Robot controlled, continuous passive movement of the ankle reduces spinal cord excitability in participants with spasticity: a pilot study.

Spasticity of the ankle reduces quality of life by impeding walking and other activities of daily living. Robot-driven continuous passive movement (CPM) is a strategy for lower limb spasticity management but effects on spasticity, walking ability and spinal cord excitability (SCE) are unknown. The objectives of this experiment were to evaluate (1) acute changes in SCE induced by 30 min of CPM at the ankle joint, in individuals without neurological impairment and those with lower limb spasticity; and, (2) the effects of 6 weeks of CPM training on SCE, spasticity and walking ability in those with lower limb spasticity. SCE was assessed using soleus Hoffmann (H-) reflexes, collected prior to and immediately after CPM for acute assessments, whereas a multiple baseline repeated measures design assessed changes following 18 CPM sessions. Spasticity and walking ability were assessed using the Modified Ashworth Scale, the 10 m Walk test, and the Timed Up and Go test. Twenty-one neurologically intact and nine participants with spasticity (various neurological conditions) were recruited. In the neurologically intact group, CPM caused bi-directional modulation of H-reflexes creating 'facilitation' and 'suppression' groups. In contrast, amongst participants with spasticity, acute CPM facilitated H-reflexes. After CPM training, H-reflex excitability on both the more-affected and less-affected sides was reduced; on the more affected side H@Thres, H@50 and H@100 all significantly decreased following CPM training by 96.5 ± 7.7%, 90.9 ± 9.2%, and 62.9 ± 21.1%, respectively. After training there were modest improvements in walking and clinical measures of spasticity for some participants. We conclude that CPM of the ankle can significantly alter SCE. The use of CPM in those with spasticity can provide a temporary period of improved walking, but efficacy of treatment remains unknown.

Similar barriers and facilitators to physical activity across different clinical groups experiencing lower limb spasticity.

Purpose Given the importance of physical activity in maintaining health and wellness, an improved understanding of physical activity patterns across different clinical populations is required. This study examines the facilitators for, and barriers to, participation in physical activity across multiple contexts for three clinical groups with chronic lower limb spasticity (individuals with stroke, multiple sclerosis and incomplete spinal cord injury). Method This cross-sectional study employed quantitative measures for spasticity, ankle range of motion, pain, falls, cognition, mobility, and physical activity as well as qualitative semi-structured interviews. Results There were similar impairments in body functions and structures and limitations in activities across the clinical groups. These impairments and limitations negatively impacted participation in physical activity, which was low. Environmental and personal factors exacerbated or mitigated the limiting effects of body functions and structures and activities on physical activity in many areas of life. Conclusions In this population, participation in physical activity includes activities such as housework which are different than what is typically considered as physical activity. Further, the presence of similar barriers and facilitators across the groups suggests that support and services to promote valued forms of physical activity could be organised and delivered based on limitations in mobility and functioning rather than clinical diagnosis. Implications for rehabilitation Physical activity is of utmost importance in maintaining health and wellness in clinical populations. This research highlights the desired and actual physical activity for these populations can look different than what may traditionally be considered as physical activity (e.g. housework is not typically considered participation physical activity). Therefore, rehabilitation interventions need to be directly designed to enhance clients' ability to perform these activities and these activities should be an integral focus of ongoing physical activity programs. Individuals who have lower limb spasticity shared similar impairments in body structures and functions and limitations in activities across the clinical groups and these impairments and limitations negatively impacted participation in physical in a similar way in all groups. Further, the environmental and personal factors exacerbated or mitigated the limiting effects of body functions and structures and activities on physical activity in many areas of life in a similar way in all groups. The presence of similar barriers and facilitators across the clinical groups suggests that rehabilitation assessment and treatment as well as support and services to promote valued forms of physical activity could be organised and delivered based on limitations in mobility and functioning rather than clinical diagnosis. This work affirms that a mixed methods research approach is critical for completely understanding the complexities of the barriers and facilitators engaging in physical activity across clinical groups, including multiple sclerosis, stroke, and incomplete spinal cord injury who have chronic lower limb spasticity.

Clinical application of sensory protection of denervated muscle.

Following proximal peripheral nerve injury, motor recovery is often poor due to prolonged muscle denervation and loss of regenerative potential. The transfer of a sensory nerve to denervated muscle results in improved functional recovery in experimental models. The authors here report the first clinical case of sensory protection. Following a total hip arthroplasty, this patient experienced a complete sciatic nerve palsy with no recovery at 3 months postsurgery and profound denervation confirmed electrodiagnostically. He underwent simultaneous neurolysis of the sciatic nerve and saphenous nerve transfers to the tibialis anterior branch of the peroneal nerve and gastrocnemius branch from the tibial nerve. He noted an early proprioceptive response. Electromyography demonstrated initially selective amelioration of denervation potentials followed by improved motor recovery in sensory protected muscles only. The patient reported clinically significant functional improvements in activities of daily living. The authors hypothesize that the presence of a sensory nerve during muscle denervation can improve functional motor recovery.

A methodological guide to performing a cost-utility study comparing surgical techniques.

BACKGROUND: When recommending the adoption of a new surgical intervention as opposed to maintaining an old one, surgeons need to consider the opportunity cost, which is the value of the forgone benefits. To inform these decisions, surgeons can use economic analyses of surgical practices. Unfortunately, economic analyses conducted alongside randomized controlled trials in surgery are rare. OBJECTIVES: The objective of the present study was to use data from a small randomized controlled trial to illustrate the methodology for a cost-utility analysis comparing two techniques of carpal tunnel release: open release without ('usual' technique) and with ('novel' technique) ligament reconstruction. METHODS: Eighteen eligible patients were entered into this prospective study. Fifteen were followed to six weeks postoperatively. One day preoperatively, and five days, three weeks and six weeks postoperatively, patients completed a self-administered Health Utilities Index Mark 2-3 questionnaire (utilities) and a case report form from which resource utilization (cost) was collected. Utilities were expressed as quality-adjusted life weeks, a fraction of quality-adjusted life years. RESULTS: The mean total cost of the usual technique was lower than the novel technique, and the mean quality-adjusted life week was higher, favouring the usual technique. Indirect costs were four to nine times higher than direct costs in both techniques. CONCLUSION: The novel technique was more costly and less effective, and fell in the 'lose-lose' quadrant of the cost-effectiveness plane; it was rejected in favour of the usual technique. This methodology should be applied when deciding whether to adopt novel surgical techniques in plastic surgery to optimize scarce health care resources.

HISTORIQUE: Au moment de recommander l'adoption d'une nou-velle intervention chirurgicale au lieu de conserver une ancienne intervention, les chirurgiens doivent tenir compte du coût de renonciation, qui correspond à la valeur des avantages auxquels ils renoncent. Pour étayer leurs décisions, les chirurgiens peuvent utiliser des analyses économiques des pratiques chirurgicales. Malheureusement, les analyses économiques menées conjointement avec des essais aléatoires et contrôlés sont rares. OBJECTIFS: La présente étude visait à utiliser les données d'un petit essai aléatoire et contrôlé pour illustrer la méthodologie d'une analyse coût-utilité comparant deux techniques de libération du tunnel du canal carpien : une libération ouverte sans (la technique « habituelle ¼) et avec (la « nouvelle ¼ technique) reconstruction ligamentaire. MÉTHODOLOGIE: Dix-huit patients admissibles ont participé à cette étude prospective. Quinze ont été suivis jusqu'à six semaines après l'opération. Un jour avant l'opération, puis cinq jours, trois semaines et six semaines après l'opération, les patients ont rempli eux-mêmes un questionnaire Health Utilities Index Mark 2-3 (utilité) et un formulaire de rapport de cas à partir duquel l'utilisation des ressources (coût) a été col-ligée. L'utilité était exprimée selon le nombre de semaines-personnes sans invalidité, une fraction des années-personnes sans invalidité. RÉSULTATS: Le coût total moyen de la technique habituelle était inférieur à celui de la nouvelle technique, et les semaines-personnes moyennes sans invalidité étaient plus élevées, ce qui favorisait la technique habituelle. Dans les deux techniques, les coûts indirects étaient de quatre à neuf fois plus élevés que les coûts directs. CONCLUSION: La nouvelle technique était plus coûteuse et moins efficace, et se classait dans le quadrant de double contrainte des régimes coût-efficacité. Elle a donc été rejetée en faveur de la technique habituelle. Cette méthodologie devrait être appliquée au moment de décider s'il est préférable d'adopter une nouvelle technique chirurgicale en chirurgie plastique, afin d'optimiser des ressources de santé limitées.

WITHDRAWN: Second AAEM literature review of the usefulness of nerve conduction studies and needle electromyography for the evaluation of patients with carpal tunnel syndrome.

Ahead of Print article withdrawn by publisher.