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After reading this chapter, the reader will be able to:

  • Discuss the reasons why rehabilitation of the hand and upper extremity should commence as soon as medically possible in the individual with tetraplegia

  • Discuss the goals of upper extremity management in the acute, subacute, and chronic phases of spinal cord injury and the role of splinting

  • Describe the tenodesis grasp, what is required for tenodesis grasp to be effective, and the motions that should be avoided in order to preserve tenodesis grasp

  • Describe the general process by which tendon transfer procedures are undertaken to provide power to a paralyzed muscle and identify the most important grip pattern to restore with tendon transfer procedures

  • Describe the fundamental elements of the postsurgical rehabilitation protocol for an individual who has undergone a tendon transplant procedure


For individuals with tetraplegia due to spinal cord injury (SCI), upper extremity impairment is among the most disabling aspects of this injury. The loss of hand and arm function severely limits an individual's independence and quality of life. Several studies support the importance of focusing on upper extremity rehabilitation as part of the comprehensive management program. As early as 1976, Hanson and Franklin1 documented the importance of restoring hand function, both for the individual with SCI and the individual's caregiver. Early in the collective experience treating individuals with tetraplegia, Waters2 noted, " … the greatest potential for improvement in the quality of life lies in the rehabilitation and maximal restoration of upper extremity function." More recent studies continue to reaffirm the value that upper extremity rehabilitation has in this population of individuals.3,4,5

Since the 1940s, the body of knowledge related to rehabilitation of the hand and arm in individuals with tetraplegia has expanded considerably. Proper management of the upper extremity throughout the individual's continuum of care is essential for optimizing functional outcomes. The main goals of upper extremity management include restoring as much function as possible, maintaining normal appearance, and preserving joint integrity so that the hands remain supple and flexible. Achieving these goals requires a coordinated, interdisciplinary team approach that incorporates the expertise of therapists, physiatrists, and surgeons, as well as the supportive care provided by case managers, nurses, and all ancillary staff. In this chapter, options for the non-surgical and surgical management of the upper extremity following cervical SCIs will be reviewed for all phases of rehabilitation, from the acute phase to chronic phase of injury.

Acute Phase of Injury

Rehabilitation of the upper extremity begins as soon as medically permissible. While the immediate care of the individual with SCI is rightly devoted to life-saving measures and to preserving neurological function, failure to attend to the limbs, especially the arms and hands, can have devastating consequences on the subsequent potential to restore function. Left unattended in the early stages ...

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