Successful long-term management of spasticity in people with multiple sclerosis using a software application: Results from a randomized, controlled, multicenter study.

BACKGROUND AND PURPOSE: Successful long-term treatment of spasticity in people with multiple sclerosis (pwMS) is challenging. We investigated the effects of multidisciplinary inpatient rehabilitation (MIR) and an individualized self-training program delivered by an app on spasticity in pwMS. METHODS: First, we assessed the efficacy of 4-week MIR in ambulatory pwMS (Expanded Disability Status Scale < 7.0) with moderate to severe lower limb spasticity (defined by ≥4 points on the Numeric Rating Scale for spasticity [NRSs]) in a cohort of 115 pwMS at seven rehabilitation centers in Austria. In the case of a clinically relevant improvement in spasticity of ≥20% on the NRSs following MIR (n = 94), pwMS were randomly allocated in a 1:1 ratio to either the newly designed MS-Spasticity App or to a paper-based self-training program for 12 weeks. The primary outcome was change in NRSs (German Clinical Trials Registry DRKS00023960). RESULTS: MIR led to a significant reduction of 2.0 points on the NRSs (95% confidence interval [CI] = 2.5-2.0, p < 0.000). MIR was further associated with a statistically significant improvement in spasticity on the Modified Ashworth Scale, strength, and all mobility outcomes. Following MIR, self-training with the MS-Spasticity App was associated with a sustained positive effect on the NRSs, whereas paper-based self-training led to a worsening in spasticity (median NRSs difference = 1.0, 95% CI = 1.7-0.3, p = 0.009). The MS-Spasticity App was also associated with a significantly better adherence to self-training (95% vs. 72% completion rate, p < 0.001). CONCLUSIONS: In pwMS, MIR is able to significantly improve lower limb spasticity, strength, and mobility. Following MIR, an individually tailored antispasticity program delivered by an app leads to sustained positive long-term management.

Women With Cerebral Infarction Feature Worse Clinical Profiles at Admission but Comparable Success to Men During Long-Term Inpatient Neurorehabilitation.

Objective: Little is known about possible sex and gender differences in post-stroke neurorehabilitation outcomes. We aimed to analyze if functional performance, prevalence and impact of comorbidities at admission, and success of inpatient stroke-neurorehabilitation differ between men and women. Methods: Retrospective cohort analysis of 1,437 men and 907 women with prior cerebral infarction treated at a neurorehabilitation clinic between 2012 and 2017; multiple linear regression was used to examine the influence of sex/gender as well as multiple confounders on health and functional outcomes. The main outcome measures were Barthel index (BI) at admission and its change during 4 weeks inpatient neurorehabilitation. Results: Men had been diagnosed with osteoporosis less frequently than women but more often with type 2 diabetes mellitus, coronary artery or chronic kidney disease (p ≤ 0.01). Although twice as many women presented with pre-stroke depression compared to men, the risk of post-stroke depression detected during rehabilitation was comparable. Men were more likely to have less than 30 days between diagnosis and neurorehabilitation start than women (p < 0.03). At admission, women exhibited less autonomy, a lower BI, a higher pain score and worse 2-min walk test (2'WT) compared to men (p < 0.001). Among males osteoporosis and peripheral artery disease independently predicted BI at admission, in women it was pre-stroke depression, dementia, and arterial fibrillation. During neurorehabilitation, both sexes improved regarding BI, pain and walk tests (p < 0.001). Despite comparable rehabilitation effectiveness, women still had worse functional outcomes than males at discharge. Time after stroke to start of neurorehabilitation and length of the stay but, most strongly, the simple 2'WT at admission, and in women, pain intensity independently predicted post-stroke functional status and recovery. Conclusion: Women presented with worse functional status at admission to neurorehabilitation. Although men and women showed similar rehabilitation effectiveness, women still displayed worse clinical outcome measures and higher levels of pain at discharge. Early access and gender-sensitive, personalized post-stroke care with more focus on different comorbidities and psychosocial factors like pain levels and management, could further improve neurorehabilitation outcomes.

The configuration and relaxation of motor task sets.

Often the performance of a task does not only require the processing of certain stimuli in certain ways, but also certain patterns of interlimb coordination. We studied shifts between different tasks involving different patterns of intermanual coupling by means of the timed-response procedure, which allows to trace state variables related to task sets. The tasks required the production of rapid bimanual reversal movements with symmetric or parallel directions. Symmetric movements are associated with symmetric coupling, as indicated by positive intermanual correlations between the directions of left-hand and right-hand movements, whereas parallel movements are associated with parallel coupling, as indicated by negative intermanual correlations. Task switches were associated with gradual changes of the intermanual correlations, which indicate the state of intermanual coupling as a major ingredient of a task set, in the course of action preparation. At short preparation intervals intermanual correlations were those appropriate for the preceding trial; with increasing preparation time they were replaced by those appropriate for the current trial, but the influence of the preceding trial did not disappear completely. In-between trials, intermanual coupling drifted toward a symmetric coupling, but not to uncoupled limbs. After a change of the task the specification of movement directions was slowed, but its initiation was not delayed. According to these results, task sets relax toward attractors which can be different from the absence of task sets. They are gradually configured during task preparation with a persistent influence of the preceding task, and the specification of response characteristics does not wait until the configuration of the new task set is completed.

Intermanual interactions related to movement amplitudes and endpoint locations.

In almost all studies of bimanual movements with same and different amplitudes, the difference between amplitudes has been confounded with a difference between endpoint locations. The present authors varied those parameters orthogonally. In addition, they presented target locations on the surface on which the movements were produced (direct cues) and on a monitor (indirect cues). Participants' (N = 12) reaction times were longer when both amplitudes and endpoint locations differed than when they were the same. Intermanual amplitude correlations were reduced whenever 1 of the movement parameters differed for the 2 hands; only when cues were presented on the monitor was the amplitude correlation further reduced when both movement parameters were different. The results indicate that structural constraints on bimanual movements take effect on both amplitudes and endpoint locations. The relative importance of those 2 parameters is largely independent of the type of cue.

The influence of movement cues on intermanual interactions.

In two experiments, we studied intermanual interactions in bimanual reversal movements and bimanual aiming movements. Targets were presented on a monitor or directly on the table on which the movements were produced. Amplitudes for each hand were cued symbolically or spatially either in advance of an imperative signal or simultaneous with it. In contrast to findings of Diedrichsen et al. (Psychological Science, 12, 493-498, 2001), reaction times for different-amplitude movements were longer than for same-amplitude movements both for symbolic and spatial cues presented on the monitor and directly on the table. However, with symbolic cues the effect of the relation between target amplitudes was considerably stronger than with spatial cues, no matter where the cues were presented. Intermanual correlations of amplitudes, movement times, and reaction times were smaller with different than with same target amplitudes, and this modulation was more pronounced when targets and cues were presented on the monitor than when they were presented on the table. The findings are taken to suggest that the basic reaction-time disadvantage of different-amplitude movements results from interference between concurrent processes of amplitude specification. Additional factors like interference between concurrent processes of mapping cues on movement characteristics may add strongly to it.

The modulation of intermanual interactions during the specification of the directions of bimanual movements.

In two experiments bimanual movements with various combinations of target directions were studied by means of the timed-response procedure. The findings revealed an adaptive modulation of intermanual interactions during direction specifications depending on particular target directions. For symmetric movements intermanual correlations of movement directions are positive, indicating a symmetric coupling. For parallel movements the positive intermanual correlations, observed at short preparation intervals, turn into negative correlations as the time available for motor preparation increases. Biases of mean directions, that can be observed for movements to targets with different eccentricities, reflect one or the other kind of coupling, symmetrical for symmetric target directions and parallel for parallel target directions. These biases are static, that is, they are present at long preparation times, and they are phasically enhanced at shorter preparation intervals. The task-adaptive modulation of intermanual interactions is superposed on a basic symmetry bias.

Intermanual interactions in discrete and periodic bimanual movements with same and different amplitudes.

In two experiments we compared intermanual interactions in discrete and periodic movements with same and different amplitudes. In the first experiment there was only a weak amplitude assimilation in first cycles of movements with 1, 3, and 10 cycles, but a strong assimilation in later cycles. Whereas movement times of concurrent short-amplitude and long-amplitude movements were different in first cycles, in the later cycles they were essentially identical. In the second experiment the timed-response procedure was used to study the specification of same and different amplitudes of discrete reversal movements and periodic movements with three cycles. Differences in the time courses of amplitude specifications were only small. In periodic movements a dependence of amplitudes on the preparation interval was seen not only in the first cycles, but also in the later ones. However, in the later cycles the characteristic dependence of assimilation effects and intermanual correlations on the preparation interval was absent. Taken together, these findings strongly suggest that intermanual interactions arise transiently in the specification of both discrete and periodic movements, and that additional kinds of interactions become effective during execution of periodic movements.

The effects of total sleep deprivation on the generation of random sequences of key-presses, numbers and nouns.

According to a recent hypothesis, executive functions should be particularly vulnerable to the effects of total sleep deprivation. Random generation is a task that taps executive functions. In three experiments we examined the effects of total sleep deprivation on random generation of key-presses, numbers, and nouns, in particular on the suppression of prepotent responses and the selection of next responses by way of applying a local-representativeness heuristic. With random key-presses suppression of prepotent responses did not suffer from lack of sleep, but it became poorer at a sufficiently high pacing rate. In contrast, suppression of prepotent responses suffered when numbers and nouns were generated. According to these findings different types of random generation tasks involve different types of inhibitory process. With only four response alternatives, but not with larger response sets, application of the local-representativeness heuristic was impaired after a night without sleep. In terms of a simple formal model, serial-order representations of the preceding responses are used in selecting the next response only for the small response set, and not for larger response sets. Thus, serial-order representations are likely to suffer from loss of sleep. These findings strongly suggest that random generation involves multiple processes and that total sleep deprivation does not impair all sorts of executive functions, but only some.

Total sleep deprivation increases the costs of shifting between simple cognitive tasks.

In two experiments we studied the effects of one night of total sleep deprivation on task-shift costs. In different conditions shifts were between types of judgment (extradimensional shifts) and between stimulus-response mappings (intradimensional shifts). In addition, with an alternating-runs procedure we used short and long response-to-stimulus intervals and also external precues to vary the opportunities for advance configuration of task sets. Under all conditions sleep deprivation increased shift costs derived from the 20% slowest reaction times, which were insensitive to the opportunities for advance configuration. Shift costs derived from the 20% fastest reaction times were increased only for extradimensional shifts. As indicated by congruency effects, the increase of shift costs after a night without sleep cannot be attributed to increased interference between competing task sets. The findings suggest that total sleep deprivation increases task-set instability and thus lapsing, in particular in conditions with long stimulus-to-response intervals and in shift trials. In addition total sleep deprivation seems to increase the duration of an exogenously controlled process involved in extradimensional shifts.

One night of total sleep deprivation impairs implicit learning in the serial reaction task, but not the behavioral expression of knowledge.

Implicit sequence learning in the serial reaction task suffers from total sleep deprivation. The authors compared implicit-learning scores in a sleep-deprivation (SD) group (n = 12) and a control group (n = 6). Both groups were tested immediately after learning a 1st sequence; a delayed test was conducted on the next day (after a night without sleep in the SD group). Immediately after the delayed test a 2nd sequence was learned, followed by an immediate test and a delayed test toward the end of the experiment. In the SD group implicit-learning scores were reduced in both tests of the 2nd sequence, but in neither test of the 1st sequence. Thus, 1 night of total sleep deprivation impairs the acquisition of implicit sequence knowledge, but not its behavioral expression.

Involuntary Rotations of a Steering Device Induced by Voluntary Rotations of the Head and Maintained Eccentric Head Positions.

In a series of 4 experiments, the authors examined involuntary rotations of a steering device (handlebar or wheel) that were associated with periodic head rotations and eccentric head positions. Periodic head rotations resulted in isodirectional involuntary rotations of a horizontally arranged steering device of very small amplitude. When the orientation of a steering wheel was changed to vertical and to a backward tilt, the involuntary rotations were in the opposite direction. That pattern of results is consistent with the assumption that small movements of the shoulder girdle, which are associated with head turns and which cannot be prevented by mechanical immobilization of the shoulder, are propagated to the wheel, but is not consistent with previous suggestions that involuntary rotations of a steering device can result from the action of the tonic neck reflex. Effects that correspond to the pattern of the tonic neck reflex were found only when a spring-centered handlebar was held in an eccentric position; maintenance of the eccentric position was facilitated when the participant's head was turned in the opposite direction. The findings strongly suggest that head movements can result in involuntary movements of a steering device via different mechanisms.