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PubMed2003

Surgical management of the hand in infantile spastic hemiplegia.

Selected spastic patients with cerebral palsy can be helped by peripheral reconstructive surgery, of the upper limb. Although surgery cannot make a limb that was functionally poor into a perfect one, it can greatly improve the preoperative condition. Most poor surgical results are caused by incorrect selection of patients or poor execution of surgical procedures. The worst mistake is to perform soft tissue procedures--tendinous release or tendinous transfers--on a patient with pure athetosis. The results in these cases are unpredictable and often fail. The same concept is applied to rigidity, hypotonia, dystonia, and ataxia. The surgical program is organized according to the type and severity of the deformity (clinical groups). The goals are to correct the deformities and to improve the muscular balance of the hand in one surgical stage. It must be remembered that spastic muscle cannot be used for tendon transfer with the same efficiency as in patients with a flaccid paralysis. Results were satisfactory in 92% of cases of groups I and II. If group III is included, the percentage of satisfactory results reduces significantly.

Cerebral Palsy↗
PubMedDate not supplied

Analysis of the medical use of marijuana and its societal implications.

OBJECTIVE: To review the pharmacology, therapeutics, adverse effects, and societal implications of the medical use of marijuana. DATA SOURCES: MEDLINE and manual searches of English-language marijuana literature, supplemented with interviews of scientists currently conducting cannabinoid research. Search terms included pain OR palliative care AND cannabis or ALL marijuana; cachexia OR appetite OR appetite stimulants; muscle spasticity OR spasm; immune system and cannabis; nausea and vomiting and cancer and cannabis. MEDLINE search terms: cannabis OR marijuana smoking OR marijuana abuse; all glaucoma; multiple sclerosis AND cannabis OR marijuana smoking OR marijuana abuse. STUDY SELECTION: Studies on pharmacology, risks, and medical potential of marijuana. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: The most prominent effects of marijuana are mediated by receptors in the brain. Acute intoxication is characterized by euphoria, loss of short-term memory, stimulation of the senses, and impaired linear thinking. Depersonalization and panic attacks are adverse effects. Increased heart rate and reddened conjunctivae are common physical effects. Chronic, high doses may cause subtle impairment of cognitive abilities that are appear to be long-term, but of unknown duration. Marijuana may be a risk factor for individuals with underlying mental illness. It causes dependence, but compared with cocaine, alcohol, heroin, and nicotine, marijuana has little addictive power and produces only mild withdrawal symptoms. Marijuana shows clinical promise for glaucoma, nausea and vomiting, analgesia, spasticity, multiple sclerosis, and AIDS wasting syndrome. CONCLUSION: As a recreational drug, marijuana poses dangers, particularly to social and emotional development during adolescence and young adulthood. As a medical drug, marijuana should be available for patients who do not adequately respond to currently available therapies.

Acquired Immunodeficiency Syndrome↗
PubMed2002

Effect of a rigid ankle-foot orthosis on hamstring length in children with hemiplegia.

Eighteen children with hemiplegia, mean age 8 years 5 months, underwent gait analysis and musculoskeletal modelling using specially designed software. The maximum lengths of the hamstrings were determined for each child walking in and out of an ankle-foot orthosis (AFO). The muscles were deemed to be short if shorter than the normal average -1SD. In bare feet 8 participants had short medial hamstrings with a higher proportion of these in the less involved individuals. All participants showed an increase in maximum hamstring length when wearing an AFO. In all but one child this was sufficient to restore hamstring length to within normal limits. These finding suggest that hamstring pathology in hemiplegic gait is usually secondary to more distal lower limb pathology.

Ankle Joint↗
PubMed2005

Pedobarometric evaluation of equinus foot disorder after injection of botulinum toxin A in children with cerebral palsy: a pilot study.

The purpose of this pilot study was to evaluate the effect of treatment with botulinum toxin A (BTX-A) injections on function in children with cerebral palsy (CP) using pedobarometric data collected in a standing position. Ten children with CP (seven males, three females) participated, five with diplegia and five with hemiplegia. All children exhibited signs of unilateral dynamic equinus foot disorder and were community ambulators. Age range at the time of treatment was 6 to 13 years (mean age 9 y, SD 2.5). A comprehensive clinical examination and a pedobarometric evaluation were performed before and after BTX-A injection. All children received at least one injection in each spastic muscle. BTX-A was given to eight children unilaterally and to two children bilaterally. A maximum dose of 4 to 8 units of BTX-A per kilogram body weight was administered. In comparison with pretreatment values, the pedobarometric evaluation revealed a significant increase in the whole plantar surface area on the affected side (p < 0.05), an increase in the peak pressure value at the hindfoot on the affected side (p < 0.05), and a significant shift in the body centre of mass to the affected limb (p < 0.05) 1 month after treatment with BTX-A. A significant decrease in the peak pressure value at the hindfoot on the unaffected side was also observed. Similarly, a decrease in the modified Ashworth scale and an increase in the range of motion were observed. Thus, BTX-A produces a significant plantar surface modification and a significant shift of the body centre of mass which represents an indirect measure of postural attitude. Pedobarometric evaluation can also be useful in quantifying clinical changes after treatment with BTX-A.

Adolescent↗
PubMed2006

The effectiveness of passive stretching in children with cerebral palsy.

Passive stretching is widely used for individuals with spasticity in a belief that tightness or contracture of soft tissues can be corrected and lengthened. Evidence for the efficacy of passive stretching on individuals with spasticity is limited. The aim of this review was to evaluate the evidence on the effectiveness of passive stretching in children with spastic cerebral palsy. Seven studies were selected according to the selection criteria and scored against the Physiotherapy Evidence Database scale. Effect size and 95% confidence intervals were calculated for comparison. There was limited evidence that manual stretching can increase range of movements, reduce spasticity, or improve walking efficiency in children with spasticity. It appeared that sustained stretching of longer duration was preferable to improve range of movements and to reduce spasticity of muscles around the targeted joints. Methods of passive stretching were varied. Further research is required given the present lack of knowledge about treatment outcomes and the wide use of this treatment modality.

Cerebral Palsy↗
PubMed1979

The neuropathy of Charlevoix-Saguenay ataxia: an electrophysiological and pathological study.

Two female patients aged 30 and 40 years with the Charlevoix-Saguenay ataxia were studied. Both had absent sensory action potentials in upper and lower extremities but, unlike typical cases of Friedreich's ataxia, they displayed a marked slowing of motor conduction velocities. Sural nerve biopsies taken from calf and ankle revealed a severe loss of large myelinated axons contrasting with a normal myelinated fiber density. Evidence for active axonal degeneration was scarce, with no indication of axonal regeneration. Teased myelinated fibers revealed an increased variability of internodal length but no evidence for myelin breakdown. These findings support, as a primary defect, a developmental abnormality of peripheral nerve, namely a lack of maturation of large myelinated axons and possibly a faulty myelination of nerve fibers. We think it is unlikely to represent a progressive axonal atrophic or dystrophic process, as suggested in Friedreich's ataxia.

Action Potentials↗
PubMed2004

Botulinum toxin in urology: evaluation using an evidence-based medicine approach.

Clinical reports documenting the beneficial effects of botulinum toxin (BTX) to treat various lower urinary tract disorders of muscle spasticity (e.g. detrusor hyperreflexia, detrusor sphincter dyssynergia) have led to its expanded application in non-neurogenic conditions such as idiopathic detrusor overactivity, detrusor underactivity and benign prostatic hyperplasia (BPH). As greater numbers of investigators report their results utilizing this agent, it becomes more important that clinicians are able to synthesize and describe the findings of current clinical studies in a meaningful way. Evidence-based medicine is a platform on which investigations concerning a particular topic can be evaluated for their levels of scientific evidence, so that rational clinical recommendations can be formulated. This review article applies evidence-based practices to the use of BTX in common urologic conditions. Appreciating the benefits as well as limitations of currently available studies will hopefully drive the development of well-controlled, randomized studies of BTX, particularly in highly prevalent conditions such as idiopathic detrusor overactivity and BPH.

Botulinum Toxins↗
PubMed1990

Functional neuromuscular stimulation in 4 patients with complete paraplegia.

The effect of functional neuromuscular stimulation (FNS) on muscle strength and endurance was studied in 3 patients with long-standing complete injuries (T7-T12) and in 1 patient with a recent complete injury (T5). All 4 patients became strong enough to rise, stand and to walk a few steps within parallel bars. However, only 1 patient was able to walk without parallel bars (60 m). The energy demand of FNS-assisted walking was measured to be more than 60% of the maximal endurance capacity of this patient. This finding partly explains the low patient acceptance of FNS.

Adult↗
PubMed1993

A complicated trochanteric pressure sore: what is the best surgical management? Case report.

Pressure sores are a common complication after spinal cord injury. But great advances in their management (nursing care, prevention and surgery) have been made in the last four decades. Neglected pressure ulcers may affect the adjacent joint, leading to septic arthritis. We report a paraplegic patient with a large trochanteric sore with hip arthritis, in whom we performed an upper femoral resection and acetabular curettage (Girdlestone's technique) and coverage with the homolateral vastus lateralis muscle flap in one stage. Some questions pertaining to this operation are discussed and there is a comparison with other ways of management described in the literature. We conclude that a successful outcome with the management of such large sores depends on a radical, aggressive operation to remove all of the affected tissue, and ensure a safe coverage with a reliable, viable muscle flap. The collaboration and the positive attitude of the patient towards the procedure and the result obtained are decisive in preventing recurrences.

Adult↗
PubMed1998

Selecting candidates for a lower limb stimulator implant programme: a patient-centred method.

OBJECTIVE: To develop an effective selection procedure for lower limb functional neurostimulation (LLFNS) for standing in paraplegia. DESIGN: The selection procedure and exclusion criteria were based on the previous experience for two clinical centres with experience of LLFNS. SETTING: Two Regional Spinal Injuries units in southern England. SUBJECTS: 254 fully rehabilitated paraplegics living in the community. INTERVENTION: Patients were invited to participate in the programme, and if suitable to subject themselves to a rigorous staged selection procedure from which they could withdraw at any time. OUTCOME MEASURE: Functionally successful home standing using closed-loop surface electrical stimulation. RESULTS: 57/254 patients were suitable on paper and were accessible. 19 of these (CI = 10-28) were interested in the project and attended one of the spinal centres for details. Twelve (CI = 5-19) of these fulfilled the selection criteria and started on the training programme; and 10 of them completed the muscle training programme successfully. Seven patients (CI = 2-12) achieved closed-loop standing in the laboratory and four patients (CI = 1-8) did so at home.

Adult↗
PubMed2003

Neuromuscular treatments for speech and swallowing: a tutorial.

Despite the proliferation of oral motor therapies, much controversy exists regarding the application and benefit of neuromuscular treatments (NMTs) such as strength training for alleviating dysarthria and/or dysphagia. Not only is limited empirical support available to validate the use of NMTs, but clinicians may also lack the foundational information needed to judge the theoretical soundness of unstudied treatment strategies. This tutorial reviews the theoretical foundations for several NMTs, including active exercises, passive exercises, and physical modalities. It highlights how these techniques have been used to address neuromuscular impairments in the limb musculature and explores potential applications to the speech and swallowing musculature. Key issues discussed in relation to active exercise are the selection of treatment targets (e.g., strength, endurance, power, range of motion), specificity of training, progression, and recovery. Factors influencing the potential effectiveness of passive exercises and physical modalities are presented, along with discussion of additional issues contributing to the controversy surrounding oral motor therapies.

Deglutition Disorders↗
PubMed1999

Effects of dorsolateral spinal lesions on stretch reflex threshold and stiffness in awake cats.

Measurements of threshold angle and incremental dynamic stiffness (IDS) were derived from triceps surae stretch reflexes, elicited by ramp and hold flexion at the ankle joint of four cats that were tested while awake. Stretch reflexes were assessed from trials that began from different ankle joint start positions or were matched using a post-hoc analysis for initial background force during testing sessions before and following unilateral lesions of the dorsolateral funiculus at levels ranging from T13 to L3. Unilateral lesions of the dorsolateral funiculus (DLF) produced significant ipsilateral decreases in stretch reflex threshold and increases in reflex gain, measured as incremental dynamic stiffness (IDS). ANCOVA testing indicated that the reduction in threshold, but not the increase in IDS, was dependent upon the level of background force. Reflex testing from different start angles demonstrated that DLF lesions diminished the correlation between threshold and IDS. Intravenous infusion of ketamine dose-dependently reduced IDS, compared with testing in the unanaesthetized state. Postoperative reflex testing during infusion of ketamine at 22.2 mg/kg per h, when electromyographic responses were reduced to 24% of control levels, abolished differences in IDS between the ipsilateral and contralateral hindlimbs. These and related observations suggest that the postoperative increase in IDS in awake animals was not due to an increase in passive stiffness.

Anesthetics, Dissociative↗