Skeletal muscle contractures represent the permanent shortening of a muscle-tendon unit, resulting in loss of elasticity and, in extreme cases, joint deformation. They may result from cerebral palsy, ...spinal cord injury, stroke, muscular dystrophy, and other neuromuscular disorders. Contractures are the prototypic and most severe clinical presentation of increased passive mechanical muscle force in humans, often requiring surgical correction. Intraoperative experiments demonstrate that high muscle passive force is associated with sarcomeres that are abnormally stretched, although otherwise normal, with fewer sarcomeres in series. Furthermore, changes in the amount and arrangement of collagen in the extracellular matrix also increase muscle stiffness. Structural light and electron microscopy studies demonstrate that large bundles of collagen, referred to as perimysial cables, may be responsible for this increased stiffness and are regulated by interaction of a number of cell types within the extracellular matrix. Loss of muscle satellite cells may be related to changes in both sarcomeres and extracellular matrix. Future studies are required to determine the underlying mechanism for changes in muscle satellite cells and their relationship (if any) to contracture. A more complete understanding of this mechanism may lead to effective nonsurgical treatments to relieve and even prevent muscle contractures.
Nerve transfers (neurotizations) performed under optimal conditions can restore some voluntary control in muscles of the upper extremities in patients with tetraplegia. However, the type of ...motoneuron lesions in target muscles for nerve transfers influences the functional outcome. Using standardized maps of motor point topography, surface electrical stimulation reliably defines the kind and extent of motoneuron lesion in the selected muscles. In a muscle with an intact lower motor motoneuron, nerve transfers can often successfully reinnervate the chosen key muscle. Conversely, in a lower motoneuron lesion, the nerve transfer outcome is less predictable. However, direct muscle stimulation appears to ameliorate the morphological precondition, a finding that necessitates new preoperative approaches to optimize reinnervation in denervated/partially denervated muscles. Therefore, understanding the impact of electrical stimulation in diagnostics, prognostics, and treatments of upper limbs in tetraplegia is critical for neurotization procedures.
Abstract Objective To achieve consensus on a multidisciplinary treatment guideline for carpal tunnel syndrome (CTS). Design Delphi consensus strategy. Setting Systematic reviews reporting on the ...effectiveness of surgical and nonsurgical interventions were conducted and used as an evidence-based starting point for a European Delphi consensus strategy. Participants In total, 35 experts (hand surgeons selected from the Federation of European Societies for Surgery of the Hand, hand therapists selected from the European Federation of Societies for Hand Therapy, physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy. Interventions Not applicable. Main Outcome Measures Each Delphi round consisted of a questionnaire, analysis, and feedback report. Results After 3 Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of CTS. The experts agreed that patients with CTS should always be instructed, and instructions combined with splinting, corticosteroid injection, corticosteroid injections plus splinting, and surgery are suitable treatments for CTS. Relevant details for the use of instructions, splinting, corticosteroid injections, and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified as follows: severity and duration of the disorder and previous treatments received. A relation between the severity/duration and choice of therapy was found by the experts and reported in the guideline. Conclusions This multidisciplinary treatment guideline may help physicians and allied health care professionals to provide patients with CTS with the most effective and efficient treatment available.
Damage to lower motor neuron causes denervation and degeneration of the muscles affected. Experimental and clinical studies of muscle denervation in lower extremities demonstrated that direct ...electrical stimulation (ES) of muscle can prevent denervation atrophy and restore contractility. The aim of this study was to identify possible myogenic effect of ES on denervated forearm and hand muscles in persons with spinal cord injury (SCI) and tetraplegia.
This prospective interventional study with repeated measurement design included 22 patients aged 48·6 (± 15·7), 0·25 (0·1/46) years after spinal cord lesion, AIS A-D. In each patient, two electrophysiologically-confirmed denervated muscles in the hand and forearm were analyzed – one extrinsic (Extensor Carpi Ulnaris - ECU) and one intrinsic (1st Dorsal Interosseus - IOD1). Muscles were stimulated for 33 min, five times per week over a 12-weeks period. Using ultrasonography (USG), muscle thickness (MT) and pennation angle (PA) of these muscles were determined at start and end of the stimulation period.
MT of IOD1 increased from 6·3 mm (± 3·2 mm) to 9·2 mm (± 2·4 mm) (p = 0·004) and the PA from 5·5° (± 3·0°) to 11° (± 2·2°) (p = 0·001). The corresponding values for the ECU were 5·5 mm (± 2·5 mm) to 7·0 mm (± 2·2 mm) (p = 0·039) and 5·5° (± 3·4°) to 9·4° (± 3·8°) (p = 0·005), respectively. The correlation of MT between baseline and completion was r = 0·58 (p = 0·037) for the ECU and r = 0·63 (p = 0·008) for the IOD1.
12 weeks of direct muscle stimulation increases the MT and PA of the denervated intrinsic and extrinsic hand muscles studied.
Swiss Paraplegic Centre, Switzerland
This review represents our summary of what makes a great collaboration between a surgeon and a scientist. At first, with no perspective, such a collaboration seems easy and natural. But as time goes ...on, with more perspective, you realize how special it is. Now, in our 60s, with approximately 35 years of collaboration and 75 coauthored papers (most of them in The Journal of Hand Surgery), we are thankful and humbled for this tremendously fruitful and, importantly, enjoyable collaboration. We are not so foolish to think that we made this great collaboration-it was a gift. However, we now recognize many characteristics that make it great and have developed the following 10 tips.
Central and peripheral nervous system lesions may disrupt the intricate balance of the prime movers of the wrist. In spasticity, hyperactive wrist flexors create a flexion moment and, if untreated, ...can lead to flexion contractures. In patients with C6 spinal cord injury and tetraplegia, the posterior interosseus nerve is typically affected by a complex pattern of upper and/or lower motoneuron lesions causing radial deviation of the wrist due to loss of ulnar deviation actuators. In this report, we illustrate severe pathomechanics that may occur even with relatively modest changes in wrist balance. These results illustrate how thorough understanding of muscle-tendon-joint interaction aids in designing tendon and nerve reconstructive surgeries to normalize wrist positions and balance in neuromuscular conditions.
Introduction
Functional electrical stimulation (FES) synchronized with robot‐assisted lower extremity training is used in spinal cord injury (SCI) rehabilitation to promote residual function.
Methods
...Data of SCI inpatients who trained lower limb mobilization on a stationary robotic system were retrospectively analyzed. The primary outcome was the improvement of muscle strength from the first through to the last training session during FES‐induced as well as voluntarily induced flexion and extension. The secondary outcome was the sum score of voluntary muscle function in the lower limbs before and after the training period.
Results
Data from 72 patients with SCI (AIS A‐D) were analyzed. For extension, FES‐assisted strength increased (p < 0.001) from 25.2 to 44.0 N, voluntary force (p < 0.001) from 24.4 to 39.9 N. For flexion, FES‐assisted flexion (p < 0.006) increased from 14.1 to 19.0 N, voluntary flexion (p < 0.005) from 12.6 to 17.1 N. There was a significant correlation between the increase in FES‐assisted force and voluntary flexion (r = 0.730, p = 0.001) as well as between the increase in FES‐assisted force and voluntary extension (r = 0.881, p < 0.001). The sum score in muscle test increased from 15 to 24 points.
Conclusion
Robot‐assisted training with FES seems to support the regeneration of residual functions after SCI. This is evidenced by an improvement in motor function and strength in the lower limbs.
Results of the increase in FES‐assisted as well as in voluntary force of the lower limbs in patients with subacute spinal cord injury.
Different Thumb Positions in the Tetraplegic Hand Koch-Borner, Sabrina; Bersch, Ulf; Grether, Silke ...
Archives of physical medicine and rehabilitation,
01/2024, Letnik:
105, Številka:
1
Journal Article
Recenzirano
To analyze factors associated with malposition that affects function of the thumb in individuals with tetraplegia.
Retrospective cross-sectional study.
Rehabilitation Center for Spinal Cord Injury.
...Anonymized data from 82 individuals (68 men), mean age 52.9±20.2 (SD) with acute/subacute cervical spinal cord injury C2-C8 AIS A-D recorded during 2018-2020.
Not applicable.
Motor point (MP) mapping and manual muscle test (MRC) of 3 extrinsic thumb muscles (flexor pollicis longus (FPL), extensor pollicis longus (EPL), and abductor pollicis longus (APL)).
159 hands in 82 patients with tetraplegia C2-C8 AIS A-D were analyzed and assigned to "key pinch" (40.3%), "slack thumb" (26.4%), and "thumb-in-palm" (7.5%) positions. There was a significant (P<.0001) difference between the 3 thumb positions depicted in lower motor neuron (LMN) integrity tested by MP mapping and muscle strength of the 3 muscles examined. All studied muscles showed a significantly different expression of MP and the MRC values (P<.0001) between the "slack thumb" and "key pinch" position. MRC of FPL was significantly greater in the group "thumb-in-palm" compared with "key pinch" position (P<.0001).
Malposition of the thumb due to tetraplegia seems to be related to the integrity of LMN and voluntary muscle activity of the extrinsic thumb muscles. Assessments such as MP mapping and MRC of the 3 thumb muscles enable the identification of potential risk factors for the development of thumb malposition in individuals with tetraplegia.
Tetraplegia Management Update Fridén, Jan, MD, PhD; Gohritz, Andreas, MD
The Journal of hand surgery (American ed.),
12/2015, Letnik:
40, Številka:
12
Journal Article
Recenzirano
Tetraplegia is a profound impairment of mobility manifesting as a paralysis of all 4 extremities owing to cervical spinal cord injury. The purpose of this article is to provide an update and analyze ...current management, treatment options, and outcomes of surgical reconstruction of arm and hand function. Surgical restoration of elbow and wrist extension or handgrip has tremendous potential to improve autonomy, mobility, and critical abilities, for example, eating, personal care, and self-catheterization and productive work in at least 70% of tetraplegic patients. Tendon and nerve transfers, tenodeses, and joint stabilizations reliably enable improved arm and hand usability, reduce muscle imbalance and pain in spasticity, and prevent joint contractures. One-stage combined procedures have proven considerable advantages over traditional multistage approaches. Immediate activation of transferred muscles reduces the risk of adhesions, facilitates relearning, avoids adverse effects of immobilization, and enhances functional recovery. Transfer of axillary, musculocutaneous, and radial nerve fascicles from above the spinal cord injury are effective and promising options to enhance motor outcome and sensory protection, especially in groups with limited resources. Improved communication between medical disciplines, therapists, patients, and their relatives should help that more individuals can benefit from these advances and could empower many thousands tetraplegic individuals “to take life into their own hands” and live more independently.
BACKGROUND:Local disruption of the cord that causes contracture of the finger in Dupuytren disease can be achieved either through mechanical division by percutaneous needle fasciotomy (PNF) or ...through enzymatic digestion by injectable collagenase Clostridium histolyticum (CCH). This study was designed to compare clinical and patient-reported outcomes between patients who had been treated with each method.
METHODS:A prospective, randomized, single-blinded, controlled trial was designed and included 156 patients with a contracture of the metacarpophalangeal (MCP) joint of ≥20°. The patients were allocated to treatment with either PNF or CCH. The primary outcome was a reduction of the MCP contracture to <5°. Secondary outcomes included the reduction of any concomitant contracture of the proximal interphalangeal (PIP) joint, the presence of Dupuytren cords, and changes in patient-reported outcomes as measured with the URAM (Unité Rhumatologique des Affections de Main) and QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand DASH) questionnaires and visual analog scales for patient satisfaction. All treatments were performed by a single surgeon and all blinded follow-up measurements were made by a single physiotherapist. The participants were assessed at 1 week, 6 months, and 1 and 2 years after the interventions.
RESULTS:A total of 152 patients (97%) were examined at 2 years, at which time 58 patients (76%) treated with CCH and 60 (79%) treated with PNF retained a straight MCP joint. No cords were detectable in >50% of the patients at 2 years. There were no significant differences in the reduction of PIP contracture, range of motion, or patient-reported outcomes between the 2 treatments.
CONCLUSIONS:This trial demonstrated no advantage of CCH treatment compared with PNF in terms of clinical outcome at any time during the 2-year follow-up. The significant decrease in the number of pathological cords (p < 0.0001, Wilcoxon signed-rank test) after disruption regardless of the method used may indicate that resorption of pathological collagen occurs when the tension in the Dupuytren cord is diminished.
LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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