Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up.

PURPOSE: Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery. METHODS: We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27-61). At a mean of 19.8 years (15.4-30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0-100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0-100, 0 being the best score) for function. RESULTS: At latest follow-up, the median VAS pain score was 49 (0-96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8-46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12-70) abduction, 20° (10-50) forward flexion and 22° (- 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction. CONCLUSION: At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement. LEVEL OF EVIDENCE III: A retrospective cohort study.

Does intensive upper limb treatment modality Hybrid Constrained Induced Movement Therapy (H-CIMT) improve grip and pinch strength or fatigability of the affected hand?

PURPOSE: To investigate the effects of Hybrid-Constrained Induced Movement Therapy (H-CIMT), defined as CIMT combined with Bimanual Intensive Movement Therapy (BIMT), on grip and pinch strength and fatigability we measured grip and pinch strength and fatigability during clinical H-CIMT. METHODS: The children participated in a H-CIMT model organized in a therapeutic summer-camp. Children received 90 hours of intensive treatment. Grip and pinch strength and fatigability was measured and fatigue was calculated according to a Static Fatigue Index (SFI). RESULTS: Pinch strength significantly increased, grip strength did not increase significantly. A non-significant decrease was seen in SFI in pinch and grip. CONCLUSIONS: H-CIMT showed to be effective in increasing muscle pinch strength in the AH. Effectiveness in decreasing muscle fatigue during grip and pinch tests is not yet shown although there was a tendency towards a decrease in muscle fatigue. However, the long-term effects on these aspects are also important in future research.

Botulinum toxin-a in children with congenital spastic hemiplegia does not improve upper extremity motor-related function over rehabilitation alone: a randomized controlled trial.

BACKGROUND: Rehabilitation of the upper extremity in children with hemiplegic cerebral palsy has not been compared to the same intensity of therapy combined with injected botulinum toxin (BTX). OBJECTIVE: To measure the short-term (2 weeks) and long-term (6 and 9 months) effects of a standardized functional training program versus without the addition of chemodenervation of forearm and hand muscles. METHODS: Twenty children with spastic hemiplegia, aged 4 to 16 years, were matched for baseline characteristics and then randomized to standardized functional physical and occupational therapies for 6 months (PT/OT group) or to the same therapies plus multimuscle BTX-A (BTX+ group). MAIN OUTCOME MEASURES: were isometric generated force, overshoot and undershoot (force production error), active and passive range of motion by goniometry (ROM), stretch restricted angle (SRA) of joints, Ashworth scores at the elbow and wrist, and the Melbourne assessment of unilateral upper limb function. All measures were performed at baseline, 2 weeks after BTX-A, 6 months (end of therapy), and then 3 months after termination of the therapy. RESULTS: Clinical measures (muscle tone, active ROM of wrist and elbow) showed improvement in both groups. However, no significant differences emerged between groups on functional measures. Generated force decreased directly after the BTX-A injection but increased during the therapy period. The PT/OT group, however, showed a significantly higher increase in force and accuracy with therapy compared with the BTX+ therapy group. CONCLUSIONS: Functional rehabilitation therapies for the upper extremity increase manual isometric flexor force at the wrist and ROM, but BTX injections cause weakness and do not lead to better outcomes than therapy alone.

Botulinum toxin A and upper limb functional skills in hemiparetic cerebral palsy: a randomized trial in children receiving intensive therapy.

The objective of this study was to determine whether the use of intramuscular botulinum toxin A (BTX-A) increases upper limb function and skills in the context of a specific therapy programme in children with hemiparetic cerebral palsy. Twenty children (nine females, 11 males) aged 4 to 16 years who were thought likely to benefit from BTX-A treatment were included. After matched pairs were made, on the basis of Zancolli grade and age, randomization took place. All patients were given structured rehabilitation (physiotherapy and occupational therapy three times a week for 6 months), and half of the patients received intramuscular BTX-A. No placebo injections were given in the control group. Participants were assessed at baseline, at 2 and 6 weeks, and at 3, 6, and 9 months after injection. The Ashworth scale, active range of motion of arm joints, the Melbourne assessment of upper limb function, the Pediatric Evaluation of Disability Inventory, and the nine-hole peg test were used for outcome measurement. Observers were blinded for treatment allocation only for scoring the Melbourne test. The children in the treatment group showed a clinically relevant increase in active dorsal flexion, and tone reduction of the wrist. For the functional outcome measures, no statistically significant differences between the groups could be demonstrated. Intramuscular BTX-A added to an intensive therapy programme reduces impairment for at least 9 months; the effect on activity level is still uncertain.