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Upper Limb Rehabilitation Following Spinal Cord Injury

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Upper Limb Rehabilitation Following Spinal Cord Injury Sandra J Connolly BHScOT, OT Reg (Ont.) Amanda McIntyre MSc Swati Mehta MA Brianne L Foulon HBA Robert W Teasell MD FRCPC www.scireproject.com Version 5.0 Key Points Neuromuscular stimulation-assisted exercise following a SCI is effective in improving muscle strength, preventing injury and increasing independence in all phases of rehabilitation. Augmented feedback does not improve motor function of the upper extremity in SCI rehabilitation patients. Intrathecal baclofen may be an effective intervention for upper extremity hypertonia of spinal cord origin. Afferent inputs in the form of sensory stimulation associated with repetitive movement and peripheral nerve stimulation may induce beneficial cortical neuroplasticity required for improvement in upper extremity function. Restorative therapy interventions need to be associated with meaningful change in functional motor performance and incorporate technology that is available in the clinic and at home. The use of concomitant auricular and electrical acupuncture therapies when implemented early in acute spinal cord injured persons may contribute to neurologic and functional recoveries in spinal cord injured individuals with AIS A and B. There is clinical and intuitive support for the use of splinting for the prevention of joint problems and promotion of function for the tetraplegic hand; however, there is very little research evidence to validate its overall effectiveness. Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity. Acupuncture and Trager therapy may reduce post-SCI upper limb pain. Prevention of upper limb injury and subsequent pain is critical. Reconstructive surgery appears to improve pinch, grip and elbow extension functions that improve both ADL performance and quality of life in tetraplegia. Nerve transfer surgery to restore hand and upper limb function in the person with tetraplegia is emerging as another surgical alternative. The use of neuroprostheses appears to have a positive impact on pinch and grip strength and ADL functions in C5-C6 complete tetraplegia, however, access to the devices are limited and continue to be expensive in use. The IST-12 neuroprosthesis, a second generation, myoelectrically controlled implantable device appears to have a positive effect on pinch and grasp functions which result in increased independence with activities of daily living. Table of Contents Abbreviations ............................................................................................................................... i 1.0 Introduction ........................................................................................................................... 1 2.0 Acute Phase of Rehabilitation ............................................................................................. 3 2.1 Exercise and Strengthening .................................................................................................... 3 3.0 Augmented Feedback on Motor Functions ........................................................................ 7 4.0 Pharmacological Interventions .......................................................................................... 10 5.0 Restorative Strategies ........................................................................................................ 12 5.1 Plasticity of Motor Systems ................................................................................................... 12 5.2 Complementary Alternative Therapies .................................................................................. 16 5.3 Splinting ................................................................................................................................ 17 6.0 Subacute Phase of Rehabilitation ..................................................................................... 19 6.1 Upper Limb Injuries ............................................................................................................... 19 6.1.1 Shoulder Injuries ...................................................................................................... 20 6.1.2 Elbow/Wrist and Hand Injuries ............................................................................... 21 7.0 Reconstructive Surgery and Tendon Transfer ................................................................. 25 7.1 Hand ..................................................................................................................................... 25 7.2 Elbow Extension ................................................................................................................... 33 7.2.1 Posterior Deltoid to Triceps .................................................................................... 33 7.2.2 Biceps to Triceps ..................................................................................................... 35 7.3 Multiple Reconstructions ....................................................................................................... 36 8.0 Nerve Transfers ................................................................................................................... 41 8.1 Fundamental Principles ........................................................................................................ 41 8.2 Advantages over Tendon Transfers ...................................................................................... 42 8.3 Potential Drawbacks of Nerve Transfers .............................................................................. 43 8.4 Assessment and Surgical Timing .......................................................................................... 43 8.5 Evidence ............................................................................................................................... 43 9.0 Neuroprostheses ................................................................................................................ 44 9.1 Types of Neuroprostheses .................................................................................................... 45 9.1.1 Freehand System ..................................................................................................... 45 9.1.2 NESS H200 (formerly HandMaster-NMS-1) ............................................................ 52 9.1.3 Bionic Glove ............................................................................................................. 53 9.1.4 ETHZ-ParaCare System ........................................................................................... 55 9.1.5 Stimulus Router System .......................................................................................... 55 9.2 Other Surface or Percutaneous Neuroprosthesis Systems .................................................. 56 9.2.1 NEC-FES System ...................................................................................................... 56 9.2.2 Rebersek and Vodovik (1973) Neuroprosthesis .................................................... 56 9.2.3 Belgrade Grasping-Reaching System .................................................................... 56 This review has been prepared based on the scientific and professional information available in 2013. The SCIRE information (print, CD or web site www.scireproject.com) is provided for informational and educational purposes only. If you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors, contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising from the use or misuse of this material. Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-74. www.scireproject.com 9.3 Reported Benefits of Neuroprosthesis Use ........................................................................... 56 9.4 Clinical Results of Neuroprosthesis Use ............................................................................... 56 9.5 Challenges in Neuroprosthesis Use ...................................................................................... 57 9.6 Second Generation Neuroprosthesis: Myoelectrically Controlled ......................................... 58 9.7 Miscellaneous ....................................................................................................................... 60 10.0 Summary ............................................................................................................................ 61 References ................................................................................................................................. 63 This review has been prepared based on the scientific and professional information available in 2013. The SCIRE information (print, CD or web site www.scireproject.com) is provided for informational and educational purposes only. If you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors, contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising from the use or misuse of this material. Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation
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