Arm Function Restoration

Posted by Nurse Linda in Life After Paralysis on October 20, 2021 # Health

hand resting on the side of a wheelchairIndividuals often inquire about the restoration of function to the arms. There are options for individuals with paralysis from spinal cord injury, stroke, brain injury and diseases. Careful consideration should be made but learning about opportunities is the first step. Last week, some basic options were presented, but this week, more unique opportunities to think about will be discussed. As always, learn all you can about a procedure prior to considering it. Always weigh your risks and benefits as an individual when discussing any procedure with your healthcare professional.

Tenodesis

Individuals with spinal cord injury at C6 (cervical spine, sixth vertebrae) generally have wrist extension but poor finger function. Some individuals with a spinal cord injury at C5 or C7 can use this technique, but it depends on the individual function and need. The development of tenodesis is a way to grasp and release things. Tenodesis is formed by a process that occurs when the knuckles are raised higher than the wrist, fingers automatically tighten or close. When the knuckles are dropped below the wrist, the fingers relax and open. Tenodesis requires shortening of the tendons in the back of the hand and some stiffness of the thumb for stability in grasping. These are accomplished through a process of therapy, but some individuals do have tendon surgery to assist in accomplishing tenodesis.

Achieving tenodesis takes some time. A tenodesis splint can assist with manipulating the wrist and fingers to enhance movement. Exercises not only help to keep your grasp functioning but also stimulate the nervous system to reorganize itself through neuroplasticity. Exercise your wrist with your fingers curled in so as not to over-stretch the tendons you are relying on for that automatic response in gripping. When your wrist is down, relax your fingers to keep them supple.

Tenodesis opens the opportunity for self-feeding, grooming, brushing your teeth, drinking, even self-catheterization. Independence in bowel programs may be achieved with the assistance of a suppository inserter and digital stimulation device.

Your healthcare provider will be able to assist in your process to develop tenodesis. Some individuals want the extra independence that tenodesis provides, while others prefer not to develop the process as the structure and look of your hand is changed. The choice is up to you if you choose to employ this technique or not.

Electrical Stimulation

Electrical stimulation has been used extensively for strengthening nerves and muscles in the body for individuals with paralysis. Electrical stimulation for arm function has three purposes. First, the rhythmic stimulation can strengthen muscles and nerve impulses; second, the increased functionality can be achieved with the stimulation on and carry over when the device is off; and third, the nerve impulses can help stimulate neuroplasticity, strengthening the current nerve pathways and creating new nerve pathways. It can also be used to strengthen shoulder muscles.

Electrodes are placed on the skin of the arms, over certain muscle groups and nerves to provide strengthening and function. Specific muscle groups are often targeted, or a larger branch of the nerve may be used to provide several functions. Because the electrodes are on the skin, this is a noninvasive therapy with the goal to improve arm movement, hand and grasp function.

Typically, one or a few muscles or nerve groups were used. However, at the University of Washington, the electrodes were placed on the back of the neck over the spinal cord. The stimulation led to a surprising increase in the function of the hands and arms. Therapy is needed to learn how to use the functions. Since this is a new application of electrical stimulation on the skin, results occur only when the device is on, but some function has been noted to remain temporarily when the device is off. You can get more information here.

Carry over when the device is off requires additional research to be conducted. A current report can be obtained here.

Implanted electrical stimulation is placed directly on or near the nerve within the body. These include a variety of devices for bowel and bladder function, walking, and arm and hand function. Signals are provided to the body to conduct activity when the message from the brain cannot get through.

One device, called the Freehand system, is a surgical implant of several electrodes in the upper extremity. Movement by the opposite shoulder causes functions in the other arm. A control unit is external to the body with a transmitter that is placed on the chest over an implanted stimulator. A shoulder sensor is on the control shoulder. Another implantable arm device is marketed by the Cleveland FES Center. In the near future, you will be able to get this device close to home. There is a therapy that is involved both prior to implantation of these devices and after surgery. More devices for implantable electrical stimulation are being studied.

Joint Stabilization and Releases

Keeping the joints supple and able to move through the full range of motion is important throughout the body. This includes the upper extremities. Due to weakened muscles and nerves, the joint can become loose, created by weak structural support. The joint can dislodge as in a subluxed shoulder or any joint in the arm. As a result, pain, decreased range of motion, and less function can occur. Stabilization equipment, strengthening exercises, electrical stimulation or even stabilizing surgery may be done.

Joints can also become less functional due to muscle contractures or tone (spasticity). In this situation, the joint cannot be put through a full range of motion. Pain is also an issue even if your body does not feel pain. It will react to it. Treatments include gentle stretching and perhaps a brace or serial casts to slowly re-stretch the muscles and thereby restore movement to the joint. Occasionally, surgery is needed to release the joint. Medication or injections for spasticity can reduce the incidence of restricted joints from tone.

Nerve and Tendon Transfers

Moving nerves and tendons in the body is another method to increase function. In the arms, tendons and nerves can be moved for increased hand and arm function. Tendons and nerves that are functioning are relocated to areas where function has decreased. A branch of the nerve is moved, or the nerve might be split. Much like a computer, the human body has redundancy in nerve function, which keeps function in the area where the nerve is moved but now adds function to the area where the nerves are affected by paralysis. In this process, therapy then is used to learn the new body function.

Areas of function include elbow, wrist, finger, thumb extension, and finger thumb flexion. The combinations of moved nerves and tendons depend on what is functioning for the individual and what is needed. Examples include transfers of axillary, musculocutaneous, and radial nerve fascicles can improve function and sensation.

It can be difficult to locate a surgeon who can perform nerve transfers at the level needed for individuals with paralysis, especially if you live outside of an area that is served by a major medical center. Check with your healthcare professional, therapist, and the community to see if there is someone that is near you or if there is an individual with a specific specialty for what you need. The Reeve Community is an excellent place to ask. Connect with a specialist at the National Paralysis Resource Center or through the Peer and Family Support Program. If you are connected with other community groups, ask there as well. Be sure to filter the information. What is right for one person might not be the individual that you need. Nurse Linda

Pediatric Consideration:

Thinking about surgery to improve function for your child can be challenging. Both making a life decision for your child as well as finding a pediatric resource is daunting. You may be unable to find a pediatric surgeon. Some adult surgeons who are educated in performing pediatric cases can also serve your needs. Surgeons who perform nerve transfers are usually found in neurosurgery or plastic and reconstructive surgery departments. Hand surgery specialists are also a possible option.

Since children are growing and developing, a choice may be to wait to see if there is a natural return of function or improved function as the child develops. Neuroplasticity can be a partner in the improvement of your child’s developing nervous system. On the other hand, waiting can create a scenario where too much time has passed in some specific cases.

It is best to discuss options with your child’s healthcare professional to decide and plan. Keeping options open is imperative. Let the healthcare professional know what is on your mind for long-term goals. They will let you know their thoughts regarding possible improvement in function and timing. If they know you are considering options, they can work with you in locating resources and timing. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

And if you want more Nurse Linda, sign up for her monthly webinars here. Don’t worry, we archive her answers so you can refer back and sift through her advice. Consider it Nurse Linda on-demand!

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.