Variants in tropomyosins TPM2 and TPM3 causing muscle hypertonia

Patients with myopathies caused by pathogenic variants in tropomyosin genes TPM2 and TPM3 usually have muscle hypotonia and weakness, their muscle biopsies often showing fibre size disproportion and nemaline bodies. Here, we describe a series of patients with hypercontractile molecular phenotypes, high muscle tone, and mostly non-specific myopathic biopsy findings without nemaline bodies. Three of the patients had trismus, whilst in one patient, the distal joints of her fingers flexed on extension of the wrists. In one biopsy from a patient with a rare TPM3 pathogenic variant, cores and minicores were observed, an unusual finding in TPM3-caused myopathy. The variants alter conserved contact sites between tropomyosin and actin.

Positional Change Used to Manage Postextubation Respiratory Failure in a Child With Cerebral Palsy

Dental treatment for patients with cerebral palsy (CP) is often performed under general anesthesia due to involuntary movements that can render dental treatment difficult. Since CP is often accompanied by spasticity, care must be taken when positioning patients during general anesthesia. We report the management of a 14-year-old girl with CP and epilepsy undergoing general anesthesia for dental treatment who experienced respiratory failure due to acute thoracoabdominal muscle hypertonia after extubation. She had a history of cardiac arrest due to respiratory failure caused by acute muscle hypertonia and successful resuscitation. General anesthesia was induced after careful positioning of the patient to prevent spastic muscle stretching, and the dental treatment was completed without complications. However, upon awakening after extubation, the patient developed respiratory failure due to acute muscle hypertonia. The patient was resedated and repositioned from a supine to a sitting position, and her symptoms improved. There was no recurrence of muscle hypertonia, and she recovered fully without complications. In this case, respiratory failure associated with acute muscle hypertonia was successfully managed by position change after initial treatment with positive-pressure ventilation and propofol. It is important to be prepared for the possibility of respiratory failure associated with acute muscle hypertonia and its countermeasures when providing general anesthesia for patients with CP.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi

OBJECTIVE

To establish international recommendations for the management of spastic equinovarus foot deformity.

DESIGN

Delphi method.

SETTING

International study.

PARTICIPANTS

A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons).

INTERVENTIONS

Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity.

MAIN OUTCOME MEASURES

A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery.

CONCLUSION

The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

Spastic co-contraction is directly associated with altered cortical beta oscillations after stroke

OBJECTIVE

Spastic co-contraction is a motor-disabling form of muscle overactivity occurring after a stroke, contributing to a limitation in active movement and a certain level of motor impairment. The cortical mechanisms underlying spastic co-contraction remain to be more fully elucidated, the present study aimed to investigate the role of the cortical beta oscillations in spastic co-contraction after a stroke.

METHOD

We recruited fifteen post-stroke participants and nine healthy controls. The participants were asked to perform active elbow extensions. In the study, multimodal analysis was performed to combine the evaluation of three-dimensional elbow kinematics, the elbow muscles electromyographic activations, and the cortical oscillatory activity.

RESULTS

The movement-related beta desynchronization was significantly decreased in post-stroke participants compared to healthy participants. We found a significant correlation between the movement-related beta desynchronization and the elbow flexors activation during the active elbow extension in post-stroke participants. When compared to healthy participants, post-stroke participants exhibited significant alterations in the elbow kinematics and greater muscle activation levels.

CONCLUSIONS

Cortical beta oscillation alterations may reflect an important neural mechanism underlying spastic co-contraction after a stroke.

SIGNIFICANCE

Measuring the cortical oscillatory activity could be useful to further characterize neuromuscular plasticity induced by recovery or therapeutic interventions.

Spastic dystonia in stroke subjects: prevalence and features of the neglected phenomenon of the upper motor neuron syndrome

OBJECTIVE

Spastic dystonia is one of the positive phenomena of the upper motor neuron syndrome (UMNS). It is characterised by the inability to relax a muscle leading to a spontaneous, although stretch-sensitive, tonic contraction. Although spastic dystonia is a recognized cause of muscle hypertonia, its prevalence among hypertonic muscles of stroke subjects has never been investigated. Differently from spasticity, which is an exaggerated stretch reflex, spastic dystonia is viewed as an efferent phenomenon, due to an abnormal central drive to motoneurons.

METHODS

In 23 hemiparetic stroke subjects showing increased muscle tone of wrist flexors, surface EMG was used to investigate the presence of spontaneous, stretch-sensitive EMG activity in flexor carpi radialis.

RESULTS

Spontaneous, stretch-sensitive EMG activity was found in 17 subjects. In the remaining 6 subjects, no spontaneous EMG activity was found.

CONCLUSIONS

The majority of stroke subjects is affected by spastic dystonia in their hypertonic wrist flexor muscles. Only a minority of subjects is affected by spasticity.

SIGNIFICANCE

To stop spastic dystonia from being the neglected aspect of UMNS, it is essential to link its definition to increased muscle tone, as occurred for spasticity. Recognizing the real phenomena underling muscle hypertonia could improve its management.

Nonsurgical Treatment Options for Upper Limb Spasticity

There are many nonsurgical treatment options for patients with upper limb spasticity. This article presents an algorithmic approach to management, encompassing evidence-based rehabilitation therapies, medications, and promising new orthotic and robotic innovations.

Effects of a hippotherapy intervention on muscle spasticity in children with cerebral palsy: A randomized controlled trial

OBJECTIVE

The aim of the present study is to evaluate the effect of a 12 weeks hippotherapy intervention protocol on hip adductors spasticity in children with spastic cerebral palsy.

DESIGN

Randomized controlled trial.

SETTINGS/LOCATION

The intervention was conducted in an Equestrian and Therapeutic Association. Patients were recruited from a Rehabilitation Unit of Cerebral Palsy.

SUBJECTS

A total of 44 children with spastic cerebral palsy (Gross Motor Function Classification System [GMFCS] levels IV-V; 28 boys and 16 girls; aged 8 years 10 months, SD 3 months) were assigned to a treatment (n = 22; mean age 9 years 6 months, SD 3 months) or a control group (n = 22; mean age 8 years 3 months, SD 3 months).

INTERVENTIONS

The control group received conventional therapy, and the treatment group received hippotherapy in addition to their conventional treatment. The intervention consisted of a 12-weeks hippotherapy program (1 time/week, 45 min).

OUTCOME MEASURES

Both groups were assessed before and after the full program with the Modified Ashworth Scale (MAS).

RESULTS

There were significant differences in the MAS scores between the treatment and the control group in both adductors (left adductors: p = 0,040; right adductors: p = 0,047), after a 12-weeks hippotherapy intervention.

CONCLUSIONS

A hippotherapy based treatment in addition to conventional therapy, in children with cerebral palsy, produces statistically significant changes in hip adductors spasticity after a 12-weeks intervention. Thus, it seems to produce benefits in the short-term.

Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes

OBJECTIVE

To assess the reliability of the Spinal Cord Assessment Tool for Spastic Reflexes (SCATS).

DESIGN

Observational reliability study of the SCATS.

SETTING

Inpatient rehabilitation unit at an education and research hospital.

PARTICIPANTS

Subjects (N=47) between the ages of 18 and 88 years with spinal cord injury (SCI) and with American Spinal Injury Association Impairment Scale grades from A to D with spasticity, who were at least 6 months postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interrater and test-retest reliability of the SCATS.

RESULTS

The SCATS had substantial to almost perfect interrater agreement (κ=.669-1.000) between the 2 physiatrists. Test-retest agreement of the SCATS was also substantial to almost perfect (κ=.614-1.000) as well. There was a significant correlation between the SCATS clonus scores and the Modified Ashworth scores of the hip, knee, and ankle. No correlation was found between SCATS extensor spasm scores and Modified Ashworth scores. The SCATS flexor spasm scores were only correlated significantly with the ankle plantar flexor Modified Ashworth scores (P<.05).

CONCLUSIONS

The SCATS is a reliable tool for assessing spasm activity and spastic hypertonia in patients with SCI.

Home-Based Versus Laboratory-Based Robotic Ankle Training for Children With Cerebral Palsy: A Pilot Randomized Comparative Trial

OBJECTIVE

To examine the outcomes of home-based robot-guided therapy and compare it to laboratory-based robot-guided therapy for the treatment of impaired ankles in children with cerebral palsy.

DESIGN

A randomized comparative trial design comparing a home-based training group and a laboratory-based training group.

SETTING

Home versus laboratory within a research hospital.

PARTICIPANTS

Children (N=41) with cerebral palsy who were at Gross Motor Function Classification System level I, II, or III were randomly assigned to 2 groups. Children in home-based and laboratory-based groups were 8.7±2.8 (n=23) and 10.7±6.0 (n=18) years old, respectively.

INTERVENTIONS

Six-week combined passive stretching and active movement intervention of impaired ankle in a laboratory or home environment using a portable rehabilitation robot.

MAIN OUTCOME MEASURES

Active dorsiflexion range of motion (as the primary outcome), mobility (6-minute walk test and timed Up and Go test), balance (Pediatric Balance Scale), Selective Motor Control Assessment of the Lower Extremity, Modified Ashworth Scale (MAS) for spasticity, passive range of motion (PROM), strength, and joint stiffness.

RESULTS

Significant improvements were found for the home-based group in all biomechanical outcome measures except for PROM and all clinical outcome measures except the MAS. The laboratory-based group also showed significant improvements in all the biomechanical outcome measures and all clinical outcome measures except the MAS. There were no significant differences in the outcome measures between the 2 groups.

CONCLUSIONS

These findings suggest that the translation of repetitive, goal-directed, biofeedback training through motivating games from the laboratory to the home environment is feasible. The benefits of home-based robot-guided therapy were similar to those of laboratory-based robot-guided therapy.

Medical complications during inpatient rehabilitation among patients with traumatic disorders of consciousness

OBJECTIVE

To assess the incidence of medical complications in patients with recent traumatic disorders of consciousness (DOCs).

DESIGN

Data on adverse events in a placebo controlled trial of amantadine hydrochloride revealed no group difference, which allowed these events to be reanalyzed descriptively as medical complications experienced by the 2 groups collectively.

SETTING

Eleven clinical facilities in the United States, Denmark, and Germany with specialty rehabilitation programs for patients with DOCs.

PARTICIPANTS

Patients (N=184) with nonpenetrating traumatic brain injury enrolled from acute inpatient rehabilitation programs between 4 and 16 weeks postinjury.

INTERVENTIONS

Participants were randomized to receive 200 to 400mg of amantadine hydrochloride or placebo daily for 4 weeks, and followed for an additional 2 weeks. Adverse events were recorded and categorized with respect to their nature, timing, and severity.

MAIN OUTCOME MEASURE

Number, type, and severity of medical complications occurring during the 6-week study interval.

RESULTS

A total of 468 medical complications were documented among the patients (.40 events per week per patient). More than 80% of patients experienced at least 1 medical complication, and 41 of these were defined as serious adverse events. New medical complications declined over time in rehabilitation and were not dependent on time since injury. Hypertonia, agitation/aggression, urinary tract infection, and sleep disturbance were the most commonly reported problems. Hydrocephalus, pneumonia, gastrointestinal problems, and paroxysmal sympathetic hyperactivity were the most likely to be severe.

CONCLUSIONS

Patients with DOCs have a high rate of medical complications early after injury. Many of these complications require brain injury expertise for optimal management. Active medical management appears to contribute to the reduction in new complications. An optimal system of care for DOC patients must provide expert medical management in the early weeks after injury.