Range of Independence with Feeding, Bladder Management and Transfers by Motor Level in Cervical-Level Spinal Cord Injury
Jana Dengler, MD1; Amanda Miller, MD2; Armin Curt, MD3; Munish Mehra, PhD4; Catherine Curtin, MD5; Doug Ota, MD6; Katherine C Stenson, MD7; Carie Kennedy, BS8; Christine B Novak, PT, PhD9; John D Steeves, PhD10; Ida K. Fox, MD11
1Washington University School of Medicine, St Louis, MO; 2Washington University, St Louis, MO; 3Spinal Cord Injury Center, Zurich, Switzerland; 4Tigermed-BDM Inc., Gaithersburg, MD; 5Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA; 6Palo Alto Veterans Healthcare System, Palo Alto, CA; 7VA St. Louis Healthcare System, St Louis, MO; 8Washington University in St. Louis, St Louis, MO; 9Toronto Western Hospital Hand Program, University of Toronto, Toronto, ON, Canada; 10ICORD, Vancouver, BC, Canada; 11Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Background: The advent of upper limb nerve transfer surgery to improve function may transform management of cervical spinal cord injury (SCI). Surgery can restore elbow and wrist extension and finger flexion and extension. Information on the implications of having these movements on activities of daily living (ADLís) is limited. The objective of this study was to assess the degree of gains in independence for a given level of upper extremity motor function.
Methods: Using the European Multi-center Study about Spinal Cord Injury (EMSCI) data set*, analysis was undertaken of eligible individuals with traumatic C5-C8 SCI to ascertain motor function recovery (6 and 12 months after injury, n = 388). Data on feeding, bladder management and transfers (bed to chair) were compared at 6 months and 12 months post-injury for each motor level. Subgroup analyses were performed: symmetric vs. asymmetric SCI; complete vs. incomplete SCI. The impact of age, gender, and degree of asymmetry on functional independence were analyzed.
Results: Independent feeding with or without assistive devices was noted in individuals with strong wrist extension (C6); feeding independently required strong finger flexion (C8). With bladder management, strong finger flexion (C8) was required for independence. Individuals that were younger, male or had trunk control (asymmetric SCI) had greater independence with bladder management. With transfers (bed to chair), elbow extension (C7) did not uniformly result in transfer independence, whereas finger flexion (C8) did. Subgroup analysis showed that people with younger age and/or trunk control also had improved ability to transfer. There was no significant increase in independence between 6 and 12 months with any activities, though a trend towards gain in function was seen.
Conclusion: Although independence with transfers might be expected in individuals with intact elbow extension movement, this was not seen. The presence of finger flexion had the most profound effect on independence with transfers, feeding and bladder function. This information that will be useful when counseling people with SCI who are considering surgical treatment for restoration of upper extremity motion.
*The EMSCI database includes rigorously and prospectively collected neurological and functional independence measurements.
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