Upper Limb Management in C4 and C5 Spinal Cord Injury

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

Top Contributors - Ewa Jaraczewska, Jess Bell, Kim Jackson and Rishika Babburu  

Introduction

Based on the patients' survey results, restoring hand function is one of the most important goals for a person with tetraplegia. Upper extremity function in a person with a high-level spinal cord injury (SCI) can improve quality of life, and it may have a direct psychological impact on maintaining the social relationships of a person with SCI. Optimal upper limb functioning (UL) depends on neurological deficits. The intervention may need to focus on preventing complications and creating 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 fifty-nine percent of individuals with tetraplegia. Therapy must be tailored to every individual with a spinal cord injury, and patient feedback is essential to ensure the use of specific interventions. This article will discuss various rehabilitative strategies for upper limb management in C4 and C5 spinal cord injury, performed by a multidisciplinary spinal cord injury team.

"Tetraplegia: This term refers to impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Tetraplegia results in impairment of function in the arms and typically in the trunk, legs, and pelvic organs (i.e., including the four extremities). It does not include brachial plexus lesions or injury to peripheral nerves outside the neural canal."

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 the 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

Glenohumeral Subluxation

Shoulder subluxation:

• Avoid extreme positions at the shoulder, which can lead to a shoulder injury. For 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 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 a 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 muscle pump activity due to muscle paralysis after a spinal cord injury causes a reduction in venous and lymphatic return, leading to oedema. Chronic oedema can restrict the upper limb range of motion and decrease the patient's ability to use the hand for functional tasks when able.

Interventions

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

• Elevate and position properly: UL elevation on the pillow when a 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 the 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 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 a bony prominence
• Medial surface of the elbow
• Scapula

Interventions:

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

Limb Protection

Maintaining an adequate range of motion in all UL joints:

• Positioning in bed and the wheelchair
• Shoulder pain prevention or shoulder pain management due to impingement syndrome, capsulitis, osteoarthritis, recurrent dislocations, rotator cuff tear, bicipital tendonitis, and myofascial 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, brachialis, 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 of the Development of Deformities

With the C5 level of a spinal cord injury, the innervation of shoulder and elbow flexors is preserved. Active elbow extension against gravity is impaired. The upper limb tends to be positioned in shoulder abduction, elbow flexion, forearm in supination, and wrist in extension. To avoid a range of motion limitations and the development of upper limb deformities, the following strategies should be implemented:

• Individuals with a spinal cord injury and their caregivers should be educated to monitor range of motion (ROM) limitations and their impact on function.
• Positional strategies and activity modifications should be emphasized during therapy sessions, as stretching may not improve ROM limitations.

Limb Protection

• Preservation of the shoulder's full active range of motion.
  • Shoulder ROM limitation may occur due to poor scapula stability
  • A reduction in scapula lateral rotation and scapulothoracic instability characterises poor scapula stability
  • Serratus anterior(innervation C5-C7) is not able to counteract the rhomboids (innervation C4-C5), leading to scapula instability

• Neck and shoulder pain prevention and management
  • Overused trapezius provides scapula elevation and retraction with no opposition from shoulder protractors (serratus anterior, pectoralis major and minor) and depressors (latissimus dorsi, pectoralis minor). The trapezius becomes short and tight.

Prevention strategies may include:

• Passive range of motion
• Positional strategies
• Taping

Preparation for Function

Adaptive Equipment trials: universal cuff, Mobile Arm Support (MAS). See the chapter below: Upper Limb Adaptive Equipment.

Upper Limb Splinting

Goals:

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

General Guidelines

• The patient must participate in decision-making and treatment plan
• The patient must demonstrate health literacy and condition understanding
• The splint must serve functional goals
• Splint choice depends on the cosmetic preferences of the patient
• The patient must tolerate the splint and perceives comfort while wearing it
• The patient and caregiver must accept the splint and follow through with the wearing schedule and maintenance
• The 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 are issued immediately after injury and worn for 23 hours daily until the onset of rehabilitation, with breaks only for the range of motion exercises.
2. Goal: Optimal wrist and finger 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 is preferred over prefabricated
• Maintains the hand in a functional position,
• Prevents deformity
• Maintains aesthetically pleasing hand
• Clinical Practice Guidelines: mostly nighttime use when wrist and digit strength is 0-3/5
• The typical hand position in the resting hand splint is as follows:
  • Wrist in 10–40° extension (30° most frequent),
  • Metacarpophalangeal joint (MCP) at 0–90 (70–90 most typical)
  • Proximal interphalangeal (PIP) at 0–75 (10–30 most typical)
  • Distal interphalangeal (DIP) at 0–70 (10–20 most typical).
  • Thumb is positioned in opposition.

Wrist splint (Futuro splint):

• Prefabricated wrist splints are preferred
• Worn during the day to increase functional activity participation
• Dorsal varieties and a U-Cuff are favourite options
• The primary wrist splint goal is to prevent overstretching of the wrist extensors, and 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 SCI (73% of patients) and C4 (40% of patients)

Long opponens

• Less frequently than other splints: 13% of patients with a C5 SCI and 6% of patients with a C4 SCI
• Custom-fabricated splints preferred
• Provides a stable post against which index finger can pinch; positions thumb in a functional key pinch position
• Potential interference with power wheelchair operation

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 for individuals with wrist extension 3-5/5 and digitise 0-2/5
• Recommended for individuals with C6, C7-8 SCI

Metacarpal-Phalangeal (MCP) blocking splint

• Custom-made splint
• Prevents hyperextension deformity of the MCP joints
• Prevent MCP hyperextension during functional hand tasks.
• Recommended for patients with C7-8 SCI if intrinsic hand weakness is present

Other

• In addition, therapists commonly use the following 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

Wheelchair Joystick Adaptation

Powered Wheelchair

• It helps to protect the upper limb by reducing repetitive forceful activity
• It should be considered before the patient complains of upper limb pain.

But......

• Using powered mobility may lead to weight gain and upper limb deconditioning in a person with tetraplegia.

A power wheelchair can be recommended for:

• Community mobility for individuals with a C6 SCI
• High-risk patients:
  • A person with a prior injury to the upper limb
  • Obese person
  • Elderly
  • A person living in a challenging environment (hills, uneven or rough terrain)

Manual Wheelchair

• The optimal manual wheelchair should be high-strength, fully customizable and made of the lightest possible material.
• The rear axle should be adjusted as far forward as possible without compromising the user's stability.
• A more forward axle position decreases rolling resistance and increases propulsion efficiency.
• Appropriate seated posture and stabilization relative to balance and stability needs should be assessed.
• Individuals with a C4 and higher SCI must be provided with the full support of the forearm and hand to decrease subluxation or dislocation

Wheelchair Modifications/Adaptive Equipment

• Wrist extension splint with wheelchair glove over it
• Arm trough support
• Elbow blocks (to assist with arm support during tilt)
• Modular hand pad
• Various joystick options
  • Ball, enlarged ball
  • T-bar
  • U shaped
  • Cylinder
  • Carrot Toggle

• The slip-resistant grip on the wheelchair hand rims (plastic coated or rubber)
• Rubber-coated projections off the push rim, however using both sides is difficult to coordinate, and they impact the chair width
• Extended brake levers

Upper Limb Adaptive Equipment/Assistive Technologies

Universal cuff (C5)

• An adaptive device that helps patients with a high-level spinal cord injury grip small objects and perform activities of daily living.
• They are considered one of the most useful tools for people with limited control of their hands.
• The universal cuff is used to augment or provide upper extremity/hand function to perform activities.
• The items remain secure even when the patient cannot grip objects with their fingers. They can still eat a meal, draw, or groom themselves.

MAS (Mobile Arm Support)or BFO (Balanced Forearm Orthosis)

• To successfully use MAS, the patient should demonstrate minimal strength of the deltoid and biceps muscles.
• Motivated patients with biceps and deltoid muscle strength < 2/5 can benefit from MAS.
• Patients are usually able to perform at least one new activity using a MAS, including eating, page-turning, driving a power wheelchair, brushing teeth, keyboarding, writing, name signing, drawing, painting, scratching nose, playing board games, accessing electronic devices, drinking, and grooming.
• MAS attached to the wheelchair increases wheelchair width and causes problems managing the arms while reclining.

Multidisciplinary Management

Everyone in the multidisciplinary team is responsible for the upper limb management in C5 and C6 tetraplegia, which must occur 24 hours/7 days a week. This team includes nursing staff, physicians, physical, occupational and speech-language pathologists, family and all other caregivers.

Education

• Education is tailored to the patient's needs with the expectation that this individualisation will improve the intervention results.
• Educate healthcare providers and persons with SCI about upper limb pain and injury risk.
• Education on reduction of the frequency of repetitive upper limb tasks to decrease the risk of developing shoulder pain and shoulder dysfunction:
  • decreasing the number of transfers needed each day
  • altering the use of a manual wheelchair with a power wheelchair or switching to a power wheelchair as appropriate
  • reduce the frequency of 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:

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

ICF and Upper Limb Management

The ICF model should be incorporated in managing the upper limb of patients with a spinal cord injury, as it helps to interpret the upper limb function outcomes following therapeutic interventions and the choice of adaptive equipment. The following is the example of the ICF assessment sheet, which presents the assessment results of all the components of functioning, environmental and personal factors from the health professional and the patient:

ICF Assessment Tool for Upper Limb Management in Tetraplegia

Treatment intervention examples based on the results of the assessment using the ICF assessment tool:

1. Family and caregiver education on the importance of working toward's patient independence in eating
2. Family and caregiver education on choosing the proper diet for the patient to facilitate the patient's participation during meal times
3. Home visit to assess patient's home access to a wheelchair with MAS attachment to the wheelchair
4. The exercise program focuses on neck muscle stretching and strengthening
5. Wheelchair seating and positioning assessment to ensure proper neck and head alignment

Resources

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