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2014-05-01 20:01:57

review of upper extremity rehab of clients with SCI lecture
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  1. Guide to planning exercise/activity:
    • level of injury (current and expected motor recovery; tenodesis needs; typical complications)
    • orthopedic evaluation of capsular structures, muscle tension, nerve tension, pain levels, sensation, ADL needs
    • previous history: degenerative changes in joint or rotator cuff
  2. Complications:
    • shoulder pain (usually bilateral)
    • risk factors (>50, decreased PROM, not initiating ROM w/in first 2 weeks of injury)
    • very serious complication, given the client's dependence on UE for ADL, transfers
  3. Etiology of Shoulder Pain
    • weakness of the shoulder girdle mm esp that which occurs w/ C6 and higher
    • -contribute to muscle shortening
    • -capsular tightening
    • -muscle imbalance -- force coupling changes of the rotator cuff
    • neuritic pain from nerve root injury or radicular pain w/ parasthesias, phantom sensations OR reflex sympathetic dystrophy
    • referred pain to the shoulder from neck and/or trapezius
    • direct trauma during initial accident
    • indirect trauma
    • pre-existing shoulder dysfunction
    • psychological issues related to control, secondary gain, manipulation
  4. Etiologies: referred pain to the shoulder from neck and/or trapezius pain:
    • neck pain is common secondary to number of neck fractures/dislocations of the cervical spine
    • trapezius pain is common secondary to overuse
    • trapezius shortening is common secondary to weakness of protractors/depressors of the shoulder girdle b/c the upper trap becomes overused in order to move scapula/shoulder
  5. UE complications:
    • overuse injuries
    • lateralization of thumb secondary to WC propulsion; can affect strength of opposed pinch
    • general loss of joint motion, atrophy, contractures
  6. Promoting optimal conditions for UE maintenance and control:
    • positioning (bed, WC, splinting, muscle shortening to aid function)
    • educate (overuse and train for management)
    • smart muscle strengthening
  7. Smart muscle strengthening
    • gravity assisted -- gravity eliminated -- against gravity -- resistance training
    • isometric -- eccentric -- concentric
    • adapt exercise for loss of hand control
    • use neuromuscular re-education principles (e-stim, PNF)
  8. UE control is enhanced by proximal stability, therefore, ...
    we must address head and trunk control when looking at UE return
  9. What do we need for effective tenodesis?
    • shortening of FDP/FDS
    • shortening of FPL for thumb approximation to fingers
    • avoid excessive stiffness in MPs and IPs of fingers
    • encourage stiffness in IP of thumb for greater stability of pinch
  10. Decision to preserve tenodesis:
    • only as good as the medical tests given
    • many times we are told someone has had a complete injury and then they have function unanticipated
    • some literature suggests preserving tenodesis for one year post injury to be sure you don't miss residual function in all clients w/ SCI
    • preserve in all C4 and above, but the conventional wisdom is gernally not to preserve above C5
  11. Goals for C1-3 Injury:
    • limited head control
    • prevent pain in UE
  12. Interventions for C1-3:
    • headwand and mouthstick activities to increase neck strength and ROM starting in gravity eliminated range
    • teach competent and thorough passive ROM to client and family ASAP
    • hand splints
  13. C1-3 Hand splints prevent:
    • hand contractures to minimize pain w/ cleaning, ROM
    • worn at night, hands free during day
  14. C4 intervention goals:
    • maximal head control
    • limited scapular control
    • prevent UE pain/hand contractures
  15. C4 Interventions
    • mouthstick activities
    • Swedish sling or balanced forearm orthoses, resting hand spling
    • facilitate strengthening upper, middle, lower trap function and PROM should to hand; if complete - tenodesis is not an issue
    • prevent shortening of trapezius and others; resting pan splint often built into WC armrest
  16. C5 Goals:
    • limited trunk stability
    • limited, assisted arm placement
    • preserve tenodesis hand function
  17. C5 trunk interventions:
    • control w/ short, long, cross leg sitting
    • PNF patterns, any challenging activity to increase strength
    • teach competence using both arms to hook onto the back of a WC or using a loop on a WC to increase trunk mobility
  18. C5 shoulder intervention: Goal of limited arm control
    • external rotation of shoulder, some flex, abd
    • elbow flexion and supination of the forearm
  19. C5 shoulder intervention: goal of limited arm control
    Challenges -
    • IR < ER
    • weak serratus limits elevation and scapular fixation on thorax
  20. C5 shoulder interventions: goal of limited arm control:
    • progressive exercise (AA/A/RROM)
    • PNF
    • theraband
    • functional activity
    • balanced forearm orthoses
    • positioning to prevent elongation; hand mitts and wrist support to exercise
  21. C5 Elbow/wrist/hand goal:
    preserve tenodesis
  22. C5 elbow/wrist/hand strengths:
    elbow flexion and supination
  23. C5 elbow/wrist/hand challenges:
    no hand function
  24. C5 elbow/wrist/hand interventions:
    • weight bearing w/ wrist extension, finger flexion
    • all ROM through tenodesis function
    • electrically-powered tenodesis splints; radial wrist and thumb spica to maintain web space
    • elbow extension splints/casts - can't loose
    • progressive exercise
  25. C5 hand splint:
    • wrist is supported in extension
    • no true tenodesis unless splint is electric
    • cuff made for utensils
  26. C6 intervention goals:
    • limited trunk stability
    • unassisted, limited arm placement
    • tenodesis hand function
  27. C6 interventions (trunk):
    • same as C5
    • progress stability w/ all
    • greater use of UE increases ability to stabilize the trunk during ADL
  28. C6 unassisted limited arm placement strengths:
    more scapular control
  29. C6 unassisted, limited arm placement challenges:
    partial serratus
  30. C6 unassisted, limited arm placement goals:
    • progressive exercise, wrist and hand supports as needed
    • accurate arm placement for function w/ attention to trunk control
  31. C6 use tenodesis for hand function:
    add partial wrist extensors and pronation to C5 function
  32. C6 use tenodesis for hand function
    no finger or wrist flexors
  33. C6 use tenodesis for hand function:
    • same as C5; do not stretch long finger flexors
    • progressive exercise
    • wrist-driven tenodesis spling
    • short opponens splint
    • use of tenodesis after arm placement in a variety of ADLs
  34. C6 Hand splint:
    • strengthen wrist ext so that tenodesis can be used
    • thumb spica splint gives some stability for pinch
    • if wrist too weak, need to include in splint like C5
    • quad cuff for phone use, electric razor, etc.
  35. C7 intervention goals:
    • fair trunk stability
    • full arm placement
    • tenodesis hand function
  36. C7 interventions (trunk):
    progressive activities as seen in C5-6
  37. C7 full arm placement:
    • serratus
    • triceps
  38. C7 full arm placement:
    • partial latissmus innervation
    • when arms stable and pushing down, aids in picking up the pelvis so the foot clears the ground
  39. C7 full arm placement:
    • progressive strengthening using tenodesis function to manage weight training devices
    • practice arm placement accuracy w/ increasing trunk challenges
  40. C7 to use tenodesis hand function; more thumb:
    • wrist flexors
    • finger ext
    • thumb ext and abd
  41. C7 to use tenodesis hand function; more thumb:
    no finger flexion or intrinsics
  42. C7 to use tenodesis hand function; more thumb:
    • progressive activity/ex
    • hand splint to maintain fingers for pinch or short opponens
    • MP flexion spring assist splint -- allows extension but springs into flexion
    • increase accuracy of tenodesis after arm placement for ADL
  43. C7 hand splint:
    will generally only use for training as may be able to use evolving strength in thumb w/o support
  44. C8 Intervention goals:
    • trunk stability
    • limited natural hand function
  45. C8 interventions (trunk)
    • advancing PNF patterns
    • advanced occupational sitting tasks
    • bilateral UE tasks from WC level (putting items in cabinets w/ arms OH)
  46. C8 limited, natural hand function:
    finger and thumb flexors, thumb adductor
  47. C8 limited, natural hand function:
    lack of intrinsics
  48. C8 limited natural hand function:
    • progressive activity/ex (adapted writing, putty)
    • small, hand-based splint to support arches as needed
    • meaningful, functional fine motor coordination activities (putting coins in a coke machine)
  49. T1 intervention goals:
    • Normal hand function
    • strengths: lumbricales, opponens and interosseus muscle function
    • challenges: above may be present but weak
    • interventions: progressive occupational activity and exercise (practice what they cannot do)
  50. Dealing w/ complications:
    • know your etiology
    • treat orthopedic conditions on impairment level
    • analyze activity and modify movement to prevent further pain/injury
    • educate on life-long process for care of the UEs