print this pageSetting Hands Free
Part Two
Ideally, she wants extensor muscles to reach a grade 3 (out of 5) and thumb and finger flexors to reach a grade 5 when being artificially stimulated. Then she sets up a sixweek home stimulation program to target these muscles and build endurance in areas that may have atrophied over the years. This home program serves two purposes: to condition the muscle and to make certain the muscle will respond as needed.
The ability of the muscles to stimulate is key. Without that potential, the surgery won't work, although patients can still opt for tendon transfer surgery to create at least a small amount of grasp ability. "Not everyone responds to electricity. We don't want to implant a bunch of electrodes that send off electricity that doesn't cause the hand to contract," says Dr. Bowman.
In addition, Garcia works on shoulder and upper back strengthening and conditioning, with a focus on scapular motion. "They will be using both arms in ways they haven't in many years, so we hope to avoid problems with fatigue," Garcia says.
Patients must meet more than physical requirements, however. Strong family support, motivation and commitment will help them get through intense rehabilitation. Because the procedure is delicate, patients must temporarily give up a level of independence.
The arm is placed in a cast for three to four weeks to prevent the elbow from straying in directions that would rupture the tendons or compromise the electrode placement. As a result, patients are restricted from flexing the elbow and making unnecessary movements with the arm. Pushing a manual chair, dressing handling bowel and bladder management or assisting with transfers are out of question.
"[Patients] and their caregivers have gotten good and efficient at what they do. Then, all of a sudden the arm is in a cast and they've become more dependent," says Dr. Bowman. "The right social support is as big a criteria as anything. They'll go from being independent to needing help for everything.
"Often patients are focused on hand function, but they don't really hear 'You'll be laid up for a while and won't be able to use the hand like you have been for years.' That's the hardest thing for them ... They didn't realize how much they did do for themselves, how efficient they were or how well they got around. Now they can't do anything at all."
The waiting can be the hardest part. Although the period of inactivity is difficult, patients should remain focused on long-term goals, which are discussed during the evaluation. The biggest question is finding out a patient's needs, desires and wants, then determining whether those expectations are possible. While the patient may set his sights high, clinicians must present a realistic picture of the level of function he can achieve.
For instance, the surgery won't help someone achieve individual finger movement, such as knitting or playing the piano. "We're not talking about creating Mozart here," says Dr. Bowman. "We want to make sure someone has a realistic idea in mind of what they are going to be able to do."
Yet it's such a new procedure that Garcia isn't surprised when someone, like Brown, goes beyond expectations. "In some areas, they're really only limited by their own imagination," she says.
Once the cast is removed and patients emerge from that inactive state, they still face several months of rehab to learn the capabilities of their newly functioning hand. The first step is introducing elbow flexion at home in gradual increments. When the procedure is combined with a posterior deltoid to triceps tendon transfer, the system is programmed to allow 15 degrees of flexion weekly, until the patient reaches 75 degrees of flexion.
The program consists of progressive flexion and functional grasp exercises, with periods of electrical stimulation at home. Floersheim uses the first few visits to adjust grip strength and motion, depending on a patient's ability to pick up objects. Patients watch the motion of bending the wrist and seeing the thumb and fingers move, since it's a motion they aren't used to feeling, she says.
With the variety of new arm motions, muscle fatigue is a common problem. Over time, patients start with light objects and proceed to more resistance, since muscle stimulation is refined to work in concert with grasp. The earliest results come from self-care chores. Beyond that, some experiment with the bounds of grip power and arm strength by carrying a bag of groceries or holding onto a dog's leash.
Progress depends on the person, yet because the spinal cord injury has produced years of inactivity; many patients don't know how far to push during rehab. With compliance and, at the least, rehab three times a week, patients can start using the hand for its intended design three or four months postsurgery.
Maintenance on the device is minimal. The internal device should be recharged every five or six years. Since the procedure is less than two years old, other long-term implications won't be known for another decade, but it has shown enough promise that some insurance companies are covering the procedure.
Since the future may hold a cure for spinal cord injuries, patients often question whether the surgery will affect their potential to take advantage of SCI breakthroughs. Clinicians can allay those fears, since the procedure is reversible.
Under these circumstances, patients have very little to lose and everything to gain. Just ask Brown. "I was stunned with the capabilities." he says. "The more you use it, the more you're going to get out of it and the stronger your arm is going to get.
"There's no way you can lose."
click here to go back to part one
article from Advance for Directors in Rehabilitation
February 2000