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Chung MMT, Ip WY. Surgical reconstruction for spasticity and contracture: An underutilised rehabilitative strategy of adult stroke. JRSM Open 2024; 15:20542704241278544. [PMID: 39314623 PMCID: PMC11418263 DOI: 10.1177/20542704241278544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Post-stroke spasticity and contracture remain prevalent and pose significant challenges in stroke rehabilitation. While non-surgical management is the mainstay, surgical reconstruction offers a valuable adjunct when conservative measures are exhausted. This clinical review article provides an overview of surgical reconstruction for limb spasticity and contracture following adult stroke, encompassing the rationale and specifics of these interventions. It highlights the underutilization of surgical reconstruction in rehabilitation of adult stroke patients with spasticity and contracture, and the importance of multidisciplinary collaboration including surgeons in stroke rehabilitation to optimize functional outcomes.
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Affiliation(s)
- Marvin Man Ting Chung
- Department of Orthopaedics and Traumatology, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wing Yuk Ip
- Department of Orthopaedics and Traumatology, University of Hong Kong, Pok Fu Lam, Hong Kong
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2
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Brown E, Kastner T, Harder J, Cox C, MacKay B. Flexor tenotomies for the treatment of bilateral wrist contracture after traumatic brain injury: A case report. Clin Case Rep 2023; 11:e7869. [PMID: 37744617 PMCID: PMC10517200 DOI: 10.1002/ccr3.7869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Traumatic brain injuries have the potential to cause the development of long-term complications. We aim to show that the use of flexor tenotomies in the treatment of flexion contractures following traumatic brain injury is a viable solution.
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Affiliation(s)
| | - Tyler Kastner
- Texas Tech University Health Sciences CenterLubbockTexasUSA
| | - Justin Harder
- Department of Orthopaedic Hand SurgeryTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Cameron Cox
- Department of Orthopaedic Hand SurgeryTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Brendan MacKay
- Department of Orthopaedic Hand SurgeryTexas Tech University Health Sciences CenterLubbockTexasUSA
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3
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Herzog S, David R, Speirs A, Hashemi M, Winston P. A Case Report Illustrating the Combined Use of Cryoneurolysis and Percutaneous Needle Tenotomy in the Treatment of Longstanding Spastic Shoulder Contractures After Stroke. Arch Rehabil Res Clin Transl 2023; 5:100285. [PMID: 37744199 PMCID: PMC10517357 DOI: 10.1016/j.arrct.2023.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Adduction and internal rotation of the shoulder is a common presentation in post-stroke patients, and can often be caused by spasticity and musculotendinous retraction causing a contracture of the pectoralis major and minor muscles. A post cerebral arteriovenous malfunction rupture patient with severe refractory left shoulder spasticity with contracture was treated with cryoneurolysis to the medial and lateral pectoral nerves, combined with a percutaneous needle tenotomy to the pectoralis major tendon. There was an improvement in shoulder forward flexion, abduction and external rotation immediately and found sustained at 8 weeks by 50°, 45°, and 15°. The patient noted an immediate cessation of limitation of shoulder abduction, a liberation of range of motion of the shoulder, and looseness in their arm and shoulder. They reported a dramatic improvement in their gait, increased independence, and an improvement in overall quality of life in a structured interview 8 weeks after the procedure. The patient relayed a positive experience with the combined neuro-orthopedic procedure of cryoneurolysis and tenotomy for the treatment of their spastic shoulder. This combined treatment could be considered as a management strategy for patients experiencing shoulder spasticity with contracture.
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Affiliation(s)
- Samuel Herzog
- Faculty of Science University of British Columbia, Vancouver BC, Canada
| | - Romain David
- Vancouver Island Health Authority, Victoria, BC, Canada
- Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, 86021 Poitiers, France
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Abby Speirs
- Vancouver Island Health Authority, Victoria, BC, Canada
| | | | - Paul Winston
- Vancouver Island Health Authority, Victoria, BC, Canada
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Faculty of Medicine, Victoria, BC, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, ON, Canada
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Yang SW, Ma SR, Choi JB. The Effect of Kinesio Taping Combined with Virtual-Reality-Based Upper Extremity Training on Upper Extremity Function and Self-Esteem in Stroke Patients. Healthcare (Basel) 2023; 11:1813. [PMID: 37444646 DOI: 10.3390/healthcare11131813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: The purpose of this study is to investigate the effect of virtual-reality-based hand motion training (VRT) in parallel with the Kinesio Taping (KT) technique on upper extremity function in stroke patients and to present a more effective therapeutic basis for virtual reality training intervention. (2) Methods: First, 43 stroke patients were randomly assigned to two groups: 21 experimental subjects and 22 controls. The experimental group performed Kinesio Taping (KT) on the dorsal part of the hand along with virtual-reality-based hand motion training, and the control group performed only virtual-reality-based hand motion training. The intervention was conducted for a total of 30 sessions over 6 weeks. To evaluate changes in upper extremity function, the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL) (including amount of use (AOU) and quality of movement (QOM)) were evaluated. In addition, the Self-Efficacy Scale (SEF) was evaluated to examine the change in the self-esteem of the study subjects. (3) Results: The experimental group who participated in the virtual reality training in parallel with the KT technique showed statistically significant improvement (** p < 0.01) in the FMA-UE, WMFT, and MAL evaluations that investigate changes in upper extremity function. SEF evaluation also showed a statistically significant improvement (** p < 0.01). A statistically significant difference between the two groups was observed in the evaluation of FMA-UE, WMFT, MAL-QOM, and SEF (†p < 0.05), showing that that combined intervention was more effective at improving upper extremity function than the existing VRT intervention. There was no statistical difference between the two groups in the MAL-AOU item, which is an evaluation of upper extremity function (p > 0.05). There was a statistically significant difference between the two groups in the amount of change in upper limb function (††p < 0.01). (4) Conclusions: It was confirmed that virtual-reality-based hand motion training performed in parallel with the KT technique had a positive effect on the recovery of upper extremity function of stroke patients. The fact that the KT technique provided stability to the wrist by assisting the wrist extensor muscles appears to have improved the upper extremity function more effectively than VRT alone.
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Affiliation(s)
- Seo-Won Yang
- Department of Occupational Therapy, Sangji University, 83 Sangjidae-gil, Wonju-si 26339, Republic of Korea
| | - Sung-Ryong Ma
- Department of Occupational Therapy, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Republic of Korea
| | - Jong-Bae Choi
- Department of Occupational Therapy, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Republic of Korea
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Patel R, Rhee PC. Assessment of 30-Day Adverse Events in Single-Event, Multilevel Upper Extremity Surgery in Adult Patients with Upper Motor Neuron Syndrome. Hand (N Y) 2022; 17:933-940. [PMID: 33305596 PMCID: PMC9465791 DOI: 10.1177/1558944720975151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome. METHODS A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery. RESULTS All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1). CONCLUSIONS With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Peter C. Rhee
- Mayo Clinic, Rochester, MN, USA
- Travis Air Force Base, CA, USA
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Fahrenkopf MP, Rhee PC. Surgical Management of Spastic Shoulder Deformities in Adult Patients. J Hand Surg Am 2022; 47:906.e1-906.e9. [PMID: 35660337 DOI: 10.1016/j.jhsa.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/24/2022] [Accepted: 03/16/2022] [Indexed: 02/02/2023]
Abstract
Spastic shoulder deformity in patients with upper motor neuron syndrome results from an imbalance of muscle forces about the shoulder girdle. In typical spastic deformities, the shoulder assumes an adducted and internally rotated posture. The severity of the deformity can range over a spectrum depending on the involved muscle groups, degree of spasticity, and presence of myostatic and/or joint contractures. Surgical options to correct the spastic shoulder deformity can be broadly classified as procedures for the functional versus nonfunctional shoulder or, in other words, preserved versus absent volitional motor control, respectively. Techniques include tenotomy, fractional lengthening, tenodesis, and periarticular soft tissue release. A focused physical examination is imperative in developing a patient-specific treatment algorithm.
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Affiliation(s)
| | - Peter C Rhee
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN.
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Barnham I, Alahmadi S, Spillane B, Pick A, Lamyman M. Surgical interventions in adult upper limb spasticity management: a systematic review. HAND SURGERY & REHABILITATION 2022; 41:426-434. [DOI: 10.1016/j.hansur.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/11/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
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Hashemi M, Sturbois-Nachef N, Keenan MA, Winston P. Surgical Approaches to Upper Limb Spasticity in Adult Patients: A Literature Review. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:709969. [PMID: 36188802 PMCID: PMC9397894 DOI: 10.3389/fresc.2021.709969] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/23/2021] [Indexed: 11/18/2022]
Abstract
Introduction: Spasticity is the main complication of many upper motor neuron disorders. Many studies describe neuro-orthopedic surgeries for the correction of joint and limb deformities due to spasticity, though less in the upper extremity. The bulk of care provided to patients with spasticity is provided by rehabilitation clinicians, however, few of the surgical outcomes have been summarized or appraised in the rehabilitation literature. Objective: To review the literature for neuro-orthopedic surgical techniques in the upper limb and evaluate the level of evidence for their efficacy in adult patients with spasticity. Method: Electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched for English, French as well as Farsi languages human studies from 1980 to July 2, 2020. After removing duplicated articles, 2,855 studies were screened and 80 were found to be included based on the criteria. The studies were then divided into two groups, with 40 in each trial and non-trial. The results of the 40 trial articles were summarized in three groups: shoulder, elbow and forearm, and wrist and finger, and each group was subdivided based on the types of intervention. Results: The level of evidence was evaluated by Sackett's approach. There were no randomized control trial studies found. About, 4 studies for shoulder, 8 studies for elbow and forearm, 26 studies for wrist and finger (including 4 for the thumb in palm deformity), and 2 systematic reviews were found. Around, two out of 40 trial articles were published in the rehabilitation journals, one systematic review in Cochrane, and the remaining 38 were published in the surgical journals. Conclusion: Most surgical procedures are complex, consisting of several techniques based on the problems and goals of the patient. This complexity interferes with the evaluation of every single procedure. Heterogenicity of the participants and the absence of clinical trial studies are other factors of not having a single conclusion. This review reveals that almost all the studies suggested good results after the surgery in carefully selected cases with goals of reducing spasticity and improvement in function, pain, hygiene, and appearance. A more unified approach and criteria are needed to facilitate a collaborative, evidence-based, patient referral, and surgical selection pathway.
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Affiliation(s)
- Mahdis Hashemi
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
- Vancouver Island Health Authority, Victoria, BC, Canada
| | - Nadine Sturbois-Nachef
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
- Orthopédic and Traumatologic Département, University Hospital of Lille, Lille, France
| | - Marry Ann Keenan
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
- Neuro-Orthopaedics, MossRehab Hospital, Elkins Park, PA, United States
- Orthopaedic Surgery (Ret), University of Pennsylvania, Philadelphia, PA, United States
| | - Paul Winston
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
- Vancouver Island Health Authority, Victoria, BC, Canada
- Department of Physical Medicine and Rehabilitation, University of British Colombia, Vancouver, BC, Canada
- *Correspondence: Paul Winston orcid.org/0000-0002-8403-6988
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Coulet B, Coroian F, Chammas M, Laffont I. What can be expected from tendon transfers in the upper limb in central nervous system disorders? HAND SURGERY & REHABILITATION 2021; 41S:S159-S166. [PMID: 34474171 DOI: 10.1016/j.hansur.2020.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 10/20/2022]
Abstract
In addition to motor deficits, central nervous system disorders combine major alterations in the motor pattern with spasticity and over time, contractures. Their varied clinical presentation makes their assessment and the therapeutic strategy more complex. For these reasons, tendon transfers in this population will have more limited indications and above all, will have to be integrated into a complex surgical program combining other procedures such as tendon lengthening, selective neurotomies and joint stabilization. The surgical strategy is far from being obvious. When faced with clinical presentations having very different objectives - functional or comfort only - it is difficult at first sight to build a standardized surgical program. We therefore propose a method to evaluate these patients, thanks to a score (INOM) that integrates prognostic factors and parameters to be corrected surgically. Three components guide this program: a prognostic factor (proximal motor control of the shoulder and elbow), correction of abnormal limb postures and restoration of active elbow, wrist and finger extension. The surgical strategy can be constructed from the INOM score which establishes the priorities for care. Nerve blocks and botulinum toxin injections are essential tools for this analysis. They help distinguish between spasticity and contracture, and can unmask certain antagonistic muscles. A tendon transfer in this population will be just as effective by the function it restores as by the action it suppresses in a malpositioned limb. For each joint, we describe the indications for tendon transfers and their relative role among the techniques with which they must be combined.
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Affiliation(s)
- B Coulet
- Service de chirurgie de la main et du membre supérieur, chirurgie des paralysies, Hôpital Lapeyronie, CHU Montpellier, Avenue du doyen Gaston Giraud, 34295 Montpellier cedex 5, France.
| | - F Coroian
- Service de Médecine Physique et de Réadaptation, Hôpital Lapeyronie, CHU Montpellier, Avenue du doyen Gaston Giraud, 34295 Montpellier cedex 5, France
| | - M Chammas
- Service de chirurgie de la main et du membre supérieur, chirurgie des paralysies, Hôpital Lapeyronie, CHU Montpellier, Avenue du doyen Gaston Giraud, 34295 Montpellier cedex 5, France
| | - I Laffont
- Service de Médecine Physique et de Réadaptation, Hôpital Lapeyronie, CHU Montpellier, Avenue du doyen Gaston Giraud, 34295 Montpellier cedex 5, France
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Fitterer JW, Picelli A, Winston P. A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm. Front Neurol 2021; 12:668370. [PMID: 34122312 PMCID: PMC8194087 DOI: 10.3389/fneur.2021.668370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway. Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators. Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.
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Affiliation(s)
- John W Fitterer
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
| | - Alessandro Picelli
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada.,Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy
| | - Paul Winston
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada.,Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, BC, Canada
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Shirzadi A, Farzad M, Farhoud A, Shafiee E. Application of continuous passive motion in patients with distal radius fractures: A randomized clinical trial. HAND SURGERY & REHABILITATION 2020; 39:522-527. [DOI: 10.1016/j.hansur.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
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Patel R, Rhee PC. Team Approach: Multidisciplinary Perioperative Care in Upper-Extremity Reconstruction for Adults with Spasticity and Contractures. JBJS Rev 2020; 8:e0164. [DOI: 10.2106/jbjs.rvw.19.00164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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13
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Rhee PC. Surgical Management of the Spastic Forearm, Wrist, and Hand: Evidence-Based Treatment Recommendations. JBJS Rev 2019; 7:e5. [DOI: 10.2106/jbjs.rvw.18.00172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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14
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Rhee PC. Surgical Management of Upper Extremity Deformities in Patients With Upper Motor Neuron Syndrome. J Hand Surg Am 2019; 44:223-235. [PMID: 30266480 DOI: 10.1016/j.jhsa.2018.07.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/09/2018] [Indexed: 02/02/2023]
Abstract
Injury to the central nervous system can create upper extremity deformities and dysfunction, typically caused by a cerebrovascular accident, traumatic brain injury, anoxic brain injury, or spinal cord injury. Regardless of the etiology, disruption of inhibitory upper motor neuron (UMN) pathways can lead to a constellation of symptoms such as muscle weakness, decreased motor control, hyperexcitable tendon reflexes, muscle spasticity, and agonist-antagonist cocontraction that characterizes a condition known as UMN syndrome. The magnitude of neurorecovery varies among patients who have sustained brain injuries and can be classified as having a functional or nonfunctional upper extremity based on the presence or absence of volitional motor control at a specific joint, respectively. Many surgical procedures can be employed to optimize function, decrease pain, improve hygiene, and enhance cosmesis in patients with UMN syndrome.
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Abstract
Upper motor neuron disease or injury can lead to muscle spasticity or nonfunction throughout the body. Imbalance in muscle forces predisposes patients to development of functional deficiencies, contractures, pain, and poor hygiene. The approach to neuro-orthopaedic patients is by necessity multidisciplinary, because a variety of nonsurgical and surgical options are available. In evaluating each patient, surgeons must consider the extent and quality of any deformity, potential for improvement in function, the ability to alleviate pain, and potential for improvement in hygiene and cosmesis. Surgical techniques include tendon lengthenings, releases, transfers, osteotomies, and bony fusions.
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Affiliation(s)
- Matthew T Winterton
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Keith Baldwin
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, University of Pennsylvania, 2 Wood Center, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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16
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Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:e98-e169. [PMID: 27145936 DOI: 10.1161/str.0000000000000098] [Citation(s) in RCA: 1596] [Impact Index Per Article: 199.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. CONCLUSIONS As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).
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Photopoulos CD, Namdari S, Baldwin KD, Keenan MA. Decision-Making in the Treatment of the Spastic Shoulder and Elbow: Tendon Release Versus Tendon Lengthening. JBJS Rev 2014; 2:01874474-201410000-00004. [DOI: 10.2106/jbjs.rvw.m.00132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Namdari S, Baldwin K, Horneff JG, Keenan MA. Orthopedic evaluation and surgical treatment of the spastic shoulder. Orthop Clin North Am 2013; 44:605-14. [PMID: 24095075 DOI: 10.1016/j.ocl.2013.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The spastic shoulder can often result from brain injury that causes disruption in the upper motor neuron inhibitory pathways. Patients develop dyssynergic muscle activation, muscle weakness, and contractures and often present with fixed adduction and internal rotation deformity to the limb. This article reviews the importance of a comprehensive preoperative evaluation and discusses appropriate treatment strategies based on preoperative evaluation.
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Affiliation(s)
- Surena Namdari
- Thomas Jefferson University Hospital, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA.
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Namdari S, Horneff JG, Baldwin K, Keenan MA. Muscle releases to improve passive motion and relieve pain in patients with spastic hemiplegia and elbow flexion contractures. J Shoulder Elbow Surg 2012; 21:1357-62. [PMID: 22217645 DOI: 10.1016/j.jse.2011.09.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 09/16/2011] [Accepted: 09/24/2011] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Patients with spastic hemiplegia after upper motor neuron (UMN) injury can develop elbow contractures. This study evaluated outcomes of elbow releases in treating spastic elbow flexion contractures in hemiplegic patients. METHODS Adults with spastic hemiplegia due to UMN injury who underwent elbow releases (brachialis, brachioradialis, and biceps muscles) were included. Nonoperative treatment was unsuccessful in all patients. Patients complained of difficulty with passive functions. Passive range of motion (ROM), pain relief, Modified Ashworth spasticity score, and complications were evaluated preoperatively and postoperatively. RESULTS There were 8 men and 21 women with an average age of 52.4 years (range, 24.1-81.4 years). Seventeen patients had pain preoperatively. Postoperative follow-up was a mean of 1.7 years (range, 1-4.5 years). Preoperatively, patients lacked a mean of 78° of passive elbow extension compared with 17° postoperatively (P < .001). The Modified Ashworth spasticity score improved from 3.3 to 1.4 (P = .001). All patients with preoperative pain had improved pain relief, and 16 (94%) were pain-free. There were 3 wound complications that resolved nonsurgically and 1 recurrence. Age, sex, etiology, and chronicity of UMN injury were not associated with improvement in motion or pain relief (P > .05). CONCLUSION Releases of the brachialis, brachioradialis, and biceps muscles can be an effective means of pain relief, improved passive ROM, and decreased spasticity in patients with elbow flexion deformity after UMN injury.
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Affiliation(s)
- Surena Namdari
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Outcomes of tendon fractional lengthenings to improve shoulder function in patients with spastic hemiparesis. J Shoulder Elbow Surg 2012; 21:691-8. [PMID: 21719314 DOI: 10.1016/j.jse.2011.03.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/14/2011] [Accepted: 03/27/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with spastic hemiparesis after upper motor neuron (UMN) injury often exhibit limited shoulder movement. We evaluated the outcomes of shoulder tendon fractional lengthenings in patients with spasticity and preserved volitional control. METHODS A consecutive series of 34 adults with spastic hemiparesis from UMN injury (23 post-stroke, 11 post-traumatic brain injury) and limited shoulder movement with preserved volitional motor control who underwent shoulder tendon fractional lengthenings (pectoralis major, latissimus dorsi, teres major) were evaluated. Active and passive shoulder motion, spasticity, pain, and satisfaction were considered pre- and postoperatively. RESULTS There were 15 males and 19 females with a mean age of 44.1 years. Mean follow-up was 12.2 months. Mean Modified Ashworth spasticity score was 2.4 preoperatively compared to 1.9 postoperatively (P = .001). Active flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .001) with most dramatic gains in external rotation. Similarly, passive extension, flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .01). Ninety-four percent (15/16) with preoperative pain had improved pain relief postoperatively with 14 (88%) being pain-free. Thirty-one (92%) were satisfied with the outcome. CONCLUSION Shoulder tendon lengthenings can be an effective means of pain-relief, improved motion, enhanced active motor function, and decreased spasticity in patients with spastic hemiparesis from UMN injury.
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Namdari S, Keenan MA. Treatment of glenohumeral arthrosis and inferior shoulder subluxation in an adult with cerebral palsy: a case report. J Bone Joint Surg Am 2011; 93:e1401-5. [PMID: 22159862 DOI: 10.2106/jbjs.k.00201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Surena Namdari
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Streets, Philadelphia, PA 19104, USA
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Namdari S, Ann Keenan M. Biceps Suspension Procedure for Treatment of Painful Inferior Glenohumeral Subluxation in Hemiparetic Patients. JBJS Essent Surg Tech 2011; 1:e11. [PMID: 34377588 DOI: 10.2106/jbjs.st.k.00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction This article describes our biceps suspension procedure for painful inferior subluxation of the glenohumeral joint in hemiparetic patients. Step 1 Position Patient and Expose the Biceps Tendon Position the patient supine and expose the long head of the biceps tendon. Step 2 Create Tunnel Use a curet to connect holes drilled at the superior and inferior aspects of the lesser tuberosity. Step 3 Prepare Biceps Tendon Incise the tendon at the musculotendinous junction to preserve as much length of the biceps tendon as possible. Step 4 Create Suspension Create a loop with the tendon, and suture the distal end to the proximal end. Step 5 Postoperative Protocol Use a sling for three months, followed by active range-of-motion exercises. Results In summary, all patients noted pain relief after surgery, ten (of eleven) noted decreased deformity, and nine were "very satisfied" with the outcome. What to Watch For IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Surena Namdari
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Streets, 2nd Floor, Silverstein Building, Philadelphia, PA 19104. E-mail address for M.A. Keenan:
| | - Mary Ann Keenan
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Streets, 2nd Floor, Silverstein Building, Philadelphia, PA 19104. E-mail address for M.A. Keenan:
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