Rating schemes for clinical/epidemiologic evidence (1-6), ergonomic evidence (1-3), grade of recommendation (A, B, C, D), and strength of panel opinion (Low, Moderate, Strong) are defined at the end of the "Major Recommendations" field.
Initial Assessment of Acute Spinal Cord Injury (SCI)
- Educate health-care providers and persons with spinal cord injury (SCI) about the risk of upper limb pain and injury, the means of prevention, treatment options, and the need to maintain fitness.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--None; Grade of recommendation--Not Applicable (NA); Strength of panel opinion--Strong)
- Routinely assess the patient's function, ergonomics, equipment, and level of pain as part of a periodic health review. This review should include evaluation of:
- Transfer and wheelchair propulsion techniques
- Equipment (wheelchair and transfer device)
- Current health status
(Clinical/epidemiologic evidence--None; Ergonomic evidence--None; Grade of recommendation--NA; Strength of panel opinion--Strong)
Ergonomics
- Minimize the frequency of repetitive upper limb tasks.
(Clinical/epidemiologic evidence--4/5; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Minimize the force required to complete upper limb tasks.
(Clinical/epidemiologic evidence--5/6; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Minimize extreme or potentially injurious positions at all joints.
- Avoid extreme positions of the wrist.
(Clinical/epidemiologic evidence--4/5; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Avoid positioning the hand above the shoulder.
(Clinical/epidemiologic evidence--6; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Avoid potentially injurious or extreme positions at the shoulder, including extreme internal rotation and abduction.
(Clinical/epidemiologic evidence--4/5; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
Equipment Selection, Training, and Environmental Adaptations
- With high-risk patients, evaluate and discuss the pros and cons of changing to a power wheelchair system as a way to prevent repetitive injuries.
(Clinical/epidemiologic evidence--2/3; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Provide manual wheelchair users with SCI a high strength, fully customizable manual wheelchair made of the lightest possible material.
(Clinical/epidemiologic evidence--2/5; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Adjust the rear axle as far forward as possible without compromising the stability of the user.
(Clinical/epidemiologic evidence--2/3; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Position the rear axle so that when the hand is placed at the top dead-center position on the pushrim, the angle between the upper arm and forearm is between 100 and 120 degrees.
(Clinical/epidemiologic evidence--2/3; Ergonomic evidence--2; Grade of recommendation--C; Strength of panel opinion--Strong)
- Educate the patient to:
- Use long, smooth strokes that limit high impacts on the pushrim.
(Clinical/epidemiologic evidence--5; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Allow the hand to drift down naturally, keeping it below the pushrim when not in actual contact with that part of the wheelchair.
(Clinical/epidemiologic evidence--5; Ergonomic evidence--2; Grade of recommendation--C; Strength of panel opinion--Strong)
- Promote an appropriate seated posture and stabilization relative to balance and stability needs.
(Clinical/epidemiologic evidence--2/3; Ergonomic evidence--NA; Grade of recommendation--C; Strength of panel opinion--Strong)
- For individuals with upper limb paralysis and/or pain, appropriately position the upper limb in bed and in a mobility device. The following principles should be followed:
- Avoid direct pressure on the shoulder.
- Provide support to the upper limb at all points.
- When the individual is supine, position the upper limb in abduction and external rotation on a regular basis.
- Avoid pulling on the arm when positioning individuals.
- Remember that preventing pain is a primary goal of positioning.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Provide seat elevation or possibly a standing position to individuals with SCI who use power wheelchairs and have arm function.
(Clinical/epidemiologic evidence--2/3; Ergonomic evidence--1; Grade of recommendation--B; Strength of panel opinion--Strong)
- Complete a thorough assessment of the patient's environment, obtain the appropriate equipment, and complete modifications to the home, ideally to Americans with Disabilities Act (ADA) standards.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Instruct individuals with SCI who complete independent transfers to:
- Perform level transfers when possible.
(Clinical/epidemiologic evidence--2/3; Ergonomic evidence--2; Grade of recommendation--C; Strength of panel opinion--Strong)
- Avoid positions of impingement when possible.
(Clinical/epidemiologic evidence--5; Ergonomic evidence--2; Grade of recommendation--C; Strength of panel opinion--Strong)
- Avoid placing either hand on a flat surface when a handgrip is possible during transfers.
(Clinical/epidemiologic evidence--2/5; Ergonomic evidence--3; Grade of recommendation--C; Strength of panel opinion--Strong)
- Vary the technique used and the arm that leads.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--2; Grade of recommendation--C; Strength of panel opinion--Strong)
- Consider the use of a transfer-assist device for all individuals with SCI. Strongly encourage individuals with arm pain and/or upper limb weakness to use a transfer-assist device.
(Clinical/epidemiologic evidence--2/5; Ergonomic evidence--2; Grade of recommendation--C; Strength of panel opinion--Strong)
Exercise
- Incorporate flexibility exercises into an overall fitness program sufficient to maintain normal glenohumeral motion and pectoral muscle mobility.
(Clinical/epidemiologic evidence--3/4; Ergonomic evidence--NA; Grade of recommendation--C; Strength of panel opinion--Strong)
- Incorporate resistance training as an integral part of an adult fitness program. The training should be individualized and progressive, should be of sufficient intensity to enhance strength and muscular endurance, and should provide stimulus to exercise all the major muscle groups to pain-free fatigue.
(Clinical/epidemiologic evidence--3/6; Ergonomic evidence--NA; Grade of recommendation--C; Strength of panel opinion--Strong)
Management of Acute and Subacute Upper Limb Injuries and Pain
- In general, manage musculoskeletal upper limb injuries in the SCI population in a similar fashion as in the unimpaired population.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--None; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Plan and provide intervention for acute pain as early as possible in order to prevent the development of chronic pain.
(Clinical/epidemiologic evidence--5/6; Ergonomic evidence--NA; Grade of recommendation--D; Strength of panel opinion--Strong)
- Consider a medical and rehabilitative approach to initial treatment in most instances of nontraumatic upper limb injury among individuals with SCI.
(Clinical/epidemiologic evidence--5/6; Ergonomic evidence--NA; Grade of recommendation--D; Strength of panel opinion--Strong)
- Because relative rest of an injured or postsurgical upper limb in SCI is difficult to achieve, strongly consider the following measures:
- Use of resting night splints in carpal tunnel syndrome
(Clinical/epidemiologic evidence--3/4; Ergonomic evidence--NA; Grade of recommendation--C; Strength of panel opinion--Strong)
- Home modifications or additional assistance
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Admission to a medical facility if pain cannot be relieved or if complete rest is indicated
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Place special emphasis on maintaining optimal range of motion during rehabilitation from upper limb injury.
(Clinical/epidemiologic evidence--2; Ergonomic evidence--NA; Grade of recommendation--B; Strength of panel opinion--Strong)
- Consider alternative techniques for activities when upper limb pain or injury is present.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Emphasize that the patient's return to normal activity after an injury or surgery must occur gradually.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Closely monitor the results of treatment, and if the pain is not relieved, continued work-ups and treatment are appropriate.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Consider surgery if the patient has chronic neuromusculoskeletal pain and has failed to regain functional capacity with medical and rehabilitative treatment and if the likelihood of a successful surgical and functional outcome outweighs the likelihood of an unsuccessful procedure.
(Clinical/epidemiologic evidence--5/6; Ergonomic evidence--NA; Grade of recommendation--D; Strength of panel opinion--Strong)
- Operate on upper limb fractures if indicated and when medically feasible.
(Clinical/epidemiologic evidence--6; Ergonomic evidence--NA; Grade of recommendation--D; Strength of panel opinion--Strong)
- Be aware of and plan for the recovery time needed after surgical procedures.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Assess the patient's use of complementary and alternative medicine techniques and beware of possible negative interactions.
(Clinical/epidemiologic evidence--6; Ergonomic evidence--NA; Grade of recommendation--D; Strength of panel opinion--Strong)
Treatment of Chronic Musculoskeletal Pain to Maintain Function
- Because chronic pain related to musculoskeletal disorders is a complex, multidimensional clinical problem, consider the use of an interdisciplinary approach to assessment and treatment planning. Begin treatment with a careful assessment of the following:
- Etiology
- Pain intensity
- Functional capacities
- Psychosocial distress associated with the condition
(Clinical/epidemiologic evidence--1; Ergonomic evidence--NA; Grade of recommendation--A; Strength of panel opinion--Strong)
- Treat chronic pain and associated symptomatology in an interdisciplinary fashion and incorporate multiple modalities based on the constellation of symptoms revealed by the comprehensive assessment.
(Clinical/epidemiologic evidence--1; Ergonomic evidence--NA; Grade of recommendation--A; Strength of panel opinion--Strong)
- Monitor outcomes regularly to maximize the likelihood of providing effective treatment.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
- Encourage manual wheelchair users with chronic upper limb pain to seriously consider use of a power wheelchair.
(Clinical/epidemiologic evidence--5/6; Ergonomic evidence--NA; Grade of recommendation--D; Strength of panel opinion--Strong)
- Monitor psychosocial adjustment to secondary upper limb injuries and provide treatment if necessary.
(Clinical/epidemiologic evidence--None; Ergonomic evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)
Definitions:
Strength of Study Rating Schema (Clinical/Epidemiologic Evidence)
- Systematic review (or meta-analysis) of randomized trials
- Randomized clinical trial (RCT)
- Systematic review (or meta-analysis) of observational studies (case-control, prospective cohort, and similar strong designs)
- Single observational study (case-control, prospective cohort, or similar strong designs)
- Case series, pre-post study, cross-sectional study, or similar design
- Case study, nonsystematic review, or similar very weak design
Strength of Ergonomic Evidence
- Strongly agrees with scientifically validated ergonomic principles
- Somewhat agrees with scientifically validated ergonomic principles
- Not supported by scientifically validated ergonomic principles
Rating Scheme for Strength of Recommendations (Grade of Recommendation)
Level A: Very Strong Support for Recommendation
- Multiple strong randomized controlled trials (RCTs) or a single strong systematic review of RCTs, and
- A great majority of studies in support of the recommendation, and
- Studies using subjects with SCI or results clearly applicable to SCI
Level B: Strong Support for Recommendation
- Single large, strong RCTs or strong systematic review of observational studies or multiple weak RCTs or multiple strong observational studies (case control or cohort) and
- A majority of studies in support of the recommendation and
- Studies using subjects with SCI or results clearly applicable to SCI or
- Strong ergonomic principles support (grade 1)
Level C: Intermediate Support for Recommendation
- Multiple case series, pre-post studies or weak case-control or cohort study or single weak RCT and
- Studies using subjects with SCI or results clearly applicable to SCI, or
- Studies listed under level A or B above, and
- Applicability of studies to SCI unclear or more than just a single study reported contrary findings, or
- Agreement with ergonomics literature somewhat (grade 2)
Level D: Weak Support for Recommendation
- Qualitative reviews, case studies, weak cross-sectional studies or very weak studies of other design and no ergonomic support (grade 3)
In addition, each recommendation has a "strength of panel opinion" rating. Panel members reviewed the literature, discussed recommendations among themselves and with other professional colleagues, reviewed field reviewer comments and suggestions, and based on that information and their clinical experience, independently rated each recommendation on a 1-5 scale, where 1 reflected disagreement and 5 strong agreement. The "strength of panel opinion" rating reflects the mean of the individual panel member ratings.
Levels of Panel Agreement with the Recommendations (Strength of Panel Opinion)
Low - Mean agreement score 1.0 to less than 2.33
Moderate - Mean agreement score 2.33 to less than 3.67
Strong - Mean agreement score 3.67 to 5.0
