Rehabilitation Considerations After Reconstruction

Amy Bohn OTR/L

Children’

This session:

• Review of contracture post-op protocols:

– Shoulder

– Elbow

– Forearm

– Wrist

– Hand

• Surgical restoration protocols

– Elbow extension

– Active pinch

– Active Grip

Contracture Releases

Post-Injury Management

A pitfall associated with treating the upper

extremity in acute SCI is “Conservative Methods” instead of aggressive program

“Therapy must begin early to prevent harmful

contractures and preserve joint mobility”

(Murphy & Chuinard, 1988)

Surgical Interventions in Upper Limb Management

• GOAL:

– Preserving passive and active function for future neurologic recovery, rehabilitation or surgical reconstruction for function

• Treated as health permits

• As aggressive as in able bodied individual

• Important so that stiffness does not set

Shoulder Contractures

• Shoulder Manipulation – Begin therapy within 1-2 days after surgery

– AAROM – try to replicate motion that was obtained in surgery

– Wear sling first 1-2 weeks for comfort but then want them to be moving

– 2-3 weeks • pt. will usually tolerate weight bearing exercises

• initiate bar exercises (1# bar and progressing)

• Theraband as tolerated (yellow and progress)

Shoulder Contractures

• Glenohumeral Release – Casted 3-4 weeks

– Out of cast: • Splint is to replicate casted position with a trunk and

posterior elbow support with elbow in flexion

– Week 1/2 post cast removal • splint is only removed for bathing and supervised

therapy

• AROM – check for compensation

• Scar management

Shoulder Contractures

– After week 2:

• splint is only removed for bathing and supervised therapy

• AROM – check for compensation

• Gentle PROM in all directions

• Scar management

• After 6 post operatively, restrictions lifted and full therapy

Elbow Lengthenings

• 3-4 weeks immobilization

• Post immobilization:

– Fabricate long arm splint with elbow in surgical position and wrist in neutral or slightly extension

– Splint off for bathing, therapy and home program

– 8 weeks splint is for night wear only

– 12 weeks discontinue use of splint

Elbow Lengthenings

Weeks 1-4 out of cast PROM elbow extension and supination avoided AROM: gentle elbow extension and forearm rotation Modalities Self care and light functional activities that promote

pronation can be introduced Scar management

Week 4 -8 out of cast Gentle PROM for elbow extension and forearm rotation Continue with AROM Light strenghtening activities for elbow flexion and

pronation can be introduced

Forearm Osteotomy

Immobilization 4-6 weeks

After immobilization: Dressing removal Long forearm based splint to prevent rotation and protect healing –

don’t block elbow ROM Splint on at all times except bathing, therapy, and HEP until well

healed AROM Scar management

Depending on healing, surgeon will dictate progression of activity OUTCOME: Functional positioning of forearm for activities of

daily living

Wrist Contractures

Lengthening Casted 3-4 weeks Week 1-3 out of cast:

Cast removed – splint in position of cast Scar management AROM Modalities Initiate light ADL skills

Week 3-6 out of cast:

Splint adjusted and night wear only Scar management AROM PROM Modalities Increase to higher level ADL skills

Finger Contractures

• Manipulation – Therapy begins 1-2 days after surgery

– Continuous passive motion machine 4-6 weeks

– Dynamic splint for when CPM is not on and for after CPM is discharged

– Modalities

– Aggressive ROM

– Functional activities as soon as possible

– HOME FOLLOW through is a key

Prevent Stiff, Contracted Hands

Surgical Restoration

Tendon Transfers

Goals of Surgical Restoration

Restore functional abilities

Reduce dependency

Improve quality of life

What do patients want?

• Surveys continue to reveal hand restoration is a priority to patients – Anderson, 2004

– Snoek, et al., 2004

– Snoek, et al., 2005

• Patients continue to report favorable outcomes following surgical reconstruction – Wuolle, et al., 2003

– Bryden, et al., 2004

General Post-operative Guidelines for Tendon Transfers

• Casted 3-4 weeks Shoulder ROM while in cast

Early activation grip transfer to prevent scarring

• After cast removal: – Fabrication of splints in protective positions – Scar Management – K-wire removal – “Firing” transfer – Incorporate functional re-training

(Hentz & Leclercq, 2002)

Case Study 1:

Bicep to Tricep

Active Pinch

Insert picture both transfers

• Elbow • Pinch

Case Study

• 27 year old male • C5/6 SCI (ASIA A) secondary to diving accident

7/03 • Completed inpatient rehabilitation 11/03 • Day program 03/04 to 04/04 • Outpatient 05/04 to 08/04 • Tendon Transfer Evaluation: 08/05/04 • RUE: active lateral pinch and elbow extension – 08/27/04 • LUE: active lateral pinch and elbow extension – 11/05/04

Case Study

• History: Skin breakdown, UTI, Autonomic Dysreflexia, spasticity (controlled)

• Psychosocial: Living with mother in accessible apartment. Mother primary caregiver – sister and brother-in-law in area to assist

• Equipment: PWC with tilt, MWC, Roll-in shower chair, hoyer lift, splints HS

Patient Wishes:

• Patient wanted elbow extension and active pinch

• Patient goals: feeding, grooming, typing, self-cath.,money management, painting, writing, transfer, w/c propulsion

• Patient wanted to do RUE first

Priority 1:

• RESTORE ELBOW EXTENSION:

– increases the workspace of the hand

– pressure relief techniques

– wheelchair propulsion

– transfer skills

– straighten arms out while lying down.

• Procedures

– Biceps to Triceps transfer

Elbow Extension – Biceps to Triceps

• Non-synergistic transfer

• Stronger donor muscle

• Stronger result

• Our preferred method

Specific - Rehabilitation Process

WEEK 1-4 out of Cast:

Weekly measurements: degrees elbow flexion to elbow extension. Later weeks, measure gravity eliminated and against gravity

• Day one out of cast – begin “firing” transfers

• Scar Management

• Light ADL tasks begin end of week 2 out of cast

• Initiate “firing” in different planes end week 3

Post-Surgical Immobilizations

Specific - Rehabilitation Process

WEEK 7-12 out of Cast:

• Begin higher resistant ADL

• Out of Bledsoe after at 90 degrees for one week (approximately 8 weeks after cast removal)

• Seek MD approval to begin weight bearing, transfers,and wheelchair propulsion

• Elbow extension splint (0 degrees at night) for 3 months after surgery

Biceps to Triceps

Priority 2:

• RESTORE ACTIVE LATERAL PINCH:

– Restore 3-5 pound pinch

– Enhance ability to perform ADL with no equipment.

• Procedures

– BR to FPL split tenodesis

– CMC Fusion

Specific: Rehabilitation Process

WEEK 1/2 out of Cast:

Weekly measurements: force of pinch on pinch meter

• Day one out of cast – begin “firing” transfers

• K-wire removed at 3-4 weeks after surgery

• Scar Management

• Light ADL tasks begin end of week 2 out of cast

Dorsal Intrinsic Plus Splint

•

Specific - Rehabilitation Process

WEEK 3-8 out of Cast:

• “Firing” different planes

• Continue with Scar Management

• Increase resistance of ADL tasks – get clearance MD when pt. wants to begin transfers/wheelchair propulsion

• CMC K-wire removed 8 weeks post-operatively

• SPLINT d/c night wear at 8 weeks post cast removal

Case Study Functional Gains

Pre-operative Post-operatively

Feeding – with u-cuffs (I) with no equipment

Brushing teeth – with u-cuffs (I) with no equipment

Washing face – MIN (A) (I) with no equipment

Shaving – with u-cuffs MIN (A) (I) with no equipment

Case Study Functional Gains

Pre-operative Post-operatively

Emptying leg bag – (D) (I) with no equipment; able to self-cath.

Bathing – UE MIN (A) (I) with UE/LE LE

MAX A with long sponge

Zipping/buttoning (I) with no equipment

MOD (A)

Case Study Functional Goals

Pre-operatively Post-operatively

ATM – MAX (A) (I) with adaptation to card

Money out of wallet (I) with no

MOD (A) equipment

Writing – with u-cuffs (I) (I) with regular pen/pencil

Case Study Functional Goals

Pre-operatively Post-operatively

Turning pages with (I) with pinching

with u-cuff (I) pencil

Typing on computer (I) with pinching pencil

With u-cuff (I)

Transfers – lateral MOD (A) (I) with transfer board

Tired easily propelling “Easier to do and further

manual wheelchair distance”

“Period of dependency was worth it to have function and independence in the long run”

(case study quote)

“...if you have nothing, a little is a lot...”

Sterling Bunnell, MD

Case Study 2

Palmar Grasp

Restoration – Palmar Grasp

• Rehabilitation same time as Lateral Pinch

• Restoration of palmar grasp:

– Restore 10-15 pound grip

– Enhance ability to perform ADL with no equipment.

Case Study

• demographics

Case Study

• History:

• Psychosocial:

• Equipment:

Patient Wishes:

Restoration – Palmar Grasp

• FDS/FDP

– ECRL to FDP transfer

• Intrinsics (if needed)

– FDS tenodesis (Zancolli)

• Finger/thumb extension (if needed)

– Tenodesis, Brachioradialis transfer

• Thumb flexion

– As per lateral pinch

Rehabilitation Process

WEEK 1/2 out of Cast:

Weekly measurements: force of grip on adapted meter and then on dynamometer ;unable to obtain first weeks out of cast – measure from DIP to Distal palmer crease

• Day one out of cast – begin “firing” transfers

• Emphasize isolating transfers pinch from grip

• K-wire removed at 3-4 weeks after surgery

• Scar Management

• Light ADL tasks begin end of week 2 out of cast

Immobilizations pictures

Rehabilitation Process

WEEK 3-8 out of Cast:

• “Firing” different planes

• Continue with Scar Management

• Increase resistance of ADL tasks – get clearance MD when pt. wants to begin transfers/wheelchair propulsion

• CMC K-wire removed 8 weeks post-operatively

• SPLINT d/c night wear at 8 weeks post cast removal

Bilateral Pinch/Grip Patient

Video of Shannon with pinch

“Wish I had done years ago, would have helped so much when kids were babies”

Past, Present, and Future

“…the greatest potential for improvement of quality of life lies in

rehabilitation and maximal restoration of upper extremity

function.”

Robert Waters, 1996