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Backgound: Metrics for movement smoothness include the number of zero-crossings on the acceleration profile (N0C), the log dimensionless jerk (LDLJ), the normalized averaged rectified jerk (NARJ) and the spectral arc length (SPARC). Sensitivity to the handedness and movement type of these four metrics was compared and correlations with other kinematic parameters were explored in healthy subjects. Methods: Thirty-two healthy participants underwent 3D upper limb motion analysis during two sets of pointing movements on each side. They performed forward- and backward-pointing movements at a self-selected speed to a target located ahead at shoulder height and at 90% arm length, with and without a three-second pause between forward and backward movements. Kinematics were collected, and smoothness metrics were computed. Results: LDLJ, NARJ and N0C found backward movements to be smoother, while SPARC found the opposite. Inter- and intra-subject coefficients of variation were lowest for SPARC. LDLJ, NARJ and N0C were correlated with each other and with movement time, unlike SPARC. Conclusion: There are major differences between smoothness metrics measured in the temporal domain (N0C, LDLJ, NARJ), which depend on movement time, and those measured in the frequency domain, the SPARC, which gave results opposite to the other metrics when comparing backward and forward movements. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to evaluate a novel composite measure of active range of motion (XA) and determine whether this measure correlates with active function. Design: Post hoc analysis of two randomized, placebo-controlled, double-blind studies with open-label extensions exploring changes in active function with abobotulinumtoxinA. Setting: Tertiary rehabilitation centers in Australia, Europe, and the United States. Subjects: Adults with upper (n = 254) or lower (n = 345) limb spastic paresis following stroke or brain trauma. Interventions: AbobotulinumtoxinA (⩽5 treatment cycles) in the upper or lower limb. Main measures: XA was used to calculate a novel composite measure (CXA), defined as the sum of XA against elbow, wrist, and extrinsic finger flexors (upper limb) or soleus and gastrocnemius muscles (lower limb). Active function was assessed by the Modified Frenchay Scale and 10-m comfortable barefoot walking speed in the upper limb and lower limb, respectively. Correlations between CXA and active function at Weeks 4 and 12 of open-label cycles were explored. Results: CXA and active function were moderately correlated in the upper limb (P < 0.0001–0.0004, r = 0.476–0.636) and weakly correlated in the lower limb (P < 0.0001–0.0284, r = 0.186–0.285) at Weeks 4 and 12 of each open-label cycle. Changes in CXA and active function were weakly correlated only in the upper limb (Cycle 2 Week 12, P = 0.0160, r = 0.213; Cycle 3 Week 4, P = 0.0031, r = 0.296). Across cycles, CXA improvements peaked at Week 4, while functional improvements peaked at Week 12. Conclusion: CXA is a valid measure for functional impairments in spastic paresis. CXA improvements following abobotulinumtoxinA injection correlated with and preceded active functional improvements. [ABSTRACT FROM AUTHOR]

Background: Tremor is the most common movement disorder, with significant functional and psychosocial consequences. Oral medications have been disappointing or limited by side effects. Surgical techniques are effective but associated with risks and adverse events. Botulinum toxin (BT) represents a promising avenue but there is still no double-blind evidence of efficacy on upper limb function. A systematic review on the effects of BT in upper-limb tremor was conducted. Methods: A systematic search of the literature was conducted up to July 2023, including the keywords "botulinum toxin" and "tremor". All randomized controlled trials (RCTs) and open-label studies were analyzed. Independent reviewers assessed their methodological quality. Results: There were only eight published RCTs and seven published open-label studies, with relatively small sample sizes. This review suggests that BT is more effective when injections are patient-tailored, with analyses based on clinical judgement or kinematics. Subjective and objective measures frequently improve but transient weakness may occur after injections, especially if wrist or fingers extensors are targeted. A number of studies had methodological limitations. Conclusions: The authors discuss how to optimize tremor assessments and effects of BT injection. Controlled evidence is still lacking but it is suggested that distal "asymmetric" BT injections (targeting flexors/pronators while sparing extensors/supinators) and proximal injections, involving shoulder rotators when indicated, may avoid excessive weakness while optimizing functional benefit. [ABSTRACT FROM AUTHOR]

Key points: The brain's internal model of the body and the sense of body ownership are fundamental to interaction with the world. It is thought that temporally congruent, repetitive multisensory stimuli are required to elicit a sense of body ownership. Here we investigate the ability of static cutaneous stimuli – passively grasping an artificial finger – to induce body ownership and alter perceived body position; we also investigate how physical characteristics of grasped objects alter these senses. We show that static cutaneous stimuli can alter perceived body position and induce an illusion of ownership and also that signals of temperature, texture and shape of grasped finger‐sized objects influence body ownership. Thus, these aspects of human proprioception can be altered by a single sustained sensory stimulus and by the physical characteristics of held objects. Abstract: Perceived body position and ownership are fundamental to our ability to sense and interact with the world. Previous work indicates that temporally congruent, repetitive multisensory stimuli are needed to alter the sense of body ownership. In the present study 30 subjects passively grasped an artificial rubber finger with their left index and thumb while their right index finger, located 12 cm below, was lightly clamped. Fingers with varied physical characteristics were also passively grasped to determine how these characteristics influenced perceived body position and ownership. Subjects immediately felt their hands to be 5.3 cm [3.4–7.3] (mean [95%CI]) closer, a feeling that remained after 3 min (6.0 cm [4.5–7.5]). By the end of the trial, perceived ownership increased by 1.2 [0.6–1.9] points on a 7‐point Likert scale, with the group average moving from ‘neither agree or disagree’ at the start to ‘somewhat agree’ at the end. Compared to grasping a control rubber finger, grasping a cold, rough, oddly shaped or rectangular shaped finger‐like object reduced perceived ownership. These results provide new insights into the role of cutaneous sensory receptors in defining these aspects of proprioception, and the speed with which these effects occur. Static touch rapidly induces large, sustained changes in perceived body position and prolonged exposure to these cutaneous inputs, alone, can induce a sense of body ownership. Also, certain physical characteristics of grasped objects influence the sense of body ownership. [ABSTRACT FROM AUTHOR]

When increasing ambulation speed in Parkinson’s disease, step cadence increases more than stride length, indicating movement scaling difficulties that affect step generation in particular. We investigated whether step length variation when increasing ambulation speed was related to disease progression. Patients with Parkinson’s disease (N = 39) and controls (N = 152) performed two timed ambulation tasks: at a 'free' (self-selected) pace and then at 'maximal' speed. The total number of steps (including during turns) and time to complete the task were clinically measured. The relative contribution of step length and cadence to increased ambulation speed was determined using two methods: the ratios of change in step length or in cadence to the change in ambulation speed, and the step length index. While the relative contribution of step length and cadence to increased ambulation speed was independent of age in both control and patient groups, in Parkinson’s disease there was a negative correlation between time from diagnosis and the ratio of change in step length to change in ambulation speed (R = 0.54; p = 0.0004) and the step length index (R = 0.56, p = 0.0002). In parallel, there was a positive correlation between time since diagnosis and the ratio of change in cadence to change in ambulation speed (R = 0.57; p = 0.0002). The relative contribution of step length and cadence to increased ambulation speed is age invariant but a marker of Parkinson's disease advancement, and can be easily determined in the clinical setting. [ABSTRACT FROM AUTHOR]

In spastic paresis, stretch applied to the antagonist increases its inappropriate recruitment during agonist command (spastic co-contraction). It is unknown whether antagonist stretch: (1) also affects agonist recruitment; (2) alters effort perception. We quantified voluntary activation of ankle dorsiflexors, effort perception, and plantar flexor co-contraction during graded dorsiflexion efforts at two gastrocnemius lengths. Eighteen healthy (age 41 ± 13) and 18 hemiparetic (age 54 ± 12) subjects performed light, medium and maximal isometric dorsiflexion efforts with the knee flexed or extended. We determined dorsiflexor torque, Root Mean Square EMG and Agonist Recruitment/Co-contraction Indices (ARI/CCI) from the 500 ms peak voluntary agonist recruitment in a 5-s maximal isometric effort in tibialis anterior, soleus and medial gastrocnemius. Subjects retrospectively reported effort perception on a 10-point visual analog scale. During gastrocnemius stretch in hemiparetic subjects, we observed: (1) a 25 ± 7 % reduction of tibialis anterior voluntary activation (maximum reduction 98 %; knee extended vs knee flexed; p = 0.007, ANOVA); (2) an increase in dorsiflexion effort perception ( p = 0.03, ANCOVA). Such changes did not occur in healthy subjects. Effort perception depended on tibialis anterior recruitment only (βARI = 0.61, p < 0.01) in healthy subjects (not on gastrocnemius medialis co-contraction) while it depended on both tibialis anterior agonist recruitment (βARI = 0.41, p < 0.001) and gastrocnemius medialis co-contraction (βCCI = 0.43, p < 0.001) in hemiparetic subjects. In hemiparesis, voluntary ability to recruit agonist motoneurones is impaired-sometimes abolished-by antagonist stretch, a phenomenon defined here as stretch-sensitive paresis. In addition, spastic co-contraction increases effort perception, an additional incentive to evaluate and treat this phenomenon. [ABSTRACT FROM AUTHOR]

Background: Movement smoothness is a potential kinematic biomarker of upper extremity (UE) movement quality and recovery after stroke; however, the measurement properties of available smoothness metrics have been poorly assessed in this group. We aimed to measure the reliability, responsiveness and construct validity of several smoothness metrics. Methods: This ancillary study of the REM-AVC trial included 31 participants with hemiparesis in the subacute phase of stroke (median time since stroke: 38 days). Assessments performed at inclusion (Day 0, D0) and at the end of a rehabilitation program (Day 30, D30) included the UE Fugl Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and 3D motion analysis of the UE during three reach-to-point movements at a self-selected speed to a target located in front at shoulder height and at 90% of arm length. Four smoothness metrics were computed: a frequency domain smoothness metric, spectral arc length metric (SPARC); and three temporal domain smoothness metrics (TDSM): log dimensionless jerk (LDLJ); number of submovements (nSUB); and normalized average rectified jerk (NARJ). Results: At D30, large clinical and kinematic improvements were observed. Only SPARC and LDLJ had an excellent reliability (intra-class correlation > 0.9) and a low measurement error (coefficient of variation < 10%). SPARC was responsive to changes in movement straightness (rSpearman=0.64) and to a lesser extent to changes in movement duration (rSpearman=0.51) while TDSM were very responsive to changes in movement duration (rSpearman>0.8) and not to changes in movement straightness (non-significant correlations). Most construct validity hypotheses tested were verified except for TDSM with low correlations with clinical metrics at D0 (rSpearman<0.5), ensuing low predictive validity with clinical metrics at D30 (non-significant correlations). Conclusions: Responsiveness and construct validity of TDSM were hindered by movement duration and/or noise-sensitivity. Based on the present results and concordant literature, we recommend using SPARC rather than TDSM in reaching movements of uncontrolled duration in individuals with spastic paresis after stroke. Trial Registration: NCT01383512, https://clinicaltrials.gov/, June 27, 2011. Highlights: Reliability, responsiveness and construct validity of SPARC were satisfactory. Responsiveness and construct validity of LDLJ, NARJ and nSUB were highly related to movement duration. LDLJ had an excellent reliability and a low measurement error, but not NARJ and nSUB. [ABSTRACT FROM AUTHOR]

Objective In chronic spastic paresis, intensity in rehabilitation programs leads to possible improvements in patients walking capacities. However, the implementation of intensive rehabilitation is limited by time and financial constraints of conventional physiotherapy programs. Thus, the use Guided Self-Rehabilitation Contract (GSC) programs makes it possible to overcome these disadvantages. GSC have proven their impact on functional activities using two rehabilitation technics: prolonged static stretch postures and motor training with fast alternating movements of maximal amplitude. The objective of this study was to compare the effects of 3 programs using GSC during 2 months on ambulation capacities in chronic spastic paresis: a program with prolonged static stretch postures, a motor training program with fast alternating movements of maximal amplitude and a combined program with prolonged static stretch postures and fast alternating movements of maximal amplitude. Material/Patients and methods Eleven patients with spastic hemiparesis were included in this prospective randomized simple-blinded study from January to June 2016. They had no botulinum toxin injection in the last 2 months. Each patient followed a 60-minutes working per day program using GSC for 2 months targeting the antagonists of active ankle dorsiflexion, knee flexion and hip flexion in the stretching group, the training group or the combined group. The primary outcome was the comparison of the maximal speed barefoot in the 10-meter ambulation test at D-15 and D60. Results The median daily working duration was 39 ± 18 minutes. No difference was found between groups on the maximal speed barefoot on the 10-meter ambulation test after 2 months of programs using GSC. The whole population increased its maximal speed barefoot on the 10-meter ambulation test (from 0.89 ± 0.38 m/s to 0.99 ± 0.43 m/s; P = 0.006, Wilcoxon). The combined group and the training group increased their maximal speed on the 10-meter ambulation test barefoot by 16%, contrary to the stretching group which increased its maximal speed only by 5%. Discussion/Conclusion No difference between the 3 programs was found although tendencies seems to be in favor of the combined group. A larger prospective study should be planned in order to confirm these tendencies. [ABSTRACT FROM AUTHOR]

Introduction: In this study of spastic hemiparesis we evaluated cocontraction during sustained agonist/antagonist efforts, before and after botulinum toxin (BoNT) injection in 1 agonist. Methods: Nineteen hemiparetic subjects performed maximal isometric elbow flexion/extension efforts with the elbow at 100° (extensors stretched). Using flexor and extensor surface electromyography we calculated agonist recruitment/cocontraction indices from 500-ms peak voluntary agonist recruitment, before and 1 month after onabotulinumtoxinA injection (160 U) into biceps brachii. Results: Before injection, agonist recruitment and cocontraction indices were higher in extensors than flexors [0.74 ± 0.15 vs. 0.59 ± 0.10 ( P < 0.01) and 0.43 ± 0.25 vs. 0.25 ± 0.13 ( P < 0.05), respectively]. Biceps injection decreased extensor cocontraction index (−35%, P < 0.05) while increasing flexor agonist recruitment and cocontraction indices. Conclusions: In spastic hemiparesis, stretch may facilitate agonist recruitment and spastic cocontraction. In the non-injected antagonist, cocontraction may be reduced by enhanced reciprocal inhibition from a more relaxed, and therefore stretched, agonist, or through decreased recurrent inhibition from the injected muscle. Muscle Nerve, 2012 [ABSTRACT FROM AUTHOR]

In post-stroke motor rehabilitation, treatment dose description is estimated approximately. The aim of this retrospective study was to quantify the treatment dose using robot-measured variables during robot-assisted training in patients with subacute stroke. Thirty-six patients performed fifteen 60 min sessions (Session 1–Session 15) of planar, target-directed movements in addition to occupational therapy over 4 (SD 2) weeks. Fugl–Meyer Assessment (FMA) was carried out pre- and post-treatment. The actual time practiced (percentage of a 60 min session), the number of repeated movements, and the total distance traveled were analyzed across sessions for each training modality: assist as needed, unassisted, and against resistance. The FMA score improved post-treatment by 11 (10) points (Session 1 vs. Session 15, p < 0.001). In Session 6, all modalities pooled, the number of repeated movements increased by 129 (252) (vs. Session 1, p = 0.043), the total distance traveled increased by 1743 (3345) cm (vs. Session 1, p = 0.045), and the actual time practiced remained unchanged. In Session 15, the actual time practiced showed changes only in the assist-as-needed modality: −13 (23) % (vs. Session 1, p = 0.013). This description of changes in quantitative-practice-related variables when using different robotic training modalities provides comprehensive information related to the treatment dose in rehabilitation. The treatment dose intensity may be enhanced by increasing both the number of movements and the motor difficulty of performing each movement. [ABSTRACT FROM AUTHOR]

Purpose: To assess functional status and robot-based kinematic measures four years after subacute robot-assisted rehabilitation in hemiparesis. Materials and methods: Twenty-two patients with stroke-induced hemiparesis underwent a ≥3-month upper limb combined program of robot-assisted and occupational therapy from two months post-stroke, and received community-based therapy after discharge. Four years later, 19 (86%) participated in this follow-up study. Assessments 2, 5 and 54 months post-stroke included Fugl-Meyer (FM), Modified Frenchay Scale (MFS, at Month 54) and robot-based kinematic measures of targeting tasks in three directions, north, paretic and non-paretic: distance covered, velocity, accuracy (root mean square (RMS) error from straight line) and smoothness (number of velocity peaks; upward changes in accuracy and smoothness represent worsening). Analysis was stratified by FM score at two months: ≥17 (Group 1) or <17 (Group 2). Correlation between impairment (FM) and function (MFS) was explored at 54 months. Results: FM scores were stable from 5 to 54 months (+1[−2;4], median [1st; 3rd quartiles], ns). Kinematic changes (three directions pooled) were: distance −1[−17;2]% (ns); velocity, −8[−32;28]% (ns); accuracy, +6[−13;98]% (ns); smoothness, +44[−6;126]% (p < 0.05). Group 2 showed decline vs. Group 1 (p < 0.001) in FM (Group 1, +3[1;5], p < 0.01; Group 2, −7[−11;−1], ns) and accuracy (Group 1, −3[−27;38]%, ns; Group 2, +29[17;140]%, p < 0.001). At 54 months, FM and MFS were highly correlated (Pearson's rho = 0.89; p < 0.001). Conclusions: While impairment appeared stable four years after robot-assisted upper limb training during subacute post-stroke phase, movement kinematics deteriorated despite community-based therapy, especially in more severely impaired patients. Trial registration: EudraCT 2016-005121-36. Registration: 2016-12-20. Date of enrolment of the first participant to the trial: 2009-11-24. [ABSTRACT FROM AUTHOR]

Objective Rehabilitation robots are commonly used to help deliver high dosage of physical treatment in hemiparesis after stroke. Kinematic measurements are provided by some robotic devices. This study aims to measure the intra-rater reliability of robot-based kinematic assessments of the paretic upper limb in subacute stroke. Rehabilitation robots are commonly used to help deliver high dosage of physical treatment in hemiparesis after stroke. Kinematic measurements are provided by some robotic devices. This study aims to measure the intra-rater reliability of robot-based kinematic assessments of the paretic upper limb in subacute stroke. Material/patients and methods Twenty subjects with subacute stroke-induced hemiparesis (age 57 ± 18, time from stroke, 60 ± 41 days, mean ± SD) participated in this study. All subjects perform 2 pointing tasks, 24 hours apart, using the InMotion™ device, which involves a planar end-effector emphasizing shoulder and elbow movements from supported hand displacement in the horizontal plane. During each pointing task, the same investigator asks the subject to reach peripheral targets equally distant on a 14-cm radius circumference around the center target. Four robot-based kinematic measures were computed: distance covered, velocity, accuracy (RMS error from straight line) and smoothness (number of velocity peaks). Intra-class correlation coefficients (ICC), coefficient of variation (CV) and mean raw difference were used to analyze intra-rater reliability of kinematic parameters. Results Intra-rater reliability was good for velocity (ICC, 69 ± 19%), accuracy (ICC, 60 ± 24%) and smoothness (ICC, 55 ± 35%) except for distance covered (ICC, 7 ± 68%). Mean CVs were 7.6 ± 4.5% for distance covered, 19.8 ± 3.9% for velocity, 33.8 ± 5.9% for accuracy and 32.7 ± 5.3% for smoothness. Mean raw differences were 0.9 ± 0.3 cm for distance covered, 2.0 ± 0.5 cm/s for velocity, 0.5 ± 0.1 cm for accuracy and 2.2 ± 0.5 peaks for smoothness. Discussion – conclusion Kinematic assessment from the InMotion™ device has good intra-rater reliability in subjects with subacute hemiparesis. Relative homogeneity and ceiling effects of distances covered across subjects (many of the subjects reached the maximal 14 cm requested by the task) may be responsible for artificially low ICCs in this study. Kinematic analysis based on robot evaluation could be useful to monitor recovery after stroke. [ABSTRACT FROM AUTHOR]

Background: When exploring changes in upper limb kinematics and motor impairment associated with motor recovery in subacute post stroke during intensive therapies involving robot-assisted training, it is not known whether trained joints improve before non-trained joints and whether target reaching capacity improves before movement accuracy.Methods: Twenty-two subacute stroke patients (mean delay post-stroke at program onset 63 ± 29 days, M2) underwent 50 ± 17 (mean ± SD) 45-min sessions of robot-assisted (InMotion™) shoulder/elbow training over 3 months, in addition to conventional occupational therapy. Monthly evaluations (M2 to M5) included Fugl-Meyer Assessment (FM), with subscores per joint, and four robot-based kinematic measures: mean target distance covered, mean velocity, direction accuracy (inverse of root mean square error from straight line) and movement smoothness (inverse of mean number of zero-crossings in the velocity profile). We assessed delays to reach statistically significant improvement for each outcome measure.Results: At M5, all clinical and kinematic parameters had markedly improved: Fugl-Meyer, +65% (median); distance covered, +87%; mean velocity, +101%; accuracy, +134%; and smoothness, +96%. Delays to reach statistical significance were M3 for the shoulder/elbow Fugl-Meyer subscore (+43%), M4 for the hand (+80%) and M5 for the wrist (+133%) subscores. For kinematic parameters, delays to significant improvements were M3 for distance (+68%), velocity (+65%) and smoothness (+50%), and M5 for accuracy (+134%).Conclusions: An intensive rehabilitation program combining robot-assisted shoulder/elbow training and conventional occupational therapy was associated with improvement in shoulder and elbow movements first, which suggests focal behavior-related brain plasticity. Findings also suggested that recovery of movement quantity related parameters (range of motion, velocity and smoothness) might precede that of movement quality (accuracy).Trial Registration: EudraCT 2016-005121-36 . Date of Registration: 2016-12-20. Date of enrolment of the first participant to the trial: 2009-11-24 (retrospective data). [ABSTRACT FROM AUTHOR]

Abstract: Objective: Spastic co-contraction is a misdirected supraspinal command in spastic paresis. We quantified the influence of effort and gastrocnemius stretch on plantar flexor co-contraction and torque during dorsiflexion efforts in hemiparetic and healthy subjects. Methods: Eighteen healthy and 18 hemiparetic subjects produced “light”, “medium” and “maximal” isometric dorsi- and plantar flexion efforts in two gastrocnemius positions, stretched (knee extended) and slack (knee flexed), ankle at 90°. Measuring ankle torque and soleus and medial gastrocnemius surface EMG, we calculated the co-contraction index (CCI) as the ratio of the EMG root mean square (RMS) from the muscle acting as antagonist over its RMS when acting as agonist in a maximal effort, in each knee position. Results: Co-contraction was abnormally high in hemiparetic subjects at all effort levels, e.g. for soleus in the knee extended position (CCISO 0.37±0.08 in hemiparesis vs 0.18±0.02 in healthy subjects, p <0.05). In hemiparetic subjects knee extended, dorsiflexion torque, (i) was reversed or canceled in 26% trials; and (ii) correlated negatively with plantar flexor CCI. Significance: Major dynamometric impact of co-contraction with stretched position of the cocontracting muscle may justify muscle length modifications (e.g. through aggressive stretch programs) to improve function in spastic paresis. [Copyright &y& Elsevier]

Descending command in hemiparesis is reduced to agonists and misdirected to antagonists. We monitored agonist and antagonist activation along the swing phase of gait, comparing paretic and non-paretic legs. Forty-two adults with chronic hemiparesis underwent gait analysis with bilateral EMG from tibialis anterior, soleus and gastrocnemius medialis. We monitored ankle and knee positions, and coefficients of agonist activation in tibialis anterior and of antagonist activation in soleus and gastrocnemius medialis over the three thirds of swing phase. These coefficients were defined as the ratio of the root-mean-square EMG from one muscle over any period to the root-mean-square EMG from the same muscle over 100 ms of its maximal voluntary isometric contraction. As against the non-paretic side, the paretic side showed lesser ankle dorsiflexion and knee flexion (P < 1.E−5), with higher coefficients of agonist activation in tibialis anterior (+100 ± 28%, P < 0.05), and of antagonist activation in soleus (+224 ± 41%, P < 0.05) and gastrocnemius medialis (+276 ± 49%, P < 0.05). On the paretic side, coefficient of agonist activation in tibialis anterior decreased from mid-swing on; coefficients of antagonist activation in soleus and gastrocnemius medialis increased and ankle dorsiflexion decreased in late swing (P < 0.05). During the swing phase in hemiparesis, normalized tibialis anterior recruitment is higher on the paretic than on the non-paretic leg, failing to compensate for a marked increase in plantar flexor activation (cocontraction). The situation deteriorates along swing with a decrease in tibialis anterior recruitment in parallel with an increase in plantar flexor activation, both likely related to gastrocnemius stretch during knee re-extension. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT03119948 • Characterization of agonist and antagonist activations around ankle during gait • In hemiparesis, descending command is misdirected to ankle antagonists during swing. • Spastic cocontraction of triceps surae increasingly impedes active dorsiflexion. • Normalized tibialis anterior recruitment is impaired in the paretic leg. • Higher tibialis anterior activation is insufficient to correct active dorsiflexion. [ABSTRACT FROM AUTHOR]

Background: After discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to "maintenance" rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.Methods: One hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician's prescription. The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.Discussion: This study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.Trial Registration: ClinicalTrials.gov: NCT02202954 , July 29, 2014. [ABSTRACT FROM AUTHOR]

Objective The effects of long-term (> 6 months) stretching in spastic paresis are unknown. The objective of this study was to compare the architectural and clinical changes in plantar flexors in patients with chronic hemiparesis following a one-year daily self-stretch program vs. standard rehabilitation. Material/patients and methods Twenty-three patients with chronic hemiparesis (8 W; mean age, 56 [12]; time since lesion 9 [8]) participated in a one-year randomized controlled trial involving either conventional therapy (CONV) or a daily self-stretch program within a Guided Self-rehabilitation Contract (GSC). Assessments involved: (i) soleus and medial gastrocnemius (MG) fascicle length, pennation angle, thickness, tendon length, measured by ultrasonography; (ii) XV1, angle of arrest at slow stretch in soleus (XV1SOL), gastro-soleus complex (XV1GAS), gluteus maximus (XV1GM) and rectus femoris (XV1RF); (iii) 10-meter maximal ambulation speed. Correlations (Pearson's) between architectural parameters and XV1 were also explored. Results After one year, soleus fascicle length increased by +16.6 mm (CI95 [+10.3; +22.9]; +42%), in the GSC group vs. −0.1 mm (CI95 [−7.3; +7.1]; −3.7%), in the CONV group ( P = 0.005, Rank-Ancova), MG fascicle length increased by +5.2 mm (CI95 [+2.75; +7.65]; +13%), in the GSC group vs. +1.2 mm (CI95 [−2.0; +4.4]; +7%), in the CONV group ( P = 0.01), soleus thickness increased by +4.3 mm (CI95 [+2.7; +5.9]; +33%), vs. −0.3 mm (CI95 [−2.4; +1.8]; −0.8%), in the CONV group ( P = 0.005). Changes in XV1 involved XV1SOL, +2.4° (CI95 [+0.9; +4.0]; +2.4%), in the GSC group vs. +0.1° (CI95 [−2.7; +2.8]; +0.1%), in the CONV group ( P = 6.9 E-05); XV1GAS, +7.4° (CI95[+5.0; +9.8]; +8%) vs. +1.5° (CI95 [−3.3; +6.3]; +1.5%; P = 0.003); XV1GM, +5.3° (CI95[+2.7; + 7.9]; 4.2%) vs. +1.5° (CI95[+0.1; +5.4]; +1.2%; P = 0.025); XV1RF, +10.5° (CI95 [+5.8; + 16.4]; +3.4%) vs. +1.5° (CI95 [−3.75; +6.65]; +1.9%; P = 0.08). Walking speed increased by +0.08 m/s (CI95 [+0.04; +0.12]; +14%, P = 0.006, t -test) in the GSC group vs. +0.04 m/s (CI95[0.0; +0.08]; +5%, NS) in the CONV group. At baseline, XV1SOL correlated negatively with soleus tendon length ( R = −0.74, P = 0.0003) and positively with muscle thickness ( R = 0.68, P = 0.015). Discussion – conclusion In patients with chronic hemiparesis, a daily self-stretch program of soleus and medial gastrocnemius through Guided Self-rehabilitation Contract over one year increased muscle fascicle length and thickness more than conventional rehabilitation. [ABSTRACT FROM AUTHOR]

Objective There is a growing body of evidence in phenotypic animal models of Parkinson's disease (PD) for neuroprotective and even neurorestorative effects of intensive and prolonged aerobic treatment. It has also been suggested that intensity of physical therapy in PD may lead prescribing physicians to reduce daily levodopa doses. We evaluated changes in levodopa prescription after an eight-week, protocol-defined, standardized, physiotherapy regimen that included the teaching of exercises to promote further guided self-practice. Material/patients and methods Thirty-eight patients with mild to moderate PD (Hoehn & Yahr 2–3) followed a standardized protocol of intensive home PT, three hours/week for eight weeks, with either conventional physical therapy (CPT) or an asymmetric motor strengthening (AMS) program. The study investigator was asked not to interfere with the levodopa prescription during the trial and the prescribing physician was unaware of the hypothesis. We collected the prescribed levodopa-equivalent daily doses (mg/d) at D1 and D150 (3 months after the end of the 8-week program). Results For 31 patients for whom the levodopa-equivalent daily dose (LED) was available at D150, the LED was 588 ± 426 mg/d at D1 and 529 ± 370 mg/d at D150 (–10%; P = 0.26, t -test). When comparing the two groups, there was no significant difference in dose reduction: 17.5% reduction in the CPT group vs. 2.7% reduction in the AMS group ( P = 0.4). Discussion – conclusion In this sample of patients with mild to moderate PD followed up 3 months after the end of an 8-week intensive PT program, there was a non-significant 10% reduction of the prescribed levodopa dose three months after the end of the PT program. No significant difference in dose reduction was observed between the two PT programs. [ABSTRACT FROM AUTHOR]

Objective The present study aimed to quantify the impact of the tension applied on triceps surae during the swing phase of gait on its cocontraction in chronic hemiparesis. Material/patients and methods Forty-one subjects with chronic hemiparesis (50 ± 15 years; time since lesion, 7 ± 7 years; mean ± SD) completed a kinematic gait analysis, barefoot at comfortable speed (10 opto-electronic cameras, 6 dynamometric force plates, 27 ± 13 cycles analyzed/subject), with electromyography of soleus (so) and gastrocnemius medialis (gm) on the paretic side. The Coefficients of Spastic Cocontraction, CSCso and CSCgm, were calculated over 3 periods of swing phase (T1, [0–33] %; T2, [34–66] %; T3, [67–100] %), by the ratio of the RMS of the electromyogram in the period of interest over the RMS of the electromyogram of the same muscle over 100 ms around the maximal agonist isometric activity (measured on standing position by a maximal effort against resistance). In addition, a coefficient of lengthening of triceps surae, CLts, was computed over each period in the sagittal plane, from the ankle/knee displacements recorded during the period of interest divided by the total range of ankle/knee movements measured across all gait cycles. CSCso, CSCgm and CLts were compared between the 3 periods (ANOVA, significant effect P < 0.05). Exploration of individual correlations were performed with all gait cycles of each patient, using univariate regression analysis with CLts as predictor and coefficients of spastic cocontraction (CSCso and CSCgm) as dependent variables. Results Between T2 et T3, CSCso increased by 233 ± 54% (mean ± SEM, P < 1E-5) and CSCgm by 67 ± 10% ( P = 0.0017). CLts increased by 23 ± 7% in T2 ( P = 0.009) and 52 ± 12% in T3 ( P < 1E-5). CLts was positively correlated with CSCso in 63% of cases ( n = 25, r = 0.63 ± 0.04, P < 0.1) and with CSCgm in 53% of cases ( n = 21, r = 0.60 ± 0.04, P < 0.1). Discussion – conclusion In chronic hemiparesis, tension (lengthening) applied on triceps surae is associated with the increase of its spastic cocontraction during swing phase of gait at comfortable speed. [ABSTRACT FROM AUTHOR]

Objective Strengthening programs are established as a symptomatic treatment in Parkinson's disease. We aimed to evaluate the effect of a one-day/week day-care rehabilitation program on motor power in parkinsonian syndromes. Material/patients and methods In this prospective open-label study, twenty-nine subjects with mild to moderate parkinsonian syndromes (66 ± 5 years, mean ± SD; 9 female; Hoehn and Yahr 2–3) underwent a standardized rehabilitation protocol, one day per week, during 6 ± 1 weeks. This program was based on four small-group sessions each rehabilitation day: physical therapy with strengthening exercises (1 h), aerobic training (30 min), occupational therapy or speech therapy (1 h) and medical tango (1 h). Before and after the program, all participants underwent measurement of maximal isometric muscle power, using a uniaxial strain gauge, for neck extension force, and torque in elbow extension and shoulder flexion, abduction and lateral rotation. Maximal forces and torques on the more and less affected sides were compared between W1 and W6 ( t -test, significant effect, P > 0.05). Results Maximal neck extension force increased by 22 ± 7% (mean ± SEM; W1, 78 ± 9 N; W6, 89 ± 9 N, P = 0.023). On the more affected side, changes in maximal torque were +13 ± 4% in shoulder flexion (W1, 40 ± 3 Nm; W6, 45 ± 3 Nm, P = 0.013) and +14 ± 5% in shoulder abduction (W1, 35 ± 3 Nm; W6, 39 ± 3 Nm, P = 0.046). On the less affected side, changes in maximal torque were +8 ± 4% in shoulder flexion (W1, 45 ± 3 Nm, W6, 47 ± 3 Nm, P = 0.069) and +6 ± 3% in shoulder abduction (W1, 40 ± 3 Nm; W6, 42 ± 3 Nm, P = 0.066). Elbow extension and shoulder lateral rotation remained unchanged. Discussion – conclusion In patients with mild to moderate parkinsonian syndromes, a day-care rehabilitation hospital program in small groups one day/week for 6 weeks was associated with proximal motor strengthening, particularly on the more affected upper limb. Functional effects will be reported separately. [ABSTRACT FROM AUTHOR]

Objective In spastic hemiparesis, quantify agonist recruitment of tibialis anterior and triceps surae spastic cocontraction during swing phase of gait. Material/Patients and methods Thirty-seven subjects with chronic hemiparesis (49 ± 14 years, mean ± SD; time since lesion, 8 ± 7 years) performed a 3D gait analysis, barefoot at comfortable speed (10 optoelectronic cameras, 6 dynamometric force plates, analysis of 9 cycles), with bilateral electromyography of tibialis anterior (TA), soleus (SO) and gastrocnemius medialis (GM). Speed, step length and maximal active dorsiflexion during swing were measured. Indices of agonist recruitment, IRATA, and spastic cocontraction, ICCSO and ICCGM, were calculated over 3 periods of swing phase (T1, [0–33%]; T2, [34–66%]; T3, [67–100%]), by the ratio of the RMS of the electromyogram in the period of interest over the RMS of the electromyogram of the same muscle over 100 ms around the maximal agonist isometric activity (measured on standing position by a maximal effort against resistance). IRA and ICC were compared between the 3 periods and between paretic and non paretic sides using repeated measures MANOVA (significant effect, P < 0.05). Results Speed, 0.68 ± 0.26 m/s; paretic step length, 0.48 ± 0.12 m, non paretic, 0.43 ± 0.15 m; paretic maximal active dorsiflexion, −3 ± 8°, non paretic, 6 ± 4°. On the paretic side: IRATA decreased between T1 and T2 (T1, 0.69 ± 0.59; T2, 0.48 ± 0.39, P = 2E-4) and then remained unchanged at T3 (0.47 ± 0.45; vs T1, P = 1E-4; vs T2, ns), while ICCSO and ICCGM increased at T3 only (ICCSO, T2, 0.25 ± 0.21; T3, 0.57 ± 0.50; P = 5E-8; ICCGM, T2, 0.39 ± 0.40; T3, 0.59 ± 0.50; P = 2E-4). On the non-paretic side, IRATA, ICCSO and ICCGM remained unchanged (IRATA, T1, 0.32 ± 0.20; T2, 0.23 ± 0.13; T3, 0.25 ± 0.10, ns; ICCSO, T1, 0.12 ± 0.12; T2, 0.13 ± 0.12; T3, 0.25 ± 0.18 ns; ICCGM, T1, 0.17 ± 0.31; T2, 0.19 ± 0.27; T3, 0.26 ± 0.25 ns). Side xperiod effect, P = 0.04. Discussion - Conclusion During comfortable gait in chronic hemiparesis, there is a decrease in tibialis anterior recruitment from mid-swing phase on and an increase in soleus and gastrocnemius spastic cocontraction at late swing were found. [ABSTRACT FROM AUTHOR]

Objective Micrographia and bradygraphia are classic features of Parkinson's disease (PD). However, the relevance of quantifying them in the clinical exam with pen and paper is unclear. Materials/patients and methods Twenty-five patients with PD (72 ± 8 years, 8F; time since diagnosis 9.8 ± 5.1 years; Hoehn and Yahr 2.5 ± 0.6) and 26 age-matched healthy controls (HC, 71 ± 16 years, 8F) wrote three times the same standard sentence in the OFF state. We measured changes from sentence 1 (S1) to sentence 3 (S3), in writing speed (WS), sentence length (SL), heights of first and last Ps (H1P, H3P), mean inter-words interval (IWI) and ratio total inter-word interval/sentence length (TIWI/SL). We also explored correlation with classical parameters of parkinsonism, including delay since diagnosis (DSD), UPDRSIII, and gait parameters such as the coefficients of ambulation speed increase (CSI) on a modified 20-meter up and go test. Results Raw values were: WS, 7.6 ± 2.4 (S1) and 8.8 ± 2.6 mm/s (S3) in HC (S1 vs S3, p = 0.000003) vs 6.4 ± 2.8 and 6.5 ± 3.0 mm/sec in PD (S1 vs S3, p = 0.65); H3P, 8.2 ± 2.4 (S1) and 8.4 ± 2.9 mm (S3) in HC (S1 vs S3; NS) vs 7.2 ± 3.2 and 6.3 ± 3.1 mm in PD (S1 vs S3, p < 0.05); IWI, 5.0 ± 1.4 (S1) and 4.8 ± 1.3 mm (S3) in HC (S1 vs S3, p < 0.05) vs 4.8 ± 1.7 and 4.2 ± 1.5 mm in PD (S1 vs S3, p < 0.001). The between-group differences in changes from S1 to S3 involved: WS, increased in HC (+ 15%) more than in PD (+ 2%; p = 0.003, ANCOVA); H3P, decreased in PD (–13.5%) while increased in HC (+ 2.6%; p = 0.012); IWI, decreased more in PD (–11.5%) than in HC (–4.5%; p = 0.048). WS, H3P and IWI did not correlate with time since diagnosis or UPDRS III. However, the coefficient of writing speed increase correlated negatively to CSI (r = –0.52, p = 0.006). Discussion/Conclusion From first to last sentence, the lack of speed increase seems to best distinguish PD patients from healthy subjects. It also correlates with markers of parkinsonism in ambulation. [ABSTRACT FROM AUTHOR]

Objective The Modified Frenchay Scale (MFS) measures active upper limb function in hemiparesis based on a video review of 10 everyday living tasks, each rated on a 10-point visual analogic scale. Six tasks are bimanual and four are unimanual performed with the paretic hand. We measured intra- and inter-rater reliability of MFS in hemiparetic patients among trained raters. Material/patients and methods After a group training session consisting in reviewing and commenting upon ten patient videos, 10 raters assessed the videos of 10 adults with chronic hemiparesis (age 52 ± 13, mean ± SD) on two occasions one week apart. Intra- and inter-rater reliability was assessed using interclass correlation coefficients, mean intra- and inter-rater differences, coefficients of variation between raters and the agreement frequency procedure, agreement being defined as a difference equal or less than 0.5 between two individual ratings. Results For the overall MFS scores, mean intra- and inter-rater ICC coefficients were respectively 0.99 [0.95; 1.00] (mean [95%CI]) and 0.98 [0.98; 1.00]. The mean intra-rater score difference between two ratings one-week apart was 0.26 ± 0.08 and the mean inter-rater standard deviation was 0.61 ± 0.17. Inter-rating differences of less than 0.5 were found in 86% of cases of intra-rater comparisons and in 52% of inter-rater comparisons. Mean inter-rater coefficient of variation was 0.11 ± 0.03. Discussion - conclusion After a group training session in using the scale, the Modified Frenchay Scale has excellent intra- and inter-rater reliability. [ABSTRACT FROM AUTHOR]