Upper Limb Management in C4 and C5 Spinal Cord Injury

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Introduction

Based on the results from the patients' survey, the restoration of hand function is one of the most important goals for the person with tetraplegia. Optimal functioning of the upper limb (UL) depends on the neurological deficits, and the intervention may need to focus on prevention of complications and creation an ideal conditions for the reconstructive phase of upper limb rehabilitation. Upper limb pain is a common complication which can delay progress and it was found in 59 percent of individuals with tetraplegia. Therapy must be tailored to every individual with a spinal cord injury and patient's feedback is essential to assure the usefulness of specific interventions. This article will discuss various rehabilitative strategies for the upper limb management in C4 and C5 spinal cord injury, performed by a multidisciplinary spinal cord injury team.

C4 Tetraplegia

1. No active movement of upper limb muscles
2. Unable to use hand
3. High risk of shoulder subluxation due to lack of innervation of shoulder girdle

Goals for UL management:

• Prevent and control the development of deformities
• Protect insensate areas from injury
• Prevent or reduce oedema
• Maintain a supple hand for human contact
• Protect the limb from irreversible changes
• Preserve the limb for future treatment paradigms

Prevention

Prevention of Development and Management of UL Deformities

Shoulder subluxation:

• Avoid extreme positions at the shoulder which can lead to shoulder injury. Example: extreme internal rotation, forward flexion and abduction can cause shoulder impingement.
• Maintain proper alignment of the glenohumeral joint while sitting in the wheelchair, during functional task and weight bearing activities.
• Educate all caregivers on proper UL handling during transfers and all other daily activities.

Hand and wrist overstretched in extension or flexion:

• Avoid extreme positions of the wrist, especially full wrist extension. Weight bearing through an extended wrist and flat hand can cause nerve injury as it compresses the median nerve in the carpal canal.
• Use closed-fist hand position and neutral wrist while transferring between surfaces, but watch for wrist instability during these tasks.
• Avoid extended periods of volar flexion

Prevention or Reduction of Oedema

Limited activity of the muscle pump due to muscle paralysis after a spinal cord injury is causing a reduction in venous and lymphatic return, which leads to oedema. Chronic oedema can restrict upper limb range of motion and decrease the patient's ability to use hand for functional task when able.

Interventions

There is no consensus how to best manage the UL oedema:

• Elevate and position properly: UL elevation on the pillow when patient lies supine in bed, UL support in alignment to prevent shoulder subluxation and pain resulting from it.
• Avoid excessive wrist flexion which can obstruct venous and lymphatic return
• Use splinting to facilitate conditions for adequate venous return
• Maintain range of motion in joints, tendons and ligaments of wrist and fingers
• Apply prolonged stretch using orthosis in case of hand spasticity to prevent contractures
• Use compression gloves (tenodesis position should be maintained and compression applied on the palmar side of the hand) or wrap each finger individually with Coban or Danamull Haft

Protection of Insensate Areas

Pressure ulcers can occur due to multiple factors that include :

• long-sustained local pressure (elbows supported on the arm troughs or wheelchair tray)

• short periods of high pressure
• shearing forces
• friction
• moisture (hand contracture)

Common location of UL pressure ulcers:

• over bony prominence
• medial surface of the elbow
• scapula

Interventions:

• Proper positioning in bed and in the wheelchair
• UL protection from friction and shearing forces during wheelchair pressure relief using reclining or tilting in space
• Proper hand hygiene
• Skin inspection performed twice a day

Limb Protection

Maintaining adequate range of motion in all UL joints:

• Positioning in bed and in the wheelchair
• Shoulder pain prevention or shoulder pain management as a result of impingement syndrome, capsulitis, osteoarthritis, recurrent dislocations, rotator cuff tear, bicipital tendinitis, and myofacial pain syndrome.
• Early and aggressive acute pain management as a result of acute musculoskeletal injuries to prevent the development of chronic pain.

Support for Function

Preserve range of motion and mobility for future treatment paradigms

C5 Tetraplegia

1. Upper limb muscle innervation: deltoid, biceps, brachial, brachioradialis
2. Lack of elbow extension
3. No wrist extension and no active movement of fingers or thumb
4. Supinated forearm
5. Wrist extension achieved through orthosis
6. No tenodesis grip

Goals:

• Prevent and control the development of deformities
• Protect insensate areas from injury
• Prevent or reduce oedema
• Prepare the limb for function (feeding)

Prevention and Control the Development of Deformities

Shoulder abduction, elbow flexion and forearm supinated, wrist in extension

Limb Protection

Poor scapula stability

Preparation for function

Adaptive Equipment trials: universal cuff, Mobile Arm Support (MAS)

Upper Limb Splinting

Goals:

• To reduce pain
• To slow the degradation process
• To recover joint space
• To improve finger performance and hand functioning by increasing grip and pinch strength.

General Guidelines

• Patient must participate in decision making and treatment plan
• Patient must demonstrate health literacy and condition understanding
• Splint must serve functional goals
• Splint choice depends on cosmetic preferences of the patient
• Patient must tolerate splint and perceives comfort while wearing it
• Patient and caregiver must accept splint and follow-through with wearing schedule and maintenance
• Clinician must perform an ongoing review of current evidence for splinting in spinal cord injury

Protocols

Limited standard protocols exist across the continuum of care.

Protocols examples from the literature:

1. Goal: Optimal muscle shortening for tenodesis.
   • Splints issued immediately after injury and worn for 23 hours daily until the onset of rehabilitation with breaks only for range of motion exercises
2. Goal: Optimal wrist and fingers positioning.
   • Resting hand splints for night time/rest when wrist and digit strength is 0–3/5
   • Futuro wrist splints for daytime hand use for individuals with elbow flexion against gravity but weak wrists and hands
   • Hand based or thumb splints and/or taping of the digits at night/rest for individuals with wrist extension against gravity but no digit movement.

Splints

Resting hand splint:

• frequently used in C4 and C5 SCI
• custom-made preferred over prefabricated
• Clinical Practice Guidelines: mostly night time use when wrist and digit strength is 0-3/5
• typical position the wrist in 10–40° extension (30° most frequent). Digits are positioned in some flexion: MCP at 0–90 (70–90 most typical); proximal interphalangeal (PIP) 0–75 (10–30 most typical); distal interphalangeal (DIP) 0–70 (10–20 most typical). The thumb is typically positioned in opposition.

Wrist splint:

• Prefabricated wrist splints are preferred by 29 of 48 clinicians who regularly prescribe wrist splints to be worn during the day to increase functional activity participation. Dorsal varieties and a U-Cuff are mentioned as favorite options. The primary wrist splint goal is to prevent overstretching of the wrist extensors, and the addition of 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 C5 (73%) and C4 (40%)

Long opponens

• Long-opponens splint use occurs less frequently than other splints, with custom fabricated splints preferred by 16 of 18 clinicians who report regular long opponens use. Clinicians state these splints are recommended for functional activities but also note potential interference with power wheelchair operation.
• 13% (C5), 6% (C4)

Short opponens

• Therapists who report regular short opponens use prefer to fabricate custom splints almost exclusively (41 of 43 respondents). These splints facilitate tenodesis by opposing the thumb and preventing thumb overstretching during functional tasks.
• C6, C7-8
• to facilitate tenodesis for individuals with wrist extension 3-5/5 and digitise 0-2/5

Metacarpal-Phalangeal (MCP) blocking splint

• All 24 clinicians who report regular MP blocking splint use fabricate custom splints to prevent MP hyperextension during functional hand tasks.
• C7-8
• if intrinsics hand weakness is present and MCP hyperextension occurs during functional tasks

Other

• In addition to the five common splints listed in the survey, therapists describe commonly using the following additional devices: elbow extension splints, elbow pillow splints, anti-spasticity splints, palm splints, intrinsic plus or minus splints, tone and positioning splints, tenodesis splints or orthotics, and finger flexion gloves or mitts.

Wheelchair Mobility

powered mobility should help protect the upper limb by reducing repetitive forceful activity and it should be considered before the patient starts complaining of the upper limb pain. The use of powered mobility may lead to weight gain and upper limb deconditioning

Power wheelchair can be recommended for:

• community mobility (C6 SCI)
• high risk patients:
  • person with a prior injury to the upper limb
  • obese person
  • elderly
  • person living in a challenging environment (hills, uneven or rough terrain)

Provide manual wheelchair users with SCI a high-strength, fully customizable manual wheelchair made of the lightest possible material.

Adjust the rear axle as far forward as possible without compromising the stability of the user.A more forward axle position decreases rolling resistance and therefore increases propulsion efficiency.

Promote an appropriate seated posture and stabilization relative to balance and stability needs. C4 and higher neurologic levels, provide full support of the forearm and hand to decrease subluxation or dislocation

Wheelchair Modifications/Adaptive Equipment

• Wrist extension splint with wheelchair glove over it

Upper Limb Adaptive Equipment/Assistive Technologies

Universal cuff (C5)

Mobile Arm Support(C5)

Multidisciplinary Management

Upper limb management in C5 and C6 tetraplegia must occur 24 hours/7days a week and it is a responsibility of everyone in the multidisciplinary team, including nursing staff, physicians, physical, occupational and speech language pathologists, family and all other caregivers.

Education

• Tailoring therapeutic education consists of adapting the intervention to patients' needs with the expectation that this individualization will improve the results of the intervention
• Education of health-care providers and persons with SCI about the risk of upper limb pain and injury
• Education on reduction the frequency of repetitive upper limb tasks:
  • decreasing the number of transfers needed each day
  • altering the use of manual wheelchair with power wheelchair or switching to a power wheelchair as appropriate
  • decreasing the frequency of the propulsive stroke during wheelchair propulsion
  • Consider alternative techniques for activities when upper limb pain or injury is present.

Mandatory periodic reassessment of the patient's function, ergonomics, and equipment, including:

• Changes in patient's medical status
• Acquisition of new medical problems (heart disease)
• Changes in weight, muscle mass, pain level
• Ageing effect on patient's functional status and mobility
  

Resources

• Preservation of Upper Limb Function: What YOU Should Know - A Guide for People with Spinal Cord Injury
• Risk Assessment in Pressure Ulcer Prevention