The Therapist’s Role in Upper Limb Surgical Planning for Tetraplegia

Written by: Danielle Wilt, OTD, OTR/L

VHSF Fellow ‘24/’25

The decision to undergo restorative surgery is a pivotal moment for persons living with tetraplegia. Regaining hand function is frequently cited as one of the top priorities, and can be life-changing, offering a level of independence not otherwise available (Wagner et al., 2007).

While the surgeon performs the procedure, the therapist plays a important role in preparing the patient for surgery and guiding team decision making. A detailed assessment and thoughtful planning ensure that the surgical interventions align with the patient’s real-world needs and resources, optimizing chances of success.

Below is a breakdown of the therapist’s critical role in surgical planning and decision-making for restorative surgery in the tetraplegic upper limb.

Initial Assessment: A Foundation for Success

1.        Functional Assessment and Identification of Patient Goals

The first step is a deep dive into the patient’s current level of function and future goals.

·      Current Functional Level: A thorough assessment of daily activities provides insights into areas in which the patient currently receives assistance and opportunities to maximize independence.

·      Fine Motor Function: How is the patient currently using their hands? What prehension patterns do they have available and are they achieved through passive tenodesis or active movement?

·      Goals for Grasp and Pinch vs Refined Movement: For patients with absent or compensatory hand function through passive tenodesis, nerve and tendon transfers offer recovery of active finger motion and improved strength. Isolated digit control and manipulative skills would not be a realistic expectation.

2.        Strength Assessment: Identifying Needs and Potential Donors

Detailed strength assessment is critical for mapping out potential donors and identifying needs. The International Classification for Surgery of the Hand in Tetraplegia (ICSHT) is often used as a reference guide for identifying potential donor muscles based on preserved muscle function. When combined with key muscles from the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), as well as other key muscles contributing to upper limb function, clinicians gain a comprehensive profile supporting surgical planning (Bryden et al., 2018)

·      Potential Donors: Muscles most be strong enough (at least MRC grade 4) to take on a new role, and redundant motor strength must be confirmed to avoid creating functional deficits. This can be done through isolated muscle testing, palpation, or in more complex cases, more invasive testing, such as EMG or diagnostic blocks, may be necessary.

·      Potential Recipients: These are muscles that have little or no activation, representing the function that needs to be restored.

·      Passive Mobility: Limitations in range of motion and joint contractures may need to be addressed, either conservatively or surgically, or they may impede functional outcomes (Fridén & Gohritz, 2015).

Common Surgical Interventions in Tetraplegia

A combination of nerve and tendon transfers may be considered based on clinical assessment and patient goals in order to reanimate the upper limb, and may be completed as a single surgery or staged-approach (Dunn et al., 2016; van Zyl et al., 2019).

Target Function	Nerve Transfers	Tendon Transfers
Elbow flexion	Spinal accessory to musculocutaneous
Elbow extension	Posterior axillary to radial (triceps)	Posterior deltoid to triceps Biceps to triceps
Wrist extension	Brachialis to ECRB	BR to ECRB
Hand closing	Brachialis to AIN Supinator to AIN	ECRL to FDP
Hand opening	Supinator to PIN	PT to EDC *EDC tenodesis (passive opening)
Pinch	Brachialis to AIN	BR to FPL

3.        Differentiating Upper Motor Neuron and Lower Motor Neuron Lesions

The neurologic presentation dictates the type of surgery and its urgency when considering nerve transfers, and a patient may present with UMN, LMN or combined presentation throughout the upper limb. Denervation is most commonly seen at the level of injury and 1-2 levels above and/or below the injury (Bryden et al., 2018)

Key features of each presentation can provide valuable insight. The therapist is uniquely suited for assessment using surface electrical stimulation.

·      Upper Motor Neuron Injuries (UMN): Increased spasticity, exaggerated reflexes, atrophy may be minimal due to voluntary control or spasticity or occurs more slowly, over time due to disuse. Strong response to NMES with tetanic contraction and movement through the range of motion suggests intact LMN pathways.

·      Lower Motor Neuron Injuries (LMN): Flaccid paralysis, decreased or absent reflexes, denervation atrophy occurring more rapidly and pronounced. No response to NMES is suggestive of denervation injury and can be confirmed via EMG or intraoperative stimulation.

In the case of LMN injury to a given muscle, nerve transfers are ideally completed between 6-9 months, not more than 12 months post injury (Crowe et al., 2025). In the case of UMN injury, nerve transfers may be completed in a delayed fashion without time sensitivity. Tendon transfers are not time sensitive and are generally delayed until individuals have maximized spontaneous recovery. However, as noted, optimal outcomes are dependent on preserved joint mobility (Dunn et al., 2016).

4.        Psychosocial Factors: Predicting Success

Restorative surgery and subsequent recovery are a marathon, requiring time and commitment from patients and caregivers. The therapist assesses non-physical factors that predict successful follow-through with post-operative care and rehabilitation. Where barriers are identified, these can often be addressed pre-operatively to mitigate challenges post-operatively.

·      Support system: What is the patient’s current living situation? Will there be reliable caregiver support during the necessary period of immobilization or restriction?

·      Transportation: Is reliable transportation available to ensure consistence attendance at therapy for the necessary duration?

·      History of Compliance: Do they have a history of non-compliance with medical or rehab recommendations – specifically, attendance, splint wearing?

·      Wound history: Active skin breakdown may interfere with positioning or participation in postoperative therapy. Chronic skin issues may be suggestive of difficulty healing and should be considered.

·      Cognitive Status: Does that patient have the capacity to follow through with recommendations or for complex motor learning/re-training?

Patient Education: Setting Realistic Expectations

The therapist can assist with ensuring that the patient’s stated goals align with the expected functional outcomes of the proposed surgery.

Pre-operative Planning: Preparing for the Transition

Time leading up to the surgery is spent optimizing the patient’s current functional independence and preparing the environment for the post-op restrictions.

·      Functional Training: Individuals and caregivers are trained on how to manage daily tasks using compensatory strategies or assistive devices before the surgery. This ensures independence is optimized during immobilization.

·      Equipment Optimizations: This may include obtaining necessary splints and assistive devices, or modification to the wheelchair to ensure adherence to post-operative restrictions.

·      Strengthening: In some scenarios, patients may benefit from strengthening of donor muscles prior to moving forward with surgery in order to maximize surgical outcomes.

·      Post-op Protocol Education: The therapist clearly reviews the expected protocol and expectations including:

o   Immobilization or restrictions and expected timeframe

o   Rehabilitation commitment and timeline

Generalized Post-Operative Timelines

	Nerve Transfers	Tendon Transfers
Immobilization	Typically 3 weeks Supportive wound care Edema management Splint at all times	0-3 weeks (may be less) Supportive wound care Edema management Splint at all times
Early Mobilization	3 weeks-6+months Prior to signs of reinnervation Donor strengthening Synergy pattern training Scar management D/c splint, no restrictions **initial training, then interval monitoring	1-6 weeks Tendon gliding Progressive unresisted AROM Synergy pattern training Scar management Splint on except for therapy/home exercises **ongoing therapy
Active Mobilization	Begins after motor reinnervation occurs Progressive strengthening **initiate more intensive therapy	Begins around 6-8 weeks Full AROM Progressive resistance Progressively wean splint to nighttime **continue ongoing therapy
Recovery Timeline	May take up to 1 year to see trace contractions Functional strength may not occur until 2+ years post-op	May reach full strength as early as 3 months, up to 1-year, post-op
Limitations	Risk for partial or no reinnervation	Risk for adhesions Risk for attenuation over time

Wrap-Up

In summary, the therapist’s contribution to restorative surgery in tetraplegia extends beyond post-operative care. By mastering key assessment elements, including assessing donor viability, distinguishing between UMN and LMN presentations, aligning functional goals with surgical outcomes, and comprehensively assessing and intervening on psychosocial barriers, the rehab professional serves as a clinical consultant. This detailed, multidisciplinary approach in the pre-operative phase in not merely supportive – it is essential for optimizing candidate selection, mitigating risks, and ensuring the highest possible functional outcomes.

References

Bryden, A., Kilgore, K. L., & Nemunaitis, G. A. (2018). Advanced Assessment of the Upper Limb in Tetraplegia: A Three-Tiered Approach to Characterizing Paralysis. Topics in spinal cord injury rehabilitation, 24(3), 206–216.

Dunn, J. A., Sinnott, K. A., Rothwell, A. G., Mohammed, K. D., & Simcock, J. W. (2016). Tendon Transfer Surgery for People With Tetraplegia: An Overview. Archives of physical medicine and rehabilitation, 97(6 Suppl), S75–S80.

Dunn, J. A., Koch-Borner, S., Johanson, M. E., & Wangdell, J. (2021). Toward Consensus in Assessing Upper Limb Muscle Strength and Pinch and Grip Strength in People With Tetraplegia Having Upper Limb Reconstructions. Topics in spinal cord injury rehabilitation, 27(3), 70–82.

Crowe, C. S., Liu, Y. K., Curtin, C. M., Hentz, V. R., Kozin, S. H., Fox, I. K., & Berger, M. J. (2025). Surgical Strategies for Functional Upper Extremity Reconstruction After Spinal Cord Injury. Muscle & nerve, 71(5), 802–815.

Fridén, J., & Gohritz, A. (2015). Tetraplegia Management Update. The Journal of hand surgery, 40(12), 2489–2500.

Hill, J. L., Turner, L. C., Jones, R. D., et al. (2019). The stages of rehabilitation following motor nerve transfer surgery. Journal of Musculoskeletal Surgery and Research, 3, 60.

Hentz, V. R., & Le Clercq, C. (2002). Surgical rehabilitation of the upper limb in tetraplegia. W.B. Saunders.

Kahn, L. C., Stonner, M. M., & Dy, C. J. (2024). Key Considerations for Nerve Transfer Rehabilitation After Surgical Reconstruction for Brachial Plexus and Peripheral Nerve Injuries. The Journal of hand surgery, 49(2), 160–168.

Wangdell, J., Bunketorp-Käll, L., Koch-Borner, S., & Fridén, J. (2016). Early Active Rehabilitation After Grip Reconstructive Surgery in Tetraplegia. Archives of physical medicine and rehabilitation, 97(6 Suppl), S117–S125.

Wagner, J. P., Curtin, C. M., Gater, D. R., & Chung, K. C. (2007). Perceptions of people with tetraplegia regarding surgery to improve upper-extremity function. The Journal of hand surgery, 32(4), 483–490.

van Zyl, N., Hill, B., Cooper, C., Hahn, J., & Galea, M. P. (2019). Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series. Lancet (London, England), 394(10198), 565–575.