Rehabilitation Strategies Following Surgical Treatment of Upper Extremity Spasticity

Contralateral C7 nerve transfer in the treatment of upper-extremity paralysis: a review of anatomical basis, surgical approaches, and neurobiological mechanisms

The previous three decades have witnessed a prosperity of contralateral C7 nerve (CC7) transfer in the treatment of upper-extremity paralysis induced by both brachial plexus avulsion injury and central hemiplegia. From the initial subcutaneous route to the pre-spinal route and the newly-established post-spinal route, this surgical operation underwent a series of innovations and refinements, with the aim of shortening the regeneration distance and even achieving direct neurorrhaphy. Apart from surgical efforts for better peripheral nerve regeneration, brain involvement in functional improvements after CC7 transfer also stimulated scientific interest. This review summarizes recent advances of CC7 transfer in the treatment of upper-extremity paralysis of both peripheral and central causes, which covers the neuroanatomical basis, the evolution of surgical approach, and central mechanisms. In addition, motor cortex stimulation is discussed as a viable rehabilitation treatment in boosting functional recovery after CC7 transfer. This knowledge will be beneficial towards improving clinical effects of CC7 transfer.

Neuromodulation Therapies for Spasticity Control: Now and Beyond

Spasticity is a major cause of disability following upper motor neuron (UMN) injury. The diagnosis and treatment of spasticity has been a focus of clinicians and researchers alike. In recent years, there have been significant advances both in strategies for spasticity assessment and in the development of novel treatments. Currently, several well-established spasticity management techniques fall into the major categories of physiotherapy, pharmacotherapy, and surgical management. The majority of recent developments in all of these broad categories have focused more on methods of neuromodulation instead of simple symptomatic treatment, attempting to address the underlying cause of spasticity more directly. The following narrative review briefly discusses the causes and clinical assessment of spasticity and also details the wide variety of current and developing treatment approaches for this often-debilitating condition.

Determining the Effectiveness of a New Device for Hand Therapy (The FEPSim Device): Feasibility Protocol for a Randomized Controlled Trial Study

Background

Impairments of the forearm, wrist, and hand affect a sizable proportion of individuals and impose a significant economic burden on health care systems. FEPSim is a medical device for hand and wrist rehabilitation. The FEPSim device could be part of the standard of care for upper extremity rehabilitation during therapeutic activities to increase range of motion, dexterity, and strength. FEPSim has not yet been tested in a health care setting; therefore, a trial of the effectiveness of FEPSim in upper extremity rehabilitation is warranted.

Objective

This study aims to assess the feasibility of conducting a definitive trial in terms of recruitment, eligibility criteria, the type and number of diagnoses included, the length and dosage of the intervention, and data collection methods. This study also aims to gather clinical and statistical information as well as information related to the cost and usability, which allows for an economic evaluation of the device.

Methods

The trial will use a randomized controlled design comprising 47 intervention participants and 47 control group participants. Participants will be adults (age≥18 years) attending outpatient rehabilitation with limitations in their forearm, wrist, or hand function due to distal radial or ulnar fractures, stroke, or osteoarthritis. This study’s primary outcome variables are related to patients’ range of motion and strength, specifically active and passive wrist flexion and extension range of motion; active and passive forearm pronation and supination range of motion; grip strength; and pinch strength. The secondary outcome variables are related to patients’ perceived wrist pain and disability in activities of daily living. The patients’ perceived wrist pain and disability in activities of daily living will be measured using the patient-rated wrist evaluation questionnaire. The control group will receive the standard of care at each of the 2 hospital facilities (Glenrose Rehabilitation and Royal Alexandra Hospitals). The intervention group will receive the same standard of care as the control group at each facility and will use the FEPSim device for therapeutic activities to increase strength, range of motion, resistance, and dexterity. All the participants will be assessed at baseline (week 0); weeks 2, 4, and 8; and postintervention (week 10).

Results

The FEPSim study was launched in April 2020. This study is currently on hold because of the global COVID-19 pandemic. The recruitment process is expected to resume by September 2020, and the primary impact analysis is expected to be conducted by December 2020.

Conclusions

This study will provide valuable information on the measurement of comparative intervention effects, technology acceptance by hand therapists, and how associated treatment and product costs will contribute to the evidence planning process, which will be crucial for the future adoption of FEPSim.

Trial Registration

International Standard Randomized Controlled Trial Number Registry ISRCTN13656014; https://www.isrctn.com/ISRCTN13656014

International Registered Report Identifier (IRRID)

PRR1-10.2196/22145

Contralateral C7 nerve transfer through posterior vertebral approach combined with selective posterior rhizotomy of the affected cervical nerve in the treatment of central upper limb spastic paralysis: A case report

INTRODUCTION

C7 nerve transfer alone can improve upper limb motor function and partial spasticity. Selective posterior rhizotomy (SPR) of the cervical nerve alone can comprehensively improve spasticity but without neuromotor regeneration. We propose a novel possible improvement of contralateral C7 (CC7) nerve transfer through the posterior vertebral approach, which was combined with SPR of the affected cervical nerve.

PATIENT CONCERNS

A 33-year-old male patient presented with cerebral hemorrhage of the left basal ganglia, paralysis of the right limbs, and hypesthesia 8 months earlier. The dysfunction of the affected hand was already present at admission. The patient reported a previous history of hypertension for several years and oral antihypertensive drugs, and blood pressure was controlled within a normal range.

DIAGNOSIS

Central upper limb spastic paralysis. The muscle strength of the right lower limb was grade IV. The Fugl-Meyer score of the right upper limb was 7 points, and the modified Ashworth score was 10.

INTERVENTIONS

The patient underwent CC7 transfer and SPR.

OUTCOMES

The patient successfully underwent CC7 transfer and SPR without complications. On the day after surgery, the left upper limb motions were normal. The Fugl-Meyer score was 9, and the modified Ashworth score of the right upper limb was 2.

CONCLUSIONS

CC7 nerve transfer through the posterior vertebral approach combined with SPR of the affected cervical nerve can possibly improve the surgical outcomes of selected patients with upper limb motor dysfunction and partial spasticity. This method has not been reported in the literature before, and additional studies are necessary.