Patient Evaluation
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Repeat exams are important to understanding an individual’s particular impairments, disabilities, and abilities.
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It is important to develop a relationship with the individual patient to understand his or her particular desires and goals so as to determine what therapeutic options are reasonable and appropriate.
Principles of Nonoperative Management
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Early intervention is critical to preventing contractures.
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Treat all individuals with acute spinal cord injury as if they will improve.
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A supple hand with a good tenodesis effect is the goal of treatment.
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Maintaining shoulder and elbow mobility is critical to hand function.
Among the most disabling aspects of traumatic tetraplegia is the loss of useful hand function. During the acute phase of injury, the focus of treatment is, of course, the patient’s survival. In the subacute phase, however, care is often shifted into the rehabilitation environment, where the long road to recovery, both mentally, and physically, begins. Focus here shifts to the long-term phase and concerns maintenance of the patient’s medical and psychological systems and reintegration into society. In this final phase, patients are hopefully discharged from a full-term care facility into a more personal environment; and, just as important, into an environment that provides them with purpose and meaningful quality of life. During this entire process, a large multidisciplinary team including physicians, nurses, therapists, and social workers cares for the patient. Since the inception of the first specialized spinal cord center established in England in 1944, and the emergence of model spinal cord injury systems in the United States in 1970, knowledge has evolved considerably concerning the care of these patients and has become so specialized in its own right, that several journals are devoted exclusively to this subject. In recent years, these centers have increasingly recognized the importance of incorporating hand and upper extremity rehabilitation into their patient care schemes. This is important, considering that research has documented the loss of hand function in tetraplegic patients to be among the most disabling features of their injury, and that they often regard the hope for restoration of hand function to be of paramount importance.
As knowledge of spinal cord injury (SCI) care has improved, so too has that of hand and upper extremity restoration. Since the late 1940s, a large body of multidisciplinary research has been devoted to the restoration of tetraplegic hands, vastly improving patients’ levels of independence. We believe that the patient is best served in the long run if hand and upper extremity treatment begins early in the acute phase of care and that this treatment extends beyond traditional concepts of exercise, physiotherapy, and splints/orthoses. In fact, true rehabilitation of the tetraplegic hand should be thought of as the judicious application of both nonoperative and operative interventions tailored to the particular patient toward the goal of maximizing function in the context of that patient’s global psychosocial and medical state.
Hand and upper extremity rehabilitation are vital in the SCI population to improving such function in people with tetraplegia. Unfortunately, some recent studies continue to demonstrate underutilization of resources and treatment. The reasons appear multifactorial. Too few surgeons and physiatrists are paying attention to the hand and upper extremity. In part, there is a lack of interest and too few interdisciplinary associations between surgeons and physiatrists. In part, misconceptions persist that people with SCI tend to be noncompliant with treatment and lack the resources and support to carry out rehabilitative protocols in an outpatient setting. Physicians also seem to be under the impression that third-party payers do not reimburse for treatment of the hand and upper extremity in the setting of SCI. None of these assumptions are valid; the reality is just the opposite of perception.
This chapter examines how the pathophysiology of SCI in tetraplegia applies to hand and upper extremity function, reviews the functional deficits the patients suffer, and describes a comprehensive approach to rehabilitation based on the former that involves both nonoperative and operative modalities.
The Scope of the Problem
Critical to grasping the magnitude of the problem of the tetraplegic hand is first understanding the epidemiology of SCI. Data gathered from the National Spinal Cord Injury Database, and recently updated in 2008, indicate that the annual incidence of SCI is on the order of 40 per million people, or about 12,000 new cases per year. It is also estimated that about 227,080 to 300,938 Americans currently live with SCI (721–906 per million). Just over half of the patients, 52.4%, are tetraplegic. Both the total number of new cases per year, and the current population have increased since the sixth edition of this book. The average age of a person who sustains an SCI is 39.5 years; patients in their twenties at the time of injury who receive modern standards of care and rehabilitation live, on average, an additional 41 years with low-level tetraplegia (C5–C8). If the patient is in his 40s, he is likely to live 24.2 additional years if the tetraplegia was low level (C5–C8). This has also improved since the last version of this book. This means that a patient who sustains low-level tetraplegia can expect a fairly long life span with the injury. To this end, estimates of the direct costs of SCI for low-level tetraplegia are $500,829 for the first year after injury, $56,905 for each subsequent year, and $1,729,754 in lifetime costs for a young patient. These figures do not, however, include indirect costs of injury such as lost income, nor does it estimate the true overall effect of the injury on the patient or his family and friends.
Tetraplegia is defined as the impairment from an injury to any of the cervical segments of the spine, but the extent of disability is primarily determined from the specific functional level of the injury. The fifth cervical spinal cord segment is not only the most common injured level in tetraplegia, it is the most common level injured in all SCI (14.9%). The next two most commonly injured levels are the C4 and C6 segments; both commonly injured levels amount to about 24% of all SCI. The remaining cervical segments constitute about 12% of all SCI. Most tetraplegic patients retain at least the ability to flex their elbows, and some can extend their wrists; but most do not retain voluntary elbow extension, wrist flexion, or finger control. It is the rare patient that retains voluntary finger control or lacks complete volitional use of his or her upper limb. Factors that influence functional ability include whether the injury is “complete,” if any cognitive impairment exists (brain injury), and if there is any other upper extremity injury. Also vital to function are the patient’s age, the presence of uncontrolled spasticity, and any contractures that limit mobility and depression.
Intuitively, the level of function and independence improves as patients retain more function. High-level tetraplegia, with functional levels from C2 to C4 generally have no movement of the arms short of some shoulder elevation. They have some control of the neck muscles, and likely rely on ventilatory support depending on the actual functional level of injury. Patients who retain voluntary innervation in the C5 myotome can flex their elbows and retain functional deltoid control. They are able to feed themselves and perhaps even groom themselves with the aid of special adaptive equipment attached to their wrists and hands. Injury at the C6 level allows a patient to voluntarily extend the wrists and enable, with the aid of adaptive equipment, and to be independent in grooming, bathing, driving, and preparing a simple meal. After an injury at the C7 level, patients retain use of their triceps and perhaps the ability to extend their fingers. These patients may be able to perform all the previous activities and, in addition, be fairly efficient in daily living tasks. Importantly, if the triceps is of sufficient strength, they may be able to independently transfer themselves provided they have voluntary control of most of their shoulder musculature; and, therefore, can live alone with the aid of special hand and environmental adaptive equipment. With the exception of this latter group, all patients require an able-bodied attendant nearly all of the time to help them with their daily activities. Although this is an oversimplified and generalized view of function based on level of injury, it is clear that any treatment or intervention that improves a level of function, for example, C5 to C6, dramatically improves both function and independence.
The extent of impairment from these injuries is truly great. The spinal cord serves not only as the conduit for transmission of efferent and afferent information between the limbs and the brain, but is also an important neural conduit for the bowel, bladder, respiration, temperature regulation, cardiovascular integrity, and sexual function. All these important physiologic systems are affected by the injury and, until recently, served as a common and serious cause of morbidity. Sir Ludwig Guttmann, one of the pioneers of SCI management, declared in 1976, “… of the many forms of disability which can beset mankind, a severe injury or disease of the spinal cord undoubtedly constitutes one of the most devastating calamities in human life. …” The affected people are young, usually otherwise healthy, and might otherwise have expected to live a long and productive life. At the time of injury, about 57.4% are employed. The effects of the injury extend well into a patient’s personal life, with sound data indicating lower rates of marriage and higher rates of divorce among SCI patients. The results of modern SCI care and management have dramatically improved the quantity of life, in terms of long-term survival, to a level near that for able-bodied individuals. Similar care has dramatically improved the quality of their lives as well; but any intervention that can increase a patient’s functional ability has a significantly positive affect beyond just the activities he or she can perform. To this end, Hanson and Franklin studied SCI patients to determine what they perceived as their greatest functional losses. Among both tetraplegic patients (76%) and caregivers (64%), the restoration of hand and upper extremity function was considered the most important function to be restored. These concepts have been reinforced in recent studies, where patients continue to place great importance in improving hand and upper extremity function among the various components of SCI rehabilitation. Robert Waters, a surgeon from Ranchos Los Amigos, noted that “… the greatest potential for improvement of quality of life lies in rehabilitation and maximal restoration of upper extremity function.” Clearly, attention should be directed to rehabilitating the hand and upper extremity as part of a more global approach to treating patients with tetraplegia.
Pathophysiology
Traumatic SCI disrupts neural communication between the central and peripheral nervous system at the level of the spinal cord. Traditional simplified patterns of nerve injury have been used to explain the resulting pathophysiology; and SCI represents loss of upper motor/sensory neurons as opposed to peripheral nerve injuries, which are lower motor/sensory neurons. Table 132-1 displays the common clinical patterns associated with these two different injury patterns. Both careful examination of a patient with an SCI and clinical research have documented that a spectrum of nerve loss is associated with the injury. It is more appropriate to think in terms of a “zone of injury” to the nervous system centered on, but not exclusively confined to, the spinal cord. This zone is three-dimensional, extending in a proximal–distal plane, and central–peripheral, or mediolateral/anteroposterior plane. This is because most SCIs are due to a high-energy blunt trauma injury (motor vehicle accident, diving) in which energy is transferred to the affected bones and soft tissues in a global pattern. This is in contrast to a sharp penetrating injury (gunshot wound, laceration) in which the energy is transmitted to a more specific area of tissue. In fact, it is now felt that the extent of the neurologic damage in SCI occurs from both the initial trauma and the secondary and reactive inflammatory response. Edema, venous stasis, spinal cord infarction, and the release of toxic biochemical compounds during the response to injury all combine to increase the extent of spinal injury.
| Upper Motor Neuron | Lower Motor Neuron | |
|---|---|---|
| Muscles involved | Groups (myotomes) are affected | Individual muscles may be affected |
| Atrophy | Slight and secondary to disuse | Pronounced, up to 70%–80% of normal bulk |
| Muscle tone | Spasticity, hyperactive tendon reflexes, Babinski’s sign present | Flaccidity, hypotonia, loss of deep tendon reflexes |
| Fascicular twitches | Absent | May be present |
| EMG/NCS | Normal NCS, no denervation on EMG | Abnormal NCS, denervation present on EMG |
Because the zone of injury can include both the cord and the peripheral nervous system about the neck, varying patterns of nerve injury are possible. Above the zone of injury, the central and peripheral systems, and their interconnections are intact and fully functional. Below this zone, the nerve pathophysiology resembles an upper motor neuron lesion with hyper-reflexia. Within the zone of injury, which can extend from the spinal cord to the level of the dorsal sensory ganglia and nerve roots, the pattern of nerve loss is a combination of pure upper motor neuron and lower motor neuron and sensory involvement. For example, the nerve root injury at the level of the intervertebral foramen from cervical fracture-dislocation, or a nerve root avulsion from the “stretching” of the initial trauma, can result in a pure lower motor/sensory neuron injury. On the other hand, injury at the level of the anterior horn cell may result in a variable upper–lower motor–sensory neuron pattern of injury. Many muscles in the upper extremity receive innervation from multiple cervical roots, and these peripheral nerves may have been separately injured at the same time that the cervical spine sustained an injury. All of these circumstances are the reasons that two patients with two seemingly similar injuries at the same level of the cervical spine can have different degrees of paralysis, spasticity, and neural loss.
Coulet and colleagues have elegantly demonstrated how the extent of this zone of injury can influence the presentation of a particular individual. This zone can be established through a combination of clinical examination, spinal imaging, and electrical studies. Muscles within the zone of injury, being completely denervated and paralyzed are both unable to maintain any degree of muscle tone and can in fact atrophy and contract. Patients with larger zones of denervation are more prone to the development of limiting contractures and counterproductive forearm and hand posturing. On the other hand, muscles below the zone of injury, as they remain innervated, maintain a dynamic tone that helps to create an inherent balance to the forearm and hand that is functional and easier to base a reconstruction on. Through their studies, they created a classification system to describe the extent of the zone of injury; and correlated certain levels with a propensity to develop both early and late forearm and hand contractures. They theorized that by understanding a particular person’s zone of injury, one might predict their tendency to develop, for example, a forearm supination contracture and therefore take preventative steps. Although these concepts have not been universally adopted, their work is promising and clinically relevant.
Several classification systems, formulated to group and characterize the patterns of injury, translate the current concepts of pathophysiology for clinically relevant use. Classification systems based on the anatomic level of injury result in too much uncertainty. The zone of cord injury and its functional consequences are not precisely concordant with the skeletal anatomic level of the injury. Health-care providers discovered that gross motor functions conferred important prognostic information. This is because the innervation of the hand and upper extremity, from spinal roots C4 through T1, proceeds in a fairly ordered and segmental pattern from proximal to distal ( Fig. 132-1 ), making predictions of functional loss and retention fairly reliable once the functional level of the injury is apparent. The classification system most commonly used, devised by the American Spinal Injury Association (ASIA), is based on this functional level and distinguishes the completeness of the injury and the motor and sensory integrity between the extremities. In this system, the most distal myotome with British Medical Research Council (BMRC) strength of at least 3 is the motor level; and, similarly, the most distal dermatome with sensation is the sensory level. Motor grade 3 was chosen because it is unambiguous, whereas motor grades 4 and 5 cannot be differentiated when examiners of varying strength test persons with varying strength. Despite the simplicity and general usefulness of the system, it is not precise enough from the standpoint of hand surgical rehabilitation. Patients with preserved myotomes can still vary in terms of the muscles with voluntary innervation. For example, a patient with an injury at the C5 level, defined by at least grade 3 elbow flexion, may or may not have a strong, voluntary brachioradialis, and a patient with an injury at the C6 level, defined by at least grade 3 wrist extension, may or may not have a strong, voluntary extensor carpi radialis brevis (ECRB). From the standpoint of surgical restoration, these differences are very significant and were the impetus for the International Classification of Tetraplegia (ICT) created in 1984 in Giens, France, during an international meeting of hand surgeons devoted to the care of tetraplegic patients. Since that time, the classification system has undergone some modification; its present form is shown in Table 132-2 . The basis for the classification is the segmental innervation of the hand; and, since tendon transfers are typically considered only in muscles with at least grade 4 strength, the system supplies the physician with the potential transferable motors. This is currently the accepted classification used by most surgeons performing tetraplegic hand surgery.
| American Spinal Injury Association (ASIA) Classification | |
|---|---|
| Spinal Cord Root Level | Functional Group at Grade 3 Strength |
| C5 | Elbow flexors |
| C6 | Wrist extensors |
| C7 | Elbow extensors |
| C8 | Finger flexors |
| T1 | Fifth finger abduction |
| International Classification for Surgery of the Hand in Tetraplegia | |
|---|---|
| Group | Muscle at Grade 4 Strength |
| 1 | Brachioradialis (BR) |
| 2 | Extensor carpi radialis longus (ECRL) |
| 3 | Extensor carpi radialis brevis (ECRB) |
| 4 | Pronator teres (PT) |
| 5 | Flexor carpi radialis (FCR) |
| 6 | Extensor digitorum communis (EDC) and finger extensors |
| 7 | Extensor pollicis longus (EPL) and thumb extensors |
| 8 | Finger flexors |
| 9 | All except intrinsics |
| 0 | Exceptions |
| T+ or T− | Triceps at grade 4 |
Patient Evaluation
Only through thorough evaluation of the patient at various points in time can one determine the appropriate goals of rehabilitation and reconstruction for that particular patient. The health-care provider must develop a relationship with the patient that provides them with insight into the patient’s own goals and desires. Consideration for rehabilitation, especially surgical intervention, requires that the patient and primary caregivers understand the reconstructive options and their risks and benefits. Surgery, for example, means that the patient will be more disabled than normal for a period while the arm is temporarily immobilized and he or she goes through a period of rehabilitation. A patient must have good support and aid systems in place to assist through what is a very trying time. He or she must be motivated to improve and be cooperative throughout the postoperative phase of rehabilitation. Similarly, the patient’s general medical condition and cognition must be stable enough to undergo an operation and participate in a supervised postoperative rehabilitation program. The success of restorations requires continual effort on the part of the patient, both physically and mentally; otherwise, he or she may lose the benefits of any surgical reconstruction. Then, too, if the patient or surgeon is too overly optimistic about the results of surgery, the patient can lose the motivation to continue rehabilitation and may be worse off for it. Clearly, the decision to undergo surgical restoration must not be taken likely.
Other factors must be considered as vital to the success of any restorative program. Patients should be easily transferable to a wheelchair and have good trunk support and adequate seating so they can stay seated in order to take full advantage of any use of their upper extremities. Any restorative program should be delayed until it is apparent that no further motor recovery is predicted. This may take as long as 1 year from the time of a complete cord injury, or even longer in the case of incomplete injury. When the lesion is well defined and severe and there is no progression, early intervention is justified. Because many of the restorative procedures involve the transfer of voluntary muscles to more effective insertions (tendon transfers), the patient must have supple joints and sufficient strength of the donor muscle for the procedures to be successful. A patient who is allowed to develop joint contractures of the hands, wrists, forearms, elbows, and shoulders will be a poor candidate for a complete restorative program that includes surgical reconstruction or even an orthotic program. A muscle that is spastic and difficult to control with therapy or medication cannot serve as a useful donor. These criteria have been established through years of experience and remain a useful guideline for determining which patients have a good chance of success after surgical restoration. The addition of medications, such as Botox, that selectively weaken spastic muscles and reduce contractures is an essential part of early management.
Physical Examination
Although the relationship and understanding between the patient and providers help formulate the achievable goals of any hand rehabilitation program, it is the physical examination on which the actual plans are founded. The integrity and function of both the motor and sensory systems in the upper extremity must be understood. The motor system must be evaluated in its entirety, from the proximal muscles in the shoulder to the intrinsic muscles in the hand, to determine which muscles retain voluntary function and which are spastic or flaccid. Each muscle must be evaluated independently. The examiner should not prematurely discontinue the examination because of what appears to be an ASIA level since voluntary innervation may “skip” myotomes depending on whether the injury is complete. As indicated, an individual’s particular neural anatomy and zone of injury can be unique. We use the well-accepted BMRC grading system (strength graded from 0 to 5). If patients have spastic muscles, those muscles should be assessed for the degree of spasticity and whether they are functional. For example, a patient with spasticity of the flexor pollicis longus (FPL) muscle, on voluntary wrist extension may have a strong lateral pinch that should neither be sacrificed nor necessarily augmented. At the same time, if the spasticity of the FPL is constant and severe, the FPL cannot be used in a tendon transfer nor as an electrically stimulated muscle. Neither can useful lateral pinch occur without chemical or surgical release of that muscle. Uncontrolled, global spasticity is considered a contraindication to restorative surgery and is fortunately rare. Sensory exam stresses the two-point discrimination in the digits, particularly the thumb. Much has been written concerning the presence of two-point discrimination in the thumb as both a means of classifying the injury under the international system and understanding the outcomes of surgical restoration. Many authors have stressed that goals should be limited in patients who require direct visualization of grasp because they lack meaningful sensation; however, others, like ourselves, have found that patients adapt well and prefer increased function even in the face of poor sensation. The motion of the joints, both passive and active, must be ascertained. A final aspect of our motor assessment involves determining which muscles are electrically excitable using therapeutic electrical stimulation (TES). This is because previous study has documented that up to 50% of ASIA C5 patients and 13% of C6 patients have important muscle groups that are not electrically excitable.
Evaluation of the upper extremity in the patient with a new injury should begin within 48 hours of admission within the limits of precautions. The evaluation should consist of a brief social and functional history. The patient’s physical appearance should be documented identifying incisions, edema, scars, and any apparent atrophy of the muscles. Examination of strength, sensation, and motion should be completed as indicated previously. Reevaluation of the upper extremity should then take place at regular intervals, typically every 4 weeks.
Patients manifest injury very differently depending on their zone of injury. Detailed and critical examination is therefore paramount to an appropriate custom-tailored rehabilitation plan. Over time, we have come to emphasize certain aspects of the exam in formulating plans. Resting thumb and finger position is important to note. The thumb ideally rests in a position near opposition with the fingers gently flexed, especially at the metacarpophalangeal (MCP) joint. The wrist tenodesis effect should produce a nice alignment with the thumb resting near the radial side of the index, and the fingers gently flexing at the MCP and interphalangeal (IP) joints. A hand that rests with the fingers or thumb flat in the plane of the palm, including intrinsic-minus positions, is more troublesome. Thumb carpometacarpal (CMC) stability is also important to assess, especially once surgical plans are being formulated. An unstable CMC joint generally requires an arthrodesis, as does a stiff one; as does a stiff thumb flat in the plane of the hand. A stable and mobile CMC joint can be reconstructed with either an arthrodesis or an opponens/adductor-plasty as described by House. Some CMC joints can be left alone if the tenodesis effect of the wrist produces excellent lateral pinch alignment and the joint remains stable. Finally, it is important to pay attention to extensor lags of the proximal interphalangeal joints. This usually indicates a stretched intrinsic tendon and central slip. If this is not corrected, either by orthotic positioning, or at the time of surgery, extension of the fingers may prove insufficient for grasp.
Principles of Nonoperative Management
Nonoperative treatment begins in the early phases of recovery from SCI and continues in one form or another throughout an individual’s life. Whether or not surgical intervention is used, nonoperative management helps to maintain hand and upper extremity function. The spectrum of this care includes physiotherapy, functional splinting, orthoses, and pharmacologic therapy. One of the recurring themes of this chapter is that the choice of a rehabilitation strategy must be individualized to the patient’s general condition. In addition to variations based on the zone of injury discussed in an earlier section, each individual may present with his or her own combination of associated injuries that may include direct trauma to the hand and upper extremity. Although a nonoperative program maintains the same principles and goals, its application varies from individual to individual.
Maximizing, achieving, or maintaining an individual’s physical independence is the treatment goal for every individual with tetraplegia. Forethought is critical during the early phases of injury recovery. The authors believe that a systems approach to treating the hand and upper extremity should be incorporated from the early stages of injury. Just like programs for skin and bowel and bladder care, early attention to the hand and upper extremity is warranted. On one end of the spectrum are individuals with tetraplegia who undergo interventions designed to optimize upper extremity use and function. On the other end are individuals whose potential is negated or mitigated by impairing articular contractures of the shoulder, elbow, forearm, and hand. Regardless of whether patients in the former group undergo surgical restoration for hand function, their hand and upper extremity function should be optimized for their level of injury. On the other hand, individuals in the latter group are more likely to be hampered by contractures and stiffness, a problem that worsens their level of disability. Tetraplegic individuals with a C6-level injury and an elbow flexion contracture may function at the level of a patient with a C5-level injury if the contracture interferes with the ability to transfer. The importance of appropriate nonoperative programs to prevent contractures and maximize function cannot be overemphasized.
This means that joints should be kept supple, and consideration should be given to an early multifaceted program that includes pharmacotherapy, physiotherapy, and other modalities. These other modalities include the use of more advanced measures such as intrathecal spasmolytics, injectable targeted spasmolytics (botulinum toxin), and TES to maintain muscle strength and metabolism to innervated motor groups. Even if an individual is never a candidate for surgical restoration or chooses not to undergo surgery despite meeting criteria, it remains important to create an appropriate individualized program to maintain joint suppleness and prevent spasticity or positioning from creating fixed articular contractures. The relationship between the patient and care providers is critical because it helps determine the choice of therapy, orthoses, and surgery.
Therapeutic intervention should begin as soon as the spine has been deemed clinically and radiographically stable and continue throughout the individual’s life. With the patient’s motor and sensory functioning understood, therapy can be directed to maintaining or restoring range of motion (ROM) and strength. Passive range of motion (PROM) and stretching of the muscles should be completed twice daily. The patient should assist with these exercises when volitional movement is present. Stretching should be done slowly and joints should not be forced. Stretching the wrist and fingers in the natural tenodesis pattern should be emphasized to take advantage of the functional nature of this synergistic motion complex. The fingers should be extended when the wrist is flexed and the fingers flexed when the wrist is extended. MCP joint hyperextension should be avoided to prevent clawing and loss of the important palmar supports needed in grasp. Thumb CMC joint hyperextension should be equally avoided for similar reasons. Edema in the upper extremity is one important cause of limited ROM and is minimized through daily active and PROM exercises. Retrograde massage is another useful tool, as well as proper positioning of the upper extremity in the wheelchair and in bed.
Since the strength of a muscle contraction increases as more motor units are recruited, increasing the load requirements of voluntary movements is an important component of therapy. Weight training and endurance training, with particular emphasis on functional motions and activities, are effective in strengthening muscles. Another modality that has been shown to improve muscle strength and endurance is TES. The role of TES in the therapy program is discussed later. When establishing a strengthening program, it is important to begin thinking about possible surgical procedures and tendon transfers that could increase functional independence. These muscles, if voluntary, should be incorporated into the strengthening program. Muscles that should be targeted include the posterior deltoid (PD; elbow extension transfer), the biceps (elbow extension transfer), the brachioradialis (BR; wrist extension, thumb pinch, thumb opposition, finger extension transfers), the extensor carpi radialis longus (ECRL; finger flexion transfer), and the pronator teres (PT; thumb pinch).
Orthotic Positioning and Orthoses
Orthotic positioning is an important means of preventing deformity, enhancing function, and promoting a normal appearance of the hand. Two schools of thought have emerged regarding the management of the upper extremity with orthoses. One thought is to maximize function by encouraging contractures in a tenodesis posture that may provide sufficient lateral pinch to pick up light objects. The fingers and thumb are essentially made into the tongs of a “pliers” controlled by the wrist through stiffening the IP and MCP joints. The other school of thought emphasizes the supple hand as its goal. By keeping the fingers supple, more options can be used, including universal cuff and flexor hinge orthoses. Additionally, through the use of static positioning at night and careful monitoring, tendon tightness in patterns of tenodesis can be encouraged without sacrificing supple joints. Contractures resulting from the intentional development of a stiff hand are almost impossible to overcome by conservative methods in a reasonable amount of time ( Fig. 132-2C ). These contractures must be surgically released, which both delays other procedures and limits the surgical alternatives for restoration. We have found that a person has better functional outcomes with the use of functional electrical stimulation (FES) or tendon transfers (or both) when the hand is supple. In fact, difficult contractures usually represent a contraindication to surgical restoration since outcomes tend to be poor. A supple hand without contractures is also more aesthetically pleasing and acceptable to the patient, a feature the patients themselves are all too aware of (see Fig. 132-2A, B ). We recommend that contractures be avoided and patients educated and encouraged to use functional orthoses during early rehabilitation. We have found it more efficient to create a tenodesis posture later when final planning is done and all options can be considered.
It is important to establish clear goals with the patient regarding orthoses. Different ones provide different functional advantages, and understanding the individual patient’s needs is critical to providing the most effective orthoses ( Table 132-3 ). Orthoses should be incorporated early during recovery. Patients who begin to use orthoses early following their injury and realize functional gains because of them are more likely to continue to use them. We have found certain orthoses to be more useful in promoting functional hand positions and diminishing the degree of contractures (see Table 132-3 ). Individuals with injuries at the C5 and C6 motor levels have been the most challenging population for whom to establish a successful orthotic positioning protocol. Patients with a C5-level injury (no voluntary wrist control) benefit from a dorsal wrist support with a universal cuff when performing activities of daily living (ADL) and an orthosis at night for better hand position. Those with C6-level injuries (voluntary wrist extension) benefit from the use of a flexor hinge orthosis on the dominant hand and a short opponens orthosis on the opposite hand. Occasionally, patients prefer flexor hinge orthoses bilaterally.
| Level of Injury | Orthosis | Purpose | Wearing Schedule |
|---|---|---|---|
| C1–C4 | Resting hand orthosis | Maintains the hand in a functional position, prevents deformity, maintains aesthetically pleasing hand | When in bed, complete PROM regularly |
| C5 | Long opponens orthosis | Provides a stable post against which index finger can pinch; positions thumb in a functional key pinch position | As needed to increase function |
| Dorsal wrist support | Protects integrity of wrist joint; acts as a universal cuff to increase function. | As needed to increase function | |
| Modified resting hand orthosis | Protect the integrity of wrist and fingers; orthosis should allow wrist flexion with MCP, PIP, DIP extension, thumb extension. | When in bed | |
| Elbow extension orthosis | Prevents biceps contraction | When in bed | |
| C6 | Short opponens | Provides a stable post against which index finger can grasp; thumb in key pinch based on preference of patient | As needed to increase function |
| Wrist drive flexor hinge orthosis | Augments natural tenodesis and alignment of fingers | As needed to increase function | |
| Modified resting hand orthosis | Protect the integrity of wrist and fingers; orthosis should allow wrist flexion with MCP, PIP, DIP extension, thumb extension. | When in bed | |
| Elbow extension orthosis | Prevents biceps contraction | When in bed | |
| C7 | MCP block orthosis | Prevents hyperextension deformity of the MCP joints | As needed to increase function and decrease deformity |
Despite a carefully chosen program, however, the rate of orthotic use among tetraplegic patients varies from as low as 39% to as high as 89%. We have found that becoming brace-free, and hence more able-bodied in appearance, is among the major goals of patients who desire surgical reconstruction. Moberg felt that as many as 60% of tetraplegic patients could benefit from traditional surgical restoration, but Gorman and coworkers found that approximately 36% of consecutively admitted tetraplegic individuals to a rehabilitation center qualified for traditional surgical restoration (13% met the rigid criteria for FES). Careful patient evaluation addresses these issues.
Pharmacotherapy and Contractures
Muscle spasticity is present in some patients with tetraplegia depending on their zone of injury. Some individuals also have sustained a traumatic brain injury in addition to the SCI. Dalyan and associates found that delayed admission to a model SCI system, the presence of pressure ulcers, and spasticity with head injury were all associated with higher rates of joint contracture in the setting of acute spinal cord injury. The ability of a physiotherapy program alone to help manage contractures associated with spasticity is in doubt, and the ultimate consequence of spasticity is the formation of myostatic and then articular contractures, which are difficult to treat without surgical intervention.
Pharmacotherapy is often incorporated in the management of spasticity or contractures. Medications include orally or intrathecally administered spasmolytics (e.g., baclofen pump). Although these medications are felt to be very useful, the literature does not provide either clear guidelines for usage or conclusions about their efficacy. The use of botulinum toxins as part of a physiotherapy program to treat spasticity before the onset of fixed contractures is also useful. These toxins cannot restore mobility to a contracted joint, but they can help achieve or maintain mobility when spasticity alone interferes with the effectiveness of physiotherapy. As with other medications, clear guidelines and applications for botulinum toxin in the setting of SCI remain unknown. In the setting of fixed myostatic or articular contractures, surgery is the only viable intervention for restoring mobility.
Role of Electrical Stimulation
TES is a technique that applies electrical pulses to peripheral nerve fibers through the skin surface, causing paralyzed, but innervated, muscles to contract. Functional electrical stimulation (FES) involves the stimulation of the motor unit and control of useful patterns with an electrical impulse, usually applied by implanted electrodes. Although the nerves remain functional, the muscles they innervate do undergo atrophy and develop type II glycolytic metabolism. These changes can be reversed by electrical stimulation of the intact peripheral nerve branch in a conditioning and exercise program. A suprathreshold stimulus applied directly to the nerve and muscle at a frequency of 12 hertz for 8 hr/day has been effective in changing the contractile properties of the muscle to a slow oxidative metabolic state, rendering them more fatigue-resistant. Over time, consistent exercise will soften joint capsular contractures and reduce spasticity during the stimulation. Increasing the strength of weak, but innervated muscle groups, decreasing the effects of muscle atrophy, increasing muscle endurance, and increasing the ROM of tight tendons before contractures develop are among the effects of a TES program. Several centers now incorporate TES-exercise programs for lower extremities based on such research. Stimulation-induced contracture of BMRC grade 2 or higher muscles can also be strengthened by electrical stimulation to functional levels of force. Strengthening innervated, but paralyzed, muscles improves the efficacy of orthotic positioning programs, tendon transfers, and FES systems.
We have found TES beneficial when also applied early in the rehabilitation process. We start patients with as little as 20 minutes of stimulation/day/muscle group and advance slowly to a total of 4 to 6 hr/day. Patients tolerate the program quite well and are compliant if properly motivated. Improved strength and endurance of involuntary, innervated functional muscle groups is the goal of a TES program. Muscle groups emphasized include finger flexors (median/ulnar nerve), thumb flexors/abductors (median nerve), and thumb/finger extensors (radial nerve). Based on our experience, we believe TES has a valid role as part of a therapy protocol that seeks to maintain motion, prevent contractures, and prevent atrophy.
Principles of Surgical Reconstruction
The ultimate goal of upper extremity rehabilitation is to provide patients with the ability to manipulate objects in space efficiently and effectively; that is, to create an “able-bodied” person’s arm and hand. We must strike a balance with what is achievable (which requires an understanding of what minimal functions will confer improvements in ability) and what are the reasonable goals for a particular patient. As a rule of thumb, surgical restoration improves a patient by one or two levels on the ASIA scale. Not all patients meet our strict criteria for surgical reconstruction. Dedicated and experienced multidisciplinary teams in regional referral centers are continuously working to improve on current methods toward the end of restoring the patients to independence, social integration, and occupation. Our current bias is that surgical restoration as outlined later on should be undertaken by surgeons skilled and experienced in taking care of patients with tetraplegia and be done in concert with similarly experienced teams of physiatrists, nurses, and therapists.
Most individuals with tetraplegia are injured around the C5 and C6 levels. This means that for most, shoulder stability and mobility are voluntarily present. Elbow flexion is also present, as is forearm supination. Voluntary elbow extension is typically absent in these individuals. The presence of strong, voluntary wrist extension and forearm pronation depends on the zone of injury. Elbow extension, wrist flexion, and digital extension are not present unless the zone of injury is at or below the C7 myotome. The following discussion focuses on the average person with tetraplegia, but the same principles apply regardless of the level of injury.
The fundamental functions we seek to restore, in order of priority, include elbow extension ( Figs. 132-3, 132-4A ), wrist extension, lateral pinch and release, and palmar grasp and release ( Figs. 132-4B, 132-5 ). Current surgical techniques and technology do not allow us to reliably restore shoulder function yet, and therefore, patients with ASIA motor levels proximal to C5 are rarely candidates for surgery.
The combination of shoulder function and elbow extension allows patients to effectively “reach out” to manipulate objects in space in front of them and above them. Without this ability, a patient’s effective “workspace” is limited. Another way to think about this is to imagine the shoulder and elbow working in concert to transport the hand to a location in space so that it may manipulate a desired object. Better mobility, stability, and strength of the shoulder and elbow confer a large potential workspace for the hand. This is especially valuable for people with tetraplegia since they are fixed to a wheelchair and cannot move around their immediate space the way an able-bodied individual can. In fact, the provision of elbow extension can enable functional abilities such as self-care, hygiene, wheelchair propulsion, and transferring, all of which are critical to functional independence. Wrist extension activates the natural tenodesis grasp pattern and serves as the foundation on which finger function is activated and restored (see Fig. 132-2 ). Surgical restoration of hand function, in fact, builds on wrist tenodesis pinch and grasp. Although it would be ideal to restore all the different grasp patterns, previous study has demonstrated that lateral pinch, not opposition or tip pinch, and palmar grasp are utilized most commonly. Since lateral pinch is used more often for ADL, we prioritize this form of grasp over palmar grasp when both cannot be restored. Planning the reconstruction begins with a balance of the remaining voluntary, nonspastic function, and, as also previously discussed, is best suited for patients whose hands and arms are reasonably supple.
Too much can be attempted, however, and experience and research has taught us that on occasion it is necessary to “downsize” the extent of surgical restoration under certain conditions. Patients who, because of physical distance, or insufficient family infrastructure, do not have easy access to their therapists and physicians are likely to experience poor outcomes if the restorative regimen is complex and sophisticated. In these instances, it may better serve the patient to limit the goals of surgery to what he or she is able to take advantage of. This is also the case for patients with brain injury or relatively poor cognition, who can rehabilitate a simpler surgical protocol with greater ease. At the same time, a motivated, intelligent, and well-adjusted patient will be unsatisfied with a restorative program that undercuts true rehabilitative potential. We have also learned that patients occasionally require later secondary surgery to modify “loosened” transfers, augment weak transfers, arthrodese a joint that becomes unstable, and so forth. Patients must also continuously “use” and exercise the hand and arm in order to maintain the muscle tone and endurance qualities necessary for successful transfers and FES systems. Finally, the surgical program should seek to accomplish as much as possible as efficiently as possible. Prolonged postoperative periods of overburdening dependency generally lead a patient and his or her family to postpone or cancel future staged procedures, which, in turn, reduces the likelihood of success. Paul and colleagues previously demonstrated that combining multiple procedures in one stage is efficacious.
We previously discussed the hierarchical order of surgical goals, that is, elbow extension, wrist extension, key pinch, and palmar grasp. Table 132-4 outlines the specific procedures performed by level, but we follow a few generalizations in planning reconstructions as described in the following sections.
| Level | Goals of Surgery |
|---|---|
| O/Cu:0 | Elbow Extension |
| No muscles for transfer for the hand | |
| O/Cu:1 | Elbow Extension |
| BR |
|
| O/Cu:2 | Elbow Extension and Forearm Pronation |
| ECRL |
|
| O/Cu:3 | Elbow Extension and Forearm Pronation |
| ECRB |
|
| O/Cu:4 | Elbow Extension |
| PT |
|
| O/Cu:5 | Elbow Extension |
| FCR |
|
| O/Cu:6 | Grip, Pinch, and Release |
| EDC |
|
| O/Cu:7 | Grip, Pinch, and Release |
| EPL |
|
| O/Cu:8 | Grip, Pinch, and Release |
| Finger flexors (usually stronger on ulnar side) |
|
| O/Cu:9 | Grip, Pinch, and Release |
| Lack intrinsics |
|
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