Therése Ramström - Rehabilitation and outcomes after spasticity-correcting surgery in the upper limb

Link directly to the doctoral thesis

ABSTRACT

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Background: The ability to perform everyday life activities is beneficial for one’s self-identity and contributes to human well-being. Enhancement of activity performance is therefore central in all forms of rehabilitation. Spasticity is a common secondary complication after injuries to the central nervous system (CNS), which can negatively affect the ability to perform activities. There is conflicting evidence regarding the effectiveness of available spasticity treatments. Surgical treatment for spasticity has been an option for many years, but due to limitations in outcomes and the diversity of techniques, conclusions about the effectiveness cannot be drawn.

Aim: The main aim is to describe and evaluate the feasibility of a treatment algorithm for upper limb (UL) spasticity-correcting surgery with tendon lengthening and comprehensive rehabilitation and its impact on the everyday life of patients with disabling spasticity after CNS injuries. More specifically, the aims were to investigate the feasibility of the treatment algorithm, describe patients’ experiences with the treatment, describe prioritized occupational performance problems (POPPs) that patients identify before surgery, and map those problems onto the International Classification of Function, Disability, and Health (ICF). An additional aim was to translate the self-report Arm Activity Measure into Swedish (ArmA-S) and evaluate the psychometric properties of ArmA-S.

Methods: In Study I, 30 consecutive patients who underwent surgery between March 2015 and January 2017 were assessed before and 12 months after surgery. In a retrospective study (Study II), data were extracted from patients who underwent UL surgery between February 2017 and June 2019. In Study II, data from the assessments before and 6 months after surgery were used to evaluate the feasibility and outcome of the treatment algorithm allocating patients to high-, low-, or non-functioning treatment regimens (HFR, LFR, NFR). In a methodological study (Study III), the translated ArmA-S was subjected to psychometric evaluation. In a qualitative study (Study IV), interviews were conducted and analysed using a phenomenographic approach. In Study V, POPPs were identified using the Canadian Occupational Performance Measure (COPM) and mapped onto the ICF.

Results: Twelve months after surgery (Study I), significant improvements were found for UL spasticity graded according to the Modified Ashworth Scale (MAS) (average decrease: 1.4; p < 0.01) and grip strength (average increase: 4.1; p < 0.01). The regimen-specific primary outcome measures for all three groups (HFR, LFR, NFR) were significantly improved six months after surgery (Study II). In the HFR group, the average increase in the Grasp and Release Test (GRT) was 19.6 ± 19 (p < 0.001). In the LFR group, the average median (IQR) decrease for ArmA-S section B was -5 (-1 to -12.5) (p < 0.001). In the NFR group, the average median (IQR) decrease for ArmA-S section B was -12 (-10 to -14) (p < 0.02). Study III demonstrated that ArmA-S could be considered a reliable, valid, and clinically feasible measure of passive (section A) and active (section B) hand function. The interviews (Study IV) revealed the patients’ experiences with surgery in everyday life, such as bodily changes, improved occupational performance, regained control, enhanced interpersonal interactions, and psychological well-being. In Study V, 320 POPPs were translated into prioritized occupational performance goals (POPGs). The POPGs were mapped onto the ICF activity domain, most often relating to self-care (41%), domestic life (21%), and mobility (18%). Diagnosis, gender, and motor function did not influence patients’ preferences. Study V also showed significant increases in COPM scores after surgery, but these improvements were not or only weakly correlated with hand function.

Conclusions: The algorithm for spasticity-correcting surgery that customizes the postoperative treatment regimen to the individual’s degree of residual motor control was shown to be feasible and successful. Patients had improvements in various domains, such as spasticity, pain, hand function, and occupational performance, with sustained effects at long-term follow-up. ArmA-S is a suitable measure for monitoring changes in patients receiving UL spasticity-correcting surgery. Participants’ improvements experienced in everyday life include activities, body functions, and psychological and social well-being. Yet the treatment-induced significant gains in occupational performance had no clear correlation with gains in grip ability or grip strength. Independently of diagnosis, gender, and residual motor function, it seems to be important for patients to address self-care activities, but also activities relating to domestic life and mobility, in the rehabilitation after spasticity-correcting surgery

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