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Rehabilitation After Surgical Reconstruction to Restore Function to the Upper Limb in Tetraplegia: A Changing Landscape

  • M. Elise Johanson
    Correspondence
    Corresponding author M. Elise Johanson, DPT, Veterans Affairs Palo Alto Health Care System, Research and Spinal Cord Injury Service, 3801 Miranda Ave/128, Palo Alto, CA 94304.
    Affiliations
    Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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      Abstract

      Upper limb reconstructive surgical procedures for individuals with tetraplegia are performed in many centers internationally. Most recipients of surgery return to local communities and nonsurgical centers for postoperative rehabilitation and long-term follow-up. This supplement focuses on the clinical significance of upper extremity reconstruction, addressing issues related to the availability and choice for surgery, preoperative assessments, postoperative training paradigms, and appropriate outcome measures. Comprehensive intervention protocols are described in terms of dose, timing, specific activities, modalities, and related outcomes. Shared knowledge of current rehabilitation practice, as it relates to reconstructive surgery, can expand treatment options communicated to patients, increase the availability of postoperative muscle reeducation programs, and motivate long-term follow-up assessments.

      Keywords

      List of abbreviations:

      FES (functional electrical stimulation), SCI (spinal cord injury)
      An audio podcast accompanies this article.
      Restoring upper limb function is rated among the highest priorities for individuals with cervical spinal cord injuries (SCIs).
      • Anderson K.D.
      Targeting recovery: priorities of the spinal cord-injured population.
      • Snoek G.J.
      • Ijzerman M.J.
      • Hermens H.J.
      • Maxwell D.
      • Biering-Sorensen F.
      Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics.
      Reestablishing active grasp and pinch strength to the hand has a profound effect on independence, the ability to return to work, participation in society, and quality of life. Even small improvements can be the difference in whether an automated teller machine card can be retrieved or a mobile device can be accessed. Health care providers address this challenge with innovative strategies that include both surgical and nonsurgical approaches. Therapies that aim to restore or reorganize spared neural circuitry with physical activity and practice, either alone
      • Spooren A.I.
      • Janssen-Potten Y.J.
      • Kerckhofs E.
      • Bongers H.M.
      • Seelen H.A.
      ToCUEST: a task-oriented client-centered training module to improve upper extremity skilled performance in cervical spinal cord-injured persons.
      • Spooren A.I.
      • Janssen-Potten Y.J.
      • Kerckhofs E.
      • Bongers H.M.
      • Seelen H.A.
      Evaluation of a task-oriented client-centered upper extremity skilled performance training module in persons with tetraplegia.
      or in combination with sensory stimulation,
      • Beekhuizen K.S.
      Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal cord injury.
      robotic-assisted training,
      • Backus D.
      • Cordo P.
      • Gillott A.
      • Kandilakis C.
      • Mori M.
      • Raslan A.M.
      Assisted movement with proprioceptive stimulation reduces impairment and restores function in incomplete spinal cord injury.
      • Vanmulken D.A.
      • Spooren A.I.
      • Bongers H.M.
      • Seelen H.A.
      Robot-assisted task-oriented upper extremity skill training in cervical spinal cord injury: a feasibility study.
      or repetitive transcranial magnetic stimulation,
      • Gomes-Osman J.
      • Field-Fote E.C.
      Improvements in hand function in adults with chronic tetraplegia following a multiday 10-Hz repetitive transcranial magnetic stimulation intervention combined with repetitive task practice.
      are exciting possibilities for those individuals with incomplete injuries. For those with motor complete classification of SCI, reconstructive surgery (eg, tendon or nerve transfer) and implanted neuroprostheses are the primary methods for reanimating motor function in the upper limb.
      • Keith M.W.
      • Lacey S.H.
      Surgical rehabilitation of the tetraplegic upper extremity.
      • Hentz V.R.
      Surgical strategy: matching the patient with the procedure.

      Hentz VR, Leclercq C. Surgical rehabilitation of the upper limb in tetraplegia. London: WB Saunders; 2002.

      • Ho C.H.
      • Triolo R.J.
      • Elias A.L.
      • et al.
      Functional electrical stimulation and spinal cord injury.
      • Fridén J.
      • Gohritz A.
      Tetraplegia management update.
      Postoperative therapy is critical to achieving a successful functional outcome; therefore, the availability of rehabilitation expertise is an important criterion for surgery. Even though functional outcomes are due to the combined effects of surgery and postoperative therapy, descriptions of surgical techniques (see references in Dunn et al
      • Dunn J.A.
      • Sinnott K.A.
      • Rothwell A.G.
      • Mohammed K.D.
      • Simcock J.W.
      Tendon transfer surgery for people with tetraplegia: an overview.
      ) and outcome measures dominate the literature.
      • Connolly S.J.
      • Aubut J.L.
      • Teasell R.
      • Jarus T.
      SCIRE Research Team
      Enhancing upper extremity function with reconstructive surgery in persons with tetraplegia: a review of the literature.
      • Kalsi-Ryan S.
      • Verrier M.C.
      A synthesis of best evidence for the restoration of upper-extremity function in people with tetraplegia.
      Specific guidelines for postoperative training paradigms are not available.
      Reconstructive surgery is often perceived as a specialized area of expertise dominated by knowledge of surgical techniques and advanced through biomechanical research. In centers where surgical expertise does not exist, enthusiasm for integrating upper limb surgery into the plan of care for patients with tetraplegia is also less likely to exist. Nonetheless, many recipients of surgery return to local communities and nonsurgical centers for postoperative care and long-term follow-up. After surgery, voluntary strength is restored to muscles distal to the injury level that were paralyzed or weak when the level and severity of SCI was classified. Reestablishing strength to select muscle groups enables surgical recipients to participate in interventions that incorporate similar activity and task-specific training techniques under investigation for those with incomplete injuries. The collection of articles in the Archives supplement is an opportunity for clinicians who partner directly with surgeons to communicate current trends in practice associated with surgical procedures. With this shared knowledge, we hope to expand the treatment options communicated to patients, increase the availability of postoperative muscle reeducation programs for surgical recipients, and motivate long-term follow-up assessments of upper limb function for individuals with cervical SCI.
      The society of professionals who specialize in surgical restoration of hand function share clinical and research experience at the International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia. The conference brings together multiple disciplines, including surgeons, biomedical engineers, physicians, and therapists, every 3 years. The programming encompasses advancements in surgical procedures, applied biomechanics, evaluation procedures, and clinical outcomes. At the 2013 meeting in Hong Kong, presentations from the therapist symposium highlighted emerging themes for improving preoperative assessments, postoperative training, and multicenter collaborations as they relate to surgical reconstruction. Findings from the work presented in the symposium are reported in this supplement. There was also broad recognition that without documentation of current treatment protocols and associated outcomes, it would be impossible to demonstrate the benefits of new treatment approaches. The need to document the accumulated experience in pre- and postoperative aspects of care related to surgical intervention inspired collective enthusiasm for disseminating site-specific information of postoperative therapy protocols. This effort will contribute to advancing upper limb rehabilitation practice by enabling objective evaluation of novel treatment approaches, interpreting outcomes from multicenter studies, and comparing tendon transfer outcomes with nonsurgical approaches to upper limb rehabilitation.

      General principles of surgical rehabilitation

      The series of articles in this supplement is introduced with an overview of the general principles that guide surgical rehabilitation. The article by Dunn et al
      • Dunn J.A.
      • Sinnott K.A.
      • Rothwell A.G.
      • Mohammed K.D.
      • Simcock J.W.
      Tendon transfer surgery for people with tetraplegia: an overview.
      is a brief description of the process for identifying surgical candidates, a description of functional goals of surgery, and a summary of common procedures, postoperative rehabilitation strategies, and expected outcomes. These topics outline the focus of subsequent articles that describe surgical rehabilitation practice in greater detail and reduce the need to restate general principles in each article. Dunn brings attention to both surgical and nonsurgical aspects of the rehabilitation process based on clinical experience and international published literature.

      Making the choice for surgery

      Health care providers have a key role in assisting patients to make informed decisions that fit with their individual needs. Previous studies have reported an underutilization of surgeries to restore upper limb function in tetraplegia.
      • Curtin C.M.
      • Gater D.R.
      • Chung K.C.
      Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study.
      • Fox P.M.
      • Suarez P.
      • Hentz V.R.
      • Curtin C.M.
      Access to surgical upper extremity care for people with tetraplegia: an international perspective.
      That is, individuals who are candidates to receive surgery do not undergo the procedure. Two articles in the supplement direct attention to eliminating unnecessary barriers in the delivery of care and empowering patients to make informed choices. In a special communication, Punj and Curtin
      • Punj V.
      • Curtin C.
      Understanding and overcoming barriers to upper limb surgical reconstruction after tetraplegia: the need for interdisciplinary collaboration.
      identify patient, provider, and health care system barriers, shown to influence an individual's choice and the availability of resources to receive surgical intervention. Overcoming the existing barriers through interdisciplinary collaboration and timely patient education can make surgical options available to all patients who are appropriate candidates.
      A conceptual framework of the decision-making process for upper limb surgery follows in an article by Dunn et al.
      • Dunn JA
      • Hay-Smith E.J.
      • Keeling S.
      • Sinnott K.A.
      Decision-making about upper limb tendon transfer surgery by people with tetraplegia for more than 10 years.
      This work uses a semistructured interview of persons with chronic tetraplegia to explore the decision-making process and the issues affecting their choice to undergo surgery. The significance of Dunn's work is to deepen our awareness, from the patient's perspective, of the complex and often competing priorities that challenge individuals with tetraplegia as they consider their options. Greater awareness of the patient's concerns will assist health care providers to more effectively guide patients in developing their personal strategy for upper limb rehabilitation.

      Matching the patient to the intervention

      Treatment paradigms (surgical and nonsurgical) for improving upper limb function vary according to the level and severity of the SCI. In particular, the classification of injuries as complete or incomplete has a profound effect on what options are under consideration for upper limb rehabilitation. Because of the heterogeneity of this patient population, methodology that helps to identify specific mechanisms of paralysis has the potential to improve individualized treatment plans and to identify patients with similar characteristics for comparing treatment interventions.
      Differentiating upper versus lower motor neuron damage results in a more complete characterization of functional changes after SCI with objective criteria to stratify individuals within a broader classification. Bryden et al
      • Bryden A.M.
      • Hoyen H.A.
      • Keith M.W.
      • Mejia M.
      • Kilgore K.L.
      • Nemunaitis G.A.
      Upper extremity assessment in tetraplegia: the importance of differentiating between upper and lower motor neuron paralysis.
      report the advantages of including an early assessment of lower motor neuron integrity with surface electrical stimulation. Examples of surgical and nonsurgical interventions that benefit from assessment of the lower motor neuron include functional electrical stimulation (FES), task-based therapy, and nerve transfer. Implementing methods for stratifying patients according to neurologic characteristics will accelerate the process of selecting the optimal intervention and understanding the determinants of therapeutic outcome.

      After surgery: current postoperative treatment practices

      Three international multicenter studies detail therapy protocols after tendon transfer procedures to restore pinch,
      • Johanson M.E.
      • Jaramillo J.P.
      • Dairaghi C.A.
      • Murray W.M.
      • Hentz V.R.
      Multicenter survey of the effects of rehabilitation practices on pinch force strength after tendon transfer to restore pinch in tetraplegia.
      grip,
      • Wangdell J.
      • Bunketorp-Käll L.
      • Koch-Borner S.
      • Fridén J.
      Early active rehabilitation after grip reconstructive surgery in tetraplegia.
      and elbow extension.
      • Koch-Borner S.
      • Dunn J.A.
      • Fridén J.
      • Wangdell J.
      Rehabilitation after posterior deltoid to triceps transfer in tetraplegia.
      In a separate article, Wangdell and Fridén
      • Wangdell J.
      • Fridén J.
      Rehabilitation after spasticity-correcting upper limb surgery in tetraplegia.
      describe therapy after tendon lengthening and release procedures that aim to reduce the effects of spasticity and improve the ability to open the hand. The articles state unpublished comprehensive descriptions of the timing, dose, specific activities, progression, and follow-up care related to specific surgical procedures. Each article also reports functional measures (postoperative strength and a self-reported activity measure) to quantify the outcome of surgery and postoperative therapy protocols. The multicenter studies exemplify the benefits of using equivalent postoperative therapy protocols and outcome measures to assess functional outcomes by sharing data from a larger cohort of patients. The combined description of surgical and postoperative intervention protocols, with measured outcomes, contributes to establishing a baseline from which to compare new approaches.

      Exploring innovative changes to conventional practice

      A selection of articles describes novel treatment paradigms that aim to modify or enhance current protocols for postoperative rehabilitation. Novel approaches to postoperative therapy coincide with advances in surgical techniques. Wangdell et al
      • Wangdell J.
      • Bunketorp-Käll L.
      • Koch-Borner S.
      • Fridén J.
      Early active rehabilitation after grip reconstructive surgery in tetraplegia.
      • Wangdell J.
      • Fridén J.
      Rehabilitation after spasticity-correcting upper limb surgery in tetraplegia.
      advantaged the use of stronger surgical attachment techniques to accelerate the initiation of postoperative therapy. Supervised movement was initiated as early as 1 day postoperatively for both grip reconstruction and hand opening procedures with positive results. Johanson et al
      • Johanson M.E.
      • Dairaghi C.A.
      • Hentz V.R.
      Evaluation of a task-based intervention after tendon transfer to restore lateral pinch.
      report improvements in pinch strength and muscle activation after transfer recipients participated in a novel task-based program. The home-based training demonstrates the potential for improving surgical outcomes even after conventional therapy and discharge to the community. Bersch and Fridén
      • Bersch I.
      • Fridén J.
      Role of functional electrical stimulation in tetraplegia hand surgery.
      explore the benefits of using FES as an integral component of both pre- and postoperative care. Modalities are seldom used for patients who receive surgery,
      • Johanson M.E.
      • Jaramillo J.P.
      • Dairaghi C.A.
      • Murray W.M.
      • Hentz V.R.
      Multicenter survey of the effects of rehabilitation practices on pinch force strength after tendon transfer to restore pinch in tetraplegia.
      but the authors present a strong rationale for using FES to augment therapy to restore hand function and/or elbow extension. Nerve transfer procedures present several new challenges to rehabilitation: identifying activities to promote nerve regeneration and training to disassociate the actions of the donor and recipient muscles that share the same innervation after surgery. Hahn et al
      • Hahn J.
      • Cooper C.
      • Flood S.
      • Weymouth M.
      • van Zyl N.
      Rehabilitation of supinator nerve to posterior interosseous nerve transfer in individuals with tetraplegia.
      describe a rehabilitation protocol to address these goals in therapy after nerve transfer, a relatively new surgical procedure to restore function in the upper extremity.

      Muscle reeducation after surgical procedures

      A common theme for every article describing the aims of conventional or novel treatment approaches is muscle reeducation. Surgical transfer of a tendon or a nerve represents a unique challenge to reestablish voluntary motor control in the upper limb after SCI. The transferred muscle has a new anatomic path (or innervation) and must coordinate with different synergists and antagonists to accomplish functional tasks. Activity and practice are known to be key elements of learning new motor skills
      • Winstein C.
      • Lewthwaite R.
      • Blanton S.R.
      • Wolf L.B.
      • Wishart L.
      Infusing motor learning research into neurorehabilitation practice: a historical perspective with case exemplar from the accelerated skill acquisition program.
      and muscle coordination.
      • Carson R.G.
      Changes in muscle coordination with training.
      Emerging postoperative treatment paradigms, guided by principles of motor learning and skill development, have the potential to improve the capacity for upper limb function in tetraplegia.
      • Johanson M.E.
      • Dairaghi C.A.
      • Hentz V.R.
      Evaluation of a task-based intervention after tendon transfer to restore lateral pinch.

      Outcome measures and international database

      The strong foundation of clinical outcome measures developed for this patient population is critical to determining the effects of surgical and nonsurgical treatment approaches. Do small improvements in force result in meaningful functional change? Do modalities enhance postoperative treatment effects? Which patients should receive nerve transfer versus tendon transfer? Are activity-dependent training protocols beneficial for muscle reeducation after surgical procedures? How does surgical reconstruction compare with conservative approaches? The use of standardized outcome measures to assess upper limb function is necessary to support interdisciplinary communication and make possible multicenter studies of therapeutic efficacy.
      Development and selection of standardized measures appropriate to detecting postoperative changes in this small, heterogeneous patient population has been a primary topic of the therapy symposia at every international conference on surgical rehabilitation of the upper limb. This combined interest from the therapists became a catalyst for the international therapist consensus group described by Sinnott et al.
      • Sinnott K.A.
      • Dunn J.A.
      • Wangdell J.
      • Johanson M.E.
      • Hall A.S.
      • Post M.W.
      Measurement of outcomes of upper limb reconstructive surgery for tetraplegia.
      The extensive review of standardized measures across multiple domains of the International Classification of Functioning, Disability and Health summarizes the psychometric properties of tests and measures recommended for assessment of upper limb and hand function for persons with tetraplegia. Of special interest is the development of an international registry (New Zealand) promoting shared resources for informing clinical practice. Uniformity in outcome measures represents a critical step toward the goal of evaluating responsiveness to various treatment approaches and combining data sets for larger, multicenter studies.

      Supplemental Data

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