Improving Hand Recovery With Neuromodulation in Tetraplegia: A Case Study

PURPOSE: The purpose of this study was to explore participant experiences with occupation-based and intensive task-oriented therapy during client-centered care that specifically focused on upper extremity recovery.

DESIGN: This descriptive case-study with a female with a chronic C6 incomplete spinal cord injury (SCI) was randomized into receiving active or sham transcranial magnetic stimulation (t-DCS) along with 24 two-hour sessions of occupation-based intensive, task specific interventions.

METHOD: Outcome measures were conducted pre, post, 1-month, and 4-month follow-up, including: Spinal Cord Independence Measure (SCIM-III), Manual Muscle Testing using Medical Research Council Scale (MRC Scale), Canadian Occupational Performance Measure (COPM), and Graded and Redefined Assessment of Strength, Sensibility, and Prehension GRASSP and semi-structured Interviews (Pre, Post, 1 month).

RESULTS: The participant demonstrated clinically relevant change in her respiratory and sphincter management on the SCIM at post and at the 4-month follow-up. On the COPM, she revealed clinically relevant score changes in driving, transfers, doing hair, socializing and crossfit at post and follow-up. The participant showed an increase in the depth and breadth of motor cortex activation from the transcranial magnetic stimulation. Therefore, Quantitative outcomes demonstrated the client’s increased hand function from baseline and her perception of performance and satisfaction in COPM goals increased. Qualitatively, the participant expressed increased confidence in doing, developed meaningful roles and enhanced identity as an occupational being. The client expressed having a transformative experience developing new roles and routines and being able to contribute at home with her occupational performance.

CONCLUSION: Research suggests improvement in upper extremity motor recovery and quality of life in occupational performance is possible in chronic SCI. It remains to be evaluated if t-DCS can augment the effects of therapy. In addition, intensive, repetitive task-specific interventions produce effective motor outcomes due to the neuroplastic capabilities of the brain. (Prasad, Aikat, Labani & Khanna, 2018). When working with an individual with chronic spinal cord injury proximal fatigue may impact outcomes for distal motor learning. Therefore, working distally to proximally may improve motor recovery outcomes with task repetition. (Branscheidt, Kassavetis, Anaya, Rogers, Huang, Lindquist & Celnik, 2019).

IMPACT STATEMENT: The study is important to practice and can have a strong influence on occupational therapy as the Implementation of occupation-based and intensive task-oriented interventions support motor learning theory applied to practice and influences positive outcomes in client performance and satisfaction (Nair, Renga, Lindenberg, Zhu, & Schlaug, 2011).

References

Nair, D. G., Renga, V., Lindenberg, R., Zhu, L., & Schlaug, G. (2011). Optimizing recovery potential through simultaneousoccupational therapy and non-invasive brain-stimulation using tDCS. Restorative Neurology and Neuroscience, 29(6), 411–420. https://doi.org/10.3233/rnn-2011-0612

Prasad, S., Aikat, R., Labani, S., & Khanna, N. (2018). Efficacy of virtual reality in upper limb rehabilitation in patients with spinal cord injury: A pilot randomized controlled trial. Asian Spine Journal, 12(5), 927–934. https://doi-org.libproxy.eku.edu/10.31616/asj.2018.12.5.927

Branscheidt, M., Kassavetis, P., Anaya, M., Rogers, D., Huang, H. D., Lindquist, M. A., & Celnik, P. (2019). Fatigue induces long-lasting detrimental changes in motor-skill learning. eLife, 8. https://doi.org/10.7554/elife.40578