Outcomes of tendon transfer surgery and occupational therapy in a child with tetraplegia secondary to spinal cord injury

A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury

Objectives

To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI).

Methods

A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures.

Results

One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported.

Conclusion

The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.

Spinal cord injury: pathophysiology, treatment strategies, associated challenges, and future implications

Axonal regeneration and formation of tripartite (axo-glial) junctions at damaged sites is a prerequisite for early repair of injured spinal cord. Transplantation of stem cells at such sites of damage which can generate both neuronal and glial population has gained impact in terms of recuperation upon infliction with spinal cord injury. In spite of the fact that a copious number of pre-clinical studies using different stem/progenitor cells have shown promising results at acute and subacute stages, at the chronic stages of injury their recovery rates have shown a drastic decline. Therefore, developing novel therapeutic strategies are the need of the hour in order to assuage secondary morbidity and effectuate improvement of the spinal cord injury (SCI)-afflicted patients' quality of life. The present review aims at providing an overview of the current treatment strategies and also gives an insight into the potential cell-based therapies for the treatment of SCI.

Outcome reliability in non-ambulatory boys/men with Duchenne muscular dystrophy

INTRODUCTION

Therapeutic trials in Duchenne muscular dystrophy (DMD) often exclude non-ambulatory individuals. Here we establish optimal and reliable assessments in a multicenter trial.

METHODS

Non-ambulatory boys/men with DMD (N = 91; 16.7 ± 4.5 years of age) were assessed by trained clinical evaluators. Feasibility (percentage completing task) and reliability [intraclass correlation coefficients (ICCs) between morning and afternoon tests] were measured.

RESULTS

Forced vital capacity (FVC), assessed in all subjects, showed a mean of 47.8 ± 22% predicted (ICC 0.98). Brooke Upper Extremity Functional Rating (Brooke) and Egen Klassifikation (EK) scales in 100% of subjects showed ICCs ranging from 0.93 to 0.99. Manual muscle testing, range of motion, 9-hole peg test, and Jebsen-Taylor Hand Function Test (JHFT) demonstrated varied feasibility (99% to 70%), with ICCs ranging from 0.99 to 0.64. We found beneficial effects of different forms of corticosteroids for the Brooke scale, percent predicted FVC, and hand and finger strength.

CONCLUSIONS

Reliable assessment of non-ambulatory boys/men with DMD is possible. Clinical trials will have to consider corticosteroid use.

Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature

PURPOSE

We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia.

METHODS

English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes.

RESULTS

Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg.

CONCLUSIONS

More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pediatric onset spinal cord injury: implications on management of the upper limb in tetraplegia

This article focuses on the pediatric upper limb after spinal cord injury and highlights the obstacles during reconstruction.

[Assessment of functional abilities, handicap and quality of life in patients with spinal cord injuries]

OBJECTIVES

A literature review of the methods of evaluating function, handicap and quality of life in patients with spinal cord injuries.

METHODS

The literature review was based on the available French and English articles published since 1990 in 3 databases: MEDLINE, Pascal and Embase.

RESULTS

The literature is dominated by descriptions of tools for evaluating functional limitations in motor deficiencies. Such descriptions involve the validation of generic tools for patients with spinal cord injuries or of specific tools during the evaluation of a particular intervention such as surgery of the tetraplegic hand or adaptation of technical help.

CONCLUSION

The tools to assess patients with spinal-cord injuries are sufficiently numerous and varied to allow us to evaluate physical, functional and psychosocial dimensions. Rigorous methodological validation is continuously at the base of those proposed tools and thus reinforces our choice to use them. Unfortunately, few evaluation tools for patients with spinal cord injuries have been published, translated into French and validated.

Motor capacities of upper limbs in tetraplegics: a new scale for the assessment of the results of functional surgery on upper limbs

STUDY DESIGN

Metrological investigation.

OBJECTIVES

To study the validity and the reliability of a Motor Capacities Scale (MCS) specifically designed for tetraplegics who undergo a functional surgery of upper limbs.

SETTING

Bouffard-Vercelli Centre, Cerbere, France.

METHODS

From diverse sources (observation of patients, review of literature, discussions with occupational therapists and physicians), we compiled a list of 300 activities relating to daily living tasks. From this list, 80 items of motor capacities were retained. They correspond to the abilities of a patient to perform basic and functional tasks regardless of contextual factors (environmental and personal factors). In a preliminary study, items were reviewed by occupational therapists and by 40 tetraplegics for criticism. An open study and an intermediate study were conducted to assess, respectively, the feasibility and the reliability of the MCS. A prefinal study was focused on construct validity. Convergent and divergent hypotheses were formulated and tested against other measures. Four criteria were identified for the elimination of some of the 36 remaining items: a variance of the item equal to 0, a low reproducibility, a high level of redundancy studied by item-to-item correlation and a low level of comprehension.

RESULTS

In all, 52 tetraplegics were included in the prefinal study. Global inter-rater reproducibility was excellent (intraclass correlation coefficient of 0.99). In accordance with the criteria of elimination, the number of items was reduced to 31. Correlations with the Sollerman test and the Asia Motor Score were, respectively, 0.959 and 0.7444 (P<0.0001). Correlation with the interval since the onset of the tetraplegia and the educational level were, respectively, 0.20 and 0.195 (P=0.163).

CONCLUSION

MCS displays a good apparent and content validity, and excellent reproducibility and construct validity. Metrological properties were good enough to allow the evaluation of sensitivity to change in the final study.

Use of the ICF conceptual framework to interpret hand function outcomes following tendon transfer surgery for tetraplegia

STUDY DESIGN

Clinical commentary

OBJECTIVE AND SETTING

This paper is a clinical commentary based on the Round Table discussion on Assessment and Outcomes at the 7th International Conference on Tetraplegia: Surgery and Rehabilitation, Bologna, Italy 6-8 June, 2001. It refers specifically to the 10-year re-review undertaken in 2001 at the Spinal Unit, Burwood Hospital, Christchurch, New Zealand.

SUBJECTS

In all, 24 tetraplegic persons at a minimum of 12 years and up to 18 years following bilateral forearm tendon transfer surgery.

METHOD

The data were interpreted using the International Classification of Functioning, Disability, and Health (ICF) conceptual framework as the basis of interdisciplinary understanding of the participation dimension.

RESULTS

The results of the study outlined confirm that outcome measurement at more than one level of functioning is desirable to determine the functional effects beyond grip strength levels and activities of daily living, to consider the dimension of participation.

CONCLUSIONS

Use of the ICF as a theoretical framework for interpretation of the results enhanced the clinical applicability of the outcome measures used in the 10-year re-review undertaken in New Zealand in 2001.

Analyse critique des modalités d’évaluation des résultats de la chirurgie fonctionnelle du membre supérieur tétraplégique. Revue de la littérature sur les 50 dernières années

OBJECTIVE

To study the methods of assessment of upper limb functional surgery in the literature.

METHODS

The literature review relating to the years 1950-2002 was carried out with three data bases: Medline, Pascal, Embase. This review also involved a thorough study of non-indexed references.

RESULTS

Although many instruments or tests are used to assess outcome after surgery, their reliability, validity and responsiveness have not been adequately proven. Methodology appears to be the major failing of the various scales used to assess these patients. The conceptual models underlying the evaluation are all too often unspecified. There is a lack of pertinence of the selected tasks for tetraplegics. There is limited documentation of the guiding framework or conceptualisation. Furthermore, the process of item selection is often unknown. Scales or instruments are also deemed to be too insensitive to document the small but meaningful functional gains made by tetraplegics after functional surgery.

CONCLUSION

To answer the need for a specific assessment tool for tetraplegics who undergo functional surgery, we have developed a national, multicenter, prospective and longitudinal study based on two concepts: the first concept is related to Life Habits that are the activities of daily living and social roles recognised by the socio-cultural context of a person according to age, sex and social and personal identity. They include activities that should be accomplished on a daily basis (nutrition, fitness, personal care, communication, mobility, etc.). Life Habits presenting a significant level of disruption can create handicap situations. The second concept is in relation with Motor Capacities that correspond to the abilities of a patient to perform basic and functional tasks regardless of contextual factors (environmental and personal factors).

Single-case experimental designs: applications in developmental-behavioral pediatrics

This article discusses single-case experimental designs (SCEDs) and their relevance to developmental-behavioral pediatrics. Information concerning SCEDs have not been described in the Journal of Developmental and Behavioral Pediatrics, despite its relevance to the field. General issues related to the underlying logic and applications of SCEDs are reviewed with examples selected from the literature to illustrate the strengths and weaknesses of different design strategies. It is suggested that SCEDs can be a useful alternative to traditional between-group designs for clinical and evaluation research because the unit of the analysis is the individual; therefore the feedback to clinicians and families is direct about the effectiveness of a behavioral intervention or medication for that individual. In the field of developmental-behavioral pediatrics, SCEDs can be especially useful in the management of vague symptoms or poorly defined diseases to improve the confidence in a treatment decision for an individual patient. This report is intended to facilitate the understanding and use of single-case methodology so that clinicians are aware that flexible, true experiential designs exist to fill the gap in knowledge and also "do the best for my patient."

Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia

PURPOSE

The purpose of this study was to evaluate and compare the deltoid to triceps and biceps to triceps transfers for restoration of elbow extension in young persons with tetraplegia.

METHODS

This was a prospective randomized study. Sixteen arms of 9 subjects between 8 and 20 years of age with cervical-level spinal cord injuries were assigned randomly to undergo either a deltoid to triceps transfer or a biceps to triceps transfer. All arms were followed-up prospectively for at least 2 years after surgery.

RESULTS

Elbow extension was restored in 8 arms via the deltoid and in 8 arms via the biceps transfers. At the 24-month follow-up evaluation 7 of the 8 biceps transfers produced antigravity strength (grade 3 or better); in contrast only one arm with the deltoid transfer was able to extend against gravity. There was a considerable but subclinical loss (no subject appreciated any functional deficit) of elbow flexion torque after both transfers. Three months after surgery the deltoid group showed a 51% loss of elbow flexion torque and the biceps group showed a 52% loss of elbow flexion torque. By 24 months after surgery both groups improved but still showed a loss of flexion torque (deltoid 32%, biceps 47%). After gaining elbow extension the subjects in both groups rated the performance of most activities of daily living (ADL) and all self-selected activities as better, as measured on the Modified University of Minnesota Tendon Transfer Functional Improvement Questionnaire and the Canadian Occupational Performance Measure, respectively. Likewise all subjects were more satisfied with performance of their goals after undergoing elbow extension reconstruction.

CONCLUSIONS

This study showed the benefits of restoring elbow extension in persons with tetraplegia and provided support for the biceps transfer as an alternative to the deltoid to triceps transfer in individuals with good brachialis and supinator strength.

Evaluation of upper extremity motor function tests in tetraplegics

OBJECTIVE

To provide an overview of arm-hand function tests useful in tetraplegic subjects. Considerations for selection of an appropriate test are also provided.

DATA SOURCES

A Medline literature search was conducted covering the period from 1967 to March 2001. Relevant references cited in the selected papers were also considered, regardless of the year of publication.

STUDY SELECTION

This review was restricted to strength tests, functional and ADL tests. Only general tests and tests designed specifically to test tetraplegic persons written in English, or in Dutch were included in the review.

RESULTS

Information is provided on four types of strength tests, 10 general and five specific functional tests and eight ADL tests.

CONCLUSION

Many tests are available to measure upper extremity motor function in tetraplegics. Selection of a test is at first determined by the outcome value in which the investigator is interested. When the type of outcome value has been determined, the most suitable test has to be selected from the range of available tests. When two tests appear to be equally suitable, the availability of information on psychometric properties of the test when used in tetraplegic patients is a decisive factor. When information on the reliability, validity and sensitivity of a test is missing, it should be gathered before using the test.

Management of the paralyzed elbow in tetraplegia

The management of the paralytic conditions in tetraplegia requires understanding neural pathophysiology. A comprehensive rehabilitative and surgical plan requires a multidisciplinary approach. Prior to redistributing the muscle forces across the elbow, a supple osseo-articular platform must be created. The authors recommend PDT and BTT transfers and a FES neuroprosthesis. Future work in this field will advance the application of neuromodulation and its deployment in different neurophysiologic states.

Neuroprostheses for the upper extremity

Functional electrical stimulation (FES) neuroprostheses can be used to replace lost motor and sensory function in persons with neurological disorders. FES technology has subsequently been shown effective and safe in restoring hand function in adults with spinal cord injury. The freehand system consists of an implanted receiver-stimulator, an external shoulder position sensor, and an external control unit. Commands are originated by voluntary movement of the contralateral shoulder and are measured by the sensor. There are several types of electrodes: epimysial, intramuscular, nerve cuff, and intraneural. Neuroprostheses are recommended within the context of all available reconstructive options for the upper limbs. Voluntary tendon transfers are the first choice. The clinical outcomes as measured by improvement on scales of impairment, activities of daily living, and satisfaction are rewarding. The next step in improvement of the motor function of person with spinal cord injury will be the addition of a controllable second upper extremity and the elimination of additional external hardware.

Implanted functional electrical stimulation hand system in adolescents with spinal injuries: an evaluation

OBJECTIVE

To study the utility and functional benefits of an implanted functional electrical stimulation (FES) system for hand grasp and release in adolescents with tetraplegia secondary to spinal cord injuries.

DESIGN

Intervention study with before-after trial measurement with each subject as his or her own control.

SETTING

Nonprofit pediatric orthopedic rehabilitation facility specializing in spinal cord injury.

PARTICIPANTS

A convenience sample of five adolescents between 16 and 18 years of age with C5 or C6 level tetraplegia at least 1 year after traumatic spinal cord injury. Key muscles for palmar and lateral grasp and release were excitable by electrical stimulation.

INTERVENTIONS

A multichannel stimulator/receiver and eight electrodes were surgically implanted to provide stimulated palmar and lateral grasp and release. In conjunction with implantation of the FES hand system, surgical reconstruction in the form of tendon transfers, tendon lengthenings and releases, and joint arthrodeses was performed to augment stimulated hand function. Rehabilitation of the tendon transfers and training in the use of the FES hand system were provided.

MAIN OUTCOME MEASURES

Measurements of pinch and grasp force, the Grasp and Release Test (GRT), and an assessment of six activities of daily living (ADL) were administered before implantation of the FES hand system and at regular follow-up intervals. Results of the stimulated response of individual muscles and surgical reconstruction were evaluated using standard and stimulated muscle testing techniques and standard assessment of joint range of motion. All subjects completed followup testing.

RESULTS

Lateral and palmar forces were significantly greater than baseline forces (p = .043). Heavy objects on the GRT could only be manipulated with FES, and FES increased the level of independence in 25 of 30 ADL comparisons (5 subjects, 6 activities) as compared to baseline. After training, FES was preferred in 21 of 30 comparisons over the typical means of task completion. Of the 40 electrodes implanted, 37 continue to provide excellent stimulated responses and all of the implanted stimulators have functioned without problems. The surgical reconstruction procedures greatly enhanced FES hand function by either expanding the workspace in which to utilize FES (deltoid to triceps transfer), stabilizing the wrist (brachioradialis to wrist extensor transfer), or stabilizing joints (intrinsic tenodesis transfer, FPL split transfer).

CONCLUSION

For five adolescents with tetraplegia, the combination of FES and surgical reconstruction provided active palmar and lateral grasp and release. Laboratory-based assessments demonstrated that the FES system increased pinch force, improved the manipulation of objects, and typically increased independence in six standard ADL as compared to pre-FES hand function. The study also showed that the five adolescents generally preferred FES for most of the ADL tested. Data on the benefits of the implanted FES hand system outside of the laboratory are needed to understand the full potential of FES.

Quantitative comparison of grasp and release abilities with and without functional neuromuscular stimulation in adolescents with tetraplegia

In this study, a functional neuromuscular stimulation (FNS) hand system designed by Case Western Reserve University (CWRU) was implemented in 5 adolescents with C5 tetraplegia and hand function with FNS was evaluated and compared to tenodesis abilities using a grasp and release test designed specifically for this purpose. The test involved the unilateral acquisition, movement and release of 6 objects of various sizes and weights. During a single test session, five 30-second trials were performed with each object with and without the FNS system where the number of completions and failures were recorded for each trial. At least 4 and as many as 8 test sessions were conducted with each subject over periods of 1.5 to 3 years. For each subject, test performance with FNS was compared statistically to tenodesis performance and session-to-session consistency was analyzed. Of 30 comparisons (5 subjects and 6 test objects), FNS was more effective in 23 cases (77%), tenodesis was better in 5 instances (17%) and in 2 cases (6%) there was no difference. Subjects were able to manipulate the 3 heaviest test objects only with FNS and in 60% of all cases involving the 3 lighter test objects there were significantly more trials in which there were more completions or fewer failures with FNS. Performance with FNS and tenodesis was generally inconsistent across sessions; possible reasons for these variations are discussed. Overall, the results of this study support those of the only previous investigation that used the grasp and release test to evaluate hand function with FNS in C5 and C6 tetraplegia.