SCI UE

• level of injury (current and expected motor recovery; tenodesis needs; typical complications)
• orthopedic evaluation of capsular structures, muscle tension, nerve tension, pain levels, sensation, ADL needs
• previous history: degenerative changes in joint or rotator cuff

• shoulder pain (usually bilateral)
• risk factors (>50, decreased PROM, not initiating ROM w/in first 2 weeks of injury)
• very serious complication, given the client's dependence on UE for ADL, transfers

• weakness of the shoulder girdle mm esp that which occurs w/ C6 and higher
• -contribute to muscle shortening
• -capsular tightening
• -muscle imbalance -- force coupling changes of the rotator cuff
• neuritic pain from nerve root injury or radicular pain w/ parasthesias, phantom sensations OR reflex sympathetic dystrophy
• referred pain to the shoulder from neck and/or trapezius
• direct trauma during initial accident
• indirect trauma
• pre-existing shoulder dysfunction
• psychological issues related to control, secondary gain, manipulation

• neck pain is common secondary to number of neck fractures/dislocations of the cervical spine
• trapezius pain is common secondary to overuse
• trapezius shortening is common secondary to weakness of protractors/depressors of the shoulder girdle b/c the upper trap becomes overused in order to move scapula/shoulder

• overuse injuries
• lateralization of thumb secondary to WC propulsion; can affect strength of opposed pinch
• general loss of joint motion, atrophy, contractures

• positioning (bed, WC, splinting, muscle shortening to aid function)
• educate (overuse and train for management)
• smart muscle strengthening

• gravity assisted -- gravity eliminated -- against gravity -- resistance training
• isometric -- eccentric -- concentric
• adapt exercise for loss of hand control
• use neuromuscular re-education principles (e-stim, PNF)

we must address head and trunk control when looking at UE return

• shortening of FDP/FDS
• shortening of FPL for thumb approximation to fingers
• avoid excessive stiffness in MPs and IPs of fingers
• encourage stiffness in IP of thumb for greater stability of pinch

• only as good as the medical tests given
• many times we are told someone has had a complete injury and then they have function unanticipated
• some literature suggests preserving tenodesis for one year post injury to be sure you don't miss residual function in all clients w/ SCI
• preserve in all C4 and above, but the conventional wisdom is gernally not to preserve above C5

• limited head control
• prevent pain in UE

• headwand and mouthstick activities to increase neck strength and ROM starting in gravity eliminated range
• teach competent and thorough passive ROM to client and family ASAP
• hand splints

• hand contractures to minimize pain w/ cleaning, ROM
• worn at night, hands free during day

• maximal head control
• limited scapular control
• prevent UE pain/hand contractures

• mouthstick activities
• Swedish sling or balanced forearm orthoses, resting hand spling
• facilitate strengthening upper, middle, lower trap function and PROM should to hand; if complete - tenodesis is not an issue
• prevent shortening of trapezius and others; resting pan splint often built into WC armrest

• limited trunk stability
• limited, assisted arm placement
• preserve tenodesis hand function

• control w/ short, long, cross leg sitting
• PNF patterns, any challenging activity to increase strength
• teach competence using both arms to hook onto the back of a WC or using a loop on a WC to increase trunk mobility

• external rotation of shoulder, some flex, abd
• elbow flexion and supination of the forearm

• IR < ER
• weak serratus limits elevation and scapular fixation on thorax

• progressive exercise (AA/A/RROM)
• PNF
• theraband
• functional activity
• balanced forearm orthoses
• positioning to prevent elongation; hand mitts and wrist support to exercise

preserve tenodesis

elbow flexion and supination

no hand function

• weight bearing w/ wrist extension, finger flexion
• all ROM through tenodesis function
• electrically-powered tenodesis splints; radial wrist and thumb spica to maintain web space
• elbow extension splints/casts - can't loose
• progressive exercise

• wrist is supported in extension
• no true tenodesis unless splint is electric
• cuff made for utensils

• limited trunk stability
• unassisted, limited arm placement
• tenodesis hand function

• same as C5
• progress stability w/ all
• greater use of UE increases ability to stabilize the trunk during ADL

more scapular control

partial serratus

• progressive exercise, wrist and hand supports as needed
• accurate arm placement for function w/ attention to trunk control

add partial wrist extensors and pronation to C5 function

no finger or wrist flexors

• same as C5; do not stretch long finger flexors
• progressive exercise
• wrist-driven tenodesis spling
• short opponens splint
• use of tenodesis after arm placement in a variety of ADLs

• strengthen wrist ext so that tenodesis can be used
• thumb spica splint gives some stability for pinch
• if wrist too weak, need to include in splint like C5
• quad cuff for phone use, electric razor, etc.

• fair trunk stability
• full arm placement
• tenodesis hand function

progressive activities as seen in C5-6

• serratus
• triceps

• partial latissmus innervation
• when arms stable and pushing down, aids in picking up the pelvis so the foot clears the ground

• progressive strengthening using tenodesis function to manage weight training devices
• practice arm placement accuracy w/ increasing trunk challenges

• wrist flexors
• finger ext
• thumb ext and abd

no finger flexion or intrinsics

• progressive activity/ex
• hand splint to maintain fingers for pinch or short opponens
• MP flexion spring assist splint -- allows extension but springs into flexion
• increase accuracy of tenodesis after arm placement for ADL

will generally only use for training as may be able to use evolving strength in thumb w/o support

• trunk stability
• limited natural hand function

• advancing PNF patterns
• advanced occupational sitting tasks
• bilateral UE tasks from WC level (putting items in cabinets w/ arms OH)

finger and thumb flexors, thumb adductor

lack of intrinsics

• progressive activity/ex (adapted writing, putty)
• small, hand-based splint to support arches as needed
• meaningful, functional fine motor coordination activities (putting coins in a coke machine)

• Normal hand function
• strengths: lumbricales, opponens and interosseus muscle function
• challenges: above may be present but weak
• interventions: progressive occupational activity and exercise (practice what they cannot do)

• know your etiology
• treat orthopedic conditions on impairment level
• analyze activity and modify movement to prevent further pain/injury
• educate on life-long process for care of the UEs