Functional posterior rhizotomy: the Tokyo experience

Purpose The author describes the history of functional posterior rhizotomy (FPR), the surgical procedure currently used, and the results together with its future perspective in Japan. The modern form of FPR was introduced to Japan in 1995, and the first surgery was carried out in 1996. Despite initial resistance from orthopedic surgeons, the procedure has eventually gained wide recognition in the country. Materials and Methods The author has operated on 98 patients (60 boys and 38 girls, aged from 2 to 19 years old) by the end of 2006. Most patients were mild to severely disabled children with spastic hypertonia because of cerebral palsy and other diseases. The surgical procedure used is based on the Peacock’s procedure with some modification for the mildly disabled children whose spasticity was predominantly the muscles of the ankle joint. Intraoperative neurophysiology was an indispensable tool for preserving urogenital function and for judging which root/rootlet to be cut. Results Seventeen to 83% of the root/rootlets were found to be abnormal and were cut, clearly correlating with the degree of disability. However, there was a wide difference in the cutting rate, even in children with the same degree of disability. The result of surgery in this group of patients was the same as in previously published data. Twenty out of 51 patients (39%) followed for more than a year at the current institute showed improved locomotion after FPR. Thirty patients (59%) demonstrated suprasegmental effects after FPR. Conclusion The role of FPR will grow in importance as a treatment for spasticity in Japan in the future.     

肛门括约肌肌电图监测下双侧L2～S2选择性脊神经后根切断术治疗痉挛性脑瘫

目的为提高手术安全性,在L2～S2选择性脊神经后根切断(SPR)手术时,对肛门括约肌进行肌电图(EMG)监测,并评价其作用。方法在SPR手术监测中,当对S2后根小束进行电刺激时,采用针状电极记录双侧肛门括约肌的反应情况,有明显反应的后根小束予以保留。手术后随访患者踝痉挛改善情况和括约肌功能变化情况。结果所有患者手术后踝痉挛均有明显改善,无大小便功能障碍发生。结论SPR手术包括S2后根时,术中括约肌EMG监测对保证疗效,保护括约肌功能,提高手术安全,具有重要意义。     

Extensor hallucis longus distal tenotomy for spasticity in a patient with interphalangeal joint hyperextension after stroke

BackgroundThe extension deformity of the interphalangeal (IP) joint of the hallux is a rare focal clinical entity usually detected in patients with no underlying pathology. It may be due to extensor hallucis longus (EHL) overactivity, although it has not been previously reported in patients with neurological disorders. The lesion should be differentiated from the persistent hyperextension of the great toe at the metatarsophalangeal (MTP) joint. Although MTP hyperextension of the hallux due to hypertonia of the EHL is a typical sequel of stroke, it has also been detected in a wide variety of disorders.Materials and MethodsA patient with right hemiparesis following stroke, which had an almost complete functional recovery, is presented. She was disabled by focal spasticity of the EHL, leading to persistent hyperextension of the IP joint of the hallux. The deformity appeared on the long-term follow-up, on both sides within a 3-year period. It was treated with bilateral percutaneous distal EHL tenotomy. On the left side, a percutaneous dorsal IP joint capsulotomy was additionally performed.Results and ConclusionA complete reduction of the deformity was achieved on both sides with functional rehabilitation. It is assumed that EHL hyperactivity following stroke in our patient was complicated by IP instead of MTP extension deformity, due to the coexistent flexor hallucis longus weakness. Bilateral distal EHL tenotomy, associated with percutaneous dorsal IP joint capsulotomy on the left side, provided satisfactory long-term results.     

Biomechanical assessment with electromyography of post-stroke ankle plantar flexor spasticity

Spasticity has been defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflex (muscle tone). Muscle tone consists of mechanical-elastic characteristics, reflex muscle contraction and other elements. The aims of this study were to determine whether to assess spasticity quantitatively, and to characterize biomechanical and electromyographic spasticity assessment parameters. These assessment parameters were described by investigating the correlation between clinical measures and the response to passive sinusoidal movement with consecutive velocity increments. Twenty post-stroke hemiplegic patients and twenty normal healthy volunteers were included in the study. Five consecutive sinusoidal passive movements of the ankle were performed at specific velocities (60, 120, 180, and 240 degrees/ sec). We recorded the peak torque, work, and threshold angle using a computerized isokinetic dynamometer, and simultaneously measured the rectified integrated electromyographic activity. We compared these parameters both between groups and between different velocities. The peak torque, threshold angle, work, and rectified integrated electromyographic activity were significantly higher in the post-stroke spastic group at all angular velocities than in the normal control group. The threshold angle and integrated electromyographic activity increased significantly and linearly as angular velocity increased, but the peak torque and work were not increased in the post-stroke spastic group. Peak torque, work, and threshold angle were significantly correlated to the Modified Ashworth scale, but the integrated electromyographic activity was not. The biomechanical and electromyographic approach may be useful to quantitatively assess spasticity. However, it may also be very important to consider the different characteristics of each biomechanical parameter.     

Correlation of quantitative measures with the modified Ashworth scale in the assessment of plantar flexor spasticity in patients with traumatic brain injury

This study of plantar flexor spasticity describes relationships among a traditional qualitative spasticity scale, three potential quantitative spasticity measures and a measure of voluntary ankle muscle function. Thirty-four volunteer adult patients with traumatic brain injuries participated. There were 28 males and 6 females; the mean age was 30.3 years. A battery of five randomly sequenced tests was performed for each subject on one ankle. Tests were: modified Ashworth scale (MAS) scoring; H-reflex testing with and without Achilles tendon vibration; H-reflex testing with and without dorsiflexor contraction; reflex threshold angle and timed toe tapping (TTT). Twenty-six subjects returned to have the second ankle tested, resulting in 60 ankles for the analyses. Spearman's coefficients for correlation of quantitative spasticity measures with MAS scores ranged from 0.39 to 0.49 with associated probabilities 0.002. Pearson coefficients for correlation of quantitative spasticity measures with TTT scores were lower but also significant (P 0.07). Multiple correlation for the set of quantitative measures yieldedR = 0.614 (P < 0.001) with MAS scores andR = 0.365 (P = 0.045) with TTT scores. These findings reveal statistically significant relationships of low to moderate strength among potential quantitative spasticity measures, a traditional qualitative spasticity scale and a simple measure of voluntary ankle muscle function. Understanding these relationships is an essential part of the ongoing search for quantitative spasticity measures.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Effects of dry needling plus exercise therapy on post-stroke spasticity and motor function: A case report

Background and purposeThe use of dry needling (DN) with other treatments may be more beneficial in managing post-stroke spasticity. We report the effects of DN plus exercise therapy (ET) on wrist flexor spasticity.Patient presentationThe patient was a 45-year-old man with an 8-year history of stroke. The outcome measures included the Modified Modified Ashworth Scale (MMAS), H_max/M_max ratio, H-reflex latency, Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), and range of motion (ROM) which were assessed before (T1), after (T2), and after 3-week follow-up (T3).ConclusionThe MMAS was improved at T2 from “3” to “2”. The H_max/M_max decreased from 0.77 to 0.53 at T3. The H-reflex latency increased from 15.4 ms to 18.5 ms at T3. The wrist active and passive ROM increased ∼30° and ∼20° at T2, respectively.A 4-session DN plus ET may improve spasticity and ROM. No meaningful improvement was observed in function.     

脑病变的部位及大小与Brunnstrom偏瘫恢复阶段及痉挛程度的关系

目的 探讨脑病变的部位及大小与Brunnstrom偏瘫阶段及痉挛程度的关系。方法 36例患者，男26例。女10例；年龄16-70岁；左侧脑病变17例。右侧19例；脑血肿17例。脑梗死及脑皮质软化灶19例。结果 脑皮质受损部位患者呈跳跃式恢复，痉挛主要表现为不能伸腕，指及踝背屈障碍，当上肢伸肌功能恢复后，屈肌痉挛消失；顶叶受损（病变体积为30-50cm^3)患者残留症状为不能并指，分指，对掌运动及踝自主背屈障碍；内囊部分病变患者主要表现为肢体远端痉挛。痉挛期与分离期重叠出现。即出现伸腕，指运动时，屈腕，指肌及屈拇长肌仍有痉挛现象存在；内囊大部分或完全病变患者，痉挛表现在四肢所有关节，运动功能恢复较差。结论 脑病变部位及大小不同，痉挛程度不同，痉挛程度与运动训练疗效关系密切。均有助于判断患者康复后期日常生活活动能力及运动功能恢复状况。     

Long-term outcome of superficialis-to-profundus tendon transfer in patients with clenched fist due to spastic hemiplegia

Background. Spastic hemiplegia is a common feature after stroke, which can result in a clenched fist deformity with secondary hygienic problems and pain. Operative treatment can improve these problems, although literature about its long-term effects is lacking.

Purpose. To determine whether Superficialis-to-Profundus tendon (StP-) transfer procedure leads to permanent improvement of hygiene and reduction of pain in patients with clenched fist due to spastic hemiplegia following stroke.

Method. Patients who underwent a StP-transfer in 2003 – 2005 were evaluated on skin condition, upper extremity joint mobility, resting position and muscle tone and with VAS scores on hygiene maintenance and pain in the hand.

Results. Six patients (mean age 54 years; duration after stroke 10 years) were included. Indications to operate were hygienic problems only (3) or combined with pain (3). The average follow-up period was 19 months. After 6 weeks of post-operative splinting, no standard follow-up was applied. Serious post-operative complications were not reported. At follow-up no hygienic problems were present and pain was decreased in all except one patient. All hands could passively be fully opened. In resting position, flexion was seen in the MCP-joints (60 – 90°). Muscle tone was raised in flexors of the wrist and fingers and m. adductor pollicis (Ashworth 1 – 2). Given the same pre- and post-operative circumstances, all patients would agree to have the surgery over again.

Conclusion. Even 19 months after the StP-transfer for clenched fist, all operated hands could still be fully opened and there was a permanent improvement of hygiene and pain reduction.     

Identification of the neural component of torque during manually-applied spasticity assessments in children with cerebral palsy

Clinical assessment of spasticity is compromised by the difficulty to distinguish neural from non-neural components of increased joint torque. Quantifying the contributions of each of these components is crucial to optimize the selection of anti-spasticity treatments such as botulinum toxin (BTX). The aim of this study was to compare different biomechanical parameters that quantify the neural contribution to ankle joint torque measured during manually-applied passive stretches to the gastrocsoleus in children with spastic cerebral palsy (CP). The gastrocsoleus of 53 children with CP (10.9 ± 3.7 y; females n = 14; bilateral/unilateral involvement n = 28/25; Gross Motor Functional Classification Score I–IV) and 10 age-matched typically developing (TD) children were assessed using a manually-applied, instrumented spasticity assessment. Joint angle characteristics, root mean square electromyography and joint torque were simultaneously recorded during passive stretches at increasing velocities. From the CP cohort, 10 muscles were re-assessed for between-session reliability and 19 muscles were re-assessed 6 weeks post-BTX. A parameter related to mechanical work, containing both neural and non-neural components, was compared to newly developed parameters that were based on the modeling of passive stiffness and viscosity. The difference between modeled and measured response provided a quantification of the neural component. Both types of parameters were reliable (ICC > 0.95) and distinguished TD from spastic muscles (p < 0.001). However, only the newly developed parameters significantly decreased post-BTX (p = 0.012). Identifying the neural and non-neural contributions to increased joint torque allows for the development of individually tailored tone management.     

Surgical management of spasticity

Intractable and severe spasticity in childhood has the ability to impact on the quality of life, function and care of the child. Where medical and physical measures have proved insufficient, a surgical approach may be pursued. Irrespective of the underlying pathology, intrathecal baclofen will reduce spasticity in a controllable and reversible fashion, whereas selective dorsal rhizotomy is reserved for the management of bilateral cerebral palsy due to early birth. Owing to the potential for complications of intrathecal baclofen and the permanence of selective dorsal rhizotomy, careful selection and preparation are required to produce satisfactory results.