Moving our arms and using our hands to grasp or reach for objects is essential for daily tasks like grooming, dressing, cooking, writing, as well as using tools or technology such as phones, computers, and cars.
After a spinal cord injury, upper extremity function can be impacted in a way that makes these daily tasks extremely challenging. One of the goals of rehabilitation is crucial to promote independence and decrease caregiver needs to accomplish daily routines.
Occupational therapists (OTs) play an instrumental role in helping clients that have suffered a spinal cord injury in their journey towards independence, specifically as it relates to hand and arm function.
In collaboration with physiotherapists, OTs help promote neuro recovery implementing specific exercises to maintain joint mobility, strength, and dexterity in the hands and arms. In addition, OTs are able to create functional adaptations for activities of daily living and splints to enhance upper extremity function.
In this blog, we will highlight the challenges that individuals with spinal cord injury usually experience with upper extremity function in relation to the level and severity of the injury, as well as the pivotal role occupational therapists play in recovery and compensation strategies in quadriplegia.
Table of Contents:
- The Multi-System Impacts of Quadriplegia
- Spinal Cord Injury Level and Upper Extremity Function Correlation
- Surgical Treatment Options
- Conclusion
The Multi-System Impacts of Quadriplegia
Quadriplegia is complex neurological condition that affects many systems in our body including musculoskeletal, vascular, and genitourinary. Some of the most common impacts include:
- Loss of sensation
- Loss of motor control or paralysis
- Autonomic dysfunctions impacting many systems in our body
People with quadriplegia report the loss of function in the arms and hands as the most debilitating and hard to deal with. This is because it impacts many activities of daily living (ADL), particularly related to the preservation of independence.[i]
In a survey completed with quadriplegia patients, 75% responded that hand function was very important for their independence in ADLs and to increase their quality of life.[ii]
Spinal Cord Injury Level and Upper Extremity Function Correlation
The level of the spinal cord injury will define the challenges with the use of the arm and hand. Also, the differences between a complete or incomplete spinal cord injury will affect the presentation and a person’s recovery potential.
For example, a complete spinal cord injury results in a total loss of motor (ability to move) and sensory (ability to feel) function. However, in cases with an incomplete spinal cord injury, some motor and/or sensory function is preserved which positively impacts the potential ability to use the arms and hands.
Occupational therapists provide a comprehensive rehabilitation approach to help clients achieve independence and improve their ability to perform daily activities. Specific upper extremity rehabilitation including exercise, sensory re-training, functional electrical stimulation, compensatory strategies, use of adaptive equipment and splinting are part of the treatment and is tailored to each individual, based on their level of injury and goals to increase independence with self care and activity participation.
Upper Cervical Nerves – C1-C4 level:
Presentation: Present as the most severe levels of injury and represents full paralysis of the arms, hands, trunk and legs. The individual will require full assistance of daily living, such as eating, dressing, bathing and getting in and out of a bed. Caregiver support is essential.
Occupational Therapy Treatment: The rehabilitation for the upper extremities will focus on maintaining the range of motion of the joints, managing the potential changes in the muscle tone, stretching, splinting for positioning and prevention of deformities. The incorporation of assistive technology is essential to optimize independence with daily activities such as use of a phone, computer access and environmental control.
Lower Cervical Nerves – C5-C6 level:
Presentation:
- C5 Injury: The individual will be to raise the arms and bend the elbows and will present with some or total paralysis at the wrist and hand as well as trunk and legs requiring assistance with most activities of daily living. However, the individual is able to use a power wheelchair after specific assessment/training which improves their mobility.
- C6 Injury: The individual has some movements at the shoulders and elbows and may have some wrist extension but presents with paralysis in the hands, trunk and legs. Can perform transfers, in and out of bed or car with assistive equipment and with proper training may drive an adapted vehicle.
- C7 Injury: The individual has the ability to perform full movement at the shoulders, elbows and some finger extension which will allow the hand to straighten. Clients may be able to perform most of the ADL tasks independently with some adaptations or support for complex tasks that requires more stability or force (open a tight jar).
- C8 Injury: The individual has the ability to move his shoulders, elbows and wrists as well as perform grasp/release of objects when using the hands. May require adaptations to complete more difficult daily tasks that require a precise dexterity or force grip. (use tweezers, fixing tools) but can perform most of the ADL tasks independently.
Occupational Therapy Treatment: The rehabilitation focused in treating individuals with C5-C6 level injuries is to maintain passive range of motion and stimulate active movement, stretching to reduce tightness and strengthening exercises to improve the use of the arms and hands. Incorporate activities and exercises to increase strength in reaching, pulling as well grasping and releasing objects with or without support/adaptations.
Sensory stimulation and sensory re-training is incorporated during activities using the arms/hands to facilitate the perception of the limb and potentially improve motor control. Functional Electrical Stimulation is often incorporated as part of the treatment to facilitate practice of reaching/pulling/grasping/releasing activities and potentialize the active motor control.
The use of splinting for position will help prevent deformities and optimize the natural position of the hands. For example, a resting splint often used at night to maintain the wrist and hands and neutral position and prevent deformities in flexion. Another example is the use of a thumb opponens splint that helps maintain the thumb in opposition facilitating tenodesis grasp and hand position.
The splints can also be used as a functional adaptation and incorporated as a tool to improve function and independence in a specific task such as writing, eating.
There are also a variety of adaptive tools such a rocker knife with upright angle, pizza cutter with enlarged handle, or dressing adaptation for zippers, and many more to facilitate grooming tasks, make-up application, and other daily tasks, improving the independence of the individuals with spinal cord injury.
Thoracic Vertebrae injuries – T1-T5:
Arm and hand function are usually normal and do not require occupational therapy for hand or upper arm rehabilitation.
Surgical Treatment Options
It is important to highlight that hand surgery can be an option to improve upper extremity function. However, the individual would need to meet the criteria for the surgical procedure and the continuation of rehabilitation would also required.
Some of the common surgeries involve tendon transfers to improve grasp and key pinch abilities and strength, which will translate in a potential better use of the hand. Researchers report that following a surgical procedure, significant improvements in grip strength and finger flexion were demonstrated in multiple studies. Consequently, performance of ADL tasks improved, and individuals were able to gain more independence.[iii],[iv],[v]
Another point to consider is that patients report feelings of improvement, psychologically and functionally, after grip reconstructive surgery.[vi],[vii]
Conclusion
The rehabilitation process for spinal cord injuries is multifaceted, with upper extremity function being a critical component. The loss of hand and arm function significantly affects an individual’s ability to perform daily tasks and engage in meaningful activities, including work and leisure pursuits.
Occupational therapy plays a vital role in restoring upper extremity function, helping individuals regain independence and improve their quality of life. By creating an individualized and tailored upper extremity treatment plan, occupational therapists can enhance social participation and support a more fulfilling, independent life for those living with spinal cord injuries.
References
[i] Welraeds, D., Ismail, A. A., & Parent, A. (2003). Functional reconstruction of the upper extremity in tetraplegia. Application of Moberg’s and Allieu’s procedures. Acta Orthop Belg, 69(6), 537-545.
[ii] Snoek, G, IJzerman, M, Hermens, H, Maxwell, D, Beiring Sorensen, F. Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics. Spinal Cord 2004 42, 526‐532
[iii] McCarthy, C. K., House, J. H., Van Heest, A., Kawiecki, J. A., Dahl, A., & Hanson, D. (1997). Intrinsic balancing in reconstruction of the tetraplegic hand. The Journal of hand surgery, 22(4), 596-604.
[iv] House, J. H., Comadoll, J., & Dahl, A. L. (1992). One-stage key pinch and release with thumb carpal-metacarpal fusion in tetraplegia. The Journal of hand surgery, 17(3), 530-538.
[v] Waters, R., Moore, K. R., Graboff, S. R., & Paris, K. (1985). Brachioradialis to flexor pollicis longus tendon transfer for active lateral pinch in the tetraplegic. The Journal of hand surgery, 10(3), 385-391.
[vi] Wangdell, J., Carlsson, G., & Fridén, J. (2013). Enhanced independence: experiences after regaining grip function in people with tetraplegia. Disability and rehabilitation, 35(23), 1968-1974.
[vii] Wangdell, J., Carlsson, G., & Friden, J. (2014). From regained function to daily use: experiences of surgical reconstruction of grip in people with tetraplegia. Disability and rehabilitation, 36(8), 678-684.
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