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Tetraplegia: update on assessment
Hand Clin 18 (2002) 377–389
Tetraplegia: update on assessment Antonio Landi, MDa,*, M.J. Mulcahey, MS, OTR\Lb, G. Caserta, MDa, N. Della Rosa, MDa a
The Hand and Microvascular Unit, Azienda Ospedaliera Policlinico, Via del Pozzo 71, 41100 Modena, Italy b Rehabilitation and Clinical Research, Shriners Hospital for Children, 3551 North Broad Street, Philadelphia, PA, USA
Historical background In the report of the First International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia [1], Erik Mo¨berg quoted the study by Hanson et al, which demonstrated that tetraplegic patients considered the function of the hand more relevant than walking, sexual performance, and bowel and bladder functions. This significant information has been reported in subsequent publications [2–5]. In their recent survey of the needs of tetraplegic patients, Snoek et al [6] among 700 members of the Scottish and Dutch Spinal Cord Injury (SCI) Associations reported that 95% of patients had indicated that the improvement of hand function was relevant to their quality of life. This score was compared with the highest score (72%) of the nonwalking group of patients in whom improvement of bladder and bowel functions were indicated. If patient whishes have not changed during this 23-year period, then the assessment, treatment, and design of outcome studies undoubtedly have switched to a more scientific approach [7]. According to the historical survey made by Hentz and Ladd [3], the earliest report on the surgical possibilities and treatment in the tetraplegic hand should be attributed to Bunnel [8] who described his results using procedures aimed to restore the so-called ‘‘opposition pinch.’’ At Rancho Los Amigos Hospital, Nickel et al [9] had performed pioneer work in the field by selecting a non-return type of operation that used
* Corresponding author. E-mail address: [email protected] (A. Landi).
multiple joint fusions in the unfavorable group of high level tetraplegia patients [9]. For neurorehabilitation, Guttman [10] in 1975 stated that less than 5% of tetraplegic patients could be considered candidates for hand surgery. Around the same time, other early pioneers started to use surgical reconstructive procedures that were aimed at improving upper limb function in the tetraplegic patient [11– 15]. In 1978, under the driving force of Mo¨berg, 18 dedicated surgeons participated in the First International Conference on this issue in Edinburgh, Scotland. (Only five of them where able to attend the second event in Giens, France, in 1984: H. Brummer from Finland, A. Freehafer and C. McDowell from the United States, G. Lindstrom from Sweden, and E. Mo¨berg from Sweden.) During the first conference, an impressive series of posterior deltoid–to–biceps transfers, including more than 10 years of follow-up had already been presented by Mo¨berg, Lamb, and DeBenedetti [1]. Consensus at the time [1] was reached on the following: Sensory testing (two point discrimination) Muscle testing (MRC grading) Timing of surgical reconstruction (rarely before 12 months following SCI) No surgical indication in patients with painful conditions Surgical goals: elbow extension and key pinch in the unfavorable groups No indication for wrist fusion The sensory classification was defined within two main categories: O for the presence of ocular sense of hand position and function and Cu for the presence of cutaneous afferent input, which was considered recordable only when a patient
0749-0712/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 2 4 - 0
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demonstrated 10 mm or less of two-point discrimination at the thumb. For both motor and sensory parameters, only the below-elbow function was considered in the International Classification (Table 1). Clearly, this was intended to be a guide to the forearm and hand only [1], because shoulder and elbow function were not included deliberately [1,2,16]. During the Seventh International Conference in Bologna, Italy, in 2001, the surgeons decided that elbow function should be considered but did not describe pertinent methods of evaluation. The authors believe that updating an assessment should comprise methods that consider the whole patient and the function of the entire upper limb, because consistent outcome studies can be designed only when the precise evaluation of impairment, disability, handicap [7], and corresponding methods of measurement are conceived, discussed, and shared. Overall assessment Over the past five decades, there has been a plethora of literature published on the assessment of the tetraplegic patient. Historically, assessment Table 1 International classification for surgical procedures at the hand in tetraplegia Group Muscle characteristics Function 0
1 2 3 4 5 6
No muscle below the elbow suitable for transfer BR ECRL ECRB PT FCR Finger extensors
7
Thumb extensors
8
Partial digital flexors
9
Lacks only intrinsic
X
Exceptions
Flexion and supination of the elbow
Extension of the wrist Extension of the wrist Pronation of the wrist Flexion of the wrist Extrinsic extension of long fingers (partial or complete) Extrinsic extension of the thumb Extrinsic flexion of the fingers Extrinsic flexion of the fingers (complete)
No specific function for BR is listed. Differentiating between ECRB and ECRL function should be reported in the subheading, ‘‘Suggested criteria for modification of the International Classification.’’ Abbreviations: BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; FCR, flexor carpi radialis; PT, pronator teres.
concentrated on (1) the need for adaptive equipment, splints, and orthoses; (2) medical issues, including respiratory and skin integrity, kidney function, muscle function, joint range of motion, and independence level in the performance of activities of daily living; and (3) comorbidity, including substance use, brain injury, and social and emotional sequelae. Technologic advances have broadened assessment further to include the evaluation for sophisticated power-seating systems, functional electrical stimulation, environmentalcontrol units, and communication systems. Additionally, the more recent understanding of disability as an individual, cultural, and social phenomenon (rather than strictly as a medical condition) has expanded the purview of assessment to include pain and painful syndromes, the effort and spontaneity of activities, and the temporal aspects of activity performance and the aging process. Any ethical assessment requires a framework or model to guide assessment choice and interpretation. Several disability models have been proposed and have caused some confusion due to language differences. Additionally, they (1) overemphasize the medical model, which views health as the absence of disease; (2) underemphasize the social models, which consider the interrelationship between human beings and their environment; and (3) have assumed a unidirectional, casual relationship among social levels. The World Health Organization has proposed the Second International Classification of Impairments, Disabilities and Handicaps (ICIDH-2) as an alternative to previous models. The ICIDH-2 provides a scientific basis to studying the consequences of health conditions; establishes a common language that crosses cultural boundaries; acknowledges complex and dynamic interactions among health conditions, the environment, and personal factors; and assumes multidirectional relationships among the factors that influence one’s health [WHO 1999]. Those who embrace the ICIDH-2 view consider disability a cultural, social, and personal phenomenon rather than just a medical condition. Laterality With tendon transfers or the Freehand system (The Cleveland FES Centre, Cleveland, Ohio), bilateral function during some activities may be achieved; however, for most activities, tetraplegic patients will function bimanually. The assessment of pre- and postinjury hand dominance is key to the surgical proposal. Establishing motor and
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sensory asymmetry is important, particularly in high-level tetraplegia in which bimanual function is required for even the simplest of activities. Perineanal care The relationship between hand function and perineanal care is crucial to the overall assessment of the tetraplegic patient. Regardless of injury level, a pretreatment assessment of the upper extremity (UE) should be directed toward bladder management because bladder regimens (eg, dependency on others for emptying the bladder) often dictate daily schedules. Even with the most successful hand reconstruction, if patients remain on rigorous bladder-emptying regimens and are dependent on others for assistance, they gain little in terms of social participation. The assessment for UE tendon transfer surgery or Freehand implantation is coupled with the assessment for urologic treatment options to augment hand surgery. In male patients who have a C5 and C6 SCI, the Freehand system allows for bilateral hand function, enabling grasping and insertion of the catheter while the noninstrumented hand stabilizes the penis. For female patients who have a similar injury level, a urinary diversion (ie, catheterizable stoma) [17,18] affords comparable levels of independence. Those with low cervical injuries who have undergone bilateral tendon transfers achieve independent bladder function; women continue to benefit from urinary diversions. Cultural, social, and personal dimensions of disability The cultural, social, and personal dimensions of disability are influenced greatly by political and economic factors. These dimensions are the predominant factors that affect social participation and quality of life and, in many cultures, foster the medicalization of disabilities. Assessing
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these factors can aid in the interpretation of medical outcomes. Case illustration for disability medicalization A boy, JJ, 12 years of age, who suffered an incomplete SCI as a result of transverse myelitis at 5 years of age, had residual hand function but was paralyzed completely in C5 muscles, which prevented shoulder and elbow flexion. Because of the severe UE impairment, JJ developed compensatory use of his feet to write, eat, brush his teeth, and play games. Based on the Functional Independence Measure, he was independent in all activities of daily living, including perineanal care by using his feet (ICIDH-2 no disability). The Canadian Occupational Performance Measure (COPM; see later section), however, showed that JJ had limited participation secondary to the cultural, social, and personal issues related to how he performed his activities. For example, JJ did not like to use his feet in public, especially in school. Consequently, JJ and his mother requested a medical intervention (UE reconstruction) to overcome the stigmas associated with his impairment. Their goal was fuller participation in school and extracurricular activities. JJ underwent multiple surgical procedures of the UE, the goal of which was to restore volitional elbow flexion and to position the forearm and hand for function. Additionally, JJ underwent surgical tendon lengthening and release in the lower extremity (LE) to correct ankle plantarflexion contractures that developed from using his feet so often. The goal of the LE surgery was to enable JJ to walk with his heels down rather than on his toes (Table 2). Following UE surgery, the rotational deformities of the UE were corrected; however, in their new position, the arms are no longer able to provide trunk stability during floor sitting and foot activities. The pectoralis-to-biceps transfer
Table 2 Surgical interventions for greater social participation in a tetraplegic child who performed activities of daily living with his feet Surgical interventions
Goal of surgery
Upper extremity
Bilateral humeral and forearm derotational osteotomies Pectoralis-to-biceps transfer
Lower extremity
Tendon lengthenings
Pronation of forearm to position hand for function Restoration of volitional elbow flexion for hand-to-mouth activities Correction of ankle plantarflexion contracture; elimination of toe walking
Tendon releases
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resulted in a grade 2 volitional elbow flexion that is insufficient for hand-to-mouth activities. The lengthening and release of the LE corrected the plantarflexion deformities but also weakened the muscles, which has caused JJ to require full-time wheeled mobility. Tragically, with the ankles in their new position, JJ is no longer able to perform activities of daily living with his feet. JJ continues to realize barriers to full participation due to social, cultural and personal issues but now also cannot perform activities. Prior to medical intervention, this child, based on the ICIDH-2, did not have a disability but realized barriers to life participation due to cultural, social and personal stigmas. Now, the child is also limited by his disability. Case illustration for positive medical outcomes negated A woman, NN, 19 years of age, who has a C5 (motor group 0) spinal injury, was dependent in all activities of daily living and participated minimally in typical adolescent roles (eg, school, work, peer relationships). Implantation of the Freehand system stimulated palmar and lateral grasp; wrist stability was provided by an external wrist splint. As a direct result of the Freehand system, NN increased her dependence level in tabletop activities to modified independence, reported an increase in ease and a decrease in time of performing activities of daily living, and reduced the amount of caregiver assistance from full-time to morning and evenings only. Despite the significant improvements in her disability, there was no change in the level of social participation, and NN did not use the Freehand system after being discharged from rehabilitation. The social and personal stigma related to the wrist splint and her perceived cosmesis of her hand prevented the integration of the Freehand system into her daily routines. Based on these initial outcomes, NN underwent a surgical revision, with the goal of relocated one electrode to achieve stimulated wrist extension, thereby eliminating the need for the wrist splint. After this procedure, there was no change in her ability to perform activities but there was a significant change in the frequency and duration of activity performance. NN has entered college, reports more involvement with friends during weekends and evenings, and expresses an improved selfimage because of the more pleasing appearance of her hand. This case demonstrates the need for prudence in the interpretation of medical intervention out-
comes; positive medical outcomes should not be misinterpreted in terms of cultural, social, and personal dimensions of disability. As illustrated, these factors can (and often are) more influential than the level of dependence. Canadian occupational performance measure Few, if any, measures are available to assess the cultural, social, and personal dimensions of disability adequately. The use of ethnographic techniques, such as in-depth interviews, case histories, and participant observation, however, yield compelling information. The COPM is an assessment tool that combines quantitative and qualitative research methodologies to assess and interpret self-perception of performance of and satisfaction with self-selected goals [Law, 1990, 1998]. Clients rate the performance and satisfaction of five selfselected activities on a Likert scale from 1 and 10, where 1 is ‘‘not satisfied’’ and ‘‘cannot perform’’ and 10 is ‘‘very satisfied’’ and ‘‘performs well.’’ The strengths of the COPM include: • The activities measured are meaningful to the clients and thus have significance in their daily lives. • The assessment can be used regardless of culture, social, and personal individuality, which allows for a comparison of outcomes among different countries. • The rating by the client provides a meaningful representation of outcomes. Physical examination and impairment assessment Classification of injury Several classifications based on the skeletal or neurologic level of the lesion are available. For better overall understanding, the authors believe that the ASIA:IMSOP (American Spinal Injurres Association: International Medicine Spinal Paraplegics) [7] (Fig. 1) and a modified version of the International Tetraplegic Hand Classification (see Table 1) should be adopted. By these standards, the neurologic level is defined as ‘‘the most caudal’’ segment of the spinal cord that provides normal sensory and motor function on both sides of the body. The segment at which normal function is found, however, often differs from side to side and in terms of sensory versus motor testing. Thus, up to four different segments may be identified: right sensory, left sensory, right motor, and left motor. For motor function, key muscles are selected for a corresponding level (see Fig. 1); thus, a
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Fig. 1. The ASIA motor and sensory evaluation chart.
patient with wrist extensor M3 to M5 has a C6 motor level. Recording sensation by light touch and pin prick in metameric sensory areas on a 3point scale (0 ¼ absent, 1 ¼ impaired, 2 ¼ normal) defines the sensory level. Although a more accurate sensory evaluation at the hand is being considered for the International Tetraplegic Hand Classification, one should bear in mind that the hand is a mechanism used not only for gripping but also for human contact [2]. The authors believe that all team members should be acquainted with the following ASIA classification and impairment scale to foster better communication among experts in different fields: A ¼ Complete: No motor or sensory function is preserved in the sacral segments S4–S5. B ¼ Incomplete: Sensory but not motor function is preserved below the neurologic level and extends through the sacral segments S4–S5. C ¼ Incomplete: Motor function is preserved below the neurologic level, and most of the key muscles below this level have a muscle grade less than 3. D ¼ Incomplete: Motor function is preserved below the neurologic level, and most of the key muscles below this level have a muscle grade greater than or equal to 3. E ¼ Normal: Motor and sensory functions are normal.
One also should be aware of other associated neurologic conditions, such as cervical cord syringomyelia, root compression, and brachial plexus injuries, especially those associated with incomplete SCI and peripheral nerve–compression syndromes. Posttraumatic myelopathies often are associated with the ‘‘tethered-cord syndrome’’ [19] and present with peculiar clinical signs (eg, worsening motor and sensory conditions, pain, hyperhydrosis, autonomic dysreflexia). When related to a syringomyelia, one might consider cyst shunting or obliteration by embryonic spinal cord tissue. Nevertheless, motor recovery is insignificant, and the authors have recorded results similar to those of Hamlin [19]: the progressive loss of the function that was restored by tendon transfers in one patient. Extent of the spinal cord injury zone In tetraplegia, signs of the association of upper and lower motor neurons often coexist. Muscles that maintain their trophicity despite not being responsive to volitional commands adjoin denervated areas of muscle fibers caused by the direct damage of the corresponding anterior horn cells. This condition can be ascertained by observing the muscle’s trophicity, by the presence of denervation signs on electromyography, and by functional electrical stimulation of either the main nerve or each single muscle of the upper limb.
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Using these recording methods, Coulet et al [5] were able to observe the following three types of SCI zones in 45 patients: Type I: Short SCI zone with low-motor-neuron integrity of all forearm and hand muscles and good tone in flexors and intrinsics (53%); the flexor superficialis is not denervated and holds its viscoelastic strength (200 gr, according to Zancolli [21]) and thus might be used more consistently for the ‘‘lasso’’ operation; the presence of the intrinsic muscles also explains why, in this group, the claw posture of the paralyzed hand is negligible or absent and why passive stabilization procedures at the long fingers (the lasso operation) or the thumb (carpometacarpal fusion) can be avoided Type II: Intermediate SCI zone in which the flexors are denervated but the intrinsic muscles maintain their trophicity (11%) Type III: Long SCI zone, including almost all the upper limb’s muscles (36%); in this group, the hand is flat and supination contracture of the forearm frequently is observed; the authors believe that evaluation of the low-motor-neuron integrity at the upper limb is as relevant as standard muscle testing. Brachial plexus lesions and entrapment neuropathies in patients with spinal cord injury The diagnosis of an associated Brachial plexus lesion often is missed, especially with incomplete lesions in which a clear discrepancy between the neurologic status of the two upper limbs should alert the examiner. Alp et al [22] performed a study of orthodromic sensory- and motor-conduction velocities and ascertained 11 ulnar nerve entrapments at the elbow, 1 ulnar nerve entrapments at the wrist, and 9 median nerve entrapments at the wrist. This observation should alert the examiner to the possibility that incorrect posture in the wheelchair and other factors might be responsible for the underlying atrophy. Additionally, these issues can hamper the prognosis and the possibility of implanting a neuroprothesis.
Local examination and corresponding classification of impairment The International Classification [1,5a] was developed by dedicated surgeons to provide simple selection criteria as guidelines for surgical treat-
ment (see Table 1). It has stood the test of time for simplicity and efficacy by providing an at-aglance neurologic summary of the below-elbow sensorimotor conditions in tetraplegic patients [2,3,5,7]. The greatest difficulties that have been encountered between the first [1] and second international conferences were related to the definitions of groups 2 and 3. Proof of the validity of both radial wrist extensors can be accomplished on clinical grounds. Florence Kendall used to evaluate the presence of the flexor carpi radialis brevis by flexing the trunk of the patient (whenever possible) to obtain a complete elbow flexion on the table. The wrist then is placed in full radial extension and active wrist extension is tested. This method is similar the to one proposed by Bean [23]. At the time of the original classification, problems with classifying odd cases had already been encountered, especially when dealing with a ‘‘higher’’ innervated muscle that was found to be weak. The example given was that of a pronator teres being weak despite the presence of a strong wrist flexor. It was decided that one should retain the classification of group 5 but that a note should be added about the weakness of this muscle. The authors believe that this classification, despite of its indisputable merits, is insufficient as a background for the comprehensive planning of medical-audit and outcome studies. Thus, more proximal areas and functions should be examined routinely. Paralytic spine deformity Every child injured before skeletal maturity [24,25,20] and up to 50% of adolescents injured before 20 years of age [26] develop paralytic spine deformity; there may be an increased incidence with injuries of the elderly. The implication of paralytic spine deformity is most significant for those with C5 and C6 SCI who develop curves greater than 40 and have subsequent spinal fusions to correct the deformity. For these individuals, who rely on compensatory hand-to-head strategies for independent feeding, oral hygiene, traditional phone use, hair care, and other tabletop activities, spinal fusions correct the paralytic deformity but prevent any spine mobility, resulting in loss of hand-to-head strategies. As a direct result of adolescents losing the ability to feed themselves and perform other simple activities of daily life after spine-fusion surgeries, surgeons are studying techniques to correct paralytic spine deformities
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without functional compromise. Until a technique is developed and shown to be effective, however, the overall assessment of tetraplegic patients should include the degree to which they use compensatory hand-to-head techniques owing to UE weakness and poor endurance. Thoracoscapular stability The thoracoscapular area also should be examined routinely. Fig. 2 shows a clear example of an O-Cu patient in whom the primary stabilizers of the thoracoscapular joint (ie, the serratus anterior, subscapularis, romboids, trapezius, and teres major and minor) are paralyzed. In more severe conditions, the inferior corners of the scapula might even overlap. Significant scapula winging, deformity, and pain can be contraindications for UE reconstruction. The Shiners surgical experience with the correction of scapula instability via fusion and synthetic grafts has attained varying results. In one patient with C4 (motor group 0) spinal injury, bilateral scapula fusions were successful; the patient did not have any UE function, and the surgery was performed for cosmesis, skin integrity, and pain reduction. In another patient with C5 (motor group 1) spinal injury, bilateral scapula fusions proved devastating because she lost function. In a third patient
Fig. 2. In this O-Cu patient, only the middle portion of the deltoid (A) can be observed clearly. The thoracoscapular joint is unstable. Supination deformity at the forearm (not shown) also was associated.
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with the same level injury, scapula stability via grafting provided sufficient stability without losing all mobility and was successful. One area of research continues to concern the issues of scapula instability and its relationship to surgical reconstruction of the distal limb. A static sitting posture is an important requisite for function; however, there are other dynamic postural requirements for function that, if unable to achieve, place the tetraplegic patient at a disadvantage for performing activities regardless of UE function. Table 3 lists key questions for assessing sitting and dynamic postures as they relate to the patient. Shoulder function In the past, no great attention has been given to the recording of the muscle’s function at the shoulder girdle. A longitudinal study from 1991 to 2000 in 56 patients (9 female and 47 male) with an average age of 30.5 years (range 16–59 years) was completed in 101 limbs. Every case with a history of associated trauma at the shoulder level was excluded, and the following individual muscles and functions were examined: trapezius, latissimus dorsi, deltoid, serratus anterior (Table 4) and pectoralis major (clavicular heads and sternal), the external and internal rotators of the shoulder (Table 5). The corresponding muscle grading was recorded. The authors have been able to define four shoulder groups in which the muscles with a corresponding M2/M5 grade were reported in order of appearance and frequency for each group (Table 6). For example, in 100% of cases, the authors observed that patients in shoulder group 4 (Sh4) presented the following M2 to M5 muscles: trapezius, deltoid, internal rotators, external rotators, serratus anterior, the clavicular head of pectoralis major. Additionally, recovery of the sternal head (Sh5) constantly followed recovery of the clavicular head. In group 0, no surgical possibilities have been contemplated to date. Abduction of the shoulder is absent and the biceps is graded M3 (ASIA classification 3–4). In two such cases, the authors have transferred (1) the levator scapulae to the supraspinatus, and (2) half of the upper trapezius to the deltoid and the other half to the biceps (Fig. 3A,B). Although these produced discouraging results (~40 active shoulder abduction), they did have some beneficial effects on personal hygiene (Fig. 3C,D). The main drawbacks were prolonged cast immobilization and the consistent underlying
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Ulnar extensors Extensor digiti minimi Radial extensors
lack of trunk stabilization. Future surgical procedures probably will be improved by integrating functional nerve stimulation systems. Elbow function Elbow function, which is related strictly to the ASIA classification and to the extent of the SCI zone, can be categorized into the following groups: Group 1: Flexion and supination Group 2: Pronation and supination Group 3: Extension and supination Group 3 is the most favorable. Flexion and extension of the elbow (graded M4–M5) is present in association with independent pronosupination (also graded M4–M5). The below-elbow functions are the only ones considered in the International Classification (see Table 1). Within its boundaries, all groups have been well defined and verified with time and should be maintained; however, a new entry, extra, should be added to record the presence of other occasional muscles that might be of great value when considering possible tendon transfers. For example, a group 5–6 grown patient in whom an extensor digiti minimi is also present should be recorded and listed as extra (Fig. 4). Basically, a complete muscle testing (especially in the most favorable group of patients) is mandatory for ascertaining the presence of each individual muscle (eg, the flexor superficialis of the ring finger) because this adds options to the surgeon’s selection. The authors believe that group 6 should be divided into the following subgroups:
In the authors’ clinical practice, the ulnar extensors seem to anticipate the radial extensors on a regular basis. Multicenter studies might confirm this observation. The same seems to apply for the IC group 8 patients in whom the flexors of ulnar digits also seem to anticipate the radial ones. Sensory evaluation remains mandatory, and the authors do not believe that the classification of Cu (ie, a 10-mm, two-point discrimination at the thumb) should be altered. There is a natural trend to increase this limit [3] to 12 to 15 mm because surgical indications have expanded beyond Mo¨berg’s strict principles. In the author’s clinical experience, the Cu valuation was attributable only to 60% of the IC group 2 patients (Table 7). Other relevant clinical parameters When assessing a patient, three possible impairing factors must be recorded and measured: spasticity, joint stiffness, and instability. Spasticity Spasticity is a disorder of the muscle tone and should not be confused with occasional prolonged contractions and stiffness. The authors believe that spasticity should be recorded at different levels: the shoulder, elbow, forearm, hand, and intrinsic muscles. The Ashworth scale should be used for defining the different levels. Spasticity is seldom present above the elbow joint. At this level, in
Table 3 Key questions and implications for the assessment of sitting and dynamic posture in tetraplegic patients
Sitting posture Dynamic posture
Key question
Implication
Does performance of activities depend on sitting posture? Can the person independently assume the variety of postures required for the different activities performed?
Dependence on certain postures decreases spontaneity and increases effort of activity Inability to assume a variety of postures independently (rather than upper extremity function) is the main reason why some persons depend on others for performance of activities of daily living Automated components to power seating systems available but costly Skin breakdown; poor posture causing back and neck pain ‘‘Hooking’’ the elbow or wrist can cause peripheral nerve injuries
Are compensatory strategies for balance and stability available? Are compensatory patterns maladaptive or inhibiting overall function? Are compensatory patterns causing subclinical injuries?
1 4 1 6
3
2
1 1
4 14 16
1
2 3 1 2 2 2 1
1
1 3 1 4 2
Abbreviations: IC, International Classification; NE, not evaluated.
2
1
1 6 5 4
1 4 2 12 12
1
2 5 3 6 4
3 14 12 5
1
0 1 2 3 4 5
3 14 13 1 1
MO M1 M2 M3 M4 M5 NE
Pectoris major (sternum)
2 7 4
1 7 4 2 4 3
IC group MO M1 M2 M3 M4 M5 NE
Pectoris major (clavicle)
Table 5 The shoulder muscle evaluation in tetraplegia
Abbreviations: IC, International Classification; NE, not evaluated.
2
1 1 3 2 14 16
MO M1 M2 M3 M4 M5 NE
1 8 11 9 20 18
2 8 8 3
3 8 14 1
0 1 2 3 4 5
Latissimus dorsi
IC group MO M1 M2 M3 M4 M5 NE
Trapezius
Table 4 The shoulder muscle evaluation in tetraplegia
1
1
8 1 1 7
External rotation
1 1
7 23 8 17 19 1
1
4 2 1
1
1
1
2 1
7 10 6 9 1
4 9 2 10 16
2 4 2 4 7
MO M1 M2 M3 M4 M5 NE
4
MO M1 M2 M3 M4 M5 NE
Deltoid
2
2 1
2 6 5 2
Internal rotation
1 1
4 11 4 14 16
1 7 8 2 6 3
4 1
2
5 2 1 1 1
4 10 3 8
2 8 5 11 16
4 5 2 4 2
MO M1 M2 M3 M4 M5 NE
3
MO M1 M2 M3 M4 M5 NE
Serratus anterior
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Table 6 Classification of shoulder function in tetraplegia IC group
No. of limbs
0 1
4 18
2
25
3
11
4
24
5
19
Muscle
Incidence (%)
Trapezius Deltoid Internal rotators External rotators Serratus Internal rotators Serratus External rotators External rotators Pectoris major (clavicle) Latissimus dorsi Pectoris major (clavicle) Latissimus dorsi Pectoris major (sternum) Pectoris major (sternum)
100% 100% 92% 87% 72% 100% 100% 95% 100% 90% 66% 100% 100% 95% 100%
Abbreviation: IC, International Classification.
almost all patients, secondary myostatic and joint contractures may occur because of the unbalanced tone of the elbow flexors. Spasticity usually affects the flexor muscles and may be advantageous when a simple key pinch is indicated in the unfavorable groups [2,16]. Under favorable conditions, anesthetic blocks or botulinum toxin injections might be useful as a diagnostic tool when considering
procedures that should be performed before tendon transfers [7]. Contracture and stiffness Contracture and stiffness usually are located at the elbow (in IC group 0–1 patients) at the metacarpophalangeal joint, the proximal interphalangeal joint, and the carpometacarpal joint of the thumb, especially in poorly attended patients. The paralytic supination contracture of the forearm represents a challenge in the unfavorable patient groups [14]. Simultaneous volar elbow release and rotational radius osteotomy have been presented as a new possibility [27]. Residual range of motion should be recorded for a better understanding, regardless of whether the functional ranges are preserved or addictioned surgical releasing procedures should be considered before tendon transfers [28]. Some attention also should be given to the triggering or locking metacarpophalangeal joints [29]. These conditions resemble the noisy reversible swan-neck deformity and have been observed mostly in the unfavorable patient groups; however, this attitude it might be of use in some unfavorable patients because it allows a natural tenodesis effect of the long fingers, which provides basic key grip (Fig. 5). A stiff carpometacarpal joint of the thumb can be advantageous only if a functional posture (30 of anteposition and 25 of extension) is provided. Stiffness in extension interferes with any subse-
Fig. 3. Shrinking was the only shoulder function. Elbow flexion was graded M3. Surgery was aimed at restoring some abduction and at increasing elbow flexion for better hygiene and hand-to-mouth activities for the dominant limb.
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Table 7 Cutaneous sensation and surgical procedure International classification group
No. of limbs
Cu
0 1 2 3 Totals
4 19 30 11 64
1 (25%) 5 (26.3%) 18 (60%) 9 (81.8%) 33 (51%)
Procedures performed in both sites were one keypinch restoration and seven posterior deltoid–to–triceps transfers. Abbreviation: Cu, cutaneous afferent input.
represent the crucial crossroads for the proper grasping and releasing functions of the hand (Table 8). Instability
Fig. 3 (continued )
quent reconstructive procedures and should be treated by surgical release or fusion. Some guidelines for surgical treatment also can be obtained by accurately recording the type of stiffness at the proximal interphalangeal joints, because they
The unstable joints usually are located at the first ray level. A great laxity of the carpometacarpal joint of the thumb, as well an excessive hyperextension of the metacarpophalangeal joint (>25), usually interferes with the reconstruction of a useful key grip [2] because forces are dissipated when passive or active tenodesis are performed. Consistent results have been obtained in 12 patients by modifying the bone-to-bone capsulodesis technique proposed by Zancolli [30]. The unstable carpometacarpal joint of the thumb (ie, an intrinsic laxity associated with neural atrophy of the thenar muscles) is best treated by joint fusion, at least on one side. Finally, physical and impairment assessment and all the pertinent data that have been collected can provide objective information for the most appropriate rehabilitation for the chosen surgical treatment. Reliable outcome studies have been designed Whiteneck [31].
Summary
Fig. 4. The extensor digiti minimi in this IC group 5 patient was graded M4, whereas the ulnar extensor was graded M3. This muscle should be recorded as an extra unit in that group, after which several surgical options may be considered: the extensor digiti minimi to (1) the extensor digitorum communis, (2) the extensor pollicis longus, or (3) the abductor pollicis brevis.
The overall assessment in the tetraplegic patient should be comprehensive and detailed. This paper discusses aspects of the medical and physical assessment that normally may go unrecognized but are extremely important in the outcome of the tetraplegic patient. A comprehensive classification also is provided as a new guideline for rehabilitation and surgery. Additionally, the power of
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Fig. 5. The possibility of self-locking the metacarpophalangeal joints of the long fingers (owing to a limited shortage of the collateral ligaments) allows the patient to achieve a spontaneous key grip.
cultural, social, and personal dimensions of disability are illustrated and the importance of these dimensions as they relate to assessment is examined. Finally, the COPM is introduced as an outcome measure capable of crossing cultural
boundaries and allowing for the comparison of interventions.
Table 8 Procedures to correct deformities at the proximal interphalangeal joint
[1] Mc Dowell CL, Mo¨berg EA, Graham S. International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia. J Hand Surg [Am] 1979; 4:387–90. [2] Ejeeskar A. Upper limb surgical rehabilitation in high-level tetraplegia. Hand Clin 1998;4:585–99. [3] Hentz VR, Ladd AL. Functional restoration of the upper extremity in tetraplegia. In: Peimer CA, editor. Surgery of the hand and upper extremity. New York: McGraw Hill; 1996. p. 1499–516. [4] Landi A, et al. Esperienza preliminare sulla chirurgia palliativa nella tetraplegia. Riv Chir Riab Mano Arto Sup 1994;31:17. [5] Coulet B, Allieu Y, Chammas M, et al. Variability of the spinal cord injury zone extent in high level tetraplegia and consequences on conventional functional surgery indications especially in key grip construction. In: Abstracts from The Seventh
Deformity
Procedure
Flexion deformity
The ‘‘anticlaw’’ house procedure: The two-staged active transfer 1 PT to superficialis 2 Superficialis to lateral band þ the ‘‘rhombus’’ (Landi procedure)
passive ROM
Flexion deformity No ROM Fusion With limited ROM The ‘‘anticlaw’’ house procedure Extension deformity Joint release (usually in IC group 6 patients) Abbreviations: IC, International Classification; PT, pronator teres; ROM, range of motion.
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International Conference on Tetraplegia. Bologna, Italy; June 5–8, 2001. Mc Dowell CL, House JH. Tetraplegia. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery. 4th ed. London: Churchill Livingstone; 1999. pp. 1588–606. Snoeck G, Ijezerman M, Baardman G, et al. Survey of patientÕs needs in tetraplegia: the value of treating hand function loss. In: Abstracts from The Seventh International Conference on Tetraplegia. Bologna, Italy; June 5–8, 2001. Graham C, Keith MW. Principles of upper extremity surgery in tetraplegia. In: Peimer CA, editor. Surgery of the hand and upper extremity. New York: McGraw Hill; 1996. p. 1483–97. Bunnel S. Tendon transfer in the hand and forearm. American Academy of Orthopedic Surgeons Instructional Course Lecture. St. Louis: CV Mosby. 1949;VI:106–12. Nickel VL, Perry J, Garret AL. Development of useful function in the severely paralyzed hand. J Bone Joint Surg Am 1963;45:933. Guttman L. Spinal cord injuries: comprehensive management and research, 2nd ed. Oxford, England: Blackwell Scientific 1976. p. 588. Freehafer AA, Mast WA. Transfer of the brachioradialis to improve wrist extension in high spinal cord injury. J Bone J Surg Am 1967;49:648. Lamb DW, Chan KM. Surgical reconstruction of the upper limb in traumatic tetraplegia: a review of 41 patients. J Bone J Surg Br 1983;65:291. Mo¨berg E. Surgical treatment for absent single hand grip and elbow extension in quadriplegia: principles and preliminary experience. J Bone J Surg Am 1975;57:196. Zancolli E. Paralytic supination contracture of the forearm. J Bone J Surg Am 1967;49:1275. Zancolli E. Surgery for the quadriplegic hand with active, strong wrist extension preserved: a study of 97 cases. Clin Orthop 1975;112:101. Mc Dowell CL, Mo¨berg EA, House JH. The Second International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia (Quadriplegia). J Hand Surg Am 1986;11:604–8. Mitromanoff P. Trans-appendicular continent cystotomy in the management of the neurogic bladder. Chir Pediatr 1980;21:297–305. Reidmiller H, Burger R, Muller S, et al. Continent appendix stoma: a modification of the Mainz pouch technique. J Urol 1990;143:1115–7.
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[19] Hamlin C. The guidelines for surgical treatment. In: Abstracts from The Seventh International Conference on Tetraplegia. Bologna, Italy; June 5–8, 2001. [20] Dearolf WW, Bets RR, Vogel LC, et al. Scoliosis in pediatric spinal cord injury patients. J Pediatr Orthop 1990;10:214–8. [21] Zancolli E. The founder member lecture. Presented at the Sixth International Conference on Tetraplegia, Cleveland, OH, 1998. [22] Alp M, Gencosmanodlu E, Altinta H, et al. Entrapment neuropathies of upper extremity in patients with spinal cord injuries. In: Abstracts from The Seventh International Conference on Tetraplegia. Bologna, Italy; June 5–8, 2001. [23] Mohamemd KD, Rothwell AG, Sinclair SW, et al. Upper limb surgery for tetraplegia. J Bone Joint Surg Br 1992;74:873–9. [24] Betz RR, Mulcahey MJ. Spinal cord injury rehabilitation. In: Weinstein SL, editor. The pediatric spine: principles and practice, vol. 1. New York: Raven Press; 1994, p. 781–810. [25] Cambell J, Bonnet C. Spinal cord injury in children. Clin Orthop 1975;112:114–23. [26] Lancourt JE, Dickson JH, Carter RE. Paralytic spine deformity following traumatic spinal cord injury in children and adolescents. J Bone Joint Surg Am 1981;63:47–53. [27] Protomastro P, Bryden A, Merberg B, et al. Elbow release and rotational osteotomy improve hand position. In: Abstracts from The Seventh International Conference on Tetraplegia, Bologna, Italy, June 5–8, 2001. [28] Landi A, Caserta G, Menarini M, et al. The role of arthrolysis in the tetraplegic upper limb. In: Abstracts from The Seventh International Conference on Tetraplegia. Bologna, Italy; June 5–8, 2001. [29] Landi A, et al. La metacarpo-phalangie´nne bloque´e: facteurs etiologiques et traitment. Ann Chir Main 1988;VOL:232–7. [30] Landi A, Caserta G, Buscaroli L, et al. Arthrorysis at the MP joint of the thumb. In: Abstracts from The Seventh International Conference on Tetraplegia. Bologna, Italy; June 5–8, 2001. [31] Whiteneck GG, Charlifue SW, Gerhart KA, et al. Quantifying handicap: a new measure of long-term rehabilitation outcomes. Arch Phys Med Rehabil 1992;73:519.
Tetraplegia: update on assessment Antonio Landi, MDa,*, M.J. Mulcahey, MS, OTR\Lb, G. Caserta, MDa, N. Della Rosa, MDa a
The Hand and Microvascular Unit, Azienda Ospedaliera Policlinico, Via del Pozzo 71, 41100 Modena, Italy b Rehabilitation and Clinical Research, Shriners Hospital for Children, 3551 North Broad Street, Philadelphia, PA, USA
Historical background In the report of the First International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia [1], Erik Mo¨berg quoted the study by Hanson et al, which demonstrated that tetraplegic patients considered the function of the hand more relevant than walking, sexual performance, and bowel and bladder functions. This significant information has been reported in subsequent publications [2–5]. In their recent survey of the needs of tetraplegic patients, Snoek et al [6] among 700 members of the Scottish and Dutch Spinal Cord Injury (SCI) Associations reported that 95% of patients had indicated that the improvement of hand function was relevant to their quality of life. This score was compared with the highest score (72%) of the nonwalking group of patients in whom improvement of bladder and bowel functions were indicated. If patient whishes have not changed during this 23-year period, then the assessment, treatment, and design of outcome studies undoubtedly have switched to a more scientific approach [7]. According to the historical survey made by Hentz and Ladd [3], the earliest report on the surgical possibilities and treatment in the tetraplegic hand should be attributed to Bunnel [8] who described his results using procedures aimed to restore the so-called ‘‘opposition pinch.’’ At Rancho Los Amigos Hospital, Nickel et al [9] had performed pioneer work in the field by selecting a non-return type of operation that used
* Corresponding author. E-mail address: [email protected] (A. Landi).
multiple joint fusions in the unfavorable group of high level tetraplegia patients [9]. For neurorehabilitation, Guttman [10] in 1975 stated that less than 5% of tetraplegic patients could be considered candidates for hand surgery. Around the same time, other early pioneers started to use surgical reconstructive procedures that were aimed at improving upper limb function in the tetraplegic patient [11– 15]. In 1978, under the driving force of Mo¨berg, 18 dedicated surgeons participated in the First International Conference on this issue in Edinburgh, Scotland. (Only five of them where able to attend the second event in Giens, France, in 1984: H. Brummer from Finland, A. Freehafer and C. McDowell from the United States, G. Lindstrom from Sweden, and E. Mo¨berg from Sweden.) During the first conference, an impressive series of posterior deltoid–to–biceps transfers, including more than 10 years of follow-up had already been presented by Mo¨berg, Lamb, and DeBenedetti [1]. Consensus at the time [1] was reached on the following: Sensory testing (two point discrimination) Muscle testing (MRC grading) Timing of surgical reconstruction (rarely before 12 months following SCI) No surgical indication in patients with painful conditions Surgical goals: elbow extension and key pinch in the unfavorable groups No indication for wrist fusion The sensory classification was defined within two main categories: O for the presence of ocular sense of hand position and function and Cu for the presence of cutaneous afferent input, which was considered recordable only when a patient
0749-0712/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 2 4 - 0
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demonstrated 10 mm or less of two-point discrimination at the thumb. For both motor and sensory parameters, only the below-elbow function was considered in the International Classification (Table 1). Clearly, this was intended to be a guide to the forearm and hand only [1], because shoulder and elbow function were not included deliberately [1,2,16]. During the Seventh International Conference in Bologna, Italy, in 2001, the surgeons decided that elbow function should be considered but did not describe pertinent methods of evaluation. The authors believe that updating an assessment should comprise methods that consider the whole patient and the function of the entire upper limb, because consistent outcome studies can be designed only when the precise evaluation of impairment, disability, handicap [7], and corresponding methods of measurement are conceived, discussed, and shared. Overall assessment Over the past five decades, there has been a plethora of literature published on the assessment of the tetraplegic patient. Historically, assessment Table 1 International classification for surgical procedures at the hand in tetraplegia Group Muscle characteristics Function 0
1 2 3 4 5 6
No muscle below the elbow suitable for transfer BR ECRL ECRB PT FCR Finger extensors
7
Thumb extensors
8
Partial digital flexors
9
Lacks only intrinsic
X
Exceptions
Flexion and supination of the elbow
Extension of the wrist Extension of the wrist Pronation of the wrist Flexion of the wrist Extrinsic extension of long fingers (partial or complete) Extrinsic extension of the thumb Extrinsic flexion of the fingers Extrinsic flexion of the fingers (complete)
No specific function for BR is listed. Differentiating between ECRB and ECRL function should be reported in the subheading, ‘‘Suggested criteria for modification of the International Classification.’’ Abbreviations: BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; FCR, flexor carpi radialis; PT, pronator teres.
concentrated on (1) the need for adaptive equipment, splints, and orthoses; (2) medical issues, including respiratory and skin integrity, kidney function, muscle function, joint range of motion, and independence level in the performance of activities of daily living; and (3) comorbidity, including substance use, brain injury, and social and emotional sequelae. Technologic advances have broadened assessment further to include the evaluation for sophisticated power-seating systems, functional electrical stimulation, environmentalcontrol units, and communication systems. Additionally, the more recent understanding of disability as an individual, cultural, and social phenomenon (rather than strictly as a medical condition) has expanded the purview of assessment to include pain and painful syndromes, the effort and spontaneity of activities, and the temporal aspects of activity performance and the aging process. Any ethical assessment requires a framework or model to guide assessment choice and interpretation. Several disability models have been proposed and have caused some confusion due to language differences. Additionally, they (1) overemphasize the medical model, which views health as the absence of disease; (2) underemphasize the social models, which consider the interrelationship between human beings and their environment; and (3) have assumed a unidirectional, casual relationship among social levels. The World Health Organization has proposed the Second International Classification of Impairments, Disabilities and Handicaps (ICIDH-2) as an alternative to previous models. The ICIDH-2 provides a scientific basis to studying the consequences of health conditions; establishes a common language that crosses cultural boundaries; acknowledges complex and dynamic interactions among health conditions, the environment, and personal factors; and assumes multidirectional relationships among the factors that influence one’s health [WHO 1999]. Those who embrace the ICIDH-2 view consider disability a cultural, social, and personal phenomenon rather than just a medical condition. Laterality With tendon transfers or the Freehand system (The Cleveland FES Centre, Cleveland, Ohio), bilateral function during some activities may be achieved; however, for most activities, tetraplegic patients will function bimanually. The assessment of pre- and postinjury hand dominance is key to the surgical proposal. Establishing motor and
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sensory asymmetry is important, particularly in high-level tetraplegia in which bimanual function is required for even the simplest of activities. Perineanal care The relationship between hand function and perineanal care is crucial to the overall assessment of the tetraplegic patient. Regardless of injury level, a pretreatment assessment of the upper extremity (UE) should be directed toward bladder management because bladder regimens (eg, dependency on others for emptying the bladder) often dictate daily schedules. Even with the most successful hand reconstruction, if patients remain on rigorous bladder-emptying regimens and are dependent on others for assistance, they gain little in terms of social participation. The assessment for UE tendon transfer surgery or Freehand implantation is coupled with the assessment for urologic treatment options to augment hand surgery. In male patients who have a C5 and C6 SCI, the Freehand system allows for bilateral hand function, enabling grasping and insertion of the catheter while the noninstrumented hand stabilizes the penis. For female patients who have a similar injury level, a urinary diversion (ie, catheterizable stoma) [17,18] affords comparable levels of independence. Those with low cervical injuries who have undergone bilateral tendon transfers achieve independent bladder function; women continue to benefit from urinary diversions. Cultural, social, and personal dimensions of disability The cultural, social, and personal dimensions of disability are influenced greatly by political and economic factors. These dimensions are the predominant factors that affect social participation and quality of life and, in many cultures, foster the medicalization of disabilities. Assessing
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these factors can aid in the interpretation of medical outcomes. Case illustration for disability medicalization A boy, JJ, 12 years of age, who suffered an incomplete SCI as a result of transverse myelitis at 5 years of age, had residual hand function but was paralyzed completely in C5 muscles, which prevented shoulder and elbow flexion. Because of the severe UE impairment, JJ developed compensatory use of his feet to write, eat, brush his teeth, and play games. Based on the Functional Independence Measure, he was independent in all activities of daily living, including perineanal care by using his feet (ICIDH-2 no disability). The Canadian Occupational Performance Measure (COPM; see later section), however, showed that JJ had limited participation secondary to the cultural, social, and personal issues related to how he performed his activities. For example, JJ did not like to use his feet in public, especially in school. Consequently, JJ and his mother requested a medical intervention (UE reconstruction) to overcome the stigmas associated with his impairment. Their goal was fuller participation in school and extracurricular activities. JJ underwent multiple surgical procedures of the UE, the goal of which was to restore volitional elbow flexion and to position the forearm and hand for function. Additionally, JJ underwent surgical tendon lengthening and release in the lower extremity (LE) to correct ankle plantarflexion contractures that developed from using his feet so often. The goal of the LE surgery was to enable JJ to walk with his heels down rather than on his toes (Table 2). Following UE surgery, the rotational deformities of the UE were corrected; however, in their new position, the arms are no longer able to provide trunk stability during floor sitting and foot activities. The pectoralis-to-biceps transfer
Table 2 Surgical interventions for greater social participation in a tetraplegic child who performed activities of daily living with his feet Surgical interventions
Goal of surgery
Upper extremity
Bilateral humeral and forearm derotational osteotomies Pectoralis-to-biceps transfer
Lower extremity
Tendon lengthenings
Pronation of forearm to position hand for function Restoration of volitional elbow flexion for hand-to-mouth activities Correction of ankle plantarflexion contracture; elimination of toe walking
Tendon releases
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resulted in a grade 2 volitional elbow flexion that is insufficient for hand-to-mouth activities. The lengthening and release of the LE corrected the plantarflexion deformities but also weakened the muscles, which has caused JJ to require full-time wheeled mobility. Tragically, with the ankles in their new position, JJ is no longer able to perform activities of daily living with his feet. JJ continues to realize barriers to full participation due to social, cultural and personal issues but now also cannot perform activities. Prior to medical intervention, this child, based on the ICIDH-2, did not have a disability but realized barriers to life participation due to cultural, social and personal stigmas. Now, the child is also limited by his disability. Case illustration for positive medical outcomes negated A woman, NN, 19 years of age, who has a C5 (motor group 0) spinal injury, was dependent in all activities of daily living and participated minimally in typical adolescent roles (eg, school, work, peer relationships). Implantation of the Freehand system stimulated palmar and lateral grasp; wrist stability was provided by an external wrist splint. As a direct result of the Freehand system, NN increased her dependence level in tabletop activities to modified independence, reported an increase in ease and a decrease in time of performing activities of daily living, and reduced the amount of caregiver assistance from full-time to morning and evenings only. Despite the significant improvements in her disability, there was no change in the level of social participation, and NN did not use the Freehand system after being discharged from rehabilitation. The social and personal stigma related to the wrist splint and her perceived cosmesis of her hand prevented the integration of the Freehand system into her daily routines. Based on these initial outcomes, NN underwent a surgical revision, with the goal of relocated one electrode to achieve stimulated wrist extension, thereby eliminating the need for the wrist splint. After this procedure, there was no change in her ability to perform activities but there was a significant change in the frequency and duration of activity performance. NN has entered college, reports more involvement with friends during weekends and evenings, and expresses an improved selfimage because of the more pleasing appearance of her hand. This case demonstrates the need for prudence in the interpretation of medical intervention out-
comes; positive medical outcomes should not be misinterpreted in terms of cultural, social, and personal dimensions of disability. As illustrated, these factors can (and often are) more influential than the level of dependence. Canadian occupational performance measure Few, if any, measures are available to assess the cultural, social, and personal dimensions of disability adequately. The use of ethnographic techniques, such as in-depth interviews, case histories, and participant observation, however, yield compelling information. The COPM is an assessment tool that combines quantitative and qualitative research methodologies to assess and interpret self-perception of performance of and satisfaction with self-selected goals [Law, 1990, 1998]. Clients rate the performance and satisfaction of five selfselected activities on a Likert scale from 1 and 10, where 1 is ‘‘not satisfied’’ and ‘‘cannot perform’’ and 10 is ‘‘very satisfied’’ and ‘‘performs well.’’ The strengths of the COPM include: • The activities measured are meaningful to the clients and thus have significance in their daily lives. • The assessment can be used regardless of culture, social, and personal individuality, which allows for a comparison of outcomes among different countries. • The rating by the client provides a meaningful representation of outcomes. Physical examination and impairment assessment Classification of injury Several classifications based on the skeletal or neurologic level of the lesion are available. For better overall understanding, the authors believe that the ASIA:IMSOP (American Spinal Injurres Association: International Medicine Spinal Paraplegics) [7] (Fig. 1) and a modified version of the International Tetraplegic Hand Classification (see Table 1) should be adopted. By these standards, the neurologic level is defined as ‘‘the most caudal’’ segment of the spinal cord that provides normal sensory and motor function on both sides of the body. The segment at which normal function is found, however, often differs from side to side and in terms of sensory versus motor testing. Thus, up to four different segments may be identified: right sensory, left sensory, right motor, and left motor. For motor function, key muscles are selected for a corresponding level (see Fig. 1); thus, a
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Fig. 1. The ASIA motor and sensory evaluation chart.
patient with wrist extensor M3 to M5 has a C6 motor level. Recording sensation by light touch and pin prick in metameric sensory areas on a 3point scale (0 ¼ absent, 1 ¼ impaired, 2 ¼ normal) defines the sensory level. Although a more accurate sensory evaluation at the hand is being considered for the International Tetraplegic Hand Classification, one should bear in mind that the hand is a mechanism used not only for gripping but also for human contact [2]. The authors believe that all team members should be acquainted with the following ASIA classification and impairment scale to foster better communication among experts in different fields: A ¼ Complete: No motor or sensory function is preserved in the sacral segments S4–S5. B ¼ Incomplete: Sensory but not motor function is preserved below the neurologic level and extends through the sacral segments S4–S5. C ¼ Incomplete: Motor function is preserved below the neurologic level, and most of the key muscles below this level have a muscle grade less than 3. D ¼ Incomplete: Motor function is preserved below the neurologic level, and most of the key muscles below this level have a muscle grade greater than or equal to 3. E ¼ Normal: Motor and sensory functions are normal.
One also should be aware of other associated neurologic conditions, such as cervical cord syringomyelia, root compression, and brachial plexus injuries, especially those associated with incomplete SCI and peripheral nerve–compression syndromes. Posttraumatic myelopathies often are associated with the ‘‘tethered-cord syndrome’’ [19] and present with peculiar clinical signs (eg, worsening motor and sensory conditions, pain, hyperhydrosis, autonomic dysreflexia). When related to a syringomyelia, one might consider cyst shunting or obliteration by embryonic spinal cord tissue. Nevertheless, motor recovery is insignificant, and the authors have recorded results similar to those of Hamlin [19]: the progressive loss of the function that was restored by tendon transfers in one patient. Extent of the spinal cord injury zone In tetraplegia, signs of the association of upper and lower motor neurons often coexist. Muscles that maintain their trophicity despite not being responsive to volitional commands adjoin denervated areas of muscle fibers caused by the direct damage of the corresponding anterior horn cells. This condition can be ascertained by observing the muscle’s trophicity, by the presence of denervation signs on electromyography, and by functional electrical stimulation of either the main nerve or each single muscle of the upper limb.
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Using these recording methods, Coulet et al [5] were able to observe the following three types of SCI zones in 45 patients: Type I: Short SCI zone with low-motor-neuron integrity of all forearm and hand muscles and good tone in flexors and intrinsics (53%); the flexor superficialis is not denervated and holds its viscoelastic strength (200 gr, according to Zancolli [21]) and thus might be used more consistently for the ‘‘lasso’’ operation; the presence of the intrinsic muscles also explains why, in this group, the claw posture of the paralyzed hand is negligible or absent and why passive stabilization procedures at the long fingers (the lasso operation) or the thumb (carpometacarpal fusion) can be avoided Type II: Intermediate SCI zone in which the flexors are denervated but the intrinsic muscles maintain their trophicity (11%) Type III: Long SCI zone, including almost all the upper limb’s muscles (36%); in this group, the hand is flat and supination contracture of the forearm frequently is observed; the authors believe that evaluation of the low-motor-neuron integrity at the upper limb is as relevant as standard muscle testing. Brachial plexus lesions and entrapment neuropathies in patients with spinal cord injury The diagnosis of an associated Brachial plexus lesion often is missed, especially with incomplete lesions in which a clear discrepancy between the neurologic status of the two upper limbs should alert the examiner. Alp et al [22] performed a study of orthodromic sensory- and motor-conduction velocities and ascertained 11 ulnar nerve entrapments at the elbow, 1 ulnar nerve entrapments at the wrist, and 9 median nerve entrapments at the wrist. This observation should alert the examiner to the possibility that incorrect posture in the wheelchair and other factors might be responsible for the underlying atrophy. Additionally, these issues can hamper the prognosis and the possibility of implanting a neuroprothesis.
Local examination and corresponding classification of impairment The International Classification [1,5a] was developed by dedicated surgeons to provide simple selection criteria as guidelines for surgical treat-
ment (see Table 1). It has stood the test of time for simplicity and efficacy by providing an at-aglance neurologic summary of the below-elbow sensorimotor conditions in tetraplegic patients [2,3,5,7]. The greatest difficulties that have been encountered between the first [1] and second international conferences were related to the definitions of groups 2 and 3. Proof of the validity of both radial wrist extensors can be accomplished on clinical grounds. Florence Kendall used to evaluate the presence of the flexor carpi radialis brevis by flexing the trunk of the patient (whenever possible) to obtain a complete elbow flexion on the table. The wrist then is placed in full radial extension and active wrist extension is tested. This method is similar the to one proposed by Bean [23]. At the time of the original classification, problems with classifying odd cases had already been encountered, especially when dealing with a ‘‘higher’’ innervated muscle that was found to be weak. The example given was that of a pronator teres being weak despite the presence of a strong wrist flexor. It was decided that one should retain the classification of group 5 but that a note should be added about the weakness of this muscle. The authors believe that this classification, despite of its indisputable merits, is insufficient as a background for the comprehensive planning of medical-audit and outcome studies. Thus, more proximal areas and functions should be examined routinely. Paralytic spine deformity Every child injured before skeletal maturity [24,25,20] and up to 50% of adolescents injured before 20 years of age [26] develop paralytic spine deformity; there may be an increased incidence with injuries of the elderly. The implication of paralytic spine deformity is most significant for those with C5 and C6 SCI who develop curves greater than 40 and have subsequent spinal fusions to correct the deformity. For these individuals, who rely on compensatory hand-to-head strategies for independent feeding, oral hygiene, traditional phone use, hair care, and other tabletop activities, spinal fusions correct the paralytic deformity but prevent any spine mobility, resulting in loss of hand-to-head strategies. As a direct result of adolescents losing the ability to feed themselves and perform other simple activities of daily life after spine-fusion surgeries, surgeons are studying techniques to correct paralytic spine deformities
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without functional compromise. Until a technique is developed and shown to be effective, however, the overall assessment of tetraplegic patients should include the degree to which they use compensatory hand-to-head techniques owing to UE weakness and poor endurance. Thoracoscapular stability The thoracoscapular area also should be examined routinely. Fig. 2 shows a clear example of an O-Cu patient in whom the primary stabilizers of the thoracoscapular joint (ie, the serratus anterior, subscapularis, romboids, trapezius, and teres major and minor) are paralyzed. In more severe conditions, the inferior corners of the scapula might even overlap. Significant scapula winging, deformity, and pain can be contraindications for UE reconstruction. The Shiners surgical experience with the correction of scapula instability via fusion and synthetic grafts has attained varying results. In one patient with C4 (motor group 0) spinal injury, bilateral scapula fusions were successful; the patient did not have any UE function, and the surgery was performed for cosmesis, skin integrity, and pain reduction. In another patient with C5 (motor group 1) spinal injury, bilateral scapula fusions proved devastating because she lost function. In a third patient
Fig. 2. In this O-Cu patient, only the middle portion of the deltoid (A) can be observed clearly. The thoracoscapular joint is unstable. Supination deformity at the forearm (not shown) also was associated.
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with the same level injury, scapula stability via grafting provided sufficient stability without losing all mobility and was successful. One area of research continues to concern the issues of scapula instability and its relationship to surgical reconstruction of the distal limb. A static sitting posture is an important requisite for function; however, there are other dynamic postural requirements for function that, if unable to achieve, place the tetraplegic patient at a disadvantage for performing activities regardless of UE function. Table 3 lists key questions for assessing sitting and dynamic postures as they relate to the patient. Shoulder function In the past, no great attention has been given to the recording of the muscle’s function at the shoulder girdle. A longitudinal study from 1991 to 2000 in 56 patients (9 female and 47 male) with an average age of 30.5 years (range 16–59 years) was completed in 101 limbs. Every case with a history of associated trauma at the shoulder level was excluded, and the following individual muscles and functions were examined: trapezius, latissimus dorsi, deltoid, serratus anterior (Table 4) and pectoralis major (clavicular heads and sternal), the external and internal rotators of the shoulder (Table 5). The corresponding muscle grading was recorded. The authors have been able to define four shoulder groups in which the muscles with a corresponding M2/M5 grade were reported in order of appearance and frequency for each group (Table 6). For example, in 100% of cases, the authors observed that patients in shoulder group 4 (Sh4) presented the following M2 to M5 muscles: trapezius, deltoid, internal rotators, external rotators, serratus anterior, the clavicular head of pectoralis major. Additionally, recovery of the sternal head (Sh5) constantly followed recovery of the clavicular head. In group 0, no surgical possibilities have been contemplated to date. Abduction of the shoulder is absent and the biceps is graded M3 (ASIA classification 3–4). In two such cases, the authors have transferred (1) the levator scapulae to the supraspinatus, and (2) half of the upper trapezius to the deltoid and the other half to the biceps (Fig. 3A,B). Although these produced discouraging results (~40 active shoulder abduction), they did have some beneficial effects on personal hygiene (Fig. 3C,D). The main drawbacks were prolonged cast immobilization and the consistent underlying
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Ulnar extensors Extensor digiti minimi Radial extensors
lack of trunk stabilization. Future surgical procedures probably will be improved by integrating functional nerve stimulation systems. Elbow function Elbow function, which is related strictly to the ASIA classification and to the extent of the SCI zone, can be categorized into the following groups: Group 1: Flexion and supination Group 2: Pronation and supination Group 3: Extension and supination Group 3 is the most favorable. Flexion and extension of the elbow (graded M4–M5) is present in association with independent pronosupination (also graded M4–M5). The below-elbow functions are the only ones considered in the International Classification (see Table 1). Within its boundaries, all groups have been well defined and verified with time and should be maintained; however, a new entry, extra, should be added to record the presence of other occasional muscles that might be of great value when considering possible tendon transfers. For example, a group 5–6 grown patient in whom an extensor digiti minimi is also present should be recorded and listed as extra (Fig. 4). Basically, a complete muscle testing (especially in the most favorable group of patients) is mandatory for ascertaining the presence of each individual muscle (eg, the flexor superficialis of the ring finger) because this adds options to the surgeon’s selection. The authors believe that group 6 should be divided into the following subgroups:
In the authors’ clinical practice, the ulnar extensors seem to anticipate the radial extensors on a regular basis. Multicenter studies might confirm this observation. The same seems to apply for the IC group 8 patients in whom the flexors of ulnar digits also seem to anticipate the radial ones. Sensory evaluation remains mandatory, and the authors do not believe that the classification of Cu (ie, a 10-mm, two-point discrimination at the thumb) should be altered. There is a natural trend to increase this limit [3] to 12 to 15 mm because surgical indications have expanded beyond Mo¨berg’s strict principles. In the author’s clinical experience, the Cu valuation was attributable only to 60% of the IC group 2 patients (Table 7). Other relevant clinical parameters When assessing a patient, three possible impairing factors must be recorded and measured: spasticity, joint stiffness, and instability. Spasticity Spasticity is a disorder of the muscle tone and should not be confused with occasional prolonged contractions and stiffness. The authors believe that spasticity should be recorded at different levels: the shoulder, elbow, forearm, hand, and intrinsic muscles. The Ashworth scale should be used for defining the different levels. Spasticity is seldom present above the elbow joint. At this level, in
Table 3 Key questions and implications for the assessment of sitting and dynamic posture in tetraplegic patients
Sitting posture Dynamic posture
Key question
Implication
Does performance of activities depend on sitting posture? Can the person independently assume the variety of postures required for the different activities performed?
Dependence on certain postures decreases spontaneity and increases effort of activity Inability to assume a variety of postures independently (rather than upper extremity function) is the main reason why some persons depend on others for performance of activities of daily living Automated components to power seating systems available but costly Skin breakdown; poor posture causing back and neck pain ‘‘Hooking’’ the elbow or wrist can cause peripheral nerve injuries
Are compensatory strategies for balance and stability available? Are compensatory patterns maladaptive or inhibiting overall function? Are compensatory patterns causing subclinical injuries?
1 4 1 6
3
2
1 1
4 14 16
1
2 3 1 2 2 2 1
1
1 3 1 4 2
Abbreviations: IC, International Classification; NE, not evaluated.
2
1
1 6 5 4
1 4 2 12 12
1
2 5 3 6 4
3 14 12 5
1
0 1 2 3 4 5
3 14 13 1 1
MO M1 M2 M3 M4 M5 NE
Pectoris major (sternum)
2 7 4
1 7 4 2 4 3
IC group MO M1 M2 M3 M4 M5 NE
Pectoris major (clavicle)
Table 5 The shoulder muscle evaluation in tetraplegia
Abbreviations: IC, International Classification; NE, not evaluated.
2
1 1 3 2 14 16
MO M1 M2 M3 M4 M5 NE
1 8 11 9 20 18
2 8 8 3
3 8 14 1
0 1 2 3 4 5
Latissimus dorsi
IC group MO M1 M2 M3 M4 M5 NE
Trapezius
Table 4 The shoulder muscle evaluation in tetraplegia
1
1
8 1 1 7
External rotation
1 1
7 23 8 17 19 1
1
4 2 1
1
1
1
2 1
7 10 6 9 1
4 9 2 10 16
2 4 2 4 7
MO M1 M2 M3 M4 M5 NE
4
MO M1 M2 M3 M4 M5 NE
Deltoid
2
2 1
2 6 5 2
Internal rotation
1 1
4 11 4 14 16
1 7 8 2 6 3
4 1
2
5 2 1 1 1
4 10 3 8
2 8 5 11 16
4 5 2 4 2
MO M1 M2 M3 M4 M5 NE
3
MO M1 M2 M3 M4 M5 NE
Serratus anterior
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Table 6 Classification of shoulder function in tetraplegia IC group
No. of limbs
0 1
4 18
2
25
3
11
4
24
5
19
Muscle
Incidence (%)
Trapezius Deltoid Internal rotators External rotators Serratus Internal rotators Serratus External rotators External rotators Pectoris major (clavicle) Latissimus dorsi Pectoris major (clavicle) Latissimus dorsi Pectoris major (sternum) Pectoris major (sternum)
100% 100% 92% 87% 72% 100% 100% 95% 100% 90% 66% 100% 100% 95% 100%
Abbreviation: IC, International Classification.
almost all patients, secondary myostatic and joint contractures may occur because of the unbalanced tone of the elbow flexors. Spasticity usually affects the flexor muscles and may be advantageous when a simple key pinch is indicated in the unfavorable groups [2,16]. Under favorable conditions, anesthetic blocks or botulinum toxin injections might be useful as a diagnostic tool when considering
procedures that should be performed before tendon transfers [7]. Contracture and stiffness Contracture and stiffness usually are located at the elbow (in IC group 0–1 patients) at the metacarpophalangeal joint, the proximal interphalangeal joint, and the carpometacarpal joint of the thumb, especially in poorly attended patients. The paralytic supination contracture of the forearm represents a challenge in the unfavorable patient groups [14]. Simultaneous volar elbow release and rotational radius osteotomy have been presented as a new possibility [27]. Residual range of motion should be recorded for a better understanding, regardless of whether the functional ranges are preserved or addictioned surgical releasing procedures should be considered before tendon transfers [28]. Some attention also should be given to the triggering or locking metacarpophalangeal joints [29]. These conditions resemble the noisy reversible swan-neck deformity and have been observed mostly in the unfavorable patient groups; however, this attitude it might be of use in some unfavorable patients because it allows a natural tenodesis effect of the long fingers, which provides basic key grip (Fig. 5). A stiff carpometacarpal joint of the thumb can be advantageous only if a functional posture (30 of anteposition and 25 of extension) is provided. Stiffness in extension interferes with any subse-
Fig. 3. Shrinking was the only shoulder function. Elbow flexion was graded M3. Surgery was aimed at restoring some abduction and at increasing elbow flexion for better hygiene and hand-to-mouth activities for the dominant limb.
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387
Table 7 Cutaneous sensation and surgical procedure International classification group
No. of limbs
Cu
0 1 2 3 Totals
4 19 30 11 64
1 (25%) 5 (26.3%) 18 (60%) 9 (81.8%) 33 (51%)
Procedures performed in both sites were one keypinch restoration and seven posterior deltoid–to–triceps transfers. Abbreviation: Cu, cutaneous afferent input.
represent the crucial crossroads for the proper grasping and releasing functions of the hand (Table 8). Instability
Fig. 3 (continued )
quent reconstructive procedures and should be treated by surgical release or fusion. Some guidelines for surgical treatment also can be obtained by accurately recording the type of stiffness at the proximal interphalangeal joints, because they
The unstable joints usually are located at the first ray level. A great laxity of the carpometacarpal joint of the thumb, as well an excessive hyperextension of the metacarpophalangeal joint (>25), usually interferes with the reconstruction of a useful key grip [2] because forces are dissipated when passive or active tenodesis are performed. Consistent results have been obtained in 12 patients by modifying the bone-to-bone capsulodesis technique proposed by Zancolli [30]. The unstable carpometacarpal joint of the thumb (ie, an intrinsic laxity associated with neural atrophy of the thenar muscles) is best treated by joint fusion, at least on one side. Finally, physical and impairment assessment and all the pertinent data that have been collected can provide objective information for the most appropriate rehabilitation for the chosen surgical treatment. Reliable outcome studies have been designed Whiteneck [31].
Summary
Fig. 4. The extensor digiti minimi in this IC group 5 patient was graded M4, whereas the ulnar extensor was graded M3. This muscle should be recorded as an extra unit in that group, after which several surgical options may be considered: the extensor digiti minimi to (1) the extensor digitorum communis, (2) the extensor pollicis longus, or (3) the abductor pollicis brevis.
The overall assessment in the tetraplegic patient should be comprehensive and detailed. This paper discusses aspects of the medical and physical assessment that normally may go unrecognized but are extremely important in the outcome of the tetraplegic patient. A comprehensive classification also is provided as a new guideline for rehabilitation and surgery. Additionally, the power of
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Fig. 5. The possibility of self-locking the metacarpophalangeal joints of the long fingers (owing to a limited shortage of the collateral ligaments) allows the patient to achieve a spontaneous key grip.
cultural, social, and personal dimensions of disability are illustrated and the importance of these dimensions as they relate to assessment is examined. Finally, the COPM is introduced as an outcome measure capable of crossing cultural
boundaries and allowing for the comparison of interventions.
Table 8 Procedures to correct deformities at the proximal interphalangeal joint
[1] Mc Dowell CL, Mo¨berg EA, Graham S. International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia. J Hand Surg [Am] 1979; 4:387–90. [2] Ejeeskar A. Upper limb surgical rehabilitation in high-level tetraplegia. Hand Clin 1998;4:585–99. [3] Hentz VR, Ladd AL. Functional restoration of the upper extremity in tetraplegia. In: Peimer CA, editor. Surgery of the hand and upper extremity. New York: McGraw Hill; 1996. p. 1499–516. [4] Landi A, et al. Esperienza preliminare sulla chirurgia palliativa nella tetraplegia. Riv Chir Riab Mano Arto Sup 1994;31:17. [5] Coulet B, Allieu Y, Chammas M, et al. Variability of the spinal cord injury zone extent in high level tetraplegia and consequences on conventional functional surgery indications especially in key grip construction. In: Abstracts from The Seventh
Deformity
Procedure
Flexion deformity
The ‘‘anticlaw’’ house procedure: The two-staged active transfer 1 PT to superficialis 2 Superficialis to lateral band þ the ‘‘rhombus’’ (Landi procedure)
passive ROM
Flexion deformity No ROM Fusion With limited ROM The ‘‘anticlaw’’ house procedure Extension deformity Joint release (usually in IC group 6 patients) Abbreviations: IC, International Classification; PT, pronator teres; ROM, range of motion.
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