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A-1160 Surgical Treatment Algorithms in Spasticity
Jan Fridén, Nottwil, Switzerland
Friday, June 15, 2018 · 9:44 a.m. · 14m 53s
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thank you very much uh so i would like to address it more of a traditional surgical approach to uh
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uh removing or a limb rating problems from specificity and
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as you all known specificity comes in very many flavours it
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can range from isolate each superficial finger flex or two
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manifest a contractor's muscle contractors in the whole upper
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extremity i think however eh it is a
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interesting and a necessary to a divide this
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into different that parts because the primary
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heart like space t. c. d. that you can reduce very easily in the beginning
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can develop into muscle contractors muscle contractor itself is
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yeah hi passive tension within the muscle as a result of
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loss of star come years in length that means that
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uh the uh the part of the couldn't uh exist helen
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matrix around them also need to adapt by shortening
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and yeah after some time this is not anymore a possible to address
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uh other than surgical ways and yes and and stage you end
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up with a joint deformity that is a much bigger problem
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so if you look at a cross section of
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a normal muscle that put under stress
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increased tension to the right it response with that lengthening
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of the muscle that's sort of the classical
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yeah uh immobile i stationed at the lengths of session uh experiments that were
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done in seventies to the left is a typical c. p. muscle
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that with the buttons of a extra seller
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matrix connective tissue and very few
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a muscle fibres that can respond to be generation
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class we know that the satellite pool
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in this past the muscles is reduce still
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their capacity fellini regeneration it's extremely limited
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this shows the composition all the different call it gets in c.
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p. muscles compared to normal muscles from the labour that
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and it was previously stated that the different ice of forms of of ecology
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it's responding differently so that would be morris yeah
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expression nor cross sectional et cetera but you see
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it's basically the same composition relative composition in
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its plastic muscles and in a normal bus so it's not that it is the
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three fold increase all the extra seven matrix that really is is a major restriction here
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and just to look into this uh interesting well the all of a a
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of electron microscopy come full c. c. two different muscle fibres here and
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between the and you have this matrix basis is is so cold
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college and cables that are going in different directions and eunice plastic muscle is
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truly going you know what kind of directions so that is just
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sort of the background what what we're dealing with when we're doing started but
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really not that we are addressing needs to correct the imbalance if possible
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if we have muscle contraction or the and we may have another goal
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but nevertheless we need to establish some sort of balance or comfort for the patients
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i saw the ultimate goal of of of course to have a
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good functionality but that's depending on the remaining functions of course
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we need also to to consider this a a static page uh
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impression of the hand and are not seldom the patient a
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a judge this is a very disturbing social factor so as we
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hard we can do that happen on rotation wreck to me
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we can also do a really easy some awesome can do lengthening of the muscle
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and we can even do teen o. d. c.s and even transfers
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in this most so i just want to walk
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through the experience based a safe procedures
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uh when we're doing this and when we come to the shoulder we have basically you have to address
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the picture all is that the serbs couple hours most
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both our very whether reachable for surgical lengthening
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the stair step lengthening which allow us to come out with the shoulder
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and then allow us frequently to strengthen the antagonist that's the rotate or got muscles
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which can be very successfully strengthened with electrical stimulation as we are about
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yeah earlier and that gives not only
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the better position it case in a better ability for the patient to reach of mao
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and by strength thing in the muscles the muscle bottle this building up
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and that is self visit and mechanical prevention of subjects
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station of the shoulder in a callable direction
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so we should neck not neglect this a possibility just pipe
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simple uh uh the tendon lengthening procedures that allows the shoulder we were free
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for the elmo we have already hard about the the
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biceps and the brecht yeah alice and lengthening procedures
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uh with or without combination of nor a surgery but i
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would like to just mention to hand surgeons that
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the brecht yeah this is a very solid muscle it has
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two heads it has a very small superficial had
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but with a very strong tendency you'd need to identify the brecht yeah
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less superficial hand on which is as low rocks only laughter really
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uh located tendered so if you miss that use sort of miss out the effect you want a cheap
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also you you have in jar muscular tendon and bundles
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that are stretching way up uh on the distant part of the humans
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for the rest lengthening procedures for f. c. r. f. c. u.
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this about twenty millimetres and that usually
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allows the race to be
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um i moved into extension unless we
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have an establishment subcontractor probably them
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with a a deformity in a hundred and thirty degrees objections what we see sometime
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been more extensive starter is uh is needed like proximal rocker back to me
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we also have upstart multiple times the subjects
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station all the easy way into
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a more dollar position at the wrist that means if it's functioning the it is uh
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acting as a flex or every time the patients try to extend the rest
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which is sort of contradiction it's up so just by moving that into a mechanically more favour
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position you can achieve your effect yeah with
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the functional wrist expenses after releasing flexes
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so the prone make sure the primitive paris is a trigger
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a force plus the city and if you don't want to do anything else
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uh approach make to release these highly recommended but it's twenty mean a
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it's a a surgery it's easy down you definitely realise the trigger
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in my experience has a cost a lot of benefits to the patient
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and sometimes that is sort of open up and then tyre or
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so that is definitely worth while you have to remember that in the thirty
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percent of the patients they have uh you moral had all the connector
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that is it's have very a very tiny muscle but with also select ten
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so you need to identify if there is is such an extra tandem after releasing then you have to just detection
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uh yes it's past each fingers while simple lengthening at the
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uh the level of the rest works extremely well it's also in
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the same ballpark all around twenty millimetres we need however
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to make sure that the balance of the fingers is secured
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and the cascade is is uh in in balance
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because if you do it without that control the and you
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can end up with an on balance a finger position
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for the fingers also the other being realise the tapping up opposite of soap soap soaps
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ah it was cool meeting right there
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so uh detecting that other patch all the opponent losses at the proximal
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phalanx level is very efficient to realise that tight intrinsic situation
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uh for this plastic from have yeah lengthening there you have to consider
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maybe not as much as the other fingers because if you realise
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the f. f. the flex our side if you release a and f. c. or
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allowing the patient to reach into more of an extended position of the race
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that also will allow the farm to work against the index finger in a better
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way so that there you should consider to be a little more conservative
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when it comes to the abductor we also talked about that briefly
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that is also very successful procedure and very often a course
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of a non functional hands so that is together
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with whining all the force quit space a very efficient way of
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of doing this kind of a treatment uh according to this
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allegory so the length thing stash that simple procedure this is the effect
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of an isolated lengthening of the uh uh it's wrist flex or
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and with monitoring the range of
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specificity motion of the rest
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who really op and one year after the simple f. c. or lengthening and it's not
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only the attitude that is very minimal of course with this past the reflector
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it's also the the the ability for the patient to do the range of motion
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in a synchronous way like control way just with a simple only on matters that was mentioned
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so just like correcting the position of the strippers or uh specifically all the superficial
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finger flex or we can reach quite a lot in and sever action
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we have mentioned are the grenade release and the necessity
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or addressing also potential extra ten down there
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this is a is a patient with wrist flexion spots the city and
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i pray to realise together will lengthening of respects or can't really make big changes
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for the family i just want to recommend the widening of the
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first web space be extremely generous doing these types are
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very because it's as a lot of functionality with the long
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longer far reaching more opening a web space much more
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and after all this arteries don then we need to do rehab and in order to do really have
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we need to include in my opinion the electrical stimulation
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has to do with because we can really
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i identify the key muscles we need to see for example need to be able to separate
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the finger expenses and the rest extends shape because they horse have sort of
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opposite effect anyway if we allow the patient to stretch erased again
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and we are in voluntarily strengthening in the finger expenses that it's not going
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to be a very functional huh because that's going to end up in
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crow handy when the patient is extending the wrist with a finger extensive so
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therefore we haven't mapped the motor point to identify the coordinates for all
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that extends ours in the uh form and it is quite
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hey it's extremely a consistent i would say and and very well stimulated and you can separate the
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different motors web so reaching a balance by active
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training and with electrical stimulation and a
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and then yeah possibly you can use it also we e. m. g. triggered a um
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uh electrical stimulation is of the patient lose to reach a
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little bit of voluntary control and then get a push
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uh by the electrical stimulation that way coming over that a threshold
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A-1160 Surgical Treatment Algorithms in Spasticity
Jan Fridén, Nottwil, Switzerland
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158 views
