Preservation of Upper Limb Function Following Spinal Cord Injury - 24

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PRESERVATION OF UPPER LIMB FUNCTION FOLLOWING SPINAL CORD INJURY

turntable book holders, and voice-input software. It is reasonable to ask friends and co-workers to lift heavy items and help with other upper limb tasks. A paid assistant should be considered to help with job and personal tasks. Flexible scheduling, including later starting times, shorter hours, more frequent breaks, and telecommuting, should also be considered. 25. Emphasize that the patient’s return to normal activity after an injury or surgery must occur gradually.
(Clinical/epidemiologic evidence–None; Ergonomic evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

(Clinical/epidemiologic evidence–5/6; Ergonomic evidence–NA; Grade of recommendation–D; Strength of panel opinion–Strong)

During the subacute phase of healing from an upper limb injury, return to function should occur gradually. Weight-bearing activities should be initiated only within an acceptable level of pain. Patients should be encouraged to rebuild their tolerance to transfers, manual wheelchair propulsion, overhead grooming, and other functional tasks in much the same way they were performed during the initial rehabilitation period following the spinal cord injury. Education and training in energy conservation techniques and alternative mobility should be added to home and/or clinic programs. A sudden return to activity can lead to a return of pain. 26. Closely monitor the results of treatment, and if the pain is not relieved, continued workups and treatment are appropriate.
(Clinical/epidemiologic evidence–None; Ergonomic evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Nonoperative management should include a consistent exercise program in addition to other adjunctive treatments. If the condition shows no improvement in approximately three months, surgical intervention should be considered. The potential benefits should be weighed against the risks of surgery and postoperative immobilization. Numerous studies have investigated outcomes after surgical procedures. One goal of these studies is to identify factors that predict success. Unfortunately, the results of these studies are mixed. The limited studies that investigated the return to activity after surgery found that individuals who returned to work that required forceful use of the arm had worse outcomes from both rotator cuff tears (Gazielly et al., 1994) and carpal tunnel syndrome (Katz et al., 1997; Yu et al., 1992) surgery. It follows that individuals with SCI, particularly manual wheelchair users, may be at increased risk of poor outcomes from surgery if manual wheelchair use continues or if other repetitive upper limb tasks are not changed. 28. Operate on upper limb fractures if indicated and when medically feasible.
(Clinical/epidemiologic evidence–6; Ergonomic evidence–NA; Grade of recommendation–D; Strength of panel opinion–Strong)

It is particularly important for clinicians to monitor the response to treatment because if a treatment fails, patients may assume that the health-care team is unable to help and may not return, even though other treatment options are available. The result may be greater tissue injury, poor outcomes if surgery is performed, and chronic pain. Therefore, clinicians should meticulously follow the progress—or lack of progress— of patients under their care. 27. Consider surgery if the patient has chronic neuromusculoskeletal pain and has failed to regain functional capacity with medical and rehabilitative treatment and if the likelihood of a successful surgical and functional outcome outweighs the likelihood of an unsuccessful procedure.

Surgical treatment of upper limb fractures allows for early mobilization of the patient and facilitates rehabilitation. Fractures in neurologically compromised extremities have a higher nonunion rate than fractures in nonneurologically impaired individuals. Although little in the literature specifically discusses the spinal cord injured patient, a review of humerus fractures in patients with brachial plexus injuries revealed a 50 percent nonunion rate in those fractures treated nonoperatively (Brien et al., 1990). When deciding on appropriate treatment and accepting a reduction of a fracture as adequate, clinicians should be aware that paralysis limits the ability to compensate for malrotations or poor alignment. 29. Be aware of and plan for the recovery time needed after surgical procedures.
(Clinical/epidemiologic evidence–None; Ergonomic evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

On average, recovery time from surgery, which is defined as the time until weight bearing is unrestricted, is as follows:
Preservation of Upper Limb Function Following Spinal Cord Injury

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