[Spasticity-correcting surgery can have long-lasting effects]. / Spasticitetskorrigerande kirurgi kan ge långvariga förbättringar.

Spasticity is a common secondary complication after injuries to the central nervous system (CNS). Spasticity may severely impair arm and hand function, and consequently, affect an individual's function, resulting in disabilities or limiting activities and participation. Today, there is conflicting evidence regarding the effectiveness of available spasticity treatments. The population of adults with spasticity problems due to a CNS injury is heterogenic. A multidisciplinary approach is essential in customizing treatment to individual needs. The planning of treatment should consider the remaining upper limb functions and the patient's potential to improveme. Spasticity-correcting surgery is an option that seems underutilized. This article describes a structured and standardized program for the preoperative assessment, the surgical technique and the postoperative rehabilitation of patients undergoing upper limb spasticity-correcting surgery.

A comparison of health-related factors between patients diagnosed with ME/CFS and patients with a related symptom picture but no ME/CFS diagnosis: a cross-sectional exploratory study.

BACKGROUND: In chronic fatigue syndrome/myalgic encephalomyelitis (ME/CFS), the capacity for activity and participation is strongly limited. The disease definition is very broad, and considering the lack of evidence for best treatment, it is important to understand what is ME/CFS-specific in the biopsychosocial perspective in comparison with similar syndromes. The objective was to study the difference between those diagnosed with ME/CFS and those with similar symptoms but no ME/CFS diagnosis for self-perceived level of physical activity, work ability, anxiety/depression, and health-related quality of life. METHODS: This was a clinical cross-sectional study with data collected from mailed questionnaires. The following variables were compared between patients diagnosed with ME/CFS (n = 205) and those with similar symptoms but no diagnosis (n = 57); level of physical activity, Work ability index (WAI), Hospital anxiety and depression scale (HAD-A/HAD-D), and RAND-36 Physical functioning, Role limitations due to physical health problems, Role limitations due to personal or emotional problems, Social functioning, Energy/fatigue, Bodily pain, Emotional well-being, and General health perceptions. The Chi-squared test (nominal data), the Mann-Whitney U test, the Student's t test and regression analysis were used to analyze the data. RESULTS: The group diagnosed with ME/CFS had a more impaired physical and mental exertion ability as compared to the group that had similar symptoms but was not diagnosed with ME/CFS, shown by a RAND-36 lower index of physical role functioning, social functioning, energy, worse pain and poorer overall health (p ≤ 0.05). In contrast, no significant group differences emerged for weekly level of physical activity, work ability, anxiety/depression, and RAND-36 Emotional role limitation and well-being. CONCLUSION: Our results indicate that those with a diagnosis of ME/CFS are characterized by an impaired ability for physical or mental exertion, worse pain, and poorer overall health as compared to individuals with similar symptoms but for whom ME/CFS-diagnosis was not established. The results may be cautiously interpreted as support when focusing on patients' self-care in terms of management of energy levels. The results must however be verified in future studies.

Linking Prioritized Occupational Performance in Patients Undergoing Spasticity-Correcting Upper Limb Surgery to the International Classification of Functioning, Disability, and Health.

Background: Spasticity is generally caused by damage to the spinal cord or the areas of the brain that controls movements, which poses significant limitations in occupational tasks. Objectives: The aims of the study were to (I) describe prioritized occupational performance problems (POPP) among patients who underwent upper limb spasticity-correcting surgery and map them to the International Classification of Function, Disability, and Health (ICF); (II) assess outcomes postsurgery; (III) assess whether the results are influenced by the diagnosis, gender, and residual muscle function; and (IV) assess correlation between changes in COPM and gains in grasp ability and grip strength. Methods: In this retrospective study, assessments occurred pre- and postsurgery, including the Canadian Occupational Performance Measure (COPM), grip strength, and grasp ability. POPP were transformed to prioritized occupational performance goals (POPG) during subsequent rehabilitation. Results: 60 patients with a history of spinal cord injury (SCI) (n = 42; 59%), stroke (n = 25; 34%), traumatic brain injury (TBI) (n = 4; 6%), and reason unknown (n = 1; 1%) were included, with a mean age of 57 (±13) years. Of those, 11 had bilateral surgery, generating 71 COPM forms and 320 POPG. The POPG were mapped to the ICF activity and participation chapter, most often to self-care (n = 131; 41%), domestic life (n = 68; 21%), and mobility (n = 58; 18%). COPM scores were significantly increased postsurgery, irrespective of diagnosis, gender, and muscle function. No clear correlation between COPM improvement and hand function gains was shown. Conclusion: Patients who underwent spasticity-correcting upper limb surgery identified difficulties with a wide range of occupational tasks that they considered as important to regain. Treatment-induced gains in occupational performance were significant but had no clear correlation with gains in grasp ability and hand strength. Independent of diagnosis, gender, and residual muscle function, it seems important to address the activity- and participation-specific aspects in the assessment and rehabilitation of patients.

The impact of upper limb spasticity-correcting surgery on the everyday life of patients with disabling spasticity: a qualitative analysis.

PURPOSE: The aim of this study was to explore the patient perspective of their experiences of daily life after spasticity-correcting surgery for disabling upper limb (UL) spasticity after spinal cord injury (SCI) and stroke. MATERIALS AND METHODS: Eight patients with UL spasticity resulting from SCI (n= 6) or stroke (n= 2) were interviewed 6-9 months after spasticity-correcting surgery. A phenomenographic approach was used to analyze the interviews. RESULTS: Five themes emerged from the interviews: (1) bodily changes, such as increased muscle strength, range of motion, and reduced muscle-hypertonicity; (2) improved occupational performance, facilitating tasks, mobility, and self-care; (3) regained control, explicating the perception of regaining bodily control and a more adaptable body; (4) enhanced interpersonal interactions, entailing the sense of being more comfortable undertaking social activities and personal interactions; and (5) enhanced psychological well-being, including having more energy, increased self-esteem, and greater happiness after surgery. CONCLUSIONS: The participants experienced improvements in their everyday lives, including body functions, activities, social life, and psychological well-being. The benefits derived from surgery made activities easier, increased occupational performance, allowed patients regain their roles and interpersonal interactions, and enhanced their psychological well-being.Implications for rehabilitationSpasticity-correcting surgery benefits patients by improving bodily functions, which in turn, enable gains in activities, social life, and psychological well-being.Patients' experiences of increased body functions, such as enhanced mobility and reduced muscle hypertonicity, appear to increase the sense of bodily control.The surgery can increase participation and psychological well-being, even for patients whose functional or activity level did not improve after the treatment.The benefits expressed by the individuals in this study can be used to inform, planning, and in discussion with patients and other healthcare professionals about interventions targeting spasticity.

Regional estimates of cortical thickness in brain areas involved in control of surgically restored limb movement in patients with tetraplegia.

Context/Objective: Spinal cord injury (SCI) causes atrophy of brain regions linked to motor function. We aimed to estimate cortical thickness in brain regions that control surgically restored limb movement in individuals with tetraplegia. Design: Cross-sectional study. Setting: Sahlgrenska University hospital, Gothenburg, Sweden. Participants: Six individuals with tetraplegia who had undergone surgical restoration of grip function by surgical transfer of one elbow flexor (brachioradialis), to the paralyzed thumb flexor (flexor pollicis longus). All subjects were males, with a SCI at the C6 or C7 level, and a mean age of 40 years (range = 31-48). The average number of years elapsed since the SCI was 13 (range = 6-26). Outcome measures: We used structural magnetic resonance imaging (MRI) to estimate the thickness of selected motor cortices and compared these measurements to those of six matched control subjects. The pinch grip control area was defined in a previous functional MRI study. Results: Compared to controls, the cortical thickness in the functionally defined pinch grip control area was not significantly reduced (P = 0.591), and thickness showed a non-significant but positive correlation with years since surgery in the individuals with tetraplegia. In contrast, the anatomically defined primary motor cortex as a whole exhibited substantial atrophy (P = 0.013), with a weak negative correlation with years since surgery. Conclusion: Individuals with tetraplegia do not seem to have reduced cortical thickness in brain regions involved in control of surgically restored limb movement. However, the studied sample is very small and further studies with larger samples are required to establish these findings.

Adaptive motor cortex plasticity following grip reconstruction in individuals with tetraplegia.

BACKGROUND: Tendon transfer is a surgical technique for restoring upper limb motor control in patients with cervical spinal cord injuries (SCI), and offers a rare window into cortical neuroplasticity following regained arm and hand function. OBJECTIVE: Here, we aimed to examine neuroplasticity mechanisms related to re-established voluntary motor control of thumb flexion following tendon transfer. METHODS: We used functional Magnetic Resonance Imaging (fMRI) to test the hypothesis that restored limb control following tendon transfer is mediated by activation of that limb's area of the primary motor cortex. We examined six individuals with tetraplegia who underwent right-sided surgical grip reconstruction at Sahlgrenska University Hospital, Sweden. All were right-handed males, with a SCI at the C6 or C7 level, and a mean age of 40 years (range = 31-48). The average number of years elapsed since the SCI was 13 (range = 6-26). Six right-handed gender- and age-matched control subjects were included (mean age 39 years, range = 29-46). Restoration of active thumb flexion in patients was achieved by surgical transfer of one of the functioning elbow flexors (brachioradialis), to the paralyzed thumb flexor (flexor pollicis longus). We studied fMRI responses to isometric right-sided elbow flexion and key pinch, and examined the cortical representations within the left hemisphere somatomotor cortex a minimum of one year after surgery. RESULTS: Cortical activations elicited by elbow flexion did not differ in topography between patients and control participants. However, in contrast to control participants, patients' cortical thumb flexion activations were not topographically distinct from their elbow flexion activations. CONCLUSION: This result speaks against a topographic reorganization in which the thumb region regains thumb control following surgical tendon transfer. Instead, our findings suggest a neuroplastic mechanism in which motor cortex resources previously dedicated to elbow flexion adapt to control the thumb.

Early Active Rehabilitation After Grip Reconstructive Surgery in Tetraplegia.

OBJECTIVE: To describe and evaluate the concept of early active rehabilitation after tendon transfer to restore grip function in tetraplegia. DESIGN: Retrospective cohort study. SETTING: Two nonprofit rehabilitation units in Sweden and Switzerland. PARTICIPANTS: All patients with tetraplegia who underwent tendon transfer to restore grip ability during 2009 to 2013 (N=49). INTERVENTION: Reconstructive tendon transfer surgery with early active rehabilitation to restore grip ability in tetraplegia. MAIN OUTCOME MEASURES: Grip and pinch strength, grip ability test, and outcome of prioritized activities. RESULTS: In the 49 surgeries performed, postoperative complications included 2 patients with bleeding and 2 infections related to the surgery. There were no reported ruptures or lengthening of transferred tendons. Within 24 hours after surgery, all 47 patients (100%) with finger flexion reconstruction succeeded to activate their finger flexion. All but 1 patient with reconstructed thumb flexion sucessfully activated their thumb flexion (n=40). Three weeks after surgery, all patients (100%) were able to perform basic activities of daily living, and instrumental activities of daily living were achieved by 74%. One year after surgery, the maximum grip strength in restored finger flexion was on average 6.9kg (range, 1.5-15kg; n=29). The maximum pinch strength in restored thumb flexion was on average 3.7kg (range, 1-20; n=29). On average, grip ability improved from 33 to 101 (n=19) according to the COPM. Prioritized activity limitations, as measured with the COPM, equated to an average of 3.5 steps (2.5 steps preoperatively to 6 steps postoperatively). Patients' perceived satisfaction with this improvement was 4 steps (increasing from 2 steps preoperatively to 6 steps postoperatively). CONCLUSIONS: Grip reconstructive surgery followed by early active rehabilitation can be considered a reliable procedure that leads to substantial improvements in grip and pinch strength and activity performance among patients with tetraplegia.