Flexor Carpi Research Articles

Effects of Blood Flow Restricted Exercise on Electromechanical Delay and Time to Peak Force after Task Failure: A Randomized Crossover Trial

Introduction: Electromechanical delay (ED) and time to peak force (TPF) could be used to investigate the central or peripheral sources of performance decline in fatiguing tasks. Exercise with partial blood flow restriction (BFR) has been shown to induce fatigue, but the repercussions of exercise with partial BFR on ED and TPF are unclear. The present study aimed to compare the ED and TPF after an intermittent isometric task until failure with BFR and free blood flow (FBF). Methods: In this crossover randomized clinical trial, 15 healthy and physically active men volunteered in this study. Volunteers performed two intermittent isometric handgrip exercise (IIHE) to failure (72 h apart), combined with either BFR or FBF. Maximum voluntary isometric force (MVIF) concomitant with the electromyographic activity of the wrist and finger flexor muscles were assessed before (PRE) and one minute after (POST) the task failure. Within (PRE vs. POST) and between comparisons (eFBF vs. eBFR) of peak force, time to peak force, rate of force development (RFDpeak) and ED were carried out. Results: No significant between-intervention differences were identified pre- or post-exercise. Peak force and RFDpeak reduced significantly after both blood flow conditions (p < 0.05), but without between-condition difference. TPF was statistically higher after exercise only in the FBF intervention (p < 0.05). None of the interventions induced a significant change in the ED after IIHE. Conclusion: ED and TPF were similar after BFR and FBF, indicating both conditions induce similar acute performance impairments after IIHE, which seems not to be caused by local (i.e., muscular) factors, but probably by central (i.e., neural) factors.

People with mild Parkinson's disease have impaired force production in upper limb muscles: A cross-sectional study.

There has been little examination of force production of the upper limb in people with Parkinson's disease (PD), despite its impact on activities of daily living and clear evidence that force production is significantly reduced in lower limb muscle groups. The aim of this study was to determine the force production of the major muscle groups of the upper limb in people with PD during the "on" phase after medication, compared with aged-matched neurologically-normal controls. A cross-sectional study was carried out. Thirty people with mild PD (Hoehn Yahr mean 1.1) and 24 age-matched neurologically-normal controls. Maximum isometric force production of the shoulder flexors, extensors, abductors, adductors, internal rotators and external rotators, elbow flexors and extensors, wrist flexors and extensors and hand grip using dynamometry. There was a significant impairment in force production in all upper limb muscle groups, compared with control participants, except in the wrist flexors. On average the deficit in force production was 22%, despite people with PD having mild disease, being physically active and being measured during the "on" phase of medication. The most severely affected muscle groups were the upper limb extensors. People with PD have a significant deficit in force production of the upper limb muscle groups compared with age-matched neurologically normal controls. Regular assessment of strength of the upper limb should be considered by clinicians and strengthening interventions could be implemented if a deficit is identified.

Quantitative measurement of resistance force and subsequent attenuation during passive isokinetic extension of the wrist in patients with mild to moderate spasticity after stroke

BackgroundSpasticity is evaluated by measuring the increased resistance to passive movement, primarily by manual methods. Few options are available to measure spasticity in the wrist more objectively. Furthermore, no studies have investigated the force attenuation following increased resistance. The aim of this study was to conduct a safe quantitative evaluation of wrist passive extension stiffness in stroke survivors with mild to moderate spastic paresis using a custom motor-controlled device. Furthermore, we wanted to clarify whether the changes in the measured values could quantitatively reflect the spastic state of the flexor muscles involved in the wrist stiffness of the patients.Materials and methodsResistance forces were measured in 17 patients during repetitive passive extension of the wrist at velocities of 30, 60, and 90 deg/s. The Modified Ashworth Scale (MAS) in the wrist and finger flexors was also assessed by two skilled therapists and their scores were averaged (i.e., average MAS) for analysis. Of the fluctuation of resistance, we focused on the damping just after the peak forces and used these for our analysis. A repeated measures analysis of variance was conducted to assess velocity-dependence. Correlations between MAS and damping parameters were analyzed using Spearman’s rank correlation.ResultsThe damping force and normalized value calculated from damping part showed significant velocity-dependent increases.There were significant correlations (ρ = 0.53–0.56) between average MAS for wrist and the normalized value of the damping part at 90 deg/s. The correlations became stronger at 60 deg/s and 90 deg/s when the MAS for finger flexors was added to that for wrist flexors (ρ = 0.65–0.68).ConclusionsThis custom-made isokinetic device could quantitatively evaluate spastic changes in the wrist and finger flexors simultaneously by focusing on the damping part, which may reflect the decrease in resistance we perceive when manually assessing wrist spasticity using MAS.Trial registration UMIN Clinical Trial Registry, as UMIN000030672, on July 4, 2018

Assessment of muscular effort in workers performing an actual use-case manual material handling with and without the assistance of Bazar robot

Human-robot collaboration (HRC) technologies represent one of the new options for the prevention of work-related musculoskeletal disorders (WMDs) [1]. They share the workspace with workers, communicate with them, manage the human partner's flexibility and ergonomics and physically interact, to work together on a common goal [2]. Reconfigurable collaborative robots adapt to the workers’ intentions and task variations, offloading them from external loads and keeping them in ergonomic working circumstances, to improve efficiency and quality of the task execution. Although collaborative work is a widespread method for lowering WMDs, the scientific literature reveals conflicting findings on its efficacy, due to factors affecting team capacity, autonomy, and coordination [3]. To measure motor coordination during dynamic tasks, a common approach is muscle co-activation that may become functionally unfavorable [3]. Therefore, this research aims to evaluate upper limb muscle coactivation in workers performing an industrial use case manual material handling (MMH), proposed by the SME HANKAMP (Netherlands), by comparing a scenario where the workers are helped by a dual-arm cobot BAZAR [4] with a scenario without BAZAR. This cobot BAZAR is being assessed in the context of SOPHIA (http://www.project-sophia.eu) project funded by the European Union's Horizon 2020 (grant agreement No. 871237). Eleven participants (5 females and 6 males; 27.73±5.99 years; BMI: 23.06±3.93 kg/m2) took part in the study carried out at the University of Montpellier in accordance with the Helsinki Declaration and authorized by the local Ethics Committee (Protocol number IRB-EM 2103 A). Six bipolar electrodes (FreeEMG300 System, BTS, Italy, sampling rate at 1000 Hz) were placed on the flexors and extensors muscles of the shoulder (anterior and posterior deltoideus), elbow (biceps and triceps brachii caput longum) and wrist (flexor and extensor carpi radialis) joints. The experiments are shown in the video available at: https://youtu.be/vul8iLO0Sdw. Each participant, after being instructed, completed the task 3 times without BAZAR and 3 with BAZAR (Fig. 1A). We randomly ordered the 2 conditions for each subject. Furthermore, participants performed a specific exercise twice with each muscle to obtain the isometric maximal voluntary contractions (iMVCs) [1,3]. The envelope of each task's sEMG signals was then extracted, normalized respect to the average iMVC peak value for each muscle, time-normalized and then interpolated according to the brushing sub-task duration (400 samples) [1,3]. The time-varying multi-muscle coactivation function (TMCf) [3] was estimated and the mean and maximum values were calculated. A statistical analysis was carried out to evaluate whether the help of the cobot had determined significant changes in each parameter (p-value < 0.05). Fig. 1 B show the mean and standard deviation of mean and max values of evaluated TMCf for each condition. Significant effects of the presence of BAZAR were found for mean (p<0.001) and max (p=0.001) values of TMCf: the values significantly decrease when the task is performed with BAZAR. The results showed a reduction in upper limb co-activation when the specific MMH was performed with BAZAR. Therefore, HRC technologies, which share the workspace with workers, not only offload workers from external loads and improve the task execution efficiency and quality. They also allow a better coordination and reduce the worker’s physical effort while she/he physically interacts with the robot, and positively affect her/his physiological motor strategy.

VP.28 Psychometric properties of muscle strength assessment by hand-held dynamometry in healthy adults: A reliability study

Maximal isometric muscle strength (MIMS) assessment is a key component of physiotherapist' work. Hand-held dynamometry (HHD) is a simple and quick method to obtain quantified MIMS values. However, the lack of MIMS reference values with well-known psychometric properties in healthy adults limits the use and the interpretation of the measures obtained with HHD in clinic. To determine the intra- and inter-rater reliability, standard error of measurement (SEM) and minimal detectable changes (MDC) of MIMS values obtained with HHD. MIMS measurements of 17 muscle groups were assessed by two independent raters at three different times in 30 healthy adults aged between 18 and 70 years old using a standardized HHD protocol: T1(day 1: rater 1), T2 (day 5: rater 2) and T3 (day 14: rater 1). Intra- and inter-rater reliability were measured using intra-class correlation coefficients (ICC: 95% confidence interval) and the SEM and MDC were calculated from these reliability data. Intra-rater reliability and inter-rater reliability were good to excellent with ICC (95% confidence interval) varying from 0,90 to 0,99 (0,85-0,99) and 0,89 to 0,99 (0,55-0,995) respectively, except for the wrist flexors and the internal hip rotators, which showed moderate to excellent inter-rater reliability. Relative and absolute SEM and MDC for intra-rater reliability ranged from 0.14 to 3.20 Nm and 0.50 to 3.45 % for the SEM and 0.38 to 8.87 Nm and 1.38 to 7.88% for the MDC, respectively for all muscle groups. Relative and absolute SEM and MDC for inter-rater reliability ranged from 0.17 to 5.80 Nm and 0.49 to 3.25 % for the SEM and 0.47 to 16.06 Nm and 1.35 to 9.02% for the MDC, respectively. The good to excellent intra- and inter-rater reliability of the standardized HHD protocol make of the HHD protocol used a method of choice in clinical or research setting. Knowing the psychometric properties of MIMS values obtained with HHD standardized measurement protocols will allow an optimal use of the reference values established. Hand-held dynamometry, muscle strength, psychometric properties, quantitative evaluation.

Immediate effects of counterforce brace with and without vibration on pain, muscle strength and range of motion in participants with lateral epicondylitis. A pilot study

ABSTRACT Lateral epicondylitis is one of the most common elbow problems. Counterforce braces are commonly used to manage lateral epicondylitis. Recent studies showed that vibration can decrease pain and increase muscle strength by improving motor abilities. The aim of this study was to evaluate the effects of a counterforce brace with and without vibration on pain, muscular strength, wrist and elbow joints range of motion in the participants with lateral epicondylitis. In this repeated measure pre-post clinical trial study, 28 participants with lateral epicondylitis were included. Pain were measured with Visual Analogue Scale (VAS), wrist and elbow flexor/extensor muscles strength with digital dynamometer, wrist and elbow flexion/extension range of motion with goniometer in 3 condition baseline, counterforce brace and counterforce brace with vibration. Pain using counterforce bracing with vibration showed a significant reduction as compared with baseline and counterforce bracing (P < 0.001). Wrist flexor muscles strength (P = 0.005), elbow flexor/extensor muscles strength respectively (P = 0.04, P = 0.02), wrist flexion/extension range of motion (P < 0.001) following the use of counterforce bracing with vibration increased significantly compared with baseline. The results show that the counterforce bracing with and without vibration relieves pain and improves range of motion and muscles strength in lateral epicondylitis participants, but this improvement is more significant with the use of vibration.

Relationship Between Wrist Flexor Muscle Thickness, Grip Strength, And Sonographic Characteristics Of The Ucl

Medial elbow joint complex injuries have been reported in competitive and recreational athletes. Ultrasound imaging (USI) is a common method for assessing the morphology of the ulnar collateral ligament (UCL). Previous research has indicated that the long wrist flexor muscle group may also function secondarily as an active stabilizer of the medial elbow joint complex. It is surmised that the relative strength of this muscle group may reduce the load placed on the UCL, thereby potentially altering the morphology of the UCL and displacement of the medial elbow joint space (MJS) as determined through sonography. PURPOSE: The purpose of this preliminary study was to examine the relationship of UCL thickness, MJS displacement, and wrist flexor muscle thickness as measured by musculoskeletal ultrasound to grip strength in college-aged recreational athletes. METHODS: Twenty-eight asymptomatic collegiate recreational athletes (age 22.3 ± 1.5yrs) participated. Participants were placed supine with the elbow joint complex position at 30 degrees of flexion with a wedge placed underneath the humerus creating a gravity-induced valgus force on the MJS. Thickness of the UCL at mid- substance (mm), MJS width (mm), and wrist flexor group thickness (mm) was measured using a GE LOGIQ E ultrasound unit. Grip strength was assessed with a Jamar hydraulic hand dynamometer measured in pounds. The Pearson product moment correlation coefficient was used to determine the relationship among each of the variables. Significance was accepted at P < 0.05. RESULTS: A moderate significant relationship between grip strength and UCL ligament thickness was observed (r= .43, p< .05). No other statistically significant relationships were found among the variables. CONCLUSIONS: This preliminary investigation found a moderate relationship between grip strength and UCL ligament thickness. Suggesting that the greater ones grip strength the greater the stabilizing force the wrist flexors may have against a valgus load absorbed by the UCL at the elbow joint complex. No relationships were found among grip strength, muscle thickness, and MJS width. Further research is needed to further understand these potential relationships, particularly in symptomatic, competitive overhead-sport athletic populations.

427.9: Total Bilateral Arm Transplantation: Functional Recovery and Psychosocial Outcomes at One Year

Introduction: Although arm loss causes severe disability and compromission of body image, functional recovery after allotransplantation still presents many challenges. Objective: A bilateral arm transplantation including reconstruction of the left shoulder was performed on January 13, 2021 in Lyon (France). Functional recovery and psychosocial outcomes are reported one year after the transplantation. Materials and Methods: The recipient was a 48-year old patient with bilateral amputation at proximal arm level after electric shock in January 1998, who underwent liver transplantation in 2002. The patient used mechanic prostheses with poor satisfaction. The surgical procedure consisted in a total arm transplantation on the left side with reconstruction of the gleno-humeral joint. The maintenance immunosuppressive therapy included tacrolimus, mycophenolate mofetil and prednisone. Rehabilitation therapy started on day one. It progressively included manual lymphatic drainage, passive motion of all joints in a total range except limitations for the shoulders during the first 6 weeks. Then, electrostimulation on denervated muscles was performed. After 6 weeks the protocol included hand therapy, psychomotricity, physical activities, occupational therapy and sensory-motor simulation training approaches (motor imagery, virtual mirror therapy, virtual reality). Results: Motor recovery was already appreciated 8 months after the transplantation. At one year, passive ranges of motion of upper limbs are subnormal. According to MRC scale, muscular strength at shoulder level is from 3 to 4/5 on the right side and from 1 to 2/5 on the left side; from 3 to 4/5 for elbow flexors and from 1 to 2 for elbow extensors on both sides; 3/5 for wrist flexors on the right side and 0/5 on the left side; 1 to 2/5 for wrist extensors on both sides; 3/5 for pronators and supinators on the right side and 1/5 on the left side. Slight contraction and movements of the extrinsic flexors and extensor muscles of the fingers have been evidenced on both sides, and the first prehension movements started on the right hand. The Semmes-Weinstein monofilament test for sensory threshold was 6.65 in the right palm and below the left elbow; deep pressure sensation is recovered in both hands. Functional Independence Measure is 96/126 and the DASH score 75.8. The patient is able to perform the same daily activities as with the prostheses before the transplantation.The patient was psychologically tested during the follow-up using a specific questionnaire for upper extremity allotransplantation and MADRS, Hamilton and Rosenberg tests. The results (Table 1) show the difficulties, the patient’s strong motivation and capacity to cope, and his satisfaction reached at the first year of follow-up. Conclusions: The patient is very satisfied of his grafts and of his restored body image, which was his main expectation.

Efficacy and Safety of Botulinum Toxin Type A (NABOTA) for Post-stroke Upper Extremity Spasticity: A Multicenter Phase IV Trial.

ObjectiveTo evaluate the efficacy and safety of Daewoong botulinum toxin type A (NABOTA) after its launch in South Korea.MethodsThis prospective, multicenter, open-label phase IV clinical trial included 222 patients with stroke. All patients visited the clinic at baseline and at weeks 4, 8, and 12 after injection of upto 360 units of NABOTA into the wrist, elbow, and finger flexor muscles at the first visit. The primary outcome was the change in Modified Ashworth Scale (MAS) score for the wrist flexor muscles between baseline and week 4. The secondary outcomes were the changes in MAS, Disability Assessment Scale (DAS), and Caregiver Burden Scale (CBS) scores between baseline and each visit, and the Global Assessment Scale (GAS) score at week 12.ResultsThere was a statistically significant decrease in the MAS score for the wrist flexors between baseline and week 4 (−0.97±0.66, p<0.001). Compared with baseline, the MAS, DAS and CBS scores improved significantly during the study period. The GAS was rated as very good or good by 86.8% of physicians and by 60.0% of patients (or caregivers). The incidence of adverse events was 14.4%, which is smaller than that in a previous trial.ConclusionNABOTA showed considerable efficacy and safety in the management of upper limb spasticity in stroke patients.

A Clinical Trial Protocol to Compare the Effect of Dry Needling and Acupoint Dry Needling on Wrist Flexor Spasticity after Stroke.

Stroke is the leading cause of disability in adults worldwide, with spasticity after stroke being one of the more common complications. Dry needling (DN) has been demonstrated to decrease spasticity in stroke patients, although its effects on improving function remain unclear. The purpose of this study protocol is to compare the short-term effects of DN versus acupoint DN on wrist flexor spasticity and upper extremity function in patients with stroke. A double-blind, randomized clinical trial will be conducted to include patients with stroke and upper extremity spasticity and functional disability. Twenty-four patients with stroke will be randomly assigned to either the DN or acupoint DN (DNap) group. These groups will receive three DN sessions during a one-week period of the wrist flexor muscles or at the LI4 & TE5 acupoints, respectively. The primary outcome measure is the Modified Modified Ashworth Scale (MMAS) of spasticity. The secondary outcomes are the Fugl-Meyer Assessment of motor function (FMA) and the goniometry to assess the active and passive range of motion of the wrist. Data will be collected at baseline, immediately after the end of three sessions DN, and at a one-week follow-up visit. The results of this comparative study will help to determine the more effective method for reducing spasticity and improving motor function in patients with stroke.

Reduced wrist flexor H-reflex excitability is linked with increased wrist proprioceptive error in adults with cerebral palsy.

Although most neurophysiological studies of persons with cerebral palsy (CP) have been focused on supraspinal networks, recent evidence points toward the spinal cord as a central contributor to their motor impairments. However, it is unclear if alterations in the spinal pathways are also linked to deficits in the sensory processing observed clinically. This investigation aimed to begin to address this knowledge gap by evaluating the flexor carpi radialis (FCR) H-reflex in adults with CP and neurotypical (NT) controls while at rest and during an isometric wrist flexion task. The maximal H-wave (Hmax) and M-wave (Mmax) at rest were calculated and utilized to compute Hmax/Mmax ratios (H:M ratios). Secondarily, the facilitation of the H-wave was measured while producing an isometric, voluntary wrist flexion contraction (i.e., active condition). Finally, a wrist position sense test was used to quantify the level of joint position sense. These results revealed that the adults with CP had a lower H:M ratio compared with the NT controls while at rest. The adults with CP were also unable to facilitate their H-reflexes with voluntary contraction and had greater position sense errors compared with the controls. Further, these results showed that the adults with CP that had greater wrist position sense errors tended to have a lower H:M ratio at rest. Overall, these findings highlight that aberration in the spinal cord pathways of adults with CP might play a role in the sensory processing deficiencies observed in adults with CP.

Predictors of high dose of massed practice following stroke.

ObjectiveThe aim of this study is to determine the factors that affect patients’ ability to carry out high dose of massed practice.MethodsPatients with stroke were included in the study if they had no severe impairment in motor and cognitive functions. Dose of massed practice, motor function, perceived amount and quality of use of the arm in the real world, wrist and elbow flexors spasticity, dominant hand stroke, presence of shoulder pain, and central post-stroke pain were assessed on the first day. Dose of massed practice was assessed again on the second day. The data were analyzed using descriptive statistics and linear multiple regression.ResultsOnly motor function (β = –0.310, r = 0.787, P < 0.001), perceived amount of use (β = 0.300, r = 0.823; 95% CI = 0.34–107.224, P = 0.049), severity of shoulder pain (β = –0.155, r = –0.472, P = 0.019), wrist flexors spasticity (β = –0.154, r = –0.421, P = 0.002), age (β = –0.129, r = –0.366, P = 0.018), dominant hand stroke (β = –0.091, r = –0.075, P = 0.041), and sex (β = –0.090, r = –0.161, P = 0.036) significantly influenced patients’ ability to carry out high dose of massed practice.ConclusionMany factors affect patients’ ability to carry out high dose of massed practice. Understanding these factors can help in designing appropriate rehabilitation.

Isometric strength of upper limb muscles in youth using hand-held and hand-grip dynamometry.

The present study aimed to determine the isometric strength profile of the upper limb muscles of children and adolescents between 7–15 years of age. Furthermore, to (a) identify the age at which differences in strength are observed between sexes; to (b) determine the age range at which significant progression of strength could be observed; and (c) identify the role of each muscle on the total upper limb strength. Cross-sectional study that evaluated the isometric strength of nine muscle groups of the upper limb of 243 Chilean children, split into 9 age groups, separated by 1-year intervals. For this, hand-held dynamometry and hand-grip dynamometry were used. A two-factor analysis of variance for the maximum isometric strength and a stepwise multiple linear regression analysis were performed. From 11 years of age, wrist flexors were the first muscle group that revealed a significant difference in isometric strength in favor of boys (P=0.0143). In boys, the narrowest and earliest age range in the progression of isometric strength was 10 to 12 years for wrist flexors (P=0.0392). Shoulder flexors was the main factor that explained the performance of the total upper limb strength (R2=0.742; P<0.001). The most progressive isometric strength development occurred from age 10 years in the ventral and distal muscles of the upper limb; and from this age the boys begin to present a greater isometric strength than girls. In addition, the isometric strength of shoulder flexors explained the higher total upper limb strength performance.

Cannabinoid Effect and Safety in Spasticity Following Stroke: A Double-Blind Randomized Placebo-Controlled Study.

BackgroundNabiximols is a cannabis-based drug to treat spasticity-associated symptoms currently approved for patients with multiple sclerosis only. Cannabinoids are useful in an increasing number of medical conditions but may bear an increased risk for cardiovascular events. SativexStroke is a double-blind randomized placebo-controlled crossover monocentric clinical trial investigating the efficacy and safety of nabiximols in patients with spasticity following stroke.MethodsPatients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Cardiovascular safety was assessed before and during the trial. Primary endpoints were changes in spasticity numeric rating scale scores and electromyographic recording of the stretch reflex in affected wrist flexors. Secondary outcome measures were numeric rating scale scores for pain, sleep and bladder function, the number of daily spasms and clinical assessment of spasticity with the modified Ashworth scale. The study was registered with the EudraCT number 2016-001034-10.ResultsBetween May 2, 2018, and February 20, 2020, 41 patients entered the study. Seven patients did not complete the study, so 34 were included in the analysis. Two serious adverse events occurred, but none related to cardiovascular function. Primary and secondary efficacy outcome measures did not change from baseline during nabiximols treatment relative to placebo.ConclusionThis study suggests that nabiximols use is probably safe in stroke patients, therefore cannabinoid usefulness may be further investigated. The lack of nabiximols effect could be related to low pain levels in recruited patients or different spasticity mechanisms between post-stroke and multiple sclerosis patients. Similarly, a beneficial effect of nabiximols could have emerged if more patients with a higher level of spasticity at baseline were recruited.Clinical Trial Registrationhttps://www.clinicaltrialsregister.eu/ctr-search/trial/2016-001034-10/IT.

Combined effects of dry needling and exercises therapy on muscle spasticity and motor function in chronic stroke: a pretest-posttest pilot study

Aim: Spasticity is one of the most common symptoms in post-stroke patients. Dry needling (DN) is a relatively new method for the management of muscle spasticity. A multimodal treatment may be more effective in spasticity management. The purpose of this study was to explore the short-term combined effects of DN and exercise therapy on wrist flexor spasticity, motor function, and motor neuron excitability in patients with chronic stroke. Methods: Ten patients with stroke and a mean age of 52 ± 4.9 years participated in this pretest-posttest pilot study. Patients received four sessions of DN and exercise therapy. Affected flexor carpi radialis and flexor carpi ulnaris muscles were needled each for 1 min. Patients underwent exercise therapy for about 30 min, once a week after DN. The outcome measures were the Modified Modified Ashworth Scale (MMAS), the maximal amplitude of H wave/maximal amplitude of M wave ratio (Hmax/Mmax Ratio), H-reflex latency, wrist extension active and passive range of motion (ROM), Action Research Arm Test (ARAT), and Fugl-Meyer Assessment (FMA). Assessments were performed at baseline, after four sessions of treatment, and three weeks after treatment. Results: After treatment, significant improvements in MMAS, wrist passive ROM, ARAT, and FMA were obtained (P ≤ 0.05). Conclusions: DN combined with exercise therapy improved muscle spasticity and motor function in patients with chronic stroke. Further investigations with a randomized controlled trial design with a comparator group of DN only are warranted (https://www.irct.ir/; IRCT ID: IRCT20180611040061N1).

Effects of dry needling on muscle spasticity of the upper limb in a survivor of traumatic brain injury: a case report

BackgroundSurvivors of moderate and severe traumatic brain injury typically present with spasticity, an upper motor neuron lesion associated with hyperexcitability of the stretch reflex due to disinhibition of cortical influences on spinal cord circuits and structural and functional changes in skeletal muscle. There is growing evidence supporting the effectiveness of dry needling in abating spasticity.Case presentationThe present case aims to quantify the effects of dry needling on upper limb spastic muscles in a survivor of severe traumatic brain injury in a 27-year-old Iranian man. The treated muscles were biceps brachii, brachialis, flexor digitorum superficialis and profundus, flexor carpi radialis, flexor carpi ulnaris, opponens pollicis, and adductor pollicis. Outcome measures were evaluated before and 1 hour after the intervention. Our results showed that the patient’s upper limb recovery stage and hand function improved one grade according to Brunnstrom recovery stages. Spasticity assessed using the Modified Modified Ashworth Scale in all movements showed one-grade abatement, except in the forearm pronator. Passive resistance force decreased in all movements except in forearm supination. Active range of motion and passive range of motion increased in all movements except in active and passive forearm supination. Hand dexterity improved in both affected and unaffected hands.ConclusionsResults shown that dry needling could be a favorable option for reducing spasticity.

Treatment of finger spasm after stroke with wheat grain moxibustion at Shixuan (EX-UE 11) combined with rehabilitation training: a randomized controlled trial

To compare the clinical effect of wheat grain moxibustion combined with rehabilitation training and simple rehabilitation training on finger spasm after stroke. A total of 80 patients with finger spasm after stroke were randomly divided into an observation group and a control group, 40 cases in each group. The control group was given routine rehabilitation training, once a day, 30 min each time. The observation group was given wheat grain moxibustion at Shixuan (EX-UE 11) on the basis of the control group, 8~10 moxibustion cones at each point, once a day. Both groups were treated for 6 days as one course of treatment for 4 courses. The motor function of the affected hand (Fugl-Meyer assessment [FMA] score) and muscle tension (modified Ashworth scale [MAS] grading), surface EMG indexes (wrist dorsiflexor muscle and flexor carpal metacarpal muscle mean square [RMS] value), hand muscle strength (neurological deficit score [NDS]) and daily living ability (modified Barthel index [MBI] score) were compared between the two groups before and after treatment, and clinical efficacy was evaluated. After treatment, FMA and MBI scores in the 2 groups were increased compared with before treatment (P<0.05), and those in the observation group were higher than the control group (P<0.05). The RMS value of wrist dorsiflexor muscle and flexor carpal metacarpal muscle in relaxation and passive function testsand and NDS in the 2 groups were lower than those before treatment (P<0.05), and those in the observation group were lower than the control group (P<0.05). MAS grading in the 2 groups was improved compared with before treatment (P<0.05), and that in the observation group was better than the control group (P<0.05). The total effective rate of the observation group was 92.5% (37/40), which was higher than that of the control group (80.0%, 32/40, P<0.05). Wheat grain moxibustion at Shixuan (EX-UE 11) combined with rehabilitation training can improve the hand motor function and daily living ability of patients with finger spasm after stroke, improve the degree of spasm and the function of wrist dorsiflexor muscle and flexor carpal metacarpal muscle, the clinical effect is better than simple rehabilitation training.

The cross-sectional area of the median nerve: An independent prognostic biomarker in amyotrophic lateral sclerosis

IntroductionUltrasound changes in the cross-sectional area of the median nerve (CSAmn) could be of interest as biomarkers in patients with amyotrophic lateral sclerosis (ALS). MethodsEighty-four ALS patients (51 men [60.7%]; mean 62.0 [SD 11.46] years old) and forty-six controls (27 men [58.7%]; mean 59.9 [SD 8.08] years old) of two different cohorts were recruited between September 2013 and February 2018. The CSAmn was measured bilaterally in each cohort, by two different examiners with two different ultrasound machines (one in each cohort). Its association with clinical variables (disease duration, muscle strength, disability, progression rate and tracheostomy-free survival) was assessed. ResultsThe CSAmn was smaller in patients than in controls, and the study cohort did not influence its values. A mild correlation between the strength of the wrist flexor and the CSAmn was found. In the multivariable analysis, the probability of this association being true was 90%. In the cox regression, both a faster progression rate and a larger CSAmn independently predicted poor survival (HR=4.29, [Cr.I95%: 2.71–6.80], p<0.001; and HR=1.14, [Cr.I95%: 1.03–1.25], p=0.01), after adjusting by age, body mass index, bulbar onset, and diagnostic delay. ConclusionsThe CSAmn is an easy to assess biomarker that seems reliable and reproducible. Our data also suggest that it could act as a progression and prognostic biomarker in ALS patients. Longitudinal studies with repeated measures are warranted to confirm its usefulness in the clinical practice.

Evaluation of surgical skill using machine learning with optimal wearable sensor locations.

Evaluation of surgical skills during minimally invasive surgeries is needed when recruiting new surgeons. Although surgeons’ differentiation by skill level is highly complex, performance in specific clinical tasks such as pegboard transfer and knot tying could be determined using wearable EMG and accelerometer sensors. A wireless wearable platform has made it feasible to collect movement and muscle activation signals for quick skill evaluation during surgical tasks. However, it is challenging since the placement of multiple wireless wearable sensors may interfere with their performance in the assessment. This study utilizes machine learning techniques to identify optimal muscles and features critical for accurate skill evaluation. This study enrolled a total of twenty-six surgeons of different skill levels: novice (n = 11), intermediaries (n = 12), and experts (n = 3). Twelve wireless wearable sensors consisting of surface EMGs and accelerometers were placed bilaterally on bicep brachii, tricep brachii, anterior deltoid, flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and thenar eminence (TE) muscles to assess muscle activations and movement variability profiles. We found features related to movement complexity such as approximate entropy, sample entropy, and multiscale entropy played a critical role in skill level identification. We found that skill level was classified with highest accuracy by i) ECU for Random Forest Classifier (RFC), ii) deltoid for Support Vector Machines (SVM) and iii) biceps for Naïve Bayes Classifier with classification accuracies 61%, 57% and 47%. We found RFC classifier performed best with highest classification accuracy when muscles are combined i) ECU and deltoid (58%), ii) ECU and biceps (53%), and iii) ECU, biceps and deltoid (52%). Our findings suggest that quick surgical skill evaluation is possible using wearables sensors, and features from ECU, deltoid, and biceps muscles contribute an important role in surgical skill evaluation.

Implications of providing wrist-hand orthoses for children with cerebral palsy: evidence from a randomised controlled trial

Purpose To investigate the effects of providing rigid wrist-hand orthoses plus usual multidisciplinary care, on reducing hand impairments in children with cerebral palsy. Methods A pragmatic, multicentre, assessor-blinded randomised controlled trial aimed to enrol 194 children aged 5–15 years, with wrist flexor Modified Ashworth Scale score ≥1. Randomisation with concealed allocation was stratified by study site and passive wrist range. The treatment group received a rigid wrist-hand orthosis, to wear ≥6 h per night for 3 years. Analysis included repeated measures mixed-effects linear regression models, using intention-to-treat principles. Results The trial stopped early due to insufficient recruitment: 74 children, across all Manual Ability Classification System levels, were randomised (n = 38 orthosis group; n = 36 control). Mean age was 10.2 (SD 3.1) years (orthosis group) and 9.1 (SD 2.8) years (control). Data showed some evidence that rigid wrist-hand orthosis impacted passive wrist extension with fingers extended in the first year [mean difference between-groups at 6 months: 13.15° (95%CI: 0.81–25.48°, p = 0.04); 12 months: 20.94° (95%CI: 8.20–33.69°, p = 0.001)]. Beyond 18 months, participant numbers were insufficient for conclusive findings. Conclusion The study provided detailed data about short- and long-term effects of the wrist-hand orthosis and highlighted challenges in conducting large randomised controlled trials with this population. Trial Registration: Australia and New Zealand Clinical Trials Registry: U1111-1164-0572 IMPLICATIONS FOR REHABILITATION There may be incremental benefit, for children with cerebral palsy, at 6 and 12 months on passive wrist range from wearing a rigid wrist-hand orthosis designed according to this protocol. The rigid-wrist-hand orthosis evaluated in this study, which allowed for some tailoring for individual children’s presentations, differed in design from past recommendations for “resting hand” positioning. Longitudinal follow up of children with cerebral palsy prescribed a rigid wrist-hand orthosis is essential to monitor any benefit. Minor adverse events were commonly experienced when wearing the orthosis and should be discussed prior to prescription of a rigid wrist-hand orthosis.