Rehabilitation After Spasticity-Correcting Upper Limb Surgery in Tetraplegia

  • Johanna Wangdell
    Corresponding author Johanna Wangdell, OT, PhD, Sahlgrenska University Hospital, Mölndals sjukhus, House U1 Floor 5, SE-431 80 Mölndal, Sweden.
    Center of Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Gothenburg, Sweden
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  • Jan Fridén
    Center of Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Gothenburg, Sweden

    Department of Hand Surgery, Institute of Clinical Sciences, The Sahlgrenska Academy at Göteborgs University, Gothenburg, Sweden

    Swiss Paraplegic Center, Nottwil, Switzerland
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      To describe the early active rehabilitation concept developed for spasticity-correcting surgery in tetraplegia and to report the outcomes in grip ability and change of performance and satisfaction in patients' prioritized activities 1 year postoperatively.


      Retrospective case-control study.


      Nonprofit rehabilitation unit.


      All patients who underwent surgeries for correction of spasticity in tetraplegic hands between 2009 and 2013 in the studied unit (N=37).


      Spasticity-correcting upper limb surgery with early active rehabilitation to restore grip ability in tetraplegia.

      Main Outcome Measures

      Grasp and release test (GRT) and modified Canadian Occupational Performance Measure (COPM).


      All patients could accomplish the early active rehabilitation concept. The complication rate related to the treatment was low. Compared with preoperatively, all evaluated individuals experienced improvements in grasp ability and activity performance and satisfaction at 1-year follow-up. The performance in prioritized activities, as measured by the COPM, improved by 2.6 scale steps. Satisfaction with performance improved 3.0 scale steps postoperatively (n=21). The grasp ability, measured by the GRT, improved significantly, from 80 preoperatively to 111 (n=10).


      The surgery, combined with the early active rehabilitation protocol, is a reliable and safe procedure. The ability to use the hand improved, and gains were maintained at least 1 year after surgery in all patients with respect to both the objective grasp ability and patients' subjective rating of their performance and satisfaction in their prioritized activities. The procedure should therefore be considered as an adjunct to other treatments of upper limb spasticity in spinal cord injury.


      List of abbreviations:

      ASIA (American Spinal Injury Association), COPM (Canadian Occupational Performance Measure), GRT (grasp and release test), SCI (spinal cord injury)
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        • Levi R.
        • Hultling C.
        • Seiger A.
        The Stockholm Spinal Cord Injury Study. 3. Health related issues of the Swedish annual level-of-living in SCI subjects and controls.
        Paraplegia. 1995; 33: 726-730
        • Maynard F.M.
        • Karunas R.S.
        • Waring 3rd, W.P.
        Epidemiology of spasticity following traumatic spinal cord injury.
        Arch Phys Med Rehabil. 1990; 71: 566-569
        • Skold C.
        • Levi R.
        • Seiger A.
        Spasticity after traumatic spinal cord injury: nature, severity, and location.
        Arch Phys Med Rehabil. 1999; 80: 1548-1557
        • Adams M.M.
        • Hicks A.L.
        Spasticity after spinal cord injury.
        Spinal Cord. 2005; 43: 577-586
        • Wyndaele M.
        • Wyndaele J.J.
        Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey?.
        Spinal Cord. 2006; 44: 523-529
        • Boyd RN
        • Ada L.
        Physiotherapy management of spasticity.
        in: Barnes MP Johnson GR Upper motor neurone syndrome and spasticity. Clinical management and neurophysiology. Cambridge University Pr, Cambridge2001: 95-121
        • Norman K.E.
        • Pepin A.
        • Barbeau H.
        Effects of drugs on walking after spinal cord injury.
        Spinal Cord. 1998; 36: 699-715
        • Treanor W.J.
        • Moberg E.
        • Buncke H.J.
        The hyperflexed seemingly useless tetraplegic hand: a method of surgical amelioration.
        Paraplegia. 1992; 30: 457-466
        • Pidgeon T.S.
        • Ramirez J.M.
        • Schiller J.R.
        Orthopaedic management of spasticity.
        R I Med J (2013). 2015; 98: 26-31
        • Namdari S.
        • Horneff J.G.
        • Baldwin K.
        • Keenan M.A.
        Muscle releases to improve passive motion and relieve pain in patients with spastic hemiplegia and elbow flexion contractures.
        J Shoulder Elbow Surg. 2012; 21: 1357-1362
        • Anakwenze O.A.
        • Namdari S.
        • Hsu J.E.
        • Benham J.
        • Keenan M.A.
        Myotendinous lengthening of the elbow flexor muscles to improve active motion in patients with elbow spasticity following brain injury.
        J Shoulder Elbow Surg. 2013; 22: 318-322
        • Reinholdt C.
        • Friden J.
        Selective release of the digital extensor hood to reduce intrinsic tightness in tetraplegia.
        J Plast Surg Hand Surg. 2011; 45: 83-89
        • Wangdell J.
        • Bunketorp-Käll L.
        • Koch-Borner S.
        • Fridén J.
        Early active rehabilitation after grip reconstructive surgery in tetraplegia.
        Arch Phys Med Rehabil. 2016; 97: S117-S125
        • Sultana S.S.
        • MacDermid J.C.
        • Grewal R.
        • Rath S.
        The effectiveness of early mobilization after tendon transfers in the hand: a systematic review.
        J Hand Ther. 2013; 26 (quiz 21): 1-20
        • Friden J.
        • Reinholdt C.
        Current concepts in reconstruction of hand function in tetraplegia.
        Scand J Surg. 2008; 97: 341-346
        • Dunn J.A.
        • Hay-Smith E.J.
        • Whitehead L.C.
        • Keeling S.
        Liminality and decision making for upper limb surgery in tetraplegia: a grounded theory.
        Disabil Rehabil. 2013; 35: 1293-1301
        • Dunn J.A.
        • Hay-Smith E.J.
        • Whitehead L.C.
        • Keeling S.
        Issues influencing the decision to have upper limb surgery for people with tetraplegia.
        Spinal Cord. 2012; 50: 844-847
        • Friden J.
        • Shillito M.C.
        • Chehab E.F.
        • Finneran J.J.
        • Ward S.R.
        • Lieber R.L.
        Mechanical feasibility of immediate mobilization of the brachioradialis muscle after tendon transfer.
        J Hand Surg Am. 2010; 35: 1473-1478
        • Tsiampa V.A.
        • Ignatiadis I.
        • Papalois A.
        • Givissis P.
        • Christodoulou A.
        • Friden J.
        Structural and mechanical integrity of tendon-to-tendon attachments used in upper limb tendon transfer surgery.
        J Plast Surg Hand Surg. 2012; 46: 262-266
        • Engrav L.H.
        • Heimbach D.M.
        • Rivara F.P.
        • et al.
        12-Year within-wound study of the effectiveness of custom pressure garment therapy.
        Burns. 2010; 36: 975-983
        • Bloemen M.C.
        • van der Veer W.M.
        • Ulrich M.M.
        • van Zuijlen P.P.
        • Niessen F.B.
        • Middelkoop E.
        Prevention and curative management of hypertrophic scar formation.
        Burns. 2009; 35: 463-475
        • Gracies J.M.
        Pathophysiology of spastic paresis. I: Paresis and soft tissue changes.
        Muscle Nerve. 2005; 31: 535-551
        • Midwood K.S.
        • Williams L.V.
        • Schwarzbauer J.E.
        Tissue repair and the dynamics of the extracellular matrix.
        Int J Biochem Cell Biol. 2004; 36: 1031-1037
        • Carr J.H.
        • Shepherd R.B.
        A motor relearning programme for stroke.
        2nd ed. Aspen Publishers, Rockville1987
        • Carr J.H.
        • Shepherd R.B.
        Movement science: foundations for physical therapy in rehabilitation.
        2nd ed. Aspen Publishers, Gaithersburg2000
        • Carr J.H.
        • Shepherd R.B.
        Neurological rehabilitation: optimizing motor performance.
        2nd ed. Churchill Livingstone, Edinburgh2010
        • Shumway-Cook A.
        • Woollacott M.H.
        Motor control: theory and practical applications.
        2nd ed. Lippincott Williams & Wilkins, Philadelphia2001
        • Shumway-Cook A.
        • Woollacott M.H.
        Motor control: translating research into clinical practice.
        4th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia2012
        • Harvey L.
        Management of spinal cord injuries. A guide for physiotherapists.
        Elsevier, Sydney2008
        • Wangdell J.
        • Carlsson G.
        • Friden J.
        From regained function to daily use: experiences of surgical reconstruction of grip in people with tetraplegia.
        Disabil Rehabil. 2014; 36: 678-684
        • Wuolle K.S.
        • Van Doren C.L.
        • Thrope G.B.
        • Keith M.W.
        • Peckham P.H.
        Development of a quantitative hand grasp and release test for patients with tetraplegia using a hand neuroprosthesis.
        J Hand Surg Am. 1994; 19: 209-218
        • Law M.
        • Baptiste S.
        • McColl M.
        • Opzoomer A.
        • Polatajko H.
        • Pollock N.
        The Canadian occupational performance measure: an outcome measure for occupational therapy.
        Can J Occup Ther. 1990; 57: 82-87
        • Law M.
        The Canadian Occupational Performance Measure.
        CAOT Publications, Ottawa1998
        • Carswell A.
        • McColl M.A.
        • Baptiste S.
        • Law M.
        • Polatajko H.
        • Pollock N.
        The Canadian Occupational Performance Measure: a research and clinical literature review.
        Can J Occup Ther. 2004; 71: 210-222