Upper Limb Function in Spinal Cord Injury: Difference between revisions

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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. <ref>Consortium for Spinal Cord Medicine. ''Outcomes following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-care Professionals.'' Consortium for Spinal Cord Medicine; 1999.</ref>  It is therefore important that a thorough examination of the upper limb with regarding to muscle strength, sensation and function is performed.  
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. <ref>Consortium for Spinal Cord Medicine. ''Outcomes following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-care Professionals.'' Consortium for Spinal Cord Medicine; 1999.</ref>  It is therefore important that a thorough examination of the upper limb with regarding to muscle strength, sensation and function is performed.  


== Tenodesis Function ==
=== [[Tenodesis Function in Spinal Cord Injury]] ===
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 ===
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.<ref name=":0">Bersch I, Koch-Borner S, Friden J. Electrical stimulation-a mapping system for hand dysfunction in tetraplegia. ''Spinal Cord.'' 2018;56(5):516.</ref>
 
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.<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]] ===
=== [[Management of the Upper Limb in the Acute Phase]] ===
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Revision as of 22:10, 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 in Spinal Cord Injury[edit | edit source]

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

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

Measurement of Upper Limb Function in Spinal Cord Injury[edit | edit source]

Resources[edit | edit source]

References[edit | edit source]

  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.
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