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PubMed1993

Grasp synthesis for upper-extremity FNS. Part 2. Evaluation of the influence of electrode recruitment properties.

Functional neuromuscular stimulation (FNS) has been used in upper extremity neuroprostheses to provide grasp and release for quadriplegic individuals. The goal of this project was to determine the electrode/muscle input/output characteristics with the greatest influence on the grasp output. This was evaluated by simulating the grasp synthesis procedure, using a model of the electrode/muscle output as a function of stimulus level and joint angle. The parameters of this model were determined from experimental data from 112 electrodes. The grasp output for 500 different modelled pairs of electrodes were analysed, with each pair consisting of a thumb flexor and a thumb extensor. The simulation results indicate that the most influential electrode input/output characteristics are the output stiffness, defined as the change in force output for a unit change in joint angle at a constant level of stimulation, and the length dependency mean-squared error. Recruitment gain was found to be of secondary influence on the grasp output, and the threshold, force direction and non-linearity of the stimulus level to force relationship were found to have little influence on the grasp output. These results establish criteria for electrode selection and implantation for use in upper extremity FNS.

Electric Stimulation Therapy↗

PubMed1981

[Pedicle flap plastic surgery in the primary care of large skin and soft tissue defects of the upper extremity].

Pedicle flaps from the chest or abdomen are still most suitable to cover large skin and soft tissue defects on the upper extremity. Compared to free tissue transfer with microvascular anastomosis, the conventional techniques ave advantages with regard to size, technical execution, technical differentiation and rate of healing in. Every skin and soft tissue defect on the upper extremity, however large it is, can be primarily treated by means of a pedicle flap.

Adult↗

PubMed1995

Effect of EMG biofeedback compared to applied relaxation training with chronic, upper extremity cumulative trauma disorders.

This study examined the relative effectiveness of EMG biofeedback, applied relaxation training and a combined procedure in the management of chronic, upper extremity cumulative trauma disorder. Forty-eight patients with a history of about 5-6 years of upper extremity pain were randomly assigned to 1 of 4 treatment conditions, namely applied relaxation training, EMG biofeedback, a combined approach or a wait-list control. Treatments were conducted on an individual basis, twice per week for 4 weeks. Patients in all 3 treatment conditions showed significant short-term reductions in pain and psychopathology in comparison to the wait-list group who showed minimal change. Six-month follow-up data were obtained for patients in the treatment conditions, but not the wait-list group. There was some evidence of relapse on measures of depression, anxiety and pain beliefs for treated patients during the 6-month follow-up period, although measures remained significantly below pre-treatment levels for most outcome indices. Self-monitored pain continued to decrease for the treatment groups through follow-up. Contrary to predictions, however, the strongest short-term treatment benefits were shown by patients receiving applied relaxation training on measures of pain, distress, interference in daily living, depression and anxiety. By 6-month follow-up, differences between treatment groups were no longer evident.

Adult↗

PubMed2000

Upper extremity fractures in restrained front-seat occupants.

BACKGROUND: The aim of our study was to analyze the injury mechanism of upper extremity fractures in car crashes, to create a basis for developing prophylactic devices. METHODS AND RESULTS: During 1985-1995, 3,260 restrained car drivers (1,228 front-seat passengers) were injured in 9,380 crashes involving cars. A total of 179 drivers (5.5%) (front-seat passengers: n = 53, 4.3%) sustained fractures of the arm. The hand (25%), wrist (23%), and forearm (23%) were affected most often, and the elbow (9%), upper arm (10%), and shoulder (10%) were seldom affected. No considerable differences of the injury mechanism were found comparing drivers with front-seat passengers. Fractures were mainly caused by head-on collisions (n = 119, 51%) or multiple collisions (n = 78, 34%). In 73% of the crashes (n = 166), delta-v exceeded 30 km/h (18.6 mph). A lower Delta-v resulted mainly in fractures affecting the shoulder and wrist. CONCLUSION: Because more than half of the upper extremity fractures resulted from a direct impact to the hand, arm, or both, modifications to improve the energy absorption by padding dashboard and inner door or by additional airbags are promising.

Abbreviated Injury Scale↗

PubMed1995

[Timing of management of severe injuries of the upper extremity by free flap-plasty].

From October 1986 until December 1993, fifty-five patients with severe injuries to the upper extremity were treated with 59 free flaps. The mean follow-up period was 34 months (8 TO 87 months). The average hospital stay was 19 days (8 to 40 days). Depending on the timing of reconstruction, the patients were divided into three groups: emergency reconstruction (within 24 hours after injury), delayed reconstruction (up to seven days) and late reconstruction (after seven days). In this paper we present our regime of treatment of severe upper extremity injuries using a free flap and discuss the principles of free flap choice.

Adolescent↗

PubMed1998

Management of severe proximal vascular and neural injury of the upper extremity.

PURPOSE: Early amputation has been suggested to be the optimal treatment for severe combined vascular and neural injuries of the proximal upper extremity. This retrospective study was done to evaluate the long-term clinical outcome of our policy of limb salvage by revascularization and delayed treatment of neural injuries. METHODS: Forty-six patients with neural and vascular trauma to the upper extremity were treated at our institution. All of these patients had aggressive treatment directed at limb salvage with restoration of vascular supply and nerve function. Long-term vascular and neurologic outcomes were recorded. Neurologic deficits were validated by the American Medical Association's standardized disability impairment scale (0% to 100%). RESULTS: The rate of preoperative disability was 83%, which improved to 52% (p < 0.01) after treatment (mean follow-up, 43 months). Overall, 87% showed improvement. CONCLUSION: These results suggest that early amputation should not be performed unless there is massive tissue loss or an attempt at limb salvage might endanger life. Final outcomes cannot be predicted on the basis of initial clinical presentation. As a group, the majority of these patients improved with aggressive intervention.

Adolescent↗

PubMedDate not supplied

Case report: a modified constraint-induced therapy (mCIT) program for the upper extremity of a person with chronic stroke.

The purpose of this case report was to assess the effect of a reduced intensity protocol for daily modified constraint-induced therapy (mCIT) without use of a restraint on the function of the upper extremity (UE) in an individual with a chronic stroke. A 57 year-old patient one year following a stroke participated in a two-hour mCITprogram for ten weekdays over a period of two weeks. During this period, voluntary use of the involved extremity was encouraged for 90% of waking hours at home without use of a restraint. Examination was conducted before and after intervention, and at a one month follow-up visit. Outcome measures included: the Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), and motion analysis of a reach and grasp task using Charnwood's CODA mpx 30. The patient improved or remained the same in functional upper extremity tasks on both the WMFT and MAL. The data from the motion analysis showed that grasp time and maximum pinch angle improved for bilateral UEs. Reaching profile graphed over time had fewer changes in velocity and fewer periods of acceleration and deceleration post-intervention. This reduced intensity program shows promise as an effective, feasible, and patient-preferred application of mCIT in a clinical setting.

Female↗

PubMed1997

Surgical management of eosinophilic fasciitis of the upper extremity.

Eosinophilic fasciitis is a rare inflammatory disease associated with peripheral eosinophilia, hyper-gammaglobulinaemia and contractures of any joint in the upper extremity. Although conservative treatments are generally advocated, this study reports the results of surgical intervention. Four patients aged from 20 to 48 years underwent fasciectomy followed by oral administration of prednisolone. All presented with contractures of digits, wrist, or elbow due to eosinophilic fasciitis in the upper extremities. Despite one case that required a second operation for recurrence, all patients regained the range of motion of the affected joints a few weeks after surgery. The recovery was much sooner than in previously reported cases treated conservatively, suggesting that surgical management of eosinophilic fasciitis is effective in alleviating symptoms quickly and allows patients to resume activities of daily living sooner.

Adult↗

PubMed2001

Understanding work-related upper extremity disorders: clinical findings in 485 computer users, musicians, and others.

Four hundred eighty five patients whose chief complaints were work related pain and other symptoms received a comprehensive upper-body clinical evaluation to determine the extent of their illness. The group had a mean age of 38.5 years. Sixty-three percent of patients were females. Seventy percent were computer users, 28% were musicians, and 2% were others engaged in repetitive work. The time between the onset of symptoms and our initial visit ranged from 2 weeks to over 17 years. A majority sought care within 30 months with the greatest number of them seeking care before 12 months. Fifty nine percent of subjects were still working when seen despite increasing pain and symptoms such as weakness, numbness, tingling, and stiffness. Following a history, a physical assessment utilizing commonly employed clinical tests were performed including evaluation of joint range of motion, hyperlaxity, muscle tenderness, pain, strength, and imbalance. Neurologic tests included Tinel's sign performed in wrist, elbow, tricipital sulcus, and neck and tests for thoracic out syndrome (TOS). Specific tests such as Finkelstein's test for deQuervain's tenosynovitis, Phalen's test for carpal tunnel syndrome and grip strengths were included in the examination protocol. Significant findings included postural misalignment with protracted shoulders (78%), head forward position (71%), neurogenic TOS (70%), cervical radiculopathy (0.03%), evidence of sympathetic dysfunction (20%), and complex regional pain syndrome (RSD) (0.6%). Hyperlaxity of fingers and elbows was found in over 50%, carpal tunnel syndrome in 8%, radial tunnel syndrome in 7%, cubital tunnel in 64%, shoulder impingement in 13%, medial epicondylitis in 60%, lateral epicondylitis in 33%, and peripheral muscle weakness in 70%. We conclude that despite initial presentation distally, work-related upper-extremity disorders are a diffuse neuromuscular illness with significant proximal upper-body findings that affect distal function. While neurogenic TOS remains a controversial diagnosis, the substantial number of patients with positive clinical findings in this study lends weight to the concept that posture related neurogenic TOS is a key factor in the cascading series of physical events that characterize this illness. A comprehensive upper-body examination produces findings that cannot be obtained through laboratory tests and surveys alone and lays the ground work for generating hypotheses about the etiology of work related upper-extremity disorders that can be tested in controlled investigations.

Adolescent↗

PubMed1989

Comparison of motor copy and targeted biofeedback training techniques for restitution of upper extremity function among patients with neurologic disorders.

A total of 30 targeted training electromyographic biofeedback treatments were administered to the hemiplegic upper extremities of 12 chronic stroke and head-injured patients (TT Group). The 30 treatments were divided into three series of 10 treatments each directed to the shoulders; the elbow; and the wrist, fingers, and thumb, respectively. Evaluations for function, active range of motion, and integrated EMG activity were undertaken five times before treatment (baseline measurements), after each series of 10 treatments, and at follow-up intervals for one year. Data from these evaluations were compared with those obtained over an identical time course from 14 chronic stroke and head-injured patients undergoing a motor copy procedure (MC Group) in which the patients matched EMG output viewed on a screen from homologous upper extremity muscles. Both groups showed appropriate significant changes among many independent variables. Changes within the TT Group, however, appeared more treatment-related, whereas changes among the MC Group were latent, occurring more frequently at follow-up evaluations. There were no substantial correlations between EMG activity, active ROM, or function, thus highlighting the continuing difficulty of identifying a causative relationship between physiologic change and enhanced motor capabilities among patients with neurologic disorders. Nonetheless, the results do suggest that both techniques are of clinical benefit, with the motor copy technique offering potential cost-effectiveness because patients can self-train.

Biofeedback, Psychology↗

PubMed1992

[Thoracic sympathectomy in the treatment of chronic ischemia of upper extremities and excessive sweating of the palms].

The results are presented of treatment of 65 patients with chronic peripheral ischaemia of upper extremities and excessive sweating of the palms, in whom 78 thoracic sympathectomies were done by the Smitwick method in the years 1972-1989. The cause of ischaemia in 45 patients were organic changes (TO, AO), in 18 cases--functional changes (Raynaud syndrome), and in two patients--excessive sweating of the palms. Patients with trophic changes were 72% of those surgically treated. Long-term follow-up (8.5 years on the average) demonstrated a significant improvement in the group of organic changes in 84% of the surgically treated cases, in the group of functional changes in 83.2% of cases, and in excessive sweating of the palms in 100% of cases. In five patients contralateral effect of thoracic sympathectomy was observed. The authors discussed the extent of sympathetic trunk removal. They think that thoracic sympathectomy is a procedure of choice in cases of peripheral ischaemic changes in upper extremities not responding to conservative treatment.

Adolescent↗

PubMed2006

Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial.

CONTEXT: Single-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year. OBJECTIVE: To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months. DESIGN AND SETTING: The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003. PARTICIPANTS: Two hundred twenty-two individuals with predominantly ischemic stroke. INTERVENTIONS: Participants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function. MAIN OUTCOME MEASURES: The Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed. RESULTS: From baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05). CONCLUSION: Among patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year. Trial Registration clinicaltrials.gov Identifier: NCT00057018.

Activities of Daily Living↗

PubMed2004

Upper extremity pain seen with fly-casting technique: a survey of fly-casting instructors.

OBJECTIVE: To identify the prevalence of upper extremity pain symptoms in fly-casting instructors and examine the association between pain and casting style and equipment. METHODS: We used a cross-sectional survey of a randomly selected group of 577 fly-casting instructor mailing-list members and recorded equipment; casting styles; pain symptoms; and Disability of the Arm, Shoulder, and Hand inventory. We used univariate statistical tests to examine the associations between pain and casters' equipment and styles. RESULTS: In 292 usable surveys, pain was reported in the shoulder (50%), elbow (39%), and wrist (36%) of those surveyed and was characterized as moderate-to-severe by 25% of all respondents. Overhead casting was associated with less frequent wrist and elbow pain than was sidearm or elliptical casting. Respondents who used multiple casting styles had significantly less elbow pain than did single-style casters (7% vs 38% overhead, P = .04: 45% sidearm, P = .02; 71% elliptical, P = .003). Pain was significantly more frequent in those who cast with a haul (75% vs 33%, P = .04), used shooting heads (79% vs 66%, P = .04), or added weight to sinking flies (78% vs 60%, P = .01). Moderate-to-severe pain was more frequent in fishers of heavy saltwater fish. CONCLUSIONS: Upper extremity pain was frequent, but not often severe, in this group of fly-casting instructors. Increased weight on the line and "haul" technique appeared to increase pain symptoms. Modifications in casting style and equipment may help in avoiding or reducing pain.

Animals↗

PubMed1997

[Various possibilities for taking advantage of the Chinese flap in reconstruction of post-traumatic soft tissue defects in the upper extremity].

A forearm flap based on radial artery (Chinese Flap) is one of the most often used flaps in reconstruction of posttraumatic tissue defects within upper extremity. It may be used as free flap or pediculated one. Long vascular pedicle allows easy transposition of the flap within upper extremity. Microsurgical techniques do not have to be employed. Flap anatomy enables one stage reconstruction of majority of posttraumatic defects both during acute or planned operations. The material includes 10 patients. Satisfactory functional results have been achieved in all cases.

Adult↗

PubMed1993

Three-phase bone scintigraphy. Asymmetric patterns in the upper extremities of asymptomatic normals and reflex sympathetic dystrophy patients.

Three-phase Tc-99m MDP scans of 61 patients with asymptomatic upper extremities randomly mixed with 17 studies of patients previously diagnosed with reflex sympathetic dystrophy were blindly interpreted by three observers. Asymmetry in any of the phases was recorded and a final diagnostic impression made. Thirteen of 17 reflux sympathetic dystrophy studies were rated abnormal by at least two observers. Mild to striking asymmetry was occasionally seen in all three phases in asymptomatic upper extremities. Twenty of 61 asymptomatic patients (33%) were rated abnormal by at least one observer, and 5 of 61 studies (8%) were rated abnormal by all observers. Asymmetries in normal patients occurred more commonly in the earlier phases, while asymmetry in the delayed images was mild in all but one. Tightening the criteria to exclude mild asymmetry in delayed images resulted in unacceptably low sensitivity for reflex sympathetic dystrophy (29%). Interobserver variability was most prominent in the flow and immediate images. In the diagnosis of reflex sympathetic dystrophy a greater reliance should be placed on the delayed images, which in themselves have an overall sensitivity of 94%. It is important, however, to recognize that occasional mild and rare moderate asymmetries in even the delayed images of normal individuals result in an overall lower specificity of 77%.

Arm↗

PubMedDate not supplied

Distressing upper extremity phantom limb sensation during intravenous regional anesthesia.

BACKGROUND AND OBJECTIVES: The objective of this article is to describe a case of distressing upper extremity phantom limb sensation during intravenous regional anesthesia (IVRA). CASE REPORT: A 33-year-old American Society of Anesthesiologists (ASA) status I female with an uncomplicated intrauterine gestation presented for endoscopic carpal tunnel release. Following gravity-assisted exsanguination of the vertically positioned left upper extremity, she underwent an IVRA. Within minutes of her arm being repositioned for surgery she remarked that the arm felt as if it was still in the vertical position. This sensory disturbance was described as fatiguing and exhausting. Despite reassurance and medication with intravenous narcotics, her symptoms became intolerable. Her phantom sensation disappeared upon dissipation of the IVRA. CONCLUSIONS: There are no previous reports regarding the development of phantom phenomena during an IVRA. The occurrence of distressing phantom sensations during an otherwise adequate IVRA may be interpreted as block failure and may lead to conversion to general anesthesia. Practitioners are encouraged to consider these phenomena when performing IVRA.

Adult↗

PubMed2004

Ergonomic stressors and upper extremity musculoskeletal disorders in automobile manufacturing: a one year follow up study.

AIMS: To estimate the one year cumulative incidence and persistence of upper extremity (UE) soft tissue disorders, in a fixed cohort of automotive manufacturing workers, and to quantify their associations with ergonomic exposures. METHODS: At baseline and at follow up, cases of UE musculoskeletal disorders were determined by interviewer administered questionnaire and standardised physical examination of the upper extremities. The interview obtained new data on psychosocial strain and updated the medical and work histories. An index of exposure to ergonomic stressors, obtained at baseline interview, was the primary independent variable. Cumulative incidence and persistence of UE disorders (defined both by symptoms and by physical examination plus symptoms) were analysed in relation to baseline ergonomic exposures, adjusting for other covariates. The incidence of new disorders was modelled using multivariate proportional hazards regression among workers who were not cases in the first year and the prevalence on both occasions was modelled by repeated measures analysis. RESULTS: A total of 820 workers (69% of eligible cohort members) was examined. Follow up varied slightly by department group but not by baseline exposure level or other characteristics. Among the non-cases at baseline, the cumulative incidence of UE disorders was 14% by symptoms and 12% by symptoms plus examination findings. These rates increased with index of physical exposures primarily among subjects who had the same jobs at follow up as at baseline. Increased exposure during follow up increased risk of incidence. The persistence of UE disorders from baseline to follow up examination was nearly 60% and somewhat associated with baseline exposure score. CONCLUSIONS: These longitudinal results confirm the previous cross sectional associations of UE musculoskeletal disorders with exposure to combined ergonomic stressors. The exposure-response relation was similar for incident cases defined by symptoms alone and those confirmed by physical examination.

Adult↗

PubMed2001

Venous Thrombosis of the Upper Extremities.

The goals of treating patients with upper-extremity deep vein thrombosis (UEDVT) are to relieve acute symptoms of venous occlusion, prevent pulmonary embolism, reduce the likelihood of recurrent thrombosis, and avoid the development of postphlebitic syndrome. Although the details of management differ, depending on the underlying cause and precipitating factors, anticoagulant therapy should be the first-line treatment of choice in all cases. For patients with primary or idiopathic UEDVT (Paget-von Schroetter syndrome), aggressive measures including catheter-directed thrombolysis, vascular procedures (eg, balloon angioplasty, stenting, filter), and surgical maneuvers (eg, first rib resection) have been advocated by some surgeons, but none of these high-risk interventions has been evaluated properly in prospective controlled trials. In contrast, for patients with catheter-associated central venous thrombosis (CACVT), or other secondary cases of UEDVT, many clinicians simply withdraw the catheter and avoid anticoagulant therapy. Because well-designed clinical trials are lacking, recommendations about the management of UEDVT are derived from descriptive studies and case series. Until further research identifies the natural history and optimum management of UEDVT, it seems reasonable to base treatment on anticoagulant regimens with proven effectiveness in lower-extremity deep vein thrombosis (LEDVT). The use of additional intervention(s) should be reserved for carefully selected patients.

Journal Article↗