Abstract
Purpose: To capture patients' relearning processes from regained function to improvements in daily life after grip reconstructive surgery in tetraplegia. Subjects: Eleven people with ...tetraplegia who underwent grip reconstructive surgery during February 2009 to March 2011. Methods: Qualitative interviews were conducted 7 to 17 months after surgery and analysed using grounded theory. Results: Determination to reach a higher level of independence was the core concept to integrate regained function into daily life. There were 3 phases identified; "Initiate activity training," "Establish hand control in daily activities," and "Challenge dependence." Between the phases psychological stages occurred, first; "a belief in improved ability", and later in the process; "confidence in ability". The process to fully integrate regain function in daily life was described as long and time-consuming. However, the participants claimed it useful to do the skills training in their home environment, without long-term in clinic rehabilitation. Conclusion: Relearning activities in daily life after a grip reconstruction is a time-consuming and demanding process. It includes skills training, mental strategies and psychological stages together with environmental and social factors. Accordingly, rehabilitation after grip reconstruction in tetraplegia should focus on both grip skills and psychological stages, to encourage that patient's keep their determination and achieve greater independence.Implications for RehabilitationThere is a stepwise process to transform improved function into daily use.The most important factor to transform improved function into daily use was motivation to reach a higher independence. Other important factors were; skills training, use of individual learning strategies, belief and confidence in personal ability, social and environmental factors.There was a long and demanding process to fully transform the improved function into daily use.The participants preferred to do activity training in the specific environment, usually at home.
Tendon transfer surgery restores function by rerouting working muscle–tendon units to replace the function of injured or paralyzed muscles. This procedure requires mobilizing a donor muscle relative ...to its surrounding myofascial connections, which improves the muscle’s new line of action and increases excursion. However, the biomechanical effect of mobilization on a donor muscle’s force-generating function has not been previously studied under in vivo conditions. The purpose of this study was to quantify the effect of surgical mobilization on active and passive biomechanical properties of 3 large rabbit hind limb muscles.
Myofascial connections were mobilized stepwise from the distal end to the proximal end of muscles (0%, 25%, 50%, and 75% of muscle length) and their active and passive length-tension curves were measured after each degree of mobilization.
Second toe extensor, a short-fibered muscle, exhibited a 30% decline in peak stress and 70% decline in passive stress, whereas extensor digitorum longus, a short-fibered muscle, and tibialis anterior, a long-fibered muscle, both exhibited similar smaller declines in active (about 18%) and passive stress (about 65%).
The results highlight 3 important points: (1) a trade-off exists between increasing muscle mobility and decreasing force-generating capacity; (2) intermuscular force transmission is important, especially in second toe extensor, because it was able to generate 70% of its premobilization active force although most fibers were freed from their native origin; and (3) muscle architecture is not the major influence on mobilization-induced force impairment.
These data demonstrate that surgical mobilization itself alters the passive and active force-generating capacity of skeletal muscles. Thus, surgical mobilization should not be viewed simply as a method to redirect the line of action of a donor muscle because this procedure has an impact on the functional properties of the donor muscle itself.
Abstract
Purpose: To explore how surgical reconstruction of grip affects everyday life for patients with tetraplegia, with special emphasis on patients perspective of their perceived changes. Design: ...Qualitative method. Subjects: Eleven people (aged 22-73) with tetraplegia who had undergone surgical reconstruction to restore grip function. Methods: Qualitative interviews were conducted 7-17 months after surgery and analysed using Grounded theory. Results: The core concept describing the participants experienced gains after grip reconstructive surgery was "enhanced independence". It was associated with changes in both practical and psychological aspects of independence. Practical aspects identified were: "perform more activities", "smoother everyday life", "renewed ability to participate in social activities", "less dependence on assistance" and "less restricted by physical environment". Psychological aspects of independence included "regained privacy", "increased manageability", "regained identity", "recapture a part of the body" and "share positive experiences with relatives and friends". Encompassing all categories was the concept "self-efficacy in hand control". It was seen as a result included in the enhanced independency core but also as an important factor for the development of all the other categories. Conclusion: Participants in this study experienced enhanced independence after grip reconstructive surgery and rehabilitation. The enhanced independence included both practical and physical aspects and it influenced all domains using the International Classification of Function, Disability and Health model; body function and structure, activities, participation, personal factors and environmental factors.Implications for RehabilitationPatients with tetraplegia experience grip reconstruction as a useful intervention, an enhanced independence, related to their improved hand control.The increased hand control impacted not only physical aspects but also practical and psychological aspects. It also influenced social and community participation and the interference the environment had on the person.Self-efficacy was both a result of the intervention and a catalyst allowing the subcategories to develop. Therefore, self-efficacy in hand control seems to be an important factor to focus on during the rehabilitation process.
This study represents a retrospective observational cohort study.
The objective of this study was to investigate the impact of thumb position on postoperative patient-rated and functional outcomes in ...grip reconstruction surgery.
All consecutive adult patients with tetraplegia undergoing grip reconstruction surgery at the Swiss Paraplegic Centre between 06/2008 and 11/2020 were assessed for eligibility.
Standardized photo or film documentation was used for individually recreating and categorizing thumb position and trajectory during key pinch. Outcome measurements included key pinch strength, Canadian Occupational Performance Measure (COPM) and Grasp Release Test (GRT).
Fifty-six hands of 44 patients (mean age 42.2 years, range 18-70 years) with a mean follow-up of 14.8 months (range 6 months to 12 years) were included. There was a significant postoperative improvement of key pinch strength, COPM score and GRT. COPM improvement was more pronounced for hands with more palmar abducted trajectories of the thumb.
Regardless of reconstruction type, pinch strength, patient satisfaction and grasp and release abilities improved significantly after surgery. Thumb position and trajectory are strong determining factors for the selected outcome measurements.
Purpose Regaining hand function has been identified as the highest priority for persons with tetraplegia. In many patients, finger flexion can be restored with a tendon transfer of extensor carpi ...radialis longus to flexor digitorum profundus (FDP). In the absence of intrinsic function, this results in a roll-up finger movement, which tends to push large objects out of grasp. To enable patients to grasp objects of varying sizes, a functional grasp is required that has a larger excursion of fingertip-to-palm distance than can be supplied without intrinsic function. The aim of this study was to quantify the role of intrinsic muscle force in creating a functional grasp. Methods Finger kinematics during grasp were measured on 5 cadaveric hands. To simulate finger flexion, the FDP was activated by a motor and intrinsic muscles were loaded at various levels (0, 125, 250, 375, or 500 g). Finger movement was characterized by the order of metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joint flexion and by the maximal fingertip-to-palm distance during finger closure. Results Without any intrinsic muscle contribution (0-g load), FDP activation resulted in flexion of all 3 joints, whereby flexion began at the proximal interphalangeal joint, followed by the distal interphalangeal joint, and then the metacarpophalangeal joint. With increasing intrinsic muscle load, finger flexion was initiated at the metacarpophalangeal joint, followed by the proximal interphalangeal and distal interphalangeal joints. This altered joint flexion order resulted in a larger maximal fingertip-to-palm distance during finger flexion. The difference between the 2 extreme conditions (0 g vs 500 g of intrinsic muscle load) was 19 mm. Conclusions These findings demonstrate that simultaneous activation of the FDP and the intrinsic muscles results in an apparently more functional hand closing compared with FDP activation alone because of altered kinematics and larger fingertip-to-palm distances. Clinical relevance These findings suggest that intrinsic muscle balancing during reconstruction of grasp in tetraplegic patients may improve function.
The passive mechanical properties of small muscle fiber bundles obtained from surgical patients with spasticity (n = 9) and patients without neuromuscular disorders (n = 21) were measured in order to ...determine the relative influence of intracellular and extracellular components. For both types of patient, tangent modulus was significantly greater in bundles compared to identical tests performed on isolated single cells (P < 0.05). However, the relative difference between bundles and single cells was much greater in normal tissue than spastic tissue. The tangent modulus of normal bundles (462.5 ± 99.6 MPa) was 16 times greater than normal single cells (28.2 ± 3.3 MPa), whereas the tangent modulus of spastic bundles (111.2 ± 35.5 MPa) was only twice that of spastic muscle cells (55.0 ± 6.6 MPa). This relatively small influence of the extracellular matrix (ECM) in spastic muscle was even more surprising because spastic muscle cells occupied a significantly smaller fraction of the total specimen area (38.5 ± 13.6%) compared to normal muscle (95.0 ± 8.8%). Based on these data, normal muscle ECM is calculated to have a modulus of 8.7 GPa, and the ECM from spastic muscle of only 0.20 GPa. These data indicate that spastic muscle, although composed of cells that are stiffer compared to normal muscle, contains an ECM of inferior mechanical strength. The present findings illustrate some of the profound changes that occur in skeletal muscle secondary to spasticity. The surgical implications of these results are discussed. Muscle Nerve 28: 464–471, 2003
To describe and evaluate the rehabilitation concept after posterior deltoid to triceps transfer in patients with tetraplegia.
Retrospective observational study.
Rehabilitation units.
Patients with ...tetraplegia who had posterior deltoid to triceps tendon transfer and had muscle strength measurements 1 year postsurgery from 2009 to 2013 (N=44).
Posterior deltoid to triceps tendon transfer to restore elbow extension and postoperative rehabilitation.
Elbow extension range of motion and muscle strength and the modified Canadian Occupational Performance Measure (COPM).
Surgery was performed on 53 arms. No major complications (eg tendon rupture, lengthening) were reported. Muscle strength measured 1 year after surgery was on average grade 3 (out of 5) in the 53 operated arms. The ability to extend the elbow against gravity was achieved in 62% of the arms (muscle strength of grade ≥3). In patients with a preoperative elbow extension deficit (n=14), the deficit was reduced on average from 16° to 9°. The performance of the prioritized activities as measured with the COPM improved on average 2.6 scale steps, from 3.3 to 5.9. Satisfaction with the performance improved on average 3.2 scale steps, from 2.8 to 6.0.
The posterior deltoid to triceps tendon transfer with the applied rehabilitation protocol is a safe and effective procedure. There were no tendon ruptures, and all patients were able to complete the rehabilitation protocol. The shorter restriction time after surgery allows the patient to be independent at an earlier stage of the rehabilitation and reduces hospitalization or care burden.
Context/Objective: Spinal cord injury (SCI) causes atrophy of brain regions linked to motor function. We aimed to estimate cortical thickness in brain regions that control surgically restored limb ...movement in individuals with tetraplegia.
Design: Cross-sectional study.
Setting: Sahlgrenska University hospital, Gothenburg, Sweden.
Participants: Six individuals with tetraplegia who had undergone surgical restoration of grip function by surgical transfer of one elbow flexor (brachioradialis), to the paralyzed thumb flexor (flexor pollicis longus). All subjects were males, with a SCI at the C6 or C7 level, and a mean age of 40 years (range = 31-48). The average number of years elapsed since the SCI was 13 (range = 6-26).
Outcome measures: We used structural magnetic resonance imaging (MRI) to estimate the thickness of selected motor cortices and compared these measurements to those of six matched control subjects. The pinch grip control area was defined in a previous functional MRI study.
Results: Compared to controls, the cortical thickness in the functionally defined pinch grip control area was not significantly reduced (P = 0.591), and thickness showed a non-significant but positive correlation with years since surgery in the individuals with tetraplegia. In contrast, the anatomically defined primary motor cortex as a whole exhibited substantial atrophy (P = 0.013), with a weak negative correlation with years since surgery.
Conclusion: Individuals with tetraplegia do not seem to have reduced cortical thickness in brain regions involved in control of surgically restored limb movement. However, the studied sample is very small and further studies with larger samples are required to establish these findings.
Over the past decade, collagenase treatment and needle fasciotomy (NF) have gained widespread popularity in the treatment of Dupuytren contracture. This prospective study was designed to compare the ...results of these treatments in terms of clinical and patient-reported outcomes.
A prospective, randomized, controlled trial included patients with a contracture of 20° or more in a single metacarpophalangeal joint. Patients were allocated to treatment with either NF or collagenase Clostridium histolyticum. The primary outcome was a reduction in the metacarpophalangeal joint contracture to less than 5°. Secondary outcomes included recurrence, the presence of Dupuytren cords, and changes in patient-reported outcomes. The participants were examined 5 years after the intervention.
The study cohort comprised 156 patients divided into 2 equally sized groups. After 5 years, data were collected from 143 (92 %) of the initially enrolled participants. The mean time for the clinical follow-up was 5.1 years. In the remaining cohort without a second procedure, 51% (23 patients) in the collagenase Clostridium histolyticum group and 47% (27 patients) in the NF group still had extension deficits of less than 5°. Among the participants with a successful initial procedure, the recurrence rate was 56% (36 patients) in the collagenase Clostridium histolyticum group and 45% (30 patients) in the NF group. There were no differences between the 2 treatments in regard to passive joint extension, reduction of contracture, range of motion, or patient-reported outcomes.
The 5-year outcomes for NF are similar to those for collagenase in terms of sustained correction, recurrence, presence of Dupuytren cords, and patient-reported outcomes for the treatment of metacarpophalangeal joint contractures.
Therapeutic I.
We characterized the architecture, fiber type, titin isoform distribution, and collagen content of 27 portions of 22 muscles in the murine forelimb. The mouse forelimb was different from the human ...arm in that it had the extensor digitorum lateralis muscle and no brachioradialis muscle. Architecturally, the mouse forelimb differed from humans with regard to load bearing, having a much larger contribution from extensors than flexors. In mice, the extensor : flexor PCSA ratio is 2.7, whereas in humans it is only 1.4. When the architectural difference index was calculated, similarities became especially apparent between flexors and extensors of the distal forelimb, as well as pronators. Discriminant analysis revealed that biochemical measures of collagen, titin, and myosin heavy chain were all strong between‐species discriminators. In terms of composition, when compared with similar muscles in humans, mice had, on average, faster muscles with higher collagen content and larger titin isoforms. This report establishes the anatomical and biochemical properties of mouse forelimb muscles. Given the prevalence of this species in biological studies, these data will be invaluable for studying the biological basis of mouse muscle structure and function.
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