Upper Limb Rehabilitation Following Spinal Cord Injury Danielle Rice PhD (c) Pavlina Faltynek P MSc McIntyre A MSc RN Swati Mehta PhD Brianne Foulon HBA Robert Teasell MD FRCPC www.scireproject.com Version 6.0 Key Points Neuromuscular stimulation-assisted exercise following a SCI is effective in improving muscle strength, preventing injury and increasing independence in all phases of rehabilitation. Augmented feedback does not improve motor function of the upper extremity in SCI rehabilitation patients. Intrathecal baclofen may be an effective intervention for upper extremity hypertonia of spinal cord origin. Afferent inputs in the form of sensory stimulation associated with repetitive movement and peripheral nerve stimulation may induce beneficial cortical neuroplasticity required for improvement in upper extremity function. Restorative therapy interventions need to be associated with meaningful change in functional motor performance and incorporate technology that is available in the clinic and at home. The use of concomitant auricular and electrical acupuncture therapies when implemented early in acute spinal cord injured persons may contribute to neurologic and functional recoveries in spinal cord injured individuals with AIS A and B. There is clinical and intuitive support for the use of splinting for the prevention of joint problems and promotion of function for the tetraplegic hand; however, there is very little research evidence to validate its overall effectiveness. Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity. Acupuncture and Trager therapy may reduce post-SCI upper limb pain. Prevention of upper limb injury and subsequent pain is critical. Reconstructive surgery appears to improve pinch, grip and elbow extension functions that improve both ADL performance and quality of life in tetraplegia. Nerve transfer surgery to restore hand and upper limb function in the person with tetraplegia is emerging as another surgical alternative. 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 youThe have usea health of problem, neuroprostheses you should consult yourappears health care to provider. have Thea positive SCIRE editors, impact contributors on andpinch supporting and partnersgrip shall strength not be liable and for anyADL damages, functions claims, liabilities, in C5 -costsC6 orcomplete obligations arising tetraplegia, from the use however,or misuse of thi s material. Riceacce D, Faltynekss to P, the McIntyre devices A, Mehta, are S, Foulonlimited BL, andTeasell continue RW. (2016). Upperto be Limb expensive Rehabilitation in Following use. 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.The Spinal IST -C12ord neuroprosthesis,Injury Rehabilitation Evidence. a second Version 6.0: generation, p 1-121. myoelectrically controlled www.scireproject.comimplantable 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 ........................................................................................... 4 2.1 Exercise and Strengthening ................................................................................................. 6 3.0 Augmented Feedback on Motor Functions .....................................................................12 4.0 Pharmacological Interventions ........................................................................................16 5.0 Restorative Strategies ......................................................................................................17 5.1 Plasticity of Motor Systems .................................................................................................19 5.2 Complementary Alternative Therapies ................................................................................29 5.3 Splinting ..............................................................................................................................32 6.0 Subacute Phase of Rehabilitation ..............................................................................35 6.1 Shoulder Injuries ...........................................................................................................40 6.2 Elbow, Wrist and Hand Injuries ......................................................................................44 7.0 Reconstructive Surgery and Tendon Transfer ................................................................46 7.1 Hand ...................................................................................................................................46 7.1.1 Pinch .......................................................................................................................48 7.1.2 Pinch and Grasp (Key-Pinch and Hook Grip) .......................................................51 7.2 Elbow Extension .................................................................................................................56 7.2.1 Posterior Deltoid to Triceps ...................................................................................56 7.2.2 Biceps to Triceps....................................................................................................59 7.3 Multiple Reconstructions .....................................................................................................61 8.0 Nerve Transfers .................................................................................................................69 Advantages over Tendon Transfers ..........................................................................................69 Potential Drawbacks of Nerve Transfers ...................................................................................70 Assessment and Surgical Timing ..............................................................................................70 9.0 Neuroprostheses ...............................................................................................................74 Reported Benefits of Neuroprosthesis Use ...............................................................................75 Clinical Results of Neuroprosthesis Use....................................................................................75 Challenges in Neuroprosthesis Use and Reasons for Not Using Neuroprosthesis ....................76 9.1 Surface or Percutaneous Neuroprosthesis Systems ...........................................................80 9.1.1 Freehand System....................................................................................................80 9.1.2 NESS H200 (formerly HandMaster-NMS-1) ...........................................................88 9.1.3 Bionic Glove ...........................................................................................................89 9.1.4 ETHZ-ParaCare System ..........................................................................................91 9.1.5 Stimulus Router System ........................................................................................92 9.1.6 Exo-Glove ...............................................................................................................92 9.1.7 NEC-FES System ....................................................................................................94 9.1.8 Rebersek and Vodovik (1973) Neuroprosthesis ...................................................94 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. Rice D, Faltynek P, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2016). 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 6.0: p 1-121. www.scireproject.com 9.1.9 Belgrade Grasping-Reaching System ...................................................................95 9.3 Myoelectrically Controlled Neuroprostheses ........................................................................95 10.0 Brain Interface Neuroprostheses ...................................................................................97 11.0 Virtual Reality ..............................................................................................................98 12.0 Summary..........................................................................................................................99 References ...........................................................................................................................