Hip Displacement in Cerebral Palsy: The Role of Surveillance

IntroductionHip displacement is common in cerebral palsy (CP) and is related to the severity of neurological and functional impairment. It is a silent, but progressive disease, and can result in significant morbidity and decreased quality of life, if left untreated. The pathophysiology of hip displacement in CP is a combination of hip flexor-adductor muscle spasticity, abductor muscle weakness, and delayed weight-bearing, resulting in proximal femoral deformities and progressive acetabular dysplasia. Due to a lack of symptoms in the early stages of hip displacement, the diagnosis is easily missed. Awareness of this condition and regular surveillance by clinical examination and serial radiographs of the hips are the key to early diagnosis and treatment.Hip surveillance programmesSeveral population-based studies from around the world have demonstrated that universal hip surveillance in children with CP allows early detection of hip displacement and appropriate early intervention, with a resultant decrease in painful dislocations. Global hip surveillance models are based upon the patients’ age, functional level determined by the Gross Motor Function Classification system (GMFCS), gait classification, standardized clinical exam, and radiographic indices such as the migration percentage (MP), as critical indicators of progressive hip displacement.ConclusionDespite 25 years of evidence showing the efficacy of established hip surveillance programmes, there is poor awareness among healthcare professionals in India about the importance of regular hip surveillance in children with CP. There is a need for professional organizations to develop evidence-based guidelines for hip surveillance which are relevant to the Indian context.     

Effects of weak antagonist on fast elbow flexion movements in man

Summary By using a mathematical model and experiments involving electrical simulation of antagonistic muscles, we have formed the hypothesis (Wierzbicka et al. 1986) that in one-joint movements the antagonist muscle not only provides braking torque but also controls movement time. To get additional experimental support for this hypothesis, we studied elbow flexion movements performed by patients with spinal cord injury at the C 5–6 level who had relatively normal strength in their biceps muscle and little or no voluntary control of the triceps. Seven quadriplegic patients and six control subjects performed elbow flexion movements of 10°, 20°, and 30° as fast and accurately as possible. Despite the lack of antagonist, patients used the same pulse height strategy as control subjects to scale their responses with movement amplitude. However, patients' movement time was on average twice that of control subjects, and durations of both accelerative and decelerative phases of movement were increased. Movement speed and acceleration were reduced to 20–50% of the corresponding values of control subjects. Patients tended to overshoot the target to a larger extent than control subjects, particularly 10° targets, with nearly twice the error. We performed the same experiments using an external torque motor to assist the weak triceps. When a constant extensor torque of 2.5 or 5 Nm was provided by the motor, patients were able to move faster, and movement accuracy improved to within the normal range. These results provide direct evidence that the lack of an antagonist has an important effect on completion time and accuracy of fast goal-directed movements.     

Case series of two patients with Fibrocartilaginous Embolism mimicking Transverse Myelitis of the Spinal Cord

Fibrocartilaginous Embolism (FCE) refers to the extrusion of some of the fibro-cartilaginous nucleus pulposus material from within the inter-vertebral disc to eventually embolize into one of the spinal cord vessels with resultant spinal cord infarction. According to a 2016 review, AbdelRazek et al. (2106) [1] there are 41 pathologically confirmed and 26 clinically suspected cases in the literature till the end of 2015. We add two more clinically diagnosed cases.     

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis

Objectives

To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization.

Reliability and validity of the capabilities of upper extremity test (CUE-T) in subjects with chronic spinal cord injury

Abstract

Objective

To determine the reliability and validity of the capabilities of upper extremity test (CUE-T), a measure of functional limitations, in patients with chronic tetraplegia.

Design

Repeated measures.

Setting

Outpatient rehabilitation center.

Participants

Fifty subjects (36 male/14 female) with spinal cord injury (SCI) of ≥1-year duration participated. Subjects were 17–81 years old (mean 48.1 ± 18.2); neurological levels ranged from C2 through T6, American Spinal Injury Association Impairment Scale grades A–D.

Interventions

Not applicable.

Outcome measures

Intraclass correlation coefficients (ICC), weighted kappa and repeatability values for CUE-T; Spearman correlations of CUE-T with upper extremity motor scores (UEMS), and self-care and mobility portions of the Spinal Cord Independence Measure, vIII (SCIM III).

Results

Score ranges for UEMS were 8–50, CUE-T 7–135, self-care SCIM 0–20, and mobility SCIM 0–40. The ICC values for total, right, and left side scores were excellent (0.97–0.98; 95% confidence interval 0.96–0.99). Item weighted kappa values were ≥0.60 for all but five items, four of which were right and left pronation and supination. Repeatability of total score was 10.8 points, right and left sides 6.3 and 6.1 points. Spearman correlations of the total CUE-T with the UEMS and SCIM self-care and mobility scores were 0.83, 0.70, and 0.55 respectively.

Conclusions

The CUE-T displays excellent test–retest reliability, and good–excellent correlation with impairment and capacity measures in persons with chronic SCI. After revising pronation and supination test procedures, the sensitivity to change should be determined.     

Quadriplegia complicating parenteral nutrition

An infant developed quadriplegia during parenteral hyperalimentation from spinal cord injury secondary to inferior vena caval thrombosis and a subsequent caval-cerebrospinal fluid communication.     

Lidocaine Anal Block Limits Autonomic Dysreflexia During Anorectal Procedures in Spinal Cord Injury: A Randomized, Double-Blind, Placebo-Controlled Trial

PURPOSE Autonomic dysreflexia is a common and potentially dangerous hypertensive response to stimulation below the level of injury that occurs in patients with spinal cord injury at T6 or above. Rectosigmoid distention and anal manipulation are among the stimuli that may precipitate autonomic dysreflexia. Instillation of topical local anesthetic into the rectum is the recommended prophylaxis against autonomic dysreflexia of anorectal origin. However, a previous randomized, double-blind, placebo-controlled trial showed that topical lidocaine in the rectum does not blunt the autonomic dysreflexia response to anorectal procedures. The purpose of this study was to determine whether lidocaine anal sphincter block would be effective in limiting anorectal procedure-associated autonomic dysreflexia.METHODS We enrolled patients with chronic, complete spinal cord injury above T6, who were having anorectal procedures (flexible sigmoidoscopy and/or anoscopic hemorrhoid ligation). In a double-blind fashion, patients were randomized for intersphincteric anal block with 1 percent lidocaine or normal saline (placebo) before the procedure. Blood pressure was measured before, during, and after the block and procedure.RESULTS Thirteen patients received lidocaine, and 13 received placebo. The groups were similar in age, level of injury, duration of spinal cord injury, type of procedure, and procedure duration. The mean maximal systolic blood pressure increase for the lidocaine group was 22 ± 14 mmHg, significantly lower than the placebo group’s 47 ± 31 mmHg (P = 0.01).CONCLUSIONS Lidocaine anal block significantly limits the autonomic dysreflexia response in susceptible patients undergoing anorectal procedures.     

An artificial grasping evaluation system for the paralysed hand

Neuromuscular electrical stimulation (NMES) has been used in upper limb rehabilitation towards restoring motor hand function. Quantitative evaluation of the artificially generated movement is necessary to achieve proper muscle activation. Custom-made gloves instrumented with force and position transducers were used to evaluate artificial quadriplegic grasping for a drinking activity. In spite of different sensor position, stimulation parameter dependence and lack of repeatability, grasp patterns achieved with the application of NMES follow the same patterns previously obtained with normal subjects, regarding force distribution among fingers and the shape of force curves. Larger forces were exerted by the thumb (average ranged from 2.8 to 4.5 N) following by index or long finger (average ranged from 1.8 to 3 N). The forces exerted ranged within the same interval as those previously measured and were sufficient to grasp an object of 10 N. Finger position achieved by interphalangeal joint status indicated the opening size of the hand throughout the range of movement. The instrumented gloves offer an alternative force and position feedback system for use in cylindrical grasp evaluation. The gloves can be used in a closed-loop control system, allowing on-line adjustment or in a clinical application to evaluate the results of a rehabilitation programme.