Nerves, Muscles and Bones
A number of different conditions can affect your nerves, muscles. and bones after spinal cord injury. The sections in this chapter will describe each situation, its advantages and disadvantages, and what you can do about it.
Towards Healthy Hands (supplement material)
Courtesy of the the Alberta Education Initiative
If you have a spinal cord injury (SCI) at the C8 level or higher, it is likely that your
hands have been affected in some way. Your hands may look different, feel different, and work differently than they did before your injury.
Why is that?
After a spinal cord injury, the nervous pathways which tell your hand muscles how to move have been affected or cut. This means your hand may rest in a certain position, that there are some movements you can’t do, or that your hands are weak. The pathways which tell you that you are touching something and what it feels like are also cut or affected.
Why do my hands seem different from other peoples’ with spinal cord injuries?
How you move and use your hands is very individual. If your spinal cord has been totally damaged, all pathways have been affected, so you will likely have more problems with weakness/paralysis. If you have less spinal cord damage, fewer nervous pathways have been affected and you may have more movement/strength.
You may have a lot of problems with tightness and spasticity. You may also have other injuries or problems, such as a fracture, that affect your hands. What is important now is that you get to know your hands again, to get them moving and working the way you need. There will be some movements that are difficult or that you can’t do at all. But, it may be possible to learn ways to use your hands. Your therapist will help you do this, but don’t let it stop there. The more you do with your hands, the stronger and more useful they can become.
I’ve had a lot more movement back since my injury. Won’t my hands just get better and better as my spinal cord heals?
It’s true that some use of your affected neuropathways will recover over time and you may notice more feeling and movement in your hands. It is very hard for your doctor or therapists to tell you how much recovery you will experience, if at all, especially if you have partially preserved function or sensation below your lesion. The best thing is for you to get started with your hand therapy now, and to work with what you have. This will keep your hands as strong and flexible as possible.
How can we help?
My injury has affected my hands. What can be done to make them function normally again?
This is a difficult question to answer as every injury is different, including the problems you are experiencing with your hands. Consequently, each individual will experience different losses and different degrees of recovery. Some damage may be permanent and some function may return during therapy. The main thing to remember is the recovery process takes a long time and is often unpredictable.
So how can therapy help me?
Your therapists will first want to assess how your SCI has affected your hand function to determine how they can best help you. An individual hand therapy program will be developed to maximize improvement of your hand function. This will consist of some or all of the following:
- strengthening of muscles that are weak
- stretching muscles and ligaments that have become too tight
- maintaining or improving the range of motion of all of your finger and hand joints
- splinting your hands to protect against deformities
- selectively allowing some tendons to tighten to improve the use of your hands
- teaching you new ways of using your hands. For example something called a “Tenodesis” grip. A “Tenodesis” grip is the natural tendency for your fingers to close when you lift up your wrist. To develop this into a stronger grip your occupational therapist will work with you to develop good thumb positioning and the tightening of long finger tendons in your hand and forearm. This is done by never stretching out those tendons fully. For example, you should never straighten your fingers and bend your wrist back at the same time.
If I work hard, will all my hand muscles become strong again?
Not all your muscles will fully recover as some of them have absent or reduced messages from the spinal cord. Strengthening exercises will help develop muscles that have intact messages. These muscles can return to normal. Exercise will also help develop muscles with partial messages from the spinal cord. They may improve but not reach full strength no matter how much you work because they are getting less input from the spinal cord.
These muscles may work well enough to allow you to use your hands to accomplish daily tasks, however, the muscles will still feel weak. Some messages that are getting through to your muscles have changed and actually make your muscles contract uncontrollably at times (spasms). Sometimes strengthening these muscles will only cause them to spasm more and will actually make moving other muscles more difficult. It is important that your therapist determine whether you have spasticity in hand muscles before developing a strengthening program.
Do I need splints? What can they do for me? How long do I have to wear them?
Typically, with paralysis, changes will occur to the muscles, joints, and ligaments of your hands. Sometimes different muscle strengths lead to an imbalance of forces pulling on a joint. This will cause that joint to slowly stretch abnormally, causing a deformity. Other times, a lack of muscle strength will result in shortening of structures that require movement to stay stretched and flexible. Again, this can lead to deformity and may even become painful.
Finally, without adequate muscle strength your hand may hang in one-position and stretch muscles that are responsible for moving the hand out of that position. This too can lead to deformity and reduce strength gains in those muscles. Deformities should be avoided unless they can increase your independent function (i.e. tenodesis). They interfere with your ability to use your hand effectively especially when trying to grasp and release objects.
Splints are designed to keep your hand structures flexible and supported to avoid deformity and thus improve hand function. Your occupational therapist will determine what, if any, splint is best for you. The therapist will also discuss when and for how long you should wear a splint. Some splints may be only worn to bed.
Other splints are worn during functional activities only. Splint use may be discontinued if muscle strength and movement of joints in the hand improve.
How does stretching make my hands any better?
Your muscles, ligaments, and joints were designed to be constantly moving in order to maintain their flexibility. Without this flexibility, movements are harder to achieve with weakened muscles. This compounds the problem as reduced movement leads to further inflexibility and thus further reduction of mobility. A vicious circle occurs until structures become so tight (contractured) that they are impossible to stretch. This leads to permanent deformity, which will restrict your ability to use your hands effectively. Your occupational therapist can create a personalized stretching program for your hands. Regular stretching can help to avoid contractures and deformities, which maintains both the normal appearance of your hands as well as effective function.
Help! My hands hurt…
Sometimes I’ll just be lying in bed, and I’ll get these shooting pains in my hand. Why do they hurt even when I’m not doing anything?
The nervous pathways which send pain messages to your brain have been damaged. Even though nothing painful is happening to your hand, these pathways are “feeling” pain because they are injured.
So what can I do about it?
There are no easy answers to this. The injured pathways cannot be repaired and so you have to find ways to make the pain less severe. Talk to your doctor about medications that might help. Talk to your therapists about warm wax, stretching, massage, and vibration. Only you will be able to tell what makes a difference.
The other thing I’ve noticed is that sometimes when I touch things my hand feels painful, and warm water feels like it’s burning my hand. Why is that?
This means that your hand is “hypersensitive” or over-sensitive. Sometimes it can be so sensitive you try to avoid using your hand because touching things feels so painful. You may need to “desensitize” your hand. You need to get your hand used to touching things even though it feels strange or painful. Start slowly with things that aren’t too painful, and work your way up. Your therapist may get you to move your hands around in buckets of small objects or to try holding your hands as long as you can in warm water. The more you can get used to, the less this “hypersensitivity” will affect you.
I can hardly move one of my hands at all. Why does it get so swollen?
Fluid tends to build up in your hand if you can’t move it. The position you keep your arm in can help keep the swelling down. Generally, the higher your hand is the better. Propping your hand up on a wedge of foam will help the fluid drain away from your hand. Your therapist may have other helpful suggestions such as massage or pressure garments. It’s important to know that swelling can be a sign of other serious problems. If you notice a lot of new swelling, you should see your doctor.
Getting around in my wheelchair is hard on my hands. How can I best protect them?
Many people who do a lot of wheeling wear some kind of cycling gloves. Not only do gloves help to protect your hands, they can help your wheeling. If pushing is hard for you, you can get gloves that give you extra friction against your wheel rims. When you’re choosing gloves, make sure you can get them on and off. If you’re having trouble finding what you need, your occupational therapist can make suggestions, or even adapt your gloves to work better for you.
Spasticity
Will spasticity affect how my hands work?
Yes. but the effects of spasticity are different from person to person.
Spasms
It may be that you have spasms, and during these spasms you can’t control your arms and hands. Your doctor will help determine the best medications to control your spasms. Your therapists will recommend positions and movements that are less likely to cause spasms. As well, you will learn how to avoid setting off spasms and how to control them when they happen.
Spasticity
Sometimes spasticity causes certain muscles to contract with any attempted movement. People with incomplete injuries usually have more problems with this. This may make some movements even more difficult. The harder you try to work against this, the harder these muscles resist you. Your therapists have ways of helping you learn how to cause those muscles to relax. Usually, they will help you practice slow, gentle movements with your body and arms. They may have you avoid some strengthening exercises with your hands and arms, as these may just make the spasticity worse.
Is this spasticity what makes my neck and shoulders so stiff?
Spasticity may be part of your problem. It may also be that you have to use your shoulders more now that your arms and hands are weaker. Before you had your injury, you could bring your hand to your chin by just bending your elbow. Now, if the muscles for bending your elbow are weak, you may need to shrug your shoulder and raise your whole arm to get your hand to the same place.
The less you use your shoulders to make your hands work, the better. As your arms and hands get stronger, it’s important to concentrate on using them without having your shoulders contract. You may still need to use your shoulders, though, depending on how strong your arms and hands get. The important thing is to work with your therapists to develop the best methods of optimizing your hand function.
Future considerations
I am not able to use my hands as effectively as I want to. Are there any other methods that can help improve my hand function?
Health care professionals are continually developing techniques to improve hand function. Unfortunately, many of these techniques are not consistently successful with all individuals. However, this does not mean they are not worth trying. Alternative techniques we are aware of but do not offer to everyone (or at all) at the Glenrose or Foothills include the following:
- nerve regeneration drug therapy
- hand massage
- diet/vitamin supplements
- surgery
- tendon transfer surgery (hand)
Hand surgery
Tendon transfer surgery is not routinely done on spinal cord injured patients, however this information is included so you better understand your options. This surgery is intended to improve grasp and hand function for people with quadriplegia. Some of the activities that people who have had surgery are better able to do include:
- driving a car
- pushing a manual chair
- transfers
- writing
- feeding oneself
- dressing oneself
What is a tendon transfer?
The hand works partly by muscles in the fingers and palm, but mostly by muscles in the forearm which are joined to the hand by tendons. A tendon transfer operation involves transferring a tendon (or strand of a tendon) that is part of a working (non-paralyzed) muscle, to replace a paralyzed tendon. Surgery might also involve attaching the tendon of a paralyzed muscle directly to a bone. This does not allow you to actively move a paralyzed joint, but it may provide better joint stability and therefore better grasp.
After surgery
Surgery is never performed earlier than 12 months post-injury. The literature on tendon transfer surgery reports good success rates, both from a surgical as well as client-satisfaction perspective. It is important to know, however, that there is a 6 to 8 week rehabilitation period that can be difficult because independence is significantly limited. For at least 3 to 4 weeks, you will be wearing a cast or a splint, you will need assistance with transfers, and if you use a wheelchair, you will have to use a power chair. You will probably need more assistance with everyday personal care activities. Once the splint is removed, you can gradually resume daily activities, and begin re-educating your arm and hand muscles. By the end of 2 months, you should be able to return to all your regular activities.
More information
Aside from discussing surgery with health care professionals, a good way to learn more about hand surgery is to see what it has done for others. Your occupational therapist or physiotherapist can help you find out more about this.
Hand surgery is not a magical cure for people with quadriplegia, and it is not even something everyone with quadriplegia will want to consider. It is, however, something worth looking into and asking questions about if one of your rehabilitation goals is to improve your hand function.
Overuse Injuries
Overuse injuries have become common in recent years. With the use of computers and more repetitive high tech jobs, overuse syndromes and the pain and disabilities that happen because of these jobs are increasing. Employers and insurance companies spend millions of dollars each year on time off work and medical care.
Ergonomics, the science that looks at fitting a person’s physical characteristics to a job in a way to improve well being, is growing by leaps and bounds. New products to help prevent and lessen overuse injuries are being made all the time. Overuse injuries is a problem that is just beginning to be understood.
What does overuse syndrome Damage happens as a single motion is repeated many times, and the repeated trauma leads to injury, pain and maybe more disability. There are lots of medical diagnoses that are related to overuse syndrome. Many people have heard some of these terms from a doctor or therapist – bursitis, tendonitis, arthritis, impingement syndrome (swimmer’s shoulder), rotator cuff tears, trigger points, lateral epicyondylitis (tennis elbow) and carpal tunnel syndrome are all terms that describe overuse syndrome. mean? It is a term used to describe a group of changes that occur due to a repeated stress on an area of the body.
Persons with spinal cord injuries are more prone to overuse injuries. People with spinal cord injuries are 50% to 75% more likely to get shoulder and arm pain than the general public. There are many reasons for this. Think of all the motions you repeat over and over during a normal day: wheeling, transfers, working on high counter tops while sitting. Often awkward positions are used to do activities. All of this combined with abnormal muscle control and tone, increases a persons likelihood of overuse injury.
Overuse syndromes can have a big impact on people who suffer from them. The most common complaint is chronic pain, often in the neck, shoulders and elbows. Pain can be very disabling. It may vary from mild discomfort to unbearable suffering. Pain tends to bring about reactions in the rest of the body. Increased spasms and autonomic dysreflexia commonly result from the pain. Other problems may include muscle and joint stiffness, skin problems if you can’t shift your weight, less independence, decreased quality of life, and even depression.
Some causes of overuse syndrome in persons with spinal cord injuries
Muscle paralysis
Paralysis after a spinal cord injury affects muscle strength and creates muscle imbalances. The joints of the body move by muscles working together. A weak muscle in a group can lead to abnormal motions at the joint and cause injury over time. Spasms may also be considered here. Spasms are rarely the same on each side of the body and tend to be stronger on one side of the body. Postural changes, such as a scoliosis, happen over time and may make an overuse injury worse.
Increased stress on joints
People with spinal cord injuries must use their joints in abnormal ways to function during the day. Transfers are a good example. During a transfer you are picking up the weight of your body through your shoulder joints. The shoulder is made to move the hand through space and has a hard time holding up the weight of the body. The shoulder is doing a job that the hip does. Think of the times you have heard of elderly people with hip and knee arthritis. You can imagine the number of shoulder overuse injuries that happen as people with SCIs get older. Another example is working on a high counter where your elbows are above your shoulders, such as washing the dishes at the kitchen sink. This position for the shoulder increases the chance of an overuse injury over time. The shoulder works better when the arms are at the side.
Repetition of activities
There are many motions done over and over during a day by a person with a spinal cord injury. Some include wheeling, weight shifting, transfers, and, for some, walking with crutches.
Muscle imbalances
Muscle imbalances were talked about earlier in the content on paralysis after a spinal cord injury, but there is another kind of muscle imbalance that occurs. When a muscle is used too much and the opposite muscle is not used enough, the muscle can become short and strong while the opposite muscle can become stretched and weak. This can lead to abnormal movements at the joint and changes in posture.
An example of this type of imbalance would be the changes that happen around the shoulder after years of wheeling a manual chair. The muscles in the front of the shoulder and chest become strong and start to tighten up while the back and shoulder blade muscles become small. The shoulder is now unbalanced and changes will occur. There is another common example, “hooking.” Many persons with quadriplegia hook their arm around the cane of the wheelchair back for balance and to improve their abilities to do many things. Most people who use hooking tend to use one side only, while using their other hand to do a task. Once again, a condition develops where some muscles are shortened and others become over-stretched.
Posture and seating
Proper seating and posture has come a long way since the days of sling seats and steel wheelchairs. Now it is clear that proper posture is the most important step in preventing overuse injuries and decreasing the pain that can occur. Sitting posture is closely related to neck, shoulder and arm function.
Unfortunately, finding a proper seating posture can be hard to do. It takes time, patience and commitment. Changing the sitting posture of a wheelchair user can affect other aspects of that person’s life. Transfers may need to be changed, balance may need to be re-learned, and environments might need to be altered to include the new setup.
See Positioning in Your Wheelchair.
Management and prevention
Managing and preventing overuse syndromes means knowing why the injury happens, problem solving to find a solution, and then making changes to your lifestyle and physical presentation. Physiotherapists, massage therapists, acupuncturists, and chiropractors can help break the pain and inflammation cycle, but until you know the cause of the problem the pain and injury will likely come back. Here are some ideas to look at.
Correct or lessen muscle imbalances
An exercise program that includes strengthening and stretching can help. A good therapist can look at you and assist with an exercise program. Usually this means strengthening the weak muscles and stretching the tight muscles. By looking at your daily activities you can be creative and come up with quick and simple things to do. You might wheel backwards up a hill or use the other arm to “hook” with.
Posture, posture, posture
Regularly checking your posture is an important and ongoing step. Posture should be checked often. A simple plan is to pick one day of the year, your birthday works great, and take a front, side, and rear picture of yourself, without a shirt on, sitting in your wheelchair. You can then look at your posture over time and take action when you need to. For example, you may require new seating or a different exercise or a different exercise and stretching program.
Protect joints during activities
Be aware of this. Cut down on the overhead reaching you do and change your environment so there is less reaching that must be done. Be aware of how you transfer and be careful using an overhead trapeze. Change your hooking and wheeling patterns. Pace yourself and take breaks. The phrase “use it or lose it” is not necessarily always true.
Change activities and look at your equipment
If doing a certain activity causes you pain, change the way you do it. This may be changing the way you transfer or using adaptive aids. Equipment is always changing as more is learned about overuse and disability. Wheelchairs are lighter and easier to push and lift into a car. Proper wheelchair set-up and seating position is a must.
Sliding boards are helpful for reducing stresses on the shoulder. This doesn’t mean carrying a sliding board around wherever you go. Use it for the more difficult or frequent transfers and save your joints for times when you don’t have a board. Some people find changing to a power wheelchair helpful as they age. There are criteria to meet to get a power chair. If you feel it is time to consider a change discuss the options with a health care professional.
Make changes to your environment
Ergonomics is a growing and important new field. Many companies have persons employed to make changes to workstations to prevent overuse syndromes. Take advantage of this. It is a good idea for anybody. Overuse syndromes occur in many people. It happens more often and earlier in people with spinal cord injuries and can affect health, function, and independence. It is important to catch overuse injuries early and think of possible causes. Overuse is part of aging, but if you know what to do, its onset can be avoided or delayed.