Aging effects on electrical and hemodynamic responses in the sensorimotor network during unilateral proximal upper limb functional tasks.

Healthy aging leads to poorer performance in upper limb (UL) daily living movements. Understanding the neural correlates linked with UL functional movements may help to better understand how healthy aging affects motor control. Two non-invasive neuroimaging methods allow for monitoring the movement-related brain activity: functional near-infrared spectroscopy (fNIRS) and electroencephalography (EEG), respectively based on the hemodynamic response and electrical activity of brain regions. Coupled, they provide a better spatiotemporal mapping. The aim of this study was to evaluate the effect of healthy aging on the bilateral sensorimotor (SM1) activation patterns of functional proximal UL movements. Twenty-one young and 21 old healthy participants realized two unilateral proximal UL movements during: i) a paced reaching target task and ii) a circular steering task to capture the speed-accuracy trade-off. Combined fNIRS-EEG system was synchronised with movement capture system to record SM1 activation while moving. The circular steering task performance was significantly lower for the older group. The rate of increase in hemodynamic response was longer in the older group with no difference on the amplitude of fNIRS signal for the two tasks. The EEG results showed aging related reduction of the alpha-beta rhythms synchronisation but no desynchronisation modification. In conclusion, this study uncovers the age-related changes in brain electrical and hemodynamic response patterns in the bilateral sensorimotor network during two functional proximal UL movements using two complementary neuroimaging methods. This opens up the possibility to utilise combined fNIRS-EEG for monitoring the movement-related neuroplasticity in clinical practice.

What can be expected from tendon transfers in the upper limb in central nervous system disorders?

In addition to motor deficits, central nervous system disorders combine major alterations in the motor pattern with spasticity and over time, contractures. Their varied clinical presentation makes their assessment and the therapeutic strategy more complex. For these reasons, tendon transfers in this population will have more limited indications and above all, will have to be integrated into a complex surgical program combining other procedures such as tendon lengthening, selective neurotomies and joint stabilization. The surgical strategy is far from being obvious. When faced with clinical presentations having very different objectives-functional or comfort only-it is difficult at first sight to build a standardized surgical program. We therefore propose a method to evaluate these patients, thanks to a score (INOM) that integrates prognostic factors and parameters to be corrected surgically. Three components guide this program: a prognostic factor (proximal motor control of the shoulder and elbow), correction of abnormal limb postures and restoration of active elbow, wrist and finger extension. The surgical strategy can be constructed from the INOM score which establishes the priorities for care. Nerve blocks and botulinum toxin injections are essential tools for this analysis. They help distinguish between spasticity and contracture, and can unmask certain antagonistic muscles. A tendon transfer in this population will be just as effective by the function it restores as by the action it suppresses in a malpositioned limb. For each joint, we describe the indications for tendon transfers and their relative role among the techniques with which they must be combined.

Assessment of the upper limb of the tetraplegic patient.

The aim of our study is to describe the assessment of the upper limb in tetraplegic patients to follow his (her) neurological progression and to define the medical or surgical treatment program. We selected upper limb assessment tools and scales for tetraplegic patients described in the medical literature through a PubMed search over the last four decades. For each method, we present the implementation rules and its metrological properties, including its validity in French. We selected five clinical scales for functional evaluation of grasping, as well as four scales for evaluating the overall function of these patients. Finally, we identified three complementary precision assessment tools. The AIS (ASIA Impairment Scale) classification describes the level and the severity of the spinal cord lesion. The Giens classification is more practical for describing the upper limb in middle and low tetraplegia. Impairments can be assessed with most common generic scales and nonspecific measurement devices: range of motion, strength, sensory loss, spasticity, joint pain. Measurement of pinch and grip strength is widely used and easy to perform. The Capabilities of Upper Extremity (CUE) and the Jebsen Taylor Test are the best validated and usable scales. At a general functional level, the Spinal Cord Independence Measure (SCIM) is the most relevant scale in these patients. Motor nerve blocks, electromyography, movement analysis and echography are promising additional methods. Assessment of the upper limb of tetraplegic patients relies both on generic and specific assessment tools and scales.

Kinect-based assessment of proximal arm non-use after a stroke.

BACKGROUND: After a stroke, during seated reaching with their paretic upper limb, many patients spontaneously replace the use of their arm by trunk compensation movements, even though they are able to use their arm when forced to do so. We previously quantified this proximal arm non-use (PANU) with a motion capture system (Zebris, CMS20s). The aim of this study was to validate a low-cost Microsoft Kinect-based system against the CMS20s reference system to diagnose PANU. METHODS: In 19 hemiparetic stroke individuals, the PANU score, reach length, trunk length, and proximal arm use (PAU) were measured during seated reaching simultaneously by the Kinect (v2) and the CMS20s over two testing sessions separated by two hours. RESULTS: Intraclass correlation coefficients (ICC) and linear regression analysis showed that the PANU score (ICC = 0.96, r2 = 0.92), reach length (ICC = 0.81, r2 = 0.68), trunk length (ICC = 0.97, r2 = 0.94) and PAU (ICC = 0.97, r2 = 0.94) measured using the Kinect were strongly related to those measured using the CMS20s. The PANU scores showed good test-retest reliability for both the Kinect (ICC = 0.76) and CMS20s (ICC = 0.72). Bland and Altman plots showed slightly reduced PANU scores in the re-test session for both systems (Kinect: - 4.25 ± 6.76; CMS20s: - 4.71 ± 7.88), which suggests a practice effect. CONCLUSION: We showed that the Kinect could accurately and reliably assess PANU, reach length, trunk length and PAU during seated reaching in post stroke individuals. We conclude that the Kinect can offer a low-cost and widely available solution to clinically assess PANU for individualised rehabilitation and to monitor the progress of paretic arm recovery. TRIAL REGISTRATION: The study was approved by The Ethics Committee of Montpellier, France (N°ID-RCB: 2014-A00395-42) and registered in Clinical Trial (N° NCT02326688, Registered on 15 December 2014, https://clinicaltrials.gov/ct2/show/results/NCT02326688 ).

Results and complications of superficialis-to-profundus tendon transfer in brain-damaged patients, a series of 26 patients.

INTRODUCTION: In hemiplegic patients with a spastic clenched fist deformity, one of the goals of surgery is to address the hygiene, nursing and appearance problems. Transfer of the flexor digitorum superficialis (FDS) to the flexor digitorum profundus (FDP), initially described by Braun and colleagues, opens the non-functional hand in these patients. The primary objective of our study was to confirm the effectiveness of this technique for correcting these deformities. The secondary objectives were to demonstrate potential functional gains and to identify potential complications. MATERIAL AND METHODS: A Braun procedure was performed in 26 patients (9 women, 17 men, ranging in age from 36 to 79 years). The overall appearance of the hand was graded using the Keenan classification system. Complications related to the surgery were documented. The hand's function was evaluated with the House score. RESULTS: The average follow-up was 47 months. Preoperatively, all patients had a class V hand: severe clenched-fist deformity with zero pulp-to-palm distance. Postoperatively, 10 patients had a type I hand (open hand, with less than 20° spontaneous extension deficit of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints) and 12 patients had a type II hand (20° to 40° spontaneous extension deficit of the MCP and PIP joints). The mean House score for all patients went from 0 to 0.88, and seven patients had functional improvements. Four patients had a forearm supination posture, 10 had intrinsic deformity with spontaneous MCP flexion and 6 had a swan-neck deformity. CONCLUSION: Superficialis-to-profundus tendon transfer (STP) provides satisfactory outcomes in terms of hand opening, with some patients also experiencing improved hand function. However, the complications cannot be ignored. LEVEL OF EVIDENCE: IV-retrospective or historical series.

Proximal arm non-use when reaching after a stroke.

After a stroke, many people "cannot and do not" use their paretic upper limb. With recovery, some people "can but do not" use their paretic upper limb and this non-use should be counteracted with specific rehabilitation. The aim of the study was to quantify one aspect of the non-use: proximal arm non-use when reaching within one's arm length in 45 post-stroke and 45 age matched controls. Arm use refers to the contribution of the shoulder and elbow motion to the hand movement towards the target. Proximal arm non-use is calculated as the ratio of the difference between spontaneous arm use and maximal arm use. We found that proximal arm non-use has very good test-retest reliability, does not depend on time since stroke, increases with impairment (Fugl-Meyer) and loss of function (Box & Block), and most importantly, that 61% of patients with lower impairment (Fugl-Meyer >28/42) exhibit proximal arm non-use. We conclude that quantifying proximal arm non-use in post-stroke individuals provides novel information that complements routine clinical measures. It is likely that proximal arm non-use quantifies one aspect of the motor reserve that therapists can target in patient specific rehabilitation programs.

Kinematics in the brain: unmasking motor control strategies?

In rhythmical movement performance, our brain has to sustain movement while correcting for biological noise-induced variability. Here, we explored the functional anatomy of brain networks during voluntary rhythmical elbow flexion/extension using kinematic movement regressors in fMRI analysis to verify the interest of method to address motor control in a neurological population. We found the expected systematic activation of the primary sensorimotor network that is suggested to generate the rhythmical movement. By adding the kinematic regressors to the model, we demonstrated the potential involvement of cerebellar-frontal circuits as a function of the irregularity of the variability of the movement and the primary sensory cortex in relation to the trajectory length during task execution. We suggested that different functional brain networks were related to two different aspects of rhythmical performance: rhythmicity and error control. Concerning the latter, the partitioning between more automatic control involving cerebellar-frontal circuits versus less automatic control involving the sensory cortex seemed thereby crucial for optimal performance. Our results highlight the potential of using co-registered fine-grained kinematics and fMRI measures to interpret functional MRI activations and to potentially unmask the organisation of neural correlates during motor control.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

Combining balneotherapy and health promotion to promote active and healthy ageing: the Balaruc-MACVIA-LR® approach.

Scaling up and replication of successful innovative integrated care models for chronic diseases is one of the targets of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). MACVIA-LR® (MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon) is a Reference Site of the EIP on AHA. The main objective of MACVIA-LR® is to develop innovative solutions in order to (1) improve the care of patients affected by chronic diseases, (2) reduce avoidable hospitalization and (3) scale up the innovation to regions of Europe. The MACVIA-LR® project also aims to assess all possible aspects of medicine-including non-pharmacologic approaches-in order to maintain health and prevent chronic diseases. These approaches include hydrotherapy and balneotherapy which can be of great importance if health promotion strategies are considered. Balneotherapy at Balaruc-les-Bains focusses on musculoskeletal diseases and chronic venous insufficiency of the lower limbs. Each year, over 46,000 people attend an 18-day course related to a new falls prevention initiative combining balneotherapy and education. On arrival, each person receives a flyer providing information on the risk of fall and, depending on this risk, a course is proposed combining education and physical activity. A pilot study assesses the impact of the course 6 and 12 months later. This health promotion strategy for active and healthy ageing follows the FEMTEC (World Federation of Hydrotherapy and Climatotherapy) concept.

Brain computer interfaces for neurorehabilitation ­ its current status as a rehabilitation strategy post-stroke.

The idea of using brain computer interfaces (BCI) for rehabilitation emerged relatively recently. Basically, BCI for neurorehabilitation involves the recording and decoding of local brain signals generated by the patient, as he/her tries to perform a particular task (even if imperfect), or during a mental imagery task. The main objective is to promote the recruitment of selected brain areas involved and to facilitate neural plasticity. The recorded signal can be used in several ways: (i) to objectify and strengthen motor imagery-based training, by providing the patient feedback on the imagined motor task, for example, in a virtual environment; (ii) to generate a desired motor task via functional electrical stimulation or rehabilitative robotic orthoses attached to the patient's limb ­ encouraging and optimizing task execution as well as "closing" the disrupted sensorimotor loop by giving the patient the appropriate sensory feedback; (iii) to understand cerebral reorganizations after lesion, in order to influence or even quantify plasticity-induced changes in brain networks. For example, applying cerebral stimulation to re-equilibrate inter-hemispheric imbalance as shown by functional recording of brain activity during movement may help recovery. Its potential usefulness for a patient population has been demonstrated on various levels and its diverseness in interface applications makes it adaptable to a large population. The position and status of these very new rehabilitation systems should now be considered with respect to our current and more or less validated traditional methods, as well as in the light of the wide range of possible brain damage. The heterogeneity in post-damage expression inevitably complicates the decoding of brain signals and thus their use in pathological conditions, asking for controlled clinical trials.

Innovative technologies applied to sensorimotor rehabilitation after stroke.

Innovative technologies for sensorimotor rehabilitation after stroke have dramatically increased these past 20 years. Based on a review of the literature on "Medline" and "Web of Science" between 1990 and 2013, we offer an overview of available tools and their current level of validation. Neuromuscular electric stimulation and/or functional electric stimulation are widely used and highly suspected of being effective in upper or lower limb stroke rehabilitation. Robotic rehabilitation has yielded various results in the literature. It seems to have some effect on functional capacities when used for the upper limb. Its effectiveness in gait training is more controversial. Virtual reality is widely used in the rehabilitation of cognitive and motor impairments, as well as posture, with admitted benefits. Non-invasive brain stimulation (rTMS and TDCS) are promising in this indication but clinical evidence of their effectiveness is still lacking. In the same manner, these past five years, neurofeedback techniques based on brain signal recordings have emerged with a special focus on their therapeutic relevance in rehabilitation. Technological devices applied to rehabilitation are revolutionizing our clinical practices. Most of them are based on advances in neurosciences allowing us to better understand the phenomenon of brain plasticity, which underlies the effectiveness of rehabilitation. The acceptation and "real use" of those devices is still an issue since most of them are not easily available in current practice.

Isokinetic muscle strengthening after acquired cerebral damage: a literature review.

OBJECTIVE: Isokinetic strengthening is a rehabilitation technique rarely used in stroke patients. However, the potential benefits of force and endurance training in this population are strongly suspected. METHOD: This literature review synthesizes the results of clinical trials on this topic. The research was conducted on PubMed, using "Stroke", "rehabilitation", "isokinetic", "upper limb" and "training" as keywords. RESULTS: Seventeen studies focusing on the use of isokinetics in assessment or rehabilitation (six studies) following stroke were reviewed. For the lower limb, muscle strength and walking ability improved after isokinetic rehabilitation programs. For the upper limb, the only two studies found in the literature suggest improvement in the strength of the trained muscles, of grip force, of the Fugl-Meyer motor score and of global functional capacities. This review does not reveal any consensus on the protocols to be implemented: type of muscle contraction, velocities…. CONCLUSION: While isokinetic strengthening has not proven its efficiency in rehabilitation of the upper limb following stroke, its interest with regard to rehabilitation of the lower limbs has been recognized. Randomized controlled trials in this field are necessary to confirm its efficiency, especially concerning upper arm rehabilitation.

Self-catheterization acquisition after hand reanimation protocols in C5-C7 tetraplegic patients.

STUDY DESIGN: Case series from a prospectively acquired database and phone survey. OBJECTIVES: To assess the efficacy of upper limb reanimation (ULR) protocols on acquisition of intermittent self-catheterization (ISC) in C5-C7 ASIA tetraplegic patients. SETTING: University Hospital, Paris, France. METHODS: A prospectively acquired database of 152 tetraplegic patients followed in ULR consultation between 1997 and 2008 in a rehabilitation unit was studied. A total of 20 patients met the inclusion criteria, which mainly were traumatic C5-C7 tetraplegic adult patients who were unable to perform ISC, and who benefited from ULR with the objectives of improving hand abilities and of ISC acquisition, through urethral orifice for males or via a continent urinary stoma for females. The main outcome measure was ISC acquisition (ISC+) proportion. Population characteristics and secondary outcome measures: ISC+/ISC- patients were compared regarding epidemiological and surgical data, key-grip strength, patient global improvement score, activities of daily living and quality of life (PGI-I, Wuolle questionnaire, verbal rating scale). RESULTS: ISC+ was 75%. It depended on key-grip strength (P<0.05) and led to a statistically significant improvement of urinary status compared with ISC- patients (P<0.01). ULR improved patients' abilities and QoL in both ISC+ and ISC- patients. CONCLUSION: ULR protocols allow ISC in most C5-C7 tetraplegic patients. Multidisciplinary care with surgeons and PRM physicians improves patients' vital and functional prognosis by changing their urological-management method.

Reproducibility of isokinetic peak torque assessments of the hip flexor and extensor muscles.

OBJECTIVES: Isokinetic assessment is currently the reference method for measuring dynamic muscle strength. We have sought to evaluate the reproducibility over time of isokinetic testing of the hip flexor (FI) and extensor (Ext) muscles and to establish whether there is a significant difference in peak torque (PT) between the left and right hips. PATIENTS AND METHODS: Ten adults were tested once a week for 3 weeks by the same investigator and according to the same protocol, with two velocities (60 degrees /s and 180 degrees /s) for the hip FI and Ext in concentric tests and one velocity (30 degrees /s) for the Ext only in eccentric tests. The reproducibility of the measured PT was analyzed by using the intraclass correlation coefficient (ICC) and a Bland and Altman plot. The difference in PT between the right and left hips was tested using Student's T test. RESULTS: The ICC for the observed PT values revealed very good reproducibility (with a value of between 0.75 and 0.96) for the hip FI and Ext measurements (regardless of the body side, test velocity or contraction mode). We did not observe any significant PT differences between the right and left hips. CONCLUSION: The isokinetic assessment of the concentric and eccentric PT values generated by the hip FI and Ext is highly reproducible. There is no difference between dominant and nondominant body sides, which enables the use of the contralateral limb as a reference.

Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: technique and results.

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.