Muscle-nerve-muscle neurotization of the orbicularis oris muscle

INTRODUCTION

A denervated half of the orbicularis oris muscle is not reinnervated spontaneously by axon sprouting from the intact contralateral side. The borderline between the facial nerve territories seems to act as a barrier. The muscle-nerve-muscle technique was advocated as a technique to reneurotize a denervated half of the orbicularis oris muscle in cases of marginal mandibular paralysis.

MATERIAL AND METHODS

This muscle-nerve-muscle neurotization was tried to induce reinnervation of a denervated angle of the mouth in four patients. Grafts were harvested from the sural nerve. Functional recovery was assessed by measurement of facial movements and by electrophysiological examination.

RESULTS

In three of the four cases presented, this technique helped to improve function of the lower lip. The clinical relevance of the results is discussed.

Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure: a single-blind, randomized, controlled trial

OBJECTIVE

To determine the impact of an 8-wk neuromuscular stimulation program of thigh muscles on strength and cross-sectional area in patients with refractory heart failure listed for transplantation.

DESIGN

Forty-two patients with a stable disease course were assigned randomly to a stimulation group (SG) or a control group (CG). The stimulation protocol consisted of biphasic symmetric impulses with a frequency of 50 Hz and an on/off regime of 2/6 sec.

RESULTS

Primary outcome measures were isometric and isokinetic thigh muscle strength and muscle cross-sectional area. Our results showed an increase of muscle strength by mean 22.7 for knee extensor and by 35.4 for knee flexor muscles. The CG remained unchanged or decreased by -8.4 in extensor strength. Cross-sectional area increased in the SG by 15.5 and in the CG by 1.7.

CONCLUSIONS

Activities of daily living as well as quality of life increased in the SG but not in the CG. Subscales of the SF-36 increased significantly in the SG, especially concerning physical functioning by +7.5 (1.3-30.0), emotional role by +33.3 (0-66.6), and social functioning by +18.8 (0-46.9), all P < 0.05. Neither a change nor a decrease was observed in the CG. Neuromuscular electrical stimulation of thigh muscles in patients with refractory heart failure is effective in increasing muscle strength and bulk and positively affects the perception of quality of life and activities of daily living.

Experimental study of muscle-nerve-muscle neurotization

A laboratory model for the study of possible reinnervation by muscle-nerve-muscle (MNM) neurotization is presented. Preliminary studies revealed that MNM neurotization occurs in synergistically closely-related facial muscles. However, for larger antagonistic somatic muscle (flexor and extensor), this phenomenon could not be reproduced. The potential clinical relevance of these findings is presented and discussed.

Electromyogram-controlled functional electrical stimulation for treatment of the paralyzed upper extremity

Spinal cord lesions at level C5 to C6 lead to loss of hand functions and lesions at C4 to additional deficits of arm functionality. The presented dual channel surface stimulator with dual channel electromyogram (EMG) measurement was developed to investigate control strategies for an EMG-controlled implantable stimulation system and serves in addition as a therapy device for patients with partial innervation but weak muscle force. Four different control strategies for stimulation amplitude are available. The amplitude can be preset manually or can follow the preprocessed EMG signals proportionally. The shoulder control program allows proportional control of both stimulation channels with one EMG channel while the second EMG channel serves as the channel selector. Finally, a special feedback training program triggers a stimulation burst when EMG activity is detected. During a 2 year patient study, 18 patients from 2 hospitals and 1 rehabilitation center performed the feedback training. Almost all patients obtained an improvement of functionality. Apart from muscle strengthening, the feedback effect led to an improvement of proprioception and supported relearning of motions. For the documentation of the training status, functional muscle test (British Medical Research Council) and measurements of power, angle, torque, muscle fatigue, and EMG were performed. Obviously, EMG triggered stimulation provides several advantages compared to conventional passive electrical stimulation.

Function of reinserted abductor muscles after femoral replacement

We compared two methods of reconstruction of the abductor mechanism in 15 patients after prosthetic replacement of the upper femur, to assess abductor strength and function.

Six patients in group I had direct fixation of the gluteus medius tendon and a segment of the original bone to the prosthesis. Nine patients in group 2 had the abductor tendon fixed to the iliotibial band. We assessed clinical function, isometric muscle strength and muscle cross-sectional area for each patient.

The patients in group 1 had better clinical and functional results (p = 0.059), with average peak torques for hip abduction of 92% of that in the non-operated leg in group 1, and of 57% in group 2. Group 1 had a mean muscle cross-sectional area of 69% and a mean value of strength per cross-sectional area of 134% when compared with the control side. The respective values for group 2 were 52% and 91%.

Direct fixation of the abductor muscles to the prostheses gave improved function and higher isometric abductor muscle force.

Function of reinserted abductor muscles after femoral replacement

We compared two methods of reconstruction of the abductor mechanism in 15 patients after prosthetic replacement of the upper femur, to assess abductor strength and function. Six patients in group I had direct fixation of the gluteus medius tendon and a segment of the original bone to the prosthesis. Nine patients in group 2 had the abductor tendon fixed to the iliotibial band. We assessed clinical function, isometric muscle strength and muscle cross-sectional area for each patient. The patients in group 1 had better clinical and functional results (p = 0.059), with average peak torques for hip abduction of 92% of that in the non-operated leg in group 1, and of 57% in group 2. Group 1 had a mean muscle cross-sectional area of 69% and a mean value of strength per cross-sectional area of 134% when compared with the control side. The respective values for group 2 were 52% and 91%. Direct fixation of the abductor muscles to the prostheses gave improved function and higher isometric abductor muscle force.

[Therapy relevant aspects of anatomy, pathophysiology and diagnosis of urinary incontinence in women]

Many aspects of the pathogenesis of urinary incontinence are poorly understood. Most studies show good results for physical therapy for instance for pelvic floor exercises and biofeedback. Unfortunately most of these studies lack an objective diagnostic and neurophysiological assessment. This could be one reason for the strongly divergent therapeutical success rates reported (30 to 90%). We recommend the use of objective parameters, for instance the PAD test with standardized bladder volume and a neurophysiological and short urodynamic assessment as well as subjective parameters [satisfaction with the outcome of treatment measured with the VAS (visual analog scale), documentation of the changes in ADL (activities of daily living)] in future therapeutical studies. A more precise assessment of the pathological cause of the impairment will help to develop optimal therapeutic procedures. Because of poor documentation in the past the analysis of therapeutic failures and the decision if mono-or complex physiotherapy is more appropriate has not been possible. This aspect will become even more important as the cost-effectiveness of treatments becomes a more important issue.

[Functional and esthetic assessment of donor site defects following transfer of the gracilis muscle]

In order to determine donor-site morbidity after elevation of the gracilis flap, 53 patients from four different departments were examined. The patients filled out a questionnaire about their complaints. 36 patients underwent dynamometric measurements. The adduction strength of the hip-joint was decreased by 11% after elevation of the gracilis muscle. This decrease in strength was not noticed by the patients. 53% of the patients complained about hypesthesia or dysesthesia corresponding to the cutaneous territory of the obturator nerve. The contour of the thigh was adversely affected after elevation of a musculocutaneous flap. The gracilis flap has a low but definite donor-site morbidity, especially concerning the esthetic aspect.