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 there are fewer studies than may be expected 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 neuroprostheses. Advancements in understanding the mechanisms related to SCI have 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, in an effort to establish objective, reliable and measurable outcomes. Other areas for further research have been identified throughout the chapter.
There is level 1a evidence (from one randomized controlled trial: Trumbower et al. 2017) that acute intermittent hypoxia combined with daily hand opening practice significantly improves hand opening in some, but not all, aspects of hand function.
There is level 1b evidence (from one randomized controlled trial: Nightingale et al. 2018) that six weeks of home-based upper-body exercise improves aspects of health-related quality of life.
There is level 2 evidence (from one randomized controlled trial: Hicks et al. 2003) that physical capacity continues to improve 1- year post discharge and is correlated to a decrease in stress, pain, and depression.
There is level 2 evidence (from one prospective controlled trial: Haisma et al. 2006) that physical capacity (strength and respiratory function) improve during and after inpatient rehabilitation.
There is level 4 evidence (from one pre-post study: Gant et al. 2018) that multi-modal exercise improves muscle strength and function in individuals with SCI.
There is level 4 evidence (from one pre-post study: Hoffman et al. 2017) that weekly activity-based hand therapy is feasible and efficacious at increasing hand task performance in individuals with SCI.
There is level 4 evidence (from one pre-post study: Drolet et al. 1999) that overall muscle strength continues to improve up to 15 months post hospital discharge for both persons with tetraplegia and paraplegia despite large variability in patients.
There is level 1b evidence (from one randomized controlled trial: Harvey et al. 2006) that 12 weeks of nightly stretch with a thumb splint does not reduce thumb web-space contractures in persons with a neurological condition (i.e., stroke, ABI, SCI).
There is level 2 evidence (from one randomized controlled trial: DiPasquale-Lehnerz 1994) that wearing a thumb splint improves pinch strength and functional use of the hand.
There is level 4 evidence (from one pre-post test: Portnova et al. 2018) that wearing wrist-driven orthoses as an assistive device may improve hand function and grasp strength.
There is level 1b evidence (from two randomized controlled trials: Yeo et al. 2018; Rice et al. 2014) that education improves wheelchair skills.
There is level 2 evidence (from one randomized controlled trial: Curtis et al. 1999) that education about shoulder exercises reduces the intensity and duration of shoulder pain post-SCI.
There is level 4 evidence (from two pre-post studies: Di Rienzo et al. 2014b, 2015) that MI treatment incorporated into physiotherapy for individuals with SCI may help to improve movement time and variability performance.
There is level 4 evidence (from one post-test study: Scandola et al. 2014) that showed that the induction of the rubber hand illusion through synchronous multisensory visuo-tactile bodily stimulation resulted in ownership of the hand.
There is level 2 evidence (from one prospective controlled study: Frullo et al. 2017) that subject-adaptive upper extremity robotic exoskeleton therapy is feasible, however, no gains in arm function were observed.
There is level 4 evidence (from one pre-post study: Capello et al. 2018) that use of a fabric-based soft robotic glove significantly improves hand function when completing activities of daily living in individuals with SCI.
There is level 4 evidence (from one pre-post study: Kim et al. 2017) that the GRIPIT exoskeleton quantitatively and qualitatively improves writing when compared to conventional pen holders, although it is more difficult to wear.
There is level 4 evidence (from two pre-post studies: Backus et al. 2014; Cortes et al. 2013) that an end effector robotic device can be safely used in patients with tetraplegia to significantly improve upper limb function.
There is level 4 evidence (from one post-test study: Tigra et al. 2018) that an end effector robotic device may improve hand grasping function in individuals with SCI.
There is level 4 evidence (from two case series: Popovic et al. 1999; Prochazka et al. 1997) that the Bionic Glove increases motor and upper limb function in individuals with SCI.
There is level 1b evidence (from one randomized controlled trial: Osuagwu et al. 2016) that BCI-FES should be considered as a therapeutic tool rather than solely an assistive device, as combined BCI-FES therapy results in better neurological recovery and muscle strength than FES alone.
There is level 2 evidence (from two prospective controlled trials: Athanasiou et al. 2017; Pfurtscheller et al. 2009) that robotic control of a wireless or EEG-controlled BCI is possible in SCI patients, however, multiple training sessions and tailored BCI algorithms are needed to improve performance.
There is level 4 evidence (from one pre-post test: Foldes et al. 2015) that a MEG based BCI may provide realistic, efficient and focused neurofeedback in SCI patients to promote neuroplasticity.
There is level 4 evidence (from one pre-post test: Pedrocchi et al. 2013) that the MUNDUS platform may provide functional assistance in activities of daily living to patients with SCI.
There is level 1a evidence (from one randomized controlled trial: Kohlmeyer et al. 1996) that augmented feedback is not effective in improving upper limb function in tetraplegia.
There is level 2 evidence (from one randomized control trial: Klose et al. 1993) that the addition of biofeedback does not improve patient scores in rehabilitation more than physical exercise alone.
There is level 4 evidence (from one pre-post test: Bruker and Bulaeva 1996) that EMG biofeedback sessions can significantly improve normal EMG muscle test scores of both triceps.
There is level 4 evidence (from two pre-post tests: Kilgore et al. 2018 and Kilgore et al. 2008) that a surgically implanted neuroprosthesis significantly improves grip strength/pinch force to enhance hand function and ADLs in individuals with SCI.
There is level 4 evidence (from five pre-post studies: Peckham et al. 2001; Taylor et al. 2001; Hobbey et al. 2001; Carroll et al. 2000; Mulcahey et al. 1997) that the implanted Freehand System results in positive increases in grip strength, grasping and overall independence.
There is level 4 evidence (from two pre-post studies: Alon and McBride 2003; Snoek et al. 2000) that with sufficient practice using the NESS H200 neuroprosthesis, individuals with SCI may regain grasp, hold and release abilities.
There is level 4 evidence (from eight case series: Mulcahey et al. 2004; Memberg et al. 2003; Taylor et al. 2002; Bryden et al. 2000; Wuolle et al. 1999; Kilgore et al. 1997; Smith et al. 1994; Smith et al. 1996) that the implanted Freehand System increases grip strength, grasping, ADL and function, and overall independence.
There is level 4 evidence (from one case series: Mangold et al. 2005) that the ETHZ-ParaCare neuroprosthesis is flexible (non-surgical) and has significant positive outcomes in rehabilitation and the ability to perform daily living tasks.
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 2 evidence (from one randomized control trial: Klose et al. 1993) that the addition of NEMS does not improve patient scores in rehabilitation more than physical exercise alone.
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 1a evidence (from one crossover RCT: Gomes-Osman & Field-Fote 2015) that TENS and tDCS, when combined with functional task practice improves aspects of hand-related function.
There is level 1a evidence (from three randomized controlled trials: Bekkhuizen & Field-Fote 2005, 2008; Hoffman & Field-Fote 2013) 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 1b evidence (from one randomized controlled trial: Gomes-Osman et al. 2017) that peripheral sensory stimulation combined with functional task practice improves grip force in individuals with SCI.
There is level 4 evidence (from one pre-post test: Gad et al. 2018) that transcutaneous spinal cord stimulation combined with hand grip training significantly improves hand function.
There is level 4 evidence (from one pre-post study: Nasser et al. 2014) that showed massed practice and somatosensory stimulation significantly improved motor function and pinch grip strength compared to traditional rehabilitation programs over time.
There is level 1b evidence (from two randomized controlled trials: Harvey et al. 2017; Popovic et al. 2006) that FES has no added benefit over conventional therapy.
There is level 2 evidence (from one randomized controlled trial: Iwahashi et al. 2017) that therapeutic electrical stimulation has no effect on upper extremity motor function.
There is level 2 evidence (from two randomized controlled trials: Zoghi and Galea 2017; Hoffman & Field-Fote 2013) that FES in combination with intensive hand task training improves upper extremity motor function.
There is level 2 evidence (from one prospective controlled trial: Hodkin et al. 2018) that multiple FES sessions improves upper extremity motor function.
There is level 1a evidence (from one randomized controlled trial: Gomes-Osman & Field-Fote 2015) that pinch strength significantly improves with vibration therapy but this does not translate to improvements in functional outcomes.
There is level 4 evidence (from one pre-post study: Backus et al. 2014) that an end effector utilizing muscle vibration can be safely used in patients with tetraplegia to significantly improve upper limb function.
There is level 1b evidence (from one randomized controlled trial: Tolmacheva et al. 2017) that TMS combined with PNS significantly improves muscle function of the hand.
There is level 1b evidence (from one randomized control trial: Gomes-Osman & Field-Fote 2014) that rTMS may reduce corticospinal inhibition and enhance clinical/functional outcomes for several weeks after treatment.
There is level 2 evidence (from two prospective controlled trials: Bunday et al. 2018; Bunday et al. 2014) that PCMS applied during voluntary activity may enhance spinal plasticity after SCI.
There is level 2 evidence (from one prospective controlled trial: Peterson et al. 2017) that TMS delivered to the motor cortex after elbow extension reconstructive surgery significantly improves elbow extension.
There is level 4 evidence (from one pre-post study: Belci et al. 2004) that TMS may lower intracortical inhibition and improve clinical motor scores.
There is level 1b evidence (from one RCT: Cortes et al. 2017) that a single session of tDCS significantly improves hand grasp in patients with chronic SCI, however, larger clinical trials are necessary to determine the effectiveness of tDCS as a long-term rehabilitation strategy.
There is level 2 evidence (from one cohort study: Potter-Baker et al. 2018) that tDCS paired with massed practice training may provide some advantage in improving the strength of proximal/hand muscles, however, larger clinical trials are necessary.
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 2 evidence (from one prospective controlled trial: Coulet et al. 2018) that active key pinch CMC reconstructive surgery increases key pinch strength when compared to passive key pinch reconstructive surgery.
There is level 3 evidence (from one retrospective study: Forner-Cordero et al. 2003) that the outcomes of pinch and grasp reconstructive surgeries overall improve the individuals’ hand function and meet individual expectations.
There is level 4 evidence (from seven case studies and one pre-post test: Mohindra et al. 2017; Meiners et al. 2002; Lo et al. 1998; Failla et al. 1990; Gansel et al. 1990; Rieser and Waters 1986; Kelly et al. 1985; Colyer and Kappleman 1981) that pinch and grasp reconstructive surgeries are effective in increasing motor function, strength, and grip of the hand. Patients also report high satisfaction with their surgical results.
There is level 2 evidence (from one RCT: Mulcahey et al. 2003) that biceps to triceps surgery can increase elbow extension strength, reaching and overall performance improvement.
There is level 4 evidence (from two case series: Kozin et al. 2010; Kuz et al. 1999) that elbow extension surgery improves elbow extension and overall functionality of the joint.
There is level 4 evidence (from one pre-post test: Medina et al. 2017) that biceps-to-triceps transfer significantly improved upper extremity functional outcomes in individuals with SCI.
There is level 2 evidence (from one cohort study: Dunn et al. 2004) that active transfer procedures may have little benefit over tenodesis procedures as the rate of decline post-surgery is greater and other functional outcomes are equal.
There is level 3 evidence (from one case-control study: Friden et al. 2012b) that patients who had multiple stage BR to FPL through the interosseous membrane had significantly greater active pronation, while other measures remained similar.
There is level 4 evidence (from one pre-post study: Friden et al. 2012a) that multiple reconstructions can improve key-pinch and grip strength.
There is level 4 evidence (from nine case series: Rothwell et al. 2003; Welraeds et al. 2003; Freehafer 1998; Mohammed et al. 1992; Ejeskar and Dahllof 1988; Freehafer et al. 1984; Lamb and Chan 1983; Hentz et al. 1983; Friden et al. 2014) that multiple reconstructive surgery over all increases motor function as well as the ability to perform daily living tasks.
There is level 4 evidence (from one post-test: Gregersen et al. 2015) that a variety of reconstructive surgeries can be used to improve overall elbow function and strength.
There is level 2 evidence (from one cohort study: Fox et al. 2015b) that the risk of negative outcomes for nerve transfer surgery, such as postoperative decline compared to baseline, are low.
There is level 4 evidence (from one pre-post and one post-test study: Bertelli et al. 2017; Bertelli et al. 2015) that nerve transfer surgery can increase motor hand function without compromising donor site function in patients with SCI.
There is level 4 evidence (from one case series: Fox et al. 2018) that patients presenting years after SCI are eligible candidates for nerve transfer surgery.
There is level 4 evidence (from two case series: Simcock et al. 2017; Fox et al. 2015a) that nerve transfer surgery can increase functionality and grasp strength in some patients, however not all patients have successful surgical outcomes.
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 2 evidence (from one randomized controlled trial: Wong et al. 2003) that use of concomitant auricular and electrical acupuncture therapy may improve the neurological and functional recovery of acute spinal cord injured individuals.
