The Ultimate Grip Strength Workout
There is little controversy regarding the relative roles of conventional techniques versus microneurosurgical reconstruction for incomplete brachial plexus palsies that involve primarily the upper elements of the plexus (ie, C5-C6 or C5-C7 palsies). The patients retain useful hand function but are unable to position this functional hand to perform necessary tasks. The patients' issues relate to control of the shoulder and elbow, and less frequently, the wrist. The relative roles of conventional versus microsurgical treatment are discussed accordingly.
Restoration of hand function is a high priority for individuals with mid-cervical level spinal cord injury. Although orthotics are available, the function is limited and the rejection is high.2,3 For lower cervical injuries (C7,C8), surgical alterations to transfer muscles under voluntary control are possible.4,5 Neuroprostheses utilizing FES for restoration of hand function have been clinically implemented and investigated by four independent research groups worldwide, including our center in Cleveland (see Chapter 3 for another example). Two of these groups use systems employing surface electrodes, and a third uses a percutaneous system.6 In Cleveland, we have employed both of these types of systems over the past 25 years7-11 but have focused most extensively on implantable systems. Although we believe that both surface and percutaneous stimulation have potential application in muscle conditioning and in short-term research applications, it has been our clinical experience that...
Other problems, such as epididymitis (inflammation of the epididymis), may go unrecognized without self-examination or visual inspection. Men with MS may have diminished hand function or sensation. Examination by a spouse or care provider will be a key factor in the early identification of changes and potential problems. Lumps, redness, swelling, pain, or discharge should signal the need for contact with a physician and prompt medical attention.
Malnutrition prevalence depends in part on the parameters that were chosen to determine nutritional status. For example, when 50 patients with cirrhosis were assessed according to subjective global assessment (SGA), prognostic nutritional index (PNI) and handgrip strength (HG), malnutrition was diagnosed in 28 based on SGA, 18.7 by PNI and 64 by HG. HG was superior in predicting poor clinical outcome when compared with SGA and PNI 4 . In another study, Figueiredo et al. 5 measured body cell mass (BCM) by isotope dilution in 69 patients awaiting liver transplantation. Patients were also evaluated based on SGA, anthropometry, HG dynamometry, laboratory tests and dual-energy X-ray absorptiometry (DXA). Only one-half of the patients in
Apart from the thumb, the radial two digits play the dominant role in global hand function for most patients, especially during fine manipulation, and should be preferentially reconstructed (Fig. 2) 16,17,29 . A few patients, nevertheless, have specific demands for maximal hand span for them, an ulnar digit may be more important.
And subsequent neurorraphy of the muscle's motor nerve to a recipient motor nerve for reinnervation. The use of FFMT in brachial plexus reconstruction is another example of the application of neurotization and it has been shown to be effective and has become increasingly popular. The gracilis myocutaneous FFMT is the best choice for the donor muscle in brachial plexus reconstruction 26-28 . The most common extraplexus donor nerves include the XI, the IC, and the CC7, which all require a two-stage procedure elongation with a nerve graft (cable nerve grafts or vascularized ulnar nerve graft) at the first stage followed by an FFMT at the second stage 26-30 . The Ph nerve can be also used as a neurotizer. Intraplexus donor nerves include part of the ulnar nerve, part of the median nerve, or more proximally from the infraclavicular or suprascapular nerves, which require nerve elongation and FFMT in a two-stage procedure. The results from FFMT are more satisfactory than those provided by...
Although shoulder adduction was once thought more important than abduction, good recovery of shoulder abduction can provide greater range of motion for the arm and forearm, which is more appreciated by most patients. Shoulder adduction by fusion can increase shoulder grasp power but is technically difficult and also limits shoulder excursion. In nearly 1500 cases, fewer than 10 patients required shoulder fusion because of failed nerve reconstruction, but achieved elbow and hand function by functioning free muscle transfers.
The overriding question when confronted with an amputation should be, ''from my knowledge of hand surgery, fractures, tendon, and nerve repairs, what is the realistic potential for this digit to contribute to function, or might it not only be functionless but even worse, interfere with the remaining hand function '' In making this judgment, it is implied that the surgeon knows the function of each digit and at each level and what the disability will be if the part is not reattached. By definition, the novice resident alone in the emergency trenches at 3 am will not be struck with enlightenment. In fairness to patient, resident, and public purse, amputations should be evaluated by an experienced surgeon. In general terms, the radial three digits are concerned with pulp pinch grip and work as a team. Therefore, sensibility excellence is of greater importance than mobility. Sensory return in replanted digits is normally more reliable than is restoration of movement. Amputations of the...
People with spinal cord injury have many needs, depending on the level and severity of the injury. The highest priority for people with quadriplegia is the restoration of arm and hand function. Improved trunk stability and restoration of bladder, bowel, and sexual functions are ranked among the top priorities of people with quadriplegia and paraplegia, followed closely by the desire for restored stepping (Anderson, 2004). Various approaches have been taken in addressing these needs, including the use of FES. This section reviews some of the main FES systems currently available for restoring standing and walking after spinal cord injury. The use of ISMS in achieving similar functions is discussed later.
The thumb is a vital part of the hand. After traumatic loss of the thumb, hand function diminishes considerably. The loss of the great toe, on the other hand, although unsightly, is not a considerable functional loss to the foot. Aesthetic and functional losses are restored to the hand following great toe transplantation to the thumb position, with very little functional loss to the foot. Anatomic and operative details are discussed, along with preoperative and postoperative management. Postoperative functional evaluations of the thumb and donor site are assessed. Forty years of experience with this composite tissue transplantation has proven that great toe to thumb microvascular transplantation is the gold standard for thumb reconstruction after traumatic amputation.
The functional recovery following an axonot-metic injury may not be complete, as several factors can potentially influence the ability of a regenerating axon to reach the proper target 2 . First, anatomically complex nerves with more branching have a decreased chance of proper reinnervation compared to less complex nerves. Secondly, functionally complex nerves with both motor and sensory components less accurately re-innervate compared to nerves that are only motor or sensory. Thirdly, the need for precise innervation to maintain function varies between nerves. For example, clinical recovery from a distal tibial nerve injury often gives a more gratifying result compared to a distal ulnar nerve injury, because proper hand function is dependent on more precise innervation.
Unlike the loss of the thumb, which causes a 40 to 50 loss of global hand function, single finger amputations produce insignificant functional impairment for most patients 15 . Single finger reconstruction with toe transplantation has therefore not gained wide acceptance. In select patients, however, particularly those with distal amputations and higher manual functional or esthetic demands because of their occupations or hobbies, single finger reconstruction can usually offer satisfactory results even if performed solely for cosmetic reasons 12,16-18 . The livelihood of some individuals depends on a full set of
Two further RCTs (Ib) and two CCTs (IIa) examined the interventions of t'ai chi, Chinese medicine, relaxation training and a multimodal intervention program. The results of the CCT assessing t'ai chi reported significant changes in patients' assessment of their symptoms at three month follow-up.457 One CCT of a multimodal intervention program reported significant effects on five of the eight areas assessed. These included two measures of list learning and memory, improved BDI scores, one measure of grip strength and one of tactile sensitivity458 (IIb). One of the RCTs looked at relaxation training and biologically orientated imagery treatment.459 The results showed a significant improvement on state anxiety, but not on trait anxiety or the other three tests examining mood or health states. The last RCT compared the efficacy of traditional Chinese medicine combined with Western medicine to treatment with Western medicine alone. The results indicated beneficial effects upon remittance...
Patients may decline on the basis that they want to return to work rapidly. Cosmetic concerns will determine many decisions. Age negatively affects the digit's capacity to recover, especially sensation, and it affects the patient's ability and will to rehabilitate. Sophisticated hand function and cosmetic considerations are less relevant in the elderly, and many will elect not to replant. On the other hand, elderly patients' hands are relatively stiff and compromised so that loss of digits will theoretically affect them more. Replanted digits in such hands, even if suboptimal, may closely approximate preinjury status and be highly prized. Medical fitness for prolonged anesthesia and prolonged rehabilitation also must be considered. Major associated injuries may mitigate against replantation as would uncooperative patients, for example, with mental
There is much less controversy regarding babies who suffer injury to all elements of the plexus. Complete or global palsy at birth that does not evolve within days to a pattern more suggestive of an upper plexus injury is an indication for early microneurosurgical treatment. As opposed to the circumstances in the adult with a total brachial plexus palsy, or the more rare, isolated C8, T1 palsy (Klumpke), there is the possibility of restoring good hand function and even intrinsic muscle function if early plexus reconstruction is performed in babies with global palsy. This is the one good opportunity to make these babies better, because the results of secondary conventional surgery, such as muscle-tendon transfers, are far from predictable. One must consider that any muscle that might be considered expendable later (for a secondary tendon transfer) was once a paralyzed muscle itself. The secondary procedures most reliable to improve hand function include radio-carpal fusion to control...
An 18-year-old man had a C5 and C6 avulsion injury of his left upper limb. He underwent double neurotization with Ph nerve transfer to the posterior division of the upper trunk and XI nerve transfer to the suprascapular nerve (extraplexus neurotization) and part of the ulnar nerve transfer to the musculocutaneous nerve (close target neurotization). He achieved good shoulder function (A) and elbow flexion (B, C), but still showed subclinical deficits of the left ulnar nerve (hand grip strength, right 52 kg, but left 32 kg) 3 years after surgery (D). Fig. 2. An 18-year-old man had a C5 and C6 avulsion injury of his left upper limb. He underwent double neurotization with Ph nerve transfer to the posterior division of the upper trunk and XI nerve transfer to the suprascapular nerve (extraplexus neurotization) and part of the ulnar nerve transfer to the musculocutaneous nerve (close target neurotization). He achieved good shoulder function (A) and elbow flexion (B, C), but still...
In the patient who is able to follow commands, muscle mass can be determined from handgrip strength by the use of a bedside tool known as a handgrip dynamometer (Fig. 1.4). Hospitalized patients with poor grip strength have been shown to have an increase in hospital length of stay, reduced ability to return home and increased mortality 26 .
Treatment of the sleep apnea may improve the overall daytime sleepiness in some MS patients. No studies to date have been performed to evaluate the effect of treatment of sleep apnea on MS. CPAP is the standard treatment of sleep apnea in the general population. If sleep apnea is diagnosed in MS patients, CPaP use is advised. These patients must be evaluated for their dexterity and hand strength for application of CPAP or oral appliances. Motor and cognitive disability might make the use of CPAP a challenge. We have found that caregiver involvement in the fitting and education of CPAP use is very helpful. Many MS patients are using opiates for the relief of spasticity and pain. Physicians and patients must be aware of the risk of opiates on further respiratory compromise, especially during sleep.
Another important issue that merits further investigation is the effect of different types of lesions on the function maps generated by fMRI. It is reasonable to suppose that the functionality of adjacent brain will be different in infiltrative vs displacing lesions. Schreiber et al. (72) examined the alterations in fMRI maps for hand function in glial and nonglial space-occupying lesions. Motor cortex activation ipsilateral to nonglial lesions increased by 14 , in contrast to a 36 decrease with infiltrating gliomas. Their observations support the conclusion that gliomatous infiltration significantly alters cerebral hemodynamics and or cor-
FIGURE 7.2 Preparatory 7-Hz rhythm recorded in human inferior parietal cortex. (A) Mean ECoG of 30 trials of hand grip aligned on EMG onset. (B) Subset of three successive trials showing superimposed ECoG waveforms and surface EMG (rectified) of the flexor digitorum communis muscle. (Adapted from Reference 21, with permission.) FIGURE 7.2 Preparatory 7-Hz rhythm recorded in human inferior parietal cortex. (A) Mean ECoG of 30 trials of hand grip aligned on EMG onset. (B) Subset of three successive trials showing superimposed ECoG waveforms and surface EMG (rectified) of the flexor digitorum communis muscle. (Adapted from Reference 21, with permission.)
Reconstructive surgery is an empirical merry-go-round of indecision based on the recollections and scars of our last experience. ''I'll never 'hep-arinize' these patients again,'' until the next thrombosis occurs and the mantra changes. ''I always use K-wires,'' until the next pin track infection, or ''replants are easy,'' until two consecutive cases fail. ''I'll never do a replantation again.'' But, done for the right reason and performed with disciplined method and meticulous attention to detail, digital replantation is one of the most demanding yet rewarding procedures that the hand surgeon encounters. Like much of surgery, many times the operation begins with great expectations and progressively degenerates into a frustrating compromise, but provided the indication was correct, the digit is highly likely to contribute to global hand function.
There are three kinds of active prostheses myoelectric prostheses, activated by electric signals produced by muscular contraction kinematic prostheses, activated by bodily energy and hybrid prostheses, which combine a myoelectric control of the hand function and a kinematic control of the elbow function.
Motor function can be differentially affected depending on experimental parameters. For example, unilateral brain injury models often produce hemiparesis-like effects that may be reflected by deficits in grip strength, balance, and turning behavior, or may induce forepaw flexion. Many drugs can have either sedative or stimulant properties. Consequently, several models have been developed to examine specific motor deficits such as these. Two commonly used procedures are thus described.
Sensory return in great toe-to-thumb transplants averaged 8 mm of 2-point discrimination with a range from 5 mm to protective sensation. Average MCPJ motion was 44 degrees (63 of the range of motion when compared with the opposite side) interphalangeal joint motion averages 40 degrees (59 of the opposite side). Grip strength was 77 that of the uninjured side. Pinch strength was 67 of the uninjured side (Fig. 7).
The thumb is a vital part of the hand. After traumatic loss of the thumb, hand function diminishes considerably. The loss of the great toe, on the other hand, although unsightly, is not a considerable functional loss to the foot. Aesthetic and functional losses are restored to the hand following great toe transplantation to the thumb position, with very little functional loss to the foot. Anatomic and operative details are discussed, along with preoperative and postoperative management. Postoperative functional evaluations of the thumb and donor site are assessed. Forty years of experience with this composite tissue transplantation has proven that great toe-to-thumb microvascular transplantation is the gold standard for thumb reconstruction after traumatic amputation.
A core component skill underlying individual variation in intelligence is speed of cognitive processing 30 . As our NAA-intelligence findings emerged from voxels containing mostly myelinated axonal fibers, we hypothesized that NAA might be most related to neuropsychological measures tapping speeded cognitive performance 19 . Our battery of neuropsychological tests was split into those emphasizing rapid processing (i.e., timed performance measures) vs. those that did not (e.g., word finding ability). Left posterior white matter NAA accounted for 42 of the variance on a composite measure of speeded performance, vs. 8 (non-significant) on non-speeded tests. Interestingly, as also found in our TBI studies, correlations between NAA and motor tests were low (Grooved Pegboard Test, r 0.18 Grip Strength, r -0.05). Finally, one recent study reports that left frontal gray matter NAA predicts greater verbal intelligence, though only in women 31 . Thus, studies to date suggest that there may be...
Cunningham and Phillips also present a lucid analysis of the strengths, weaknesses, and future promise of gene targeting technologies (4). In particular, they note the need for stringent behavioral controls to enable straightforward interpretation of the results from such studies as relevant specifically to alcohol. One aspect of such control is the selection of the phenotype tested. As they note, virtually all studies of alcohol reward chose a single assay of reinforcement, two-bottle preference drinking, to compare knockouts and wild types. However, they note that this paradigm (like all others) has several problems that hinder its interpretation. Multiple assays that target a putative behavioral domain (e.g., reinforcement, anxiety ) should be studied before inferring a genetic effect on that domain. One example is studies of sensitivity to alcohol-induced motor incoordination conducted in mice lacking the serotonin 1B receptor. The 5-HT1B null mutants were less sensitive to...
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