Finger Extension Research Articles

Approach to the Pan-brachial Plexus Injury: Variation in Surgical Strategies among Surgeons

Background:Treatment of pan-brachial plexus injuries has evolved significantly over the past 2 decades, with refinement and introduction of new surgical techniques, particularly free functional muscle transfer. The extent to which contemporary brachial plexus surgeons utilize various techniques as part of their treatment algorithm for pan-plexus injuries and the rationale underlying these choices remain largely unknown.Methods:A case scenario was posed to 12 brachial plexus surgeons during semi-structured qualitative interviews. The case involved a young patient presenting 6 weeks after a pan-plexus injury from a motorcycle accident. Surgeons were asked to formulate a treatment plan. Inductive thematic analysis was used to identify commonalities and variation in approach to treatment.Results:For shoulder function, the majority of surgeons would graft from a viable C5 nerve root, if possible, though the chosen target varied. Two-thirds of the surgeons would address elbow flexion with nerve transfers, though half would combine this with a free functional muscle transfer to increase elbow flexion strength. Free functional muscle transfer was the technique of choice to restore finger flexion. Finger extension, intrinsic function, and sensation were not prioritized.Conclusions:Our study sheds light on current trends in the approach to pan-plexus injuries in the U.S. and identifies areas of variability that would benefit from future study. The optimal shoulder target and the role for grafting to the MCN for elbow flexion merit further investigation. The role of FFMT plays an increasingly prominent role in treatment algorithms.

Nerves transfers for functional hand recovery in traumatic lower brachial plexopathy.

Background: Distal nerve transfers are an innovative modality for the treatment of C8-T1 brachial plexus lesions. The purpose of this case series is to report the authors’ results with hand restoration function by nerve transfer in patients with lower brachial plexus injury.Methods: Three consecutive nerve transfers were performed in a series of 11 patients to restore hand function after injury to the lower brachial plexus: brachialis motor branch to anterior interosseous nerve (AIN) and supinator branch to the posterior interosseous nerve (PIN) in a first surgical procedure, and AIN to pronator quadratus branch of ulnar nerve between 4 and 6 months later.Results: In all, 11 male patients underwent 33 surgical procedures. Time between brachial plexus injury and surgery was a mean of 11 months (range 4–13 months). Postoperative follow-up ranged from 12 to 24 months. We observed recovery of M3 or better finger flexion strength (AIN) and wrist extension (PIN) in 8 of the 11 surgically treated upper limbs. These patients recovered full thumb and finger extension between 6 and 12 months of surgery, without significant loss of donor function.Conclusion: Nerve transfers represent a way of restoring volitional control of upper extremity function in patients with C8-T1 brachial plexus injury.

Drop Foot Secondary to a Peroneal Intraneural Ganglion Connected to the Superior Tibiofibular Joint: A Case Report

AbstractPeroneal neuropathy is the most frequent mononeuropathy of the lower extremity. Intraneural ganglion cysts (INGCs) are among rare causes of peroneal nerve palsy. According to the articular (synovial) theory, the articular branch plays the key role in the pathogenesis. Patients present with pain around the fibular head and neck, motor weakness resulting in foot drop and paresthesia in the anterolateral calf and foot. Ultrasonography (US) and MRI are both useful in the diagnosis, but MRI is the best imaging modality in the demonstration of the articular connection and the relation of the cyst with adjacent structures, even without special neurography sequences. We present a 32-year-old male patient referred to our neurosurgery clinic with suspicion of lumbar radiculopathy. He presented with right foot drop which began 3 weeks prior. On examination, there was 90% loss in the ankle dorsiflexion and finger extension. Ankle eversion was also weakened. There was no low back or posterolateral thigh pain to suggest L5 radiculopathy and sciatic neuropathy. Following negative lumbar spine MRI, peripheral neuropathy was concerned. Electrodiagnostic evaluations findings were consistent with acute/subacute common peroneal nerve (CPN) axonal neuropathy. Subsequent MRI of knee showed a homogeneous, thin-walled tubular cystic lesion, extending along the course of the CPN and its articular branch. Full recovery of the neuropathy was achieved with early diagnosis and decompression via microsurgical epineurotomy. The diagnosis of INGC was confirmed by histopathologic examination. INGCs, although rare, should also be considered in the differential diagnosis of peripheral mononeuropathies.

Structure of Population Activity in Primary Motor Cortex for Single Finger Flexion and Extension.

How is the primary motor cortex (M1) organized to control fine finger movements? We investigated the population activity in M1 for single finger flexion and extension, using 7T functional magnetic resonance imaging (fMRI) in female and male human participants and compared these results to the neural spiking patterns recorded in two male monkeys performing the identical task. fMRI activity patterns were distinct for movements of different fingers, but were quite similar for flexion and extension of the same finger. In contrast, spiking patterns in monkeys were quite distinct for both fingers and directions, which is similar to what was found for muscular activity patterns. The discrepancy between fMRI and electrophysiological measurements can be explained by two (non-mutually exclusive) characteristics of the organization of finger flexion and extension movements. Given that fMRI reflects predominantly input and recurrent activity, the results can be explained by an architecture in which neural populations that control flexion or extension of the same finger produce distinct outputs, but interact tightly with each other and receive similar inputs. Additionally, neurons tuned to different movement directions for the same finger (or combination of fingers) may cluster closely together, while neurons that control different finger combinations may be more spatially separated. When measuring this organization with fMRI at a coarse spatial scale, the activity patterns for flexion and extension of the same finger would appear very similar. Overall, we suggest that the discrepancy between fMRI and electrophysiological measurements provides new insights into the general organization of fine finger movements in M1.SIGNIFICANCE STATEMENT The primary motor cortex (M1) is important for producing individuated finger movements. Recent evidence shows that movements that commonly co-occur are associated with more similar activity patterns in M1. Flexion and extension of the same finger, which never co-occur, should therefore be associated with distinct representations. However, using carefully controlled experiments and multivariate analyses, we demonstrate that human fMRI activity patterns for flexion or extension of the same finger are highly similar. In contrast, spiking patterns measured in monkey M1 are clearly distinct. This suggests that populations controlling opposite movements of the same finger, while producing distinct outputs, may cluster together and share inputs and local processing. These results provide testable hypotheses about the organization of hand control in M1.

SOME WORDS ABOUT FRACTURES OF RADIAL HEAD

A visible posterior fat pad on the lateral view of the elbow is a sign of occult intraarticular pathology.
 Early elbow ROM is needed to prevent stiffness. If you fixed the fracture, but not well enough to move the elbow, you did not fix it.
 The “safe zone” for placing hardware on the radial head lies in the interval between the radial styloid and Lister’s tubercle.
 Examine the wrist when examining all elbow injuries; a radial head fracture may be accompanied by a tear of the interosseous membrane and disruption of the distal radioulnar joint.
 The posterior interosseous nerve (controlling finger and wrist extension) can be damaged by a radial head injury or by the surgery performed to treat the fracture. Therefore, document functional status preoperatively. The severity of these injuries runs the gamut from minimally displaced fractures needing minimal treatment to those with major displacement or comminution, requiring surgical fixation, excision, or replacement.

Comprehensive Respiratory Muscle Training Improves Pulmonary Function and Respiratory Muscle Strength in Acute Stroke Patients.

To evaluate the effects of respiratory muscle training (RMT) on pulmonary function, respiratory complications, and stroke-related disabilities in patients with acute stroke. One hundred twenty-two subjects with stroke admitted to the stroke rehabilitation center of Inje Hospital between August 2016 and May 2018 were recruited. After the initial exclusion, the remaining patients were assigned to the RMT group (36 patients) or the standard rehabilitation (SR) group (28 patients who did not undergo RMT). A total of 44 patients completed the study, with 22 patients in each group. The RMT program consisted of air-stacking exercise, manually assisted coughing, inspiratory and expiratory muscle strengthening, cough exercises, and respiratory reeducation. Pulmonary function and respiratory muscle strength were evaluated before commencement and after 1 mo of RMT. The Functional Ambulation Category score, Korean version of the Modified Barthel Index, Shoulder Abduction and Finger Extension score, and handgrip power were assessed. The incidence of pneumonia was also evaluated. Both pulmonary function and respiratory muscle strength significantly improved in both groups. However, differences (%) in the RMT group was greater for all parameters of pulmonary function and respiratory muscle strength. Respiratory complications at 1 yr were significantly lower in the RMT group (P = .016). Four weeks of comprehensive RMT in patients with acute stroke resulted in significantly greater improvements in both pulmonary function and respiratory muscle strength than SR. Therefore, RMT has the potential to reduce post-stroke respiratory complications.

Distal Arthrogryposis in Newborn: Clinical Case

Background. Arthrogryposis is severe congenital musculoskeletal disease with contractures of two or more joints of the lower and/or upper limbs and usually in combination with muscular hypo- or atrophy.Clinical Case Description. Child F. was hospitalized in the department of newborns and premature babies’ pathology on 6th day of life in critical condition. Spontaneous motor activity was severely decreased. He responds to the examination with little increase in motor activity and weak painful scream. Muscle tone is dystonic: it is diffusely reduced in the proximal parts of the upper and lower limbs, in the distal parts of the upper limbs it is significantly increased, there are flexion contractures of the fingers on both hands (mostly on the left one). Passive fingers contractures reversal is difficult. There were no feet deformities or craniofacial anomalies. Hereditary history is burdened: child’s father (1984 year of birth), great-grandfather and cousin uncle (on the paternal line) have finger deformities on both hands. Father and relatives have not been diagnosed before. The clinical diagnosis was established after consultation of geneticist and orthopedist: «Distal arthrogryposis, type 2A, autosomal dominant type of inheritance with incomplete penetrance». The molecular genetic testing was not performed due to the refusal of the child's parents. Therapeutic gymnastics, stage plaster correction of finger contractures were performed in the department during the child hospitalization (21 days). Positive dynamics was noted: finger extension amplitude has increased.Conclusion. Early conservative treatment of infants with arthrogryposis allows to correct musculoskeletal deformities. Early initiation of treatment is expected to increase the amplitude of both passive and active movements in the hand joints, whereas, it will improve the function of hand grasping and self-care capacities of patients.

Functional Electrical Stimulation for Upper Limbs Flexion-Extension and Prehension Movements in Rehabilitation

Functional Electrical Stimulation (FES), is a tecnique that uses low-energy electrical pulses to artificially generate muscle contractions, in individuals with damages regarding the central nervous system. The application of FES in clinical environment involves both patients care and rehabilitation. Aim of this work is to introduce a clinical FES protocol for upper limbs rehabilitation, in order to assist and train the execution of complex movement, such as flexion- extension of wrist and fingers and palmar prehension. The new FES protocol has been tested on a cohort of five subjects with different upper limb neuromotor deficits, during their rehabilitation. The benefits deriving from the application of the new FES protocol have been evaluated by comparing specific quantitative electromyographic parameters assessed before and after the treatment. Results show effective improvements in performances of 4 patients out of 5.

Functional Electrical Stimulation for Upper Limbs Flexion-Extension and Prehension Movements in Rehabilitation

Functional Electrical Stimulation (FES), is a tecnique that uses low-energy electrical pulses to artificially generatemuscle contractions, in individuals with damages regarding the central nervous system. The application of FES inclinical environment involves both patients care and rehabilitation. Aim of this work is to introduce a clinical FESprotocol for upper limbs rehabilitation, in order to assist and train the execution of complex movement, such asflexion- extension of wrist and fingers and palmar prehension. The new FES protocol has been tested on a cohort offive subjects with different upper limb neuromotor deficits, during their rehabilitation. The benefits deriving from theapplication of the new FES protocol have been evaluated by comparing specific quantitative electromyographic parameters assessed before and after the treatment. Results show effective improvements in performances of 4 patientsout of 5.

Functional Electrical Stimulation for Upper Limbs Flexion-Extension and Prehension Movements in Rehabilitation

Functional Electrical Stimulation (FES), is a tecnique that uses low-energy electrical pulses to artificially generate muscle contractions, in individuals with damages regarding the central nervous system. The application of FES in clinical environment involves both patients care and rehabilitation. Aim of this work is to introduce a clinical FES protocol for upper limbs rehabilitation, in order to assist and train the execution of complex movement, such as flexion- extension of wrist and fingers and palmar prehension. The new FES protocol has been tested on a cohort of five subjects with different upper limb neuromotor deficits, during their rehabilitation. The benefits deriving from the application of the new FES protocol have been evaluated by comparing specific quantitative electromyographic parameters assessed before and after the treatment. Results show effective improvements in performances of 4 patients out of 5.

Intraneural perineurioma of the radial nerve in the spiral canal as the cause of a 6-year progressive paresis of hand and finger extension

Intraneural perineurioma of the radial nerve in the spiral canal as the cause of a 6-year progressive paresis of hand and finger extension

Multiple Huge Tendinous Xanthomas with Normal Lipid Profiles in All Extremities

Xanthomas are grayish-yellow masses composed of lipid-filled foamy histiocytes and are usually accompanied by familial hypercholesterolemia or some other disease associated with dysfunctional lipid metabolism. Here, we report a case of multiple huge tendinous xanthomas with normal lipid profiles involving all extremities. These masses were large enough to cause pain, dysfunction of extremities, and cosmetic compromise and the condition was accompanied by cerebrotendinous xanthomatosis. Due to the presence of many masses in all extremities, a two-stage operation was planned with a time gap of several months. At 1-month follow-up visits after first and second surgeries, although extension of the left middle finger was poor as a result of sacrificing the 3rd extensor digitorum communis tendon, no problems such as wound dehiscence, hematoma formation, or infection at operative sites were noted.

Characterizing upper extremity motor behavior in the first week after stroke.

BackgroundAnimal models of brain recovery identify the first days after lesioning as a time of great flux in sensorimotor function and physiology. After rodent motor system lesioning, daily skill training in the less affected forelimb reduces skill acquisition in the more affected forelimb. We asked whether spontaneous human motor behaviors of the less affected upper extremity (UE) early after stroke resemble the animal training model, with the potential to suppress clinical recovery.MethodsThis prospective observational study used a convenience sample of patients (n = 25, mean 4.5 ±1.8) days after stroke with a wide severity range; Controls were hospitalized for non-neurological conditions (n = 12). Outcome measures were Accelerometry, Upper-Extremity Fugl-Meyer (UEFM), Action Research Arm Test (ARAT), Shoulder Abduction/ Finger Extension Test (SAFE), NIH Stroke Scale (NIHSS).ResultsAccelerometry indicated total paretic UE movement was reduced compared to controls, primarily due to a 44% reduction of bilateral UE use. Unilateral paretic movement was unchanged. Thus, movement shifted early after stroke; bilateral use was reduced and unilateral use of the non-paretic UE was increased by 77%. Low correlations between movement time and motor performance prompted an exploratory factor analysis (EFA) revealing a 2-component solution; motor performance tests load on one component (motor performance) whereas accelerometry-derived variables load on a second orthogonal component (quantity of movement).ConclusionsEarly after stroke, spontaneous overall UE movement is reduced, and movement shifts to unilateral use of the non-paretic UE. Two mechanisms that could influence motor recovery may already be in place 4.5 ± 1.8 days post stroke: (1) the overuse of the less affected UE, which could set the stage for learned non-use and (2) skill acquisition in the non-paretic limb that could impede recovery. Accurate UE motor assessment requires two independent constructs: motor performance and quantity of movement. These findings provide opportunities and measurement methods for studies to develop new behaviorally-based stroke recovery treatments that begin early after onset.

A User-Driven Wearable Hand Robot for Functional Task Training After Stroke

Abstract Date Presented 03/27/20 Regaining adequate hand function for participation is a challenge for many stroke survivors. Eleven participants completed 12 grasp, transport, and release training sessions with a user-driven hand robot that provides active-assist for finger extension. Mean gain of 2.63 points (P = .03) on the Fugl-Meyer was observed, with most gains in the distal subscale (2.27 points, P < .001). This intervention is a promising adjunct to conventional therapy to promote typical grasp patterns and functional use. Primary Author and Speaker: Sangwoo Park Additional Authors and Speakers: Daniel Geller Contributing Authors: Sangwoo Park, Lynne Weber, Cassie Meeker, Lauri Bishop, Joel Stein, Matei Ciocarlie

The influence of skin tears following collagenase treatment of Dupuytren's disease on treatment outcomes.

This study investigated influence of skin tears on patient-reported outcomes of injection of collagenase clostridium histolyticum for Dupuytren's disease and association between extension deficit of digits before injection and skin tear after the injection. From 2016 to 2018, 391 Dupuytren's cords were treated in 184 patients in a prospective cohort study and the patients were evaluated before injection and six months after injection. Skin tears occurred in 50% of these patients. We found no significant differences in the patient-reported outcomes between patients with or without skin tears. A higher extension deficit before treatment was associated with significantly increased frequency of skin tears. We conclude that the incidence of skin tears after injection does not affect patient reported outcomes six months after collagenase injection, but the incidence of skin tears is significantly associated with the severity of pre-treatment finger extension deficits.Level of evidence: II.

Lesion Topography Impact on Shoulder Abduction and Finger Extension Following Left and Right Hemispheric Stroke.

The existence of shoulder abduction and finger extension movement capacity shortly after stroke onset is an important prognostic factor, indicating favorable functional outcomes for the hemiparetic upper limb (HUL). Here, we asked whether variation in lesion topography affects these two movements similarly or distinctly and whether lesion impact is similar or distinct for left and right hemisphere damage. Shoulder abduction and finger extension movements were examined in 77 chronic post-stroke patients using relevant items of the Fugl-Meyer test. Lesion effects were analyzed separately for left and right hemispheric damage patient groups, using voxel-based lesion-symptom mapping. In the left hemispheric damage group, shoulder abduction and finger extension were affected only by damage to the corticospinal tract in its passage through the corona radiata. In contrast, following the right hemispheric damage, these two movements were affected not only by corticospinal tract damage but also by damage to white matter association tracts, the putamen, and the insular cortex. In both groups, voxel clusters have been found where damage affected shoulder abduction and also finger extension, along with voxels where damage affected only one of the two movements. The capacity to execute shoulder abduction and finger extension movements following stroke is affected significantly by damage to shared and distinct voxels in the corticospinal tract in left-hemispheric damage patients and by damage to shared and distinct voxels in a larger array of cortical and subcortical regions in right hemispheric damage patients.

Изменение ЭЭГ в частотном диапазоне α-ритма у детей с детским церебральным параличом при применении роботизированной терапии

It was demonstrated previously that neurorehabilitation with the BCI-controlled robotic device Exohand-2 combined with conventional therapeutic modalities resulted in significant motor improvement in children with cerebral palsy. However, EEG records were not analyzed in the previous study. The aim of this paper was to describe the reactivity patterns of the EEG α-rhythm during a series of 10 BCI-based neurorehabilitation sessions. The study was carried out in 32 boys and girls aged 10 to 18 years with right- or left-side hemiparesis. EEG was recorded from 21 electrodes at rest and during kinesthetic imagery of finger extension. During the first session, patterns of α-rhythm reactivity during motor imagery differed between patients with left- and right-side hemiparesis. The differences were statistically significant at Р2 during left hand movement rehearsal (F1, 30 = 5.10; p < 0.05). During the final session, the pattern of α-rhythm reactivity was different: synchronization was taken over by desynchronization at some electrode sites, suggesting increased activity of the neocortex. The most conspicuous EEG changes were observed in children with left-side hemiparesis (F20, 300 = 1.84; p < 0.05). By the end of the rehabilitation course, the differences between patients with left-and right-side hemiparesis became much less pronounced. Rearrangements in the EEG patterns in the α-frequency band can be regarded as signs of beneficial reorganization of neural circuits responsible for planning and executing complex hand movements.

Cortical Activation During Shoulder and Finger Movements in Healthy Adults: A Functional Near-Infrared Spectroscopy (fNIRS) Study.

Characterization of cortical activation patterns during movement of the upper extremity in healthy adults is helpful in understanding recovery mechanisms following neurological disorders. This study explores cortical activation patterns associated with movements of the shoulder and fingers in healthy adults using functional near-infrared spectroscopy (fNIRS). Twelve healthy right-handed participants were recruited. Two motor tasks (shoulder abduction and finger extension) with two different trial lengths (10 s and 20 s) were performed in a sitting position at a rate of 0.5 Hz. The hemodynamic response, as indicated by oxy-hemoglobin (HbO) and deoxy-hemoglobin (HbR), over both hemispheres was acquired using a 54-channel fNIRS system. We found a generalized bilateral cortical activation during both motor tasks with greater activation in the contralateral compared to the ipsilateral primary motor cortex. Particularly in the more medial part of the contralateral hemisphere, significant higher activation was found during the shoulder compared to finger movements. Furthermore, cortical activation patterns are affected not only by motor tasks but also by trial lengths. HbO is more sensitive to detect cortical activation during finger movements in longer trials, while HbR is a better surrogate to capture active areas during shoulder movement in shorter trials. Based on these findings, reporting both HbO and HbR is strongly recommended for future fNIRS studies, and trial lengths should be taken into account when designing experiments and explaining results. Our findings demonstrating distinct cortical activation patterns associated with shoulder and finger movements in healthy adults provide a foundation for future research to study recovery mechanisms following neurological disorders.

Brain-Machine Neurofeedback: Robotics or Electrical Stimulation?

Neurotechnology such as brain-machine interfaces (BMI) are currently being investigated as training devices for neurorehabilitation, when active movements are no longer possible. When the hand is paralyzed following a stroke for example, a robotic orthosis, functional electrical stimulation (FES) or their combination may provide movement assistance; i.e., the corresponding sensory and proprioceptive neurofeedback is given contingent to the movement intention or imagination, thereby closing the sensorimotor loop. Controlling these devices may be challenging or even frustrating. Direct comparisons between these two feedback modalities (robotics vs. FES) with regard to the workload they pose for the user are, however, missing. Twenty healthy subjects controlled a BMI by kinesthetic motor imagery of finger extension. Motor imagery-related sensorimotor desynchronization in the EEG beta frequency-band (17–21 Hz) was turned into passive opening of the contralateral hand by a robotic orthosis or FES in a randomized, cross-over block design. Mental demand, physical demand, temporal demand, performance, effort, and frustration level were captured with the NASA Task Load Index (NASA-TLX) questionnaire by comparing these workload components to each other (weights), evaluating them individually (ratings), and estimating the respective combinations (adjusted workload ratings). The findings were compared to the task-related aspects of active hand movement with EMG feedback. Furthermore, both feedback modalities were compared with regard to their BMI performance. Robotic and FES feedback had similar workloads when weighting and rating the different components. For both robotics and FES, mental demand was the most relevant component, and higher than during active movement with EMG feedback. The FES task led to significantly more physical (p = 0.0368) and less temporal demand (p = 0.0403) than the robotic task in the adjusted workload ratings. Notably, the FES task showed a physical demand 2.67 times closer to the EMG task, but a mental demand 6.79 times closer to the robotic task. On average, significantly more onsets were reached during the robotic as compared to the FES task (17.22 onsets, SD = 3.02 vs. 16.46, SD = 2.94 out of 20 opportunities; p = 0.016), even though there were no significant differences between the BMI classification accuracies of the conditions (p = 0.806; CI = −0.027 to −0.034). These findings may inform the design of neurorehabilitation interfaces toward human-centered hardware for a more natural bidirectional interaction and acceptance by the user.

Dexterous Force Estimation during Finger Flexion and Extension Using Motor Unit Discharge Information.

With the development of advanced robotic hands, a reliable neural-machine interface is essential to take full advantage of the functional dexterity of the robots. In this preliminary study, we developed a novel method to estimate isometric forces of individual fingers continuously and concurrently during dexterous finger flexion and extension. Specifically, motor unit (MU) discharge activity was extracted from the surface high-density electromyogram (EMG) signals recorded from the finger extensors and flexors, respectively. The MU information was separated into different groups to be associated with the flexion or extension of individual fingers and was then used to predict individual finger forces during multi-finger flexion and extension tasks. Compared with the conventional EMG amplitude-based method, our method can obtain a better force estimation performance (a higher correlation and a smaller estimation error between the predicted and the measured force) when a linear regression model was used. Further exploration of our method can potentially provide a robust neural-machine interface for intuitive control of robotic hands.