Guided Self-rehabilitation Contract vs conventional therapy in chronic peripheral facial paresis: VISAGE, a multicenter randomized controlled trial.

BACKGROUND: One year after persistent peripheral facial paresis (PFP), prescriptions of conventional rehabilitation are often downgraded into maintenance rehabilitation or discontinued, the patient entering what is seen as a chronic stage. This therapeutic choice is not consistent with current knowledge about behavior-induced plasticity, which is available all life long and may allow intense sensorimotor rehabilitation to remain effective. This prospective, randomized, multicenter single-blind study in subjects with chronic unilateral PFP evaluates changes in facial motor function with a Guided Self-rehabilitation Contract (GSC) vs. conventional therapy alone, carried out for six months. METHODS: Eighty-two adult subjects with chronic unilateral PFP (> 1 year since facial nerve injury) will be included in four tertiary, maxillofacial surgery (2), otolaryngology (1) and rehabilitation (1) centers to be randomized into two rehabilitation groups. In the experimental group, the PM&R specialist will implement the GSC method, which for PFP involves intensive series of motor strengthening performed daily on three facial key muscle groups, i.e. Frontalis, Orbicularis oculi and Zygomatici. The GSC strategy involves: i) prescription of a daily self-rehabilitation program, ii) teaching of the techniques involved in the program, iii) encouragement and guidance of the patient over time, in particular by requesting a quantified diary of the work achieved to be returned by the patient at each visit. In the control group, participants will benefit from community-based conventional therapy only, according to their physician's prescription. The primary outcome measure is the composite score of Sunnybrook Facial Grading System. Secondary outcome measures include clinical and biomechanical facial motor function quantifications (Créteil Scale and 3D facial motion analysis through the Cara system), quality of life (Facial Clinimetric Evaluation and Short-Form 12), aesthetic considerations (FACE-Q scale) and mood representations (Hospital Anxiety and Depression scale). Participants will be evaluated every three months by a blinded investigator, in addition to four phone calls (D30/D60/D120/D150) to monitor compliance and tolerance to treatment. DISCUSSION: This study will increase the level of knowledge on the effects of intense facial motor streng-          Facial paralysisthening prescribed through a GSC in patients with chronic peripheral facial paresis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04074018 . Registered 29 August 2019. PROTOCOL VERSION: Version N°4.0-04/02/2021.

Reliability of the Modified Frenchay Scale for the Assessment of Upper Limb Function in Adults With Hemiparesis.

OBJECTIVES: To investigate the reliability of the Modified Frenchay Scale (MFS) in adults with hemiparesis. DESIGN: Prospective analysis of videos. SETTING: Study conducted in a Neurorehabilitation Unit of a University Hospital. PARTICIPANTS: Fifty-one patients (17 women [33%], age 46±15, time since injury 5.2±6.7 years) with hemiparesis secondary to stroke (N=47), tumor (N=3), or spinal cord injury (N=1) were enrolled. INTERVENTION: The MFS measures active upper limb function in spastic hemiparesis based on a video recording of 10 daily living tasks, each rated from 0 to 10. Six tasks are bimanual and 4 are unimanual with the paretic hand. MFS videos performed in routine care of patients with hemiparesis between 2015 and 2021 were collected. After a 3-hour group training session, each MFS video was assessed twice, 1 week apart by 4 rehabilitation professionals with various levels of experience in using the scale. MAIN OUTCOME MEASURES: Internal consistency was determined using Cronbach's alpha. Intra- and inter-rater reliability was measured using intraclass correlation coefficients (ICC, mean [95% CI]), mean differences between ratings and minimal detectable change (MDC). Bland-Altman plots were also performed for inter-rater assessments. RESULTS: The mean overall MFS score was 4.95±1.20 with no floor or ceiling effect. Cronbach's α was 0.97. For the overall MFS score, intra- and inter-rater ICCs were 0.99[0.99;1.00] and 0.97[0.95;0.98], respectively; mean intra- and inter-rater differences were 0.10±0.04 and 0.24±0.12, respectively; and MDC were 0.17 and 0.37, respectively. CONCLUSIONS: The MFS is an internally consistent and reliable scale to assess upper limb function in adults with hemiparesis.

Three-Dimensional Quantification of Facial Morphology and Movements Using a Wearable Helmet.

This work proposes a 3D normative database of facial ranges of motion in adults free from facial disorders. Ten facial movements were analyzed, each targeting the activity of specific muscle groups innervated by the facial nerve. The experimental protocol included a test-retest reliability positioning procedure of 25 skin markers based on clinical expertise in facial morphology. Three maximal voluntary contractions were recorded for each facial movement studied, using a 3D facial motion capture helmet. We included 53 adults free from facial disorders (26 men; age 43 ± 14), evaluated twice one week apart. The reliability of marker positioning was expressed as absolute measurement errors. The range of motion vectors of all markers from the best rest to the maximal voluntary contraction was calculated for each muscle group. Primary, secondary, and tertiary markers were extracted for each facial movement. 3D Procruste and asymmetry indices were developed. This allowed the identification of common thresholds of 10% for the asymmetry index and of 6 mm for the Procruste index, beyond which facial motions would be considered abnormally asymmetric. The normative database quantifies facial motions and allows assessment of the degree of clinical disorders by comparison. This protocol is currently being investigated in patients with chronic unilateral peripheral facial paresis.

Identification of five frailty profiles in community-dwelling individuals aged 50-75: A latent class analysis of the SUCCEED survey data.

OBJECTIVES: We sought to identify frailty profiles in individuals aged 50-75 by considering frailty as an unobservable latent variable in a latent class analysis (LCA). STUDY DESIGN: 589 prospectively enrolled community-dwelling individuals aged 50-75 (median: 61.7 years) had undergone a standardized, multidomain assessment in 2010-2015. Adverse health outcomes (non-accidental falls, fractures, unplanned hospitalizations, and death) that had occurred since the assessment were recorded in 2016-2017. MAIN OUTCOME MEASURES: The LCA used nine indicators (unintentional weight loss, relative slowness, weakness, impaired balance, osteoporosis, impaired cognitive functions, executive dysfunction, depression, and hearing impairment) and three covariates (age, gender, and consultation for health complaints). The resulting profiles were characterized by the Fried phenotype and adverse health outcomes. RESULTS: We identified five profiles: "fit" (LC1, 29.7% of the participants; median age: 59 years); "weight loss, relative slowness, and osteoporosis" (LC2, 33.2%; 63 years); "weakness and osteopenia" (LC3, 21.9%; 60 years); "impaired physical and executive functions" (LC4, 11%; 67 years); and "impaired balance, cognitive functions, and depression" (LC5, 4.3%; 70 years). Almost all members of LC3 and LC4 were female, and were more likely than members of other profiles to have a frail or pre-frail Fried phenotype. Non-accidental falls were significantly more frequent in LC4. LC5 (almost all males) had the highest number of comorbidities and cardiovascular risk factors but none was frail. CONCLUSIONS: Our data-driven approach covered most geriatric assessment domains and identified five frailty profiles. With a view to tailoring interventions and prevention, frailty needs to be detected among young seniors.

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.

The neurophysiology of deforming spastic paresis: A revised taxonomy.

This paper revisits the taxonomy of the neurophysiological consequences of a persistent impairment of motor command execution in the classic environment of sensorimotor restriction and muscle hypo-mobilization in short position. Around each joint, the syndrome involves 2 disorders, muscular and neurologic. The muscular disorder is promoted by muscle hypo-mobilization in short position in the context of paresis, in the hours and days after paresis onset: this genetically mediated, evolving myopathy, is called spastic myopathy. The clinician may suspect it by feeling extensibility loss in a resting muscle, although long after the actual onset of the disease. The neurologic disorder, promoted by sensorimotor restriction in the context of paresis and by the muscle disorder itself, comprises 4 main components, mostly affecting antagonists to desired movements: the first is spastic dystonia, an unwanted, involuntary muscle activation at rest, in the absence of stretch or voluntary effort; spastic dystonia superimposes on spastic myopathy to cause visible, gradually increasing body deformities; the second is spastic cocontraction, an unwanted, involuntary antagonist muscle activation during voluntary effort directed to the agonist, aggravated by antagonist stretch; it is primarily due to misdirection of the supraspinal descending drive and contributes to reducing movement amplitude; and the third is spasticity, one form of hyperreflexia, defined by an enhancement of the velocity-dependent responses to phasic stretch, detected and measured at rest (another form of hyperreflexia is "nociceptive spasms", following flexor reflex afferent stimulation, particularly after spinal cord lesions). The 3 main forms of overactivity, spastic dystonia, spastic cocontraction and spasticity, share the same motor neuron hyperexcitability as a contributing factor, all being predominant in the muscles that are more affected by spastic myopathy. The fourth component of the neurologic disorder affects the agonist: it is stretch-sensitive paresis, which is a decreased access of the central command to the agonist, aggravated by antagonist stretch. Improved understanding of the pathophysiology of deforming spastic paresis should help clinicians select meaningful assessments and refined treatments, including the utmost need to preserve muscle tissue integrity as soon as paresis sets in.

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.

A Bidimensional System of Facial Movement Analysis Conception and Reliability in Adults.

OBJECTIVE: To design a bidimensional facial movement measuring tool and study its reliability. METHODS: We utilized the free video-analysis software Kinovea that can track preselected points during movements and measure two-point distances off-line. Three raters positioned facial markers on 10 healthy individuals and video-taped them during maximal bilateral contractions of frontalis, corrugator, orbicularis oculi, zygomaticus, orbicularis oris, and buccinator, on two occasions. Each rater also analyzed the first video twice, one week apart. For each muscle, intrarater reliability was measured by percent agreements (PA) and intraclass correlation coefficients (ICC) between two assessments of the same video one week apart and between assessments of two videos collected one week apart. Interrater reliability was measured by PA, ICC, and coefficients of variation (CV) between assessments of the first video-recording by the three raters. RESULTS: Intrarater and interrater reliabilities were good to excellent for frontalis (PA and ICC > 70%; CV < 15%), moderate for orbicularis oculi, zygomaticus, and orbicularis oris, and poor for corrugator and buccinators. DISCUSSION: Without formal prior training, the proposed method was reliable for frontalis in healthy subjects. Improved marker selection, training sessions, and testing reliability in patients with facial paresis may enhance reliability for orbicularis oculi, zygomaticus, and orbicularis oris.