Analysis of tetraplegic reaching in their 3D workspace following posterior deltoid-triceps tendon transfer

Clinical outcome of elbow extension restoration by posterior deltoid-to-triceps transfer in tetraplegia: a retrospective review of 51 patients

In this study, we report the functional and perceived outcomes of 51 posterior deltoid-to-triceps transfers in patients with tetraplegia. With a minimum follow-up of 12 months, patients were divided into two subcategories based on preoperative posterior deltoid strength: Medical Research Council (MRC) 3 and MRC 4/5. At 12-month follow-up, all patients achieved antigravity elbow extension. Patients with a stronger posterior deltoid (MRC 4/5) attained an elbow extension with a strength grade MRC 3.7 (SD 0.6), while those with a weaker posterior deltoid (MRC 3) reached an elbow extension of MRC 3.1 (SD 0.6). Patient-reported outcome measure was evaluated using the Canadian Occupational Performance Measure (COPM) and demonstrated a significant improvement for both performance and satisfaction. No difference in the COPM scores could be found between the two subcategories. This study indicates that tetraplegic patients with a posterior deltoid strength grade of both MRC 4/5 as well as MRC 3 benefit from the procedure.Level of evidence: III.

Evaluation of Upper Extremity Reachable Workspace in Children With Brachial Plexus Birth Injury

PURPOSE

Brachial plexus birth injury (BPBI) results in upper extremity (UE) movement limitations. Current assessments of UE function used to inform clinical decision-making only evaluate a limited set of static postures and/or movements and have been criticized for being insensitive to certain meaningful differences in function. Reachable workspace provides a numeric and visual assessment of global UE movement ability by quantifying the regions in space that patients can reach with their hands, and it can be collected using real-time feedback to elicit a best-effort acquisition of function. This study evaluated the ability of a real-time feedback reachable workspace tool to assess UE movement in BPBI.

METHODS

Twenty-two children with BPBI participated. Reachable workspace data were collected with three-dimensional motion capture using real-time visual feedback to measure UE reaching ability in all regions surrounding the body. All outer, far-from-body points reached by the hand were recorded and analyzed by region. A two-way, within-subjects analysis of variance was used to assess interlimb differences in percentage workspace reached and median reach distance for each of the six regions.

RESULTS

The affected limb had significantly less percentage workspace reached than the unaffected limb for all six regions (mean interlimb differences by region, 5.7%-38.6%). The affected limb had significantly less median reach distance than the unaffected limb for all six regions (mean interlimb differences by region, 3.1%-36.8%).

CONCLUSIONS

The workspace approach was capable of detecting UE movement impairments of the BPBI-affected limb. The reported deficits in workspace on the affected limb correspond to common movement impairments in BPBI, such as limitations in shoulder elevation, external rotation, extension, and elbow extension.

CLINICAL RELEVANCE

The real-time feedback reachable workspace tool is sufficiently robust for assessing UE movement impairments in children with BPBI.

Clinical, Kinematic and Muscle Assessment of Bilateral Coordinated Upper-Limb Movements Following Cervical Spinal Cord Injury

Cervical spinal cord injury (cSCI) often results in bilateral impairment of the arms, leading to difficulties in performing daily activities. However, little is known about the neuromotor alterations that affect the ability of individuals with cSCI to perform coordinated movements with both arms. To address this issue, we developed and tested a functional assessment that integrates clinical, kinematic, and muscle activity measures, including the evaluation of bilateral arm movements. Twelve subjects with a C5-C7 spinal lesion and six unimpaired subjects underwent an evaluation that included three tests: the Manual Muscle Test, Range Of Motion test and Arm stabilisation test, a subsection of the "Van Lieshout arm/hand function test". During the latter, we recorded kinematic and muscle activity data from the upper-body during the execution of a set of movements that required participants to stabilize both arms against gravity at different configurations. Analytical methods, including muscle synergies, spinal maps, and Principal Component Analysis, were used to analyse the data. Clinical tests detected limitations in shoulder abduction-flexion of cSCI participants and alterations in elbows-wrists motor function. The instrumented assessment provided insight into how these limitations impacted the ability of cSCI participants to perform bilateral movements. They exhibited severe difficulty in performing movements involving over-the-shoulder motion and shoulder internal rotation due to altered patterns of activity of the scapular stabilizer muscles, latissimus dorsi, pectoralis, and triceps. Our findings shed light on the bilateral neuromotor changes that occur post-cSCI addressing not only motor deficits, but also the underlying abnormal, weak, or silent muscle activations.

An international survey mapping practice and barriers for upper-limb assessments in movement analysis

BACKGROUND

Upper-limb movement analysis could improve our understanding of function, pathological mechanisms and inform rehabilitation and surgical decision-making. Despite the potential benefits, the use of clinical upper-limb motion analysis is not well established and it is not clear what the barriers to clinical motion analysis are.

RESEARCH QUESTION

What is current practice for assessment of the upper-limb and what are the barriers currently limiting upper-limb motion analysis being routinely used in clinical practice?

METHODS

A web-based questionnaire was used to collect responses through international professional movement analysis society coordinators over an 18 month-period.

RESULTS

A total of 55 responses were received and 75% of laboratories performed some form of upper-limb assessment. In total 44% of laboratories performed upper-limb assessments for clinical purposes and only 33% did 3D-movement analysis. The most commonly seen patient groups were those with neurological injury e.g. cerebral palsy (adults and children) and normal controls for comparative purposes. Barriers to upper-limb motion analysis were the availability of standard reference tasks, protocols, software, funding and clinical need. Practice was variable with no universally identified approaches to upper-limb movement analysis. Differences in practice were also identified between laboratories accredited by the Clinical Movement Analysis Society of the UK and Ireland and other international professional societies and affiliate laboratories.

SIGNIFICANCE

These findings may be used to inform the development of practice standards and progress the use of clinical motion analysis in the upper-limb. This study provides a summary and describes current practice, potentially providing access to peer support and experience for laboratories with an identified clinical need looking to conduct upper-limb assessment. A national picture (UK and Ireland) for practice regarding upper-limb assessment in this sub-population is presented. We have laid out further work which is needed to establish standards of practice or consensus initiatives for enhancing clinical upper-limb motion analysis.

Reachable workspace with real-time motion capture feedback to quantify upper extremity function: A study on children with brachial plexus birth injury

Clinical upper extremity (UE) functional assessments and motion capture measures are limited to a set of postures and/or motions that may provide an incomplete evaluation of UE functionality. Reachable workspace analysis offers a more global assessment of UE function, but is reliant on patient compliance with instructions and may result in underestimates of a patient's true UE function. This study evaluated a clinical tool that incorporates real-time visual feedback with motion capture to provide an innovative means of engaging patients to ensure a 'best effort' quantification of their available UE workspace. Reachable workspace for 10 children with brachial plexus birth injury was collected with and without real-time feedback on the affected and unaffected limbs. Real-time feedback consisted of subjects reaching for virtual targets surrounding their physical space using a virtual cursor controlled by the real-time location of their hand. Real-time feedback resulted in significantly greater workspace in multiple regions on both the affected (3/6 octants; mean differences 10.8%-20.0%) and unaffected (6/6 octants; mean differences 24.3%-40.0%) limbs. Use of real-time feedback also yielded significant interlimb differences in workspace across more regions (4/6 octants; mean differences 29.0%-39.9% vs. 1/6 octants; mean difference 17%). Finally, real-time feedback resulted in significant interlimb differences in median reach distance across more regions (4/6 octants; mean differences 7.5%-44.8% vs. 1/6 octants; mean difference 11.2%). A reachable workspace tool with real-time feedback results in more workspace and UE function recorded and offers a highly visual and intuitive depiction of a patient's UE abilities.

A Comparative Outcome Study of Hamstring Versus Tibialis Anterior and Synthetic Grafts for Deltoid to Triceps Transfers

PURPOSE

To assess elbow extension strength and complications after deltoid-triceps transfers using hamstring tendon graft compared with tibialis anterior and synthetic tendon grafts.

METHODS

A retrospective review of deltoid-triceps transfers in patients with tetraplegia performed between 1983 and 2014.

RESULTS

Seventy-five people (136 arms) had surgery performed, with the majority undergoing simultaneous bilateral surgery (n = 61; 81%). Tibialis anterior tendon grafts were used in 68 arms, synthetic grafts in 23 arms, and hamstring tendon grafts in 45 arms. The average age at surgery was 31 years. Sixty-three arms (46%) were assessed between 12 and 24 months after surgery. Seventy percent of the group (n = 54) were able to extend their elbow against gravity (grade 3 of 5 or greater) following surgery. Seventy-nine percent of those with hamstring grafts achieved grade 3 of 5 or more compared with 77% with tibialis anterior and 33% with synthetic grafts. There was a statistically significant difference in postsurgery elbow extension between the tibialis anterior group and the synthetic graft group and the hamstring and the synthetic graft group but not between the tibialis anterior and the hamstring group. Complications occurred in 19 arms (14%), the majority occurring immediately after surgery and associated with the wounds. The remaining complications were with the synthetic graft group in which dehiscence of the proximal attachment occurred in 30% of the arms.

CONCLUSIONS

Autologous tendon grafting is associated with achievement of antigravity elbow extension in a greater proportion of individuals than with prosthetic grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Motor imagery reinforces brain compensation of reach-to-grasp movement after cervical spinal cord injury

Individuals with cervical spinal cord injury (SCI) that causes tetraplegia are challenged with dramatic sensorimotor deficits. However, certain rehabilitation techniques may significantly enhance their autonomy by restoring reach-to-grasp movements. Among others, evidence of motor imagery (MI) benefits for neurological rehabilitation of upper limb movements is growing. This literature review addresses MI effectiveness during reach-to-grasp rehabilitation after tetraplegia. Among articles from MEDLINE published between 1966 and 2015, we selected ten studies including 34 participants with C4 to C7 tetraplegia and 22 healthy controls published during the last 15 years. We found that MI of possible non-paralyzed movements improved reach-to-grasp performance by: (i) increasing both tenodesis grasp capabilities and muscle strength; (ii) decreasing movement time (MT), and trajectory variability; and (iii) reducing the abnormally increased brain activity. MI can also strengthen motor commands by potentiating recruitment and synchronization of motoneurons, which leads to improved recovery. These improvements reflect brain adaptations induced by MI. Furthermore, MI can be used to control brain-computer interfaces (BCI) that successfully restore grasp capabilities. These results highlight the growing interest for MI and its potential to recover functional grasping in individuals with tetraplegia, and motivate the need for further studies to substantiate it.

Reliability and validity of active-seated: An outcome in dystrophinopathy

INTRODUCTION

Traditional upper extremity measures typically focus on distal abilities and do not quantify the unique progression of decline in dystrophinopathy. We designed ACTIVE-seated to meet this need. Our objective was to establish the tool's validity and reliability.

METHODS

ACTIVE-seated uses the Microsoft Kinect gaming interface to quantify functional reaching ability while playing a custom-designed game. A skeletal tracking algorithm was used to determine the furthest arm excursion in all planes in 61 subjects with dystrophinopathy and 16 controls.

RESULTS

Total reachable area was scaled based on arm length to standardize comparisons across subjects and accommodate growth. ACTIVE-seated discriminately ranked subjects from normal controls and by Brooke level (P < 0.001). Scores were highly correlated with parent reports of daily activities and mobility (P < 0.05). Test-retest reliability of ACTIVE-seated was excellent (ICC = 0.97, P < 0.0001).

CONCLUSIONS

Initial evaluation of reliability and validity suggests that ACTIVE-seated shows promise as a clinical and research outcome for individuals with dystrophinopathy.

Upper limb kinematics after cervical spinal cord injury: a review

Although a number of upper limb kinematic studies have been conducted, no review actually addresses the key-features of open-chain upper limb movements after cervical spinal cord injury (SCI). The aim of this literature review is to provide a clear understanding of motor control and kinematic changes during open-chain upper limb reaching, reach-to-grasp, overhead movements, and fast elbow flexion movements after tetraplegia. Using data from MEDLINE between 1966 and December 2014, we examined temporal and spatial kinematic measures and when available electromyographic recordings. We included fifteen control case and three series case studies with a total of 164 SCI participants and 131 healthy control participants. SCI participants efficiently performed a broad range of tasks with their upper limb and movements were planned and executed with strong kinematic invariants like movement endpoint accuracy and minimal cost. Our review revealed that elbow extension without triceps brachii relies on increased scapulothoracic and glenohumeral movements providing a dynamic coupling between shoulder and elbow. Furthermore, contrary to normal grasping patterns where grasping is prepared during the transport phase, reaching and grasping are performed successively after SCI. The prolonged transport phase ensures correct hand placement while the grasping relies on wrist extension eliciting either whole hand or lateral grip. One of the main kinematic characteristics observed after tetraplegia is motor slowing attested by increased movement time. This could be caused by (i) decreased strength, (ii) triceps brachii paralysis which disrupts normal agonist-antagonist co-contractions, (iii) accuracy preservation at movement endpoint, and/or (iv) grasping relying on tenodesis. Another feature is a reduction of maximal superior reaching during overhead movements which could be caused by i) strength deficit in agonist muscles like pectoralis major, ii) strength deficit in proximal synergic muscles responsible for scapulothoracic and glenohumeral joint stability, iii) strength deficit in distal synergic muscles preventing the maintenance of elbow extension by shoulder elbow dynamic coupling, iv) shoulder joint ankyloses, and/or v) shoulder pain. Further studies on open chain movements are needed to identify the contribution of each of these factors in order to tailor upper limb rehabilitation programs for SCI individuals.

Primary and submovement control of aiming in C6 tetraplegics following posterior deltoid transfer

BACKGROUND

Upper limb motor control in fast, goal-directed aiming is altered in tetraplegics following posterior-deltoid musculotendinous transfer. Specifically, movements have similar end-point accuracy but longer duration and lower peak velocity than those of age-matched, neurotypical controls. Here, we examine in detail the interplay between primary movement and submovement phases in five C6 tetraplegic and five control participants.

METHODS

Aiming movements were performed in two directions (20 cm away or toward), with or without vision. Trials that contained a submovement phase (i.e., discontinuity in velocity, acceleration or jerk) were identified. Discrete kinematic variables were then extracted on the primary and submovements phases.

RESULTS

The presence of submovements did not differ between the tetraplegic (68%) and control (57%) groups, and almost all submovements resulted from acceleration and jerk discontinuities. Tetraplegics tended to make a smaller amplitude primary movement, which had lower peak velocity and greater spatial variability at peak velocity. This was followed by a larger amplitude and longer duration secondary submovement. Peak velocity of primary movement was not related to submovement incidence. Together, the primary and submovement phases of both groups were equally effective in reducing end-point error.

CONCLUSIONS

C6 tetraplegic participants exhibit some subtle differences in measures of motor behaviour compared to control participants, but importantly feedforward and feedback processes work effectively in combination to achieve accurate goal-directed aiming.

Surgical rehabilitation of a tetraplegic hand: comparison of various methods of reconstructing an absent pinch and hook

BACKGROUND

Since complete functional restoration after spinal cord injury may not always be possible, the major focus in such cases has to be on rehabilitation. We performed surgery in such patients to reconstruct important absent hand functions viz. pinch and hook using various methods described in literature and compared their outcome.

METHODS

A total of 29 procedures were performed in ten patients (18 upper limbs) with tetraparesis consequent to cervical spine injury distal to C6 level who had at least grade 3 power of elbow extension but had not documented any significant improvement in hand function, at least 6 months post injury. Key pinch was reconstructed in 14 upper limbs using brachioradialis (BR) to flexor pollicis longus (FPL) transfer in 11 and pronator teres (PT) to FPL transfer in three limbs. Hook was reconstructed in 15 upper limbs: PT to flexor digitorum profundus (FDP) (n = 7), BR to FDP (n = 2), and FDP tenodesis (n = 6). The gains achieved were measured at intervals of 4 weeks, 3 months, and 6 months postoperatively and at a final possible follow-up of every patient, the average follow-up being 32 months. The functional outcome was assessed by the modified Lamb and Chan score.

RESULTS

For key pinch reconstruction, both BR and PT turned to be equally efficacious donors, while for hook reconstruction, PT and BR transfer to FDP turned out to be superior to FDP tenodesis. The functional outcome as assessed by the modified Lamb and Chan score revealed good to fair outcome in 70 % of patients while poor in 30 %. Complications resulted from stretching of transfer, rupture of tenodesis, and maltensioning.

CONCLUSION

Surgery can routinely be offered to suitable tetraplegics with deficient hand function in whom no useful recovery of any function is expected with at least 6 months elapsed post injury. Single-staged bilateral procedures enable maximal possible rehabilitation in minimal possible duration.

Proof of concept of the ability of the kinect to quantify upper extremity function in dystrophinopathy

INTRODUCTION

Individuals with dystrophinopathy lose upper extremity strength in proximal muscles followed by those more distal. Current upper extremity evaluation tools fail to fully capture changes in upper extremity strength and function across the disease spectrum as they tend to focus solely on distal ability. The Kinect by Microsoft is a gaming interface that can gather positional information about an individual's upper extremity movement which can be used to determine functional reaching volume, velocity of movement, and rate of fatigue while playing an engaging video game. The purpose of this study was to determine the feasibility of using the Kinect platform to assess upper extremity function in individuals with dystrophinopathy across the spectrum of abilities.

METHODS

Investigators developed a proof-of-concept device, ACTIVE (Abilities Captured Through Interactive Video Evaluation), to measure functional reaching volume, movement velocity, and rate of fatigue. Five subjects with dystrophinopathy and 5 normal controls were tested using ACTIVE during one testing session. A single subject with dystrophinopathy was simultaneously tested with ACTIVE and a marker-based motion analysis system to establish preliminary validity of measurements.

RESULTS

ACTIVE proof-of-concept ranked the upper extremity abilities of subjects with dystrophinopathy by Brooke score, and also differentiated them from performance of normal controls for the functional reaching volume and velocity tests. Preliminary test-retest reliability of the ACTIVE for 2 sequential trials was excellent for functional reaching volume (ICC=0.986, p<0.001) and velocity trials (ICC=0.963, p<0.001).

DISCUSSION

The data from our pilot study with ACTIVE proof-of-concept demonstrates that newly available gaming technology has potential to be used to create a low-cost, widely-accessible and functional upper extremity outcome measure for use with children and adults with dystrophinopathy.

Reliability of movement workspace measurements in a passive arm orthosis used in spinal cord injury rehabilitation

BACKGROUND

Robotic and non-robotic training devices are increasingly being used in the rehabilitation of upper limb function in subjects with neurological disorders. As well as being used for training such devices can also provide ongoing assessments during the training sessions. Therefore, it is mandatory to understand the reliability and validity of such measurements when used in a clinical setting. The aim of this study was to evaluate the reliability of movement measures as assessed in the Armeo Spring system for the eventual application to the rehabilitation of patients suffering from cervical spinal cord injury (SCI).

METHODS

Reliability (intra- and inter-rater reliability) of the movement workspace (representing multiple ranges of movement) and the influence of varying seating conditions (5 different chair conditions) was assessed in twenty control subjects. In eight patients with cervical SCI the test-retest reliability (tested twice on the same day by the same rater) was assessed as well as a correlation of the movement workspace to retrieve self-care items as scored by the spinal cord independence measure (SCIM 3).

RESULTS

Analysis of workspace measures in control subjects revealed intra-class correlation coefficients (ICC) ranging from 0.747 to 0.837 for the intra-rater reliability and from 0.661 to 0.855 for the inter-rater reliability. Test-retest analysis in SCI patients showed a similar high reliability with ICC = 0.858. Also the reliability of the movement workspace between different seating conditions was good with ICCs ranging from 0.844 to 0.915. The movement workspace correlated significantly with the SCIM3 self-care items (p < 0.05, rho = 0.72).

CONCLUSION

The upper limb movement workspace measures assessed in the Armeo Spring device revealed fair to good clinical reliability. These findings suggest that measures retrieved from such a training device can be used to monitor changes in upper limb function over time. The correlation between the workspace measures and SCIM3 self-care items indicates that such measures might also be valuable to document the progress of clinical rehabilitation, however further detailed studies are required.

Sensory-motor equivalence: manual aiming in C6 tetraplegics following musculotendinous transfer surgery at the elbow

Cervical spinal lesions at C6 result in paralysis of the triceps brachii while leaving deltoid and elbow flexor function intact. We examined the spatial-temporal characteristics of goal-directed aiming movements performed by C6 tetraplegics who had undergone musculotendinous transfer surgery in which the posterior deltoid replaces the triceps as the elbow extensor. On some trials, liquid crystal goggles were used to eliminate vision of the limb and target upon movement initiation. Although tetraplegic participants achieved the same degree of movement accuracy/consistency as control participants, their movement times were longer regardless of whether the movements were made away from (elbow extension) or towards the body (elbow flexion). Longer movement times were related to lower peak velocities, and not the symmetry of the aiming profiles. The tetraplegic participants were no more dependent on visual feedback for limb regulation than control participants. Although the characteristics of the movement trajectories were surprisingly similar, in both vision conditions, tetraplegics required more real and proportional time to reduce spatial variability in the limb's trajectory for elbow extensions. Our results indicate that the sensorimotor system is adaptable and that the representations governing limb control are not muscle specific.