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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; 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.

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.

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 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.

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.

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).

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 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.

There 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.

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.

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.