Use of Botulinum Toxin in Upper-Limb Tremor: Systematic Review and Perspectives.

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.

Measurement properties of movement smoothness metrics for upper limb reaching movements in people with moderate to severe subacute stroke.

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.

Test-Retest and Inter-Rater Reliability of the 20-Meter Ambulation Test in Patients with Parkinson's Disease.

OBJECTIVE: In patients with Parkinson's disease, limited sit-to-stand, walk and turn contribute to decreased independence and quality of life. The 20-meter Ambulation Test (AT20) evaluates walking a total of 20 m, over a 10-m distance, back and forth between 2 chairs, starting and ending in a seated position. The aim of this study was to evaluate test-retest and inter-rater reliability of the AT20 in patients with Parkinson's disease. METHODS: Patients with idiopathic Parkinson's disease performed the AT20 in 3 conditions: free speed, fast speed, and with large steps, twice 1 week apart. The total number of steps and the time to complete the task were recorded manually by 4 independent raters. The main outcome criteria were the test-retest and inter-rater intraclass correlation coefficients and coefficients of variation for speed, step length and cadence in the 3 conditions. RESULTS: Twenty participants completed the 2 visits. Across all conditions, test-retest and inter-rater intraclass correlation coefficients for step length and speed were > 95%. Test-retest and inter-rater coefficients of variation were < 0.08. CONCLUSION: The AT20 is a reliable ambulation test in Parkinson's disease, with excellent test-retest and inter-rater reliability for step length and speed in all 3 conditions: at free speed, fast speed, and with large steps. The AT20 might be useful to assess ambulation in parkinsonism in clinical practice.

Comparison of Various Smoothness Metrics for Upper Limb Movements in Middle-Aged Healthy Subjects.

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.

Worldwide Survey of Clinician Practice on use of Adjunctive Therapies Following Botulinum Toxin Injection for Spasticity.

OBJECTIVE: Non-pharmacological adjunctive therapies can be used alongside botulinum toxin injection to enhance its efficacy. The objective of this global study was to determine the current practice and perception among clinicians of the use of adjunctive therapies after botulinum toxin injections for the treatment of limb spasticity. METHODS: A questionnaire with 22 questions on clinical practice demographics, self-reported use and clinician opinion on barriers to the use of complementary therapies, and priorities for future research was translated into 7 languages and distributed worldwide through national and international professional associations concerning (neuro)rehabilitation. RESULTS: A total of 527 clinicians from 52 countries responded to the survey. Most commonly used physical interventions were: active exercise programmes at home (81%), stretching programmes at home (81%), and splinting (70%), followed by active movement exercises (65%) and within 30 min of botulinum toxin injection and constraint induced movement therapy (63%). The main barriers reported by clinicians to provision of these interventions were clinicians' lack of time, limited financial resources, and lack of evidence. Future research should focus primarily on immediate active movement exercises and passive stretching. CONCLUSION: Worldwide, clinicians often recommend adjunctive therapies after a botulinum toxin injection to reduce spasticity. The most commonly used physical interventions among clinicians were active exercises at home, stretching at home, and splinting. Lack of evidence, time and financial constraints were identified as barriers to providing these interventions.

Do Muscle Changes Contribute to the Neurological Disorder in Spastic Paresis?

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.

Using Robot-Based Variables during Upper Limb Robot-Assisted Training in Subacute Stroke Patients to Quantify Treatment Dose.

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.

Quantified clinical measures linked to ambulation speed in hemiparesis.

BACKGROUND: 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. METHODS: 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. RESULTS: 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, ß=-0.20, p=.03; CWK, comfortable, ß=-0.21, p=.010; fast, ß=-0.21, p =.012), rectus femoris (CSH, comfortable, ß=-0.41, p=6E-7; fast, ß=-0.43, p=5E-7; CWK, comfortable, ß=-0.36, p=5E-5; fast, ß=-0.33, p=.0003) and gluteus maximus (CSH, comfortable, ß=-0.19, p=.02; fast, ß=-0.26, p=.002; CWK, comfortable, ß=-0.26, p=.002; fast, ß=-0.22, p=.010). Ambulation speed was not correlated with CSP. CONCLUSIONS: 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.

Agonist and antagonist activation at the ankle monitored along the swing phase in hemiparetic gait.

BACKGROUND: 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. METHODS: 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. FINDINGS: 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). INTERPRETATION: 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.

Composite active range of motion (CXA) and relationship with active function in upper and lower limb spastic paresis.

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.

Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial.

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.

Ultrasound Structural Changes in Triceps Surae After a 1-Year Daily Self-stretch Program: A Prospective Randomized Controlled Trial in Chronic Hemiparesis.

INTRODUCTION: The effects of long-term stretching (>6 months) in hemiparesis are unknown. This prospective, randomized, single-blind controlled trial compared changes in architectural and clinical parameters in plantar flexors of individuals with chronic hemiparesis following a 1-year guided self-stretch program, compared with conventional rehabilitation alone. METHODS: Adults with chronic stroke-induced hemiparesis (time since lesion >1 year) were randomized into 1 of 2, 1-year rehabilitation programs: conventional therapy (CONV) supplemented with the Guided Self-rehabilitation Contract (GSC) program, or CONV alone. In the GSC group, specific lower limb muscles, including plantar flexors, were identified for a diary-based treatment utilizing daily, high-load, home self-stretching. Blinded assessments included (1) ultrasonographic measurements of soleus and medial gastrocnemius (MG) fascicle length and thickness, with change in soleus fascicle length as primary outcome; (2) maximum passive muscle extensibility (XV1, Tardieu Scale); (3) 10-m maximal barefoot ambulation speed. RESULTS: In all, 23 individuals (10 women; mean age [SD], 56 [±12] years; time since lesion, 9 [±8] years) were randomized into either the CONV (n = 11) or GSC (n = 12) group. After 1 year, all significant between-group differences favored the GSC group: soleus fascicle length, +18.1mm [9.3; 29.9]; MG fascicle length, +6.3mm [3.5; 9.1]; soleus thickness, +4.8mm [3.0; 7.7]; XV1 soleus, +4.1° [3.1; 7.2]; XV1 gastrocnemius, +7.0° [2.1; 11.9]; and ambulation speed, +0.07m/s [+0.02; +0.16]. CONCLUSIONS: In chronic hemiparesis, daily self-stretch of the soleus and gastrocnemius over 1 year using GSC combined with conventional rehabilitation increased muscle fascicle length, extensibility, and ambulation speed more than conventional rehabilitation alone.

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study.

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 self-rehabilitation 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. TRIAL REGISTRATION NUMBER: NCT02944929.

Evolution of upper limb kinematics four years after subacute robot-assisted rehabilitation in stroke patients.

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.

Intra- and inter-rater reliability of the 10-meter ambulation test in hemiparesis is better barefoot at maximal speed.

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.

Effect on Passive Range of Motion and Functional Correlates After a Long-Term Lower Limb Self-Stretch Program in Patients With Chronic Spastic Paresis.

BACKGROUND: In current health care systems, long-duration stretching, performed daily, cannot be obtained through prescriptions of physical therapy. In addition, the short-term efficacy of the various stretching techniques is disputed, and their long-term effects remain undocumented. OBJECTIVE: To evaluate changes in extensibility in 6 lower limb muscles and in ambulation speed after a ≥1-year self-stretch program, the Guided Self-rehabilitation Contract (GSC), in individuals with chronic spastic paresis. DESIGN: Retrospective study. SETTING: Neurorehabilitation clinic. PARTICIPANTS: Patients diagnosed with hemiparesis or paraparesis at least 1 year before the initiation of a GSC and who were then involved in the GSC program for at least 1 year. INTERVENTIONS: For each patient, specific muscles were identified for intervention among the following: gluteus maximus, hamstrings, vastus, rectus femoris, soleus, and gastrocnemius. Prescriptions and training for a daily, high-load, prolonged, home self-stretching program were primarily based on the baseline coefficient of shortening, defined as CSH = [(XN -XV1)/XN] (XV1 = PROM, passive range of motion; XN = normally expected amplitude). MAIN OUTCOME MEASUREMENTS: Six assessments were performed per year, measuring the Tardieu XV1 or maximal slow stretch range of motion angle (PROM), CSH, 10-m ambulation speed, and its functional ambulation category (Perry's classification: household, limited, or full). Changes from baseline in self-stretched and nonself-stretched muscles were compared, with meaningful XV1 change defined as ΔXV1 >5° for plantar flexors and >10° for proximal muscles. Correlation between the composite XV1 (mean PROM for the 6 muscles) and ambulation speed also was evaluated. RESULTS: Twenty-seven GSC participants were identified (14 women, mean age 44 years, range 29-59): 18 with hemiparesis and 9 with paraparesis. After 1 year, 47% of self-stretched muscles showed meaningful change in PROM (ΔXV1) versus 14% in nonself-stretched muscles (P < .0001, χ2). ΔCSH was -31% (95% confidence interval [95% CI] -41.5 to -15.2) in self-stretched versus -7% (95% CI -11.9 to -2.1) in nonself-stretched muscles (P < .0001, t-test). Ambulation speed increased by 41% (P < .0001) from 0.81 m/s (95% CI 0.67-0.95) to 1.15 m/s (95% CI 1.01-1.29). Eight of the 12 patients (67%) who were in limited or household categories at baseline moved to a higher functional ambulation category. There was a trend for a correlation between composite XV1 and ambulation speed (r = 0.44, P = .09) in hemiparetic patients. CONCLUSION: Therapists should consider prescribing and monitoring a long-term lower limb self-stretch program using GSC, as this may increase muscle extensibility in adult-onset chronic paresis. LEVEL OF EVIDENCE: III.

Time, touch and temperature affect perceived finger position and ownership in the grasp illusion.

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.

Pattern of improvement in upper limb pointing task kinematics after a 3-month training program with robotic assistance in stroke.

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).

Beliefs of rehabilitation professionals towards guided self-rehabilitation contracts for post stroke hemiparesis.

Purpose To 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. Method A 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. Results The 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). Conclusions The 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.