Therapeutic principles in upper limb trauma

Background: Upper limb trauma is an injury caused by cutting, tearing, or crushing which leads to the limb becoming unrecognizable. In essence, there are two treatment options amputation and salvage reconstruction. Objective: The aim of this study was to assess the outcome of reconstructive surgery in upper limb trauma. Patients and Methods: This study was conducted upon 30 patients (24 males and 6 females) with mean age 28.53 ± 9.06 years presented with more than two elements, e..g. bone and tendons, vascular, nerve and skin. They were selected from Al-Azhar University Hospitals. They were admitted in General Surgery Department, Al-Azhar University Hospital, Faculty of medicine (Damietta), between April 2011 and January 2016. After appropriate consent, clinical assessment and radiological evaluation, reconstruction of upper limb trauma by repaired tendons, vascular, skin injuries and bone fixation were done. Postoperative clinical assessments of sensation and function were done. Hand functions were grouped as excellent, good, fair and poor. Nerve injury was tested using both sensory and motor components, while assessment of the hand and fingers vascularity was carried out by original and modified Allan's test. All cases were followed up in first postoperative year for vascularity, sensation and functions of the hand. Results: For 30 patients over a period of a year of clinical follow up, there was marked reduction in morbidity and mortality with satisfactory significant improvement in upper limb and hand functions, and no ischemia, neuroma or tendon ruptures were observed during the follow-up period. Conclusion: Upper limb trauma reconstruction required a thorough understanding of the advantages and limitations of local, regional, distant, and free flap options. Only those wounds with exposed neurovascular structures, tendon, or bone typically require flap coverage. Multidisciplinary team can prevent or at least minimize post-operative functional disability of upper limb.

Purpose To investigate the variables per International Classification of Functioning, Disability and Health (ICF)-domain that are associated with upper limb (UL) function in women after breast cancer surgery. Materials and Methods PubMed and Web of Science were searched until 7 January 2020. Eligibility criteria were: prospective investigation of an association between one or more variables of the ICF model and UL function in women after breast cancer surgery. PRISMA guidelines were used to conduct and report the systematic review. The Quality In Prognosis Studies tool (QUIPS) was used to evaluate risk of bias. Results Twelve studies were included (2244 participants). Risk of bias of the included studies was low to moderate. Variables at the ICF-function level that were systematically associated with decreased UL function across multiple included papers were: increased UL pain, decreased shoulder range of motion, decreased handgrip strength and a higher number of comorbidities. Results on the association between UL function and variables at other ICF-domains were conflicting. Conclusion UL function was associated with certain variables at the ICF-function level. Variability in disease stages, treatment and measurement methods might explain inconsistent associations with other variables. Only limited studies investigated associations between UL function and psychosocial factors. IMPLICATIONS FOR REHABILITATION This paper gives an overview of associations between different variables of the ICF model and UL dysfunctions in women after breast cancer surgery. Identified associated factors are situated at the ICF function level, i.e., UL pain, decreased handgrip strength and shoulder (abduction) ROM. These factors are modifiable and should be monitored, prevented and treated in physical therapy practice. UL dysfunction is not consistently associated with treatment-related variables. The role of psychosocial personal factors in UL dysfunctions should be considered and further explored.

Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Virtual reality (VR) with its engagement, interaction, and real time feedback could be a solution, with immersive VR systems having preliminary evidence in stroke to be more effective in improving UL outcomes in comparison to non-immersive VR. However, immersive VR research is limited within the realm of MS rehabilitation. Therefore, the main aim of the PhD was to explore immersive VR as an approach for UL rehabilitation for people with MS (pwMS). This was achieved in four stages: 1) a systematic review of the current evidence for VR in UL rehabilitation in MS; 2) predevelopment focus groups to determine requirements for the development of bespoke immersive VR games; 3) software development of bespoke VR games to potentially improve UL function for pwMS; and 4) a feasibility study of the games and immersive VR for pwMS’ UL rehabilitation. The systematic review initially yielded ten articles with varying study design, VR intervention and UL outcome measures used. There were some statistically significant improvements after VR interventions in outcomes such as in nine-hole peg test (NHPT), hand grip strength and active range of motion. There were however conflicting results regarding if VR was more effective than conventional approaches. Whilst the review demonstrated there were positive results for VR improving UL function, most of the studies had small sample sizes and were inadequately powered, and the level of immersion on effectiveness in MS remains unknown. The predevelopment focus groups recruited ten pwMS and eight specialist clinicians to explore their views on immersive VR as an approach to UL rehabilitation and determine requirements to develop VR games for this purpose. PwMS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many pwMS neglected UL exercise and found strategies for adapting to their UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a potential solution, as it was convenient for pwMS to access and could provide a more engaging and disguised approach to exercise. Although, there were shared concerns about cybersickness and disengagement while using VR approaches. Finally, both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and pwMS suggesting more abstract activities. Recommendations were made for the development of VR rehabilitation games which could be personalised and customisable for the varying abilities of pwMS. Using theme-based content analysis and requirement analysis, requirements for the software development of immersive VR games were created and developed using Unity game engine. Three games, “Piano”; “Catch-a-falling-star” and “VR Whack-a-mole” which targeted dexterity and strength for pwMS were developed, with different difficulty levels implemented to adapt to varying ability of pwMS. The final stage of this PhD was a randomised, controlled feasibility study to investigate an intervention of immersive VR involving the three co-produced games for pwMS’ UL rehabilitation. Participants were randomised to either an intervention group consisting of 30 minutes of VR co-produced games, twice/week, for eight weeks, or to a control group of usual care. Participants were recruited from the NHS and third sector organisations. Nineteen pwMS were recruited (intervention n=11, control n=8), with a recruitment rate of 3.2 participants/month. Only minor adverse events were reported (n=9), such as fatigue and UL pain. Adherence was good with 87% (±12%) session completed, and two dropouts were reported in the control group. There were positive trends for improving NHPT and hand grip strength, but there was an observed ceiling effect in the Action Research Arm Test. Participants reported high levels of satisfaction and good usability of the co-produced VR games, as measured by the USE questionnaire. Thematic analysis revealed participants enjoyed the distraction and atmospheres that immersive VR provided, and believed the games were fit for purpose with the majority of participants reporting improvements in their UL function. Participants suggested more variety and progression of exercises for future development. Overall, these studies show that immersive VR has the potential to be beneficial for UL rehabilitation and is feasible and safe for pwMS. Therefore, future work should refine VR games for long-term application and explore the clinical and cost effectiveness of this approach.

Objective: To assess long term effects at 1 year after stroke in patients who participated in an upper and lower limb intensity training programme in the acute and subacute rehabilitation...

Hemiplegia resulting from a stroke leads to a distinct gait pattern and dysfunction in the upper limb. The objective of this study was to determine a correlation between the functionality of the upper limb and selected spatiotemporal parameters of gait in patients with hemiplegia following a stroke. The study comprised a sample of 80 outpatients (45 males and 35 females) with post-stroke hemiplegia, with an average age of 60.78 years, selected using a convenient sampling method. To assess the functionality of the affected upper limb, the study employed the QuickDASH questionnaire, which is a shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire. Concurrently, the participants were recorded on video while performing the 4-meter walk test (4mWT). The recorded videos were meticulously analyzed using Kinovea software (version 0.8.15) to calculate gait parameters such as comfortable and maximum speeds, stride length and time on the paretic and affected side, number of steps taken to cover the 4m, and cadence. Pearson Correlation analysis was conducted to explore potential associations between these gait parameters and the QuickDASH score, with a significance level of p < 0.05.
 The findings revealed significant correlations between upper limb functionality and selected gait parameters. Reduced upper limb functionality correlated with decreased comfortable speed (p < 0.05), maximum speed (p < 0.05), and cadence (p < 0.05) during the 4mWT. In contrast, impaired upper limb function linked to prolonged time to complete the 4m distance (p < 0.05), increased steps taken by both affected (p < 0.05) and unaffected (p < 0.05) sides, and extended stride time on both sides (p < 0.05). However, no substantial correlation emerged between upper limb functionality and stride length on either side (p > 0.05).
 In conclusion, this study emphasizes the correlation between upper limb functionality and specific gait parameters in post-stroke hemiplegic patients. The correlation between upper limb functionality and selected spatiotemporal parameters of gait underscores the necessity for integrated rehabilitation strategies targeting both upper limb and gait training. These findings contribute to a deeper comprehension of the connection between upper limb disability and gait parameters, emphasizing the significance of personalized treatments in order to maximize the restoration of functionality in individuals who have suffered a stroke.

The neural correlates of bilateral upper limb training after stroke: a systematic review

The purpose of this study was to investigate the effects of live and video form action observation training (AOT) on upper limb (UL) movement acceleration and function in children with cerebral palsy (CP). In total, 12 children (7 boys, 5 girls) with CP participated in this study. The children were allocated randomly to live (experimental) and video (control) AOT groups. All children completed 20 treatment sessions, each 30 minutes in duration, 5 days per week for a month. Mediolateral (ML) and vertical (VT) acceleration data, Jebsen-Taylor Hand Function (JTHF) scores, and Box and Block Test (BBT) scores were obtained at baseline and at 4 weeks after the intervention. ML and VT movement acceleration and JTHF scores were significantly lower in the live group (p< 0.05). The BBT score was significantly higher in the live than in the video group (p< 0.05). Our findings suggest that live AOT is more effective than video AOT for improving UL movement acceleration and function. Clinically, our findings offer important insights for clinicians when planning AOT interventions to reduce UL movement acceleration and improve UL function.

How does the interaction of presumed timing, location and extent of the underlying brain lesion relate to upper limb function in children with unilateral cerebral palsy?

Short-term effects of Pilates-based exercise on upper limb strength and function in people with Parkinson's disease

Some upper-limb function assessments can evaluate treatments in the non-ambulatory stage of Duchenne muscular dystrophy (DMD). The Functional Classification of the Upper Extremities (FCUE) was developed for DMD in Japan. The FCUE is easier to use than the Performance of Upper Limb (PUL) and is more detailed than the Brooke Upper Extremity Scale. This study aimed to determine the concurrent validity of FCUE with other methods of assessment for DMD. This retrospective study reviewed the medical records of 39 boys with DMD from the National Center of Neurology and Psychiatry to evaluate the concurrent validity of the FCUE and PUL using non-parametric Spearman rank correlation (ρ). We also determined the concurrent validity of the Brooke Upper Extremity Scale and PUL for comparison. The ρ value between the FCUE and PUL was -0.914 (P<0.001). The FCUE showed robust concurrent validity with the PUL. That correlation between the FCUE and Brooke Upper Extremity Scale gave a ρ value of -0.854 (P<0.001). The FCUE had a higher concurrent validity with the PUL than with the Brooke Upper Extremity Scale. The FCUE is considered a valid assessment tool of upper-limb function in boys with DMD. Selecting the best assessment method depends on the severity of the patient's condition and a balance between assessment accuracy and evaluation time.

본 연구는 뇌졸중 후 상지기능의 관련 요인과 각 요인의 상대적 영향력을 알아보기 위해 시행되었다. MMSE-K(Mini Mental State Examination Korean version) 24점 이상인 100명의 뇌졸중 환자를 대상으로 하였다. 상지기능은 성별, 우세손, 뇌손상 원인, 뇌반구 손상부위, 신체마비 부위, 언어장애 유무와는 유의한 차이가 없었으나(p>0.05), 아탈구 유무는 상지기능에 유의한 차이를 보였다(p<0.05). 상지기능은 상지근력(Manual Muscle Testing), 고유수용성감각(Proprioception), 근 긴장도 (Modified Ashworth Scale), 장악력(Grip strength), 통증(Visual Analog Scale)과 상관관계를 보였다(p<0.05). 위의 변수를 모두 포함하여 분석하면 77.6%의 상지기능 설명력을 보였고 이 중 상지근력이 가장 높은 설명력을 보였다. 뇌졸중 환자의 상지기능 재활을 위해서는 특히 상지근력 강화와 더불어 고유수용성감각, 근 긴장도, 장악력, 통증 그리고 아탈구 유무의 관련 요인들을 포괄적으로 중재에 포함시켜야 할 것으로 사료된다. This study was carried out to identify the factors which correlated with upper limb function after stroke and to analyze the effect of related factors on upper limb function. The 100 stroke patients(MMSE-K>24) were participated. The upper limb function according to gender, hand dominance, stroke type, affected location, site of paralysis, speech disorder showed no significant difference, and show significant difference according to shoulder subluxation. The upper limb muscle strength(Manual Muscle Testing), proprioception, muscle tone(Modified Ashworth Scale), grip strength(Dynamometer), paint (Visual Analog Scale) showed significant correlations with upper limb function. These predictors explained 77.6% of the upper limb function and the most significant affecting factor of upper limb function was upper limb muscle strength. In conclusion, the upper limb muscle strengthening will be effective strategy to improving the upper limb function and considering the proprioception, muscle tone, grip strength, pain, subluxation will be helpful to develop the strategies.

Background: Stroke is one of the leading causes of adult disability, and up to 80% of stroke survivors undergo upper extremity motor dysfunction. Constraint-Induced Movement Therapy (CIMT) and Robot-Assisted Therapy (RT) are used for upper limb stroke rehabilitation. Although CIMT and RT are different techniques, both are beneficial; however, their results must be compared. The objective is to establish the difference between RT and CIMT after a rehabilitation program for chronic stroke patients.Method: This is a randomized clinical trial, registered at ClinicalTrials.gov (ID number NCT02700061), in which patients with stroke received sessions of RT or CIMT protocol, combined with a conventional rehabilitation program for 12 weeks. The primary outcome was measured by Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment—Upper Limb (FMA-UL). Activities of daily living were also assessed.Results: Fifty one patients with mild to moderate upper limb impairment were enrolled in this trial, 25 women and 26 men, mean age of 60,02 years old (SD 14,48), with 6 to 36 months after stroke onset. Function significantly improved regardless of the treatment group. However, no statistical difference was found between both groups as p-values of the median change of function measured by WMFT and FMA were 0.293 and 0.187, respectively.Conclusion: This study showed that Robotic Therapy (RT) was not different from Constraint-Induced Movement Therapy (CIMT) regardless of the analyzed variables. There was an overall upper limb function, motor recovery, functionality, and activities of daily living improvement regardless of the interventions. At last, the combination of both techniques should be considered in future studies.

Purpose: Postural control deficits in people with multiple sclerosis (MS) are common and aggravate in dual tasking. Spinal stabilization approaches like Pilates and aquaplyometric exercises may have a positive effect on postural control. We aimed to determine the effects of combined Pilates and aquaplyometric exercises on postural control with and without dual task and physical functions in people with MS with this study.Materials and Methods: Twelve people with MS were recruited to 8-week combined exercise programme applied twice in a week and evaluated before and after the exercise training. Timed up and go test was performed for functional mobility and Biodex Balance System was used to evaluate the limits of stability (LoS) with and without a cognitive task. Upper limb functions were evaluated with nine-hole peg test (NHPT) and grip strength where 5-Repetition Sit-To-Stand (STS) and timed 25-Foot walk test were used for lower limb functions.Results: Eight-week combined exercise programme improved postural control, upper limb functions and lower limb functions. Additionally, there was no significant difference between LoS tests scores with and without dual task. Conclusion: Eight-week combined aquatic plyometrics and Pilates exercises were effective in improvement of postural control, upper and lower limb functions in people with MS.

Persons with multiple sclerosis (pwMS) could have an impaired trunk and reduced postural control, which negatively impacts activities of daily living. Evidence is growing to consider the positive effects of trunk training on fall incidence and balance problems. Effects on trunk and upper limb performance is unknown. This systematic review provides an overview of trunk training programs and their effects in MS, specifically focusing on the content of training modalities and the effects on trunk and upper limb performance. Two electronic databases were used: PubMed and Web Of Science (WOS). Intervention studies (with- and without control group) published in English, investigating the effects of active trunk training on trunk and upper limb performance in pwMS, were included. Sixteen studies met the criteria, investigating different rehabilitation modalities. The included interventions in the review varied between more generic postural interventions such as Pilates (N.=8) and Ai Chi (N.=1), with a focus on abdominal muscle activation, breathing, neutral position and lower extremity movements. Further, specifically developed trunk training programs like GroupCoreDIST/ SIT / CoDuSe (N.=6) and Bobath based trunk training (N.=1) are detected, with the main focus on trunk strengthening and dynamic movements. An overall improvement in trunk performance was reported in several tests on trunk strength, stability and coordination. While the majority of the programs integrated the upper limb, only half of them used upper limb outcome measures to evaluate the effect. Here, overall significant improvements were found for the upper limb. This systematic review showed that different types of trunk training programs can improve trunk and upper limb function in PwMS. The findings of this review suggest that a focus on trunk training to achieve effects on upper limb is reasonable. Future research is needed to further explore relations and the effect sizes.

Introduction: Stroke is the third-leading cause of major long-term disability and the second-leading cause of mortality worldwide. Paralysis, paresis (muscle weakness), spasticity, difficulty walking, difficulty controlling motions, and limb discomfort are frequent limb impairments. Nearly 80% of stroke survivors are affected. Stroke survivors suffer with physical disabilities in addition to a reduced quality of life in terms of their health, a higher degree of worry, and a loss of independence. With a prevalence of 55% to 75%, hand motor deficits are the most prevalent post-stroke.1 The most common impairment is motor dysfunction, which affects 90% of stroke survivors with some kind of upper limb motor disability. Motor dysfunction is a strong indicator of poor functional recovery. The most typical post-stroke symptom is hemiparesis.1 Objectives: The study's objective was to use a virtual reality system to enhance upper limb strength and function in hemiparesis. The study's secondary goal was to lessen tension and anxiety in stroke Survivors. Methods: This research was experimental. A patient was chosen from UEM Hospital in Jaipur, Rajasthan, based on inclusion and exclusion criteria. Upper Extremity Functional Index (UEFI) and Depression Anxiety Stress Scale (DASS-21) were employed as outcome measures to evaluate the patients. Result: The outcome of the post-intervention data revealed that the Upper Extremity Functional Index (UEFI) had significant values of P.311. P .002 was used to determine the importance of the Depression Anxiety Stress Scale (DASS-21). That indicates that following the intervention, all outcome indicators showed a considerable improvement. Conclusion: The post-intervention values of the depression anxiety stress scale (DASS 21) and the upper extremity functional index (UEFI) both indicated a substantial improvement. In order to improve strength and upper limb functions following hemiparesis and to lessen tension and anxiety as a result of the handicap, a low-cost VR system might be employed.