Incidence. Upper limb involvement. Manual Ability Classification System. Upper limb involvement 02/03/2015

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The spastic hand

Matthew Nixon

Consultant orthopaedic hand surgeon

Why neuromuscular conditions?

• Complex decision making

• MDT approach

• Often told “nothing can be done”

• Variety of surgical treatments

• Multilevel, tendon transfers, fusions

• Little need for complex / expensive kit

MPS Dystonic CP OBPI Stroke hemiplegia arthrogryposis FSHD Spastic CP CP hemiplegia

What is spasticity?

Spasticity

• Velocity dependent hypertonia

1st_{catch - Fast stretch}

2nd_{catch - Slow stretch}

–

Corticospinal tract

–

Primary pathway of motor neurons

–

Not directly affected in spasticity

–

Rubrospinal tract

–

Cyclical, non-voluntary movements

–

Reticulospinal tract

–

Inhibitory function => dec tone

–

Eg prevent flexor response to stimuli

–

Vestibulospinal tract

–

Excitatory function to maintain

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Kennard MA. Age and other factors in motor recovery from precentral lesions in monkeys. Am J Physiol 1936; 115: 137–46. Staudt M. Two types of ipsilateral reorganization in congenital hemiparesis. Brain. 2002

Kennard principle:

Activation of unaffected hemisphere

Small lesion intermediate Large lesion

Pathophysiology of neuromuscular conditions

Weakness / Spasticity

Imbalance of forces

Correctable

contracture

Fixed contracture

Skeletal deformity

Incidence

• Cerebral palsy

–

Most common physical disability in children

–

1 in 2000, many living into adulthood

• Incidence of upper limb involvement

–

82% had some upper limb involvement

–

69% had reduced motor control

–

36% had a upper limb contracture

–

Only 12% had seen a specialist for treatment of UL

Matthew Nixon. Prevalence and pattern of upper limb involvement in cerebral palsy. J Child Orthop. 2014.

Upper limb involvement

92% Wrist

59 deg flexion

85 deg pronation

15% Shoulder

Add & Int rotation

contracture

77% Elbow

55 deg flexion

50% Hand

65% thumb in palm

35% finger deformity

Matthew Nixon. Audit of cerebral palsy upper limb involvement at RMCH. 2014.

Upper limb involvement

Motor function

Grasp

Release

Dexterity

Mirror movements

Carer

Washing

Dressing

Hand hygiene

Pain

Joint

subluxations

Spasticity

Appearance

Manual Ability Classification System

1

2

3

4

5

Reduced speed Needs adaptations Poor despite adaptations Severe limitations Easy manipulation

13%

33%

16%

19%

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Gross Motor Functional Classification System

• Widely used.

• Observer measured score 1-5.

• Measure of lower limb function and

mobility.

• Strong correlation to MACS

1

2

3

4

5 Differences in management of

upper and lower limb spasticity

Lower limb

Closed kinetic chain (Stabilised by ground reaction force)

=> Harder to over correct Power important

Upper limb

Open kinetic chain (No ground reaction force) => Very easy to over correct Fine motor control important

Age

Time since

injury

Dystonia

Spasticity

vs FFD

Functional

contracture

Active

control

Decision making factors

Age dependent factors

Hägglund G.. Development of spasticity with age in children with CP. BMC Musculoskelet Disord. 2008

Spasticity Growth velocity

Age

• High spasticity • Very high risk of over

correction

3-7 years

• Moderate spasticity • more growth potential • risk of over-correction

7-12 yrs

• Less spasticity • Less growth potential

>13 yrs

Unconstrained

_rebalancing

Constrained

procedure

Patterson J, Late deformities following the transfer of FCU to ECRB in children with CP J Hand Surg Am. 2010.

Botox

neurectomy

Thumb in palm

Wrist flexion

Elbow flexion

Most

disabling

* * * * * *

M Nixon et al. Functional impact of CP hand contractures. J Children’s Orthopaedics. 2014

comparison of AbliHand logit score vs normal * all p<0.01 MWU

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One third of older children have

cosmetic concerns

Odds Ratio =

3.1 (1.1 to 8.6),

Chi sq= 0.029

Nixon et al. Functional impact of CP hand contractures. J Children’s Orthopaedics (in press). 2014

1

Mild ↑ tone Catch <50% ROM

2

Mod ↑tone Catch >50% ROM

3 Severe ↑ tone

Entire ROM

4 Fixed deformity

Spasticity

Early disease Overactive muscle Botox, splinting Tendon transfers

Contracture

Head Injury Fibrosis & contracture Poor response to botox Contracture release

Joint stabilisation Modified Ashworth classification

Spasticity vs contracture

Is there active control?

Active control present

Joint rebalancing -contracture release -tendon transfer No active control Joint stabilisation -splints, arthrodesis

Management

Upper motor neuron

• Muscle relaxants, ITB

Spine

• Selective dorsal rhizotomy

Lower motor neuron

• Selective peripheral neurotomy

Neuromuscular junction

• Botulinium toxin

Muscle / Tendon

• Tendon transfer

Joint

• Arthrodesis, splints

Hand therapy: CIMT

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Sakzewski L. RCT of upper limb CIMT versus standard care for children with unilateral cerebral palsy. Dev Med Child Neurol. 2015 Jan Coghill J. Do Lycra garments improve function and movement in children with cerebral palsy? Arch Dis Child. 2010 May

Thomson K. Commercial gaming devices for stroke upper limb rehabilitation: a systematic review. Int J Stroke. 2014

Botulinium toxin

• Cochrane review

–

Benefits for 3-6 months

• NICE (2012)

–

Motor function, cosmesis, pain, hygiene

• Role in my practice

–

Diagnose which muscles misfiring

–

Dystonia vs spasticity

–

Buy time in young children

–

Those not suitable for surgery

PT

FCR

PT

B Hoare. Botulinium toxin as an adjunct for children with CP. Cochrane review. 2010

Selective Dorsal Rhizotomy

• Removes afferent feedback

• Has a place in lower limb

spasticity

• Good for generalised

reduction in spasticity

• No evidence for specific

use in the upper limb

Gigante P, M Reduction in upper-extremity tone after lumbar SDR in children with spastic cerebral palsy. J Neurosurg Pediatr. 2013

Selective peripheral neurotomy

• Young (4-10 years), high

spasticity, good response to botox

• 50% reduction spasticity

• Reduction associated pain

• Improvement in function

• Benefits last up to 5 years

A- median nerve B- AIN

C- pronator teres muscle. D- pronator teres nerve E- flexor carpi radialis, F- flexor digitorum profundus G- flexor digitorum supercialis

Maarrawi J, Long-term results of selective peripheral neurotomy for the treatment of spastic upper limb. J Neurosurg. 2006 Kyung Woo Kwak, Surgical Results of Selective Median Neurotomy for Spasticity. J Korean Neurosurg. Aug 2011.

Elbow

• Brachialis aponeurosis

• Biceps lengthening

• +- Brachioradialis/elbow capsule

• Outcome at 5 years

–

50 deg ↑ resting posture

–

20 deg ↑ active extension

–

5 deg ↓ active flexion

–

No change supination

Gong HS. Early results of anterior elbow release in patients with CP. J Hand Surg Am. 2014

Wrist – deforming forces

• Wrist vs finger flexors

• Pronator teres

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Wrist

spasticity

Flexion contracture

Wrist flexed, fingers extended Wrist flexed, fingers flexed

Fingers flex as wrist extended Wrist flexors isolated

Finger flexor

spasticity

Wrist flexion deformity

• FCU

Rebalancing

• ECRB transfer

• EDC transfer

Active

control

+

Passively

correctable

FCU => ECRB FCU => EDC

Beach WR. Use of the Green transfer in treatment of patients with spastic CP: 17-year experience. JPO 1991.

Outcome at 17 years

• 90% cosmetic improvement

• 80% functional improvement

Wrist flexion deformity

• Proximal row

carpectomy

• Wrist fusion

Fixed

flexion

contracture

Van Heest AE, Strothman D. Wrist arthrodesis in cerebral palsy. J Hand Surg Am. 2009.

Outcome of 41 wrists

-

98% union, 94% satisfiaction

- Disability Assess. Scale from 9.6 to 5.5

- Improvement appearance VAS by 7.9

Wrist fixed flexion with clasp hand

1. PRC + arthrodesis 2. Fractional lengthening

3. FCU to EDC transfer

Hand

Swan neck deformity

- Grasp and release

Clasp hand

- Hand hygiene

Thumb in palm

- Manual dexterity

Thumb in palm - classification

MC adduction contracture Adductor Policis spasticity MCPJ flexion contracture

Flexor Pol Brevis spasticity CMCJ Instability AP & FPB spasticity EPL/APL active MCPJ and IPJ contracture AP &FPB spasticity FPL spasticity 1 2 3 4

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Tonkin MA, Sesamoid arthrodesis for hyperextension of the thumb metacarpophalangeal joint. J Hand Surg Am. 1995 Gwilym S, Giele HP. Sesamoid arthrodesis of the thumb: a technique using a Mitek anchor and wire suture. Ann R Coll Surg Engl. 2005

Contracture release

-1st_webspace

-Intrinsic/extrinsic release

Joint stabilisation

-MCPJ arthrodesis

-Sesamoid arthrodesis

_Rebalancing

-EPL translocation -FPL lengthening +- BR

transfer

Swan neck deformity

• FDS and lumbrical spasticity

• Hyperlaxity

• Central slip release

–

Simple, effective

• Lateral band advancement

–

40% 5 year recurrence

Carlson MG.J Hand Surg Am. 2007. Surgical treatment of swan-neck deformity in hemiplegic cerebral palsy. de Bruin M. J Pediatr Orthop. 2010. Long-term results of lateral band translocation in cerebral palsy.

Acquired brain injury

• Glove and stocking

• Shoulder subluxation

• Skeletally mature

• High anaesthetic risk

• Botulinium toxin

Hand hygiene Skin maceration Poor grasp and release

STP transfer

Pre-op

Distal FDS release

Proximal FDP release Mass anastamosis

Post op

The hemiplegic shoulder

Inferior subluxation:

Biceps suspension procedure

Reduces pain (mean VAS 1.5) Maintains passive ROM

Nixon M, Manara J. Management of shoulder pain after stroke. J Shoulder elbow Surgery. Accepted 2014 Namdari S, Outcomes of the biceps suspension procedure for inferior glenohumeral subluxation in hemiplegia. JBJSAm. 2010

Flaccid paralysis

Spastic paralysis

Contractures:

Soft tissue release

Pec major, Lat dorsi, subscap

0 2 4 6 8 10 12 14 16 Age (yrs)

Therapy / CIMT

Botulinium / neurectomy constrained

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