Multidisciplinary Neuro-rehabilitation and precisely targeted botulinum toxin restores hand function following a severe brain injury

julian harrissDr Julian Harriss is Medical Director of Queen Elizabeth’s Foundation for Disabled People, Clinical Lead in Rehabilitation Medicine at the Lane Fox Clinic, St Thomas Hospital London, and Honorary Senior Lecturer at KCL.

He has over twenty years experience of multidisciplinary spasticity management, and he offers an impressive track record of establishing spasticity services -internationally, within the NHS, and most recently within the charitable sector. As a Canadian-trained Consultant in Physical Medicine and Rehabilitation he brings a goal-focused and outcome driven perspective to the UK. Dr Harriss emphasises objective assessments, and he insists on the routine use of ultrasound or EMG/electrical stimulus-guidance; he attributes this attention to detail to his patients’ often life-changing recovery of function.

E: jharriss@doctors.org.uk

Amy Dennis-Jones (PT),

Nicolette Hugo (OT)

We use our hands to engage with the world,relying on a variety of discrete grasps to perform countless essential daily tasks. At the Queen Elizabeth’s Foundation (QEF) our emphasis is on restoring abilities through a multi-disciplinary approach including medical treatments and rehabilitation.At the Centre we have established a treatment protocol for spasticity in the upper limbs which seeks to restore hand function, without risking loss of strength in unaffected muscles.

Mr RC’s history illustrates the importance of precisely targeted botulinum toxin treatments, combined with specialist multidisciplinary, goal-directed therapies. He was 19 yrs old, looking forward to a career as a Police Constable, when as the passenger in a police car he suffered a severe brain injury: he sustained a left frontal lobe haematoma and diffuse axonal injury. His injuries were life-threatening, and he spent several months on acute medical and surgical wards before being admitted for rehabilitation.

When he was admitted to QEF in October of 2013 he had limited functional hand movements and RC was left entirely dependent on his carers for all of his needs.

Botulinum toxin injections were administered approximately quarterly through 2013 and 2014 using Clavis EMG/stimulus guidance in an attempt to allow the shoulders, elbows and wrists to be brought back to a more functional resting position. Great care was taken not to treat the finger and thumb flexors: the goal was to enable restoration of active hand function.

On admission, physically, RC presented with:

  • Increased tone in both upper limbs, specifically within his pectoral muscles, biceps and wrist and finger flexors
  • Loss of range of movement
  • Decreased  grasp and  fine motor movements in both upper limbs, including: span, cylindrical, key, ball, pincer and tripod grips. He however had some lateral grip in his right upper limb
  • Decreased  active and controlled upper limb  movement and dexterity
  • Impaired sensation (Light touch and proprioception were reduced throughout)
  • Left side affected more than right side

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julian h ashworth boxMr RC had difficulty participating in standardised formal UL testing. Within the Rivermead motor assessment for the upper limb component he initially scored 2/15 on the left and 3/15 on the right.

Functionally, Mr RC tried, with little success, to engage his right upper limb within everyday tasks of living (e.g. in washing and dressing his upper part of his body and feeding himself). In feeding he had difficulty loading food onto his spoon and taking this to his mouth and was also unable to use a knife and fork to feed himself.

RC was wheelchair dependent however his upper limbs impeded his ability to use a powered wheelchair independently.

Management:

Mr RC participated within a full inter-disciplinary team rehabilitation programme including Physiotherapy,Occupational Therapy, Speech and Language Therapy, Psychology, Education and Vocational.

Mr RC’s care also included an IDT spasticity management programme. His oral anti-spasticity medications were reviewed before he came to QEF whereby oral Baclofen was reduced to relieve truncal weakness. Focal spasticity was treated with several Botulinum toxin injections, always using EMG/stimulus to precisely target flexor muscles within his upper limbs, administered approximately quarterly through 2013 and 2014 using Clavis EMG/stimulus guidance to precisely target flexor muscles within his upper limbs.

Great care was taken not to treat the finger and thumb flexors: the goal was to enable restoration of active hand function.

Goals of Botulinum Injections

  • Increase passive and active range of movement at wrist and hands
  • Reduced flexor tone at wrists and hands
  • Increase functional ability and use upper limbs/hands for reach/grasp.
  • Facilitate the  implementation of an effective splinting regime

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Following initial botulinum toxin injections at QEF two-joint splints and bilateral soft/scotch splints were fabricated. These helped to control elbow extension and supported the hand and wrist in a more neutral position.These were worn every day for several hours for a period of 8 weeks. Splints were removed during active upper limb rehabilitation.

Botulinum injections were then repeated with the following target muscles below.

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Following this, bi-lateral soft/scotch wrist and finger extension resting splints were fabricated to specifically target his hand and wrists only as his elbow range of movement had improved dramatically.

Maximising benefits using specialist technology and interventions

During active upper limb rehabilitation, specialist equipment and techniques were used to maximise functional gains.These included FES, SAEBO MAS, SAEBO glide programme, and task-specific practice.

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FES was used to reinforce wrist extension. Thereafter wrist extension was reinforced through practice and functional grasp work.

 

 

SaeboMAS:

The SaeboMAS is a weight support upper limb exerciser, which takes the weight of Mr RC’s upper limbs allowing him to move his arms freely in a gravity eliminated plane. This afforded the team an opportunity to work on RC’s postural control in sitting whilst allowing his upper limbs to dissociate and move away from his trunk. The functional task of feeding was used in conjunction with the SAEBO MAS to allow Mr RC to improve the movements involved in feeding, along with increasing his endurance.The activity was graded by adjusting the gravity and task requirements.julian h saebomas

Reductions to impairment:

With a combination of botulinum toxin, splinting regime and upper limb rehabilitation, the tone and range of movement in Mr RC’s upper-limb improved dramatically.

With much-improved range of movement and normalisation of tone, he can now perform active functional movement in his upper limbs.

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Functional improvements:

Mr RC is now actively able to use his upper limbs for meaningful tasks:

  • Due to the improvements within the range and power of his upper limbs in combination with the increase in   postural control, Mr RC can transfer instead of being hoisted
  • Mr   RC    can   independently operate his iPad and iPhone and touch screen devices.
  • Mr RC can now use a joystick to mobilise his powered wheelchair.
  • Mr RC can now brush his hair, dress his upper limbs and brush his teeth.
  • He is now able to feed  himself using a fork or a spoon, as well as cut some food (e.g half an apple) using a knife and a fork.

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The Future

Mr RCs will continue to receive botulinum toxin treatments, always under EMG/stimulus guidance, along with ongoing therapies. His hand function has steadily improved over the past year, and he has regained even more independence since leaving QEF. He lives at home, with his family rather than in a care home, which might have been his only option had we not helped him to improve his upper limb function. He will continue to benefit from ongoing botulinum toxin treatments, always under EMG/stimulus guidance, along with ongoing therapies to further improve his upper limb functioning.