UE Intervention and Exercise for Spinal Cord Injury PT 672

Screen every patient for:

• Blood pressure and autonomic dysreflexia risk
• Orthostatic hypotension symptoms
• Skin integrity and pressure/shear risk
• Orthopedic precautions and fracture risk
• Fall risk and guarding needs
• Overstretching risk: tenodesis, hamstrings, lumbar paraspinals
• Shoulder overuse/stress

Compensation in SCI Rehabilitation Involves using

unaffected body parts, assistive devices, or braces to perform tasks the injured system cannot (e.g., transfers, dressing).

Compensation in SCI Rehabilitation Often needed early on, particularly during

spinal shock or when no muscle activation is present or if return of MMT does not occur.

Compensation in SCI Rehabilitation is important for ensuring

safe discharge during short inpatient stays,
especially due to insurance limits

risk of Compensation in SCI Rehabilitation

Over-reliance on compensation can suppress activation of
impaired neural circuits, leading to maladaptive plasticity and
limiting potential recovery but it is often necessary to use
compensatory strategies

Compensation Strategies in SCI Muscle and Mechanical Substitution

Use available muscles, gravity, passive tension, body position, and
closed-chain mechanics to accomplish a task

Muscle and Mechanical Substitution C6 example:

without functional triceps, shoulder position, external
rotation, weight bearing, and mechanical alignment can help
stabilize the elbow in extension

Muscle and Mechanical Substitution Tenodesis

wrist extension creates passive finger flexion for grasp

what are Compensation Strategies in SCI for Momentum & Head–Hips?

Generate momentum with available body segments to help move
body segments that cannot move actively.

what are Compensation Strategies in SCI for Momentum & Head–Hips during transfers?

movement of the head/trunk in one direction helps
move the pelvis in the opposite direction

what are Compensation Strategies in SCI for Momentum & Head–Hips during rolling?

movement of head and UE helps move trunk

C6 Grasp Substitution Techniques

Tenodesis Grasp using wrist extension andrelease using flexion

what are UE Compensatory Strategies

• Supinated hand
• Hand as a hook
• Tenodesis
• Using the unaffected or less affected limb to complete tasks
• Adaptive equipment

Adaptive Equipment:

use of device to compensate for lost grip, pinch or wrist control

environmental modifications

adjusting home or workstation set up, using assistive technology, installing grab bars or lamps.

what is Splinting for?

• Helps facilitate tenodesis
• Maintains tendon length and prevents over lengthening
• Maintains functional positions
• Help with hygiene
• Increase hand function
• Help with spasticity
• Most patients show a preference to avoid splint or
disuse as soon as possible

what is Elbow Extension Splint

C5 SCI Prevents bicep contracture – in bed

what is a tenodesis splint?

A functional custom made orthosis designed for
individuals with active wrist extension but no
active finger movement—most commonly used
in C6 and some C7 spinal cord injuries

what is the harnessess the natural tenodesis effect?

Wrist extension passively flexes the fingers and thumb, enabling grasp; wrist flexion allows release

tenodesis splint ideal for patients with :

• Fair to normal wrist extensor strength (≥ grade 3/5)
• No active hand or finger movement
• C6–C7 tetraplegia

Can be used as a training device or as a
permanent orthosis to promote independence
in ADLs (e.g., feeding, grooming, writing)

What is the downside to compensatory hand strategies?

• Only work in certain situations
• Energy
• May require multiple trials
• Risk of shoulder impingement and tendonitis
• Limited ability to pick up heavy items

what are UE interventions to improve function after SCI?

1. Promote Recovery / Motor Learning

2. enable or compensate for function

3. reconstruct function

what is Promote Recovery / Motor Learning

Functional task practice
Massed practice
Robotics
VR/motor imagery
FES task practice
Neuromodulation (transcranial magnetic stimulation)

what is enable or compensate for function

Tenodesis
Adaptive equipment
Orthoses and functional neuroprostheses

what is reconstruct function

Tendon transfer
Nerve transfe

Recovery-based approaches aim to improve

function of impaired neural systems through activity-dependent
practice and motor learning.

Recovery in SCI Rehabilitation Emphasizes motor learning through

• Maximal attention and effort by the patient.
• Allowing errors to promote skill acquisition
• High repetitions, of task-specific movements, to drive
cortical and spinal reorganization

How do I choose? Recovery vs.
Compensation?

• After spinal cord injury, rehabilitation aims to maximize independence and quality of life.
• Most patients benefit from a combination of strategies that promote both restoration of lost function (recovery) and adaptation to permanent deficits (compensation)
• Recovery strategies often most affective in incomplete SCI or when some neural pathways remain intact

Can The Impaired System Contribute?

YES / emerging function

→ Challenge it
→ Practice it
→ Strengthen it
→ Increase repetition

Can The Impaired System Contribute?

NO / insufficient for the task

→ Compensate
→ Modify the task/environment
→ Adaptive equipment
→ Protect independence and safety

C5 available function to build on

shoulder control and elbow flexion; little to no active wriest or hand function

C5 massed practice examples

Reach to targets • slide/move larger objects • hand-to-face practice • push
objects across table • repeated UE placement for grooming/feeding with
adaptive equipmen

C6 available function to build on

wrist extension --> tenodesis grip

C6 massed practice examples

Pick up/release cups or cans • grasp/release blocks • cup to mouth • hold
toothbrush/utensil • move objects between locations • progress to smaller
objects

C7 available function to build on

triceps and wrist flexion/extension; increasing hand function depending on completeness

C7 massed practice examples

Reach–grasp–place • squeeze toothpaste • open/close containers • turn cards •
turn doorknob • pour from pitcher • manipulate clothing

C8-T1 available function to build on

increasing finger flexion/extension, intrinsic hand control

C8-T1 massed practice examples

Coins • buttons • zippers • pegboard • keys • beads/lacing • nuts and bolts •
screwdriver • small containers • phone/typing tasks

CIMT parameters for SCI

2 hrs/day, 5 days/wk, 3 wks

CIMT outcomes for SCI

improved grip and pinch strength, sensory function, faster performance on functional tasks; neuroplastic changes

what is robotic assisted UE intervention

• Established as safe and feasible with minimal adverse effects in subacute and chronic SCI
• Some gains in UE motor scores, grip, pinch and ADL's
• Benefits greatest when robotic therapy combined with conventional OT or PT
• Small studies that lacked control groups and not all showed statistically significant or clinical meaningful improvements when compared to conventional therapy alone

Transcutaneous:

only uses surface electrodes
• Many types to improve grasp; most devices vary in type
of the grasps they elicit and the switch that triggers it

Functional Electrical Stimulation can use

surface, percutaneous or implanted electrodes
• Can be worn as a neuroprosthesis or part of therapy
to restore motor function

what is Prognosis of UE Function

• SCI clients often have significant improvements in sensorimotor and grasping function during the first year after injury
• Most rapid improvement during 50-100 days
• Recovery continues for 300 days
• Motor function recovers more than sensory function during this period
• Early upper extremity motor scores strongly predict future grasping ability

does motor or sensory function recover more in terms of UE function

motor

early UE motor scores strongly predict future...

grasping ability

what is SCI Interventions?

• Functional Mobility (Lab)
• ROM
• Strengthening
• Electrical stimulation
• Exercise and Physical Activity

what are ROM Interventions After SCI

• Maintain shoulders in slight abduction/external rotation, elbows extended (not hyperextended), wrists in 30–45° extension, and support the limb to prevent subluxation and pressure injuries.
• Prevent joint contracture
• C6–C7 injuries, always extend the wrist with fingers flexed during stretching and splinting to maintain optimal tenodesis
• Maximize use of available muscle function while positioning to prevent contracture of unopposed muscles and denervated muscles

Progressive strengthening after spinal shock has resolved and patient is

medically stable consider safety with partially innervated muscles and spasticity

what muscles are key to strengthen for shoulder health and transfer ability

Rotator cuff, serratus anterior, latissimus dorsi, pectoralis major, triceps

what two key muscles are important for ambulation

gastroc, quads

what are functional training examples?

seated bicep curl with leg lifter, lateral leans, serratus punch, wrist ex for grasp, reaching, sit to stand

Intact triceps often propel manual chairs __

independently

__ may need power for community distances for wheelchair use

C5/C6

__ injuries usually need power wheelchairs

higher cervical

A __ patient must be able to weight shift correctly to get a manual wheelchair

tetraplegia

All w/c users to weight shift every

15-20 minutes
(forward/lateral or push up)

Section IV — Exercise After SCI

what is Exercise Response

Often have blunted HR and BP response (decreased
cardiac output, lower peak HR and post exercise
hypotension)

what is Peak HR in tetraplegia for exercise response?

Peak HR in tetraplegia often 100-120 bpm RPE 13-17

SCI patients participate in less physical activity than people
without SCI after

adjusting for age, sex, BMI, and socioeconomic status

Individuals with SCI have higher rates of

cardiovascular and metabolic disease

Body composition changes occur with

months and during the
years following a SCI

__% decline in hip and knee bone mass fist year after
injury and ¼ have OP (Pelletier et al. 2014)

30-50%

Obesity in __ % of population (Edwards et al. 2008)

20-78%

Benefits of Exercise for Individuals with SCI
Improves fitness:

Cardiorespiratory fitness, power output, and muscle strength
increase with regular exercise (aerobic and resistance training)

Benefits of Exercise for Individuals with SCI

Effective exercise types:

Arm cycling, rowing, hybrid arm–leg exercise, wheeling,
exoskeleton-assisted ambulation, and body weight-supported treadmill training

Benefits of Exercise for Individuals with SCI

Health outcomes:

Some evidence for improved cardiometabolic health, body
composition, and blood lipids, though high-quality trial data are limited

Benefits of Exercise for Individuals with SCI

Neuromuscular electrical stimulation:

Shown to improve body composition

Benefits of Exercise for Individuals with SCI

Quality of life:

Long-term exercise enhances well-being, quality of life, and social
connectedness

Benefits of Exercise for Individuals with SCI

Pain reduction:

Both acute and chronic exercise can reduce neuropathic pain