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F - Reaching, Grasping and Manipulation

Figure 4.0 Sites participating in upper limb research Key Clinical Issues: What is Needed for Best Practice? 1. Optimize sensorimotor plasticity in the early phase of injury Little is known about the effect of sensory deprivation of the hand, early post-SCI, and what effect amplification of sensory input might have on recovery. For best practice, in terms of assessment, it is essential to capture palmar sensation on the surface of the hand, and to monitor changes in sensation systematically over the course of rehabilitation. 2. New paradigms for providing sensory stimulation to the hand Opportunities for active exploration of the hand need to be developed and embedded into the therapeutic intervention early on post-injury, coupled with detailed assessment. 3. Training in the application of new therapeutic paradigms Training to implement newer therapy modalities (such as functional electrical stimulation, as an adjunct training technique, during inpatient rehabilitation) to ensure more informed application and to enhance patient outcomes, should be implemented across the country and/or at national meetings where therapists gather to learn new best practices. 4. Restoration and comprehensive management of upper limb spasticity Adequacy of maintaining and restoring upper limb function, as specified in CSCM clinical practice guidelines, should be the gold standard for practice, in all sites across Canada. Particular monitoring of elbow extension should be undertaken, on a routine basis, to ensure adequacy for transfers. 5. Determine minimal clinical important difference (MCID) As MCID often drives length of stay, access to care and clinical decision-making, indicators for MCID should be determined, based on neurological status. Appropriate services, across the continuum of care, should be put in place, including assistive technology to ensure adequacy of therapeutic interventions. Key Research Priorities 1. Determine the metrics of rehabilitation therapy that promote enhanced recovery. Based on the current animal literature, there is controversy about the right time to optimize recovery, as well as the dosage of the intervention to be given. A research focus on the metrics of early intervention needs to be developed to ensure that the right parameters are optimized, at the right times, post-injury. 2. Test new therapeutic approaches with the sub-acute population. For most research, the focus has been directed towards the chronic SCI population, based on the concept that natural recovery has already occurred. Carefully designed studies are required to evaluate interventions which enhance the natural recovery, combined with current standard of care. 3. Develop a model to incorporate and monitor the effects of the upper limb rehabilitation component, in future clinical trials. With the emergence of new, basic science approaches to promote neurorecovery, a model is needed to account for the rehabilitation component when assessing primary and secondary outcomes, longitudinally. 72 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


F - Reaching, Grasping and Manipulation
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