In the last decade there has been incredible interest and advancement in the surgical care of adult patients with upper motor neuron (UMN) injuries. Spasticity represents a prevalent and debilitating feature of UMN syndrome, which can result from cerebral palsy, spinal cord injury, cerebrovascular accident and traumatic or anoxic brain injury. While several diagnostic tools and management strategies have been described for upper limb spasticity, evidence-based practice guidelines do not currently exist due to low patient volume and a paucity of surgeons routinely performing surgeries in UMN syndrome patients. As such, expert consensus may help provide guidance for patients, therapists and clinicians alike. In this article an expert panel was assembled, and the Delphi method was utilized to present diagnostic considerations, define operative indications, discuss surgical treatment modalities and encourage a standard set of outcome measures for patients with upper extremity spasticity.
AlewijnseJVKreulenMvan LoonJSmeuldersMJC.Extensor pollicis longus rerouting for thumb-in-palm deformity in cerebral palsy: a biomechanical analysis. J Hand Surg Eur. 2019,
44: 785–9.
2.
AshfordSSladeMTurner-StokesL.Conceptualisation and development of the arm activity measure (ArmA) for assessment of activity in the hemiparetic arm. Disabil Rehabil. 2013,
35: 1513–8.
3.
AshworthB.Preliminary trial of Carisoprodol in multiple sclerosis. Practitioner. 1964,
192: 540–2.
4.
CheemaTAFiroozbakhshKDe CarvalhoAFMercerD.Biomechanic comparison of 3 tendon transfers for supination of the forearm. J Hand Surg Am. 2006,
31: 1640–4.
5.
DavidsJRPeaceLCWagnerLVGidewallMABlackhurstDWRobersonWM.Validation of the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) for children with hemiplegic cerebral palsy. J Bone Jt Surg Am. 2006,
88: 326–33.
6.
FahrenkopfMPRheePC.Management of a thumb-in-palm deformity in adult patients with upper motor neuron syndrome. J Hand Surg Am. 2023,
48: 91.e1–e11.
7.
GharbaouiIKaniaKColeP.Spastic paralysis of the elbow and forearm. Semin Plast Surg. 2016,
30: 39–44.
8.
GongHSChoHEChungCYParkMSLeeHJBaekGH.Early results of anterior elbow release with and without biceps lengthening in patients with cerebral palsy. J Hand Surg Am. 2014,
39: 902–9.
9.
GuoXWallaceRTanYOetomoDKlaicMCrocherV.Technology-assisted assessment of spasticity: a systematic review. J Neuroeng Rehabil. 2022,
19: 138.
10.
HankinsSMBezwadaHPKozinSH.Corrective osteotomies of the radius and ulna for supination contracture of the pediatric and adolescent forearm secondary to neurologic injury. J Hand Surg Am. 2006,
31: 118–24.
11.
HaughABPandyanADJohnsonGR.A systematic review of the Tardieu Scale for the measurement of spasticity. Disabil Rehabil. 2006,
28: 899–907.
12.
HofferMMLehmanMMitaniM.Long-term follow-up on tendon transfers to the extensors of the wrist and fingers in patients with cerebral palsy. J Hand Surg Am. 1986,
11: 836–40.
13.
HouseJHGwathmeyFWFidlerMO.A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Jt Surg Am. 1981,
63: 216–25.
14.
KeenanMAKorchekJIBotteMJSmithCWGarlandDE.Results of transfer of the flexor digitorum superficialis tendons to the flexor digitorum profundus tendons in adults with acquired spasticity of the hand. J Bone Jt Surg Am. 1987,
69: 1127–32.
15.
KerstenPKüçükdeveciAATennantA.The use of the visual analogue scale (VAS) in rehabilitation outcomes. J Rehabil Med. 2012,
44: 609–10.
16.
KozinSHKeenanMA.Using dynamic electromyography to guide surgical treatment of the spastic upper extremity in the brain-injured patient. Clin Orthop Relat Res. 1993,
288: 109–17.
17.
KritiotisCTryfonidisMMishraARajaH.Upper limb spasticity surgery in adults: what we learned in 5 years of practicing it. J Musc Surg Res. 2019,
3: 75.
18.
Krumlinde‐SundholmLEliassonA.Development of the assisting hand assessment: a Rasch‐built measure intended for children with unilateral upper limb impairments. Scand J Occup Therapy. 2003,
10: 16–26.
19.
LawMBaptisteSMcCollMOpzoomerAPolatajkoHPollockN.The Canadian occupational performance measure: an outcome measure for occupational therapy. Can J Occup Ther. 1990,
57: 82–7.
20.
LeclercqCPerruisseau-CarrierAGrasMPancieraPFulchignoniCFulchignoniM.Hyperselective neurectomy for the treatment of upper limb spasticity in adults and children: a prospective study. J Hand Surg Eur. 2021,
46: 708–16.
21.
LittlerJW.Restoration of the oblique retinacular ligament for correcting hyperxtension deformity of the proximal interphalangeal joints. In: TubianaR (ed). La main rheumatoide expansion scientifique Francaise,
Paris, 1969, 39–42
22.
MalizosKNLiantsisAKVaritimidisSEDailianaZHRigopoulosNS.Functional gains after surgical procedures in spastic upper extremity: a comparative study between children and adults. J Pediatr Orthop B. 2010,
19: 446–53
23.
MatevI.Surgery of the spastic thumb-in-palm deformity. J Hand Surg Br. 1991,
16: 127–32.
24.
Meseguer-HenarejosABSánchez-MecaJLópez-PinaJACarles-HernándezR.Inter- and intra-rater reliability of the modified Ashworth Scale: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2018,
54: 576–90.
25.
NamdariSHorneffJGBaldwinKKeenanMA.Muscle releases to improve passive motion and relieve pain in patients with spastic hemiplegia and elbow flexion contractures. J Shoulder Elbow Surg. 2012,
21: 1357–62.
26.
NeuhausVKadzielskiJJMudgalCS.The role of arthrodesis of the wrist in spastic disorders. J Hand Surg Eur. 2015,
40: 512–7.
27.
OkoliCPawlowskiSD.The Delphi method as a research tool: an example, design considerations and applications. Inf Mgmt. 2004,
42: 15–29.
28.
PanXZhaoGYangX, et al.
Contralateral C7 nerve transfer via the prespinal route in treatment of spastic paralysis of upper limb after cerebral palsy. Br J Neurosurg. 2020, 1–5.
29.
PappasNBaldwinKKeenanMA.Efficacy of median nerve recurrent branch neurectomy as an adjunct to ulnar motor nerve neurectomy and wrist arthrodesis at the time of superficialis to profundus transfer in prevention of intrinsic spastic thumb-in-palm deformity. J Hand Surg Am. 2010,
35: 1310–6.
30.
PatelRRheePC.Assessment of 30-day adverse events in single-event, multilevel upper extremity surgery in adult patients with upper motor neuron syndrome. Hand. 2022,
17: 933–40.
31.
PatelRRheePC.Team approach: multidisciplinary perioperative care in upper-extremity reconstruction for adults with spasticity and contractures. JBJS Rev. 2020,
8: e0164.
32.
PhotopoulosCDNamdariSBaldwinKDKeenanMA.Decision-making in the treatment of the spastic shoulder and elbow: tendon release versus tendon lengthening. JBJS Rev. 2014,
2: 01874474-201410000-00004.
33.
PowerD.Commentary. The role of arthrodesis of the wrist in spastic disorders: (V. Neuhaus, J. J. Kadzielski, C. S. Mudgal. J Hand Surg Eur. 2015, 512–7). J Hand Surg Eur. 2015,
40: 518–9.
34.
ReevesMLisabethLWilliamsL, et al.
Patient-reported outcome measures (PROMs) for acute stroke: rationale, methods and future directions. Stroke. 2018,
49: 1549–56.
35.
RekandT.Clinical assessment and management of spasticity: a review. Acta Neurol Scand Suppl. 2010,
190: 62–6.
36.
RheePC.Surgical management of the spastic forearm, wrist, and hand: evidence-based treatment recommendations: a critical analysis review. JBJS Rev. 2019a,
7: e5.
37.
RheePC.Surgical management of upper extremity deformities in patients with upper motor neuron syndrome. J Hand Surg Am. 2019b,
44: 223–5.
38.
SpinnerRJShinAYBishopAT.Rewiring to regain function in patients with spastic hemiplegia. N Engl J Med. 2018,
378: 83–4.
39.
StreckerWBEmanuelJPDaileyLManskePR.Comparison of pronator tenotomy and pronator rerouting in children with spastic cerebral palsy. J Hand Surg Am. 1988,
13: 540–3.
40.
Thevenin-LemoineCDenormandiePSchnitzlerALautridouCAllieuYGenêtF.Flexor origin slide for contracture of spastic finger flexor muscles: a retrospective study. J Bone Jt Surg Am. 2013,
95: 446–53.
41.
Van HeestAEBagleyAMolitorFJamesMA.Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Jt Surg Am. 2015,
97: 529–36.
42.
Van HeestAHansonDLeeJWentdorfFHouseJ.Split flexor pollicus longus tendon transfer for stabilization of the thumb interphalangeal joint: a cadaveric and clinical study. J Hand Surg Am. 1999,
24: 1303–10.
43.
Van HeestAE.Surgical technique for thumb-in-palm deformity in cerebral palsy. J Hand Surg Am. 2011,
36: 1526–31.
44.
ZhengMXHuaXYFengJT, et al.
Trial of contralateral seventh cervical nerve transfer for spastic arm paralysis. N Engl J Med. 2018,
378: 22–34.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
