Preservation of Upper Limb Function Following Spinal Cord Injury - 23

CLINICAL PRACTICE GUIDELINE

studies (Burke et al., 1994; Kruger et al., 1991; Manente et al., 2001; Celiker et al., 2002). Use of splints during upper extremity activities is controversial. Gel-padded gloves may be another way to provide pain relief (Deltombe et al., 2001). Protecting an involved elbow or shoulder presents greater challenges.
(Clinical/epidemiologic evidence–3/4; Ergonomic evidence–NA; Grade of recommendation–C; Strength of panel opinion–Strong)

23. Place special emphasis on maintaining optimal range of motion during rehabilitation from upper limb injury.
(Clinical/epidemiologic evidence–2; Ergonomic evidence–NA; Grade of recommendation–B; Strength of panel opinion–Strong)

b. Home modifications or additional assistance.
(Clinical/epidemiologic evidence–None; Ergonomic evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

The most logical and cost-effective way to rest an injured limb is by adding technology that alters the home environment. Additional transfer equipment such as lift systems, hospital beds, and alternative wheelchairs may be required. If a caregiver isn’t available in the home, hired attendants may be required for assistance with bathing; grooming; bowel, bladder, and skin care; home management; transfers; and mobility in the home and/or community. Any new caregiver or attendant will require training and education in these areas of care. c. Admission to a medical facility if pain cannot be relieved or if complete rest is indicated.

Treatment of an upper limb injury is often dual: relative rest, supplemented with range-ofmotion exercises. Range-of-motion exercises should be emphasized because in the absence of movement the joint capsule and ligaments will adaptively shorten, limiting movement. A shortened posterior glenohumeral capsule may shift the humeral head forward and decrease the subacromial space, altering the mechanics of movement. Range-of-motion and stretching programs are needed to prevent losses in range of motion. Manual therapy mobilization techniques applied to these areas can increase range of motion and have been shown to decrease pain when added to traditional therapeutic approaches (Conroy and Hayes, 1998). Lap trays with custom-made adaptive supports fabricated with splint material and Velcro™ allow patients with tetraplegia to be slowly stretched from internal rotation to external rotations. Avoiding hypermobility is imperative. 24. Consider alternative techniques for activities when upper limb pain or injury is present.
(Clinical/epidemiologic evidence–None; Ergonomic evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

People with limited social, economic, and physical support systems may not be able to alter their own environments, hire attendants, or purchase secondary mobility and transfer devices. If additional help is not available and complete rest is indicated, admission to a supported setting, such as a skilled nursing or assisted living facility, is recommended to ensure proper management of the upper limb. The short-term cost of admission may prevent the long-term cost of increased disability.
(Clinical/epidemiologic evidence–None; Ergonomic evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Persons with a spinal cord injury and a degenerative disorder or injury face a special challenge in resting the involved structures. Because activities of daily living and mobility necessitate use of the upper limbs, additional measures may be required to protect the involved structures.

Overhead activities of daily living, transfer strategies, and mobility techniques should be examined, as discussed in previous recommendations. During the recovery phase of an injury, use of a power wheelchair should be considered for primary manual wheelchair users. Reachers and other long-handled equipment may decrease the shoulder range of motion necessary to complete overhead tasks. Compensatory strategies with the unaffected limb, while challenging, should be explored, and adaptive equipment should be issued when appropriate. Overhead activities that require muscle endurance as well as strength, such as grooming, can be made easier by attaching overhead slings to a chair or stationary surface. These sling-and-bracket systems support the weight of the arm, potentially decreasing the stress on the rotator cuff muscles, yet allow movement of the upper limb. Items to be considered in the work and home settings include environmental control units, mouse/trackball software, adjustable-height desks,

Preservation of Upper Limb Function Following Spinal Cord Injury

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