Satisfaction with upper-extremity surgery in individuals with tetraplegia

OBJECTIVE: To measure the satisfaction of individuals with tetraplegia with their upper-extremity reconstructive surgery. DESIGN: Survey. SETTING: Two Spinal Cord Injury Model Systems centers. PARTICIPANTS: Sixty-seven individuals with spinal cord injury at the C4 through C8 motor level (107 arms). INTERVENTIONS: Participants had upper-extremity surgery to improve function. The surgical procedures included tendon transfers for elbow extension, wrist extension, hand grasp, and pinch or hand grasp neuroprosthesis. MAIN OUTCOME MEASURE: A survey was mailed to participants, who were asked to respond to statements such as, "If I had it to do over, I would have the hand/arm surgery again," using a 5-level Likert scale (ranging from strongly agree to strongly disagree). RESULTS: Seventy percent of the participants were generally satisfied with the results of their upper-extremity surgery, 77% reported a positive impact on their lives, 68% reported improvements in activities of daily living (ADLs), 66% reported improved independence, 69% reported improvement in occupation, 71% reported improved appearance or neutral, 78% reported their hand worked as well (or neutral) as it did when surgery was first performed, and 86% reported postoperative therapy as being beneficial. CONCLUSIONS: Upper-extremity surgery had a positive impact on life, increased ability to perform ADLs and to be independent, and improved quality of life.     

Evaluation of a stair-climbing power wheelchair in 25 people with tetraplegia

Laffont I, Guillon B, Fermanian C, Pouillot S, Even-Schneider A, Boyer F, Ruquet M, Aegerter P, Dizien O, Lofaso F. Evaluation of a stair-climbing power wheelchair in 25 people with tetraplegia.

Objective

To compare the performance of a power wheelchair with stair-climbing capability (TopChair) and a conventional power wheelchair (Storm3).

Design

A single-center, open-label study.

Setting

A physical medicine and rehabilitation hospital.

Participants

Patients (N=25) who required power wheelchairs because of severe impairments affecting the upper and lower limbs.

Interventions

Indoor and outdoor driving trials with both devices. Curb-clearing and stair-climbing with TopChair.

Main Outcome Measures

Trial duration and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) tool; number of failures during driving trials and ability to climb curbs and stairs.

Results

All 25 participants successfully completed the outdoor and indoor trials with both wheelchairs. Although differences in times to trial completion were statistically significant, they were less than 10%. QUEST scores were significantly better with the Storm3 than the TopChair for weight (P=.001), dimension (P=.006), and effectiveness (P=.04). Of the 25 participants, 23 cleared a 20-cm curb without help, and 20 climbed up and down 6 steps. Most participants felt these specific capabilities of the TopChair—for example, curb clearing and stair climbing—were easy to use (22/25 for curb, 21/25 for stairs) and helpful (24/25 and 23/25). A few participants felt insecure (4/25 and 6/25, respectively).

Conclusions

The TopChair is a promising mobility device that enables stair and curb climbing and warrants further study.     

Effect of a pushrim-activated power-assist wheelchair on the functional capabilities of persons with tetraplegia

OBJECTIVES: To test the differences between a pushrim-activated power-assisted wheelchair (PAPAW) and a traditional manual wheelchair while performing common driving activities and to assess their relative merits for people with tetraplegia. DESIGN: Repeated measures. SETTING: An activities of daily living (ADL) laboratory within a rehabilitation research center. PARTICIPANTS: Fifteen full-time manual wheelchair users with tetraplegia due to a spinal cord injury. INTERVENTIONS: Participants propelled both their own manual wheelchairs and a PAPAW 3 times over an ADL course. The order in which the 2 different wheelchairs were presented to the participants was randomized. MAIN OUTCOME MEASURES: Each participant's heart rate was monitored throughout testing by a digital, wireless heart-rate monitor. Time to complete the course was recorded, and participants were surveyed with a visual analog scale after the first, third, fourth, and sixth trials to determine the ease of completing each obstacle and their ergonomic preferences between the 2 wheelchairs. Participants also were observed throughout the trials to determine how much assistance they needed to complete each obstacle course. RESULTS: After using a Bonferroni adjustment, 4 obstacles (carpet, dimple strips, up a ramp, up a curb cut) were rated as being significantly easier ( P <.001) to complete when using the PAPAW. Participants also showed a significant decrease in mean heart rate throughout all 3 trials ( P =.015, P =.001, P =.003, respectively) when using a PAPAW. The amount of assistance needed by participants, the responses to ergonomic questions, and the overall time to complete the ADL course did not differ significantly between the 2 wheelchairs. CONCLUSIONS: For subjects with tetraplegia, PAPAWs have the potential to improve functional capabilities during certain ADLs, especially when propelling up ramps, over uneven surfaces, and over thick carpet.     

Impact of a pushrim-activated power-assisted wheelchair on the metabolic demands, stroke frequency, and range of motion among subjects with tetraplegia

OBJECTIVES: To determine differences in metabolic demands, stroke frequency, and upper-extremity joint range of motion (ROM) during pushrim-activated power-assisted wheelchair (PAPAW) propulsion and traditional manual wheelchair propulsion among subjects with tetraplegia. DESIGN: Repeated measures. SETTING: A biomechanics laboratory within a Veterans Affairs medical center. PARTICIPANTS: Fifteen full-time manual wheelchair users who had sustained cervical-level spinal cord injuries. INTERVENTIONS: Participants propelled both their own manual wheelchairs and a PAPAW through 3 different resistances (slight, 10W; moderate, 12W; high, 14W) on a wheelchair dynamometer. Each propulsion trial was 3 minutes long. MAIN OUTCOME MEASURES: Primary variables that were compared between the 2 wheelchairs were participants mean steady-state oxygen consumption, ventilation, heart rate, mean stroke frequency, and maximum upper-extremity joint ROM. RESULTS: When using the PAPAW, participants showed a significant ( P <.05) decrease in mean oxygen consumption and ventilation throughout all trials. Mean heart rate was significantly lower when using the PAPAW for the high resistance trial. Stroke frequency was significantly lower when using the PAPAW for the slight and moderate resistances. Overall joint ROM was significantly lower when using the PAPAW. CONCLUSIONS: For subjects with tetraplegia, PAPAWs reduce the energy demands, stroke frequency, and overall joint ROM when compared with traditional manual wheelchair propulsion.     

Long-term ventilation for high-level tetraplegia: a report of 2 cases of noninvasive positive-pressure ventilation

Toki A, Tamura R, Sumida M. Long-term ventilation for high-level tetraplegia: a report of 2 cases of noninvasive positive-pressure ventilation.Ventilator-dependent patients with tetraplegia rarely use noninvasive positive-pressure ventilation (NPPV) for long-term ventilation. We report 2 patients with high-level traumatic tetraplegia who were able to return home after being changed from traditional ventilation to NPPV. When they were referred to our hospital from acute care hospitals 2 to 6 months after injury, both were on tracheostomy ventilation with a cuff inflated 24 hours a day, and tidal volume (Vt) settings were low. In case 1, a man with complete C1 tetraplegia was admitted to our hospital 6 months after injury. We changed ventilator settings to high Vt and introduced NPPV. He was discharged home with NPPV with a volume-setting ventilator. Case 2 involved a man in his late twenties with complete C1 tetraplegia who was discharged home with NPPV. After discharge, he trained in glossopharyngeal breathing by himself, enabling him to breathe up to 1900mL of maximum insufflation capacity. Both have lived nearly 1 year without pulmonary complications in the community. They use visiting nurses 3 times a week and services of visiting caregivers. Further study is needed to determine the usefulness of NPPV for long-term ventilatory management.     

Effects of early rehabilitation in improvement of paediatric burnt hands function

BACKGROUNDHands are one of the most common burn sites in children. Hypertrophic scar contractures in hands after wound healing result in further reductions in their range of motion (ROM), motility, and fine motor activities. Rehabilitation can improve the function of hands. But the optimal time of rehabilitation intervention is still unclear. Therefore, this study was designed to investigate the effects of early rehabilitation management of paediatric burnt hands and to compare the efficacy between early and later rehabilitation intervention.AIMTo investigate the effects of early rehabilitation management of paediatric burnt hands. METHODSA total of 52 children with burnt hands were allocated into the early intervention group (≤ 1 mo from onset) and a late intervention group (> 1 mo from onset) between January 2016 and December 2017. The children received the same rehabilitation programme including skin care, scar massage, passive ROM exercises, active ROM exercises, compression therapy, orthotic devices wearing and game or music therapy. Rehabilitation assessments were performed before and after the rehabilitation treatment.RESULTSIn the early intervention group, the ROM of the hands was significantly improved after rehabilitation (P = 0.001). But in the late group the effect was not significant statistically (P = 0.142). In the early group, 38.5% of the patients showed significant improvement, while in the late group, 69.2% of the patients showed no significant improvement. The time from onset to posttraumatic rehabilitation (P = 0.0007) and length of hospital stay (P = 0.003) were negatively correlated with the hand function improvement. The length of rehabilitation stay was positively correlated with the hand function improvement (P = 0.005). CONCLUSIONThese findings suggest that early rehabilitation might show better results in terms of ROM.     

Sensory stimulation augments the effects of massed practice training in persons with tetraplegia

Beekhuizen KS, Field-Fote EC. Sensory stimulation augments the effects of massed practice training in persons with tetraplegia.

Objective

To compare functional changes and cortical neuroplasticity associated with hand and upper extremity use after massed (repetitive task-oriented practice) training, somatosensory stimulation, massed practice training combined with somatosensory stimulation, or no intervention, in persons with chronic incomplete tetraplegia.

Design

Participants were randomly assigned to 1 of 4 groups: massed practice training combined with somatosensory peripheral nerve stimulation (MP+SS), somatosensory peripheral nerve stimulation only (SS), massed practice training only (MP), and no intervention (control).

Setting

University medical school setting.

Participants

Twenty-four subjects with chronic incomplete tetraplegia.

Interventions

Intervention sessions were 2 hours per session, 5 days a week for 3 weeks. Massed practice training consisted of repetitive practice of functional tasks requiring skilled hand and upper-extremity use. Somatosensory stimulation consisted of median nerve stimulation with intensity set below motor threshold.

Main Outcome Measures

Pre- and post-testing assessed changes in functional hand use (Jebsen-Taylor Hand Function Test), functional upper-extremity use (Wolf Motor Function Test), pinch grip strength (key pinch force), sensory function (monofilament testing), and changes in cortical excitation (motor evoked potential threshold).

Results

The 3 groups showed significant improvements in hand function after training. The MP+SS and SS groups had significant improvements in upper-extremity function and pinch strength compared with the control group, but only the MP+SS group had a significant change in sensory scores compared with the control group. The MP+SS and MP groups had greater change in threshold measures of cortical excitability.

Conclusions

People with chronic incomplete tetraplegia obtain functional benefits from massed practice of task-oriented skills. Somatosensory stimulation appears to be a valuable adjunct to training programs designed to improve hand and upper-extremity function in these subjects.     

Aerophagia as a cause of ineffective phrenic nerve pacing in high tetraplegia: a case report

We report an unusual case of aerophagia after traumatic spinal cord injury (SCI), which shows the profound effects of abdominal distension on respiratory ability in such individuals. In this case, abdominal distension resulting from aerophagia reduced the effectiveness of phrenic nerve pacing on diaphragm function necessitating greater use of positive-pressure ventilatory (PPV) support. Reduction of postprandial gastric air and abdominal distension with insertion of a percutaneous endoscopic gastrostomy tube ameliorated the condition and allowed for more effective phrenic nerve pacing and greater PPV-free breathing. We are unaware of a similar case involving an individual with an SCI.     

A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function

Hart DL, Wang Y-C, Stratford PW, Mioduski JE. A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function.

Objectives

To describe the use of a computerized adaptive test (CAT) in routine clinical practice and evaluate content coverage and construct validity, sensitivity to change, and responsiveness of hip CAT functional status (FS) measures.

Design

Longitudinal, prospective observational cohort study.

Setting

Two hundred fifty-seven outpatient rehabilitation clinics in 31 states (United States).

Participants

Two samples were examined: intake and discharge rehabilitation FS data from patients (N=8714) treated for hip impairments between January 2005 and June 2007 and data from patients (N=444) used to develop the hip CAT were examined for comparison (2002-2004).

Interventions

Not applicable.

Main Outcome Measures

Hip functional status and global rating of change.

Results

The CAT used on average 7 items to produce precise estimates of FS that adequately covered the content range with negligible floor and slight ceiling effects. Test information functions and SEs supported FS measure precision. FS measures discriminated patients in clinically logical ways. Sixty-one percent of patients obtained discharge FS measures greater than or equal to minimal detectable change (95% confidence intervals). Change of 6 FS units (scale: 0-100) represented minimal clinically important improvement, which 64% of patients obtained.

Conclusions

The hip CAT was efficient; produced valid, responsive measures of FS for patients receiving therapy for hip impairments; and functioned well in routine clinical application but would benefit from more difficult items.     

Triceps denervation as a predictor of elbow flexion contractures in C5 and C6 tetraplegia

OBJECTIVE: To determine whether the existence of elbow flexion contractures in persons with C5 or C6 tetraplegia is related to a lack of residual voluntary triceps function and triceps denervation (ie, lower motoneuron damage). DESIGN: A retrospective study of impairment data from 74 arms to identify the incidence of elbow flexion contractures and the contributing factors toward this deformity. SETTING: Five spinal cord injury (SCI) rehabilitation centers in the United States, 1 in England, and 1 in Australia. PARTICIPANTS: Forty-three subjects with motor complete C5 or C6 traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Active and passive elbow extension, triceps voluntary muscle strength, and triceps response to electric stimulation. RESULTS: Subjects with weak voluntary triceps had significantly fewer and less severe elbow flexion contractures than those with paralyzed triceps ( P =.024). Subjects with completely denervated triceps (ie, no response to electric stimulation) had significantly more elbow flexion contractures than subjects with even a weak response to electric stimulation ( P =.003). Overall, 51% of the arms could not be passively extended to zero. Forty-six percent of the arms classified as C5 lacked full passive elbow extension, compared with 63% of the arms classified as C6 ( P =.302). CONCLUSIONS: A relationship has been found between elbow flexion contractures and lack of residual voluntary triceps and triceps denervation in subjects with C5 or C6 tetraplegia. There should be a greater awareness of the elbow flexion contractures that may develop as a result of this relationship. A better understanding of this deformity and its characteristics can lead to more effective clinical treatment and prevention strategies.     

A new type of chopsticks for patients with impaired hand function

OBJECTIVES: To present a method for adapting chopsticks to persons with hand impairments and to compare the efficiency of the adapted chopsticks with spoons among adults with cervical spinal cord injury (SCI). DESIGN: Equipment development and pilot evaluation. SETTING: Rehabilitation center. PARTICIPANTS: Two adults with complete C8-level SCI and 9 adults with incomplete SCI from the C6 to C8 level. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Instructions for adapting chopsticks and the time to pick up and manipulate 4 types of food (noodle strips, cubed carrots, unshelled peanuts, tofu cube) by using adapted chopsticks as compared with spoons. RESULTS: The mean time for manipulating tofu was comparable between the adapted chopsticks and spoon, but the adapted chopsticks were sufficiently faster than spoons for noodle strips, carrots, and unshelled peanuts. CONCLUSIONS: Adapted chopsticks convert gross grasp into 2-point pinch. They are inexpensive, easily constructed, and may benefit patients with lower cervical SCI and residual gross grasp.     

Measurement of upper-extremity function early after stroke: properties of the action research arm test

OBJECTIVE: To examine the responsiveness and validity of the Action Research Arm Test (ARAT) in a population of subjects with mild-to-moderate hemiparesis within the first few months after stroke. DESIGN: Data were collected as part of the Very Early Constraint-Induced Therapy for Recovery from Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were studied at baseline (day 0), after treatment (day 14), and after 90 days (day 90) poststroke. SETTING: Inpatient rehabilitation hospital; follow-up 3 months poststroke. PARTICIPANTS: Fifty hemiparetic subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: At each time point, subjects were tested on: (1) the ARAT, (2) clinical measures of sensorimotor impairments, (3) in the kinematics laboratory where they performed reach and grasp movements, and (4) clinical measures of disability. Blinded raters performed all evaluations. Analyses at each time point included calculating effect size as indicators of responsiveness, and correlation and regression analyses to examine relationships between ARAT scores and other measures. RESULTS: The ARAT is responsive to change, with effect sizes greater than 1.0 and responsiveness ratios of 7.0 at 3 months poststroke. ARAT scores were related to sensorimotor impairment measures, 3-dimensional kinematic measures of movement performance, and disability measures at all 3 time points. CONCLUSIONS: The ARAT is a responsive and valid measure of upper-extremity functional limitation and therefore may be an appropriate measure for use in acute upper-extremity rehabilitation trials.     

20例类风湿性关节炎手功能的康复

对20例类风湿性关节炎患者进行手功能康复,经综合康复医疗,各项观察指标如握力、腕关节活动度、手的日常生活动作(ADL)评分、手的关节功能指数(SOFI)评分等康复前后变化有非常显著的意义,P<0.01。对类风湿性关节炎患者手功能的康复宜采用综合康复措施,应突出伸肌的锻炼,过多锻炼屈肌只能引起或加重手指挛缩。     

Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function

We delineate the methodology for constraint-induced movement therapy (CIMT) modified for children with hemiplegic cerebral palsy (CP) and describe important considerations that need to be made when testing this intervention in children. The resulting intervention evolved from piloting and testing it with 38 children with hemiplegic CP who were between the ages of 4 and 14 years. Thirty-seven successfully completed the treatment protocol. The intervention retains the 2 major elements of the adult CIMT (repetitive practice, shaping) and was constructed to be as child-friendly as possible. It involves restraining the noninvolved extremity with a sling and having the child engage in unimanual activities with the involved extremity 6 hours a day for 10 days (60 h). Specific activities are selected by considering joint movements with pronounced deficits and improvement of which interventionists believe have greatest potential. The activities are chosen to elicit repetitive practice and shaping. The intervention is conducted in groups of 2 to 3 children to provide social interaction, modeling, and encouragement. Each child is assigned to an interventionist to maintain at least a 1:1 ratio. CIMT can be modified to be child-friendly while maintaining all practice elements of the adult CIMT. The modified therapy is tolerated by most children. Further modifications will likely be required to hone in on the specific components of the intervention that are most effective before applying them to children who are most likely to benefit.     

Interrater reliability of the international standards for neurological classification of spinal cord injury in youths with chronic spinal cord injury

Mulcahey MJ, Gaughan JP, Chafetz RS, Vogel LC, Samdani AF, Betz RR. Interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury in youths with chronic spinal cord injury.

Objectives

To evaluate the interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in children with chronic spinal cord injury (SCI), and to define the lower age limit at which the examinations have clinical utility.

Design

Repeated measures, multicenter reliability study.

Setting

Two U.S. pediatric specialty hospitals with recognized SCI programs.

Participants

Children (N=236) with chronic SCI.

Interventions

Subjects underwent 4 examinations by 2 raters: sensory tests (pin prick [PP] and light touch [LT]), a motor test, and a test of anal sensation (AS) and anal contraction (AC).

Main Outcome Measures

A 2-way general linear model analysis of variance was used for analysis. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were calculated for PP, LT, motor, AS, and AC.

Results

No child younger than 6 years completed the examination. When examined as a function of age, interrater reliability for motor, PP, LT, AS, and AC was moderate (ICC=.89) to high (ICC=.99). There was poor reliability for AS (ICC=.49) in subjects with complete injuries but moderate reliability for all other variables. There was moderate to high reliability for classification of type (tetraplegia/paraplegia) and severity (complete/incomplete) of injury across age groups.

Conclusions

The ISNCSCI does not have utility for children younger than 6 years. For children older than 6 years, interrater reliability of PP, LT, and motor examinations is high.     

Respiratory effects of combined truncal and abdominal support in patients with spinal cord injury

OBJECTIVE: To determine whether a custom girdle, designed to provide truncal stability and abdominal support, will improve pulmonary function, enhance inspiratory muscle activity, and reduce the sensation of respiratory effort in patients with spinal cord injury (SCI). DESIGN: Pulmonary function, transdiaphragmatic pressure time product (PTP di ), twitch (Tw Pdi) and maximal transdiaphragmatic pressures (Pdi), and perception of respiratory effort (Borg Rating of Perceived Exertion score) were measured with and without an abdominal girdle in a seated position. SETTING: Rehabilitation hospital. PARTICIPANTS: Ten patients with posttrauma SCI (injury level, C5-T6). INTERVENTION: Application of the abdominal girdle. MAIN OUTCOME MEASURES: Borg score and measures of lung volumes, dynamic abdominal compliance, and Tw Pdi and maximal Pdi. RESULTS: Wearing of the girdle was associated with a lower Borg score (P = .002) and reduced functional residual capacity (P = .006) but increased inspiratory capacity (P = .02) and forced vital capacity (P = .02). Although there was a decrease in dynamic abdominal compliance (P < .001) and an increase in PTP di (P = .02), this was accompanied by an increase in both Tw Pdi (P = .02) and maximal Pdi (P = .03). CONCLUSIONS The custom girdle reduced the sensation of respiratory effort in patients with SCI by optimizing the operating lung volumes and decreasing abdominal compliance, which enhanced diaphragm performance.