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PubMed2004

Robot-assisted laparoscopic Heller cardiomyotomy: preliminary UK results.

BACKGROUND/AIM: Laparoscopic Heller cardiomyotomy is an established modality in the surgical treatment of patients having achalasia cardia. We present our initial experience in robot-assisted laparoscopic Heller cardiomyotomy without addition of an antireflux procedure and discuss the relative merits and disadvantages of the procedure. PATIENTS AND METHODS: Five patients underwent robot-assisted laparoscopic Heller cardiomyotomy between August 2001 and October 2002. The diagnosis had been confirmed by radiology and manometry in all patients prior to surgery. RESULTS: All procedures were completed successfully using the robotic system, without conversion to open procedure. Mucosal perforation occurred in 1 patient and was sutured robotically. The average operative time was 114.8 (range 65-160) min which is comparable to laparoscopic procedures. After a mean follow-up period of 9.4 (range 3-17) months, 4 patients remained completely asymptomatic, and 1 patient has benefited from symptomatic improvement. CONCLUSIONS: The enhanced dexterity and the high-quality three-dimensional vision available with robot-assisted surgery make the application of this technology highly suitable for Heller cardiomyotomy. The minimal lateral and posterior dissection due to the wristed instruments avoids the need for an antireflux procedure.

Adult↗

PubMed2006

First results after introduction of the four-armed da Vinci Surgical System in fully robotic laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy offers less post-operative pain, less complications, and faster recovery compared with open cholecystectomy. However, laparoscopic surgery can be demanding because of several technical drawbacks. Robotic surgery allows dexterity skills to be performed faster and shortens the learning curve, possibly leading to faster and safer laparoscopic surgery. METHODS: In this paper, we report the results of our first 12 cases of fully robotic laparoscopic cholecystectomy using the da Vinci Surgical System, comparing them with 12 cases of conventional laparoscopic cholecystectomy. Using a fourth arm in robotic laparoscopy enables the surgeon to perform surgery without the use of a tableside assistant, leading to non-tiring, tremble-free assistance and reducing salary costs. Primary end points are operating time and costs. Secondary end points are operative complications and duration of admission. RESULTS: Fully robotic cholecystectomy was completed in all 12 cases without increased complication rate and without conversions. However, robotic assistance results in an increased overall operating room stay of 31 min and increased costs of EUR 1,180.62. CONCLUSION: Fully robotic laparoscopic cholecystectomy is safe and feasible but seems more expensive and time consuming at this moment.

Adult↗

PubMed1994

Ventroposterolateral pallidotomy.

Recent laboratory experiments have produced increasing evidence that nigral-striatal dopamine deficiency causes an inhibitory hyperactivity in the medial globus pallidus (MGP), where it freezes the initiation of movement and thus causes bradykinesia, rigidity and tremor. Surgical lesions in the ventroposterolateral (VPL) pallidum in man not only improve the parkinsonian bradykinesia, but also the tremor, rigidity, and the L-dopa-induced dyskinesias disappear or diminish. The present study shows that VPL pallidotomy improves several psychomotor functions, such as walking speed and manual dexterity. Right-sided VPL thalamotomy also increases the speed and accuracy in verbal performance. Ventrolateral thalamotomy increases bradykinesia. The findings support the concept that the parkinsonian symptoms in man develop in the MGP. Intact pathways from MGP via thalamus to the premotor and motor cortex seem necessary for normal motor functioning. The author also discusses the mechanisms of pallidotomy and thalamotomy.

Adult↗

PubMed1994

Subthalamotomy improves MPTP-induced parkinsonism in monkeys.

Hyperactivity of the subthalamic nucleus (STN) is major characteristic of parkinsonism secondary to substantia nigra lesions. Interruption of the STN-internal pallidum (GPi) pathway is a new stereotactic target for Parkinson's disease. We have studied the antiparkinsonian efficacy of STN lesions in MPTP-treated monkeys. Four rhesus monkeys were made parkinsonian by MPTP (i.v. 0.15 +/- 1 mg/kg) administration over 3 months. Unilateral subthalamotomy (kainic acid) was performed by a standard stereotactic method. Severity was rated from 0 (normal) to V by fine manual motor tests. Three monkeys (severity state III/IV) showed marked improvement in spontaneous activity, facial expression and manual dexterity bilaterally but significantly greater in the limb contralateral to the lesion. Mild hemichorea was present in 2 and hemiballism in one. L-Dopa treatment (50 mg b.i.d.) enhanced the hemidyskinesias moderately. The therapeutic effect has persisted for over 8 months postsurgery. Monkey No.4 (severity stage V) showed chorea in the lower limb contralateral to the lesion but no improvement and died a few days later. Subthalamotomy improves parkinsonism in moderately severe parkinsonian monkeys. Dyskinesia might be a persistent complication.

1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine↗

PubMed1983

What happened to VIM thalamotomy for Parkinson's disease?

A prospective review of 75 of 190 parkinsonian patients undergoing unilateral thalamotomy was displayed with a computer graphics technique examining three equal consecutive groups from the pre-, early, and late L-dopa eras. Histograms for average function and scattergrams of individual patient's performance preoperatively and up to 2 years postoperatively were prepared. No ipsilateral effects or consistent iatrogenic deterioration of any function were identified. 2 years after surgery, 82% had no tremor in the contralateral fingers or hand and 7% had almost no tremor; contralateral tremor elsewhere was infrequent. Rigidity and manual dexterity improved less strikingly, the latter only reflecting abolition of tremor; locomotion, speech, facial movement and handwriting did not improve. There was no mortality, but 8% had persistent significant complications. VIM thalamotomy remains the treatment of choice for severe drug-resistant parkinsonian tremor.

Adult↗

PubMed1982

Quantification of the effect of epidural spinal electrostimulation (ESES) in central motor disorders.

The importance of film documentation for objective and quantitative assessment of the results of epidural spinal electrical stimulation (ESES) was shown. Our experience is based on 25 patients with central motor disorders, predominantly of spinal origin. 17 were selected for internalization of a receiver system. By means of description and clinical registration of spasticity, reduced mobility, motor strength, dexterity, etc., or by means of electrophysiological tests, complex motor performance such as standing, sitting, dressing and undressing, eating and writing cannot be sufficiently evaluated. Short scenes of these activities when demonstrated by motion picture enable the therapist to compare better the condition of the patient before and with ESES, and thereby facilitate the selection of patients for internalization of receiver systems.

Adult↗

PubMed1977

Pharmacology of Huntington's chorea. Personal experience.

Dipropylacetic acid (DPA), gamma-aminobutyric acid (GABA), physostigmine, CB 154 and butyrophenones were administered to 26 patients affected by Huntington's chorea. The evaluation of the pharmacologic activity of the different drugs was determined by means of some clinical parameters and motor performance tests. Butyrophenones succeeded to ameliorate the hyperkinesias and the motor dexterity, CB 154 provoked a worsening of the motor signs of the disorder, while DPA, GABA and physostigmine did not modify the clinical pattern. The relationship between these results and the Hungtington's chorea physiopathology is discussed and a hypersensitivity of DA receptors is suggested.

Acetates↗

PubMed1990

Origins of descending spinal pathways in prehensile birds: do parrots have a homologue to the corticospinal tract of mammals?

In mammals, the supraspinal descending projections that influence distal limb muscles are the rubrospinal and corticospinal tracts. The former, which is found in other vertebrates, shows greater somatotopy in mammals that are 'dextrous' (e.g. monkeys) than those that are not (e.g. opossums). Similarly, the corticospinal tract, which is found only in mammals, has more extensive connections (i.e. direct corticomotoneural) in mammals that are dextrous than in mammals that are not. Descending spinal pathways have been described in 'non-dextrous' avian species (chickens, ducks, geese and pigeons), and the purpose of this study was to determine if there are any differences in the origins of descending projections to the spinal cord in 'dextrous' or prehensile parrots (sulphur-crested cockatoo, Cacatua galerita, and eastern rosella, Platycerus eximius). True Blue or wheat germ agglutinin-horseradish peroxidase was injected into the lumbar or cervical spinal cord. The distribution of retrogradely labelled cells was similar to that previously reported for non-prehensile birds. We found no evidence of any direct spinal projections from the telencephalon (including any pathway homologous to the corticospinal tract of mammals), nor any specialized anatomical organization of the descending pathways that could account for the pedal dexterity of these species.

Animals↗

PubMed1995

The pattern of motor deficits in relation to the site of stroke lesions.

Thirty-two patients with hemispheric stroke lesions of distinct cortical functional zones (premotor, precentral, parietal) or of striatocapsular or striatothalamic subcortical territories were scored at the acute and chronic stage for the following sensorimotor arm-hand functions: force, praxis, motor attention, sensation and dexterity. The selection criterion was that in spite of the wide variation of lesion sites all patients had hemiparesis as the presenting clinical sign. Analysis of the scores showed that most patients showed apraxia, motor neglect or disturbed sensation in addition to hemiparesis. The distribution and severity of these deficits varied, so that different lesion groups showed different patterns. The actual functional impairment of arm-hand function was determined by the combined effect of these different sensorimotor dysfunctions.

Adult↗

PubMed1983

Contralateral as well as ipsilateral projections to raccoon cerebellum from external cuneate nuclei and cell groups f and x.

To assess the locations and densities of cells in the dorsal medulla giving rise to ipsilateral versus contralateral projections to the mechanosensory regions of cerebellar cortex in the anterior lobe and paramedian lobule, these cortical regions were injected unilaterally with horseradish peroxidase in each of 5 raccoons. To show injection sites and retrogradely labelled cells in the medulla, sections through the medulla and the cerebellum, in at least two different planes for each, were reacted with tetramethylbenzidine; alternate sections were reacted with cobalt-enhanced diaminobenzidine. Labelled were 60-80% of cells in the ipsilateral and 15-25% of cells in the contralateral external cuneate nuclei, as well as 25-50% of cells in the ipsilateral and the contralateral cell groups f and x near the descending vestibular nucleus. Substantial contralateral, as well as ipsilateral cerebellar projections from external cuneate nuclei and cell group x may be related to development of forelimb dexterity in raccoons, since these nuclei mediate forelimb muscular sensibility. The numerical complementarity of ipsilaterally versus contralaterally projecting cells suggests that they represent two separate populations.

Animals↗

PubMed1975

Effect of mesoridazine administration and withdrawal on performance in an older age group.

Seven subjects, aged 48-62 years, took a placebo capsule nightly for 3 weeks, mesoridazine 10 mg for 3 weeks, and then placebo for 3 weeks. Mesoridazine is a short half-life phenothiazine useful as a hypnotic. Performance was assessed during three experimental sessions on each test day. In spite of subjective sleepiness 20 min after rising, psychomotor performance 1-3 h later was not imparied, except possibly manual dexterity after the first dose. Neither auditory vigilance, nor digit symbol substitution were affected noticeably by the drug at any time of day. Card sorting of varying degrees of complexity was unimpaired, though there was a suggestion that the drug might be associated with better performance on the most complex task.

Age Factors↗

PubMed2003

Spasticity after stroke: its occurrence and association with motor impairments and activity limitations.

BACKGROUND AND PURPOSE: There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). METHODS: Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. RESULTS: Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients. CONCLUSIONS: Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient's disabilities is essential before a decision is made on the most proper rehabilitation approach.

Activities of Daily Living↗

PubMed2006

Impact of time on improvement of outcome after stroke.

BACKGROUND AND PURPOSE: Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke. The aim of the present study was to study the effects of progress of time on observed improvements in motor strength, synergisms, and activities during the first 16 weeks poststroke. METHODS: Based on data from a previous study, 101 patients with first-ever ischemic middle cerebral artery strokes were prospectively investigated during the first 16 weeks after stroke. Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model. The biweekly time change (progress of time) was related to improvement in upper and lower limb motor recovery assessed with Fugl-Meyer score and Motricity Index, reduction in visuospatial inattention based on the letter cancellation task, and improvement in walking ability, dexterity, and activities of daily living measured with the Functional Ambulation Categories, Action Research Arm test, and Barthel Index. RESULTS: Time explained a significant change of 8.4 (42%) measurement units on the Barthel Index for the first 10 weeks poststroke, 1.1 (22%) measurement units on Functional Ambulation Categories, and 19% on the Action Research Arm test for the first 6 and 8 weeks poststroke. Approximately 25% (for Fugl-Meyer-arm) to 26% (for Motricity Index-arm) of the significant change in measurements units was explained by time alone for the upper limb compared with 33% for Fugl-Meyer-leg and 39% for Motricity Index-leg of the lower limb. Time accounted for a reduction of 16% in the letter cancellation task. Observed associations did not change after controlling for covariates such as age, gender, hemisphere of stroke, type of stroke, or intervention. CONCLUSIONS: Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining &16% to 42% of the observed improvements in the first 6 to 10 weeks after stroke onset.

Activities of Daily Living↗

PubMed1998

A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke.

BACKGROUND AND PURPOSE: Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems; all of these are potentially modifiable with exercise. The purposes of this randomized, controlled pilot study were (1) to develop a home-based balance, strength, and endurance program; (2) to evaluate the ability to recruit and retain stroke subjects; and (3) to assess the effects of the interventions used. METHODS: Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were randomized to a control group or to an experimental group that received a therapist-supervised, 8-week, 3-times-per-week, home-based exercise program. The control group received usual care as prescribed by the patients' physicians. Baseline and postintervention assessments included the Fugl-Meyer Motor Assessment, the Barthel Index of Activities of Daily Living (ADL), the Lawton Scale of Instrumental ADL, and the Medical Outcomes Study-36 Health Status Measurement. Functional assessments of balance and gait included a 10-m walk, 6-Minute Walk, and the Berg Balance Scale. Upper extremity function was evaluated by the Jebsen Test of Hand Function. RESULTS: Of 22 patients who met study criteria, 20 completed the study and 2 refused to participate. The experimental group tended to improve more than the control group in motor function (Fugl-Meyer Upper Extremity: mean change in score, 8. 4 versus 2.2; Fugl-Meyer Lower Extremity: 4.7 versus -0.9; gait velocity: median change, 0.25 versus .09 m/s; 6-Minute Walk: 195 versus 114 ft; Berg Balance Score: 7.8 versus 5; and Medical Outcomes Study-36 Health Status Measurement of Physical Function: 15. 5 versus 9). There were no trends in differences in change scores by the Jebsen Test of Hand Function, Barthel Index, and Lawton Instrumental ADL Scale. CONCLUSIONS: This study demonstrated that a randomized, controlled clinical trial of a poststroke exercise program is feasible. Measures of neurological impairments and lower extremity function showed the most benefit. Effects of the intervention on upper extremity dexterity and functional health status were equivocal. The lasting effects of the intervention were not assessed.

Activities of Daily Living↗

PubMed1998

A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm.

BACKGROUND AND PURPOSE: This study describes the methodology, patient outcome, and use of hospital and rehabilitation services at 3 months of a population-based randomized controlled trial. The purpose was to evaluate rehabilitation at home after early supported discharge from the Department of Neurology, Huddinge Hospital, for moderately disabled stroke patients in southwest Stockholm. METHODS: The patients were eligible if they were continent, independent in feeding, had mental function within normal limits, and had impaired motor function and/or aphasia 1 week after stroke. Patients were randomized either to early supported discharge with continuity of rehabilitation at home for 3 to 4 months or to routine rehabilitation service in a hospital, day care, and/or outpatient care. The home rehabilitation team consisted of two physical therapists, two occupational therapists, and one speech therapist; one of the therapists was assigned as case manager for the patient. The rehabilitation program at home emphasized a task- and context-oriented approach. The activities were chosen on the basis of the patient's personal interests. Spouses were offered education and individual counseling. A total of 81 patients were followed up for a minimum of 3 months. Patient outcome was assessed by the Frenchay Social Activity Index, Extended Katz Index, Barthel Index, Lindmark Motor Capacity Assessment, Nine-Hole Peg Test, walking speed over 10 m, reported falls, and subjective dysfunction according to the Sickness Impact Profile. Patient use of hospital and home rehabilitation service and patient satisfaction with care were studied. RESULTS: Overall there were no statistical significant differences in outcome. Multivariate logistic regression analysis suggested a systematic positive effect for the home rehabilitation group in social activity, activities of daily living, motor capacity, manual dexterity, and walking. A considerable difference in resource use during such a 3-month period was seen. A 52% reduction in hospitalization was observed: from 29 days in the routine rehabilitation group to 14 days in the home rehabilitation group. Patient satisfaction was in favor of the latter group. CONCLUSIONS: Early supported discharge with continuity of home rehabilitation services for the majority of moderately disabled stroke patients during the first 3-month period after acute stroke is not less beneficial than routine rehabilitation and can be a rehabilitation service of choice if follow-up at 6 and 12 months confirms the suggested effectiveness and considerable reduction in use of health care.

Activities of Daily Living↗

PubMed2001

Ipsilateral motor responses to focal transcranial magnetic stimulation in healthy subjects and acute-stroke patients.

BACKGROUND AND PURPOSE: Prevalence and characteristics of ipsilateral upper limb motor-evoked potentials (MEPs) elicited by focal transcranial magnetic stimulation (TMS) were compared in healthy subjects and patients with acute stroke. METHODS: Sixteen healthy subjects and 25 patients with acute stroke underwent focal TMS at maximum stimulator output over motor and premotor cortices. If present, MEPs evoked in muscles ipsilateral to TMS were analyzed for latency, amplitude, shape, and center of gravity (ie, preferential coil location to elicit them). In stroke patients, possible relationships between early ipsilateral responses and functional outcome at 6 months were sought. RESULTS: With relaxed or slightly contracting target muscle, maximal TMS over the motor cortex failed to elicit ipsilateral MEPs in the first dorsal interosseous (FDI) or biceps of any of 16 normal subjects. In 5 of 8 healthy subjects tested, ipsilateral MEPs with latencies longer than contralateral MEPs were evoked in FDI muscle (in biceps, 6 of 8 subjects) during strong (>50% maximum) contraction of the target muscle. In 15 of 25 stroke patients, ipsilateral MEPs in the unaffected relaxed FDI (in biceps, 6 of 25 stroke patients) were evoked by stimulation of premotor areas of the affected hemisphere. Their latencies were shorter than those that MEPs evoked in the same muscle by stimulation of the motor cortex of the contralateral unaffected hemisphere. Such responses were never obtained in normal subjects and were mostly observed in patients with subcortical infarcts. Patients harboring these responses had slightly better bimanual dexterity after 6 months. CONCLUSIONS: Ipsilateral MEPs obtained in healthy individuals and stroke patients have different characteristics and probably different origins. In the former, they are probably conveyed via corticoreticulospinal or corticopropriospinal pathways, whereas in the latter, early ipsilateral MEPs could originate in hyperexcitable premotor areas.

Adolescent↗

PubMed1997

Dextrous hands: human, prosthetic, and robotic.

The sensory and motor capacities of the human hand are reviewed in the context of providing a set of performance characteristics against which prosthetic and dextrous robot hands can be evaluated. The sensors involved in processing tactile, thermal, and proprioceptive (force and movement) information are described, together with details on their spatial densities, sensitivity, and resolution. The wealth of data on the human hand's sensory capacities is not matched by an equivalent database on motor performance. Attempts at quantifying manual dexterity have met with formidable technological difficulties due to the conditions under which many highly trained manual skills are performed. Limitations in technology have affected not only the quantifying of human manual performance but also the development of prosthetic and robotic hands. Most prosthetic hands in use at present are simple grasping devices, and imparting a "natural" sense of touch to these hands remains a challenge. Several dextrous robot hands exist as research tools and even though some of these systems can outperform their human counterparts in the motor domain, they are still very limited as sensory processing systems. It is in this latter area that information from studies of human grasping and processing of object information may make the greatest contribution.

Artificial Limbs↗

PubMed1995

Direct adhesion to bone marrow stroma via fibronectin receptors inhibits hematopoietic progenitor proliferation.

In long-term bone marrow cultures, stroma-adherent progenitors proliferate significantly less than nonadherent progenitors. Thus, close progenitor-stroma interactions may serve to regulate or restrict rather than promote hematopoietic progenitor proliferation. We hypothesized that signaling through adhesion receptors on hematopoietic cells may contribute to the inhibition of proliferation observed when progenitors are in contact with stroma. We demonstrate that progenitors cultured physically separated from stroma in a transwell proliferate significantly more than progenitors adherent to stroma. Furthermore, proliferation of colony forming cells (CFC) is reduced after specific adhesion to stroma, metabolically inactivated glutaraldehyde-fixed stroma, stromal-extracellular matrix, or the COOH-terminal heparin-binding domain of fibronectin. Nonspecific adhesion to poly-L-lysine fails to inhibit CFC proliferation. That the VLA-4 integrin is one of the receptors that transfers proliferation inhibitory signals was shown using blocking anti-alpha 4 monomeric F(ab) fragments. Furthermore, when synthetic peptides representing specific cell attachment sites within the heparin-binding domain of fibronectin were added to Dexter-type marrow cultures, significantly increased recovery and proliferation of CFC was observed, suggesting that these peptides disrupt adhesion-mediated proliferation inhibitory events. Thus, negative regulation of hematopoiesis may not only depend on the action of growth inhibitory cytokines but also on growth inhibitory signals resulting from direct adhesive interactions between progenitors and marrow stroma.

Amino Acid Sequence↗