Evaluation of a stair-climbing power wheelchair in 25 people with tetraplegia.

OBJECTIVE: To compare the performance of a power wheelchair with stair-climbing capability (TopChair) and a conventional power wheelchair (Storm3). DESIGN: A single-center, open-label study. SETTING: A physical medicine and rehabilitation hospital. PARTICIPANTS: Patients (N=25) who required power wheelchairs because of severe impairments affecting the upper and lower limbs. INTERVENTIONS: Indoor and outdoor driving trials with both devices. Curb-clearing and stair-climbing with TopChair. MAIN OUTCOME MEASURES: Trial duration and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) tool; number of failures during driving trials and ability to climb curbs and stairs. RESULTS: All 25 participants successfully completed the outdoor and indoor trials with both wheelchairs. Although differences in times to trial completion were statistically significant, they were less than 10%. QUEST scores were significantly better with the Storm3 than the TopChair for weight (P=.001), dimension (P=.006), and effectiveness (P=.04). Of the 25 participants, 23 cleared a 20-cm curb without help, and 20 climbed up and down 6 steps. Most participants felt these specific capabilities of the TopChair--for example, curb clearing and stair climbing-were easy to use (22/25 for curb, 21/25 for stairs) and helpful (24/25 and 23/25). A few participants felt insecure (4/25 and 6/25, respectively). CONCLUSIONS: The TopChair is a promising mobility device that enables stair and curb climbing and warrants further study.

Home trials of a speech synthesizer in severe dysarthria: patterns of use, satisfaction and utility of word prediction.

OBJECTIVE: The aim of this study was to evaluate a speech synthesizer with respect to patterns of use and satisfaction, during a 2-month trial at home, and the usefulness of the word prediction function. DESIGN: Prospective study. PARTICIPANTS: Of the 24 patients with severe dysarthria recruited, 10 completed the study. Five patients had cerebral palsy, 3 amyotrophic lateral sclerosis, one locked-in syndrome, and one anoxic brain damage. Mean age was 32 (standard deviation 21) years (range 9-66 years). METHODS: Each participant received 10 hours of training with the device (Dialo) and then used it at home for 2 months. The main outcome measures were: level of use recorded by the device, Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) satisfaction score (maximum = 5), and time needed to take dictations of standard-dictionary and personal-dictionary words with and without word prediction. RESULTS: Level of use varied widely across participants. Overall satisfaction at the end of the home trial was high, with a mean QUEST score of 3.4 (SD 1) and was related to the level of use of the device. Level of satisfaction at the end of the training session could not predict the level of use at home. No significant differences were found in dictation-taking times with and without word prediction. However, 6 of the 10 patients took dictation faster with than without word prediction. CONCLUSION: This study provides the first evidence supporting the benefits of a speech synthesizer used at home for several weeks. Word prediction is useful for some patients even if increase in dictation speed did not reach significance.

Treatment of knee flexion contracture due to central nervous system disorders in adults.

BACKGROUND: Studies concerning adult patients with spastic flexion contracture of the knee are rare. Such patients frequently have cutaneous and vascular complications as well as recurrence of the contracture after treatment. We present a strategy consisting of simultaneous correction of all deformities of both lower limbs, distal hamstring releases, and application of femorotibial external fixation when extension of the knee is limited by excessive posterior soft-tissue tension. METHODS: A consecutive series of fifty-nine patients (ninety-seven knees) between the ages of twenty-one and seventy-seven years received surgical treatment for a flexion contracture of the knee secondary to neurological impairment. The flexion contracture was bilateral in thirty-eight patients. Preoperatively, the mean flexion contracture angle was 69 degrees and the mean passive range of motion was 61 degrees. The contracture was corrected, through medial and lateral approaches, with distal hamstring lengthening. A posterior capsulotomy was performed in thirty-five knees. Full extension of thirty-four knees was achieved intraoperatively. In seventy-seven knees, partial correction was maintained with a unilateral external fixator, and passive and active mobilization was performed four times daily after temporary removal of the spanning external fixator rod. RESULTS: At the time of final follow-up, ranging from one to five years postoperatively, the mean residual flexion contracture was 6.2 degrees. Forty-five knees had complete extension, and thirty-nine knees had a residual flexion contracture of <10 degrees. No recurrence of the flexion contracture or instability was noted in any knee at the time of follow-up. There were four cutaneous complications but no vascular or neurological complications. CONCLUSIONS: We believe that our surgical strategy for correction of fixed knee flexion contracture in adult patients is safe and effective. The correction improves nursing care and sitting posture, facilitating the upright position of patients who are unable to walk, and improves walking ability for patients who are able to walk.

Breathlessness associated with abdominal spastic contraction in a patient with C4 tetraplegia: a case report.

A tetraplegic patient with C4 cervical cord injury reported breathlessness during episodes of spastic contraction of the abdominal muscles. To determine the mechanism, we performed electrophysiologic testing of the phrenic nerves. We measured abdominal pressure, esophageal pressure, and transdiaphragmatic pressure (Pdi) during a maximal inspiratory effort (Pdi max), a maximal sniff maneuver (sniff Pdi) during resting breathing, and during the episodes of breathlessness. Electrophysiologic testing of the phrenic nerves showed axonal neuropathy on the left. Sniff Pdi and Pdi max were 38cmH(2)O and 42cmH(2)O, respectively. Transient spastic contractions of abdominal muscles were associated with an increase in abdominal pressure greater than 30cmH(2)O, with a decrease in abdominal volume; this rise in abdominal pressure was transmitted to the esophageal pressure. Inspiration became effective only when esophageal pressure fell below the resting baseline value. Achieving this decrease required an increase in inspiratory effort, characterized by swings in esophageal pressure and Pdi of 30cmH(2)O and 40cmH(2)O (approximately 100% of Pdi max), respectively. During these periods, minute ventilation was markedly reduced. This is the first report that spastic abdominal muscle contractions can impose a significant load on the diaphragm, uncovering moderate diaphragmatic weakness. This has important clinical implications; abolition of the spastic abdominal muscle contraction in this patient completely resolved her intermittent respiratory symptoms.

Tendon transfers as applied to tetraplegia.

The techniques of the tendon transfers that are used primarily for the functional rehabilitation of upper limbs in tetraplegia are described in this article. The restoration of active elbow extension can be obtained either by biceps-to-triceps or by deltoid-to-triceps transfers. Grasp and key grip can be restored either by active or by passive tendon transfers. The usual motors of active transfer are the BR and ECRL. The usual tenodesis involve the FDS (via lassos), EDC, EPL, FPL, and APL.