), loss of pronation (due to biceps contracture), loss of external rotation (due to tight pectoralis muscle); shoulder pain (due to increased tone in innervated muscles and poor positioning of arm due to tightness. Orthoses and positioning of the limbs are important compliments to twice-daily passive movement.
To promote tenodesis function in the hands, it is important to avoid stretching the finger- and thumb flexor tendons when the wrist is extended.  Finger extension should only be performed with the wrist flexed (figure XX). Emphasis should be on  flexion and extension of the wrist, flexion of the MCP joints of the fingers, extension of finger PIP joints and thumb adduction - the same movements that are lost if prolonged oedema is present. If any tightness occurs, specific attention should be focused on the affected joint.
The length of time of required to perform passive movements for therapeutic benefit is unknown, but could be as long as 15 minutes per joint daily, dependent upon such factors as age, presence or absence of spasticity and pain.<sup>17</sup> The individual should therefore be taught as early as possible good habits of stretching and managing passive movements and long term positioning. Stretching should be incorporated into everyday life activities.


== Management of the Upper Limb in the Sub Acute Phase ==
== Management of the Upper Limb in the Sub Acute Phase ==

Revision as of 21:41, 13 June 2019

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Introduction[edit | edit source]

Improvement in upper limb function is identified as a top priority for people with tetraplegia following spinal cord injury. [1] Management of the tetraplegic upper limb aims to maximize hand function to enable performance of daily tasks as independently as possible.  In order to reach this goal it is important to prevent secondary complications of the upper limb occurring in the acute phase. Therefore interventions need to start early and involve all members of the rehabilitation team. Initial intervention aims to prevent secondary complications of restricted joint movement, pain, swelling and contracture. Following this, rehabilitation of the tetraplegic upper limb consists of strengthening remaining muscles and retraining skills using motor relearning, compensatory and adaptive techniques. Following neurological plateau of the injury, which is usually between 6 - 12 months in the complete spinal cord injury, there are a number of reconstructive surgery options available to further improve upper limb function. This module will provide a guideline for the management of the tetraplegic upper limb, describe rehabilitation principles to develop a function hand. Common surgical reconstruction and other interventions will also be reviewed.  

Function and Management According to Neurological Level[edit | edit source]

The limitations experienced following spinal cord injury are dependent upon the severity and level of injury. While individuals with the same motor level of injury, assessed by the ICNSCI, will have similar muscles innervated, how they use these muscles is dependent on a number of factors such as age, body composition, completeness of spinal cord injury, other injuries and motor planning.  This makes describing expected functional capacity of a specific level difficult, however publications there are clinical practice guidelines published at outline the expected skills and outcomes for each significant level of spinal cord injury. [2] It is therefore important that a thorough examination of the upper limb with regarding to muscle strength, sensation and function is performed.  

Tenodesis Function[edit | edit source]

Tenodesis function occurs when the wrist is extended the fingers and thumb flex into the palm (Fig 1a) and then when the wrist is flexed the fingers and thumb open (Fig 1b).  This function is used to facilitate grasp in people with tetraplegia who have wrist extension against gravity but no active finger function (C6 Motor Level). It is critical to gain tenodesis function to enable task performance.  

Development of Tenodesis Function[edit | edit source]

Tenodesis function is fully dependent upon active wrist extension against gravity however, the process of development of tenodesis function is not fully understood.  While SCI is commonly considered a condition of the central nervous system because of the damage to the upper motor neurons, it is not uncommon for concurrent lower motor neuron damage to occur at the level of the injury.  Recent research demonstrates lower motor neuron damage at the level of the injury of finger extensors to be a strong predictor for development of tenodesis function.[3]

Development of tenodesis function can be facilitated by:

  • Constant monitoring of the hand and promoting correct tension in muscles and reducing hypertension from spasticity that may impact the balance and function of the hand.
  • Prevention of overstretching of the finger flexors in both passive movements performed by the therapist, and functional activities such as propping on extended wrists or transferring.
  • Prevention of oedema in the hand.
  • Education of person with tetraplegia on tenodesis grasp, use of splints, self-stretches.  

Diverse splinting and taping strategies have been practiced, but no one strategy has yet proven to be superior in providing the desired tenodesis function.[4] Failure to develop tenodesis function generally results in a less functional hand. One of the common presentations is the intrinsic minus (claw hand) (Figure 2).  


Management of the Upper Limb in the Sub Acute Phase [edit | edit source]

It is accepted that the central nervous system is capable of reorganization, especially in the incomplete SCI because there is largely intact local spinal cord circuitry and some partially interconnected fibres.18 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).18

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.19 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[edit | edit source]

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.20 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.21 Studies using massed practice and/or FES have demonstrated potential for both neural and functional improvements in people with tetraplegia.22,23

Education of Movement Patterns[edit | edit source]

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[edit | edit source]

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.24  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.25

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.26 A well-balanced tenodesis function facilitates the opportunity for several adapted grips (figure XX). 

Measurement of Upper Limb Function [edit | edit source]

Currently there is no international consensus on what measures to use for tetraplegic upper limb function.27  The use of the International Classification of Functioning, Disability and Health (ICF) established by the World Health Organisation can assist in ensuring that measurement encompasses all domains of functioning and provide a common language of describing an individual functioning following illness or accident.28  To provide a complete picture of an individual’s functioning use of multiple measures that encompass the three domains of the ICF are recommended.  Commonly used measures are detailed in below and described fully in Sinnott et al (2016).29  International efforts are currently underway to establish consensus on standardising key body functions and structure measures such as muscle strength testing, and grip and pinch dynamometry.30

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References[edit | edit source]

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  1. ↑ Anderson KD. Targeting Recovery: Priorities of the Spinal Cord-injured Population. Journal of Neurotrauma. 2004;21(10):1371 - 1383.
  2. ↑ Consortium for Spinal Cord Medicine. Outcomes following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-care Professionals. Consortium for Spinal Cord Medicine; 1999.
  3. ↑ Bersch I, Koch-Borner S, Friden J. Electrical stimulation-a mapping system for hand dysfunction in tetraplegia. Spinal Cord. 2018;56(5):516.
  4. ↑ Harvey L. Principles of Conservative Management for a Non-orthotic Tenodesis Grip in Tetraplegics. J Hand Ther. 1996;9(3):238-242.
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