Upper Limb Rehabilitation Following Spinal Cord Injury

Home , Contracture, Hemiparesis, Nape, Spinal cord injury, Tetraplegia

Sandra J Connolly BHScOT, OT Reg (Ont.) Amanda McIntyre MSc Swati Mehta MA Brianne L Foulon HBA Robert W Teasell MD FRCPC

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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.

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.

Abbreviations

AbINT Activity based Intervention ADL Activities of Daily Living AIS ASIA Impairment Scale AP Action Potential APB Abductor Pollicis Brevis BGS Belgrade Grasping-Reaching System BR Brachioradialis CAM Complementary Alternative Therapies CHART Craig Handicapped Assessment and Reporting Tools CNS Central Nervous System COPM Canadian Occupational Performance Measure CPG Central Pattern Generators CSF Cerebrospinal Fluid Cu- Cutaneous CWRU Case Western Reserve University ECRB Extensor Capri Radialis Brevis ECRL Extensor Capri Radialis Longus EDM Extensor Digiti Minimi EMG Electromyography FCR Flexor Carpi Radialis FDP Flexor Digitorum Profundus FES Functional Electrical Stimulation FEV-1 Forced Expiratory Flow FIM Functional Independence Measure fMRI Functional Magnetic Resonance Imaging FNS Functional Neurostimulation FPL Flexor Pollicis Longus FVC Forced Vital Capacity GRT Grasp and Release Test HHD Handheld Dynamometry IST-12 Implanted Stimulator-Telemeter MeCFES Myoelectrically Controlled Functional Electrical Stimulation MP Massed Practice MRCS Medical Research Council Scale MRI Magnetic Resonance Imaging NMS Neuromuscular Stimulation NP Neuroprothesis NRS Numeric Rating Scale O- Ocular OT Occupational Therapy PC Performance Corrected PD Posterior third of the deltoid PET Positron Emission Topography PO Power Output PT Physiotherapy PT Pronator Teres PVA Paralyzed Veterans of America QIF Quadriplegic Index Function REL Rehabilitation Engineering Laboratory Hand Function Test

ROM Range of Motion rTMS Repetitive Transcranial Magnetic Stimulation SCI Spinal Cord Injury SCIM Spinal Cord Independence Measure SEM Standard Error of Mean SRS Stimulator Router System SS Somatosensory Peripheral Nerve Stimulation VRS Verbal Rating Scale WUSPI Wheelchair Users Shoulder Pain Index

Upper Limb Rehabilitation Following Spinal Cord Injury

1.0 Introduction Raineteau and Schwab (2001) defined a spinal cord injury (SCI) as a lesion within the spinal cord that results in the disruption of nerve fibre bundles that convey ascending sensory and descending motor information. A SCI at the cervical level results in tetraplegia, the loss of hand and upper limb function with impairment or loss of motor and/or sensory function. In incomplete spinal cord injuries, some neural transmission can still pass through the spinal cord, but it is often fragmentary or distorted which leads to additional neurological complications such as chronic pain or spasticity. Tetraplegia results in impairment of function in the arms, as well as in the trunk, legs and pelvic organs. It is estimated that cervical SCI accounts for approximately 50% of all people living with SCI (Steeves et al. 2007). The loss of upper limb function, especially the use of the hands is one of the most significant and devastating losses an individual can experience. The use of the upper extremities is critical in completing basic activities of daily living (ADL) such as self-feeding, dressing, bathing and toileting. Mobility needs such as transfers from surface to surface, transitional movements such as rolling, bridging and sit to lying down, crutch walking and wheeled mobility are also completed using their arms (Snoek et al. 2004). The level at which the injury or lesion occurs and the completeness of the lesion (incomplete or complete) indicate the level of independence of the person (Ditunno 1999).

The Paralyzed Veterans of America (PVA) have published a clinical practice guideline, “Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health Care Professionals,” that outlines the expected skills and outcomes that a person is expected to acquire and achieve at each significant level of injury (Consortium for Spinal Cord Medicine 1999). As medical care of the spinal cord injured person has improved, life expectancy now approaches the rest of the population. Secondary complications from SCI and aging are ongoing challenges and include pain, contractures and upper limb musculoskeletal injuries (Sipski & Richards 2006).

Hanson and Franklin (1976) compared sexual function to three other impairments in patients with SCI; approximately 76% of the subjects gave the highest priority to upper extremity function. Snoek et al. (2004) surveyed the needs of patients with SCI and found a high impact and high priority for improvement in hand function in those with tetraplegia comparable to that for bladder and bowel dysfunction. A recent study by Anderson (2004) found similar results in which 48.7% of persons with tetraplegia (3.3% of persons with paraplegia) reported that regaining arm and hand function would most improve their quality of life. In the same study, Anderson (2004) reported that women and men with tetraplegia had similar priorities (53.2% to 48.3%) and the priority of regaining arm and hand function did not change whether someone was injured 0-3 years or more than 3 years post SCI. Anderson (2004) reported that recovering even partial arm and hand function may have a significant impact on independence.

Given the above, the initial care, management, rehabilitation and prevention of injuries in the upper limb of those with tetraplegia are of great importance in maximizing and maintaining independence. Management of the tetraplegic upper limb tends to be eclectic involving traditional rehabilitation interventions of task directed training in which clients perform many repetitions of movements relevant to ADL, use of orthosis (splints and adaptive devices) and upper extremity surgery. According to Murphy and Chuinard (1998), management and care of

the upper limb can be divided into three phases: the acute, the subacute and the reconstructive phase. Bryden et al. (2005) proposed a similar hierarchy of upper extremity functional restoration for individuals with tetraplegia. This includes the provision of conservative treatment methods followed by surgical restoration using residual motor functions and increasing or augmenting voluntary functions with functional electrical stimulation (FES) for maximal upper limb function. The aims of the first two phases of rehabilitation are to prevent complications, to achieve optimal functioning within the limits of the neurological deficit, and to create optimal conditions for the reconstructive phase (Bedbrook 1981; Curtin 1994; Harvey 1996; Keith & Lacey 1991). In the latter phase, various surgical options and FES are available to improve positioning and stabilization of the arm as well as key and palmar grasp function (Johnstone et al. 1988; Peckham et al. 2001; Snoek et al. 2000; Triolo et al. 1996; Waters et al. 1996). The new clinical practice guidelines by the Consortium for Spinal Cord Medicine (2005) emphasize the prevention of upper limb injuries among individuals with tetraplegia to maintain independence.

Although there is no overall consensus regarding the management of the tetraplegic upper limb, Hummel et al. (2005), Snoek et al. (2005) and the Consortium for Spinal Cord Medicine (2005) provide excellent discussions and recommendations.

There is agreement that restoration of hand function is an important goal in rehabilitation. It is also worth noting that there are very few upper extremity tests that accurately evaluate upper limb function in this population (van Tuijl et al. 2002). Curtin (1994) and Krajnik and Bridle (1992) noted a great inconsistency in evaluation and documentation of the tetraplegic upper limb between therapists.

Several studies have explored increased hand function as a result of reconstructive surgery and/or neuroprosthesis. Although these, and many other treatment options exist, have proven to improve the overall functioning and functional independence of the person with tetraplegia, clinical practice has shown that suitable candidates for reconstructive surgery or FES interventions often do not accept the treatment that is offered (Snoek et al. 2004). According to Moberg (1975), over 60% of the tetraplegic population could benefit from reconstructive surgery and it continues to be widely advocated (Snoek et al. 2004). Curtin et al. (2005) reported in their study that reconstructive surgery is underutilized in this population reporting that fewer than 10% of persons with tetraplegia actually undergo surgical reconstruction. Reconstructive surgeries such as muscle/tendon transpositions of the intact arm or hand muscles are designed to substitute for lost motor function (van Tuijl et al. 2002). Despite this, controversy still exists among clinicians as to whether or not to perform reconstructive surgeries and the benefits of reconstructive surgery have not been clarified with good quality randomized clinical trials (Harvey et al. 2001). Gorman et al. (1997) deduced that 11% of the tetraplegic population could be candidates for an implanted FES device (Freehand System). Most implanted FES devices are usually combined with augmentative and substitutional reconstructive surgery (Keith et al. 1996).

The main focus in rehabilitation of the spinal cord injured person is compensation of functional loss and using those parts of the sensorimotor system, which are still intact (van Tuijl et al. 2002). Research findings regarding neuroplasticity and neurological recovery of the spinal cord also include current rehabilitation practices that focus on strategies to restore function lost after SCI as significant recovery of function is observed after incomplete and even complete SCI (Beekhuizen 2005; Bradbury et al. 2002; Buchuli & Schwab 2005; Curt et al. 2008; Kirshblum et al. 2004; Marino et al. 1999; Waters et al. 1994). There is emerging evidence demonstrating and highlighting the importance of understanding the motor control strategies that the central

nervous system (CNS) uses to govern hand movements in abled individuals. This information may be useful in guiding the rehabilitation process after cervical SCI and ensuring that the exercises performed for the hand and upper limb are effective for restoring functional ability (Backus 2010). The literature is reporting on the presence of muscle synergies that are a motor control paradigm that is being actively investigated (Bizzi et al. 2008; Cheung et al. 2005; d’Avella et al. 2003; Overduin et al. 2008).

This body of research puts forth the theory that there is a modular approach to motor control, where the CNS activates predefined combinations of muscles, rather than explicitly controlling individual muscles (Zariffa et al. 2012a). This could have implications in neurorehabilitation treatment implementation where there is explicit retraining of muscle synergies that are known to be useful in the able bodied population. It is that functional performance might be improved across a broad range of tasks (Zariffa et al. 2012a). To date most of the muscle synergy studies have explored the arm with a limited number of studied investigating the existence of muscle synergies in the hand (Zariffa et al. 2012a). Zarriffa et al. (2012a) investigated if there any synergies present in able-bodied individuals while using different types of hand grips relevant to ADLs such as pulp to pulp pinch, cylindrical grasp and lateral key pinch and attempted to determine whether the presence or absence of these synergies after SCI is correlated with functional abilities. There were several time-invariant synergies observed to occur consistently in a substantial proportion of able-bodied subjects and in the SCI population there was evidence that similar synergies existed but in different proportions and no clear relationship was found between the functional abilities of subjects with SCI and those subjects deviation from able- bodied synergy patterns. Further, Zariffa et al. (2012a) found that the most common synergy in the able-bodied population was EDC and EIP for finger extension and FDS and FCU for wrist flexion used to position the hand during grasping activities. In SCI the most common synergy was FCR and ECR for stabilizing the wrist and DII and TEMG for independent thumb movement (Latash et al. 2010; Santello et al. 1998; Weiss et al. 2004). Further research and investigation is required to determine how this information can be transferred into the treatment of the hand and upper limb of the SCI injured person for improving functional task performance.

2.0 Acute Phase of Rehabilitation

Rehabilitation and management of the person with a SCI requires an interdisciplinary team approach during the acute phase of rehabilitation. The level and classification of the injury is determined and the goals of maintaining range of motion (ROM), improving strength, managing tone, spasticity, and the prevention of secondary complications in order to achieve the person’s maximum functional ability for independent transfers, ADL and mobility are developed (Drolet et al. 1999; Haisma et al. 2006; Sipski & Richards 2006). Clinicians must be knowledgeable about the change in physical capacity based on level of injury as a prerequisite to developing optimal rehabilitation programs and for setting realistic individual rehabilitation goals.

2.1 Exercise and Strengthening In the acute phase of rehabilitation, the person with a SCI has a reduced physical capacity because of muscle weakness, loss of autonomic control below the level of injury, reduced activity and subsequent changes in metabolic and vascular function (Haisma et al. 2006). The inability to reach one’s maximum potential will result in an increased risk of medical and secondary complications and has been correlated to a reduced level of functioning and quality of life. One of the important goals of rehabilitation is to reverse the debilitative cycle of reduced physical capacity that leads to reduced activity and functioning (Haisma et al. 2006). With shorter hospital lengths of stay, individuals with a SCI have fewer training opportunities. It is

important to determine whether people with SCI can maintain their levels of physical capacity after discharge.

There are very few evidence-based analyses of the effectiveness of specific exercise therapies (Sipski & Richards 2006). Most research has only focused on one component of physical capacity (e.g., peak oxygen uptake [VO2 peak], or muscle strength, or respiratory function).

Many physical factors have been associated with optimal functional independence individual post-SCI and muscle strength is identified as an important contributor to functional independence (Drolet et al. 1999). Studies by Noreau et al. (1993), Marciello et al. (1995) and Durand et al. (1996) all noted a correlation between the level of the lesion, performance in functional abilities in relationship to peak oxygen intake and level of muscle strength. These associations were significant in individuals with tetraplegia especially in areas of sitting balance, spasticity of the lower limb, hand-grip strength, wrist extensor strength and global upper extremity strength. These functional areas have also been related to Functional Independence Measure (FIM) motor and self-care scores. It was also identified that upper extremity strength must be adequate to support the body weight during transfers and lower limb strength for walking. Optimal recovery of muscle strength following a SCI is an essential objective of functional rehabilitation of individuals with a SCI (Drolet et al. 1999).

Changes in motor function observed six months after an injury may be partially explained by collateral sprouting within the spinal cord (Mange et al. 1990). Changes between 2 and 8 months may be related to peripheral nerve sprouting and muscle fiber hypertrophy after partial denervation (Mange et al. 1990; Yang et al. 1990). Natural muscle strength recovery may occur up to two years post injury, with the recovery rate being more important for the first six months as measured by manual muscle testing (Ditunno et al. 1992; Mange et al. 1992; Waters et al. 1993). Muscle strength gains have been attributed to two different mechanisms in healthy subjects. In healthy subjects, short-term gains (2-4 weeks) might be explained by improved capacity to recruit motor units (neural adaptation) and gains observed after 4 weeks have been attributed to morphological changes within the contractile tissue inducing muscle fiber hypertrophy (Sale 1988). Additional studies regarding cardiovascular and exercise interventions are discussed in the Cardiovascular chapter and Physical Activity chapter.

Table 1 Exercise and Strengthening Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=18-45 yr; Gender: 1. No significant difference was found males=31, females=3; Level of injury: at the 4-week evaluation between tetraplegia; Time since injury=3 yr. Groups 1 and 2 (p=0.22) or between Treatment: Subjects randomly assigned Groups 2 and 3 (p=0.07). to one of three groups: Group 1 – 2. Subjects in Group 1 had a higher Needham-Shrophire et received 8 wk of neuromuscular proportion of muscles improving one al. 1997 stimulation (NMS) assisted arm ergometry or more muscle grades after 4 USA/CA exercise; Group 2 – received 4 wk of weeks of NMS cycling compared PEDro=8 NMS assisted exercise, then 4 wk of with Group 3 (p<0.003). RCT voluntary arm crank exercise; Group 3 3. Following the second 4 weeks of N =43; N =32 Initial Final (control group) – voluntary exercise for 8 training, a significant difference was wk without the application on NMS. found between Groups 1 and 3 Outcome Measures: Manual muscle (p<0.0005) and between Groups 2 test. and 3 (p<0.03). 4. No statistical difference was found

Author Year Country Score Methods Outcome Research Design Total Sample Size between Groups1 and 2 (p=0.15). Population: Age=19-65 yr; Level of 1. Overall 11 in the EX group (exercise injury: C4-L1; Severity of injury: AIS A-D; adherence 82.5%) and 13 in the Time since injury=1-24 yr. control group completed the study. Treatment: Experimental group (EX) 2. No differences were noted between participated in progressive exercise the two groups at baseline. training twice weekly for 9 months-each 3. Following training, EX gr. had Hicks et al. 2003 session offered on alternative days lasing significant increases in sub maximal Canada 90-120 minutes. arm ergometry power output (81%; PEDro=5 Outcome Measures: Perceived stress p<0.05) and significant increases in RCT scale, muscle strength, depression, upper body muscle strength (19- NInitial=34; NFinal=11 physical self-concept pain, perceived 34%; p<0.05). health and Quality of Life were assessed. 4. EX gr. reported less pain, stress and depression after training + scored higher than CON in indices of satisfaction with physical function, level of perceived health + overall quality of life (p<0.05). Population: Mean age=29.5 yr; Gender: 1. Strength values at admittance were males=27, females=4; Level of injury: inversely repeated to strengthen paraplegia=18, tetraplegia=13; Severity of changes during rehab (Pearson injury: AIS A-D; Time since injury=2 correlation coefficients ranging from months; Mean length of stay=4.5 months. -.47 (p=.001 shoulder flexors) to -.73 Treatment: Rehab included (p<.001 shoulder adductors). physiotherapy (PT), occupational therapy 2. For those with paraplegia the range (OT) and physical conditioning. There was from -.48 (p=0.049 shoulder were 4 1hr sessions of each intervention. abductors to -.72 (p=.001 elbow Drolet et al. 1999 Outcome Measures: Mean muscle flexors) compared to those with Canada strength was assessed for 6 muscle tetraplegia, the correlation Pre-post groups 4 times. Muscle strength changes coefficients ranged from -.28 NInitial=40; NFinal=31 during & after functional rehab. (p=.345 elbow extensors) to -.68 (p=.010 shoulder adductors). 3. Patterns of change in muscle strength from admittance to the 15 month follow up differed between the paraplegic group and the tetraplegic group. 4. Differences in strength have been observed for: elbow flexors (p=.001) and shoulder extensors (p=0.04). Population: Mean age=40 yr; Gender: 1. Age was related to the PO peak and males=75%, females=25%; Level of handheld dynamometry (HHD) Injury: paraplegia, tetraplegia; Severity of score (p<0.05), the older the subject injury: complete=67.5%, the more improvement in either of incomplete=32.5%; Time since injury=105 these measures was significantly dys. less than it was in younger subjects. Treatment: No treatment provided. 2. Men had greater PO peak, VO2peak Haisma et al. 2006 Outcome Measures: Power output (PO) and HHD score than women did Netherlands peak, VO2 peak, strength of upper (p<0.05), thus improvement in men Observational extremity, respiratory function. was greater than women. N =186; N =42 Initial Final 3. In tetraplegia subjects the PO peak, VO2peak, muscle strength and % of forced vital capacity (FVC) was lower (p<0.05) than it was in paraplegics but tetraplegics improved more in muscle strength and % of forced expiratory flow

Author Year Country Score Methods Outcome Research Design Total Sample Size (FEV1). 4. Those with a complete lesion had greater HHD score and lower % of FVC than those with incomplete lesions (p<0.05). Population: Age=18-45 yr; Gender: 1. All subjects showed improvement in males=10, females=1; Level of injury: C4- one or more of their manual muscle C7; Time since injury >1yr post injury. scores with the most dramatic Treatment: Testing of hybrid device, 8 wk occurring in the tricep muscle group Cameron et al. 1998 of Neuromuscular Stimulation (NMS) (average increase 1.1 +/- 0.2 for L USA assisted exercise with training sessions triceps, 0.7 +/- 0.1 for R). Case Series 3x/wk. 2. Results show NMS in combination N=11 Outcome Measures: Manual muscle test with resistive exercise can be used scores biceps, triceps, wrist flexors and safely and assists in the extensors. strengthening of voluntary contractions. Note: AIS=ASIA Impairment Scale Discussion

The five studies presented address the long-term change of upper limb strength after the spinal cord injured person has returned to community living. Needham-Shophire et al. (1997) found that Neuromuscular stimulation (NMS)-assisted exercise ergometry alone and in combination with voluntary arm crank exercise was effective for strengthening of the upper limb for SCI injured individuals well after injury (mean time since injury 3 years).

Hicks et al. (2003) demonstrated all study participants had progressive increases in muscle strength in each of the muscle groups tested and that the change scores were significant from the control group except for the left anterior deltoid. Study participants self-reported decreases in stress, pain, depression, enhanced physical self-concept and overall quality of life.

Drolet et al. (1999) conducted one of the first longitudinal studies published in muscle strength changes in individuals with SCI during rehabilitation. Significant improvement of muscle strength during rehabilitation for individuals with both paraplegia and tetraplegia was noted. Significant improvements were noted at the three-month post discharge evaluation period with the tetraplegia group in the four muscle groups (elbow flexors and extensors and shoulder flexors and extensors) and then began to plateau. One year later elbow flexors showed significant improvement in both paraplegia and tetraplegia groups and shoulder extension showed significant gains only on individuals with paraplegia. Large variability was noted indicating the recovery of strength may be influenced by a variety of individual factors such as level and severity of injury, associated health conditions, age, gender, motivation and physical condition before SCI. Improvements in strength realized in rehabilitation continue to be maintained or improved when the person with a SCI returned to community living.

Haisma et al. (2006) found positive changes in the different components of physical capacity both during and after inpatient rehabilitation. SCI subjects continued to improve and this study illustrates the importance of regularly assessing the physical capacity of people with SCI after discharge. It is important to create conditions (education, exercise facilities) that facilitate further improvements (Haisma et al. 2006).

Cameron et al. (1998) also reported improvements in upper limb strengths in combination with NMS.

Haisma et al. (2006) and Sipski and Richards (2006) recommended further research in this area:  Further research is needed to document benefits of exercise interventions post-SCI including optimal methods for strengthening muscles, merits of endurance versus strength training, ROM, gait, ADL, and transfer training.  Due to impact of body composition, age, concomitant medical problems and our limited knowledge of recovery post SCI, research needs to be performed through well-designed multicentre trials.  Longitudinal studies are needed to gain more insight into the changes that occur after inpatient rehabilitation and the factors which influence these changes.  Exercise and strengthening of the upper limb in both the acute and subacute phase of rehabilitation are important in promoting independence and prevention of injury.

Conclusions

There is level 2 evidence (from one randomized controlled trial; Hicks et al. 2003) that physical capacity continues to improve after 1- year post discharge.

There is level 1b evidence (from one randomized controlled trial; Needham-Shrophire et al. 1997) that neuromuscular stimulation-assisted exercise improves muscle strength over conventional therapy.

There is level 4 evidence (from one case series study; Cameron et al. 1998) that neuromuscular stimulation-assisted ergometry alone and in conjunction with voluntary arm crank exercise was an effective strengthening intervention for chronically injured individuals.

There is level 4 evidence (from one pre-post study; Drolet et al. 1999) that muscle strength continues to improve up to 15 months post hospital discharge for both tetraplegic and paraplegic individuals.

Neuromuscular stimulation-assisted exercise following a SCI is effective in improving muscle strength, preventing injury and increasing independence in all phases of rehabilitation.

3.0 Augmented Feedback on Motor Functions

Several studies have addressed the use of augmented feedback, such as biofeedback, with spinal cord injured populations. van Dijik et al. (2005) conducted a systematic review of RCTs on the effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients. Much of the information about augmented feedback comes from the motor learning literature where it has been noted that feedback combined with practice is a potent variable for affecting motor skill learning (Newell 1991; Schmidt & Lee 1999). There are two types of performance-related information or feedback. The first type of feedback, task intrinsic or inherent feedback, is sensory-perceptual information and is a natural part of performing a skill. The second type of feedback is augmented feedback or information-based extrinsic or artificial feedback. Augmented feedback refers to enhancing task intrinsic feedback

with an external source (Magill 2001; Schmidt & Lee 1999), such as a therapist or device (biofeedback or timer) (van Dijik et al. 2005). It has been suggested that augmented feedback may have practical implications for rehabilitation therapy since re-acquisition of motor skills is an important part of functional motor recovery (Jarus 1994; Jarus & Ratzon 2005; Kilduski & Rice 2003; Winstein 1991).

The ability to use intrinsic feedback to guide performance is impaired in patients with cognitive and perceptual impairments (Flinn & Radomski 2002). In persons who are compromised by neurological sensory impairments, augmented feedback is important (Sabari 2001).

A systematic review (van Dijik et al. 2005) found three randomized clinical controlled trials which studied augmented feedback in the SCI population (Klose et al. 1990; Klose et al. 1993; Kohlmeyer et al. 1996). In our literature search we were able to find an additional two other studies with lower level of evidence that studied augmented feedback applications.

Table 2 Augmented Feedback on Motor Functions Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Mean age=39 yr; Gender: 1. Comparison of Groups (Increment males=40, females=5; Level of injury: C4- or Decrement or No Change): no C6; Severity of injury: complete, relationship between treatment incomplete injuries. group and observed change; no Treatment: Extremities were randomly treatment produced a significantly assigned to 1 of 4 treatment groups: 1. higher proportion of individuals that conventional strengthening; 2. electrical improved relative to the proportion stimulation; 3. biofeedback and electrical showing no change or a decrement; stimulation; 4. biofeedback. Participation no change between treatment ranged from 5 to 6 weeks post SCI. groups. Kohlmeyer et al. 1996 Outcome Measures: manual muscle 2. Influence of Initial Muscle Grade: a USA test- scoring and ADL performance. correlation between the initial PEDro=10 muscle grade and increment in RCT muscle grade was seen at the end N =60; N =45 Initial Final of treatment; poorer initial muscle grades, more likely to see a larger increment in muscle grade as a result of treatment. 3. Conclusion-biofeedback and electrical stimulation both alone + together did not prove to be more effective than standard therapy for wrist extensor recovery during the acute phase of rehabilitation. Population: Age=25-70 yr; Level of 1. A great deal of variance between injury: tetraplegia; Severity of injury: AIS participants in most measures due A-D, incomplete; Time Since Injury=15- to low numbers of subjects, no 243 days; Chronicity=acute/subacute. significant differences was found Popovic et al. 2006 Treatment: The control group received between the Control and Canada conventional Occupational Therapy; Intervention groups. PEDro=6 Intervention group received Functional RCT Electrical Therapy and conventional N=21 Occupational Therapy. Outcome Measures: Functional Independence Measure (FIM); Spinal Cord Independence Measure (SCIM); Rehabilitation Engineering Laboratory

Author Year Country Score Methods Outcome Research Design Total Sample Size Hand Function Test (REL Test); Consumer Perceptions. Population: Age=18-35 yr; Gender: 1. Scores after training indicated no males=24, females=4; Level of injury: C5- significant differences for the muscle C7; Time since injury=at least 1yr post test score and functional activities injury. score between groups. Treatment: Both groups received 45 min 2. Analysis of the repeated measures Klose et al. 1993 of aggressive exercise therapy 3/wk for factor showed a significant change USA 12 weeks along with 30 min of for the manual muscle test and PEDro=5 neuromuscular stimulation (NMS) to functional activities score (p<0.05). RCT assist with upper extremity muscle N =31; N =28 Initial Final strength. Experimental group also received 12 wk of 30 min EMG biofeedback 3/wk. Outcome Measures: Manual muscle test, functional activities score. Population: Age=18-45 yr; Level of 1. No statistically significant injury: C4-C6; Severity of injury: differences were noted between the incomplete; Time since injury=at least 1yr groups. post injury. 2. Differences were noted for the Treatment: All received 3 days/wk of repeated measures of mobility, self- therapy in 2 consecutive eight week care, and the left arm muscle test treatment blocks. Treatment blocks were scores (p<0.05). as follows; Group 1: Biofeedback followed 3. The repeated measures factor was Klose et al. 1990 by supervised physical therapy exercise statistically significant in all of the USA Group 2: Biofeedback followed by analyses looking at measures of PEDro=3 neuromuscular stimulation (NMS); Group physical function (p<0.01) but not in RCT 3: NMS followed by physical therapy those that compared EMG values. N =43; N =39 Initial Final exercise; Group 4: 16 weeks physical therapy exercise. Outcome Measures: Manual muscle test assessed the biceps, triceps, wrist flexors and wrist extensors. Self-care measures looking at feeding, hygiene and dressing. Mobility measure and a muscle electrical activity were also measured. Population: Age=17-63 yr; Gender: 1. T-test analysis of the differences males=81, females=19; Level of injury: before and after initial biofeedback C2-C6; Time since injury=1-29.7 yr. treatment was done. An increase of Treatment: EMG biofeedback treatment 19.21% of normal EMG scores for sessions. right triceps and increase of 19.59% Outcome Measures: EMG scores. of normal EMG scores from the left triceps from one biofeedback treatment session were found, significant (p<.001). Brucker & Bulaeva 1996 2. T-test analysis of the difference from USA before initial biofeedback treatments Pre-post to after additional treatments, N=100 increase in percentage of normal EMG scores of 41.55% right triceps and 38.31% left triceps, significant (p<.001). Increases in percentage of normal EMG scores after initial biofeedback treatment to after additional biofeedback treatment 22.3% right triceps and 18.72% for left triceps, significant (p<.001).

Author Year Country Score Methods Outcome Research Design Total Sample Size 3. Correlation coefficient for manual muscle test score and EMG pretest before initial treatment was r=.569 for right triceps and r=.437 for left triceps, significant (p<.001). 4. Increases in percentage of normal EMG before, after, and after additional treatments was significant in right and left triceps regardless of initial manual muscle test. Note: ADL=Activities of Daily Living; AIS=ASIA Impairment Scale; EMG=Electromyography; Independence Measure;; Discussion

All of the studies concluded that there was no evidence of the effectiveness of the use of augmented feedback to improve arm function in rehabilitation. In a systematic review, van Dijik et al. (2005) recommended the following be considered in future research in this area:

 future studies need to focus on content, form and timing of the augmented feedback to clarify its importance in rehabilitation  studies should recognize the difference between performance and learning effects concerning reacquisition of motor skills by re-examining the study population after a follow up period

Conclusion

There is level 1a evidence (from two randomized controlled trials; Kohlmeyer et al. 1996; Popovic et al. 2006) that augmented feedback is not effective in improving upper limb function in tetraplegia.

Augmented feedback does not improve motor function of the upper extremity in SCI rehabilitation patients.

4.0 Pharmacological Interventions

Cervical injuries of the spinal cord frequently lead to hypertonia characterized by disabling spasticity and dystonia involving the upper and lower limb. Spasticity has been defined by Lance (1980) as “a velocity exaggerated increase in the tonic stretch reflexes (muscle tone) resulting from hyperactivity of the stretch reflex.” The EU-SPASM Thematic Network or Consortium (Support Network for the Assembly of Database for Spasticity Measurement) has presented an updated definition of spasticity that reflects a recent research findings and current clinical interpretations. Spasticity has been re-defined as “disordered sensori-motor control, resulting from an upper motor neurone lesion, presenting as intermittent or sustained involuntary activation of muscles” (Pandyan et al. 2005).

The management of severe cases of hypertonia can be challenging as it can be refractory to oral medications. Many studies have shown that intrathecal delivery of balcofen has been

effective for refractory hypertonia in the lower extremity. Baclofen, 4-amino-3 (p-chlorophenyl) butyric acid works by binding to the inhibitory presynaptic GABA-B receptors in the spinal cord (Meythaler et al. 1999). Intrathecal delivery of the drug facilitates achievement of therapeutic levels in the cerebral spinal fluid (CSF) while minimizing systemic side effects (drowsiness, confusion). Burns and Meythaler (2001) is the only study published which deals with hypertonia involving the upper extremity post-SCI. Further discussion regarding the management of hypertonia can be found in the spasticity chapter.

Table 3 Pharmacological Interventions Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=25-64 yr; Level of 1. Significant decline in UE hypertonia injury: C4-C7; Severity of injury: AIS A-D; during 12 month follow up period. Time since injury=1.2-24 yr. 2. Average baseline Ashworth score Treatment: Intrathecal baclofen. was 2.4±1.1 (SD) compared to Outcome Measures: Ashworth Scale; 1.8±1.0 (SD) at 12 months Spasm Frequency Scale; Reflex Scale. (p<0.0001). 3. The average spasm score decreased from 2.3±1.6 (SD) to 0.5±0.9 (SD), not significant at p=0.2503 (Friedman test). 4. The difference was significant Burns & Meythaler 2001 (p=0.0012 Wilcoxon signed rank USA test). UE reflexes, average baseline Case Series reflex score was 2.3±0.2 (SD) N=14 compared to 0.9±0.2 (SD) at 12 months (p<0.0001 Friedman). 5. Dosage requirements increased during the 12-month follow-up period, statistically significant (p<0.0001, Friedman). 6. Statistically significant declines in upper extremity spasm scores (1.8 points, p=0.012), reflex scores (1.4 points, p<0.0001) and Ashworth scores (0.6 points, p<0.0001) for the 1-year follow-up period. Note: AIS=ASIA Impairment Scale

Discussion

Burns and Meythaler (2001) showed a statistically significant decrease in Ashworth (tone) and reflex scores in upper extremity hypertonia due to pathology at the level of the spinal cord.

Conclusion

There is level 4 evidence (from one case series study; Burns & Meythaler 2001) that intrathecal baclofen may be an effective treatment for upper extremity hypertonia of spinal cord origin.

Intrathecal baclofen may be an effective intervention for upper extremity hypertonia of spinal cord origin.

5.0 Restorative Strategies 5.1 Plasticity of Motor Systems It has been reported that 55% of all spinal cord injured persons are classified as having complete injuries. Magnetic resonance imaging (MRI) and histopathology indicates that approximately 65% of the traumatic injuries initially classified as ‘neurologically complete’ (absence of sensory and motor function in lowest sacral segment) show some tissue and axonal sparing across the lesion (Bunge et al. 1997). It is now accepted that the CNS is capable of substantial reorganization, especially in incomplete SCI because cortical, subcortical and much of the local spinal cord circuitry remains largely intact and still partially interconnected by unlesioned fibres (Raineteau & Schwab 2001). Information may still pass through the level of the lesion on spared fiber tracts but the information may be fragmented or distorted (Beekhuizen & Field-Fote 2005). Functional recovery can occur for several years after injury in incomplete SCI, with the degree of recovery dependent upon the reorganization of circuits that have been spared by the lesion (Green et al. 1999). Cortical reorganization occurs after SCI with evidence that the sensorimotor cortex may play a role in the recovery of function in individuals with SCI (Green et al. 1999). Results of neuroimaging and neurophysiological techniques (functional magnetic resonance imaging (fMRI), transcranial magnetic stimulation (TMS) and positron emission tomography (PET) demonstrate that changes occur in the cortex following damage to the spinal cord with expansion of cortical areas corresponding to muscles spared after SCI into the cortical areas previously associated with control of muscle reinnervated at spinal cord levels below the level of the lesion (Bruehlmeier et al. 1998; Cohen et al. 1991; Levy et al. 1990; Raineteau & Schwab 2001).

In ISCI, reorganization might occur at two levels; in pre-existing circuits by modifications of synaptic strength (synaptic plasticity) or by new circuits through sprouting or anatomical reorganization, including growth of axonal branches and dendrites (anatomical plasticity) (Raineteau & Schwab 2001). Laboratory work is currently explaining and researching cortical reorganization, cortical plasticity, sub-cortical plasticity, plasticity at the red nucleus, plasticity and spontaneous adaptation of the central pattern generators and plasticity of unlesioned descending pathways. The strengthening and weakening of synapses, axonal and dendritic sprouting can occur at different levels of motor system in response to spinal cord lesions, in the cortex, the brainstem, and the spinal descending pathways and in the intraspinal circuits. All interact with each other; therefore it is difficult to interpret functional recovery processes. A SCI interrupts distinct descending fibre populations. The overall complexity of an incomplete SCI resides first in the organization of descending spinal tracts. Most of the descending systems terminate on spinal interneurons, but some direct excitatory or inhibitory connections to motor neurons also exist. Different tracts are involved in specific functions. For example, lesions of the cortical and rubrospinal systems lead to more severe and longer lasting deficits for movement of the distal extremities and lesions of the reticulo and vestibulospinal systems affect movements of proximal and axial muscles. Functional outcomes of given spinal cord lesions therefore depends on type of fibres that are interrupted (Raineteau & Schwab 2001).

Functional reorganization is based on two mechanisms; synaptic plasticity in pre-existing circuits and sprouting and anatomical reorganization that leads to the formation of new circuits. The study of animal models provides further understanding of rehabilitation treatments and development of new therapeutic approaches for people with SCI (Raineteau & Schwab 2001).

Traditional approaches to improving arm and hand function in persons with tetraplegia generally use compensatory strategies to have the muscles that are intact substitute for the lost function

of the weakened or paralyzed muscles and management of musculoskeletal complications as described in the Guidelines for Clinical Practice for the Consortium for Spinal Cord Medicine Clinical Practice Guidelines supported by the PVA 2005 (Backus 2010).

Based on the neuroplasticity research, there is a belief that there are similarities between incomplete tetraplegia after SCI and hemiplegia after stroke as incomplete tetraplegia often have altered and inappropriate sensory input and motor output and not simply the loss of sensory or motor function (Backus 2010). Persons with hemiplegia who have altered (but not absent) sensory perception and paresis (but not complete paralysis) demonstrate disordered motor control in the ULs which include the ability to balance agonist and antagonist muscles (Chae et al. 2002; Levin et al. 2000), strength imbalances (Lum et al. 2002), disruptions in initiation and cessation of movement (Chae et al. 2002) and inappropriate muscle activation (Kamper et al. 2001). Persons with tetraplegia, much like hemiplegia experience the inability to effectively activate and deactivate (relax) muscles at appropriate time and extent. The difficulty is seen in being able to control the strength or force output during movement and the altered timing and control of movement at a joint or across multiple joints. Based on this, it is thought that ISCI is said to closely resemble hemiplegia (Backus 2010).

There are several principles underlying the facilitation of neural plasticity and functional recovery such as intense activity, repeated practice, attention and somatosensory augmentation concurrent with movement practice. The interventions usually combine intense, repetitive and often rhythmical input to CNS below the level of injury. These principles are the basis for constraint induced movement therapy approach and activity based intervention (ABint) (i.e., treadmill training, FES approach, constraint-induced therapy). The goal of ABint is to facilitate long term changes in spinal and cortical circuits and improve overall function after neural injury or disease. Until the past decade, studies researching the use and effectiveness of ABint for improving function and potentially neural activity in arm and hand in persons with tetraplegia have been limited and scared in the upper limb literature (Backus 2010). The research studying the use of massed practice (MP) and/or somatosensory peripherial nerve stimulation (SS) have demonstrated potential for both neural and functional improvements in persons with tetraplegia (Beekhuizen & Field-Fote 2005; Beekhuizen & Field-Fote 2008; Hoffman & Field-Fote 2007).

Three studies were found that tested the use of MP, SS and repetitive transcranial magnetic stimulation (rTMS) in changing the cortex.

Table 4 Restorative Strategies Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=22-63 yr; Gender: 1. Pinch grip scores: differences were males=9, females=1; Level of injury: C5- noted in the MP+SS group (Z=- C7; Severity of injury: AIS C=4, D=6; 2.023, p<0.05) only. Time since injury=12-154 months. 2. The MP+SS group also showed Beekhuizen & Field-Fote Treatment: Subjects participated in 2h of greater increase in pinch grip 2005 massed practice (MP) therapy 5/wk for 3 strength than the MP group (U=2.0, USA wk or MP+median nerve somatosensory p<0.05). PEDro=8 stimulation (SS). MP training focused on 3. Upper extremity Functional tests: RCT continuous repetitions of the following: the Pre/post Wolf Motor Function N=10 gross upper extremity movement, grip, Test timed scores in the MP+SS and grip with rotation, pinch and pinch group showed a difference (Z=- with rotation. Tasks in each block were 2.023, p<0.05). No statistical performed for 25 min before moving to the differences were noted for the MP

Author Year Country Score Methods Outcome Research Design Total Sample Size next category. group. Outcome Measures: Maximal pinch grip 4. Timed test scores between the 2 force, Wolf motor function test timed task groups were also found to be scores, Jebson hand function test scores, statistically different (U=1.0, stimulus intensity required to elicit motor p<0.05). threshold response in muscles, and motor 5. Jebsen test scores: pre and posttest evoked potentials amplitude. scores were different for the MP+SS group (Z=-2.023, p<0.05). The MP+SS group showed greater improvement than the MP group (U=3.0, p<0.05). 6. Cortical Excitability: No significant differences were noted between the 2 groups. Population: Mean age=38 yr; Gender: 1. Intervention groups differed males=22, females=2; Level of injury: significantly in hand function tetraplegia; Severity of injury: AIS C=11, (p<0.001). All intervention groups D=13; Time since injury=67 months; had a significant improvement in Chronicity=chronic. their hand function (MP, p<0.01; SS, Treatment: One of four conditions 2 p<0.05; MP+SS, p<0.001), as hours per day, 5 days per week: 1) compared to the control group. The Massed practice training (MP); 2) MP+SS group improved more than Beekhuizen & Field-Fote Somatosensory peripheral nerve the MP and SS group alone 2008 stimulation (SS); 3) MP +SS combined; 4) (p<0.01). USA No intervention (control). 2. MP+SS and SS groups significantly PEDro=5 Outcome Measures: Functional hand improved motor function scores RCT use: Jebson-Taylor Hand Function Test); when compared to the control group NInitial=24; NFinal=18 Functional upper extremity use (Wolf (p<0.001, p<0.05, respectively). Motor Function Test); Pinch and grip MP+SS improved more than MP strength (Key pinch force); Sensory and SS alone (p<0.01). function (Monofilament testing); Cortical 3. MP+SS and SS groups also excitation change (Motor evoked potential significantly improved pinch grip thresholds). forces (p<0.01). 4. MP+SS was the only group to have a significant sensory function improvement (p=0.01). Population: Age=41-54 yr; Gender: 1. No difference between patients males=3, females=1; Level of injury: C5; when looking at the assessments Severity of injury: AIS D; Time since done after baseline and after sham injury=1.25-8 yr. intervention. Treatment: 5 days of sham repetitive 2. The level of intracortical inhibition transcranial magnetic stimulation (rTMS) was reduced to 37.5±8.0% of followed by 5 days of therapeutic pretreatment levels during the week stimulation (rTMS). of therapeutic treatment (p<0.05) Belci et al. 2004 Outcome Measures: AIS and 9 Hole Peg and returned to 90.2±15% of pre- UK Board. treatment levels during the follow-up Pre-post period. N=4 3. This was linked to improvements in clinical measures of both motor and pinprick of 4-10% during treatment week. (p<0.05). 4. Subjects also improved perceptual threshold to electrical stimulation of the skin and peg board test scores (p<0.05). Note: AIS=ASIA Impairment Scale; SS=Somatosensory Peripheral Nerve Stimulation

Discussion

Beekhuisen and Field-Fote (2005) suggested that MPor constraint-induced therapy promotes cortical reorganization that may be an effective rehabilitative tool for improving strength and function in individuals with cervical SCI. Improvement may be further enhanced by the addition of somatosensory stimulation. Beekhuisen and Field-Fote (2008) showed that the use of MP with somatosensory peripherial nerve stimulation (SS) and the use of SS only showed significant improvements in upper extremity function and pinch strength when compared to the results demonstrated by the control group. The study also showed that use of MP and SS together had a significant change in sensory scores and the MP with SS and MP groups only showed greater change in threshold measures of cortical excitability when compared to the control group results. Belci et al. (2004) observed clinical changes consistent with the concept that reduced corticospinal inhibition can facilitate functional recovery. Recovery involved increased AIS sensory and motor scores, improved response to cutaneous electrical stimulation over the thenar muscles and possibly improved hand/finger function. This preliminary study demonstrated rTMS treatment in patients with chronic stable incomplete SCI can produce reductions in corticospinal inhibition detectable using electrophysiological techniques. Additional research studies with appropriate controls are needed to confirm the overall effectiveness of the intervention.

There is a lack of studies evaluating the efficacy of restorative strategies. In order for these therapies to be successful in everyday clinical practice, the therapy interventions need to be associated with meaningful changes in functional motor performance and incorporate techniques that are available in the clinic and at home (Beekhuizen & Field-Fote 2005).

Conclusion

There is level 1a evidence (from two randomized controlled trials; Bekkhuizen & Field- Fote 2005, 2008) that showed that massed practice (repetitive activity) and somatosensory stimulation (median nerve stimulation) demonstrated significant improvement in upper extremity function, grip and pinch strength required for functional activity use.

There is level 4 evidence (from one pre-post study; Belci et al. 2004) that showed that rTMs treatment in individuals with chronic stable ISCI may produce reductions in corticospinal inhibition that resulted in clinical and functional changes for several weeks after treatment.

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.

5.2 Complementary Alternative Therapies Acupuncture is an ancient Chinese therapy practiced for more than 2500 years to cure disease and relieve pain (Lee & Liao 1990). There are 361 identified acupoints that have been formed into a network of 14 channels called the meridians. Acupuncture therapy has been shown to be effective in improving functional outcomes in hemiplegic stroke patients and in paraplegic spinal cord injured patients (Cheng et al. 1998). In electrical acupuncture therapy, electrical stimulation is provided directly to the acupoint areas. It has been speculated that acupuncture therapy through the correct acupoints and meridians in the acute SCI episode will assist in the minimization of posttraumatic cord shrinkage and sparing of the ventral horn neurons (Politis & Korchinski 1990; Ran et al. 1992; Tsay 1974; Wu 1990).

Table 5 Complementary Alternative Therapies Author Year Country Methods Score Outcome

Research Design Total Sample Size Population: Mean age=35 yr; Gender: 1. Acupuncture group - sensory, motor males=80, females=20; Level of injury: + FIM scores improved significantly paraplegia=63, tetraplegia=37; Severity of day of D/C + 1yr after injury injury: AIS A-B; Chronicity=acute. (p<0.05). Control group - only motor Treatment: Acupuncture was score significant improvement at 1yr Wong et al. 2003 administered to the treatment group via 4 post injury F/U p=0.023. Taiwan x 5 cm adhesive surface electrodes at the 2. Comparison of AIS + FIM scores of PEDro=5 acupoints of bilateral Hou Has (S13) and both groups not at admission; D/C + RCT Shen Mo (B62). Frequency was set at 75 1yr post significant improvement AIS N=100 hz with a pulse duration of 200 usec and + FIM in acupuncture vs. control the magnitude of stimulation was set at 10 p<0.05. mV. Sessions were 30 minutes, 5 times 3. More patients in acupuncture group per week. improved to AIS grade B + C or Outcome Measures: AIS (sensory + better at D/C + 1yr post p<0.05. motor), FIM, before + after therapy. Note: AIS=ASIA Impairment Scale

Discussion

With acupuncture thin metal needles are inserted into specific body sites and slowly twisted manually or stimulated electrically. The uncomfortable pain sensation or de qi, a prerequisite for effective acupuncture therapy, is induced by needle manipulation (Wong et al. 2003).

The randomized control trial by Wong et al. (2003) studied the use of electrical acupuncture therapy through adhesive surface electrodes and concomitant auricular acupuncture therapy in improving the neurologic or functional recovery in acute traumatic SCI patients. The study demonstrated that in the acupuncture group all sensory, motor and FIM scores improved significantly when examined on the day of discharge from hospital and one year after injury (p<0.05). The control group (auricular acupuncture) demonstrated only significant improvement in motor score at one-year post injury follow up (p=0.023). At discharge and at one year post injury follow up, the acupuncture group revealed significant improvement in all AIS and FIM scores when compared to the control group (p<0.05). An inherent bias may have been introduced into this study as the reviewer who assessed the participants was not blinded to the group assignment.

Conclusion

There is level 2 evidence (from one randomized controlled trial; Wong et al. 2003) that showed that the use of concomitant auricular and electrical acupuncture therapy may improve the neurological and functional recovery of acute spinal cord injured individuals.

5.3 Splinting Splinting of the upper extremity in the management of tetraplegia is a well-accepted therapy intervention and has been an accepted practice for many years in the management of SCI especially in the acute phase of injury for the prevention of contractures and for joint protection (Curtin 1994; Krajnik & Bridle 1992). The therapeutic goals of splinting are the immobilization, protection and support of the joints of the wrist and hand, prevention of joint malalignment, prevention and reduction of soft tissue shortening and contractures, prevention of soft tissue overstretch, counteracting hypertrophic scars, support of weak muscles, improvement of function and pain relief (Curtin 1994; Krajnik & Bridle 1992; Paternostro-Sluga & Stieger 2004). It has been shown that elbow flexion contractures greater than 25 degrees have significant impact on the independence with the spinal cord injured person especially in the ability to transfer and complete depression lift for pressure relief (Bryden et al. 2004; Dalyan et al. 1998; Grover et al. 1996). The most common static hand splints for tetraplegic patients are the resting pan or paddle splints, wrist extension splints (Futuro-type splint, long opponens splint and dorsal cock-up splint and spiral splint), short hand splints and tenodesis splints (Curtin 1994). Splints are also used to position the elbow in extension as flexion contractures of this joint are very common due to lack of triceps innervation and the effects of increased tone and spasticity (Bryden et al. 2004; Grover et al. 1996).

Table 6 Splinting of the Hand Author Year Country Score Methods Outcome Level Total Sample Size Population: Injury type: SCI=23, 1. After 12 weeks, control thumbs Stroke=14, ABI=7; Time since injury=4 yr. carpometacarpal angle mean Treatment: Experimental group: thumbs change was 45-47°. Experimental splinted into a stretched, abducted thumbs carpometacarpal angle position, every night (average 8 hours), mean change was 45-47°. The for 12 weeks. Control group: no mean difference between these two Harvey et al. 2006 intervention. With the bilateral thumb groups was 1°. Australia group, splinting was applied to one thumb 2. 22 experimental subjects wanted to PEDro=8 and no splinting to the other (own continue with the splinting regime RCT control). With unilateral thumb, subjects and 20 experimental subjects said N =44; N =43 Initial Final were divided into experimental and their thumb web space extensibility control. was increased by the splinting. Outcome Measure: Palmar abduction of 3. The intra-class correlation carpometacarpal joint; Subjective coefficient between attitudes of effectiveness and carpometacarpal angle of the control convenience of splinting. and unaffected thumbs, before and

Author Year Country Score Methods Outcome Level Total Sample Size after treatment, was 0.87.

Population: Age=18=42 yr; Gender: 1. No significant differences were males=12, females=1; Time since noted between the 2 groups-all injury=6–8 wk. subjects demonstrated improvement Treatment: Experimental group was in hand function and pinch strength. given long or short orthosis to be worn at 2. At 8 weeks the 13 subjects showed night (8hrs) as soon as the subject could improvement in their performance DiPasquale-Lehnerz tolerate it. on the checkers subtest (p<0.01), 1994 Outcome Measure: Pinch strength and simulated feeding subtest (p<0.01), USA functional activity use. and the large light object subtest PEDro=4 (p<0.01). RCT 3. At the 12-week marker, NInitial=13; NFinal=9 improvement could be seen on the card subtest (p<0.05). 4. An increase in pinch strength was noted at 8 weeks for all subjects (p<0.05) and at 12 weeks 9 remaining subjects (p<0.05)

Discussion

Even though splinting and orthotic fabrication is an accepted practice, there is minimal research data on the effectiveness of this intervention (DiPasquale-Lehnerz 1994; Krajnik & Bridle 1992), although there are numerous anecdotal descriptions of orthotic devices and rationales for orthotic intervention (DiPasquale-Lehnerz 1994). Curtin (1994) and Krajnik and Bridle (1992) also found formal assessments were often not done due to; a lack of time and staff shortages; inconsistent documentation; absence of standardized tests available for spinal cord injured patients; limited funding to purchase equipment; and/or patient declined to participate in formal assessments due to boredom and frustration. Krajnik and Bridle (1992) noted that therapists considered observation of the patient when involved in a functional activity as the most informative assessment although this was not an objective means of documenting a patient’s status and progress. There appears to be a variety of splints made for similar purposes because there is little research as to what splint is best for the level and stage of SCI (Krajnik & Bridle 1992). It was noted by Harvey et al. (2006) that the use of splints are also viewed as a major inconvenience to both the client and therapist and the overall effect of the splint needs to be substantial in order to justify the inconvenience and discomfort. Harvey et al. (2006) also reported that clients were initially agreeable to wear splints at the beginning of their treatment, but by the end of treatment they were less compliant.

In Paternostro-Sluga and Stieger’s (2004) review, the therapeutic aims of splinting and the choice of splint depend on the disease and the individual functional problem resulting from the impairment. These authors also concluded that there is insufficient evidence from clinical trials on splinting strategies in CP or SCI patients. The studies also referred to research looking at hand splints for clients with an acquired brain injury or stroke (McPherson et al. 1982; Rose & Shah 1987).

Harvey et al. (2006) noted in their study that twelve weeks of nightly stretch does not reduce thumb web-space contractures in people with a neurological condition (stroke, ABI, SCI). Even with careful monitoring of the fit of the splint for the thumb joint, it was unclear if the splint was able to produce enough torque to the thumb joint for a sufficient stretch. The study also raised questions concerning if the length of time wearing the splint was enough, if the time spent wearing the splint was accurately reported by the client and if there a difference in outcomes when considering the type of neurological condition being splinted.

DiPasquale-Lehnerz (1994) noted that there was no significant improvement in hand function as it related to passive ROM, strength of prehension or coordination in subjects with C6 tetraplegia who wore a thumb opponens orthoses during sleep as compared to those subjects with C6 tetraplegia who did not wear such an orthosis. The study did show over time a significant improvement of hand function especially pinch strength, and functional use (turning cards, picking up small objects, simulated feeding and holding onto light cans) for those wearing the splint.

There are several published surveys that addressed the use of splints in the spinal cord population with the majority of splints being functional use splints (i.e., feeding splint, writing splint, typing splint or an application for an assistive device) (Garber & Gregoria 1990; Krajnik & Bridle 1992). More research is needed in this area using larger study sizes and studying the type of neurological condition being splinting prior to determining if splinting is effective in contracture reduction.

Conclusion

There is level 2 evidence (from one randomized controlled trial; DiPasquale-Lehnerz 1994) that wearing a thumb opponens splint will improve pinch strength and functional use of the hand.

There is level 1b evidence (from one randomized controlled trial; Harvey et al. 2006) that 12 weeks of nightly stretch with a thumb splint did not reduce thumb web-space contractures in persons with a neurological condition (i.e., stroke, ABI, SCI).

6.0 Subacute Phase of Rehabilitation 6.1 Upper Limb Injuries A spinal cord injured individual is forced to rely on their upper extremities for their weight bearing activities such as transfers, mobility needs and ADLs using limbs that were designed to place hands in space (Consortium for Spinal Cord Medicine 2005; Dalyan et al. 1999; Dyson- Hudson & Kirshblum 2004). Repeated use of the upper limb for weight bearing activities such as manual wheelchair propulsion, transfers, raised ischial pressure reliefs (weight shifts) and reaching from a seated position in the wheelchair in environments designed for nondisabled individuals places a great deal of stress on the bones, joints and soft tissues of the shoulder complex. This places the structures of the upper limb at significant risk for overuse and subsequent injury (Dyson-Hudson & Kirshblum 2004). Pain in the early post injury period is

typically due to increased demands on anatomically weakened muscles or muscle weakness induced because of deconditioning.

Upper limb pain is known to interfere with a wide range of functional activities, transfers, ambulation, pressure relief and self-care (Curtis et al. 1995a, Dalyan et al. 1999); many individuals report alteration/cessation of activities critical to functional independence (Pentland & Twomey 1994; Sie et al. 1992). Shoulder pain may be functionally and economically equivalent to a higher level of lesion (Salisbury et al. 2003). Dalyan et al. (1999) reported that of individuals with upper limb pain, 26% needed additional help with functional activities and 28% reported limitations of independence. Subbarao et al. (1994) and Gerhart et al. (1993) reported that individuals with SCI reported that their dependence in personal care assistants fluctuated with upper limb pain and was a major reason for functional decline. The Consortium for Spinal Cord Medicine (2005) has written clinical practice guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals,” as a way to address upper limb problems.

6.1.1 Shoulder Injuries Upper limb pain and injury are highly prevalent in people with SCI and consequences are significant. The Consortium for Spinal Cord Medicine (2005) and Dyson-Hudson and Kirshblum (2004) reported through surveys and cross-sectional studies that shoulder pain in chronic spinal cord injured persons are common in both paraplegia and tetraplegia at a prevalence of 30-73%. In the acute phase after SCI, shoulder pain is reported in approximately 75% of patients (Silfverskiold & Waters 1991; Waring & Maynard 1991), and 33% to 63% of patients in the chronic phase (>6 months) experience shoulder pain (Nepomuceno et al. 1979; Sie et al. 1992; Silfverskiold & Waters 1991). Curtis et al. (1995a), Nichols et al. (1979) and Pentland and Twomey (1991) reported in cross sectional studies that 60-100% of long-term wheelchair users experience shoulder pain. Subbardo et al. (1994) and Sie et al. (1992) reported that there is a high prevalence of shoulder pain during the first year after injury, and in individuals 15-20 years post injury. Pain experienced above the injury level during the first 3-6 months after injury is different than the pain experienced 1 year or more after injury (Apple 2001). Pain above the level of injury in chronically injured person assumes the character of overuse syndromes (Apple 2001). Injury involving the shoulder, elbow, wrist and hand are seen at an earlier age in spinal cord injured individuals than in the general population because of the stresses of weight bearing and mobility that are added to the normal use of the upper limb (Pentland & Twomney 1994). Individuals who are older at the time of injury may experience functional changes earlier than people who are injured at a younger age (Thompson 1999).

It is also very difficult to determine whether shoulder pain is a function of duration of SCI or simply a part of the normal aging process (Neer & Welsh 1977). The wide variability in these numbers is most likely a reflection of the heterogeneity of participant populations between the studies with respect to duration of injury, age, neurologic level and severity of injury, as well as body mass index. Small sample size, selection bias and variations in participant populations across the different studies with respect to duration of injury, age, gender and neurological level and severity of injury make it difficult to assess the true prevalence of shoulder pain in individuals with shoulder pain (Pentland & Twomey 1991). The incidence of shoulder pain in acute tetraplegia (<6 months post injury) has been reported to range from 51% to 78% (Salisbury et al. 2003).

Nichols et al. (1979) was one of the first groups to report an association between chronic SCI and shoulder pain coining the term “wheelchair user’s shoulder. “ Due to the prevalence of

shoulder pain, Curtis et al. (1995b) developed a Wheelchair Users’ Shoulder Pain Index (WUSPI) that measures the severity of pain for 14 functional activities.

The following are the many identified risk factors for the development of injury and pain in the upper limb.

 The shoulder is the most common joint above the level of injury where pain complaints are reported with persons with paralysis (tetraplegia or paraplegia) (Apple 2001).  The shoulder is not well designed to handle the higher intra-articular pressures required for both weight bearing and mobility (Apple 2001).  Partial innervation and impaired balance of shoulder, scapular and thoracolumbar muscles place individuals with tetraplegia at a higher risk for developing shoulder pain especially during weight-bearing upper limb activities such as wheelchair propulsion, transfers, and pressure reliefs.  Due to differences in trunk postural control, differences may also occur between individuals with high paraplegia (T2-T7) and low paraplegia (T8-T12).  Individuals with C1-C4 motor levels of injury are also at risk for shoulder pain  SCI severity also may be associated with shoulder pain (Dyson-Hudson & Kirshblum 2004).  Lack of use of immobilization of the shoulder girdle muscles can limit their active joint movement and lead to muscle shortening and shoulder capsule tightness.  The development of pain is associated with decreased shoulder ROM  Weakness and paralysis in these muscles can lead to increased reliance on the trapezius, which can result in overuse and pain in this muscle.  Shoulder pain can occur from nerve root injury or radicular pain with dysesthesias or phantom sensations  People of certain age groups, those with higher cervical lesions and those with shorter lengths of bed rest may be at a greater risk  Gender may be associated with shoulder pain in individuals with SCI (Pentland & Twomey 1991).  Body mass index (BMI) also may play a role in shoulder injuries in manual wheelchair using individuals with SCI because it directly relates to the amount of physical strain experienced during ADLs in these individuals (Boninger et al. 2001; Jensen et al. 1996).  Shoulder pain is more common in individuals with tetraplegia and complete injuries and in women and duration of injury, older age, and higher BMI all may be risk factors for developing shoulder pain and/or abnormalities in persons with SCI (Dyson-Hudson & Kirshblum 2004).

6.1.2 Elbow/Wrist and Hand Injuries The prevalence of elbow pain and injury has been reported to be between 5-16% (Consortium for Spinal Cord Medicine 2005). Sie et al. (1992) found 15% and 16% rates of pain localized in the elbow region in persons with tetraplegia and paraplegia. Dalyan et al. (1999) in their study found 35% complained of elbow pain.

The prevalence of carpal tunnel syndrome is reported to be between 40-66% (Consortium for Spinal Cord Medicine 2005). There are four studies that found an association between length of time since injury and prevalence of carpal tunnel syndrome (Aljure et al. 1985; Gellman et al. 1988; Schroer et al. 1996; Sie et al. 1992). Some studies also found median nerve damage without clinical symptoms.

Table 7 Shoulder Treatment Interventions Author Year Country Score Methods Outcome Research Design Total Sample Size

Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=28-69 yr; Gender: 1. There was a significant effect of time males=18, females=6; Time since for both treatments on performance injury=5-33 yr; Length of shoulder pain=4 corrected (PC)-WUSPI mo -22 yr. (Acupuncture p<0.001 and Trager Treatment: Subjects received either p=0.001). acupuncture treatments (sessions lasted 2. Overall a reduction of the PC- 20 to 30 min) or Trager Psychophysical WUSPI could be seen when looking Integration - sessions lasted approx 45 at the data from the beginning of Dyson-Hudson et al. min. Consisted of both table work and treatment to the end for both groups 2001 Mentastic exercises (easy, natural (p<0.05) USA movement sequences to enhance 3. There was a significant effect of time PEDro=7 relaxation and decrease pain during table for both acupuncture and Trager RCT work). groups for average pain & most N=21 Outcome Measures: Intake severe pain (p<0.01, p<0.001 questionnaire (demographics and medical respectively), for the least severe history), Weekly log, Wheelchair users pain the acupuncture group showed shoulder pain index (WUSPI), Numeric a significant reduction (p<0.01) rating scale, Verbal rating scale (VRS), compared to the Trager group. Range of Motion (ROM). 4. Verbal response scores- there was a statistically significant treatment effect for both groups (p=0.001). Population: Age=19-65 yr; Level of 1. EX group reported less pain, stress injury: C4-L1; Severity of injury: AIS A-D; and depression after training + Time since injury=1-24 yr. scored higher than CON in indices Treatment: Experimental group of satisfaction with physical function, participated in a progressive exercise level of perceived health + overall Hicks et al. 2003 training twice weekly for 9 months-each quality of life (p<0.05). Canada session offered on alternative days lasting 2. Following training, EX gr. had PEDro=5 90-120 minutes. Control group were significant increases in sub maximal RCT offered educational sessions bimonthly arm ergometry power output (81%; NInitial=32; NFinal=24 (exercise physiology for SCI osteoporosis, p<0.05) and significant increases in post SCI relaxation methods). upper body muscle strength (19- Outcome Measures: Perceived stress 34%; p<0.05). scale, muscle strength, depression, physical self-concept pain, perceived health and Q of L were assessed. Population: Mean age=35 yr; Gender: 1. There were no significant males=35, females=7; Level of injury: differences between control and cervical to lumbar; Duration of wheelchair experimental group in age, years of use=24 yr. wheelchair use or activity levels. Treatment: Both groups completed the 2. When looking at the effect of Curtis et al. 1999 Wheelchair Users Shoulder Pain Index exercise of intervention on USA (WUSPI) every 2 mo for 6 mo. The performance corrected (PC) WUSPI, PEDro=5 experimental group attended a 60min a 2 factor repeated measures RCT educational session where they were ANOVA showed a significant effect N=42 instructed in 5 shoulder exercises. of time only (p=0.048). Outcome Measures: Self report questionnaire (demographic and medical info), Wheelchair User's Shoulder Pain Index (WUSPI), and a visual analog scale (VAS) used to rate intensity of pain. Note: AIS=ASIA Impairment Scale; Q of L=Quality of Life; VAS=Visual Analog Scale;

Discussion

The most significant activities causing pain in the wrist and hand are reported to be propelling a

wheelchair and doing transfers (Subbarao et al. 1994). Management of established upper limb pain is very difficult and thus prevention is critical. Evidence-based best practice standards have not been established for the medical, rehabilitative or surgical treatment of upper limb injuries in people with SCI. In addition, there is little consensus among health-care providers on the best treatment practices for upper limb injuries in the general population. In general, musculoskeletal upper limb injuries in the SCI population are managed in a similar fashion as the unimpaired population.

Outcome studies of surgical treatment in SCI also very limited. Two small studies report the outcome of rotator cuff repair – one showing relatively poor results (Goldstein et al. 1997) and another study showing relatively good outcomes (Robinson et al. 1993). Both studies recommend non-surgical approaches prior to surgical intervention. One randomized controlled trial found that supervised exercise produced results similar to arthroscopic surgery for patients with impingement syndrome (Brox et al. 1993), however; this study was not on SCI patients.

Exercise has been shown to reduce pain in a randomized controlled trial in which subtypes of pain were not reported (Hicks et al. 2003). Two studies found an association between restricted ROM and pain, reduced activity and/or injury (Ballinger et al. 2000; Waring & Maynard 1991). A study incorporating stretching into an exercise program for individuals who use manual wheelchairs found stretching exercises were associated with decreased reported pain intensity (Curtis et al. 1999).

One study demonstrated that acupuncture was no more effective than Trager Treatment in the treatment of shoulder pain (Dyson-Hudson et al. 2001). There are several studies that address the use of complementary or alternative medicine (CAM) with the spinal cord population, which is used at similar rates to the general population. It was reported that the most common reason CAM was used, was for dissatisfaction with conventional medicine for treatment of chronic pain (Nayak et al. 2001). The only CAM technique evaluated in the SCI population is acupuncture although studies do not provide conclusive evidence of effectiveness (Dyson-Hudson et al. 2001; Nayak et al. 2001; Rapson et al. 2003).

Psychological interventions among non-SCI individuals with chronic pain are popular and it has been suggested that selected approaches may be useful for those with SCI (Consortium for Spinal Cord Medicine 2005). Cognitive-behavioural strategies have been found to produce changes in pain experience, increase positive cognitive coping and appraisal skills and reduce pain behaviours (Morley et al. 1999). There are mixed results for the use of relaxation training for relief of chronic pain (Carroll & Seers 1998), which may also have secondary beneficial effects on muscle tension and emotional distress (Astin et al. 2002; Leubbert et al. 2001). Cognitive-behavioral interventions have not been subjected to controlled trials as to their effectiveness in the SCI population (Wegener & Haythornthwaite 2001).

As identified in the Consortium for Spinal Cord Medicine (2005) document, modification of task performance based on ergonomic analysis has been proven to reduce the incidence of upper limb pain and cumulative trauma disorders of the upper limb in various work settings (Carson 1994; Chatterjee 1992; Hoyt 1984; McKenzie et al. 1985). It is suggested that these same interventions can be used to prevent pain and injury in SCI. Although the number of studies linking activities of individual with SCI to injury may be small, the ergonomics literature provides a strong basis for evidence-based practice. Recently, Rice et al. (2013) studied the impact of a strict education protocol in the implementation of the clinical practice guideline “Preservation of Upper Limb Function Following Spinal Cord Injury” addressing the impact of an education protocol on transfer skills and wheelchair propulsion. The study demonstrated a positive effect

on the importance of proper education in improving the quality of transfers and better wheelchair propulsion biomechanics as key elements in reducing the risk of shoulder injury and pain (Rice et al. 2013).

The Consortium for Spinal Cord Medicine (2005) Clinical Practice Guideline Preservation of Upper Limb Function published the following recommendations regarding the upper limb:

 Both the spinal cord injured person and the clinician need to be educated about the prevalence of upper limb pain and injury and the potential impact of pain and possible means of prevention  Routinely assess the patient’s function, ergonomics, equipment and level of pain as part of periodic health review  Assessment of risk factors, changes in medical status, new medical problems, changes in weight  Reduce the number of non-level transfers per day  Assess work related activities  Re-evaluate current exercise program (strengthening, stretching, conditioning)

Dyson-Hudson et al. (2001) in a randomized controlled trial compared acupuncture treatment to Trager Psychosocial Integration performed by a certified Trager practitioner. The authors noted that trager therapy is a form of bodywork and movement re-education to induce relaxation and encourage the patient to identify and correct painful patterns. The theory is that chronically contracted muscles induced by stress led to pain (Dyson-Hudson et al. 2001). There was a significant effect over time for both treatment groups in reducing shoulder pain, but there was no difference between the two groups.

Curtis et al. (1999) in a randomized controlled trial and Hicks et al. (2003) studied the effectiveness of a six-month exercise and stretching protocol on shoulder pain experienced by wheelchair users. The data supported the effectiveness of this exercise and stretching protocol in decreasing the intensity of shoulder pain that was interfering with functional activity of wheelchair users.

The Consortium for Spinal Cord Medicine (2005), Sipski and Richards (2006), Campbell and Koris (1996), Dalyan et al. (1999), and Nichols et al. (1979), have identified the following as important areas of further research in the upper limb:

 Research to validate and support the adoption of a standardized classification scheme with accompanying diagnostic procedures and criteria.  Research trials could include both primary prevention and treatment of acute and chronic pain.  Determine the best methods to treat existing painful shoulder lesions and prevent others so that these individuals are as pain free and independent as possible.  Further study is needed to elucidate the mechanisms of pain in this group and to establish why some patients who have pain early in rehabilitation continue to have pain at discharge and others do not.  Multicentre RCT of intervention are also needed to reduce the severity and impact of different subtypes of SCI pain.  Possible links between pain during rehabilitation and pain in long-term SCI.  Detailed investigation of the biomechanics of activities commonly performed by people with tetraplegia to enhance understanding of the stresses placed on the shoulder and the mechanical causes of shoulder pain.  Causes of shoulder pain in the acutely injured individual compared to the chronic spinal cord injured person.  Implementation of upper limb pain prevention and management programs for persons with SCI- acute and ongoing patient education about basic biomechanical principles on avoiding impingement and overuse  Managing the early signs of strain and overuse and knowledge of several alternative techniques of ADL.  Education and training in endurance and balanced strengthening of muscles acting around the shoulder and optimizing posture to achieve a normal alignment of shoulder, head, and the spine are critical for avoidance of injuries.  Ergonomically designed environmental changes and wheelchair, home and work modifications

Conclusions

There is level 1b evidence (from two randomized controlled trials; Hicks et al. 2003; Curtis et al. 1999) that a shoulder exercise and stretching protocol reduces the intensity of shoulder pain post SCI.

There is level 1b evidence (from one randomized controlled trial; Dyson-Hudson et al. 2001) that general acupuncture is no more effective than Trager therapy in reducing post- SCI upper limb pain.

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.

7.0 Reconstructive Surgery and Tendon Transfer

7.1 Hand The loss of upper limb function especially the use of the hand is one of the most significant and devastating losses an individual can experience. Tetraplegia is responsible for many problems in daily living, mostly related to the recovery and/or preservation of independence for the tetraplegic individual (Welraeds et al. 2003). The study by Hanson and Franklin (1976) showed recovery of hand function was preferred to that of the bladder, bowel or even sexual function

among tetraplegics. In a survey of tetraplegic patients, 75% responded that hand function was very important for their independence in ADL and to increase their quality of life (Snoek et al. 2004). In another study conducted in the United States with a sample of individuals with tetraplegia, 42% of the individuals viewed upper limb function as their top restoration priority (the function they wanted restored first) and 44% of the surveyed individuals reported an interest in receiving upper extremity reconstructive surgery (Wagner et al. 2007).

Reconstructive surgery is one option to attempt to improve the function of the hand and upper limb in persons with tetraplegia. Functionally, the benefit of reconstructive surgery may be evident as improved ability to write, complete catheterizations, dress, self-feed, drive, lift objects, button, turn dials, propel their wheelchair, catch objects overhead, turn in bed and swim are only some of the activities that become possible after surgery (Rabischong et al. 1993). Surgery has been reported to improve quality of life for those people who had little or no upper limb function (Freehafer et al. 1984).

Despite the many reported studies, over 40 documented studies, hand reconstructive surgery is not common practice in many spinal units and its importance in improving hand function still remains controversial (Forner-Cordero et al. 2003). Guttmann (1976), McSweeney (1969) and Bedbrook (1969) believed that only a small percentage of tetraplegics (5%) benefit from hand surgery because they re-adjust the function of their arm and hands if properly rehabilitated, while other authors like Moberg (1975) state that 75% of tetraplegics can obtain benefit from hand surgery. A recent review of epidemiologic data from the 1988 to 2000 in the USA found that only 7% of appropriate surgical candidates actually received surgery (Curtin et al. 2005). In a study completed by Wuolle et al. (2003), they surveyed individuals with tetraplegia who received upper extremity surgery, 70% of the individuals were satisfied with their results and 68% reported improvement in ADLs. These statistics are consistent with another study that surveyed physicians who estimated that there was 75% client satisfaction, suggesting that both the client and caregiver (physician and/or surgeon) view reconstructive surgery to be beneficial and satisfying (Wagner et al. 2007). Studies by Curtin et al. (2005) and Squitieri and Chung (2008) explored the reason for underutilization of reconstructive surgery in the tetraplegic population. Issues identified were; lack of clarity in the literature about the value of reconstructive procedures, lack of access to centres that perform reconstructive surgeries, lack of qualified and experienced hand surgeons and physiatrists who have an interest in this area of surgery and negative physician bias toward reconstructive surgery. Curtin et al. (2005) identified that it is important that there is good relationships between spinal cord specialists and surgeons (surgeons were 13.1 times more likely to perform surgery; physiatrists were 2.8 times more likely to refer clients for surgery).

Reconstructive surgery and tendon transfers are generally performed following an identifiable pattern based on the level of injury and results depend on the patient’s residual motor and sensory function as identified in each group (Freehafer et al. 1984). In 1978, the International Classification for Surgery of the Hand in Tetraplegia was developed at the International Conference held in Edinburgh and modified in 1984. The classification takes into account the residual motor strength below the elbow, considering that only the muscles graded 4 or 5 according to the Medical Research Council Scale (MRCS) are adequate for muscle transfer, as well as the sensibility in thumb and index. The sensibility was evaluated by the two-point discrimination test in the thumb and the index. If it is lower than 10mm the classification belongs to the group Cutaneous (Cu-) and if it is higher than 10mm and the patient needs visual help it is classified in the group Ocular (O-).

Table 8 Modified International Classification for Surgery of the Hand in Tetraplegia (McDowell et al. 1986) Sensory Motor O- Cu- Total 0 Weak or absent Brachioradialis (BR) ≤ grade 3 - - - 1 BR (≥ grade 4) 2 1 3 2* BR, ECRL - 1 1 3* BR, ECRL, ECRB 1 1 2 4* BR, ECRL, ECRB, PT 3 4 7 5* BR, ECRL, ECRB, PT, FCR - 4 4 6* BR, ECRL, ECRB, PT, FCR, Finger Extensors - - - 7* BR, ECRL, ECRB, PT, FCR, Finger Extensors, Thumb Extensors - 1 1 BR, ECRL, ECRB, PT, FCR, Finger Extensors, Thumb Extensors, 8* 1 - 1 Finger Flexors 9* Lacks intrinsics only - 1 1 Total 7 13 20 Note: O- = Two-point discrimination in the thumb > 10mm; Cu- = Two-point discrimination in the thumb<10mm; ECRL=Extensor Carpi Radialis Longus; ECRB= Extensor Carpi Radialis Brevis; PT= Pronator Teres; FCR= Flexor Carpi Radialis; *The listing of a muscle means that it is functional (grade 4 or better).

Candidates for reconstructive surgery are carefully selected and are followed by a rehabilitation team that includes an orthopedic surgeon, rehabilitation physiatrist, and therapist over a significant period of time. The identified criteria for selection are as follows: at least one year post-injury, completed a comprehensive rehabilitation program, neurologically stable, and psychologically adjusted to their injury.

The measure of outcomes following reconstructive surgery continues to be debated in the literature. Many of the reported studies on surgical outcomes are older, are case series evaluations and lack the rigor of randomized controlled trials, and have subjective outcomes based on reported client satisfaction. In addition, there is little consensus in the literature on the assessment instruments and tools to be used in this population as their reliability, validity and responsiveness have not been adequately proven. The methodology appears to be a major failing of the various scales and the absence of clear conceptual models forming the basis of their scales. Also, the scales or instruments have been deemed to be too insensitive to document the small but meaningful functional gains made by those with tetraplegia after functional surgery (Fattal 2004). Many authors state that comparing the post-surgical condition is the best way to evaluate results (Freehafer et al. 1984). There have been several articles published that discuss the use of the ICF conceptual framework as a way to interpret hand function outcomes following tendon transfer surgery for tetraplegia (Bryden et al. 2005; Sinnott et al. 2004).

The reconstructions of upper limb to obtain functions of pinch and grasp often require multiple procedure and are also individualized to each person. The reconstructions performed are also dependent on what motor muscles/tendons are present and strong enough for transfer (Kozin 2002). Dunn et al. (2012) completed a study that addressed client’s decision making process for reconstructive UL surgery and it was found that that a client’s decision to have surgery were underpinned by 6 core influences. These influences were the overall outcome of surgery, the client’s current goals and priorities in their life, the hope that their overall quality of life (QOL) would be improved, a stable home environment, available social supports and assistance for assisting with increased care needs post-surgery and access to information on surgery. It was also found that these factors were individualized to each person and is dependent on any number of issues at one time and can change in its priority over time. The most commonly performed surgeries for reconstructive pinch are:

Key-Pinch Grip – Brachioradialis to Extensor Carpi Radialis Longus, Flexor Pollicis Longus split tenodesis. The IP joint of the thumb may need to be stabilized to prevent excessive IP flexion.

Key-Pinch Grip with or without Hook Grip – Brachioradialis to Flexor Pollicis Longus with or without Flexor Digitorum Profundus tenodesis or Brachioradialis to Extensor Carpi Radialis Longus.

Key-Pinch Grip and Hook Grip – Brachioradialis or Pronator Teres to Flexor Pollicis Longus and Brachioradialist or Extensor Carpi Radialis Longus to Flexor Digitorum Profundus.

Additional procedures to increase thumb pinch and thumb opposition may also be completed.

Table 9 Reconstructive Surgery – Pinch Studies Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=8-58 yr; Gender: 1. All patients had preoperative grip males=103, females=30; Level of injury: strength of 0. At an average follow- tetraplegia; Follow-up time=3-24 months. up period of 31 months, the average Treatment: Extrinsic hand reconstruction final grip strength was 69N (7kg) with intrinsic balancing procedures vs. and the ADL improvement score extrinsic reconstructions without intrinsic averaged 35.5. balancing procedures. 2. Patients who underwent an intrinsic Outcome Measures: Pre and post- procedure had a statistically operative assessments of grip strength stronger grip (72N) than patients (on the second position of the Jamar who did not undergo an intrinsic dynamometer) and a patient procedure (p=0.026). questionnaire evaluating 31 ADLs. 3. Ocular group: 5 patients with an intrinsic procedure had a statistically stronger grip than patients without an intrinsic procedure (p=0.028). 4. With the exception of Ocular group 7, in which 8 patients did not undergo an intrinsic procedure due McCarthy et al. 1997 to their ability to balance tension USA between the extensors and flexors, Pre-post all other Ocular groups with an N=135 intrinsic reconstruction showed stronger grip than patients without an intrinsic reconstruction. 5. ADL improvements scores were higher but not statistically significant for those with intrinsic rebalancing versus those without rebalancing. 6. There was significant difference between the hands treated by FDS lasso and those treated by intrinsic tenodesis when patients were stratified by Ocular level. 7. There was also no significant difference in grip strength results between the FDS lasso versus the intrinsic tenodesis procedures when stratified by both Ocular level and type of extrinsic reconstruction, both surgical techniques were effective in

Author Year Country Score Methods Outcome Research Design Total Sample Size improving strength and ADL. Population: Age=16-29 yr; Gender: 1. (Follow-up 1-10yr (average 3.5yr) males=14, females=4; Level of injury: C5- 2. All patients reported a significant C6; Time since injury=16 months to 12/13 increase in independent hand yr. function in relation to ADLs, no House et al. 1992 Treatment: Carpal-metacarpal fusion was patient reported hand function was USA performed; along with extensor pollicis worse after surgery. Case Series longus tenodesis and motor transfer to 3. Technique provided a reliable and N=18 flexor pollicis longus. reproducible key pinch. Outcome measures: Function of the 4. All patients had significant hand, subjective pain scale, & level of improvement in functional ADLsand satisfaction with surgery and highly satisfied with results of rehabilitation. surgery. Population: Age=20-47 yr; Gender: 1. Release of the BR and suture to the males=13, females=2; Time since FPL. In 16/17 hands , fixation of the injury=8 months - 18 yr; Follow-up IP joint of the thumb was obtained time=8-48 months. with a Moberg screw. 11/17 patients Treatment: Surgery lacked active thumb extension had Outcome Measures: Pinch strength; tenodesis of the thumb extensors to ADL reports. the MCP to prevent excessive flexion of the MCP joint. 2. FPL and EPB were secured to the dorsum of the MC. 6/11 patients did not require tenodesis had sufficient strength in the FPL to extend the thumb. 3. 2/6 EIP was transferred to FPL for active extension. 4. Satisfactory finger flexion present in 10 hands. In seven hands: intertendinous suture of all FDP tendons in 4 patients who had active flexion in the ulnar profundi of small Waters et al. 1985 and ring finger, but could not flex USA index finger. Case Series 5. Transfer of PT to all FDP tendons in N=15 2 patients; transfer of ECRL to all FDP tendons in 1 patient; transfer of FCU to all FDP tendons in one patient. 6. Preoperative lateral pinch ranged from 0- 0.15 lbs, post-operative lateral pinch ranged from 2.2-4 (depending on elbow and wrist position). 7. Residual motor function in triceps (fair plus)(11 patients) and pinch strength; lateral pinch 5.1 lbs, strength fair or less (6patients) 2.0 lbs pinch. 8. 87% (13/15) reported significant improvement; 4 patients wanted stronger pinch. 9. 80% (12/15) could name 4 ADL activities that they were able to perform. 10. 13% (2/15) were dissatisfied.

Author Year Country Score Methods Outcome Research Design Total Sample Size 11. 20% (3/15) reported discomfort tip of thumb. Note: ADL=Activities of Daily Living; BR=Brachioradialis; ECLR=Extensor Carpi Radialis Longus ; FCR=Flexor Carpi Radialis; FDp=Flexor Digitorum Profundus; FPL=Flexor Pollicis Longus

Table 10 Summary of Pinch Studies Author N Intervention Main Outcome(s) Extrinsic reconstruction with Intrinsic +ve grip strength with intrinsic McCarthy et al. Balancing vs. without Intrinsic balancing 135 patients 1997 Balancing =ADL and functional use (183 procedures) FDS Lasso vs. Intrinsic Tenodesis for =grip strength Intrinsic Balancing =ADL and functional use CMC fusion +ve pinch strength EPL tenodesis +ve ADL and functional use 18 patients House et al. 1992 BR 0r ECRL or ECRI to FPL (21 procedures) As indicated: stabilization of thumb IP joint and Zancolli Lasso procedure +ve lateral pinch strength in all BR to FPL (lateral pinch) with thumb test positions IP joint stabilization (16 hands) +ve ADL functions Waters et al. 1985 15 patients 11 patients also had EPL tenodesis +ve direct correlation between (17 procedures) and EPB to metacarpal joint; 2/17 pinch strength and amount of patients EIP to EPL procedure residual triceps and wrist extensor strength Note: ADL=Activities of Daily Living; BR=Brachioradialis; ECLR=Extensor Carpi Radialis Longus ; FCR=Flexor Carpi Radialis; FDp=Flexor Digitorum Profundus; FPL=Flexor Pollicis Longus + positive outcome,=no difference, - negative outcome

Pinch and Grasp (Key-Pinch and Hook Grip) The most commonly performed surgeries to obtain key-pinch and hook grip are:

Wrist Extension – If the person does not have adequate wrist extension, Brachioradialis (BR) to Extensor Carpi Radialis Brevis (ECRB) is performed prior to any surgery for pinch reconstruction.

Key-Pinch and Hook Grip – Extensor Carpi Radialis Longus (ECRL) to Flexor Digitorum Profundus (FDP). This is a synergistic transfer in which dorsiflexion of the wrist potentiates the effects of the transfer. The amplitude of excursion provides strong flexion of the fingers into the palm. Brachioradialis (BR) is also transferred to Flexor Pollicis Longus (FPL).

The aim of these transfers is to provide mass finger flexion for grasp and independent thumb flexion for key-pinch against the side of the middle phalanx of the index finger. Adjustment of tension in these transfers is also completed (Lamb & Chan 1983).

Table 11 Reconstructive Surgery: Pinch and Grip Studies Author Year Country Score Methods Outcome Research Design Total Sample Size Meiners et al. 2002 Population: Age=21-57 yr; Gender: 1. Operative interventions on the Germany males=21, females=3; Time since tetraplegic hand brings gains in

Author Year Country Score Methods Outcome Research Design Total Sample Size Case Series injury=9-59 months. cylindrical and lateral grip and NInitial=24; NFinal=22 Methodology: Surgery. improvement in ADL. Outcome Measures: ADL questionnaire, 2. Subjective acceptance is high. Satisfaction Survey, Key grip and lateral 3. Complication rate is high. force grip. 4. Long duration of treatment. Population: Age=19-60 yr; Gender: 1. 7 extremities had had post deltoid to males=17, females=7; Level of injury: 3 in triceps transfer before group III (normal shoulder control, elbow opponensplasty; 24 patients, 11 flexion, radial wrist extensors), 11 in (46%) had bilateral opponensplasty. group IV (same as group III with 2. 35 opponensplasties were done. 22 functioning FCR, PT & triceps, weak flexor tendon transfers were done fingers), 7 in group V (intrinsic hand for voluntary grasp and then muscle paralysis) , 4 in group VI (did not opponensplasty. classify in groupings, but had incomplete 3. 14 patients (22 extremities) paralysis); Time since injury=1-17 yr; evaluated. Follow-up time=1-17 yr. 4. Subjects reported that they would Intervention: Surgery. have the operation again (95% of Outcome Measures: Not specified. the extremities) and had improved Kelly et al. 1985 function (91%). USA 5. One patient reported that function Case Series was unchanged; 1 was dissatisfied. N=24 Overall value of key pinch 35 extremities was 1.47 +/- 1.29 kg (mean +/- SD). 6. Grasp measured in 20 extremities; 2.81 +/- 2.89 kg (mean +/-SD) (range trace to 10kg). 7. Palmar pinch; 9 of 20 extremities (45%) achieved palmar pinch (1.04 +/- 1.02 kg; mean +/- SD) (range 0.20-3.0 kg). Palmar pinch achieved in 17% of the extremities in group III, 71% in group IV, and 33% in group V. Population: Age: mean=23.6yr; age at 1. Self-assessment questionnaire Rieser & Waters 1986 time of surgery: mean=29.8yr, time from results indicated: power decreased USA injury to operation 6.2 yr, follow-up time of since surgery in all patients. Case Series this study: 7.4 yr N=23 Intervention: Surgery Outcome Measures: Not specified Population: Level of injury: C5-6; Time 1. All reported they would have surgery since injury=at least 1 yr. again. Intervention: Surgery. 2. Key pinch strength in non-op limbs Lo et al. 1998 Outcome Measures: not specified. was 1.0±1.3 kg, in surgically treated Canada arms it was 1.2±1.1 kg. Case Series 3. Minnesota rate of manipulation: non- N=9 operative limbs were 1.50±0.25 sec, post-operative limbs was 2 min 56 secs±1 min 56 sec. Population: Age=16-36 yr; Time since 1. 6 of 8 subjects were evaluated. injury=4months-18 yr. Subjects indicated they were Colyer & Kappelman Intervention: Surgery. pleased with the surgery. 1981 Outcome measures: Not specified. 2. Hand function tests indicated an USA improvement (16-49% Case Series improvement). 5 of 6 subjects N=8 showed key grip strength remained constant.

Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=9-58 yr; Level of injury: No statistical results reported-8 pts tetraplegia. interviewed, 5 completed questionnaire. Failla et al. 1990 Treatment: Surgery. 1. Conclusion-transfer of USA Outcome Measures: key pinch, grip brachioradialis tendon provides key Case Series strength, function in ADL. pinch and grip of sufficient quality to N=8 improve the ADLsin patients with loss of flexion of the thumb and fingers. Population: Age=20-62 yr; Level of 1. Strength: key-pinch strength injury: C4-C7; Time since injury=15-239 average of 17.2 kPa (5-50 kPa); months. grasp strength average 18.8 kPa (3- Treatment: Surgical reconstruction. 45 kPa). Forner-Cordero et al. Outcome Measures: Increased hand 2. No relation found between the ADLs 2003 movement and strength; improvement in test and the key=pinch strength Spain ADL; patient's satisfaction, fulfillment of (p=O.7976) or grasp strength Retrospective Follow-up patient's expectations, surgical (p=0.6948). N =15; N =14 Initial Final complications. 3. Modification of ADL questionnaire; excellent (3) 21.4%; good (7) 50.0%; fair (2) 14.3 %; poor (2) 14.3%. Scores ranged from 54-122 points. Population: Age=20-47 yr. No statistical analysis reported Intervention: Surgery. 1. Passive range of motion (ROM) of the Gansel et al. 1990 Outcome Measures: Not specified. elbow and wrist remained unchanged USA post-surgery. Functional active flexion Case Series of the fingers was gained in 10 of 11 N=19 subjects. 2. Improved performance of ADLs was reported. Note: ADL=Activities of Daily Living; FCR=Flexor Carpi Radialis;

Table 12 Summary Pinch and Grip Studies Author N Intervention Main Outcome(s) 15 patients PD to Triceps +ve key-pinch strength (20 limbs) BR to ECRB +ve grip strength Tenodesis of FPL =ADL and functional use APL to CMC joint or arthrodesis of +ve patient satisfaction Forner-Cordero et CMC joint -ve patient expectation al. 2003 BR or ECRL or PT to EDC and EPL or tenodesis of extensor tendons BR or ECRL or ECRB to FPL PT or ECRL or BR to FDP 22 patients FCR to FDP +ve lateral and cylindrical (23 hands) ECRL to FDP grip Meiners et al. 2002 +ve satisfaction with surgery +ve ADL and functional use 8 patients ERCL to FDP and BR to FPL +ve satisfaction with surgery (12 procedures) +ve key-pinch and grip Lo et al. 1998 strength +ve ADL functional use 8 patients BR to FDP or FPL +ve key-pinch and grip Failla et al. 1990 (9 hands) BR or ECRL to FPL strength +ve ADL and functional use 11 patients 11/11 PT to FDP +ve finger flexion Gansel et al. 1990 10/11 BR to FPL +ve key-pinch strength 1/11 BR to FDS +ve ADL functional use Rieser & Waters 9 patients Tenodesis of FPL, thumb IP joint -ve result, bowstringing of

Author N Intervention Main Outcome(s) 1986 (10 procedures) stabilization FPL across MP joint 6/9 MP joint tenodesis of extensor -ve grasp and lateral pinch tendons of thumb strength 2/9 BR to wrist extensor 7/9 tenodesis of EPL and EPB 24 patients 7/24 also had PD to Triceps +ve satisfaction with surgery (57 procedures) Opponensplasty- FDS to APB Flexor +ve ADL functional use tendon transfers: BR (also used PT, +ve key-pinch, palmar pinch Kelly et al. 1985 FCR, ECRL, FCU, PL) to FDP; 22/35 and grip strength Flexor tendon transfer BR to FDP (also used PT, FCR, ECRL) 6 patients FPL tenodesis +ve improved pinch strength Colyer & (8 hands) 2 also had ECRL to FDP -ve finger flexion Kappleman 1981 +ve ADL and functional use Note: ADL=Activities of Daily Living; BR=Brachioradialis; ECLR=Extensor Carpi Radialis Longus ; FCR=Flexor Carpi Radialis; FDp=Flexor Digitorum Profundus; FPL=Flexor Pollicis Longus + positive outcome; - negative outcome

7.2 Elbow Extension 7.2.1 Posterior Deltoid to Triceps

The most commonly performed surgery for elbow extension is using the posterior third of the deltoid (PD) to motor the triceps. This converts the transferred portion of the deltoid into a two joint muscle but causes no functional loss at the shoulder (Moberg 1975).

Table 13 Reconstructive Surgery – Elbow Extension Studies (Posterior Deltoid to Triceps) Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Mean age=33.6 yr; Level of 1. The muscle was tested at 6 different injury: C6; Time since injury=28-173 lengths (130, 110, 90, 70, 45 and O months; Follow-up time=46.1 mo. degrees of elbow flexion) with the Treatment: The arm and forearm were shoulder abducted at 90. locked in position and a force transducer 2. When compared, the absolute was used to assess the torque output values (dimension of torque) were isometrically. The muscle was tested at 6 significantly different between different lengths with the shoulder groups (0.00001

Author Year Country Score Methods Outcome Research Design Total Sample Size tetraplegics sat in a wheelchair. All were deltoid-to-triceps transfer by 42% asked to perform 2 movements; a straight (mean 113 SEM 11), remained arm lateral and maximal raising and significantly lower (121 SEM 12) return. than control group (p<0.0001). Outcome Measures: Straight Arm 3. Hand-to-nape-of-neck-movement-no Raising and hand-to-nape-of-neck significant improvements were noted movement. after surgery. 4. Conclusion-peaks of shoulder and elbow flexion speed are almost normal, indicating the importance of restoring elbow extension torque for improving the whole kinematic picture of the upper limb. Population: Age=23-38 yr; Time since 1. Both groups scored identically on injury=5-16 yr. the FIM. Dunkerley et al. 2000 Treatment: Surgery. 2. No significant differences in mobility UK Outcome Measures: Questionnaire, were noted (p=0.256, and p=0.432). Case-Control FIM, 10 m push, and the figure of 8 push. 3. Questionnaire was answered only N =15; N =11 Initial Final by the treatment group; clients gave positive response to the questions. Population: Level of injury: C6-C7; Time 1. No statistically significant differences since injury=24 months. between pre and post-operative Lacey et al. 1986 Treatment: Surgery. stages. USA Outcome Measures: Not specified. 2. Activities that were noted as Case Series improved were: the overhead use of N=10 the arms, use of arms while lying supine and eating. Population: Time since injury=10-242 1. 15 of 18 reported function months. improvement after surgery, 13 felt Treatment: Surgery. they gained an increase in Outcome Measures: ADLs, and use of independence. Raczka et al. 1984 wheelchair. 2. Functional improvements and USA grooming was noted. Case Series 3. Improvements were noted in NInitial=22; NFinal=18 subject’s ability to relieve ischial pressure from their wheelchair, writing improved, and driving in a small percentage was positively affected.

Table 14 Summary Elbow Extension (Posterior Deltoid to Triceps) Author N Intervention Main Outcome(s) 5 pt PD to triceps + ve straight arm raise Remy-Neris et al. 2003 17 limbs +ve speed of movement 5 elbows, 6 PD to triceps =surgical/control gr: FIM (adapted) 13 controls items =surgical/control gr: W/C propulsion Dunkerley 2000 8m&10 m push +ve elbow function indicated on questionnaire Gr 1- 8 pt PD to triceps Initial tension pt transfer at time of 11 elbows surgery is important for torque output Rabischong et al. 1993 Gr 2-control 9 R + ve ADL and functional use hand (female) 10 pt PD to triceps +ve satisfaction with surgery Lacey et al. 1986 16 procedures +ve ADL and functional use

Author N Intervention Main Outcome(s) 18 pt PD to triceps +ve elbow extension strength Raczka et al. 1984 19 transfers +ve ADL and functional use + positive outcome; - negative outcome

7.2.2 Biceps to Triceps A biceps to triceps transfer can be used to create elbow extension in patients who have active supinator and brachialis muscles to provide for the lost functions of the transferred biceps (Kuz et al. 1999).

Table 15 Reconstructive Surgery – Elbow Extension Studies (Biceps to Triceps Transfer) Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Mean age: 17.3 yr 1. Manual muscle testing for elbow (range=66.4-21.7); Level of injury: 10 at extension revealed a statistically C5, 29 at C6, 1 at C7. significant increase in preoperative to Treatment: Surgery for a biceps to postoperative muscle strength triceps tendon transfer (36 left, 32 right). (p<.001). Outcome Measures: Manual muscle 2. 42/68 arms able to extend completely testing and Canadian Occupational against gravity (manual muscle Performance Measure. testing 3/5 or greater). 3. 9/68 arms had mild extension lag against gravity (manual muscle testing of 3/5). Kozin et al. 2010 4. 75% (51/68) arms were able to USA function overhead. Case Series 5. 17/68 arms were less than 3/5 (lack NInitial=45; NFinal=40 of strength attributed to a post- operative complication). 6. Improvement in one goal on the Canadian Occupational Performance Measure was observed by each patient. 7. Canadian Occupational Performance Measure total mean score statistically increased from 2.6 to 5.6 and from 1.8 to 5.7 for performance (p<.001) and satisfaction (p<.001), respectively. Population: Gender: males=7, 1. After surgery, elbow extension females=2; Level of injury: tetraplegic. muscle strength was improved in ICSHT: 0-4; Tendon transfer for elbow bicep and deltoid groups (p<0.001). extension: deltoids n=8, biceps n=8. 2. No significant increase in elbow Treatment: Surgery. extension muscle strength was Outcome Measures: Muscle strength, found following surgery. Flexion torque, Modified University of 3. 7 of 8 bicep-to-triceps procedures Mulcahey et al. 2003 Minnesota Tendon Transfer Functional had clinical improvements in USA Improvement Questionnaire, Canadian antigravity muscle strength, in RCT Occupational Performance Measure comparison with 1 of 8 deltoid N=9 (COPM). transfers completed. 4. No significant difference between the groups was found for elbow flexion torque (47% reduction in torque after 2 years versus baseline). 5. Following surgery, 48/63 elbow extension ADL did not improve in

Author Year Country Score Methods Outcome Research Design Total Sample Size subjects and there was no alteration in the remaining 15/63. 6. Performance and satisfaction with personal goals improved post- surgery as well. Population: Level of injury: tetraplegia. 1. No statistical results reported: Treatment: Surgery. 2. Subjects indicated they were Kuz et al. 1999 Outcome Measures: Not specified. satisfied with the surgery. USA 3. Activities that required precision Case Series hand placement had improved. N=3 4. Elimination of the need for some adaptive aids was possible post- surgery.

Table 16 Summary Reconstructive Surgery - Elbow Extension Studies (Biceps to Triceps Transfer) Author N Intervention Main Outcome 40 patients Biceps to Triceps +ve elbow extension strength 36 left; 32 +ve reaching overhead right elbow Improvement in one goal on Canadian Kozin et al. 2010 surgeries Occupational Performance Measure (COPM) for each patient Statistically significant improvement in performance and satisfaction scores on COPM 9 patients Biceps to Triceps +ve elbow extension from either surgery 16 elbows Posterior Deltoid to +ve improvement in ADL skill (both Mulcahey et al. 2003 Triceps surgeries) +ve antigravity strength (biceps to triceps > posterior deltoid to triceps) 3 patients Biceps to Triceps +ve elbow extension 4 elbows +ve functional improvements through Kuz et al. 1999 ability to place the hand in space +ve satisfaction with surgery + positive outcome; - negative outcome

7.3 Multiple Reconstructions The following studies report results from multiple procedures to reconstruct the upper limb.

Table 17 Reconstructive Surgery – Multiple Reconstructions Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age range: 19-70 yr; Type of 1. Active thumb-index opening SCI: traumatic=12, non-traumatic=3; increased significantly from 2.5 (SEM Level of injury: tetraplegia=15, 1.0) cm before surgery to 9.0 (SEM Friden et al. 2012a paraplegia=0; Mean time since SCI: 0.8) cm after surgery. Sweden 54.2±42.8 mo; International classification 2. Nine patients without previous active Pre-post of patients’ upper extremities: OCu4- opening of the first web space N=15 OCu8 (with one patient who was recovered a mean thumb-index exceptional). opening of 9.1 (SEM 1.7) cm; this Treatment: All patients had their extensor distance increased an average of 2.9

Author Year Country Score Methods Outcome Research Design Total Sample Size digiti minimi (EDM) tendon transferred to (SEM 0.8) cm in six patients who had the abductor pollicis brevis (APB) through active thumb-index distance of 6.3 the interosseous membrane, in addition to (SEM 1.6 cm) before surgery ≥3.2 procedures to restore key pinch. 3. 14/15 patients were able to direct and Outcome Measures: Maximum distance coordinate key pinch and perform between the thumb and index finger tips tasks using restored APB function during active or passive opening of the including five patients whose EDM hand, maximum angle of palmar strength was rated as grade 3 before abduction, grip and key pinch strength, the transfer. and active finger range of motion (ROM). Population: Treatment group (n=6): 1. Post-operative active pronation was Mean age: 32.2±4.9 yr (25-56); Gender: significantly greater in the dorsal males=4, females=2; transfer group in comparison to the Control group (n=6): Mean age: 31.2±5.0 palmar group (149±6° and 75±3°, yr (19-52); Gender: males=4, females=2. respectively). Friden et al. 2012b Treatment: Individuals in the treatment 2. Pinch strength was similar between Sweden group had a brachioradialis (BR) to Flexor both groups (1.28±0.16 kg and Case Control pollicis longus (FPL) transfer dorsal to 1.20±0.21 kg), respectively. N=12 radius through the interosseous 3. It is feasible to reconstruct lateral key membrane whereas the control group pinch and forearm pronation received traditional palmar BR to FPL. simultaneously using only the BR Outcome Measures: Lateral key pinch muscle. and pronation range of motion (ROM). Population: Mean age=42.9 yr; Time 1. Elbow Extension: bilateral surgery since injury=20.5 yr; Time since 9/11 subjects; Hook Grip; 17 right surgery=15.1 yr; Handedness: right=22, hands (av. Grip 46.2 mm Hg in left=24; Level of Injury: 01: 6 hands; 02: 3 1991; improved slightly, not hands; 03: 5 hands; 0Cu2: 2 hands; statistical significant (p=0.30)) Left 0Cu3: 6 hands; 0Cu4: 17 hands; 0Cu5: 8 hand: 15 hands: significant increase hands; 0Cu6: 1 hand; tetraplegia. (p=<0.001), av. 28.7 mmHg to 53.2 Treatment: Surgery. mmHg; no statistical significance Outcome Measures: Lamb and Chan between right and left hook grip as questionnaire with additional 10 Burwood measured by SGM and DA in 2001 questions; Swanson sphygmomanometer (p=0.93 and p=0.97). (hook grip); Preston Pinch Meter (key 2. Key Pinch: av. key pinch 20 right pinch); Quadriplegic index of Function thumbs in 1991 25.8 N and (QIF); Digital Analyzer (key and grip decreased in time to av. 13.9 N pinch) (significant decrease p=<0.001); Rothwell et al. 2003 average pinch strength 18 left New Zealand thumbs decreased from 17.7 to 8.8 Case Series N (significant decrease p=<0.001). NInitial=29; NFinal=24 Average pinch strength measured by DA, increase in key pinch when compared to 1991, significant for both right (p=0.01) and left (p=0.01) thumbs. 3. Active Transfer Vs. Tenodeses: hook grip: active transfers 2x strength of tenodeses in 1991 (p=0.05) and 2001 (p=0.03). Pinch grip: similar to 1991 data (p=<0.001), 2001 data does not follow trend. 2001 DA data did not reach significance (p=0.06). 4. Longitudinal Comparison: hook grip strength 25 hands with active transfers significant increase 42.1 to

Author Year Country Score Methods Outcome Research Design Total Sample Size 60.2 mm Hg (p=<0.001) and pinch grip increase from 24.0 to 38.4 N in 31 thumbs that had active transfers using 2001 DA data (p=0.03). Hook strength obtained from a tenodesis in 7 hands did not weaken over time (p=0.05) but pinch strength in 7 thumbs significantly increased (p=<0.001) using 2001 DA data. 5. Questionnaire results; Lamb and Chan activity measure: showed perceived improvement of functional activities significantly lower in 2001 (p=<0.001). QIF scores of current functional independence was significantly better (p=0.004). Additional Burwood questionnaire showed levels of satisfaction, perceived expectation, gratification and opportunity enhancement were maintained over time (p=0.281). Population: Mean age=37yr; Level of 1. No statistical analysis provided- injury: C5-C8; Time since injury=7-356 gestural ability improved in more months. than 80% of the patients and Treatment: Upper limb surgery. functional gain was important in Welraeds et al. 2003 Outcome measures: Functional testing. more than half. Belgium 2. 43 procedures; Atypical procedures Case Series (2) good: 2; Moberg procedures (18) N=25 good: 17; poor: 1; Deltoid/triceps (12) good: 7; fair 3; poor 2; Additional procedures (11) good: 7; fair: 3; poor: 1. Population: Level of injury: C5-C8. 1. Oponens transfers were done 180 Treatment: Surgical reconstruction. times; transfers for finger flexion-161 Freehafer 1998 Outcome Measures: Not specified. times; posterior deltoid transfers-59 USA times; transfers for wrist extension- Case Series 17 times. N=285 2. 13 out of 285 stated that they were no better, and no patient said they were worse. Population: Mean age=27 yr; Gender: 1. Subjective Assessment: obtained for males=51, females=6; Level of Injury: 86% of the patients, av. Follow up of 00:4; 01: 6; 02: 4; 03: 6; 0X: 3; Cu3: 6; Cu 37 months (range 5-86 months); 4: 24; Cu 5: 10; Cu 6: 3; Cu X: 3; 70% reported good or excellent tetraplegia. results; 22% fair; 8% poor. Treatment: Surgery. 2. Simultaneous surgery for key-grip Outcome Measures: Subject and hook grip strength: 96% good or Mohammed et al. 1992 assessment of ADL by questionnaire; excellent results. New Zealand Objective assessment of key pinch 3. Objective Results: over 70% of Case Series (Preston Pinch Meter); Hook-grip strength patients, av. follow up of 32 months; N=57 (modified Sphygmomanometer); Elbow Key Pinch 52/68 cases (76%); av. extension: MRC grading system. strength was 2.1 kg. Hook grip measured in 42/58 cases (72%), thumb included av. strength was 42 mmHg; thumb excluded 29 mmHg. 4. Elbow extension measured in 71% of patients, obtained grade 3 or 4

Author Year Country Score Methods Outcome Research Design Total Sample Size strength. Population: Age=26-70 yr; Gender: 1. Elbow Extension: 30 elbows in 23 males=36, females=7; Level of Injury: 0:1 patients; (23/30 with free tendon 9 pts; 0:2 2 pts; 0Cu:1 4 pts; 0Cu:2 13 graft;7/30 Castro-Sierra and Lopez- pts; 0Cu:3 9 pts; 0Cu:4 5 pts; 0Cu:6 1 pt. Pita method); 5/23 with free tendon Re-examined 1-14 yr after the last graft 1/23 full ext.; 8/23 lack ext. operation. against gravity of max. 60; 10/23 Treatment: Surgery. lack even more ext.; 6/7 ext. deficit Outcome Measures: Questionnaire of 55 greater than 60. ADL tasks; opinion of the effect of surgery 2. Key Grip: 50 hands/40 patients; to perform these ADL tasks; elbow Strength 0-3.5 kg (av. 0.7 kg); 15 Ejeskar & Dahllof 1988 extension (evaluation of extension deficit cases had minimum of 1.0 kg. Sweden or holding a sand bag in hand); key grip 3. Finger Flexion: 14 hand/13 patients Case Series pinch (Preston Pinch Guage); finger (ECRL to profundi II-V); grip 0-0.27 N=43 flexion (Martin Vigorimeter). kP (av. 0.13 kP); 5/14 minimum strength 1.0 kg. 4. 4 patients reported no improvement (1 severe spasticity, 2 BR muscle transferred to wrist; 1 operation on weaker hand); 4/43 could not state how much they had improved, 35/43 average improved capacity to perform 23/55 ADL tasks; 3/43 patients a functional deterioration. Population: Mean age=15-61 yr; Level of 1. One hundred forty two transfers injury: tetraplegia; Time since injury=1-17 were performed on 68 subjects. Freehafer et al. 1984 yr. 2. No upper limbs were made worse. USA Treatment: Surgical reconstruction. 3. Four remained unimproved, all Case Series Outcome Measures: Comparison of the others that had tendon transfers N=68 post-surgical with the pre surgical improved. condition. Population: Mean age=29 yr; Gender: 1. Elbow Function: 10/16 elbows (10 males=38, females=3; Level of injury: patients): full extension; 2/16 elbows tetraplegia; Severity of injury: complete; 20 degree flexion contracture; 4/16 Follow up time=6 months - 25 yr. 15 degrees of extension lag. All 10 Treatment: Surgery. patients considered the procedure Outcome Measures: Elbow strength; beneficial. Hand function (assessment checklist 2. Hand Function: 48 hands (assessed developed); ADL (developed checklist). only 27 patients). 5 rated as excellent; 28 rated good; 11 rated as fair; 4 graded as poor. No patient had any impairment of hand function Lamb & Chan 1983 after operation. UK 3. ADL: 29 patients assessed. No one Case Series considered their functional capability N=41 deteriorated after operation. Most significant improvement in basic activities such as washing, eating and using the toilet, hold glasses and cups, wash limbs and brush hair, turn on taps, improve bladder compression, insertion of suppositories, change from complete reliance on other for self- care, more mobile, 7 able to drive a car. Improvement in UL function facilitated development of personal

Author Year Country Score Methods Outcome Research Design Total Sample Size interests. Population: Level of injury OCu 1,2,3. 1. No statistically significant findings Treatment: Reconstruction of key grip reported and active elbow extension. 2. Subjective client reports. Hentz et al. 1983 Outcome Measures: interview and/or USA questionnaire (self-care, communication, Case Series mobility), objective measurements - pre + N =30; N =23 Initial Final post op strength, ROM wrist + elbow extension, strength of key pinch, range of passive wrist flexion + functional testing Note: ADL=Activities of Daily Living;; BR=Brachioradialis; ECLR=Extensor Carpi Radialis Longus

Table 18 Summary Multiple Reconstructions Author N Intervention Main Outcome(s) Friden et al. 2012a 15 patients EDM to APB +ve key-pinch and grip strength Friden et al. 2012b 12 patients BR to FPL +ve pinch strength BR to FPL or BR and +ve key-pinch and hook grip 24 patients tenodesis FPL +ve ADL and functional use Rothwell et al. 2003 (48 reconstructions) ECRL to FDP PD to Triceps PD to Triceps +ve elbow extension 25 patients Welraeds et al. 2003 ECRL to FDS +ve key grip and grasp (43 procedures) BR to FDS +ve ADL and functional use Opponens transfer: 180 Review of surgical procedures and times recommendations. Transfers to finger 285 patients Freehafer 1998 flexors: 161 times (417 transfers) PD to Triceps: 59 times Transfers for wrist extension: 17 times PD to Triceps + hook grip strength Key-Pinch: BR or PT to +ve ADL and functional use 57 patients ECRL; FPL tenodesis Mohammed et al. 1992 (97 transfers) and IP stabilization Hook Grip: BR or ECRL to FDP PD to Triceps -ve elbow extension 43 patients Tenodesis FPL, thumb +ve key-grip and finger flexion Ejeskar & Dahllof 1988 (94 transfers) IP joint stabilization +ve ADL and functional use ECRL to Profundus iv Variation of all +ve key-pinch and grip strength 68 patients Freehafer et al. 1984 procedures +ve elbow extension (142 transfers) +ve ADL and functional use PD to Triceps +ve elbow extension and function Biceps to Triceps -ve elbow extension (biceps to Hand Grip: ECRL to triceps) FDP +ve hook grip and key pinch and BR to FPL ADL and functional use 41 patients Key-Pinch: FPL Lamb & Chan 1983 (57 reconstructions) tenodesis or FPL tenodesis plus ECRL to FDP Other: EPB to ECU, FCR to FDS, APB to EDM

Author N Intervention Main Outcome(s) PD to Triceps or Biceps +ve satisfaction with surgery to Triceps +ve pinch and grip strength 30 patients Hentz et al. 1983 FPL tenodesis (40 limbs) BR to ECRB EPL and EPB tenodesis Note: ADL=Activities of Daily Living; BR=Brachioradialis; ECLR=Extensor Carpi Radialis Longus ; EDM = extensor digiti minim ; FCR=Flexor Carpi Radialis; FDp=Flexor Digitorum Profundus; FPL=Flexor Pollicis Longus; Extensor Carpi Radialis Brevis + positive outcome - negative outcome

Discussion

In reviewing the identified studies as a whole, the operative interventions on the tetraplegic hand and upper limb bring definite gains in pinch force, cylindrical grasp, and the ability to reach above shoulder height that result in an improvement in ADL function and quality of life for the individual with tetraplegia. Despite the low level of evidence (grade 4) the subjective acceptance among patients who have had reconstructive surgery is high. One of the reported downsides of surgery is the high complication rate (infection, torn attachments) and the extended period of time post-surgery for rehabilitation and increased need for personal care (Meiners et al. 2002).

Many SCI centres do not offer or have access to reconstructive surgery or neuroprothesis interventions. It is also debated whether the overall cost of surgery or use of neuroprostheses is more beneficial to the client, as the client has to relearn new movement strategies in order to perform ADL (van Tuijl et al. 2002).

Conclusion

There is level 4 evidence (see Table 9-18) that support the use of reconstructive surgery for the tetraplegic upper limb for the improvement of ADL and quality of life.

Reconstructive surgery appears to improve pinch, grip and elbow extension functions that improve both ADL performance and quality of life in tetraplegia.

8.0 Nerve Transfers

Recently, the literature is publishing information regarding the surgical procedure of nerve transfers which is evolving as an alternative procedure compared to tendon transfers for improving the functional ability of the hand and upper limb post SCI (Keith & Peljovich 2012). A nerve transfer involves the repair of distal denervated nerve element by using a proximal foreign nerve as the donor of neurons and their axons to re-innervate the distal targets (Addas & Midha 2009; Brown et al. 2012; Midha 2004). The transfer involves sacrificing the function of a lesser valued donor nerve to revive function in the recipient nerve and muscles, which is considered functionally more critical than the donor nerve (Senjaya & Midha 2013).

Senjaya and Midha (2013) and Midha (2004) described and listed the fundamental principles, advantages and potential drawbacks of nerve transfers when compared to tendon transfers in a review article and they are summarized in the following;

8.1 Fundamental Principles

1. The recipient nerve should be repaired as close as possible to the target muscle to ensure the shortest amount of time for re-innervation in an attempt to minimize distal denervation and motor end plate changes. 2. Donor nerve should be from a muscle whose function is expendable or has redundant innervation. 3. Nerve repair should be performed directly without intervening grafts. 4. Use of a donor muscle with pure motor fibers maximizes muscle fiber re-innervation. 5. Donor nerve should have a large number of motor axons and be a reasonable size match to the recipient nerve. 6. To facilitate motor re-education, a donor nerve that has a function synergistic to the muscle reconstructed should be used because cortical re-adaptation is the physiological basis of functional recovery. 7. Motor re-education improves functional recovery post operatively.

8.2 Advantages over Tendon Transfers

Nerve transfers have many advantages over tendon transfers.

1. Tendon transfers require significantly more dissection and extended post-operative limb immobilization while the tendon heals (Brown 2012). Less surgical scarring in common areas of the hand where tendons overlap anatomically, thus fewer chances of restricted motion (Keith & Peljovich 2012) 2. Reconstruction of finger flexion and extension must be done in separate phases, owing to conflicting positions for postoperative immobilizations (Revol et al. 2002) which maybe problematic for some who are highly dependent on others for care to be incapable of performing most basic ADL for quite some time (Bertelli et al. 2011; Brown 2012; Hentz 2002) 3. Tenotomy may cause detrimental effects on muscle function owing to the fact that reduced specific force is developed (Guelinekx et al. 1998) 4. Nerve transfers take a shorter period of less restrictive immobilization probably with less pain, minimal loss of donor muscle function (Brown 2012) 5. Reconstruction of finger flexion and extension can be done at the same time- tension- insertion balance of the muscle tendon unit is preserved because there is no disruption to the insertion or attachment of the muscle in question-maintaining line of pull and excursion and avoiding scar induced restrictions of movement (Brown 2012) 6. Nerve transfers offer a greater functional gain for a given transfer (Brown 2011; Brown 2012; Brown et al. 2012), the transferred axon, which originally provided re-innervation to a single muscle can re-innervate multiple motor fibers, later on with motor re- education and central plasticity, it is possible to activate multiple functions independently by the same nerve that initially controls only a single function (Brown 2011; Brown 2012; Midha 2004). 7. Nerve transfers can be accomplished without appreciable loss of function from the donor muscle group because nerve transfer can be performed with only a portion of the donor nerve, not entirely denervating the muscle associated with the donor nerve (Brown 2011; Brown 2012).

Although the partial denervation results in a reduced number of axons to the original muscle, the residual motor axons sprout within the muscle and innervate orphaned muscle fibers to enlarge the motor unit. Each motor axon can increase innervation 5x the number of muscle fibers that it originally served (Gordon et al. 1993). This phenomenon is called adoption (Brunelli & Brunelli 1983) and in time, the donor muscle may regain its original strength.

8.3 Potential Drawbacks of Nerve Transfers

There are also a few potential drawbacks of nerve transfers (Senjaya & Midha 2013).

1. When the donor nerve and its pertinent muscle sacrificed are of suboptimal function to begin with (MRC 3 or 4), nerve transfer many significantly downgrade its function. 2. An entirely denervated muscle, as a result of its nerve being donated is no longer suitable for muscle transfer donor. 3. Central motor re-education is needed to achieve functional recovery-this re- education can be challenging for patients, especially for nerve transfers from non- synergistic nerve.

8.4 Assessment and Surgical Timing

Prior to considering surgery, a detailed and careful assessment must be completed. Coulet et al. (2002) recommended assessing the following;

The extent of LMN injury at the injured metamere must be assessed and each key muscle group evaluated to determine; a) type of motor neuron injury (LMN, UMN) by evaluating tone, trophic status, deep tendon reflex b) joint ROM and deformities c) electrodiagnostic studied are beneficial to determine extent of SCI

After a careful and complete evaluation, Coulet et al. (2002) recommended mapping the muscles to identify three the following: a) Functional muscles (innervated by supralesional segments) b) Paralyzed and denervated muscles (innervated by injured metamere with damage to LMN) c) Paralyzed but innervated muscles (innervated by infralesional segment, with preserved LMN)

The next assessment to be made is to decide what primary function to be restored. Kozin (2002) recommended the following priority: 1) restoration of elbow extension; 2) pinch restoration for hand function; and 3) grasp and release function.

Nerve transfers should be performed after a re-innervation window, to allow adequate waiting time to ensure optimal spontaneous recovery has been achieved for lesional level myotomes. Bertelli et al. (2011) recommended waiting at least 6 months. Re-innervation of muscle innervated by infralesional segment is not time-dependent and can performed years after injury (Bertelli et al. 2011).

8.5 Evidence

Restoration of elbow extension function is an integral part of UE reconstruction because recovery of this improves elbow stability, the ability to perform pressure relief maneuvers, push a manual wheelchair, reach for items and objects above shoulder height and the ability to complete functional transfers such as bed, toilet, tub and car transfers. To date there have been one case report (Brown et al. 2011) and one cadaver study (Bertelli et al. 2011) on nerve transfer for elbow extension function.

The primary goal of reconstruction in hands of a person with tetraplega is the restoration of the ability to create a pinch using the thumb and lateral side of the index finger, for example when holding a key (Bertelli et al. 2012). To date there has been four published case reports (Bertelli et al. 2012; Mackinnon et al. 2012; Brown 2011; Hsiao et al. 2009) on nerve transfer for pinch and grip.

Finger extension is required for object acquisition (grasp) and object release (let go) (Kozin 2002). Two date there have been three case reports (Brown 2011; Bertelli et al. 2010; Palazzi et al. 2006) and one cadaver study (Bertelli et al. 2009) on nerve transfer for thumb and finger extension.

Conclusion

There are only a few reported and published studies on nerve transfer surgery for restoring hand and upper limb function after a SCI and based on the published literature, nerve transfer surgery is emerging as another surgical alternative.

Nerve transfer surgery to restore hand and upper limb function in the person with tetraplegia is emerging as another surgical alternative.

9.0 Neuroprostheses

A neuroprostheses for grasping is a device designed to improve or restore the grasping, holding and reaching functions in individuals with stroke and SCI (Baker et al. 1993; Cornwall & Hausman 2004). The neuroprostheses applies FES of the motor branches of the peripheral nerve in which paralyzed muscles are electrically stimulated to produce muscle contraction, replacing the electrical signals coming from the brain through the injured spinal cord (Shimada et al. 1996; Handa 1997; Hincapie et al. 2008). The FES uses bursts of short electrical pulses (pulse widths 0-250 mSec and pulse amplitude 0-150 mA) to generate muscle contraction by stimulating motoneurons or reflex pathways. The key element for achieving synergistic activity of muscles that results with reaching and grasping is the appropriate sequencing of bursts of electrical pulses. For continuous contraction of the arm and hand muscles (tetranization), a FES system has to deliver at least 16 stimulation pulses per second to elicit action potentials (AP) in the motor nerve, causing the corresponding muscles to contract. FES enables the patients with high SCI to reconstruct grasp movements such as palmar and lateral grasps of the upper extremity (Shimada et al. 2003). The palmar grasp is used to hold bigger and heavier objects such as cans and bottles and the lateral grasp is used to hold smaller and thinner objects such as keys, paper and CDs (Popovic et al. 2002). It has been reported to be useful in improving ADL functions (Popovic et al. 2001a; Shimada et al. 1996). FES is also applied to generate elbow extension by stimulating the triceps brachii in combination with voluntary biceps contraction used to augment reaching (Grill & Peckham 1998; Popovic et al. 1998). Elbow and shoulder FES systems have not been developed into practical clinical devices.

The motor nerves can be stimulated using surface (transcutaneous), percutananeous or implanted electrodes (Mortimer 1981). Transcutaneous stimulation is performed with self- adhesive or non-adhesive electrodes that are placed on the subject’s skin in the vicinity of the motor point of the muscle that needs to be stimulated (Baker et al. 1993; Mortimer 1981). Percutaneous and fully implanted electrodes are placed close to the entry point of the motor

nerve to the muscle which should be stimulated, either epimysial or intramuscular (Cameron et al. 1997; Hoshimiya & Nanda 1989).

Individuals with C5-C7 complete SCI and with no major degree of motoneuron or nerve root damage of the stimulated muscles benefit the most from neuroprosthesis. The use of an implanted FES system can only be applied once the patient reaches stable neurological status, which usually occurs two or more years post SCI. The use of surface FES systems can be introduced during the early rehabilitation period, as the patient does not have to be neurologically stable.

Gorman et al. (1997) and Cornwall and Hausman (2004) have presented guidelines for patient selection for consideration of for an implantable neuroprosthesis. They are as follows:  Anatomic: Stable tetraplegia with C5 or C6 motor level with international classification motor scores of 0, 1, 2 or an impairment scale level of A, B, C (AIS)  Physiologic: Presence of adequate ROM in joints of the shoulder, arm, forearm, wrist and hand  Medical: Free of overwhelming medical problems  Psychosocial factors: Sufficient motivation to learn its use and use it  Adequate caregiver and/or family support  One year post injury, plateau of functional recovery.  Need for sufficient vision to provide visual feedback during training and use sufficient cognitive ability

Contraindications to neuroprothesis use include cardiac disease, arrhythmias, pace makers, chronic systemic infections, diabetes, and immune disease

9.1 Types of Neuroprostheses There are several existing neuroprostheses and these include implanted FES systems such as the Freehand System and the NEC FESMate System and surface stimulation electrode systems such as the NESS H200 (formerly Handmaster NMS-1), Bionic Glove, ETHZ-ParaCare Neuroprosthesis and systems developed by Rebersek and Vodonik (1973) and Popovic et al. (2000).

9.1.1 Freehand System The Freehand System from Cleveland, OH, USA is an implantable neuroprothesis intended to restore hand function in C5 and C6 level tetraplegics. The Freehand system can stimulate eight different muscles in order to produce a useful grip and key pinch in tetraplegic individuals. The system consists of a surgically implanted receiver/stimulator unit and electrodes with an external controller and power supply/microprocessor. It was first implanted in 1986 (Cornwall & Hausman 2004). The Freehand System has been implanted in more than 250 individuals with C5 and C6 level tetraplegia (Ragnarsson 2008).

The NeuroControl Freehand System consists of an active receiver/stimulator that is placed in the chest wall and has eight leads that come from the receiver/stimulator and pass under the skin to a connector site in the upper arm. At this point they are joined to epimyseal electrode leads that are passed under the skin from the forearm and hand. Power and control signals from the unit are passed through the skin to the receiver/stimulator from a skin-mounted coil. The patient controls the device by movement of the opposite shoulder that uses a skin surface mounted position detector. The lateral grasp is generated by first flexing the fingers to provide

opposition, which is followed by thumb flexion. Palmar grasp is generated by first forming the opposition between the thumb and palm, followed by simultaneous flexion of both the thumb and fingers. Stimulating the flexor digitorum superficialis and profundus muscles performs finger flexion and finger extension is obtained by stimulating the extensor communis digitorum. Stimulation of the thumb thenar’s muscle or median nerve produces thumb flexion. Hand opening and closure strength are proportional to the distance moved by the shoulder. Both palmar and lateral grasps are possible by pressing a button on the shoulder controller. Taylor et al. (2002) and Keith et al. (1996) reported that most clients will require several surgical procedures are needed for each client for optimal use of the device. The most common surgeries performed are brachioradialis to extensor carpi radialis for voluntary wrist extension and posterior deltoid to triceps for elbow extension (Keith et al. 1996; Taylor et al. 2002). The 1st generation of the Freehand System is no longer available from NeuroControl Corporation. There are devices still available on a selective basis in several centres (Cornwall & Hausman 2004; Ragnarsson 2008).

Table 19 Freehand System Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=13-53 yr; Gender: 1. General Satisfaction: 87% were males=26, females=8; Level of injury: positive agree or strongly agree, tetraplegia; Follow-up time=1 yr post 97% would recommend survey, including 6 months of home use. neuroprosthesis to others, 90% Treatment: Implemented with a hand were satisfied with neuroprosthesis, neuroprosthesis that provides grasp and 90% stated neuroprosthesis was release. reliable, 87% would have surgery Outcome Measures: Functional again, 80% felt the neuroprosthesis Evaluations: standardized test of grasp met their expectations, & 77% would and release (GRT), measurements of pay for the neuroprosthesis if they pinch strength and range of motion & had the money. satisfaction survey. 2. Life Impact: 88% responses were positive for life impact; 90% stated neuroprosthesis improved their quality of life; 87% positive impact on their life (90% reported did not make a negative impact); 83% Wuolle et al. 1999 provided a benefit ADL; 87% USA responses regarding changes in Case Series ADL were positive; 93% participants N =42; N =30 Initial Final could perform ADL easier; 93% could perform ADL such as painting and shaving; 90% had increased confidence when performing ADL; 83% could perform ADL more normally; 73% could perform ADL faster. 3. Independence: 81% of responses were positive; 87% reported they were able to function more independently; 83% used less adaptive equipment; 87% required less assistance from others; 67% felt more comfortable out in the community alone. 4. Occupation: 57% of responses to occupation questions were positive

Author Year Country Score Methods Outcome Research Design Total Sample Size 5. Appearance: 87% felt their hand appearance was unchanged or improved. 6. Usage: used prosthesis median of 5.5 days/week - ranged from 15 participants (44%) who donned the neuroprosthesis 7 days per week to 5 participants (15%) who used it less than 1 day/week; 24/34 participants (71%) used it 4 or more days/week; range of usage C4/C5, C5/C5, C6/C6 levels was the same (0 to 7 days/week) C5/C6 group - used it most regularly 4 to 7 days/week with most participants 8/10 reporting daily use. 7. Activities: most frequently reported activities included eating, drinking, shaving, brushing teeth, brushing hair, writing, operating a computer, playing games. 8. Quality of Life: 18/34 positive comments; 1/34 responded neutrally; 1/34 responded negatively. 9. Improvements: Additional stimulus channels, an implanted command source, smaller, lighter external control unit - easier to don, improve hand and arm function, make device operable if user is confined to bed. Population: Mean age=29.1 yr; Gender: 1. There was significant improvement males=4, females=2; Level of injury: in lateral pinch and palmar grasp tetraplegia; Time since injury=1.2 -11.3 yr; force after rehabilitation with and Chronicity=chronic. without the neuroprothesis. Treatment: The Freehand System – an 2. Force differences were not found implanted multichannel neuroprothesis. between presurgery and Outcome Measures: Pinch forces; Grasp rehabilitation without and Release Test (GRT); Activities of neuroprothesis. Carroll et al. 2000 daily living (ADL) test. 3. With neuroprothesis, subjects could Australia grasp, move and release more items Pre-post in the 30 second GRT, as compared N=6 to without the neuroprothesis. 4. In 35/48 ADL events, less assistance was used (physically or assistive equipment) with the neuroprosthesis. In 41/48 ADL events, neuroprosthesis use was preferred in all subjects. 5. After study, 5/6 subjects still used neuroprosthesis daily. Participants: Age=16-57 yr; Gender: 1. When the neuroprosthesis was Peckham et al. 2001 males=42, females=9; Level of injury: C5- activated all participants increased USA/UK/Australia C6; Time since injury=4.6 yr; Follow-up their pinch force in lateral pinch Pre-post time=3-13.9 yr. (p<0.001) and some increased their NInitial=51; NFinal=50 Treatment: Participants were trained to pinch force in palmar grasp use the neuroprosthesis and to use it for (p<0.001).

Author Year Country Score Methods Outcome Research Design Total Sample Size functional activities. Once they were 2. 98% of participants moved at least 1 satisfied with their ability to perform daily object with the neuroprosthesis activities or when they reached a plateau (p<0.001) and 37 improved by in proficiency then rehab was complete. moving at least 3 more objects Outcome Measures: Pinch strength, (p<0.001). active ROM, Grasp-Release Test, ADL 3. Disability was reduced in 49 of 50 Abilities Test, ADL Assessment Test, user participants as measured by the satisfaction survey. ADL abilities or ADL assessment tools. Population: Age=31-48 yr; Gender: 1. No statistical results reported males=7, females=1; Level of injury: C4- 2. Completion of personal care was 6; Time since injury=43-430 months; provided by outside nursing Follow-up time=8-53 months. agencies. (mean 11.5 h a day, Treatment: Interviews- reviewing use of range 3-24 hrs); 4 users had Neuro Control Freehand System. additional care from family members Outcome Measures: Amount of Care & (mean 3.4 h a day, range 2-5 hrs); The System. no users claimed that care given by family members had decreased 3. System-donning external components 5-10 min; most users reported no significant problems fitting the external equipment; 2 users had problems locating the coil; Taylor et al. 2001 3 locating the shoulder controller; 1 UK had persistent problems maintaining Pre Post the position through the day due to N =9; N =8 Initial Final the adhesive tape used becoming detached (4 reported this as an occasional problem); 4 users had problems with skin allergy to the tape or double sided adhesive rings; 2 users reported that the system made transfers more difficult; 3 users never stopped using the system due to system failure; some problems with equipment reliability; no change in paid caregiver time; 6 users felt more confident when using the system; 7 felt their quality of life had improved. Population: Level of injury: C5-C6. 1. Variation in elbow moment across Treatment: Epimysial or intramuscular subjects significantly greater than electrodes were implanted on the triceps. the variance within subjects Following surgery standard stimulation (ANOVA p< 0.001). exercise regimens were followed. 2. 10/11 elbows tested elbow moment Outcome Measures: elbow extension generated by triceps stimulation at moments at different elbow positions, different elbow angles, elbow Memberg et al. 2003 performance in controllable workspace moment weakest with elbow in more USA experiments, comparison to an alternative extended position (30 degrees Case Series method of providing elbow extension in flexion) and peaked with elbow at 90 N=22 these individuals (posterior deltoid to flexion, significant ANOVA p<0.001. triceps tendon transfer). 3. Elbow moment generated by triceps stimulation at 90 and 120 degrees elbow flexion was significantly greater than elbow moment produced by tendon transfer (ANOVA p<0.05), no difference

Author Year Country Score Methods Outcome Research Design Total Sample Size between elbow extension methods at 30 degrees elbow flexion. 4. Triceps stimulation and posterior deltoid together provided a greater elbow moment than each method separately, difference significant at each elbow position p<0.05, except at 90 degrees. 5. Quantitative workspace assessment done on 5 arms, more successful with triceps stimulation, significant for each subject, chi square p<.05). 6. Average acquisition time with triceps stimulation less than without stimulation 4/5 arms (3.2-6.4 seconds) and significant in 3/5 arms (unpaired t-test p<0.01) and not for one p=0.076. Population: Age=16-55 yr; Level of 1. 7/9 use Freehand System daily. injury: tetraplegia. 2. Provided an active grip of some Treatment: The patients, using an strength which allowed many external stimulator, built up the muscles functional activities. Hobby et al. 2001 strength in the hand and forearm, to 3. Increase in self-confidence. UK ensure the muscles were in good 4. For over 80% of their selected ADL Pre-post condition at the time of surgery. goals, user preferred to be N=9 Outcome Measures: Grip Strength, ADL. independent with their Freehand system than use previous method or have activity performed by caregiver. Population: Age=28-57 yr; Level of 1. Pinch force ranged from 8 to 25 N, injury: C5-C6; Severity of injury: complete; with stimulation and greater than Time since injury=2-9 yr; tenodesis grasp alone; all Chronicity=chronic. demonstrated functional grasp Kilgore et al. 1997 Treatment: Implanted neuroprosthesis. patterns and were able to USA Outcome Measures: Grasp force; Grasp- manipulate at least 3 more objects Case Series Release Test; Tests of ADL (functional with the neuroprosthesis; had N=5 independence); Usage Survey. increased independence and were able to use the neuroprosthesis at home on a regular basis; the implanted stimulator proved to be safe and reliable. Population: Age=16-18 yr; Level of 1. 40 electrodes implanted, 37 injury=C6, Time since injury >1yr. continued to work, all implant Treatment: Surgery. stimulators have functioned without Mulcahey et al. 1997 Outcome Measures: Grasp Release problems with follow up ranging USA Test & ADL Test before and after between 16 and 25 months. Pre-post implementation of the implanted FES 2. Grasp Release Test-lateral pinch N=5 hand system. and palmar grasp forces - Wilcoxon test, FES forces were significantly greater than tenodesis forces for both grasps (p=0.043). Population: Mean age=38.4 yr; Gender: 1. Grasp release test results: increase Taylor et al. 2002 males=7, females=1; Level of injury: C4- in the types of tasks that subjects UK C6; Time since injury=10.1 yr. could perform (pre n=1.4) and post Case Series Treatment: None listed. It was an implantation (n=5.1 p=0.011). N=9 assessment of the Freehand System. 2. One year post implantation the Outcome Measures: Grasp Release types of tasks performed was 5.5

Author Year Country Score Methods Outcome Research Design Total Sample Size Test, Grip Strength, ADLs, Sensory ability p=0.027, without the system it was (static 2 pt discrimination). 1.2 (p=0.028). 3. Number of repetitions increased post implantation from 12.7 to 37.4 (p=0.028) and without the implant post-implantation (20.2, p=0.046). 4. At one year number of repetitions was increase to 50.5, p=0.046 with the system and without 24.3, p=0.28. Population: Age=13-19 yr; Gender: 1. No predicted difference between males=5; Level of injury: C5-C6; Time electrodes in intrinsic and extrinsic since injury=3-72 months. muscles (p=0.93). Treatment: Intramuscular electrodes 2. Significant differences were were implanted in the upper extremity predicted between exit sites Smith et al. 1994 muscles. (p=0.016) + across muscle groups USA Outcome measures: The Breslow Test - (p=0.047). Case Series a non-parametric linear rank test used to 3. Survival likelihoods poorer for N=5 compare survival chances across electrodes exiting dorsally. subgroups 95% confidence limit used to 4. At 90 days after implant survivals reject the null hypothesis. probabilities of the finger + thumb extensors + thumb abductors were no significant than that of thumb adductor + flexor muscle groups. Population: Age=23-48 yr; Level of 1. No statistical analysis was complete. injury: C5-C6. 2. Passive elbow extension was within Treatment: Participants were implanted normal limits. with an upper extremity neuroprothesis 3. With stimulated triceps subjects including a triceps’ electrode to provide attained full elbow extension; stimulated elbow extension. Participants without it full range was not met. exercised triceps 4-6 hr/session using a Bryden et al. 2000 programmed electrical stimulation USA exercise regimen that includes breaks. Case Series Participants exercised either nightly or N=4 every other night-whatever was best for maintaining an optimal amount of strength. Outcome Measures: 5 overhead reaching tasks, amount of assistance required to complete the task & survey of home use.

Population: Age=13-19 yr; Gender: 1. FNS vs. Tenodesis males=3, females=2; Level of injury: C5; 2. With FNS and tenodesis each case Time since injury=3-72 months. of improved performance in later Treatment: FNS vs. Tenodesis. sessions was significantly better as Smith et al. 1996 Outcome Measures: CWRU Hand compared to the initial session. USA System (Case Western Reserve (p<0.05). Case Series University), Grasp and Release Test. 3. The average grasp forces with FNS N=5 increased; the range was from 8.9N (SD+5.2) to 22.5N (SD+8.6) and the palmar grasp forces increases from 2.1N (SD+2.9) to 11.1N (SD+6.0). Mulcahey et al. 2004 Population: Age=13-16 yr; Level of 1. No statistical results are reported. USA injury: tetraplegia; Time since injury=4-16 2. No perioperative complications Case Series weeks. reported. N=4 Treatment: The following muscles were 3. Subjects began Freehand System

Author Year Country Score Methods Outcome Research Design Total Sample Size implanted with intramuscular electrodes: use between 2=5 days after Extensor digitorum profundus, extensor implantation. pollicis longus, flexor pollicis longus, 4. Muscle Strength-no subject gained adductor pollicis, and opponens pollicis significant strength in any key for each subject. muscle on their freehand limb. Outcome Measures: Muscle Strength- 5. Pinch Force-with Freehand System - Pinch Force & Hand Function, each subject realized significant Performance of ADL, Satisfaction with + improvement in pinch force. without the Freehand System (Canadian 6. Upper Extremity Capacity-first 11 Occupational Performance Measure questions - no difference with or (COPM)), Upper Extremity Capacity, without Freehand-last set of Quadriplegic Index of Function. questions Freehand System improved scores. 7. Quadriplegic Index of Function-all subjects increased their level of independence. 8. Freehand System Open-ended Questions-all subjects would repeat implantation. Note: ADL=Activities of Daily Living; FNS=Functional Neurostimulation

Table 20 Summary Implanted Neuroprostheses (Freehand System and CWRU) Author N Intervention Main Outcome(s) =UE strength +ve ADL: QIF scores Mulcahey et al. 2004 4 Implanted Freehand System +ve Satisfaction: COPM +ve lateral and palmar pinch =UE capacity: UEC 5/11 Implanted Freehand System 6/11 CWRU 6/11 tendon transfer surgery for +ve elbow extension Memberg et al. 2003 10 elbow extension +ve workspace assessment

4 arms triceps electrode 11 triceps electrodes/10 UL +ve Grasp Release Test Taylor et al. 2002 9 Implantation of Freehand System +ve Grip Strength +ve ADL Assessment +ve lateral pinch +ve palmar grasp 51 implanted Implanted Neuroprosthesis and +ve Grasp Release Test Peckham et al. 2001 (50 evaluated) adjunctive surgeries +ve satisfaction =no change in ability and long term stability and function =no change in level of personal care assistance Taylor et al. 2001 8 Implantation of Freehand System -ve system failure +ve ADL and functional use +ve ADL and functional use (80%) +ve lateral grasp Implanted Freehand System and +ve palmar grasp Hobby et al. 2001 9 adjunctive surgeries +ve 5 finger grasp -ve several electrode failures; stimulator failure; medical complications

Author N Intervention Main Outcome(s) 7/9 use device daily +ve lateral pinch and palmar grasp force Implanted Freehand System and Carroll et al. 2000 6 +ve GRT scores adjunctive surgeries +ve ADL (35/48) activities 5/6 still use the device +ve elbow function (strength, 4 Implantation of Freehand System Bryden et al. 2000 ROM) (5 limbs) with electrode to triceps +ve ADL and functional use +ve satisfaction (87%) +ve life impact (90%) +ve ADL (87%) +ve independence (81%) Implanted Freehand System and Wuolle et al. 1999 34 +ve occupation (74%) 31 had adjunctive surgeries +ve appearance +ve usage (5.5 d/week median) +ve activities +ve QOL +ve pinch force Implanted Neuroprosthesis and +ve grasp strength Kilgore et al. 1997 5 adjunctive surgeries +ve Grasp Release Test +ve ADL and functional use Implanted Freehand System and +ve Grasp Release Test Mulcahey et al. 1997 5 adjunctive surgeries +ve ADL and functional use +ve unilateral grasp and release Smith et al. 1996 5 Implanted Neuroprosthesis abilities with FNS Smith et al. 1994 5 Implanted Neuroprosthesis -ve electrode failure Note: ADL=Activities of Daily Living; FNS=Functional Neurostimulation; COPM = Canadian Occupational Performance Measure; GRT = Grasp and Release Test; CWRU = Case Western Reserve University + positive outcome; - negative outcome

9.1.2 NESS H200 (formerly HandMaster-NMS-1) The NESS H200 developed by Nathan et al., and produced by Neuromuscular Electrical Stimulator Systems, Ra’anana, Israel is the only commercially available upper limb surface FES system (Ragnarsson 2008). It has been FDA approved for use with stroke patients. It is predominantly used as an exercise tool for stroke subjects and is commercially available in a limited number of countries (Popovic et al. 2002). The NESS H200 has three surface stimulation channels used to generate grasping function in tetraplegic and stroke subjects. One channel is used to stimulate extensor digitorum communis muscle at the volar side of the forearm. The second channel stimulates the flexor digitorium superficialis and profundus muscles. The third stimulation channel generates thumb opposition. The system is controlled with a push button that triggers the hand opening and closing functions. The system is easy to don and doff. However, it does have some limitations in its design. The system is limited by not enough sufficient flexibility to vary the position of the electrodes for stimulation of the finger flexors for grasp; it is a stiff orthosis that fixes the wrist joint angle and prevents full supination of the forearm (Popovic et al. 2002).

Table 21 NESS H200 (formerly Handmaster-NMS-1) Author Year Country Score Methods Outcome Research Design Total Sample Size Alon & McBride 2003 Population: Gender: males=7; Level of 1. All were 100% successful in using USA injury: C5-C6; Time since injury=6 the handmaster in the studied ADL Pre Post months. and grasp (hold and release) tasks.

Author Year Country Score Methods Outcome Research Design Total Sample Size N=7 Treatment: Subjects practiced with the 2. Improvements were noted in neuroprothesis daily to regain grasp, hold, strength (.57±98N to 16.5±4.4N, and release ability and to restore selected finger linear motion (0.0cm to functions of 1 of the 2 paralyzed hands. 8.4±3.2cm) and Fugi-Meyer scores Subjects were observed 2 to 3 times (p<0.05). weekly for 3 weeks. Outcome Measures: Hand function was evaluated by a series of upper limb measures: 3 ADL tasks, 3 hand impairment measures, 2 grasp and release tests. Population: Age=20-65 yr; Gender: 1. 6 people left the study for various males=8, females=2; Level of injury: C4 to reasons (>50%). Over all the 4 Snoek et al. 2000 C6; Classification: 3-Cu n=3, 1-O n=5, 2- remaining were able to perform Netherlands O n=1, 0-O n=1; Fitted hand: Right n=6, several tasks with the Handmaster Pre Post Left n=4. that they were not able to without it ( NInitial=10; NFinal=4 Treatment: Training for use of e.g.: 3/4 were able to put the splint Handmaster. on independently). Outcome Measures: Not specified. Note: ADL=Activities of Daily Living

Table 22 Summary NESS H200 (formerly Handmaster-NMS-1) Author N Intervention Main Outcome(s) +ve ADL use +ve Grasp Release Test Alon & McBride 2003 7 NESS Handmaster +ve grip strength =finger motion 10 patients -ve poor compliance, only 4 completed Snoek et al. 2000 Handmaster (7 at end) the training period + positive outcome; - negative outcome

9.1.3 Bionic Glove Developed by Prochazka and colleagues at the University of Alberta the Bionic Glove improves hand function in people with SCI. This device uses three channels of electrical stimulation to stimulate finger flexors, extensors and thumb flexors. The control signal comes from a wrist position tranducer mounted in the garment. The actual functioning of the device can be described as greatly augmenting tenodesis (Popovic et al. 2006; Prochazka et al. 1997).

The Bionic Glove is designed to enhance the tenodesis grasp in subjects that have a voluntary control over the wrist (flexion and extension). Stimulates finger flexors and extensors during tenodesis grasp, enhances strength of grasp. The Bionic Glove is available at the University of Alberta, Alberta, Canada and used primarily for clinical evaluation. A modified version of this device will be called Tetron (Popovic et al. 2002).

Overall acceptance rate for long-term use is reported in 30% of potential users. Functions of power grasp and handling of big objects were significally improved (Popovic et al. 2002). There have been several identified concerns with the device that include damage to the stimulator located on the forearm that is frequently damaged through accidental contact during functional activities and the transducer mechanism is delicate and has to be replaced frequently (Popovic et al. 2001b).

Table 23 Bionic Glove Author Year Country Score Methods Outcome Level Total Sample Size Population: Mean age=26.5 yr; Level of 1. QIF: mean was 19.0±6.5 at the injury: C5-C7; Severity of injury: beginning; at the end 28.4±5.2, complete=10, incomplete=12; Length of improvement of 49.5%. experience with device=6 months or 2. FIM: 63.8±10.4 at the beginning; more. 79.0±8.9 after 6 months. When 3 Treatment: Taught how to use the clients excluded who had 120 points device. on FIM scores were beginning Outcome Measures: Quadriplegia Index 44.4±13.5 and 64.8±16.6 after 6 of Function (QIF); Functional months (increase of 20.4 Independence Measure (FIM); Upper points/46%). Extremity Function Test; Goniometric 3. Functional task completion: 6 Measurements. subjects continued to use the device. On average, 75% of the Popovic et al. 1999 functions were performed better Yugoslavia after 6 months of use. 6/12 (50%) Case Series did not continue to use the device. N=12 C6-C7 individuals may find the device beneficial enough to use it as an assistive device. 4. Technical improvements, specifically cosmetics, positioning of the electrodes, donning/doffing, should increase the number of regular users. 5. Best candidates are individuals with complete C6-C7 tetraplegia. 6. FIM score between 25-50 (up to 75), QIF between 0-13 (up to 27), are motivated to use it, can demonstrate efficient grasp. Population: Age=22-42 yr; Gender: 1. Mean peak force of tenodesis grasp males=8, females=1; Level of injury: C6- in the nine subjects increased from C7; Time since injury=16 months – 22 yr. 2.6 N±3.8 N (passive) to 11.3 N±7.4 Treatment: Use of bionic glove. N (glove active), significant than Prochazka et al. 1997 Outcome Measures: Mean peak force of peak passive force (p=0.0064, t- Canada tenodesis grasp, qualitative ratings of test), and significant at end of 5th Case Series manual tasks. grasp 6.8 N±4.2 N, p=0.0064, Mann- N=9 Whitney rank sum test. 2. Most manual tasks improved significantly with the use of the glove.

Table 24 Summary Bionic Glove Author N Intervention Main Outcome(s) +ve QIF Popovic et al. 1999 12 Bionic Glove +ve FIM +ve UE Function Test +ve grasp Prochazka et al. 1997 9 Bionic Glove +ve compliance (60%) Note: FIM=Functional Independence Measures; QIF=Quadriplegia Index Function + positive outcome; - negative outcome

9.1.4 ETHZ-ParaCare System The ETHZ-Para Care System was developed collaboratively between ParaCare, the University Hospital Zurich, the Rehabilitation Engineering Group at Swiss Federal Institute of Technology Zurich and Compex SA, Switzerland. The system was designed to improve grasping and walking function in SCI and stroke patients. Surface stimulation FES system is programmable, with 4 stimulation channels and can be interfaced with any sensor or sensory system. The system provides both palmar and lateral grasps. The device has some reported disadvantage that includes a lengthy time to don and doff the device (7-10 minutes) and it is not commercially available. The next generation of the device will be called the Compex Motion (Popovic et al. 2001; Popovic et al. 2006). The Compex Motion device is currently available in clinical trials with approximately 80 units available. The Compex Motion stimulator was designed to serve as a hardware platform for the development of diverse FES systems that apply transcutaneous (surface) stimulation technology. One of the main designs in this system is that it is easily programmable (Popovic et al. 2006).

Table 25 ETHZ ParaCare and Compex Motion Systems Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=15-70 yr; Gender: 1. Cervical SCI patients can benefit males=9, females=2; Level of injury: C5- from transcutaneous FES of hand C7; Severity of injury: AIS A-D, FES muscles during rehabilitation with applied 1-67 mths post injury. respect to muscle strengthening, Treatment: FES was carried out with a facilitation of voluntary muscle stationary stimulation system and 2 activity and improvements of ADL Mangold et al. 2005 portable systems (ETHZ-Paracare FES functions. Switzerland system, and Complex Motion). 2. Surface FES system is more flexible Case Series Outcome Measures: videos of functional in its application and does not need N=11 tasks: hand function tests, self-designed surgical procedures. functional tests, f/u query-assessment of 3. High flexibility in electrode muscle strength. placement, stimulation programmes, and FES control devices is required in order to adapt the system to individual needs. Note: AIS=ASIA Impairment Scale; FES=Functional Electrical Stimulation

Table 26 Summary ETHZ ParaCare and Complex Motion Systems Author N Intervention Main Outcome(s) +ve Training Programme ETHZ-ParaCare FES System +ve Functional exercises in therapy Mangold et al. 2005 11 and Compex Motion =ADL function in rehab centre -ve ADL use at home + positive outcome; =no difference; - negative outcome

9.1.5 Stimulus Router System The Stimulus Router System (SRS) is an externally controlled neuroprosthesis that has only one component implanted (passive lead, pick-up terminal) under the skin and the other end (delivery terminal) is tunneled to a target nerve. A surface electrode is placed over the implanted pick-up terminal and a second electrode is placed nearby. Current pulses are passed through the skin between the electrodes. The basic properties of the SRS were explored in two animal experiments (Gan et al. 2007; Gan & Prochazka 2010) which showed that the SRS was reliable as a long term neuroprothesis and was able to selectively activate deep-lying nerves in a

graded manner over the full physiological range. A case study of the first implant of the SRS in a person with tetraplegia with bilateral hand paralysis was completed (Gan et al. 2012) which showed initial success of the system.

9.2 Other Surface or Percutaneous Neuroprosthesis Systems 9.2.1 NEC-FES System The Sendai FES team in corporation with NEC Inc. 1994 developed the NEC-FES System. The system is to restore both grasping and walking abilities. It is an implanted FES system with 16 stimulation channels. It is used almost exclusively for research purposes and is not available outside Japan.

9.2.2 Rebersek and Vodovik (1973) Neuroprosthesis This is one of the first FES systems developed for grasping three decades ago. The device has three stimulation channels (2 stimulation electrodes per channel) that are used to generate the grasping function by stimulating finger flexors and extensors and thumb flexors. The user can control the stimulation intensity via different sensory interfaces such as EMG sensor, sliding resistor and pressure sensors. The main reported disadvantages of the system are the long donning and doffing times and the selectivity of stimulation is low. This device is not commercially available (Popovic et al. 2001).

9.2.3 Belgrade Grasping-Reaching System The Belgrade Grasping-Reaching System (BGS) as proposed by Popovic et al. (1998) is a neuroprosthesis device designed for grasping and it also provides a reaching function. The device has four stimulation channels (three for generating grasping function and fourth to stimulate triceps brachii muscle for elbow extension). The grasping function is controlled via a push button that triggers hand opening and closing. The motion of grasp is performed in three phases; prehension that forms the correct aperature of the hand, a relaxation phase that allows the hand to get into good contact with the object and closure of the hand by opposing either the palm and the thumb or side of index finger and thumb. The act of hand release is completed in two stages; opening of the hand and resting. Measuring the subject’s shoulder velocity with a goniometer and then generating a synergistic elbow motion by stimulation of the triceps brachii muscle achieves the reaching function of the upper limb. It is reported that the BGS system requires more time to place electrodes compared to Handmaster system, and it is not commercially available (Popovic et al. 2002).

9.3 Reported Benefits of Neuroprosthesis Use There have been many documented and reported benefits of neuroprosthesis use with the spinal cord injured person. The training required to use the device leads to short and long-term changes within the CNS(Popovic et al. 2002). A neuroprosthesis can be used as a neurorehabilitation system that promotes recovery and better hand function in incomplete SCI and stroke subjects or as a permanent orthotic device for complete cervical lesion SCI subjects to augment the grasp and manipulation functions required for typical ADLs.

9.4 Clinical Results of Neuroprosthesis Use The following are the reported clinical results of neuroprosthesis use;  Clinical trials show improvement in grasping functions in stroke and SCI subjects  FES technology facilitates a comfortable and secure grasp that allows the individual to hold and manipulate various objects

 All except the Bionic Glove were able to facilitate both palmar (power) grasp and lateral (fine) grasp  The Handmaster-NMS-1, the BGS system, and the ETHZ-ParaCare neuroprostheses have been applied successfully as rehabilitation tools to restore grasping function in SCI individuals instead of being used as permanent orthotic systems  To control the neuroprosthesis, subjects are using either an on-off type of switch or have to apply simple analog sensors to generate desired control commands  There is a delay of 1-2 seconds from time command is issued and moment that grasp is executed which restricts the speed that an individual can grasp and release objects  Neuroprosthesis for grasping can only be used for slower grasping tasks  The most widely used and accepted neuroprostheses for grasping are the Freehand System and the Handmaster-NMS-1 and all of the other neuroprostheses mentioned are mainly used in experimental trials for research purposes.

9.5 Challenges in Neuroprosthesis Use There are several reported challenges in neuroprosthesis use:  There is a general perception within the clinical community that neuroprosthesis technology is not fully matured and the application of its use is labour intensive  Patients and families have over expectations from assistive systems as aspirations and results do not match  Acceptance of the device depends on the specific needs of the client  Complicated by variety of age and lifestyle factors represented in patients with UE paralysis  Complacent (feel comfortable, safe and happy with home and workplace adaptation and with attendant care)  Waiting for cure (refuse any other intervention)  Afraid of technology  Degree of cognitive interaction they require – high levels of attention to their neuroprosthesis may interfere with social interaction  Impact in clinical applications is limited  Reasons for poor acceptance are that it can be technical, cultural and psychological  FES technology requires intensive maintenance and skilled technician  Found to be effective in hospitals with strong engineering support  Attempts to simplify neuroprosthesis systems and reduce the system’s donning and doffing time resulted in less technical support needed but the devices then failed to address the needs of a wider population  Inadequate reliability of use (breakage of wires, electrode failure, accidental damage)  The grasping functions are robotic quality of stimulated motions and in order to design a more dexterous hand motion it would require a more complicated system  Overall cosmetics of the device  Implanted neuroprosthesis require additional surgery and it is recommended that tendon transfers be performed to augment the system  Extensive training is required to learn how to use the device, which is expensive in terms of staffing and resources  Efforts to increase reliability of system components, data on long-term reliability not yet available  Simple systems for powered tenodesis grip for individual with lesions at C6 or lower have not been fully explored in deference to volitional tendon transfer surgery (Popovic et al. 2002; Triolo et al. 1996)

Discussion

The use of neuroprosthesis whether implanted or surface electrodes appear to benefit persons with C5-C7 level tetraplegia. The studies consistently demonstrate improvements in pinch (lateral and palmar), grip strength, and ADL functioning and general satisfaction with the use of the device, although the study subject numbers are relatively small. Ongoing compliancy and use of the devices on a long-term basis continue to be problematic. Reasons for discontinuing the use of the device are with length of time and the amount of assistance required to don and doff the device, and if using the device can provide enough of a difference in overall level of functioning. The studies also consistently report both mechanical/electrode failure and adverse medical complications. Many of the devices are only available in specialized rehabilitation centres where access to rehabilitation engineering is available. In addition, many of the devices continue to be only available in clinical trials. The overall cost to use the device continues to be great when factors such as cost of the device, the extensive training period required and staff to support the programme. The next generation of implantable FES devices are being developed at the FES Centre in Cleveland, OHIO and The Shriner’s Hospital, Philadelphia, Pennsylvania. These are internally powered and wirelessly control, eliminating an external coil and control unit. Also, in Alberta, Canada the ReJoyce System by Prochazka et al. (1997) a surface FES system and the SRS is being tested and further developed.

Conclusion

There is level 4 evidence (see Table 19-26) that support the use of neuroprostheses for persons with C5-C6 complete tetraplegia in the improvement of pinch and grip strength and ADL functioning. However, many devices are only available in clinical trials in specialized rehabilitation centres and the overall cost of the device continues to be expensive.

9.6 Second Generation Neuroprosthesis: Myoelectrically Controlled Second generation of neuroprosthesis (NP) being developed at Case Western Reserve , Cleveland, OH, USA, provides control of grasp, forearm pronation and elbow extension through the use of electromyographic signals generated by voluntary musculature used to control the various functions of the NP. The system consists of an implanted stimulator-telemeter (IST-12), implanted electrodes for stimulation and recording, an external control unit and a transcutaneous inductive link. The EMG signals can be obtained from two independent muscles. The IST-12 is capable of stimulating 12 different muscles. The design feature of the IST-12 enables the size of the implanted components to remain small and provides the opportunity for customized control algorithms and stimulation patterns. The NP functions controlled via EMG signal includes grasp pattern selection (2-4 grasp patterns), opening and closing the hand in a proportional manner, turning the system on and off, turning elbow extension on and off, and the ability to lock and unlock the hand so that the grasp can be maintained in a fixed position without the need for continued control input. One EMG channel is used to control grasp opening and closing and is generally placed on the most distal UE muscle

under voluntary control, typically the extensor carpi radialis longus (ECRL) and brachioradialis (Br). The second EMG channel is used to provide state or logic commands such as system on/off and selection of grasp pattern. The latter channel is placed on a more proximal muscle such as trapezius and platysma. All of the control signals are derived from ipsilateral muscles, enabling bilateral function to be provided by implementing a second system in the contralateral limb (Kilgore et al. 2008).

Augmentive surgical procedures (arthrodeses, tendon transfers and tendon synchronization using side by side repair) to the hand and arm are often performed at the same time of the implantation to provide improved hand function when the IST-12 is not being used and to further optimize the system with electrically stimulated transfers (Kilgore et al. 2008).

Further research is also being completed on an implantable stimulator and wearable external controller (Micropulse) at the Cleveland FES Centre, Cleveland, USA. The controller, under going benching testing, is worn on the wrist and wirelessly communicates with the implantable stimulator (Wheeler & Peckham 2009).

Another device being developed is the myoelectrically controlled functional electrical stimulation (MeCFES) in Denmark. This system consists of an amplifier, a signal processor and single- channel stimulator that allows the user to proportionally control the stimulus intensity to reinforce the tendosis grip in subjects with C6-7 tetraplegia.

Table 27 Second Generation Neuroprosthesis: Myoelectrically Controlled Author Year Country Score Methods Outcome Research Design Total Sample Size Population: Age=24, 34, 43 yr; Level of 1. Functional Outcomes: all 3 subjects injury: C5=1, C6=2; Time from injury to used their NP to perform activities implant=1, 2, and 4 yr. that they could not perform prior to Treatment: A second generation implantation (post implant follow up neuroprosthesis system was implanted ranged from 2-4 years). into individuals and functional outcomes 2. Body Structures and Function: every were evaluated. subject improved in pinch force Outcome Measures: Grasp and Release strength; post op pinch force with Test, Activities of Daily Living Abilities the NP was significantly greater than (ADLAT), Craig Handicapped without the NP (paired-sample t-test, Assessment and Reporting Tool (CHART) p=.038). and the NP Usage Survey. 3. Activities: every subject was able to Kilgore et al. 2008 double the number of objects USA manipulated in the GRT with NP (2 Pre-post subjects completed 6/6 tasks; one N=3 subject 5/6 tasks) 4. ADLAT all 3 subjects improved in least 5 activities with one subject in all 9. 5. Participation: all 3 subjects increased their scores for physical independence, 1 in the mobility task, 1 in the social integration scale, 1 subject a decrease in occupation subscale. 6. Device Usage: 2/3 reported daily usage of the NP; 1/3 used the device 50% of the time Note: GRT=Grasp and Release Test; Np=Neuroprosthesis

The study by Kilgore et al. (2008) studied the first three individuals to receive a myoelectrically controlled NP (IST-12) designed for hand and arm function. The IST-12 can stimulate 12 different muscles versus the first generation NP (Freehand System) which only stimulated 8 muscles. The additional electrodes provided the user with improved hand function (activation of the intrinsic muscles), wrist extension, improved reach (triceps function) and improved shoulder stability through activation of the shoulder musculature. The IST-12 provided each of the three subjects with significantly increased pinch force and grasp function which resulted in increased independence with ADL functions. All three study subjects used the device at home on a regular basis. The durability of the implanted components was comparable to long-term results from the first generation NP, an incidence failure of<2%.

Conclusion

There is level 4 evidence (from one pre-post study; Kilgore et al. 2008) that the use of the IST-12, a second generation neuroprosthesis, combined with augmented surgical procedures (arthrodesis, tendon transfers and tendon synchronization) improved pinch force, grasp function and the functional abilities of individuals with cervical level spinal cord injuries.

9.7 Miscellaneous

Research into brain-machine interfaces is beginning to be published. Brain-machine interface is based on the concept of translating neural activity into control of an external device with the capability of producing natural movements. Just one study has been published which examined two 96-channel intracortical microelectrodes implanted into the motor cortex of a patient (Collinger et al. 2013).

Finally, there have been initial studies on exoskeleton robots (controlled by electromyographical signals (EMGs) of the user) (Ueda et al. 2010), the five degree of freedom user command controller (Scott & Vare 2013) and the use of robotic training for improving hand and upper limb control (Cortes et al. 2013; Zariffa et al. 2012b).

10.0 Summary

The treatment and management of the upper limb in persons with a SCI can be rewarding yet very challenging. Secondary complications related to repetitive strain injury, pain and hypertonicity in addition to aging presents numerous challenges for both the injured individual and the clinician. In reviewing the critical evidence of treatment interventions it was surprising that there were few studies on the effectiveness of traditional interventions such as strengthening, exercise, splinting and management of hypertonicity. The majority of research for the upper limb has been focused on reconstructive surgery and the use of neuroprosthesis. Advancements in understanding the mechanisms related to SCI has led to restorative treatment interventions especially in the management of the incomplete SCI person.

This chapter outlined the importance in the prevention of upper limb dysfunction and the impact of an injury in one’s overall level of basic independence in the areas of self-care and mobility. Further research and consensus is needed in how we assess and document upper limb function especially hand function in an effort to establish objective, reliable and measurable outcomes. Other areas for further research have been identified throughout the chapter.

There is level 2 evidence (from one randomized controlled trial; Hicks et al. 2003) that physical capacity continues to improve after 1- year post discharge.

There is level 1b evidence (from one randomized controlled trial; Needham-Shrophire et al. 1997) that neuromuscular stimulation-assisted exercise improves muscle strength over conventional therapy.

There is level 4 evidence (from one case series study; Burns & Meythaler 2001) that intrathecal baclofen may be an effective treatment for upper extremity hypertonia of spinal cord origin.

There is level 4 evidence (from one pre-post study; Belci et al. 2004) that showed that rTMs treatment in individuals with chronic stable ISCI may produce reductions in

corticospinal inhibition that resulted in clinical and functional changes for several weeks after treatment.

There is level 2 evidence (from one randomized controlled trial; DiPasquale-Lehnerz 1994) that wearing a thumb opponens splint will improve pinch strength and functional use of the hand.

There is level 1b evidence (from one randomized controlled trial; Dyson-Hudson et al. 2001) that general acupuncture is no more effective than Trager therapy in reducing post- SCI upper limb pain There is level 4 evidence (see Table 9-18) that support the use of reconstructive surgery for the tetraplegic upper limb for the improvement of ADL and quality of life.

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