Spastic Hand Research Articles

‘Does surgical management of the hand in children with unilateral spastic cerebral palsy affect muscle coordination and quality of reaching?’

SIR–Our recent review on the effect of surgery of the spastic hand of children with cerebral palsy (CP) indicated that only studies with a low level of evidence were available, i.e. series of cases.1 The existing information indicated that surgery seems to have a positive effect on supination and dorsiflexion of the wrist, may improve grip strategy, and may induce an increase of the repertoire of grips and spontaneous use of the hand. The effect of surgery of the spastic hand on muscle coordination had only been addressed by three studies in a relatively systematic way.2–4 Unfortunately, it remained unclear, whether the putatively better hand function was the result of a better positioning of the hand and fingers and/or changes in muscle coordination induced by tendon transfer. Therefore, we started a pilot study in order to obtain insight into changes in muscle coordination and quality of reaching movements after surgical muscle transfers of the upper extremity in adolescents with unilateral CP. We hypothesised that surgery would result in more coordinated and more efficient muscle recruitment, i.e. in lower muscle activation rates, a reduction in recruitment of all arm muscles in concert, and in a temporal coordination which more closely resembles that of typically developing adolescents.4–7 In addition we evaluated whether surgery would result in qualitative improvement of motor behaviour during reaching. Three adolescents with unilateral CP who had surgery for their spastic hand to improve grip strategy and functional use of the paretic hand were studied. Hand posture, movement quality, and muscle coordination during a simple reaching task were assessed preoperatively and three times during the first postoperative year. Six age-matched typically developing adolescents had a single assessment to attain normative electromyography (EMG) data. Surgical procedures and patient characteristics are summarized in Table I.8–10 Postoperative treatment consisted of 5 weeks plaster immobilization, followed by a period of 6 weeks during which a removable splint was worn and intensive occupational therapy was applied. EMG was recorded continuously with bipolar surface electrodes of the following muscles: biceps brachii, triceps brachii, wrist extensors, and wrist flexors. A computer algorithm was used for the detection of phasic muscle activity.11 The analysis focused on (1) muscle activation rate, i.e. percentage of trials during which a muscle was activated; (2) ‘In concert’ muscle activation rate, i.e. percentage of trials during which all muscles were recruited; (3) percentage of trials during which a specific muscle was the ‘prime mover’; (4) onset latency of muscle activation; and (5) sequence of muscle activation: percentage of trials during which the sequence of activation consisted of (a) wrist Extensors, (b) biceps Brachii, and (c) wrist Flexors (EBF-sequence). The participants and their parents gave written informed consent and the procedures were approved by the ethics committee of the University Medical Center in Groningen. The operated hand showed in all three participants at 3 to 12 months postoperatively improvement in hand position and movement quality of wrist and fingers. This finding is in agreement with literature reports.12–15 The EMG-data indicated that surgery did not affect the rate of isolated or in concert muscle recruitment, the nature of the ‘prime mover’, or onset latencies. It did however affect muscle recruitment order: the atypical EBF-recruitment order decreased from 55% prior to surgery to 30%, 10%, and 10% at 3, 6, and 12 months respectively after the operation (Friedman: p=0.04. Fig. 1). Wrist Extensors, biceps Brachii, and wrist Flexors. (EBF)-sequence of non-dominant extremity of typically developing adolescents and adolescents with cerebral palsy pre -and post-operative. The findings of this pilot study suggest that surgery of the spastic hand does not only result in improved hand position, but also in a better quality of wrist and finger movements and a reduction of an atypical recruitment order of arm muscles. The latter may indicate that improved hand position may improve a person’s capacity to select a more efficient strategy out of the motor repertoire.5 Further investigation into the functional consequences of surgery of the spastic hand is highly recommended.

‘User views of Emergency Health Care Plans for disabled children and young people’

Hand function in children with cerebral palsy after upper-limb tendon transfer and muscle release. Dev Med Child Neurol 1998; 40: 612–21. 14. Dahlin LB, Komoto Tufvesson Y, Salgeback S. Surgery of the spastic hand in cerebral palsy. Improvement in stereognosis and hand function after surgery. J Hand Surg 1998; 23: 334–39. 15. Matsuo T, Matsuo A, Hajime T, Fukumoto S, Chen W, Iwamoto Y. Release of flexors and intrinsic muscles for finger spasticity in cerebral palsy. Clin Orthop Relat Res 2001; 384: 162–68.

Test-Retest Reproducibility and Smallest Real Difference of 5 Hand Function Tests in Patients With Stroke

Objective. To investigate the test-retest reproducibility and smallest real difference (SRD) of 3 hand strength tests (grip, palmar pinch, and lateral pinch) and 2 dexterity tests (the Box and Block test [BBT] and the Nine Hole Peg test [NHPT]) in patients with stroke. Methods. The 5 tests were administered on 62 stroke patients in 2 sessions, 3 to 7 days apart. The intraclass correlation coefficient (ICC) was used to determine the level of reproducibility between measurements on 2 sessions. The SRD was used to determine the extent of measurement error because of chance variation in individual patients. SRD percentage (SRD relative to mean score) was used to compare test-retest reliability across tests. We analyzed the group as a whole, then in 2 subgroups (hand spasticity vs none). Results. The test-retest reproducibility of all 5 tests was high for all the patients, with ICCs ranging from 0.85 to 0.98. The SRDs for the more/less affected hand were: 2.9/4.7 kg for the grip test; 1.2/1.3 kg for the palmar pinch test; 1.4/1.0 kg for the lateral pinch test; 5.5/7.8 blocks/minute for the BBT; and 32.8/6.2 seconds for the NHPT. Unacceptably high SRD percentages (>30%) were found for the affected hand using the NHPT (54%), palmar pinch (35%), and lateral pinch (34%). When comparing these indices for participants with spasticity versus none for all 5 tests, the ICCs were lower and the SRD and SRD percentage were higher for the spasticity group. Conclusions. All 5 tests demonstrated satisfactory test-retest reproducibility for a diverse group of patients with stroke. However, all tests showed higher levels of measurement error when performed with the more affected hand and in patients with hypertonicity of that hand. Thus, baseline and postrehabilitation change scores using these common tests of strength and dexterity must be interpreted with some caution, especially in poorly controlled clinical trials. Repeated measures ought to be incorporated to examine reliability within a trial that includes participants with a hypertonic hand.

Tendon transfers for the upper extremity in cerebral palsy

Upper extremity deformities in cerebral palsy are caused by the imbalance between spastic and weak muscles acting on unstable joints. The basic goals of surgical treatment of spastic hands and upper extremities of patients with cerebral palsy can be summarized as reducing the strength of spastic muscles, strengthening the antagonist muscles, and permanent stabilization of unstable joints. Surgical techniques to achieve these goals include lengthening of spastic muscles, tendon transfers, release or plication of the joint capsule, joint arthrodesis, neurectomies, and skin procedures. Amongst these surgical treatment options, this article will present, in more detail, tendon transfers which are performed especially to achieve balance and restore motor functions.

Orthopedic selective spastic control surgery of spastic hands in hemiplegic patients

Orthopedic selective spastic control surgery of spastic hands in hemiplegic patients

A Safeguard for Dual-Energy X-Ray Absorptiometry Measurements After Kyphoplasty

Levy CE, Giuffrida C, Richards L, Wu S, Davis S, Nadeau SE: Botulinum toxin A, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study. Am J Phys Med Rehabil 2007;86:696–706 Objective: To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy. Design: Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upperextremity subtest of the Fugl–Meyer Assessment of Motor Function (FM-UE). Results: Ashworth Scale scores declined from a mean score of 2.0–1.2 (P 0.01). Four of 12 subjects were able to achieve MMC (P 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned. Conclusion: BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect. 696 Am. J. Phys. Med. Rehabil. ● Vol. 86, No. 9 RESEARCH ARTICLE Hemiparesis

Does surgical management of the hand in children with spastic unilateral cerebral palsy affect functional outcome?

The aim of this review was to examine the literature on the effects of surgery of the spastic hand in children with cerebral palsy on functional outcome and muscle coordination. We performed a search of the relevant literature in Medline, Embase, and Biological Abstracts from 1966 to June 2006. The search resulted in eight studies on the effect of surgery on functional outcome and three studies on the effect of surgery on muscle coordination. Heterogeneity in outcome measures precluded meta-analysis. The studies revealed that -- at the level of impairment -- surgery has a positive effect on supination and dorsiflexion of the wrist. At the level of function, surgery might improve grip strategy and induce an increase of the repertoire of grips and spontaneous use of the hand. The evidence for the functional effects is, however, limited. Whether the possibly improved function is mediated by alterations in muscle coordination patterns remains unclear. The muscle coordination studies provided inconclusive results. We concluded that surgery improves the position of the hand and there are indications that it might improve hand function. Future research should address the question: does surgery improve hand function and, if so, is this due solely to a better hand position or does change in muscle coordination play an additional role?

Grip force tracking system for assessment and rehabilitation of hand function

The aim of the paper is to present a novel tracking system for the assessment and training of grip force control. The system consists of two force measuring units of different shapes, which can be connected to a personal computer for visual feedback and data acquisition. We present the results of the assessment of the grip force control in 32 healthy subjects of different age groups and preliminary results obtained in a patient after head-injury who was treated with Botulinum-Toxin for hand spasticity. The proposed tracking system was also applied as a training tool in 10 post-stroke patients to possibly improve their grip force control. The results in healthy subjects showed significant differences in grip force control among different age groups. In the patient after Botulinum-Toxin treatment the method revealed noticeable effects of the therapy on the patient's tracking performance. Training with the tracking system showed considerable improvements in the grip force control in 8 out of 10 stroke patients. The proposed tracking method is aimed to be used in connection with different rehabilitation therapies (e.g. physiotherapy, functional electrical stimulation, drug treatment) to follow the influence of the therapy on patient's muscular strength and grip force control.

Thumb Deformity in the Spastic Hand: Classification and Surgical Techniques

Surgery based on an accurate determination of deforming forces, muscle weakness, and joint instability achieves reasonably predictable results in patients with cerebral palsy. Thumb deformities can be classified into those of mainly intrinsic nature, extrinsic nature, and those of a combined nature. This allows identification of which muscles are released most appropriately and which muscle function requires augmentation. Joint instability needs to be taken into consideration because tendon transfers across unstable joints will be ineffective. The various surgical procedures are outlined in the text. In 32 patients, application of these principles and techniques allowed removal of the thumb from the palm in 29 patients during fist formation. Lateral pinch was established in 26 thumbs, and functional assessment revealed improvement in one functional grade. Functional benefit may be determined by other factors beyond the control of the surgeon. Therefore, the decision to proceed to surgery may be undertaken only after detailed and repeated clinical examinations are conducted that are coordinated with the assessments of parents, caregivers, physicians, occupational and physical therapists, and social counselors.

Spastic hand deformity of cerebral vascular disease

Spastic hand deformity of cerebral vascular disease

Effecten van bewegen van de homolaterale onderarm en knijpen van de heterolaterale hand op de spastische hand, die wordt geopend door middel van elektrostimulatie

The effects of ipsilateral forearm movement and contralateral hand grasp on the spastic hand opened by electrical stimulation [Neurorehabilitation and Neural Repair 2000;14(3)199-205]

The effects of ipsilateral forearm movement and contralateral hand grasp on the spastic hand opened by electrical stimulation.

The purpose of this study was to investigate the effects of ipsilateral arm movement and contralateral hand grasp on the spastic hand opened by open-loop electrical stimulation. The major problem of applying proper electrical stimulation is variable spasticity, the intensity of which changes with posture and movements of other parts of the body. Electrical stimulation was applied to extensor digitorum communis and ulnar nerve to open the affected hand. Different procedures were then used to assess the effects of moving the ipsilateral forearm and contracting the contralateral normal hand. Electrical stimulation opened the spastic hand in more than 95% of trials in all subjects, whether stimulation was applied before or after the movement of the forearm. Moving the ipsilateral forearm did have an effect on opening the hand, and making adjustment of stimulation intensities was necessary in all subjects. The stimulation opened the spastic hand during the contraction of the contralateral normal hand. Electrical stimulation could open the spastic hands most of the time, in the presence of ipsilateral forearm movement and contralateral normal hand contraction. If electrical stimulation was applied before the ipsilateral forearm was moved toward the target, stimulation intensities needed to be adjusted.

Flexor release in patients with spastic hand

Flexor release in patients with spastic hand

4.5 YEAR FOLLOW-UP AFTER SURGICAL CORRECTION OF UPPER EXTREMITY DEFORMITIES IN SPASTIC CEREBRAL PALSY

Reconstructive surgery was carried out on 27 upper extremities in 24 children with deformities due to spastic cerebral palsy. Functional evaluation of the affected extremities was made preoperatively, at 6 months and at a mean of 4.5 years postoperatively using a score added to the assessment system described by the Committee on Spastic Hand Evaluation. According to the score, dysfunction of the arm was significantly reduced 6 months after the reconstructive surgery and the improvements remained essentially unchanged at the later follow-up. The addition of a score to the original assessment system facilitated the overall assessment of postoperative results.

Surgery of the spastic hand in cerebral palsy: Improvement in stereognosis and hand function after surgery

Thirty-six patients with hemiplegic cerebral palsy had surgical treatment for the upper limb and were followed up for 18 months postoperatively. Various operations were done. A striking finding was a significant improvement of stereognosis (ability to describe and recognize objects without vision). Most patients had improvement in different functional grasps following surgical reconstruction. Range of movement in the forearm and wrist also increased in most patients. The thumb-in-palm deformity was completely corrected in 31 of the patients and improved in the other five. Most patients had some or all of their expectations of the procedure fulfilled.

Surgery of the spastic hand in cerebral palsy: improvement of stereognosis after surgery

Surgery of the spastic hand in cerebral palsy: improvement of stereognosis after surgery

Carpectomy and fusion in adult-acquired hand spasticity.

Five adult patients with voluntary hand control, complicated by severe flexion contracture and spasticity secondary to brain injury, underwent subtotal carpectomy and radio-carpal or radio-metacarpal fusion. None of the patients were capable of functional prehension before surgery, and all had difficulty with hygiene due to their deformity. The deformities were beyond the scope of correction with soft tissue release. Two of the patients had previously undergone flexor-pronator origin release, musculo-tendinous lengthening of the wrist and finger flexors, or a combination of both. All five patients progressed to union without complication. Four achieved meaningful gains in functional grasp-release of the hand following the surgery.

後期応答について 正常例と脊椎症例

We recorded late responses from APB and EDB during voluntary contraction with supramaximal electrical stimulation in both normal controls and patients with cervical spondylosis. Late responses which were detected in the silent period had two components in controls. Onset latencies of the first component were 25.3±1.5ms at wrist stimulation. Onset latencies of the second component (voluntary potential, VP) were 48.9±2.2ms at wrist stimulation. Latencies at the end of the silent period were 93.9±7.9ms for wrist stimulation, 77.3±7.4ms for elbow stimulation. Latencies of both components and at the end of the silent period for elbow stimulation were shorter than those for wrist stimulation. These results show that afferent impulses generate both components and the end of silent period. Origin of the first component was alphamotoneuron from its latency. First component should be F wave. Origin of second component of upper limb was unkown. Onset latencies of F waves were 46.2±4.0ms for ankle stimulation. Onset latencies of second component were 69.7±4.4ms for ankle stimulation. Origin of second component in lower limb was not cortex from its latency. In cervical spondylosis VPs could not be elicited in spastic hands.

Influence of sustained stretch on late muscular responses to magnetic brain stimulation in patients with upper motor neuron lesions

Late muscular responses to transcranial magnetic stimulation occur in healthy subjects only in tonically active muscles with a proportional relationship between the amount of the EMG-response and the voluntary innervation strength. In hemiparetic stroke patients late potentials are elicited in chronically spastic hand flexors without voluntary background muscular activity probably reflecting enhanced excitability of spinal alpha-motoneurons in the spastic state. When spastic muscle hypertonus has been diminished by sustained muscle stretch late EMG-potentials are reduced or have disappeared completely. The relation between spastic muscle hypertonus and the late muscular response potentials as well as the possible mechanisms of sustained muscle stretch on the response characteristics to transcranial magnetic stimulation in spastic flexor muscles of the hand are discussed.

Influence of sustained stretch on late muscular responses to magnetic brain stimulation in patients with upper motor neuron lesions

Late muscular responses to transcranial magnetic stimulation occur in healthy subjects only in tonically active muscles with a proportional relationship between the amount of the EMG-response and the voluntary innervation strength. In hemiparetic stroke patients late potentials are elicited in chronically spastic hand flexors without voluntary background muscular activity probably reflecting enhanced excitability of spinal alpha-motoneurons in the spastic state. When spastic muscle hypertonus has been diminished by sustained muscle stretch late EMG-potentials are reduced or have disappeared completely. The relation between spastic muscle hypertonus and the late muscular response potentials as well as the possible mechanisms of sustained muscle stretch on the response characteristics to transcranial magnetic stimulation in spastic flexor muscles of the hand are discussed.