Novel Use of Botulinum Toxin in Long-Standing Adductor-Related Groin Pain: A Case Series.

BACKGROUND: Adductor-related groin pain (ARGP) is the most common groin injury in athletes. If conservative treatment fails, then adductor tenotomy to relieve tension can be considered. The use of botulinum toxin A (BoNT-A) has shown good results in other musculoskeletal pathologies. OBJECTIVE: Assess the effectiveness of BoNT-A injections in ARGP in cases where usual treatment has failed. DESIGN: Retrospective cohort study. SETTING: Orthopedic Medicine and Rehabilitation Unit, University of Bordeaux. PARTICIPANTS: Fifty patients treated by BoNT-A injection in ARGP after failure of medical and/or surgical treatment were included in this study. INTERVENTIONS: One or several adductor muscles were injected with BoNT-A, according to clinical evaluation using ultrasound and electrical stimulation guidance. Patients were followed up at 1, 3, 6, and 12 months. MAIN OUTCOME MEASURES: The primary assessment criterion was the improvement of Hip and Groin Outcome Score subscales at day 30. Secondary outcomes included pain intensity and impact on sport, work, and quality of life (QoL), the Blazina scale, and side effects. RESULTS: All the first 50 injected patients (45 male and 5 female patients) were included. A significant improvement was noted regarding the majority of Hip and Groin Outcome Score subscales at day 30 ( P < 0.05). Pain intensity and its impacts were both significantly reduced ( P < 0.001): less sport and professional disability and lower impact on QoL. Severity of symptoms assessed by the Blazina scale was significantly reduced ( P < 0.001). The improvements remained significant until 1-year postinjection. CONCLUSIONS: BoNT-A is promising as a new treatment for ARGP but should be fully assessed in a randomized controlled trial.

Are paraspinous intramuscular injections of botulinum toxin a (BoNT-A) efficient in the treatment of chronic low-back pain? A randomised, double-blinded crossover trial.

BACKGROUND: Treatment for patients with chronic low-back pain (LBP) is a public health issue. Intramuscular injections of botulinum toxin A (BoNT-A) have shown an analgesic effect on LBP in two previous randomized controlled studies. The objective of the study was to verify the efficacy of paravertebral injections of BoNT-A in patients with LBP. METHODS: Patients were included in this phase 3 randomized double-blinded trial comparing the efficacy of BoNT-A versus placebo in a crossover study on LBP. Both groups received 200 units of BoNT-A in paravertebral muscles or a placebo, and vice versa at Day 120. The main judgment criterion was LBP intensity 1 month after the injections, evaluated by using a visual pain scale (VAS). Secondary assessment criteria included: LBP intensity 90 and 120 days after injection day; number of days when an allowed antalgic oral treatment was needed in between each evaluation; functional disability measured by the Quebec Back Pain Disability Scale; quality of life; inability to work; patient satisfaction in relation to the treatment's effect; spinal mobility; and strength of spinal muscles, measured by isokinetic technique. RESULTS: Nineteen patients completed the study. There was no significant difference between the groups' average LBP during the last 8 days at Day30 (p = 0.97). There was no significant difference between the two groups regarding the secondary assessment criteria (p > 0.05). CONCLUSIONS: Injections of BoNT-A in the paravertebral muscles were not found to be effective to relieve chronic LBP. The limits of the study are that the dose of BoNT-A used was lower than in other studies, and that the limited number of patients included may explain the negative results. TRIAL REGISTRATIONS: Identifiers: NCT03181802 . Unique Protocol ID: CHUBX2003.

Patient-specific 3D models created by 3D imaging system or bi-planar imaging coupled with Moiré-Fringe projections: a comparative study of accuracy and reliability on spinal curvatures and vertebral rotation data.

PURPOSE: The aim of this study is to compare the accuracy and reliability of spinal curvatures and vertebral rotation data based on patient-specific 3D models created by 3D imaging system or by bi-planar imaging coupled with Moiré-Fringe projections. METHODS AND MATERIALS: Sixty-two consecutive patients from a single institution were prospectively included. For each patient, frontal and sagittal calibrated low-dose bi-planar X-rays were performed and coupled simultaneously with an optical Moiré back surface-based technology. The 3D reconstructions of spine and pelvis were performed independently by one radiologist and one technician in radiology using two different semi-automatic methods using 3D radio-imaging system (method 1) or bi-planar imaging coupled with Moiré projections (method 2). Both methods were compared using Bland-Altman analysis, and reliability using intraclass correlation coefficient (ICC). RESULTS: ICC showed good to very good agreement. Between the two techniques, the maximum 95 % prediction limits was -4.9° degrees for the measurements of spinal coronal curves and less than 5° for other parameters. Inter-rater reliability was excellent for all parameters across both methods, except for axial rotation with method 2 for which ICC was fair. Method 1 was faster for reconstruction time than method 2 for both readers (13.4 vs. 20.7 min and 10.6 vs. 13.9 min; p = 0.0001). CONCLUSION: While a lower accuracy was observed for the evaluation of the axial rotation, bi-planar imaging coupled with Moiré-Fringe projections may be an accurate and reliable tool to perform 3D reconstructions of the spine and pelvis.

Could trochanteric pelvic stabilization be removed from the adolescent idiopathic scoliosis brace? A prospective pilot study.

BACKGROUND: Idiopathic scoliosis is the most common musculoskeletal deformity in children. There is a dose-response relationship between compliance and improvement in scoliosis. The literature revealed that esthetic considerations have negative consequences on the quality of life (QOL) of patients and consequently on wearing time of the brace. To minimize esthetic problems and then increase QOL and wearing time, we proposed a new relay brace named "corset Collerette" without a pelvic-trochanteric base. METHODS: A prospective cohort study was conducted in the rehabilitation department of Bordeaux University Hospital. Patients consulting for adolescent idiopathic scoliosis were registered in a prospective hospital database. The patients expressing unwillingness to wear the usual brace or who had decreased compliance were offered the corset Collerette and were included in a 3-month follow-up. Outcome measures assessed at baseline and at 3 months were Scoliosis Research Society Outcomes Questionnaire (SRS-22) and Brace Questionnaire scales and wearing time. Cobb's angle evolution since the start of bracing was also collected. The primary end point was the QOL assed by the SRS-22 scale at 3 months of follow-up. RESULTS: The first 38 patients agreeing to wear the corset Collerette were included in the study. The QOL assessed by the SRS-22 was significantly improved with the corset Collerette ( p < 0.05). There was no significant increase in wearing time and thoracic Cobb's angles between baseline and follow-up ( p > 0.05). CONCLUSION: The switch to the corset Collerette allowed an improvement in the QOL of the patients and avoid a decrease in compliance with wearing the brace and maintain the same in-brace Cobb's angles.

Daily socket comfort in transtibial amputee with a vacuum-assisted suspension system: study protocol of a randomized, multicenter, double-blind multiple N-of-1 trial.

BACKGROUND: The main aim of this paper is to present the feasibility of rigorously designed multiple N-of-1 design in prosthetics research. While research of adequate power and high quality is often lacking in rehabilitation, N-of-1 trials can offer a feasible alternative to randomized controlled group trials, both increasing design power at group level and allowing a rigorous, statistically confirmed evaluation of effectiveness at a single patient level. The paper presents a multiple N-of-1 trial protocol, which aim is to evaluate the effectiveness of Unity, a prosthetic add-on suspension system for amputees, on patient-reported comfort during daily activities (main outcome measure), prosthesis wearing time, perception of limb-prosthesis fitting and stump volume and functional walking parameters. METHODS: Multicenter, randomized, prospective, double-blind multiple N-of-1 trial using an introduction/withdrawal design alternating Unity connected/disconnected phases of randomized length on twenty patients with unilateral transtibial amputation. The primary outcome measure is the Prosthetic Socket Comfort Score (SCS), a validated measure of comfort, administered daily by an phone app designed for the study. Secondary outcomes measures will be collected during the 50 days period of the N-of-1 trial: (1) by the same app, daily for patient-reported limb-prosthesis fitting, stump volume variation, and daily wearing time of the prosthesis; (2) by a pedometer for the number of steps per day; (3) by blind assessors in the rehabilitation center during adjustment visits for functional walking parameter (L-Test, 6-minute walk test), and by the patient for the QUEST, and ABC-S. Effectiveness of the Unity system regarding SCS and daily secondary outcome measures will be tested by randomization test. The secondary outcome measures assessed during visits in the rehabilitation center will be analyzed by Non Overlap of All pairs. An estimate of the effect on the amputee population will be generated by aggregating each individual clinical trial (N-of-1 trial) by Hierarchical Bayesian methods. DISCUSSION: This study protocol was designed to answer the question "which device is best for THIS patient" and to conclude at a group level on the effectiveness of a new devic, using a Multiple N-of-1 trial, which is promising but underused in prosthetics research so far. TRIAL REGISTRATION: N° ID-RCB 2020-A01309-30 Clintrial.gov : NCT04804150 - Retrospectively registered March 20th 2021.

Effect of early compensation of distal motor deficiency by the Chignon ankle-foot orthosis on gait in hemiplegic patients: a randomized pilot study.

OBJECTIVE: To compare the effect of the Chignon ankle-foot orthosis on gait versus a standard ankle-foot orthosis. METHOD: A multicentre randomized study was conducted in seven rehabilitation centres. Hemiplegic patients were recruited after unilateral stroke lasting less than six months. Exclusion criteria were: impossibility to stand for 10 seconds; ankle passive dorsiflexion <5 degrees with knee flexed to 90 degrees; triceps spasticity ≥3/4 on the Ashworth modified scale; diseases that might impair active participation in the study. Thirteen patients were randomized to the Chignon group and 15 to the control group. Included patients were given a standard ankle-foot orthosis or Chignon ankle-foot orthosis. The Chignon ankle-foot orthosis is an articulated double-stopped custom-made orthosis with elements to assist dorsiflexion and plantar flexion. Gait speed improvement (ten-metre test), kinematic assessment, and functional scales were assessed. RESULTS: Gain ratio of walking speed with the orthosis increased significantly more in the Chignon group than in the control group at day 0 (27.2 ± 36% versus -0.8 ± 17%; P = 0.006), day 30 (39.9 ± 19% versus 7.5 ± 17%; P = 0.0004) and day 90 (44.6 ± 27% versus 17.1 ± 0.3%; P = 0.04). There was also a significant improvement in kinematic parameters and spasticity in the Chignon group. CONCLUSION: Early compensation of distal motor deficiency by the Chignon ankle-foot orthosis improves the immediate gait of hemiplegics more than the standard ankle-foot orthosis and seems to modify motor recovery processes in the legs after stroke.

Reliability of magnetic resonance imaging measurements of the cross-sectional area of the muscle contractile and non-contractile components.

BACKGROUND/PURPOSE: Magnetic resonance imaging (MRI) is increasingly used to study skeletal muscles patients with muscular disorders. We report an MRI technique for evaluating the trunk muscles. This technique takes both the component surface area (CSA) and the density of the muscles on MRI axial slices into account . Using a computer-based image analysis system, we combined MRI data measuring the muscle CSA, which was separated into the contractile component (CCSA) and the non-contractile component (NCCSA). The purpose of this study was to analyze the reliability of this method of measuring the CSA, CCSA and NCCSA in trunk muscles on MRI axial slices through L4 and T12. METHODS: Thirty volunteer subjects were enrolled in this study. Two acquisitions were performed. For the reliability analyses, each of the two slices (T12 and L4) from 30 subjects was measured by three raters trained in this technique, on two occasions 2 weeks apart. Each muscle was surrounded and its CSA, NCCSA and CCSA were recorded. For each muscle, the agreement between the two sets of 30 measurements performed by three observers was evaluated by calculating an intra-class correlation coefficient (ICC). RESULTS: Regarding the slice through L4 and T12, the reliabilities of the measurement of CSA, CCSA were very good for all the muscles except the parietal muscles. CONCLUSION: MRI measurements of the trunk muscle cross-sectional areas and of the CCSA and NCCSA are reliable.

Assessing the contribution of lower limb mobilization, in the supine position, on shoulder-pelvis girdles dissociation.

BACKGROUND: Several articular, muscular and neurological diseases generate mobility loss in the shoulder and pelvis girdles. Joint mobilization contributes to improving shoulder-pelvis girdles dissociation, but current mobilization techniques are not always successful and standardized. A robotic medical device, DPA Med®, by inducing trunk mobilization through lower limb oscillation has been developed for producing such a shoulder-pelvis girdles dissociation and is already used worldwide in rehabilitation hospitals. RESEARCH QUESTION: To determine the optimal lower limb oscillation frequency that generated the best shoulder-pelvis girdles dissociation using the DPA Med® device. METHODS: Thirty healthy adult volunteers (mean age: 38.6 [SD 15.2] years, mean height: 174 [SD 11.9] cm, mean body mass: 70.3 [SD 14.7] kg) participated in this prospective study. A kinematic analysis quantified pelvic and shoulder girdle mobility (rotation and lateral tilt) at different DPA Med® frequencies, from 0.5 Hz to 1 Hz. A visual analysis of the lower limb movement was also performed, using video sensors, to better understand the kinematics involved. RESULTS: All DPA Med® frequencies have shown significant shoulder-pelvis girdles dissociation (p < 0.05). This study established an optimal oscillation frequency with the minimal interindividual variability at 0.808 Hz. It induced pelvic mobility similar to that of normal gait, in the transverse and frontal planes (10.3°, SD 2.9°, and 12.0°, SD 2.2°, respectively). This trunk mobility was achieved by producing a lemniscate-shaped motion in the lower limbs (an eight-shaped motion in the transverse plane). SIGNIFICANCE: This study has shown that the DPA Med® device is able to induce shoulder-pelvis girdles dissociation similar to that of normal gait and allowed to establish the existence of an optimal DPA Med® oscillation frequency for lower limb mobility at 0.808 Hz. Further studies are required to evaluate its potentially benefits on gait disorders.

Number of botulinum toxin injections needed to stop requests for treatment for chronic lateral epicondylar tendinopathy. A 1-year follow-up study.

BACKGROUND: Epicondylar tendinopathy ("tennis elbow") is a serious issue in manual labourers. Symptoms can persist over months or even more than 1 year, even when treated with trinitrine patches, acupuncture, sclerosis of neovessels, shock-wave therapy, autologous blood injections, platelet-rich plasma or hyaluronic acid. Botulinum toxin (BoNT-A) injections showed promising short-term results, but the long-term beneficial effects are not yet known. OBJECTIVE: We aimed to assess the long-term effect, side effects and recurrence rate after BoNT-A injections on chronic lateral epicondylar tendinopathy during 1 year. METHODS: This open study followed a 3-month randomized controlled trial. We included 50 patients followed at day 0 (V0), 90 (V1), 180-270 (V2) and 365 (V3). The main judgment criterion was the number of BoNT-A injections required to achieve pain relief with no further request for treatment by the patient. RESULTS: After one BoNT-A injection, 22/50 (44%) patients did not ask for further treatment during follow-up because of complete pain relief, and 20/50 (40%) asked for a second BoNT-A injection. For 20 patients with a second injection, 18 (90%) did not ask for further treatment during follow-up. Only 1 patient had a recurrence of pain after an initial pain relief of greater than 75%. Quality of life, and painful and maximal gripping force improved significantly at V1, V2 and V3 as compared with V0, and repercussions on daily and professional activities decreased significantly (P<0.05). CONCLUSIONS: One or 2 BoNT-A injections has favourable results for chronic epicondylar tendinopathy.

Effect of Trunk Muscle Strengthening on Gait Pattern and Falls in Parkinson's Disease.

BACKGROUND: The course of Parkinson's disease is characterized by gait disturbance and falls, which affect patients' quality of life and engender high healthcare costs. These factors are not greatly improved by levodopa therapy or deep brain stimulation of the subthalamic nuclei. Indeed, the symptoms may even worsen with these treatment. Physiotherapy may be the most appropriate treatment to reduce the incidence of falls in these cases; however, its benefits are modest. OBJECTIVE: To assess the effectiveness of trunk muscle strengthening in 10 patients with Parkinson's disease being treated with deep brain stimulation of the subthalamic nuclei who are affected by gait disturbances and falls. METHOD: A standardized physiotherapy programme centred on trunk muscle strengthening was conducted. Its effectiveness was assessed using a clinical approach combined with video-based motion analysis. RESULTS: After 4 weeks of trunk muscle strengthening, the gait item on the Unified Parkinson's Disease Rating Scale (UPDRS, part 3) together with several gait kinematic parameters (step length, walking cycle duration variability, gait speed) were significantly improved and the number of falls decreased. CONCLUSION: These preliminary findings suggest that physiotherapy centred on rachis mobility improves the quality of gait and reduces the number of falls in patients with Parkinson's disease who are being treated with deep brain stimulation of the subthalamic nuclei. This is a potentially useful supplement to the traditional physiotherapy approach, in addition to the pharmacological and surgical treatment of Parkinson's disease.

Sequential activation of axial muscles during different forms of rhythmic behavior in man.

In humans, studies of back muscle activity have mainly addressed the functioning of lumbar muscles during postural adjustments or rhythmic activity, including locomotor tasks. The present study investigated how back muscles are activated along the spine during rhythmical activities in order to gain insights into spinal neuronal organization. Electromyographic recordings of back muscles were performed at various trunk levels, and changes occurring in burst amplitudes and phase relationships were analyzed. Subjects performed several rhythmic behaviors: forward walking (FW), backward walking (BW), amble walking (where the subjects moved their arms in phase with the ipsilateral leg), walking on hands and knees (HK) and walking on hands with the knees on the edge of a treadmill (Hand). In a final task, the subjects were standing and were asked to swing (Swing) only their arms as if they were walking. It was found that axial trunk muscles are sequentially activated by a motor command running along the spinal cord (which we term "motor waves") during various types of locomotion or other rhythmic motor tasks. The bursting pattern recorded under these conditions can be classified into three categories: (1) double-burst rhythmic activity in a descending (i.e., with a rostro-caudal propagation) motor wave during FW, BW and HK conditions; (2) double-burst rhythmic activity with a stationary motor wave (i.e., occurring in a single phase along the trunk) during the 'amble' walk condition; (3) monophasic rhythmic activity with an ascending (i.e., with a caudo-rostral propagation) motor wave during the Swing and Hands conditions. Our results suggest that the networks responsible for the axial propagation of motor activity during locomotion may correspond to those observed in invertebrates or lower vertebrates, and thus may have been partly phylogenetically conserved. Such an organization could support the dynamic control of posture by ensuring fluent movement during locomotion.

Short-Term Effect of Low-Dose, Electromyography-Guided Botulinum Toxin A Injection in the Treatment of Chronic Lateral Epicondylar Tendinopathy: A Randomized, Double-Blinded Study.

BACKGROUND: Botulinum toxin A (BoNT-A) is a novel treatment for chronic lateral epicondylar tendinopathy. Preliminary studies have demonstrated promising results; however, confirmation of the effectiveness of BoNT-A treatment and further assessment of its side effects are required. This study investigated the analgesic effects of BoNT-A in the treatment of chronic lateral epicondylar tendinopathy. METHODS: This was a phase-III, single-center, randomized, double-blinded, placebo-controlled study including 60 patients with chronic lateral epicondylar tendinopathy that had been resistant to treatment for >6 months. Patients received either a 40-IU injection of BoNT-A or saline solution placebo into the extensor carpi radialis brevis (ECRB) muscle, aided by electromyographic (EMG) stimulation. Follow-up was 3 months. The primary assessment criterion was the percentage of patients whose pain was reduced by >50% at 90 days after injection. Secondary outcomes, including pain intensity, pain frequency, interference with quality of life, sick leave taken, maximum grip strength, and side effects, were assessed at days 30 and 90, and the number of participants per group requesting additional therapies at day 90 was recorded. RESULTS: Twenty-nine patients in the BoNT-A group and 28 patients in the placebo group were included in the day-90 analysis. Fifteen (51.7%) of the patients who were administered BoNT-A and 7 (25%) of the patients who received placebo reported a >50% reduction in initial pain intensity at day 90 (p = 0.005). Pain intensity and the effect on quality of life, measured using visual analog scales, were both significantly lower in the group treated with BoNT-A compared with placebo at day 90 (p < 0.05). The rate of clinically detected transitory paresis of the third finger on extension was 17.2% in the BoNT-A group, with no associated functional impairment. CONCLUSIONS: BoNT-A at 40 IU injected into the ECRB is an effective treatment for chronic lateral epicondylar tendinopathy that has been otherwise resistant to medical treatment. The rate of paresis of the third finger was low, with no associated functional impairment. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Severe and long-lasting complications of the nerve root and spinal cord after central neuraxial blockade.

BACKGROUND: Although rare, major complications after spinal and epidural anesthesia do occur. We report the complications after central neuraxial blockade occurring in 2000 in France. METHODS: A retrospective questionnaire study was sent to all French rehabilitation centers to detail severe and long-lasting neurologic complications after central neuraxial blockade. RESULTS: All specialized and 44% of the nonspecialized centers answered. Twelve cases, nine women and three men, were noted, 60% of which involved patients over 50 yr of age. All patients still had neurological deficits after 3 mo. Seven received spinal anesthesia, four had epidural anesthesia, and one had both procedures. Hemorrhagic lesions were found in only three patients. Among the nine other patients, anatomic abnormalities were common, including five instances of lumbar canal stenosis and two with spinal arachnoid cysts. CONCLUSIONS: These findings suggest the influence of underlying spinal conditions in these complications.

Coordinated network functioning in the spinal cord: an evolutionary perspective.

The successful achievement of harmonious locomotor movement results from the integrated operation of all body segments. Here, we will review current knowledge on the functional organization of spinal networks involved in mammalian locomotion. Attention will not simply be restricted to hindlimb muscle control, but by also considering the necessarily coordinated activation of trunk and forelimb muscles, we will try to demonstrate that while there has been a progressive increase in locomotor system complexity during evolution, many basic organizational features have been preserved across the spectrum from lower vertebrates through to humans. Concerning the organization of axial neuronal networks that control trunk muscles, it has been found across the vertebrate range that during locomotor movement a motor wave travels longitudinally in the spinal cord via the coupling of rhythmic segmental networks. For hindlimb activation it has been found in all species studied that the rostral lumbar segments contain the key elements for pattern generation. We also showed that rhythmic arm movements are under the control of cervical forelimb generators in quadrupeds as well as in human. Finally, it is highlighted that the coordination of quadrupedal movements during locomotion derives principally from an asymmetrical coordinating influence occurring in the caudo-rostral direction from the lumbar hindlimb networks.

An examination of camptocormia assessment by dynamic quantification of sagittal posture.

OBJECTIVE: Camptocormia is a disabling pathology of the axial system that debilitates patients in their daily life. To date, there have been no studies evaluating the impact of camptocormia on walking performance. This study presents a new method for assessing sagittal posture under walking conditions in patients with camptocormia. DESIGN: The severity of camptocormia was evaluated by measuring sagittal inclination, represented indirectly by the horizontal distance between the C7 and S1 markers (C7 sagittal arrow; C7-SAR). Sagittal inclination was measured under various behavioural conditions using clinical, radiological and kinematic approaches. PATIENTS: Forty-three patients were included in the study (17 with Parkinson's disease and 26 with idiopathic camptocormia). RESULTS: Under static conditions, C7-SAR could be assessed using different methods. During walking, there was a dramatic increase in C7-SAR values. Correlation analysis revealed a relationship between functional impairment and dynamic C7-SAR values, but not with radiological C7-SAR values. PATIENTS with Parkinson's disease behaved differently from idiopathic patients, suggesting the involvement of different underlying physiopathological mechanisms. CONCLUSION: Monitoring sagittal inclination during walking is more accurate than radiological measurements to determinine the detrimental effects of camptocormia and its consequences for quality of life.

Communication activity in stroke patients with aphasia.

OBJECTIVE: To study communication disability in stroke patients with aphasia. PATIENTS AND METHODS: Prospective, multicentric cohort study of patients with aphasia, consecutively included after a first stroke, and examined 1 year later at home. Assessment included a stroke severity scale, the Barthel Index, the boston diagnostic aphasia examination, a communication questionnaire, and the aphasia depression rating scale. RESULTS: A total of 164 patients were included. Among the 100 survivors assessed at follow-up, 24% had severe aphasia, 12% moderate aphasia and 64% mild aphasia according to the Boston diagnostic aphasia examination severity score. Patients mainly reported difficulties in conversation with strangers and/or on abstract topics, using a phone, reading and writing administrative documents, dealing with money and outdoor communication activities. Communication was strongly related to aphasia severity. Age, gender, education level, residence status and type of stroke had no influence on communication activity. On multivariate analysis, severity of stroke and severity of aphasia on inclusion were found to account for 58% of variance and were independent predictors of the communication questionnaire score at follow-up. CONCLUSION: Documenting the most impaired communication skills may help to set priority goals for speech and language therapy in aphasia.