Introduction

Raineteau and Schwab (2001) defined a spinal cord injury as a lesion within the spinal cord that results in the disruption of nerve fibre bundles that convey ascending sensory and descending motor information.  A spinal cord injury (SCI) at the cervical level results in tetraplegia, the loss of hand and upper limb function with impairment or loss of motor and/or sensory function. In incomplete spinal cord injuries, some neural transmissions can still pass through the spinal cord, but it is often fragmentary or distorted which leads to additional neurological complications such as chronic pain or spasticity.   Tetraplegia results in impairment of function in the arms, as well as in the trunk, legs and pelvic organs.  It is estimated that cervical SCI accounts for approximately 50% of all people living with SCI (Steeves et al. 2007).  The loss of upper limb function, especially the use of the hands is one of the most significant and devastating losses an individual can experience.  The use of the upper extremities is critical in completing basic activities of daily living such as self-feeding, dressing, bathing and toileting.  Mobility needs such as transfers from surface to surface, transitional movements such as rolling, bridging and sit to lying down, crutch walking and wheeled mobility are also completed using their arms (Snoek et al. 2004).  The level at which the injury or lesion occurs and the completeness of the lesion (incomplete or complete) indicate the level of independence of the person (Ditunno 1999). 

The Paralyzed Veterans of America (PVA) have published a clinical practice guideline (CPG), “Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health Care Professionals,” that outlines the expected skills and outcomes that a person is expected to acquire and achieve at each significant level of injury (Consortium for Spinal Cord Medicine 1999).  As medical care of the spinal cord injured person has improved, life expectancy now approaches the rest of the population.   Secondary complications from SCI and aging are ongoing challenges and include pain, contractures and upper limb musculoskeletal injuries (Sipski & Richards 2006). 

Hanson and Franklin (1976) compared sexual function to three other impairments in patients with SCI.  75.7% of the subjects gave the highest priority to upper extremity function.  Snoek et al. (2004) surveyed the needs of patients with SCI and found a high impact and high priority for improvement in hand function in tetraplegics comparable to that for bladder and bowel dysfunction.  A recent study by Anderson (2004) found similar results in which 48.7% of persons with tetraplegia (3.3% of persons with paraplegia) reported that regaining arm and hand function would most improve their quality of life.  In the same study, Anderson (2004) reported that women and men with tetraplegia had similar priorities (53.2% to 48.3%) and the priority of regaining arm and hand function did not change whether someone was injured 0-3 years or more than 3 years.  Anderson (2004) reported that recovering even partial arm and hand function may have a significant impact on independence.

Given the above, the initial care, management, rehabilitation and prevention of injuries in the upper limb of tetraplegics are of great importance in maximizing and maintaining independence.  Management of the tetraplegic upper limb tends to be eclectic, involving traditional rehabilitation interventions, use of orthosis (splints and adaptive devices) and upper extremity surgery.  According to Murphy and Chuinard (1998), management and care of the upper limb can be divided into three phases: the acute, the subacute and the reconstructive phase.  Bryden et al.  (2005) proposed a similar hierarchy of upper extremity functional restoration for individuals with tetraplegia.  This includes the provision of conservative treatment methods followed by surgical restoration using residual motor functions and increasing or augmenting voluntary functions with functional electrical stimulation (FES) for maximal upper limb function. The aim of the first two phases of rehabilitation is to: prevent complications; to achieve optimal functioning within the limits of the neurological deficit; and to create optimal conditions for the reconstructive phase (Bedbrook 1981; Keith & Lacey 1991; Curtin 1994; Harvey 1996).  In the latter phase, various surgical options and functional electrical stimulation (FES) are available to improve positioning and stabilization of the arm as well as key and palmar grasp function (Waters et al. 1996; Triolo et al. 1996; Johnstone et al. 1988; Snoek et al. 2000; Peckham et al. 2001).  In the new clinical practice guidelines by the Consortium for Spinal Cord Medicine (2005) emphasizes prevention of upper limb injuries of tetraplegic individuals in maintaining independence. 

Although there is no overall consensus regarding the management of the tetraplegic upper limb, Hummel et al. (2005), Snoek et al. (2005) and the Consortium for Spinal Cord Medicine (2005) provide excellent discussions and recommendations.

There is agreement that restoration of hand function is an important goal in rehabilitation.  It is also worth noting that there are very few upper extremity tests that accurately evaluate upper limb function in this population (van Tuijl et al. 2002).  Curtin (1994) and Krajnik and Bridle (1992) noted a great inconsistency in evaluation and documentation of the tetraplegic upper limb between therapists.

The main focus in rehabilitation of the spinal cord injured person is compensation of functional loss and using those parts of the sensorimotor system, which are still intact (van Tuijl et al. 2002).  Research findings regarding neuroplasticity and neurological recovery of the spinal cord also include current rehabilitation practices that focus on strategies to restore function lost after SCI. 

Several studies have explored increased hand function as a result of reconstructive surgery and/or neuroprothesis.  Although these and many other treatment options exist, and have proven to improve the overall functioning and functional independence of the person with tetraplegia, clinical practice has shown that suitable candidates for reconstructive surgery or FES interventions often do not accept the treatment that is offered (Snoek et al. 2004).  According to Moberg (1975), over 60% of the tetraplegic population could benefit from reconstructive surgery and it continues to be widely advocated (Snoek et al. 2004).  Curtin et al., (2005) reported in their study that reconstructive surgery is underutilized in this population reporting that fewer than 10% of persons with tetraplegia actually undergo surgical reconstruction.  Reconstructive surgeries such as muscle/tendon transpositions of the intact arm or hand muscles are designed to substitute for lost motor function (van Tuijl et al. 2002).  Despite this, controversy still exists among clinicians as to whether or not to perform reconstructive surgeries and the benefits of reconstructive surgery have not been clarified with good quality randomized clinical trials (Harvey et al. 2001).  Gorman et al. (1997) deduced that 11% of the tetraplegic population could be candidates for an implanted FES device (Freehand System).  Most implanted FES devices are usually combined with augmentative and substitutional reconstructive surgery (Keith et al. 1996).

This chapter will discuss the various treatment interventions during the acute, subacute phase and reconstructive/chronic phase of rehabilitation.

Connolly SJ, Mehta, S, Foulon BL, Teasell RW, Aubut JL, (2010). Upper Limb Rehabilitation Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 3.0. Vancouver: p 1-19.