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Quantitative techniques for assessment of upper extremity movement dysfunction Measurement of muscle stiffness in wrist and finger flexors Eva Pontén MD PhD Specialist in Hand Surgery and Orthopaedic Surgery Dept. of Pediatric Orthopaedic Surgery Karolinska University Hospital Stockholm, Sweden

Disclosure Information AACPDM 70th Annual Meeting | September 20-24, 2016

Speaker Name: Eva Pontén

Disclosure of Relevant Financial Relationships I have the following financial relationships to disclose: Grant/Research support from: (List company(s) here): Allergan

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The brain damage in CP is not progressive, but symptoms change §  No contractures when the child is born §  Different growth rate of bone and muscle, and early signs of

contracture (Herskind et al 2015, Gough and Shortland 2012) §  Increased whole muscle passive stiffness in the calf has been

described as early as three years of age (Willerslev-Olsen et al 2013)

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Contracture formation in CP is progressive and results in altered/deteriorated §  range of motion §  movement direction as the joint axis changes §  precision §  forces across the joint and bone growth zones

à bone and joint deformation


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Hägglund, Wagner 2011 pROM of ankle in 355 children with CP (CPUP)

§  Progressive contracture formation also with no increased tone (Ashworth 0)


Ashworth

de Bruin et al 2014

§  More collagen in the extracellular matrix surrounding larger muscle fiber bundles

§  Potential for increased stiffness of the muscle


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Forearm flexor muscles in children with cerebral palsy are weak, thin and stiff Ferdinand von Walden1, Kian Jalaleddini2, Björn Evertsson 3,4, Johanna Friberg 1,4, Francisco J. Valero-Cuevas 2,6, Eva Pontén1


p < 0.01

CP (n=9) 6 boys/3 girls scheduled for upper limb surgery TD (n=15) 10 boys/5 girls

Grip strength (10s isometric contraction)

significantly lower in CP

Grippit®

von Walden F, Jalaleddini K, Evertsson B, Friberg J, Valero-Cuevas FJ, Pontén E 2017


Black line= Measured forces Red line= Predicted forces

Ramp-and-hold perturbation of 50◦ with a low velocity (5◦/s) The hand is moving from 0 to 10 s Data was recorded for another 2 s (time 10–12 s)

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Muscle passive stiffness was increased 2-fold in CP CP 4.65 ± 3.42 vs. TD 1.96 ± 0.62, p<0.05

Viscosity didn’t differ significantly


Cross-sectional area of flexor carpi radialis (FCR) in cm2 in TD and CP. p < 0.05.

TD CP FCR encircled in ultrasound images

Did not correlate to passive stiffness or viscosity in CP or in TD children

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Muscle size correlated to age (R2=0.58, p<0.01) in TD children/adolescents

but not in CP


Muscle size correlated to body weight (R2=0.92, p<0.0001) in TD but not in CP

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Muscle size correlated to strength (R2=0.58, p<0.01) in TD and in CP

(R2=0.60, p<0.05)

Conclusion

§  Wrist flexor muscles in CP are twice as stiff as in TD children/adolescents even though the muscles have a smaller cross-sectional area

§  Grip strength is both in CP and TD related to muscle cross-sectional area of the wrist stabilizing flexor carpi radialis muscle

§  The FCR cross-sectional area in CP is not correlated to body weight or age à suggesting that the diminished growth is related to the extent of the

brain damage


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Future perspectives

§  Stiffness in even a few muscles can add obstacles to smooth and efficient movements (Valero-Cuevas et al 2015)

§  Stiffness measurements could help in planning tendon transfer surgery or tendon lengthening surgery

§  Stiffness measurement devices, with slow perturbation not eliciting spasticity, should be developed for more joints

§  Ultrasound measurements of echogenicity and stiffness should be developed for surgical planning

§  The long term relationship between intramuscular tendon release (open or percutaneous) and stiffness + strength should be evaluated and compared with control.


augusti 13, 2017 Namn Efternamn 16

References: von Walden F, Jalaleddini K, Evertsson B, Friberg J, Valero-Cuevas FJ, Pontén E. Forearm Flexor Muscles in Children with Cerebral Palsy Are Weak, Thin and Stiff. Front Comput Neurosci. 2017;11:30. Hägglund, G., and Wagner, P. (2011). Spasticity of the gastrosoleus muscle is related to the development of reduced passive dorsiflexion of the ankle in children with cerebral palsy: a registry analysis of 2,796 examinations in 355 children. Acta Orthop 82(6), 744-748 Barrett, R.S., and Lichtwark, G.A. (2010). Gross muscle morphology and structure in spastic cerebral palsy: a systematic review. Dev Med Child Neurol 52(9), 794-804 Gough, M., and Shortland, A.P. (2012). Could muscle deformity in children with spastic cerebral palsy be related to an impairment of muscle growth and altered adaptation? Dev Med Child Neurol 54(6), 495-499 Herskind, A., Ritterband-Rosenbaum, A., Willerslev-Olsen, M., Lorentzen, J., Hanson, L., Lichtwark, G., et al. (2015). Muscle growth is reduced in 15-month-old children with cerebral palsy. Dev Med Child Neurol Pontén, E., Gantelius, S., and Lieber, R.L. (2007). Intraoperative muscle measurements reveal a relationship between contracture formation and muscle remodeling. Muscle Nerve 36(1), 47-54 Ross, S.A., Foreman, M., and Engsberg, J.R. (2011). Comparison of 3 different methods to analyze ankle plantarflexor stiffness in children with spastic diplegia cerebral palsy. Arch Phys Med Rehabil 92(12), 2034-2040 de Gooijer-van de Groep, K.L., de Vlugt, E., de Groot, J.H., van der Heijden-Maessen, H.C., Wielheesen, D.H., van Wijlen-Hempel, R.M., et al. (2013). Differentiation between non-neural and neural contributors to ankle joint stiffness in cerebral palsy. J Neuroeng Rehabil 10, 81 Geertsen, S.S., Kirk, H., Lorentzen, J., Jorsal, M., Johansson, C.B., and Nielsen, J.B. (2015). Impaired gait function in adults with cerebral palsy is associated with reduced rapid force generation and increased passive stiffness. Clin Neurophysiol 126(12), 2320-2329 Willerslev-Olsen, M., Lorentzen, J., Sinkjaer, T., and Nielsen, J.B. (2013). Passive muscle properties are altered in children with cerebral palsy before the age of 3 years and are difficult to distinguish clinically from spasticity. Dev Med Child Neurol 55(7), 617-623 de Bruin, M., Smeulders, M.J., Kreulen, M., Huijing, P.A., and Jaspers, R.T. (2014). Intramuscular connective tissue differences in spastic and control muscle: a mechanical and histological study. PLoS One 9(6) Jalaleddini, S.K., Sobhani Tehrani, E., and Kearney, R. (2016). A Subspace Approach to the Structural Decomposition and Identification of Ankle Joint Dynamic Stiffness. IEEE Trans Biomed Eng. Keenan, K.G., Santos, V.J., Venkadesan, M., and Valero-Cuevas, F.J. (2009). Maximal voluntary fingertip force production is not limited by movement speed in combined motion and force tasks. J Neurosci 29(27), 8784-8789 Kutch, J.J., and Valero-Cuevas, F.J. (2011). Muscle redundancy does not imply robustness to muscle dysfunction. J Biomech 44(7), 1264-1270 Valero-Cuevas, F.J., Cohn, B.A., Yngvason, H.F., and Lawrence, E.L. (2015). Exploring the high-dimensional structure of muscle redundancy via subject-specific and generic musculoskeletal models. J Biomech 48(11), 2887-2896