Upper Limb Function in Spinal Cord Injury: Difference between revisions

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== Introduction  ==
== Introduction  ==
Improvement in upper limb function is identified as a top priority for people with tetraplegia following spinal cord injury. <ref>Anderson KD. Targeting Recovery: Priorities of the Spinal Cord-injured Population. ''Journal of Neurotrauma.'' 2004;21(10):1371 - 1383.</ref> 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.  
Improvement in upper limb function is identified as a top priority for people with tetraplegia following spinal cord injury. <ref>Anderson KD. Targeting Recovery: Priorities of the Spinal Cord-injured Population. ''Journal of Neurotrauma.'' 2004;21(10):1371 - 1383.</ref> 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 functioning hand. Common surgical reconstruction and other interventions will also be reviewed.  


== Function and Management According to Neurological Level ==
== Function and Management According to Neurological Level ==
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 ==
== Resources ==
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).  
 
== Measurement of Upper Limb Function ==
Currently there is no international consensus on what measures to use for tetraplegic upper limb function.<sup>27</sup>  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.<sup>28</sup>  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).<sup>29</sup>  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.<sup>30</sup>
 
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== References ==
== References ==
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[[Category:Spinal_Cord_Injuries]]  
[[Category:Spinal_Cord_Injuries]]  
[[Category:SCI_Content_Project]]
[[Category:SCI_Content_Project]]
[[Category:Interventions]]
[[Category:Shoulder]]
[[Category:Elbow]]
[[Category:Hand]]

Latest revision as of 16:11, 20 May 2021

Original Editor - Dr. Jennifer Dunne

Top Contributors - Naomi O'Reilly, Admin and Kim Jackson  

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 functioning 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.  

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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