Acute passive stretching has no effect on gastrocnemius medialis stiffness in children with unilateral cerebral palsy.

PURPOSE: The aim of this study was to investigate the effects of an acute high-intensity, long-duration passive stretching session of the plantar flexor muscles, on maximal dorsiflexion (DF) angle and passive stiffness at both ankle joint and gastrocnemius medialis (GM) muscle levels in children with unilateral cerebral palsy (CP). METHODS: 13 children [mean age: 10 years 6 months, gross motor function classification system (GMFCS): I] with unilateral CP underwent a 5 min passive stretching session at 80% of maximal DF angle. Changes in maximal DF angle, slack angle, passive ankle joint and GM muscle stiffness from PRE- to POST-intervention were determined during passive ankle mobilization performed on a dynamometer coupled with shear wave elastography measurements (i.e., ultrasound) of the GM muscle. RESULTS: Maximal DF angle and maximal passive torque were increased by 6.3° (P < 0.001; + 50.4%; 95% CI 59.9, 49.9) and 4.2 Nm (P < 0.01; + 38.9%; 95% CI 47.7, 30.1), respectively. Passive ankle joint stiffness remained unchanged (P = 0.9; 0%; 95% CI 10.6, - 10.6). GM muscle shear modulus was unchanged at maximal DF angle (P = 0.1; + 34.5%; 95% CI 44.7, 24.7) and at maximal common torque (P = 0.5; - 4%; 95% CI - 3.7, - 4.3), while it was decreased at maximal common angle (P = 0.021; - 35%; 95% CI - 11.4, - 58.5). GM slack angle was shifted in a more dorsiflexed position (P = 0.02; + 20.3%; 95% CI 22.6, 18). CONCLUSION: Increased maximal DF angle can be obtained in the paretic leg in children with unilateral CP after an acute bout of stretching using controlled parameters without changes in passive stiffness at joint and GM muscle levels. CLINICAL TRIAL NUMBER: NCT03714269.

Perceived impact of lockdown on daily life in children with physical disabilities and their families during the COVID-19 pandemic.

BACKGROUND: The first lockdown during COVID-19 pandemic in France led to an abrupt change in children's daily lives. For children with physical disabilities and their families, activities were limited, access to healthcare and therapy was disrupted, and family organization was altered. The objective was to report the impact of the lockdown on daily life activities and well-being of children with physical disabilities as perceived by caregivers. METHODS: Two online national surveys were addressed to the parents of children with physical disabilities (ECHO survey: 6 April to 11 May 2020) and without disabilities (E-COPAIN survey: 24 April to 11 May 2020), confined at home during the lockdown. A lockdown impact score was calculated from difficulties related to children's well-being (morale, behaviour and social interaction) and daily life activities (schooling and physical activity) and compared between groups. Data on family environment, parental stress and concerns were collected. RESULTS: One thousand three hundred seventy-six children (9.45 ± 4.78 years, 54% girls) in ECHO survey and 367 children (7.3 ± 4.4 years, 48% girls) in E-COPAIN survey were included. A negative impact of lockdown was found on 81% of children with physical disabilities. Behavioural problems were significantly more frequent (59.5% vs. 47.4%, P < .005) and parental stress was higher (6.1 ± 3.33 vs. 5.3 ± 3.01, P = .005) in the ECHO group. Associated impairments (odds ratio [OR] = 1.45 [1.30-1.62], P < .001), parental stress (OR = 1.09 [1.06-1.12], P < .001) and continuation of rehabilitation (OR = 0.80 [0.72-0.89], P < .001) were determinants of the level of difficulty experienced. CONCLUSIONS: The lockdown had a considerable, negative impact on the daily life of children with disabilities and their families. Guiding policymakers with the essential daily life activities and the services to provide for children with physical disabilities would offer valuable insights to manage such a sanitary crisis and allow to identify the most vulnerable population.

Pretreatment lesional volume impacts clinical outcome and thrombectomy efficacy.

OBJECTIVE: We aimed to characterize the association between pretreatment lesional volume measured on diffusion-weighted images and functional outcome, and estimate the impact on thrombectomy efficacy for ischemic stroke with anterior proximal intracranial arterial occlusion. METHODS: Anterior circulation ischemic stroke patients who had pretreatment diffusion-weighted imaging in the THRACE study were included. Lesional volume was semiautomatically segmented. Logistic regression was applied to model clinical outcome as a function of lesional volume. Outcomes included functional independence (modified Rankin Scale [mRS] 0-2), degree of disability (ordinal mRS 0-6), and mortality at 3 months. RESULTS: Of 298 included patients, with median lesional volume 17.2ml (interquartile range [IQR], 9.2-51.8) and median mRS 2 (IQR, 1-4), 51.0% achieved functional independence. Increased lesional volume was an independent predictor for a lower probability of functional independence (odds ratio [OR], 0.90 [95% confidence interval {CI}, 0.81-0.99] per 10ml; p < 0.001), a less favorable degree of disability (common OR, 0.86 [95% CI, 0.81-0.90] per 10ml; p < 0.001), and a higher mortality rate (OR, 1.21 [95% CI, 1.08-1.37] per 10ml; p < 0.001). For additional thrombectomy, the number of patients needed to treat to achieve functional independence in 1 patient increased with lesional volume (10 for a volume of 80ml; 15 for 135ml). No significant treatment-by-dichotomized volume interaction for functional independence and mortality was observed. INTERPRETATION: Pretreatment lesional volume is an independent predictor for functional outcome in acute ischemic stroke with proximal intracranial occlusion. The clinical benefit of adding mechanical thrombectomy to thrombolysis decreased with the increase of lesional volume. Ann Neurol 2018;83:178-185.

Benefit from revascularization after thrombectomy according to FLAIR vascular hyperintensities-DWI mismatch.

OBJECTIVES: We tested whether FLAIR vascular hyperintensities (FVH)-DWI mismatch could identify candidates for thrombectomy most likely to benefit from revascularization. METHODS: We retrospectively reviewed 100 patients with proximal MCA occlusion from 18 stroke centers randomized in the IV-thrombolysis plus mechanical thrombectomy arm of the THRACE trial (2010-2015). We tested the associations between successful revascularization on digital subtraction angiography (modified Thrombolysis in Cerebral Infarction 2b/3) and 3-month favorable outcome (modified Rankin Scale score ≤ 2), stratified on FVH-DWI mismatch status, with secondary analyses adjusted on National Institutes of Health Stroke Scale (NIHSS) and DWI lesion volume. RESULTS: FVH-DWI mismatch was present in 79% of patients, with a similar prevalence at 1.5 T (80%) and 3 T (78%). Successful revascularization (74%) was more frequent in patients with FVH-DWI mismatch (63/79, 80%) than in patients without (11/21, 52%), p = 0.01. The OR of favorable outcome for revascularization were 15.05 (95% CI 3.12-72.61, p < 0.001) in patients with FVH-DWI mismatch and 0.83 (95% CI 0.15-4.64, p = 0.84) in patients without FVH-DWI mismatch (p = 0.011 for interaction). Similar results were observed after adjustment for NIHSS (OR = 12.73 [95% CI 2.69-60.41, p = 0.001] and 0.96 [95% CI 0.15-6.30, p = 0.96]) or for DWI volume (OR = 12.37 [95% CI 2.76-55.44, p = 0.001] and 0.91 [95% CI 0.16-5.33, p = 0.92]) in patients with and without FVH-DWI mismatch, respectively. CONCLUSIONS: The FVH-DWI mismatch identifies patients likeliest to benefit from revascularization, irrespective of initial DWI lesion volume and clinical stroke severity, and could serve as a useful surrogate marker for penumbral evaluation. KEY POINTS: • The FVH-DWI mismatch, defined by FLAIR vascular hyperintensities (FVH) located beyond the boundaries of the DWI lesion, is associated with large penumbra. • Among stroke patients with proximal middle cerebral artery occlusion referred for thrombectomy, those with FVH-DWI mismatch are most likely to benefit from revascularization. • FVH-DWI mismatch provides an alternative to PWI-DWI mismatch in order to select patients who are candidates for thrombectomy.

What causes increased passive stiffness of plantarflexor muscle-tendon unit in children with spastic cerebral palsy?

PURPOSE: The term 'stiffness' is commonly used in the literature to refer to various components of 'hyperresistance' by which spastic muscles oppose to their passive lengthening, especially in children with cerebral palsy (CP). Originally, stiffness consists of mechanical resistance to passive movement in the absence of any muscle activation. Increased muscle stiffness in CP therefore refers to alterations to the mechanical properties of the tissue. It is closely linked to muscle shortening, yet the two phenomena are not equivalent. Both increased stiffness and shortening are present early in childhood in the plantarflexor muscles of children with spastic CP. METHODS: This narrative review provides a comprehensive overview of the literature on passive stiffness of the plantarflexor muscles measured at the joint, muscles, fascicles, and fiber level in children with CP. Articles were searched through the Pub'Med database using the keywords "cerebral palsy" AND "stiffness". RESULT: The ambiguous use of the term 'stiffness' has been supported by discrepancies in available results, influenced by heterogeneity in materials, methodologies and characteristics of the participants among studies. Increased stiffness at the joint and muscle belly level may be explained by altered structural properties at the microscopic level. CONCLUSION: This thorough investigation of the literature suggests that the pathophysiology and the time course of the development of stiffness and contracture remain to be elucidated. A consideration of both morphological and mechanical measurements in children with CP is important when describing the alterations in their plantarflexors.

Outcome After Reperfusion Therapies in Patients With Large Baseline Diffusion-Weighted Imaging Stroke Lesions: A THRACE Trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke) Subgroup Analysis.

BACKGROUND AND PURPOSE: Stroke patients with large diffusion-weighted imaging (DWI) volumes are often excluded from reperfusion because of reckoned futility. In those with DWIvolume >70 mL, included in the THRACE trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke), we report the associations between baseline parameters and outcome. METHODS: We examined 304 patients with anterior circulation stroke and pretreatment magnetic resonance imaging. Variables were extracted from the THRACE database, and DWI volumes were measured semiautomatically. RESULTS: Among 53 patients with DWIvolume >70 mL, 12 had favorable outcome (modified Rankin Scale score, ≤2) at 3 months; they had less coronary disease (0/12 versus 12/38; P=0.046) and less history of smoking (1/10 versus 12/31; P=0.013) than patients with modified Rankin Scale score >2. None of the 8 patients >75 years of age reached modified Rankin Scale score ≤2. Favorable outcome occurred in 12 of 37 M1-occluded patients but in 0 of 16 internal carotid-T/L-occluded patients (P=0.010). Favorable outcome was more frequent (6/13) when DWI lesion was limited to the superficial middle cerebral artery territory than when it extended to the deep middle cerebral artery territory (6/40; P=0.050). CONCLUSIONS: Stroke patients with DWI lesion >70 mL may benefit from reperfusion therapy, especially those with isolated M1 occlusion or ischemia restricted to the superficial middle cerebral artery territory. The benefit of treatment seems questionable for patients with carotid occlusion or lesion extending to the deep middle cerebral artery territory.

Impact of spinal fusion on severity health status in scoliotic adolescents with polyhandicap.

BACKGROUND: Scoliosis constitutes a prevalent comorbidity in adolescents with polyhandicap and frequently leads to other severe impairments, impacting abilities and requiring complex caregiving strategies. Therefore, spinal fusion surgeries are commonly performed to alleviate pain and provide more comfort. However, spine stabilization has not previously been proven to improve the severity health status of adolescents with polyhandicap according to specific clinical scales. OBJECTIVE: This study describes and compares the severity health status of adolescents with polyhandicap before and after they underwent spinal fusion. METHODS: A monocentric retrospective observational study was conducted in the university hospital centre of Saint-Etienne, France. We included between 2009 to 2020, 30 scoliotic adolescents with polyhandicap who underwent spinal fusion performed with the same surgical technique and the same surgeon. The main outcome was the variation in the Polyhandicap Severity Scale (PSS) score after surgery. Secondary outcomes were variations in PSS subscores, quality of life scores, fronto-sagittal X-ray parameters, and measures of surgical complication rates and lengths of stay. RESULTS: Among 30 adolescents, 27 PSS analyses were performed. We found a significant improvement between pre- and postoperative PSS scores, mainly for pain and respiratory, digestive, and skin disabilities. These improvements were accompanied by significant reductions in pelvic obliquity, in frontal and sagittal curves. The mean hospital length of stay was 45 days. During postoperative period, patients received a personalized postoperative rehabilitation procedure with spasticity and pain treatments, physiotherapy, and verticalization (wheelchair sitting and positioning devices such as contoured seat intended to increase postural stability). The mortality rate was estimated at 7%. At least 1 complication per patient occurred. CONCLUSIONS: We show that spinal fusion surgeries confer a significant improvement in the severity health status in scoliotic adolescents with polyhandicap.

Exercise training improves autonomic profiles in patients with Charcot-Marie-Tooth disease.

INTRODUCTION: The effect of an interval exercise training (ITE) program on heart rate variability (HRV) was studied in 8 patients with Charcot-Marie-Tooth (CMT) disease and 8 healthy controls. METHODS: At baseline, all subjects underwent ambulatory 24-hour Holter electrocardiographic (ECG) monitoring to evaluate HRV. HRV analysis was repeated on CMT patients after they completed a 24-week ITE program on a cycle ergometer. RESULTS: Before exercise, all HRV indices were lower in patients compared with controls, and the difference reached statistical significance for pNN50 (percent of differences between adjacent R-R intervals exceeding 50 ms). After ITE, time- and frequency-domain indices were significantly improved, particularly at night (+8% mean R-R interval, +95% pNN50, 52% reduction in low/high-frequency ratio). We observed significant increases in some of the time and frequency parameters, and values sometimes exceeded those of controls at baseline. CONCLUSIONS: Our results suggest that ITE improves HRV modulation in CMT patients by enhancing parasympathetic activity.

Mechanical properties of ankle joint and gastrocnemius muscle in spastic children with unilateral cerebral palsy measured with shear wave elastography.

The aim of this study was to describe passive mechanical and morphological properties of the ankle joint and gastrocnemius medialis (GM) muscle in paretic and contralateral legs in highly functional children with unilateral cerebral palsy (UCP) using shear wave elastography (SWE). SWE measurements on the GM muscle were performed in both paretic and contralateral legs during passive ankle dorsiflexion using a dynamometer in 11 children (mean age: 10 years 6 months) with UCP. Torque-angle and shear modulus-angle relationships were fitted using an exponential model to determine passive ankle joint and GM muscle stiffness respectively. Based on shear-modulus-angle relationship, slack angle and shear modulus of GM muscle were compared between legs. GM and Achilles tendon length were determined at rest using ultrasonography. No significant difference was found between legs for passive ankle joint (p = 0.26; 11.2%; 95 %CI: 31.9, -9.4) and GM muscle passive stiffness (p = 0.62; -4.4%; 95 %CI: 14.7, -23.4). GM shear modulus at a common angle was significantly higher on the paretic leg (p = 0.02; +56.5%; 95 %CI: 100.5, 12.6). GM slack angle on the paretic leg was significantly shifted to a more plantarflexed position (p = 0.04; +25.5%; 95 %CI: 49.7, 1.3) and this was associated with a non-significant lower muscle length compared to the contralateral leg (p = 0.05; -4.5%; 95 %CI: -0.4, -8.7). Increased passive tension on the paretic leg when compared to the contralateral one may be explained in large part by muscle shortening. The role of altered mechanical properties remains unknown.