U.S. Department of Veterans Affairs Public Access Author manuscript Arch Phys Med Rehabil. Author manuscript; available in PMC 2016 July 19. Published in final edited form as: Arch Phys Med Rehabil. 2016 June ; 97(6 Suppl): S71–S74. doi:10.1016/j.apmr.2016.03.015.

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Rehabilitation After Surgical Reconstruction to Restore Function to the Upper Limb in Tetraplegia: A Changing Landscape M. Elise Johanson, DPT Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.

Abstract

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

Keywords Outcome assessment (health care); Quadriplegia; Reconstructive surgical procedures; Rehabilitation; Spinal cord injuries; Tendon transfer; Therapeutics; Upper extremity

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Restoring upper limb function is rated among the highest priorities for individuals with cervical spinal cord injuries (SCIs).1,2 Reestablishing active grasp and pinch strength to the hand has a profound effect on independence, the ability to return to work, participation in society, and quality of life. Even small improvements can be the difference in whether an automated teller machine card can be retrieved or a mobile device can be accessed. Health care providers address this challenge with innovative strategies that include both surgical and nonsurgical approaches. Therapies that aim to restore or reorganize spared neural circuitry with physical activity and practice, either alone3,4 or in combination with sensory stimulation,5 robotic-assisted training,6,7 or repetitive transcranial magnetic stimulation,8 are exciting possibilities for those individuals with incomplete injuries. For those with motor complete classification of SCI, reconstructive surgery (eg, tendon or nerve transfer) and implanted neuroprostheses are the primary methods for reanimating motor function in the upper limb.9-13 Postoperative therapy is critical to achieving a successful functional

Corresponding author M. Elise Johanson, DPT, Veterans Affairs Palo Alto Health Care System, Research and Spinal Cord Injury Service, 3801 Miranda Ave/128, Palo Alto, CA 94304. [email protected]. Publication of this article was supported by the American Congress of Rehabilitation Medicine. Disclosures: none.

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outcome; therefore, the availability of rehabilitation expertise is an important criterion for surgery. Even though functional outcomes are due to the combined effects of surgery and postoperative therapy, descriptions of surgical techniques (see references in Dunn et al14) and outcome measures dominate the literature.15,16 Specific guidelines for postoperative training paradigms are not available.

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Reconstructive surgery is often perceived as a specialized area of expertise dominated by knowledge of surgical techniques and advanced through biomechanical research. In centers where surgical expertise does not exist, enthusiasm for integrating upper limb surgery into the plan of care for patients with tetraplegia is also less likely to exist. Nonetheless, many recipients of surgery return to local communities and nonsurgical centers for postoperative care and long-term follow-up. After surgery, voluntary strength is restored to muscles distal to the injury level that were paralyzed or weak when the level and severity of SCI was classified. Reestablishing strength to select muscle groups enables surgical recipients to participate in interventions that incorporate similar activity and task-specific training techniques under investigation for those with incomplete injuries. The collection of articles in the Archives supplement is an opportunity for clinicians who partner directly with surgeons to communicate current trends in practice associated with surgical procedures. With this shared knowledge, we hope to expand the treatment options communicated to patients, increase the availability of postoperative muscle reeducation programs for surgical recipients, and motivate long-term follow-up assessments of upper limb function for individuals with cervical SCI.

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The society of professionals who specialize in surgical restoration of hand function share clinical and research experience at the International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia. The conference brings together multiple disciplines, including surgeons, biomedical engineers, physicians, and therapists, every 3 years. The programming encompasses advancements in surgical procedures, applied biomechanics, evaluation procedures, and clinical outcomes. At the 2013 meeting in Hong Kong, presentations from the therapist symposium highlighted emerging themes for improving preoperative assessments, postoperative training, and multicenter collaborations as they relate to surgical reconstruction. Findings from the work presented in the symposium are reported in this supplement. There was also broad recognition that without documentation of current treatment protocols and associated outcomes, it would be impossible to demonstrate the benefits of new treatment approaches. The need to document the accumulated experience in pre- and postoperative aspects of care related to surgical intervention inspired collective enthusiasm for disseminating site-specific information of postoperative therapy protocols. This effort will contribute to advancing upper limb rehabilitation practice by enabling objective evaluation of novel treatment approaches, interpreting outcomes from multicenter studies, and comparing tendon transfer outcomes with nonsurgical approaches to upper limb rehabilitation.

General principles of surgical rehabilitation The series of articles in this supplement is introduced with an overview of the general principles that guide surgical rehabilitation. The article by Dunn et al14 is a brief description

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of the process for identifying surgical candidates, a description of functional goals of surgery, and a summary of common procedures, postoperative rehabilitation strategies, and expected outcomes. These topics outline the focus of subsequent articles that describe surgical rehabilitation practice in greater detail and reduce the need to restate general principles in each article. Dunn brings attention to both surgical and nonsurgical aspects of the rehabilitation process based on clinical experience and international published literature.

Making the choice for surgery Health care providers have a key role in assisting patients to make informed decisions that fit with their individual needs. Previous studies have reported an underutilization of surgeries to restore upper limb function in tetraplegia.17,18 That is, individuals who are candidates to receive surgery do not undergo the procedure. Two articles in the supplement direct attention to eliminating unnecessary barriers in the delivery of care and empowering patients to make informed choices. In a special communication, Punj and Curtin19 identify patient, provider, and health care system barriers, shown to influence an individual’s choice and the availability of resources to receive surgical intervention. Overcoming the existing barriers through interdisciplinary collaboration and timely patient education can make surgical options available to all patients who are appropriate candidates.

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A conceptual framework of the decision-making process for upper limb surgery follows in an article by Dunn et al.20 This work uses a semistructured interview of persons with chronic tetraplegia to explore the decision-making process and the issues affecting their choice to undergo surgery. The significance of Dunn’s work is to deepen our awareness, from the patient’s perspective, of the complex and often competing priorities that challenge individuals with tetraplegia as they consider their options. Greater awareness of the patient’s concerns will assist health care providers to more effectively guide patients in developing their personal strategy for upper limb rehabilitation.

Matching the patient to the intervention

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Treatment paradigms (surgical and nonsurgical) for improving upper limb function vary according to the level and severity of the SCI. In particular, the classification of injuries as complete or incomplete has a profound effect on what options are under consideration for upper limb rehabilitation. Because of the heterogeneity of this patient population, methodology that helps to identify specific mechanisms of paralysis has the potential to improve individualized treatment plans and to identify patients with similar characteristics for comparing treatment interventions. Differentiating upper versus lower motor neuron damage results in a more complete characterization of functional changes after SCI with objective criteria to stratify individuals within a broader classification. Bryden et al21 report the advantages of including an early assessment of lower motor neuron integrity with surface electrical stimulation. Examples of surgical and nonsurgical interventions that benefit from assessment of the lower motor neuron include functional electrical stimulation (FES), task-based therapy, and nerve transfer. Implementing methods for stratifying patients according to neurologic

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characteristics will accelerate the process of selecting the optimal intervention and understanding the determinants of therapeutic outcome.

After surgery: current postoperative treatment practices VA Author Manuscript

Three international multicenter studies detail therapy protocols after tendon transfer procedures to restore pinch,22 grip,23 and elbow extension.24 In a separate article, Wangdell and Fridén25 describe therapy after tendon lengthening and release procedures that aim to reduce the effects of spasticity and improve the ability to open the hand. The articles state unpublished comprehensive descriptions of the timing, dose, specific activities, progression, and follow-up care related to specific surgical procedures. Each article also reports functional measures (postoperative strength and a self-reported activity measure) to quantify the outcome of surgery and postoperative therapy protocols. The multicenter studies exemplify the benefits of using equivalent postoperative therapy protocols and outcome measures to assess functional outcomes by sharing data from a larger cohort of patients. The combined description of surgical and postoperative intervention protocols, with measured outcomes, contributes to establishing a baseline from which to compare new approaches.

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Exploring innovative changes to conventional practice

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A selection of articles describes novel treatment paradigms that aim to modify or enhance current protocols for postoperative rehabilitation. Novel approaches to postoperative therapy coincide with advances in surgical techniques. Wangdell et al23,25 advantaged the use of stronger surgical attachment techniques to accelerate the initiation of postoperative therapy. Supervised movement was initiated as early as 1 day postoperatively for both grip reconstruction and hand opening procedures with positive results. Johanson et al26 report improvements in pinch strength and muscle activation after transfer recipients participated in a novel task-based program. The home-based training demonstrates the potential for improving surgical outcomes even after conventional therapy and discharge to the community. Bersch and Fridén27 explore the benefits of using FES as an integral component of both pre- and postoperative care. Modalities are seldom used for patients who receive surgery,22 but the authors present a strong rationale for using FES to augment therapy to restore hand function and/or elbow extension. Nerve transfer procedures present several new challenges to rehabilitation: identifying activities to promote nerve regeneration and training to disassociate the actions of the donor and recipient muscles that share the same innervation after surgery. Hahn et al28 describe a rehabilitation protocol to address these goals in therapy after nerve transfer, a relatively new surgical procedure to restore function in the upper extremity.

Muscle reeducation after surgical procedures A common theme for every article describing the aims of conventional or novel treatment approaches is muscle reeducation. Surgical transfer of a tendon or a nerve represents a unique challenge to reestablish voluntary motor control in the upper limb after SCI. The transferred muscle has a new anatomic path (or innervation) and must coordinate with different synergists and antagonists to accomplish functional tasks. Activity and practice are

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known to be key elements of learning new motor skills29 and muscle coordination.30 Emerging postoperative treatment paradigms, guided by principles of motor learning and skill development, have the potential to improve the capacity for upper limb function in tetraplegia.26

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Outcome measures and international database The strong foundation of clinical outcome measures developed for this patient population is critical to determining the effects of surgical and nonsurgical treatment approaches. Do small improvements in force result in meaningful functional change? Do modalities enhance postoperative treatment effects? Which patients should receive nerve transfer versus tendon transfer? Are activity-dependent training protocols beneficial for muscle reeducation after surgical procedures? How does surgical reconstruction compare with conservative approaches? The use of standardized outcome measures to assess upper limb function is necessary to support interdisciplinary communication and make possible multicenter studies of therapeutic efficacy.

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Development and selection of standardized measures appropriate to detecting postoperative changes in this small, heterogeneous patient population has been a primary topic of the therapy symposia at every international conference on surgical rehabilitation of the upper limb. This combined interest from the therapists became a catalyst for the international therapist consensus group described by Sinnott et al.31 The extensive review of standardized measures across multiple domains of the International Classification of Functioning, Disability and Health summarizes the psychometric properties of tests and measures recommended for assessment of upper limb and hand function for persons with tetraplegia. Of special interest is the development of an international registry (New Zealand) promoting shared resources for informing clinical practice. Uniformity in outcome measures represents a critical step toward the goal of evaluating responsiveness to various treatment approaches and combining data sets for larger, multicenter studies.

List of abbreviations VA Author Manuscript

FES

functional electrical stimulation

SCI

spinal cord injury

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

Upper limb reconstructive surgical procedures for individuals with tetraplegia are performed in many centers internationally. Most recipients of surge...
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