Narrow Results

Spasticity is a common post-stroke syndrome that imposes significant adverse impacts on patients and caregivers. This study aims to improve the efficiency of botulinum toxin (BoNT) in managing spasticity, by utilizing a three-dimensional innervation zone imaging (3DIZI) technique based on high-density surface electromyography (HD-sEMG) recordings. Stroke subjects were randomly assigned to two groups: the control group ($n=6$) which received standard ultrasound-guided injections, and the experimental group ($n=6$) which received 3DIZI-guided injections. The amount of BoNT given was consistent for all subjects. The Modified Ashworth Scale (MAS), compound muscle action potential (CMAP) and muscle activation volume (MAV) from bilateral biceps brachii muscles were obtained at the baseline, 3 weeks, and 3 months after injection. Intra-group and inter-group comparisons of MAS, CMAP amplitude and MAV were performed. An overall improvement in MAS of spastic elbow flexors was observed during the 3-week visit ($p<0.01$), yet no statistically significant difference found with intra-group or inter-group analysis. Compared to the baseline, a significant reduction of CMAP amplitude and MAV were observed in the spastic biceps muscles of both groups at 3-week post-injection, and returned to approximate baseline value at 12-week post injection. A significantly higher reduction was found in CMAP amplitude ($34.71\pm 5.42$% versus $20.92\pm 6.73$%, $p<0.01$) and MAV ($71.51\pm 8.20$% versus $44.33\pm 21.81$%, $p<0.05$) in the experimental group compared to the control group. The study has demonstrated preliminary evidence that precisely directing BoNT to the innervation zones (IZs) localized by 3DIZI leads to a significantly higher treatment efficiency improvement in spasticity management. Results have also shown the feasibility of developing a personalized BoNT injection technique for the optimization of clinical treatment for post-stroke spasticity using proposed 3DIZI technique.

Spasticity is a frequently observed motor impairment that develops after stroke. The objective of this study was to evaluate the efficacy of electroacupuncture (EA) and moxibustion (Mox) on spasticity due to stroke. The subjects consisted of 35 stroke patients with elbow spasticity whose mean duration of stroke was 2.97 months. Fifteen patients were randomized to the EA group, ten to Mox, and ten to control. Every other day, 30 minutes of electrical stimulation with a frequency of 50 Hz was given through four needles on the Ch'ü-Ch'ih-San-Li (LI-11-LI-10) and Wai-Kuan-Ho-Ku (TB-5-LI-4) points of the paretic side. Direct Mox was applied to Ch'ü-Ch'ih (LI-11), San-Li (LI-10), Wai-Kuan (TB-5) and Ho-Ku (LI-4) points three times a day every other day. The control group was given only the routine acupuncture therapy for stroke and range of motion (ROM) exercise, which were also applied to the EA and Mox groups. The efficacy of treatment was measured before, immediately, 1 hour, 3 hours, 1 day, 5 days, 10 days and 15 days after the start of treatment using a modified Ashworth scale (MAS). In the EA group, spasticity was significantly reduced immediately, 1 hour and 3 hours after treatment (p < 0.05). Reductions were significant on the 5th day and thereafter (p < 0.05). In the Mox group, there was no significant change in the MAS scores after the first treatment. In the Mox and control group, there was no significant change in MAS scores. This study suggests that EA can temporarily reduce spasticity due to stroke, and if applied repeatedly it can maintain reduced spasticity.

Wrist arthrodesis is exceptionally performed in children. The main indication is severe wrist flexion contracture resulting from Volkmann's ischaemia or spasticity. In such cases, a proximal row carpectomy is usually necessary to allow the wrist to be positioned in neutral position. In young children, it is essential to preserve the distal radius growth plate, to prevent physeal closure. In these very particular indications, with high stresses along the stretched palmar soft-tissues, Kirschner wire fixation provides poor stability, and plate fixation is contra-indicated. Radio-metacarpal external fixation is an excellent alternative, preserving the distal radius growth plate and offering sufficient stability. This technique was used in a seven-year-old girl suffering from Volkmann's ischaemic contracture, treated by first carpal bone resection and subsequent arthrodesis with radio-metacarpal external fixation. Bone healing was achieved in three months, with a five years follow-up preservation of the distal radius growth plate.

Lower extremity spasticity in CP interferes with daily living activities, such as ambulation and sitting as well as hygiene. Orthopedic surgery may be needed in the prevention and correction of the deformities and malalignments. Seven girls and nine boys with ages ranging from 7 to 17 years who had at least four surgeries at different levels of their lower extremities in a single stage were presented. Minimum follow-up was two years. The mean number of surgeries performed simultaneously was 6 (4 to 11). The mean operation time was 115 minutes (35 to 225 minutes) and the mean blood loss was 200 ml (100 to 600 ml) during surgery. The hospital stay ranged from two to six days. No complication which may be related to multiple simultaneous surgery was observed. Rehabilitation was begun as soon as the pain permitted. In the postoperative period, the diplegics attended sessions of hippotherapy — therapy by horse riding — in addition to formal therapy modalities. At the latest follow-up postoperatively, all the patients had increase in their level of activities. As a conclusion, whenever needed, simultaneous correction of the lower extremity deformities in spastic CP patients decreases costs and simplifies postoperative rehabilitation without increasing surgical risk for the patients.

The study's aim was to determine the initial effects of a dynamic seating system as a therapeutic intervention in children with cerebral palsy. A two-factor, repeated-measures design was used. Twelve children with neuromuscular dysfunction (mean age 6.0, SD 2.7 years) were included in the study, randomly assigned to an experimental or a control group. At study initiation the experimental group received a wheelchair with dynamic seating components that allows limited range of motion in the hip and knee, and the control group received a static setting wheelchair. Participants were evaluated for range of motion, muscle spasticity (Modified Ashworth Scale), motor function (Gross Motor Function Measure), and level of disability (Pediatric Evaluation of Disability Inventory) at study initiation, 3-months, and 6-months post intervention. Both groups improved in motor function over time, particularly in the categories of Sitting and Crawl/Kneel. Measures of disability improved in both groups for the categories of self-care, mobility, and social function. A larger, more homogeneous sample would likely show significant group differences in measures of muscle spasticity, gross motor function and disability.

Spasticity often interferes with function, limits independence and may cause considerable disability. Elbow joint movement is involved in many daily living activities. A surface EMG driven musculoskeletal model was developed to predict joint trajectory and to compare the differences in the model parameters between the normal and spastic subjects. Three musculotendon actuators whose EMG could be assessed by surface electrodes (biceps, brachioradialis and triceps) were included in this musculoskeletal model. The proposed model took several sets of parameters (anthropometric parameters of the skeleton and muscle parameters) as inputs. Surface EMG signals of the three muscle groups were rectified, moving-averaged, scaled and converted to active states. These active states together with the initial angular position and velocity of the joint were also used as inputs for the model. The outputs were muscle forces and the trajectory of the elbow joint. Two groups of parameters, namely, maximal isometric muscle stress and electromechanical delay were estimated using the trajectory fitting algorithm. Results indicated that the model was successful in using the surface EMG as input signals in the prediction of elbow joint trajectory. The spastic subjects showed a lower maximum isometric muscle stress and longer electromechanical delay.

Functional electrical stimulation (FES) allows active exercises for correction of foot drop in stroke patients. Our objective is to evaluate and compare the effects of FES therapy in walking ability, calf muscle spasticity, and lower-extremity motor recovery between subacute and chronic stroke patients. Twenty consecutive hemiplegic patients having foot drop were assigned either to subacute or chronic group. Both group subjects were treated with conventional rehabilitation program combined with FES therapy for 12 weeks. All subjects received the electrical stimulation to the peroneal nerve of paretic limb for 15–30 min while walking.

After being treated with FES-based rehabilitation program, subacute subjects showed a mean increase in walking speed of 31.3% and chronic subjects of 19.1% and the physiological cost index (PCI), with a reduction of 66.7% in subacute subjects and 46.4% in chronic subjects between the beginning and end of the trial. Improvement was also measured in gait parameters such as cadence, step and stride lengths, ankle joint range of motion (ROM), calf muscle spasticity, and lower-extremity motor recovery assessed by Fugl-Meyer score in both group subjects, but subacute subjects improved better compared with chronic subjects. In conclusion, early and intensive interventions of FES therapy combine with conventional rehabilitation program could significantly improve the waking ability and recovery of lower-extremity motor functions in stroke survivors.

The presence of normal upper limb arm swing movement is considered an important gait movement that affects the selective coordinated locomotor control of the shoulder, elbow, and wrist joint movements. However, in patients with neurological disorders, flexor synergy is characterized by decreased selective neuromuscular control and reciprocal disinhibition of the wrist flexor muscles associated with spasticity or shortness. This research aimed to demonstrate the reliability, validity, and feasibility of the progressive exoskeletal robotic shoulder joint kinematics system. The robotic shoulder joint kinematics system comprises a gait function-retraining robot designed to provide arm swing. The changes in the shoulder joint angle between ImageJ motion analysis software and robotic shoulder joint kinematics system were compared in this research to investigate the reliability and validity of the latter. The linear regression analysis revealed good correlation between the measured angles and the shoulder angle data ($R^2=0.943$). Furthermore, the test–retest reliability test demonstrated excellent reliability ($R^2=0.978$). The robotic shoulder joint kinematics system generated successful arm swing during the locomotion and range of motion training of the shoulder.

Background: Management of upper limb spasticity remains challenging. Selective peripheral neurectomy (SPN) is a relatively recent intervention for cases refractory to medical therapy. The aim of this study was to conduct a systematic review looking at the efficacy and outcomes of SPN, in order to clarify the patient selection criteria and surgical technique.

Methods: A search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Open Grey and CINAHL was conducted. Inclusion criteria included studies comparing pre- and post-operative outcomes for SPN, neurectomy, fasciculotomy and upper limb spasticity.

Results: Only case series were reported with no randomised controlled trials found. 7 studies met the inclusion criteria with a total of 174 patients. A meta-analysis was not possible due to the degree of baseline heterogeneity. All studies had no control arm for comparison of outcomes, with a high risk of bias due to poor internal and external validity, as well as design and performance bias. Surgical techniques differ vastly between studies, with percentage of fascicles ablated between 30–80% and length of neurectomy between 5–10 mm. Some advocated removing end branches while others performed fascicular SPN proximally. 13 patients underwent orthopaedic or neurosurgical procedures, which are both confounding factors. All studies reported an improvement in spasticity although functional outcomes were reported with non-standardized measures. Recurrence rates were reported to be 0–16.1% (mean 3.72%).

Conclusions: From this systematic review, SPN appeared to be a useful technique in selected cases, but overall no firm conclusions can be drawn regarding the best surgical technique, or the extent of functional improvement.

While there are many proposed surgical treatment options for the correction of swan-neck deformities, none are perfect. We describe a partial flexor digitorum superficialis tenodesis that combines both a static volar plate with a dynamic oblique retinacular ligament vector reconstruction. This is performed through a single, short mid-lateral incision and requires no tendon grafts. The protected early active exercises are encouraged postoperatively, and our long-term results have been promising. The technique was designed for children with cerebral palsy, but the indications have since expanded.

Level of Evidence: Level V (Therapeutic)