Shu-Fen Sun

Combined Botulinum Toxin Type A With Modified Constraint-Induced Movement Therapy for Chronic Stroke Patients With Upper Extremity Spasticity: A Randomized Controlled Study

Background and objective . Botulinum toxin type A (BtxA) injection and modified constraint-induced movement therapy (mCIMT) are both promising approaches to enhance recovery after stroke. The combined application of these 2 promising modalities has rarely been studied. The aim was to investigate whether combined BtxA and mCIMT would improve spasticity and upper extremity motor function more than BtxA plus conventional rehabilitation in chronic stroke patients with upper extremity spasticity. Methods. In a prospective, randomized controlled, observer-blinded trial with 6-month follow-up, 32 patients (≥1 year after stroke) with ability to actively extend >10° at metacarpophalangeal and interphalangeal joints and 20° at wrist of the affected upper limb were randomized to receive BtxA + mCIMT (combination group) or BtxA + conventional rehabilitation (control group) for 2 hours/day, 3 days/week for 3 months.The primary outcome assessed spasticity on the Modified Ashworth Scale. Secondary outcomes assessed real-world arm function (Motor Activity Log), laboratory motor activity (Action Research Arm Test), and patients’ global satisfaction. Results. A total of 32 stroke patients were recruited, and 29 completed the study. Spasticity significantly improved in all subjects at 4 weeks and 3 months postinjection without between-group differences.The combination group showed significantly greater improvements in elbow, wrist, and finger spasticity (P = .019, P = .019, and P < .001, respectively), affected upper extremity real-world arm function (P < .001) and laboratory motor activity (P < .001) than the control group at 6-month postinjection. Patients reported considerable satisfaction and no serious adverse events occurred. Conclusions. Combining BtxA and mCIMT is an effective and safe intervention for improving spasticity and motor function in chronic stroke patients. The results are promising enough to justify further studies. We recommend future research to address the likely need for including rehabilitation with BtxA to improve function in patients with poststroke spasticity.

The Recovery of Elbow Range of Motion After Treatment of Supracondylar and Lateral Condylar Fractures of the Distal Humerus in Children

Objectives: To investigate the time required for elbow range of motion (ROM) recovery after supracondylar and lateral condylar fractures in children and to analyze the relationship between the ROM recovery and the related factors. Design: Retrospective study. Setting: Tertiary pediatric orthopaedic care unit at a general hospital. Patients/Participants: Forty-five children with distal humerus supracondylar fractures and 16 children with lateral condylar fractures were followed. Twenty-seven children with distal forearm fractures, which were immobilized with long arm casts, were used as a control group to study elbow flexion-extension recovery after immobilization without elbow fracture. Main Outcome Measurements: Elbow ROM was measured with a goniometer in a series of follow-up visits after cast removal until 90% ROM of the uninjured side had been reached. Morreys definition was used to define ROM required for functional activity of daily living. Results: The supracondylar fracture group took 29.5, 39.0, 6.1, and 11.0 days to achieve 90% ROM in extension, flexion, supination, and pronation directions. The lateral condylar fracture group needed 30.2, 35.6, 2.3, and 8.9 days, respectively, in 4 directions. In the distal forearm fracture group, the elbow total flexion-extension angle required less than 2 weeks to reach a total arc of 135 degrees. The supination range was easier to recover than the pronation motion. The flexion recovered last among 4 directions in supra- and lateral condylar fractures. Conclusions: In the uncomplicated distal humerus supracondylar and lateral condylar fractures, it takes 5 weeks to restore original elbow ROM after removal of long arm cast without physical therapy. This information could be applied in the education material to caregivers of children with elbow injuries.

Application of Combined Botulinum Toxin Type A and Modified Constraint-Induced Movement Therapy for an Individual With Chronic Upper-Extremity Spasticity After Stroke

Background and Purpose. Constraint-induced movement therapy (CIMT) is a promising intervention for retraining upper-extremity function after a stroke. The purpose of this case report is to describe the use of a combination of botulinum toxin type A (BtxA) and a modified CIMT program for a patient with severe spasticity who was unable to use his right upper extremity. Case Description. The 52-year-old patient, who had a stroke 4 years ago, did not meet the minimum motor criteria for CIMT benefit. After receiving BtxA injections targeting the elbow, wrist, and finger flexors, he completed a 4-week program of modified CIMT followed by a 5-month home exercise program. Outcomes. The patient exhibited improvement in muscle tone (the velocity-dependent resistance to stretch that muscle exhibits) and in scores on several upper-extremity function tests (Modified Ashworth Scale, Motor Activity Log, Wolf Motor Function Test, Action Research Arm Test, and Fugl-Meyer Assessment of Motor Recovery). He also reported making much progress in the functional use of the involved upper extremity. Discussion. In a patient with severe flexor spasticity and nonuse of the dominant upper extremity after a stroke, a combined treatment of BtxA and modified CIMT may have resulted in improved upper-extremity use.

Comparison of Single Intra-Articular Injection of Novel Hyaluronan (HYA-JOINT Plus) with Synvisc-One for Knee Osteoarthritis: A Randomized, Controlled, Double-Blind Trial of Efficacy and Safety

Background: Viscosupplementation has been widely used for the treatment of knee osteoarthritis. Because we found no well-controlled trial comparing single-injection regimens of hyaluronan for knee osteoarthritis, we compared the efficacy and safety of a single intra-articular injection of a novel cross-linked hyaluronan (HYA-JOINT Plus) with a single injection of Synvisc-One in patients with knee osteoarthritis. Methods: In a prospective, randomized, controlled, double-blind trial with a 6-month follow-up, 132 patients with knee osteoarthritis (Kellgren-Lawrence grade 2 or 3) were randomized to receive 1 intra-articular injection of 3 mL of HYA-JOINT Plus (20 mg/mL) (n = 66) or 6 mL of Synvisc-One (8 mg/mL) (n = 66). The primary outcome was the change from baseline in the visual analog scale (VAS) (0 to 100 mm) pain score at 6 months. Secondary outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, Likert scale), Lequesne index, timed “Up & Go” (TUG) test, single-limb stance (SLS) test, use of rescue analgesics, and patient satisfaction. Results: A total of 121 patients were available for the intention-to-treat analysis at 6 months. Both groups had a significant improvement in the VAS, WOMAC, and Lequesne index scores at each follow-up visit (p < 0.001). Patients who received HYA-JOINT Plus experienced a significantly greater improvement in the VAS pain score at 1, 3, and 6 months compared with those treated with Synvisc-One (adjusted mean difference: −12.0, −8.5, and −6.6; p = 0.001, 0.033, and 0.045, respectively). There were no significant between-group differences in any of the secondary outcomes except the WOMAC stiffness scores at 6 months, which favored HYA-JOINT Plus treatment (p = 0.043). The TUG time did not change significantly in either group during the study (p > 0.05), but the SLS time improved significantly in both the HYA-JOINT Plus and the Synvisc-One group (p = 0.004 and p = 0.022, respectively). No significant between-group differences were observed with respect to patient satisfaction or consumption of analgesics. No serious adverse events occurred following the injections. Conclusions: A single injection of either HYA-JOINT Plus or Synvisc-One is safe and effective for 6 months in patients with knee osteoarthritis. HYA-JOINT Plus is superior to Synvisc-One in terms of reducing the VAS pain score at 1, 3, and 6 months and the WOMAC stiffness score at 6 months, with similar safety. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intraarticular Botulinum Toxin A for the Treatment of Painful Ankle Osteoarthritis-A Pilot Study

Purpose: Ankle osteoarthritis (OA) can cause substantial pain and functional limitations. Effective therapy has been a key therapeutic challenge. The aim of this pilot study is to investigate the effects of intra articular Botulinum toxin type A (BoNT-A) for the treatment of patients with painful ankle OA. Methods: This was a prospective study conducted in a university-affiliated tertiary care medical center with 6- month follow-up. Patients with painful ankle OA for at least 6 months and radio graphically verified as having stage II OA according to the Kellgren-Lawrence classification were enrolled. Eligible patients received single intraarticular injections of BoNT-A (100 units). The primary outcome was the Ankle Osteoarthritis Scale (AOS) score at 6-month follow-up. Secondary outcomes measures included American Orthopaedic Foot and Ankle Society (AOFAS) ankle/ hindfoot score, Visual analog scale (VAS) for ankle pain, single leg stance test (SLS), Timed “Up-and-Go” test (TUG) and consumption of rescue analgesics. Patients were evaluated at baseline, 2 weeks, 1 month, 3 months, and 6 months post injection. Patients’ global satisfaction about therapy was assessed at 2 weeks, 1 month, 3 months, and 6 months post injection. Adverse events during the study period were recorded also. Results: Thirty-six patients completed the study. All patients showed significant improvements in AOS, AOFAS, VAS, SLS, TUG scores and consumption of rescue analgesics at 2 weeks, 1, 3 and 6 months respectively after the injection (p < 0.001 for each value compared with baseline). Patients’ global satisfaction rate was high with no serious adverse events. Conclusion: BoNT-A injection to the ankle joint is associated with improvement in pain, function and balance in patients with painful ankle OA. These effects can last for 6 months. This pilot study supports a possible role for BoNT-A as a treatment option for painful ankle OA. Future studies are needed to confirm the results.

Unilateral Knee Pain as Clinical Presentation of Spinal Dural Arteriovenous Fistula: A Case Report

Spinal dural arteriovenous fistula (SDAVF) is a rare disease. The principal clinical manifestation of SDAVF is myelopathy, with variable but nonspecific symptoms including progressive weakness of the lower extremities, back pain, bowel and bladder dysfunction, and impotence. Diagnosis is often delayed. Knee pain as the chief complaint of SDAVF is rare. The present case report describes a 49-year-old man with a history of SDAVF, for which he had twice received endovascular embolization, who presented with profound pain in the right knee when attending the study rehabilitation clinic. He had no history of trauma. Physical examination revealed upper motor neuron signs in bilateral lower extremities. Imaging studies of the right knee, including X-ray and sonography, revealed no structural lesion to which his clinical presentation could be attributed. Nerve conduction velocity and electromyography examination showed no evidence of radiculopathy or peripheral neuropathy. Digital subtraction angiography (DSA) identified recurrent SDAVF. It was, thus, believed that the patients profound right knee pain was the presentation of persistent myelopathy caused by recurrent SDAVF. Early diagnosis and treatment of SDAVF can improve patients prognosis. Treatment options include endovascular embolization and open spinal surgery. When treating patients with SDAVF, physicians should keep in mind that although two-thirds of these patients can experience motor recovery, only one-third show improvements in sensory disturbances, and pain might persist. (Tw J Phys Med Rehabil 2012; 40(2): 85 - 90)

Hyaluronate for the Treatment of Ankle Osteoarthritis

Ankle osteoarthritis (OA) is a degenerative joint disease that can cause substantial pain, muscle weakness and functional limitations. Due chiefly to its post-traumatic origin and appearance in young patients, ankle OA has a high impact on socioeconomics and patients’ quality of life. Approximately 6% to 13% of all cases of OA involve the ankle joint (Thomas and Daniels, 2003). Recent research also identify that a larger number of patients are being diagnosed with ankle OA (Saltzman et al, 2005). Currently, no curative therapy is available for OA, and thus the overall goals of management are to reduce pain and prevent disability. Treatment options include simple analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), weight reduction, physical and occupational therapy, activity modification, orthotic devices, shoe modifications, intraarticular corticosteroid injections, and surgery. Although some cases can be treated successfully with surgery, many patients are either not good candidates for surgery or may want to avoid or delay it if possible. There is a need for a treatment that reduces chronic joint pain and improves function yet avoids toxic effects of medications and the morbidity and mortality risks of surgery. One such option for these patients may be the intraarticular injection of hyaluronate. Hyaluronate, a high molecular weight polysaccharide, is a principal component of synovial fluid and extracellular matrix of articular cartilage. It contributes to the elasticity and viscosity of synovial fluid. In addition to providing joint lubrication and shock absorbancy, hyaluronate helps to maintain the structural and functional characteristics of the cartilage matrix. It also inhibits the formation and release of prostaglandins, induces proteoglycan aggregation and synthesis, and modulates the inflammatory response (Frizziero, 1998). In OA, the concentration and molecular weight of hyaluronate are reduced, limiting its role in maintaining normal joint biomechanics (Engstrom-Laurent A, 1997). Viscosupplementation with intraarticular injections of hyaluronate was approved by the Food and Drug Administration (FDA) in 1997 for treating pain associated with knee OA. Although the exact mechanism of action is not understood with certainty, recent research suggests that it exerts anti-inflammatory, analgesic, anabolic and possibly chondroprotective effects on the articular cartilage and joint synovium that reduce pain and disability and improve joint function.

Matrix Metalloproteinase-3 Expression and Structural Changes in Biomechanical Loaded Articular Cartilage

Background: Cartilage functions as a highly successful load-bearing tissue. However, frequent mechanical loading can affect cartilage metabolism and viability significantly. Intrinsic changes in the metabolism of chondrocytes have also been proposed as an important feature of osteoarthritis. Although many aspects of chondrocyte catabolism have been extensively investigated, the signals that initiate such metabolic changes, and their correlation with structural changes, remain unclear. We hypothesized that matrix metaproteinase-3 (MMP-3) may play a significant role. The purpose of this study was to investigate the activity of MMP-3 in cartilage under load, as well as degeneration-related structural changes of the cartilage matrix under load. Method: Tissue blocks of porcine cartilages were prepared for tissue culture, and biomechanical forces were applied with a FlexerCell system. Compressive stress of 20 MPa at 0.3 Hz was induced in the experimental cartilage for 240 minutes. The expression and activity of MMP-3 in the experimental cartilage were measured before and at the time points of 4 hours, 24 hours, and 48 hours after start loading. Cartilage samples without loading were used as a control. Structural and ultrastructural changes in the cartilage were investigated under Normarski light microscopy and scanning electron microscopy. Results: Our results indicated that MMP-3 activity in the loaded cartilages was significantly higher than in the control group. Structural and ultrastructural investigations found evident degradation of the cartilage matrix in loaded cartilages. This study provides information regarding the changes in MMP-3 activity in the loaded cartilages, and the changes in cartilage matrix under load. Conclusion: This study demonstrated that, under biomechanical force, the matrix of articular cartilage was degraded, with a higher expression of MMP-3.