Different Thumb Positions in the Tetraplegic Hand.

OBJECTIVE: To analyze factors associated with malposition that affects function of the thumb in individuals with tetraplegia. DESIGN: Retrospective cross-sectional study. SETTING: Rehabilitation Center for Spinal Cord Injury. PARTICIPANTS: Anonymized data from 82 individuals (68 men), mean age 52.9±20.2 (SD) with acute/subacute cervical spinal cord injury C2-C8 AIS A-D recorded during 2018-2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Motor point (MP) mapping and manual muscle test (MRC) of 3 extrinsic thumb muscles (flexor pollicis longus (FPL), extensor pollicis longus (EPL), and abductor pollicis longus (APL)). RESULTS: 159 hands in 82 patients with tetraplegia C2-C8 AIS A-D were analyzed and assigned to "key pinch" (40.3%), "slack thumb" (26.4%), and "thumb-in-palm" (7.5%) positions. There was a significant (P<.0001) difference between the 3 thumb positions depicted in lower motor neuron (LMN) integrity tested by MP mapping and muscle strength of the 3 muscles examined. All studied muscles showed a significantly different expression of MP and the MRC values (P<.0001) between the "slack thumb" and "key pinch" position. MRC of FPL was significantly greater in the group "thumb-in-palm" compared with "key pinch" position (P<.0001). CONCLUSIONS: Malposition of the thumb due to tetraplegia seems to be related to the integrity of LMN and voluntary muscle activity of the extrinsic thumb muscles. Assessments such as MP mapping and MRC of the 3 thumb muscles enable the identification of potential risk factors for the development of thumb malposition in individuals with tetraplegia.

Implications of thumb position and trajectory in tetraplegia grip reconstruction - a cohort study.

STUDY DESIGN: This study represents a retrospective observational cohort study. OBJECTIVES: The objective of this study was to investigate the impact of thumb position on postoperative patient-rated and functional outcomes in grip reconstruction surgery. SETTING: All consecutive adult patients with tetraplegia undergoing grip reconstruction surgery at the Swiss Paraplegic Centre between 06/2008 and 11/2020 were assessed for eligibility. METHODS: Standardized photo or film documentation was used for individually recreating and categorizing thumb position and trajectory during key pinch. Outcome measurements included key pinch strength, Canadian Occupational Performance Measure (COPM) and Grasp Release Test (GRT). RESULTS: Fifty-six hands of 44 patients (mean age 42.2 years, range 18-70 years) with a mean follow-up of 14.8 months (range 6 months to 12 years) were included. There was a significant postoperative improvement of key pinch strength, COPM score and GRT. COPM improvement was more pronounced for hands with more palmar abducted trajectories of the thumb. CONCLUSIONS: Regardless of reconstruction type, pinch strength, patient satisfaction and grasp and release abilities improved significantly after surgery. Thumb position and trajectory are strong determining factors for the selected outcome measurements.

Toward Consensus in Assessing Upper Limb Muscle Strength and Pinch and Grip Strength in People With Tetraplegia Having Upper Limb Reconstructions.

OBJECTIVES: To reach agreement on standardized protocols for assessing upper limb strength and grip and pinch force for upper limb reconstructive surgery for tetraplegia. METHODS: Selected members of an expert panel composed of international therapists formed at the 2018 International Congress for Upper Limb Surgery for Tetraplegia conducted a literature review of current practice that identified gaps and inconsistencies in measurement protocols and presented to workshop attendees. To resolve discrepancies, a set of questions was presented to workshop attendees who voted electronically. Consensus was set at 75% agreement. RESULTS: For manual muscle testing, consensus was reached for using the Medical Research Council scale, without plus or minus, and the use of resistance through range when testing grade 4 and grade 5 strength. Pectoralis major and serratus anterior should be routinely tested, however there was no consensus on other shoulder muscles. Grip and pinch strength should be tested according to the American Society of Hand Therapists positioning. For grip strength, either the Jamar or Biometrics dynamometer expressed in kilograms should be used. For grip and pinch strength, three measurements should be performed at each testing. No consensus was reached on a device for pinch strength. CONCLUSION: This work is an important step to enable comparable data in the future. Further consensus methods will work toward developing more comprehensive guidelines in this population. Building international consensus for pre- and postoperative measures of function supports objective evaluation of novel therapies and interpretation of multicenter studies.

Outcome from a brachialis donor for wrist extension in tetraplegia-time to reconsider the International Classification for Surgery of the Hand in Tetraplegia (ICSHT).

INTRODUCTION: Surgical reconstruction after quadriplegia represents a powerful solution to restore lost function by injury. A case is presented in which surgical reconstruction of a patient with a C4 level spinal cord injury is performed using the brachialis (BRA) muscle as the donor. CASE PRESENTATION: The patient previously had no hand function. This transfer, in combination with fusion of the thumb CMC joint and transfer of the flexor pollicis longus (FPL) tendon to the radius, gives the patient full thumb key pinch powered by BRA transferred to the wrist extensors. Theoretical analysis of muscle architectural properties demonstrates that the BRA has sufficient force and excursion to substitute for both the long and short radial wrist extensors. Furthermore, based on the fact that the BRA has almost twice the excursion compared to the extensor carpi radialis longus (ECRL), wrist extension can occur throughout the entire wrist and elbow ranges of motion. Finally, peak tension is lower than the rupture tension previously measured by us using this type of tendon-to-tendon attachment technique, suggesting that the transfer itself is safe and, importantly, can be immediately mobilized for neuromuscular rehabilitation. DISCUSSION: This procedure can thus restore tremendous functional capacity in patients who were previously categorized as group 0 by the International Classification of Hand Surgery in Tetraplegia (ICSHT). We suggest that, based on the BRA being an excellent donor for surgical reconstruction, that the ICHST system be reconsidered.

Motor Point Topography of Fundamental Grip Actuators in Tetraplegia: Implications in Nerve Transfer Surgery.

The differentiation between an upper motoneuron (UMN) lesion and lower motoneuron (LMN) lesion of forearm muscles in patients with tetraplegia is critical for the choice of treatment strategy. Specifically, the M. pronator teres (PT), M. flexor digitorum profundus III (FDPIII), and M. flexor pollicis longus (FPL) were studied since they represent key targets in nerve transfer surgery to restore grasp function. Forearm muscles of 24 patients with tetraplegia were tested bilaterally with electrical stimulation (ES) to determine whether UMN or LMN lesion was present. For detecting and testing the nerve stimulation points, a standardized mapping was developed and clinically applied. The relationship between the anatomical segmental spinal innervation and the innervation pattern tested by ES was determined. The data of 44 arms were analyzed. For PT, 19 arms showed an intact UMN, 18 arms an UMN lesion, and seven arms partial denervation. For FDPIII, three arms demonstrated an intact UMN, 26 arms an UMN lesion, 10 arms partial denervation, and five arms denervation. For FPL, two arms presented an intact UMN, 16 arms an UMN lesion, 12 arms partial denervation, and 14 arms denervation. A total of 20.1% ES tested muscles were partially denervated. In four patients, only one arm could be tested because of surgery-related limitations. According to the level of lesion and the segmental spinal innervation, most denervated muscles were present in the patient group C6 to C8. The ES, together with the developed mapping system, is reliable and can be recommended for standardized testing in surgery and rehabilitation. It offers the possibility to detect if and to what extent UMN and LMN lesions are present for the target muscles. It allows for refined pre-operative diagnostics and prognostics in spinal cord injury neurotization surgery.

Electrical stimulation-a mapping system for hand dysfunction in tetraplegia.

STUDY DESIGN: Retrospective data analysis OBJECTIVES: To define the distribution of the motor points and excitability of the key wrist and finger actuators in order to detect upper (UMN) and lower motor neuron (LMN) lesions potentially influencing the development of a tenodesis grasp. SETTING: A rehabilitation centre for spinal cord injuries, Nottwil, Switzerland. METHODS: Forearm muscles of 32 patients with tetraplegia (AIS A-D) were tested bilaterally with electrical stimulation (ES) to differentiate whether UMN or LMN was present. For testing, a standardised mapping was developed. All patients underwent the same positioning schedule. RESULTS: Sixteen hands developed a tenodesis grasps, 24 hands showed neither shortening nor tightening of the finger flexors. Two patients developed unilateral tenodesis grasp and showed no tightening of the finger flexors on the contralateral hand. Seven patients developed tenodesis grasps symmetrically and bilaterally, whereas one maintained an essentially open hand without tightening of the finger flexors. All hands that developed a tenodesis grasp showed a LMN lesion of the M. extensor digitorum communis (EDC). The frequency of the tenodesis grasp differed significantly between the groups with and without intact reflex arc (p < 0.0001). CONCLUSION: Surface ES may serve as a diagnostic tool to detect an UMN or LMN lesion of the key actuator muscles affecting the tenodesis grasp. These findings provide information that is essential for the choice of treatment to optimise function of the tetraplegic hand.

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.

Rehabilitation After Posterior Deltoid to Triceps Transfer in Tetraplegia.

OBJECTIVE: To describe and evaluate the rehabilitation concept after posterior deltoid to triceps transfer in patients with tetraplegia. DESIGN: Retrospective observational study. SETTING: Rehabilitation units. PARTICIPANTS: Patients with tetraplegia who had posterior deltoid to triceps tendon transfer and had muscle strength measurements 1 year postsurgery from 2009 to 2013 (N=44). INTERVENTIONS: Posterior deltoid to triceps tendon transfer to restore elbow extension and postoperative rehabilitation. MAIN OUTCOME MEASURES: Elbow extension range of motion and muscle strength and the modified Canadian Occupational Performance Measure (COPM). RESULTS: Surgery was performed on 53 arms. No major complications (eg tendon rupture, lengthening) were reported. Muscle strength measured 1 year after surgery was on average grade 3 (out of 5) in the 53 operated arms. The ability to extend the elbow against gravity was achieved in 62% of the arms (muscle strength of grade ≥3). In patients with a preoperative elbow extension deficit (n=14), the deficit was reduced on average from 16° to 9°. The performance of the prioritized activities as measured with the COPM improved on average 2.6 scale steps, from 3.3 to 5.9. Satisfaction with the performance improved on average 3.2 scale steps, from 2.8 to 6.0. CONCLUSIONS: The posterior deltoid to triceps tendon transfer with the applied rehabilitation protocol is a safe and effective procedure. There were no tendon ruptures, and all patients were able to complete the rehabilitation protocol. The shorter restriction time after surgery allows the patient to be independent at an earlier stage of the rehabilitation and reduces hospitalization or care burden.

Laboratory evaluation of four different devices for secretion mobilization: Acapella choice, green and blue versus water bottle.

BACKGROUND: Secretion removal is a key issue in patients with respiratory diseases, and is known to be most effective at vibration frequencies of ∼ 13 Hz and with the greatest amplitudes possible. The Acapella devices and the water bottle are used for secretion removal in daily clinical practice but without detailed knowledge on optimal settings. The aim of this study was to evaluate the 3 different Acapella devices and the water bottle at various settings and flows to determine the optimal devices and settings for effective secretion removal. METHODS: Three different Acapella devices were tested at flows of 6, 12, 20, 30, 40, and 50 L/min, and at all 5 settings. The water bottle was filled with 5, 10, or 15 cm of water, and tested at flows of 3, 6, 10, 12, and 20 L/min. For all devices and combinations of settings, we measured the frequency and amplitude of the vibrations, as well as the required pressure to generate vibrations. RESULTS: Setting 4 was the best for all 3 Acapella devices, and the filling height of the water bottle should be 5 cm. At these settings, all devices elicited vibration frequencies between 12 and 15 Hz, which is theoretically optimal for secretion mobilization. The resistance pressures of the devices to elicit these vibrations were between 5 and 11 cm H2O. However, the Acapella devices elicit higher vibration amplitudes (5-8 cm H2O) than the water bottle (1.8 cm H2O) CONCLUSIONS:: Setting 4 was optimal for all 3 Acapella devices. The Acapella devices may be more efficient for secretion mobilization than the water bottle, because they elicit greater amplitude of vibrations.