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Zerbinati P, Mazzoli D, Galletti M, Basini G, Rambelli C, Mascioli F, Bò MC, Delia C, Petroselli L, Vulpiani MC, Prati P, Bemporad J, Merlo A. A survey on the short to medium-term satisfaction of neurological patients treated by functional surgery for the correction of limb deformities. Curr Med Res Opin 2024:1-10. [PMID: 38756086 DOI: 10.1080/03007995.2024.2352855] [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: 01/16/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES Functional surgery (FS) is often used to correct congenital or acquired deformities in neurological patients. Along with functional results, short- and medium-term patient satisfaction should always be considered a key goal of surgery and rehabilitation. The aim of this study is to assess the short to medium-term satisfaction of patients who underwent FS and its correlation with perceived improvements. METHODS Invitation to an anonymous online survey was sent via e-mail to all neurological adult patients or caregivers of children who underwent lower or upper limb FS over the 2018-2020 period. The survey investigated patients' satisfaction with the surgery and the variation in pain, ADLs, level of independence, body image, self-esteem, social interaction skills, participation in social events, leisure activities and sports, and use of orthoses or walking aids. Descriptive data analysis was performed. Correlations were assessed using Kendall's tau. RESULTS 122 out of 324 adults and 53 out of 163 children's caregivers filled out the questionnaire, with a response rate approaching 40%. Eighty-three percent of adult respondents and 87% of the children's caregivers were satisfied or very satisfied in the short and medium terms and reported their expectations had been met. Satisfaction was significantly correlated (p < 0.01) with improvements in functional abilities, social participation, self-esteem, and pain reduction. Half of the adults and 40% of children stopped using their orthoses or replaced them with lighter ones. Dissatisfaction and worsened conditions were reported by <10% of the respondents. CONCLUSION According to patients and caregivers, FS was satisfactory in the short and medium terms, following improvements in all the ICF domains for most patients.
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Affiliation(s)
- Paolo Zerbinati
- Neuro-Orthopedic Surgery Unit, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Davide Mazzoli
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Martina Galletti
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Giacomo Basini
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Chiara Rambelli
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Francesca Mascioli
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Maria Chiara Bò
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Caterina Delia
- Azienda Ospedaliero-Universitaria Sant'Andrea, Roma, Italy
| | | | | | - Paolo Prati
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Jonathan Bemporad
- Neurologic Rehabilitation Unit, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
| | - Andrea Merlo
- Gait&Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, RN, Italy
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Verduzco-Gutierrez M, Raghavan P, Pruente J, Moon D, List CM, Hornyak JE, Gul F, Deshpande S, Biffl S, Al Lawati Z, Alfaro A. AAPM&R consensus guidance on spasticity assessment and management. PM R 2024. [PMID: 38770827 DOI: 10.1002/pmrj.13211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/19/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care. OBJECTIVE To develop consensus-based practice recommendations to identify and address gaps in spasticity care. METHODS The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations. RESULTS The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity. CONCLUSION This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.
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Affiliation(s)
- Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation and Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica Pruente
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Moon
- Department of Physical Medicine and Rehabilitation, Jefferson Moss-Magee Rehabilitation Hospital, Elkins Park, Pennsylvania, USA
| | | | - Joseph Edward Hornyak
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Fatma Gul
- Department of Physical Medicine and Rehabilitation Department, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Supreet Deshpande
- Department of Pediatric Rehabilitation Medicine, Gillette Children's Hospital, St.Paul, Minnesota, USA
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Susan Biffl
- Division Pediatric Rehabilitation Medicine Department of Orthopedic Surgery, UCSD Rady Children's Hospital, San Diego, California, USA
| | - Zainab Al Lawati
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abraham Alfaro
- Rehabilitation Medicine, AtlantiCare Health Services, Inc., Federally Qualified Health Center (FQHC), Atlantic City, New Jersey, USA
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De Lepeleere B, Fitoussi F. Elbow Flexor Release Combined With Selective Neurectomy of Musculocutaneous Nerve for Spastic Elbow Flexion Deformity in Children and Adolescents. J Pediatr Orthop 2024:01241398-990000000-00567. [PMID: 38770666 DOI: 10.1097/bpo.0000000000002729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Spasticity of the elbow flexors causes a dynamic and/or static elbow flexion deformity. This position interferes with the functional use of the hand, is aesthetically unpleasant and can cause problems with hygiene and comfort. A lengthening procedure of elbow flexor muscles can improve elbow posture and range of motion. However, causal spasticity is not addressed directly. Selective neurectomy of the musculocutaneous nerve has a direct effect on underlying spasticity but is not sufficient when contracture is present. In this study, we examine the long-term results of a combined surgical approach: a release procedure of the elbow flexors and selective neurectomy of the musculocutaneous nerve. METHODS A retrospective study of 14 patients with spastic flexion deformity of the elbow was performed. After a mean follow-up of 52.6 months (SD 33, range 12 to 113), the results of the combined surgical approach were evaluated. Spontaneous position of the elbow and active and passive range of motion were assesses using goniometry. Spasticity was assessed using the Modified Ashworth Scale. Function of the affected upper limb before and after surgery was assessed by the House functional classification. Patient and caretaker's satisfaction were assessed using a visual analogue scale. RESULTS The mean decrease of passive elbow extension deficit was 34 degrees (SD 21.3, P<0.05). Active elbow extension increased with a mean of 41 degrees (SD 16.5, P<0.05). Spontaneous position elbow flexion decreased by a mean of 40 degrees (SD 21.1, P<0.05).The Modified Ashworth score decreased significantly (P<0.05) from 3.27 (range 1 to 4) preoperatively to 0.64 (range 0 to 4) postoperatively.The difference between the House score preoperatively and postoperatively was not significant (P=0.180). Mean patient satisfaction was 8.2/10 (SD 2.7, range 2 to 10) and mean caregiver satisfaction was 7.1/10 (SD 2.7, range 1 to 10). CONCLUSION A combined surgical approach to elbow flexion deformity in the form of a lengthening procedure and selective neurectomy of the elbow flexors result in a significant and sustained improvement of the spontaneous position, active and passive elbow extension and elbow flexor spasticity and high patient and caregiver satisfaction. LEVEL OF EVIDENCE Case series, level IV.
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Affiliation(s)
- Bram De Lepeleere
- Department of Physical Medicine and Orthopaedic Surgery, Ghent University, Corneel Heymanslaan, Ghent, Belgium
| | - Frank Fitoussi
- Department of Pediatric Orthopedic and Reconstructive Surgery, Sorbonne Medical University, Trousseau Hospital, Paris, France
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Galletti M, Mazzoli D, Zerbinati P, Rambelli C, Basini G, Prati P, Mascioli F, Masiero S, Merlo A. Short-term reduction of ankle spasticity after surgical lengthening of the triceps surae in chronic post-stroke patients: a retrospective cohort study. Front Neurol 2024; 15:1342777. [PMID: 38562430 PMCID: PMC10984266 DOI: 10.3389/fneur.2024.1342777] [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] [Received: 11/22/2023] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction In post-stroke patients with equinovarus foot deformity (EVFD), soft tissue rearrangements may contribute to muscle overactivity when a muscle is stretched or tension is applied. Therefore, we investigated the effects of surgically restoring the triceps surae (TS) length and lengthening ability on TS spasticity. Methods This retrospective study included chronic post-stroke patients who underwent neuro-orthopedic surgery inclusive of TS lengthening. TS spasticity was measured using the Modified Tardieu Scale (MTS) before and 1 month after surgery, both with the knee extended (KE) and flexed (KF). MTS variations were analyzed using the Wilcoxon test. The time from stroke onset was compared between patients with and without post-surgical spasticity using the t-test. Statistical significance was set at 5%. Results A total of 120 patients with EVFD, aged 57 (12) years, ranging from 1 to 36 years from stroke, were included in the study. The median MTS_KE score significantly decreased from 3 (range 0-4) to 2 (0-4) (p < 0.001) after surgery. The MTS score decreased by ≥1 point in more than half of the sample. Notably, 19 and 32 patients were completely relieved from spasticity (MTS = 0) in the KE and KF conditions, respectively. Post-surgical spasticity did not depend on the time since stroke onset (p = 0.560). Discussion TS lengthening led to a short-term reduction of spasticity in 41% and 63% of chronic post-stroke patients in the gastro-soleus complex and soleus, respectively, with complete relief observed in 21% and 30% of the sample. Surgical lengthening can be considered an effective treatment that not only restores joint range of motion but also may reduce spasticity, even in chronic patients.
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Affiliation(s)
- Martina Galletti
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
| | - Davide Mazzoli
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
| | - Paolo Zerbinati
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
- Neuro-Orthopedic Unit, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
| | - Chiara Rambelli
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
- Section of Rehabilitation, Department of Neuroscience, University of Padova, Padova, Italy
| | - Giacomo Basini
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
| | - Paolo Prati
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
| | - Francesca Mascioli
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
| | - Stefano Masiero
- Section of Rehabilitation, Department of Neuroscience, University of Padova, Padova, Italy
| | - Andrea Merlo
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Torre Pedrera di Rimini, Italy
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Stiff Knee Gait Disorders as Neuromechanical Consequences of Spastic Hemiplegia in Chronic Stroke. Toxins (Basel) 2023; 15:toxins15030204. [PMID: 36977095 PMCID: PMC10053067 DOI: 10.3390/toxins15030204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Stiff knee gait (SKG) is defined as decreased knee flexion during the swing phase. It is one of the most common gait disorders following stroke. Knee extensor spasticity is commonly accepted as the primary cause. Clinical management has focused on the reduction in knee extensor spasticity. Recent advances in understanding of post-stroke hemiplegic gait suggest that SKG can present as mechanical consequences between muscle spasticity, weakness, and their interactions with ground reactions during walking. Various underlying mechanisms are presented through sample cases in this article. They include ankle plantar flexor spasticity, knee extensor spasticity, knee flexor and extensor coactivation, and hip flexor spasticity. Careful and thorough clinical assessment is advised to determine the primary cause for each patient. Understanding of these various presentations of SKG is helpful to guide clinical assessment and select appropriate target muscles for interventions.
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Campanini I, Bò MC, Salsi F, Bassi MC, Damiano B, Scaltriti S, Lusuardi M, Merlo A. Physical therapy interventions for the correction of equinus foot deformity in post-stroke patients with triceps spasticity: A scoping review. Front Neurol 2022; 13:1026850. [DOI: 10.3389/fneur.2022.1026850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveEquinus foot deformity (EFD) is the most common deformity following a stroke. Several approaches have been suggested for its correction, including pharmacological, surgical, and physical therapy (PT) interventions. This scoping review aims to map and synthesize the available evidence focusing on physical therapy treatments for EFD caused by triceps surae (TS) spasticity.MethodsScoping review methodological frameworks have been used. Pubmed, Cinahl, and Cochrane databases were searched for primary literature. Studies focusing on the treatment of EFD in adult stroke patients were included only when the intervention involved PT treatments and presented at least one outcome measure for the functional and/or structural condition of the TS. Data were systematically collected and reported in tables inclusive of type of intervention, sample characteristics, dosage, comparators, outcomes, follow-up timeline, and treatment efficacy. A narrative synthesis was also added.ResultsOf the 642 experimental or observational screened studies, 53 were included, focusing on stretching exercises, shock waves, electrical stimulation, dry needling, TENS, vibration therapy, ultrasounds, cryotherapy, and active physiotherapy. Patients with EFD benefited from specific physical therapy treatments. These usually resulted in Modified Ashworth Scale reduction, typically by 1 point, and an increase in ROM. Interventions consisting of shock waves, dry needling, and electrostimulation showed the best results in reducing EFD. Heterogeneous dosage and delivery mode generally limited conclusions.ConclusionsThis scoping review summarized available primary literature based on PT treatments for the correction of EFD. By highlighting the remaining gaps in knowledge, it provides a reference for future studies on this pathology. Further investigations are necessary to pinpoint the best dosage and delivery methods. Future studies should investigate whether early rehabilitation programs started during the acute phase might help prevent or limit the development of secondary deformities.
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