Improving Holding Function of the Hemiplegic Hand
Condition: Stroke
Study type: Observational

Summary: 
      Relevant to patients with spastic hemiparesis in the hand and upper limb, this pilot project
      proposes to measure the effects of botulinum toxin injections through observation of
      performance on a functional task known as 'hand as a holder'. This task requires the person
      with hemiplegia to insert an object into the affected hand and hold it independently.

      The project aims to demonstrate reliability and validity of a digital video method that will
      be used to measure 'insertion time'. It also aims to establish initial statistical support
      for improved object insertion time into the hemiplegic clenched fist after Botox A
      injections.
    

Detailed description: 
      Holding is an everyday hand function, objects entering the hand radially, frontally, ulnarly
      or in-between the finger spaces. After a stroke, the hand of a person with hemiplegia
      typically lacks voluntary finger extension that opens the hand. Simultaneously, the hand is
      also subjected to involuntary contraction of finger flexor muscles that close the hand,
      resulting in clenched fist and thumb-in-palm deformities. Despite these typical hemiplegic
      configurations, persons with stroke may be able to insert an object into the hand by wiggling
      and pushing it into the hemiplegic hand with their uninvolved hand, though struggle is often
      present and failure is frequent. In the hemiplegic patient, a common driver of clenched fist
      and thumb-in-palm configurations is excessive involuntary neural activation of finger and
      thumb flexors, compounded by impaired or absent voluntary finger extension. Excessive finger
      and thumb flexor contractions have been variously ascribed to involuntary phenomena such as
      spasticity, spastic dystonia, co-contraction, associated reactions and others. For the
      investigators purpose here, these involuntary phenomena generate contractile tension in hand
      and thumb muscles that choke the hand's potential to function as a holder of objects as
      described above.

      The underlying rationale of this project is to examine whether hemiplegic 'hand as a holder'
      function can be improved by weakening involuntary muscle contractions that generate clenched
      fist and thumb in palm using the neuromuscular blocking properties of Botox A. The
      investigators hypothesize that 'hand as a holder' function will improve after
      chemodenervation of relevant finger, thumb and wrist muscles selected by clinical
      examination.

      Nine subjects will be enrolled. Baseline observations will be made on two occasions prior to
      Botox A injection and outcomes measured four weeks later. A digital video method will be used
      to measure 'insertion time' at all-time points. Given the importance of the relationship
      between "statistically significant" research results and "clinically significant",
      person-oriented, functional improvement, the investigators also hypothesize that experienced
      clinicians will independently rate the performance of object insertion into the clenched fist
      as globally better after chemodenervation.
    

Intervention name(s): clenched fist
Intervention type(s): Other
Intervention description(s): Observation of performance on a standardized behavioral task pre- and post- administration of Botox A in the context of routine care. Clinical assessment and judgment will be used to determine dosing and which muscles contribute to the hand deformities of a given participant.
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        patients who are clinically appropriate for Botox A injection to treat upper limb
        spasticity due to stroke
      
Keywords: Muscle Spasticity; Botox A; Upper limb hemiplegia