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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]

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]

In spastic paresis, the respective contributions to active function of antagonist hypoextensibility, spasticity, and impaired descending command remain unknown. Objectives: We explored correlations between ambulation speed and coefficients of shortening, spasticity and, weakness for three lower limb extensors. This retrospective study identified 140 subjects with chronic hemiparesis (>6 months since injury) assessed during a single visit with barefoot 10-meter ambulation at comfortable and fast speed, and measurements of passive range of motion (XV1), angle of catch at fast stretch (XV3) and active range of motion (XA) against the resistance of gastrocnemius, rectus femoris, and gluteus maximus. Coefficients of shortening (CSH=[XN-XV1]/XN; XN, normal expected amplitude based on anatomical values), spasticity (CSP=[XV1-XV3]/XV1), and weakness (CWK=[XV1-XA]/XV1) were derived. For each muscle, multivariable analysis explored CSH, CSP, and CWK as potential predictors of ambulation speed. Ambulation speed was 0.62±0.28m/s (mean±SD, comfortable) and 0.84±0.38m/s (fast) and was correlated with CSH and CWK against gastrocnemius (CSH, comfortable, ns; fast, β=−0.20, p=.03; CWK, comfortable, β=−0.21, p=.010; fast, β=−0.21, p =.012), rectus femoris (CSH, comfortable, β=−0.41, p=6E−7; fast, β=−0.43, p=5E−7; CWK, comfortable, β=−0.36, p=5E−5; fast, β=−0.33, p=.0003) and gluteus maximus (CSH, comfortable, β=−0.19, p=.02; fast, β=−0.26, p=.002; CWK, comfortable, β=−0.26, p=.002; fast, β=−0.22, p=.010). Ambulation speed was not correlated with CSP. In chronic hemiparesis, ambulation speed correlates with coefficients of shortening and of weakness in lower limb extensors, but not with their spasticity level. This may encourage therapists to focus treatment primarily on muscle shortening by stretching programs and on impaired descending command by active training. [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]

Background: At the onset of stroke-induced hemiparesis, muscle tissue is normal and motoneurones are not overactive. Muscle contracture and motoneuronal overactivity then develop. Motor command impairments are classically attributed to the neurological lesion, but the role played by muscle changes has not been investigated. Methods: Interaction between muscle and command disorders was explored using quantified clinical methodology—the Five Step Assessment. Six key muscles of each of the lower and upper limbs in adults with chronic poststroke hemiparesis were examined by a single investigator, measuring the angle of arrest with slow muscle stretch (XV1) and the maximal active range of motion against the resistance of the tested muscle (XA). The coefficient of shortening CSH = (XN-XV1)/XN (XN, normally expected amplitude) and of weakness CW = (XV1-XA)/XV1) were calculated to estimate the muscle and command disorders, respectively. Composite CSH (CCSH) and CW (CCW) were then derived for each limb by averaging the six corresponding coefficients. For the shortened muscles of each limb (mean CSH > 0.10), linear regressions explored the relationships between coefficients of shortening and weakness below and above their median coefficient of shortening. Results: A total of 80 persons with chronic hemiparesis with complete lower limb assessments [27 women, mean age 47 (SD 17), time since lesion 8.8 (7.2) years], and 32 with upper limb assessments [18 women, age 32 (15), time since lesion 6.4 (9.3) years] were identified. The composite coefficient of shortening was greater in the lower than in the upper limb (0.12 ± 0.04 vs. 0.08 ± 0.04; p = 0.0002, while the composite coefficient of weakness was greater in the upper limb (0.28 ± 0.12 vs. 0.15 ± 0.06, lower limb; p < 0.0001). In the lower limb shortened muscles, the coefficient of weakness correlated with the composite coefficient of shortening above the 0.15 median CSH (R = 0.43, p = 0.004) but not below (R = 0.14, p = 0.40). Conclusion: In chronic hemiparesis, muscle shortening affects the lower limb particularly, and, beyond a threshold of severity, may alter descending commands. The latter might occur through chronically increased intramuscular tension, and thereby increased muscle afferent firing and activity-dependent synaptic sensitization at the spinal level. [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]

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]

Introduction Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke. Methods and analysis 220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the selfrehabilitation programme will be monitored. Ethics and dissemination Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients. [ABSTRACT FROM AUTHOR]

Objectives Reliability of clinical tests to evaluate ambulation in chronic hemiparesis may vary according to the testing condition. The 10-meter ambulation test (AT10) assesses walking speed and step length over 10 m, starting and ending in seated position. In the present study, we compared the intra- and inter-reliability of AT10 in chronic hemiparesis in four different conditions: with shoes and barefoot, at free and maximal safe speed. Methods Ten patients with hemiparesis, >1 year post-stroke (age 45 ± 12, time since stroke 16 ± 9 months, mean ± SD) participated in the reliability study (registration, ID-RCB-2017-A00090-53). All patients performed the AT10 twice, one week apart, in each of the four conditions. The number of steps and time to complete the task were manually recorded by four independent raters. The main outcome measurements were the intraclass correlation coefficients (ICC), coefficients of variation (CV), and mean raw differences (DIFF) of the three parameters of AT10 (speed, step length, and cadence) in each of the four conditions. Effects of wearing shoes and speed condition were explored using ANOVA. Results Across all conditions, mean intra- and inter-rater ICCs were, respectively, 98.5 ± 0.1 and 99.9 ± 0.1% for speed, 98.3 ± 0.1 and 99.7 ± 0.2% for step length, and 96.5 ± 0.1 and 98.9 ± 0.6% for cadence. Mean intra- and inter-rater CV for speed were 0.051 ± 0.016 and 0.022 ± 0.002, respectively. Intra-rater reliability of speed assessments was higher at maximal than at free speed (ICC, CV, DIFF, p < 0.05). At free speed, intra-rater ICCs were higher barefoot than with shoes (p < 0.05). Discussion Performing the 10-meter ambulation test barefoot at maximal speed optimizes its reliability. [ABSTRACT FROM AUTHOR]

PurposeTo investigate the beliefs of physiotherapy students (ST), professionals (PT) and physicians (MD) about engaging patients with post-stroke hemiparesis into Guided Self-Rehabilitation Contracts (GSC), to increase their exercise intensity and responsibility level. MethodA survey examining beliefs about post-stroke rehabilitation was completed by first (n = 95), second (n = 105), and third (n = 48) year STs; PTs (n = 129) and MDs (n = 65) in France. ResultsThe belief about whether a patient may exercise alone varied between the professional groups with more STs and MDs finding it acceptable: 62% of PTs vs. 74% of STs (p = 0.005) and 79% of MDs (p = 0.02). For 93% of therapists (STs and PTs together), the caregiver may take part in physical therapy sessions. The appropriate weekly duration of exercises in chronic hemiparesis should be over 5 h for 19% of PTs, 37% of STs, and 51% of MDs (MDs vs. PTs, p < 0.005). After stroke, functional progress through rehabilitation is possible all lifelong for 11% of STs, 19% of PTs (p < 0.05, STs vs. PTs), and 29% of MDs (MD vs. PT, NS). ConclusionsThe strategy of asking patients to perform exercises alone, in the practice or at home, is still not accepted by a large proportion of physical therapy professionals as compared with students or with physicians. Most therapists still see a <5-h weekly duration of exercise as sufficient after stroke. Few therapists are ready to utilize the persistence of behavior-induced brain plasticity regardless of age or delay after the lesion. [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]

In hemiparesis, Wireless, Accelerometry-Triggered Functional Electrical Stimulation (WAFES) of the common peroneal nerve may hold intrinsic rehabilitative properties. The present pilot study analyzes WAFES against conventional therapy. Twenty adults with chronic hemiparesis (time since lesion 7(6) years; median (interquartile range)) were randomized into 2 10-week rehabilitation programs: a 45-minute (min) daily walk using WAFES (n = 10) and conventional physical therapy (CPT), 3 × 45 min per week (n = 10). The outcomes were 3D sagittal speed measurements, step length, cadence, maximal amplitude and velocity of hip, knee, and ankle during gait at free and fast speed without WAFES and clinical assessments of plantar flexor angles of shortening, spasticity, and weakness, before (D1) and after the program (W10). Kinematic and spasticity improvements occurred in the WAFES group only: (i) ankle dorsiflexion velocity (D1 versus W10, free speed, WAFES, +4(5)°/sec,p = 0.002; CPT, −3(8)°/sec,p = 0.007; fast, WAFES, +8(6)°/sec,p = 0.03; CPT, −1(4)°/sec,NS); (ii) maximal passive ankle dorsiflexion (WAFES,+26(85)%; CPT,+0(27)%; group-visit,p = 0.007) and knee flexion (WAFES, +13(17)%; CPT, −1(11)%; group-visit,p = 0.006) at fast speed only; (iii) 15% plantar flexor spasticity grade reduction with WAFES. Over 10 weeks, gait training using WAFES improved ankle and knee kinematics and reduced plantar flexor spasticity compared with CPT. Studies with longer WAFES use should explore functional effects. [ABSTRACT FROM PUBLISHER]

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]