Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation.

INTRODUCTION: Practicality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes. OBJECTIVES: To determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery. DESIGN AND SETTING: Assessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility. PARTICIPANTS: Thirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3). INTERVENTION: Lokomat® or conventional gait training (CGT) in addition to standard mandated therapy time. MAIN OUTCOME MEASURES: Number of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post). RESULTS: The desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge - admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy "dose". CONCLUSIONS: With careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in study.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi.

OBJECTIVE: To establish international recommendations for the management of spastic equinovarus foot deformity. DESIGN: Delphi method. SETTING: International study. PARTICIPANTS: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). INTERVENTIONS: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. MAIN OUTCOME MEASURES: A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. CONCLUSION: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

Impact of Vaccination in the Rate of COVID-19 Staff Infection in an Acute Inpatient Rehabilitation Facility.

ABSTRACT: This brief report summarizes the comparative experience of an inpatient rehabilitation facility dealing with two episodes of COVID-19 infection, one before and one after the availability of vaccination, which was deployed to staff. The experience exemplifies the high rate of infection and potential for asymptomatic presentation of COVID-19 as well as the protective advantage of the vaccine for healthcare workers in this report. With a significant reduction in the rate of infection, from nearly 30% before vaccination to only 2.5% after vaccination. The data presented should serve as an encouragement for vaccination across all populations.

AbobotulinumtoxinA Versus OnabotulinumtoxinA in Adults with Upper Limb Spasticity: A Randomized, Double-Blind, Crossover Study Protocol.

INTRODUCTION: The safety and efficacy of both abobotulinumtoxinA and onabotulinumtoxinA for upper limb spasticity are well established, but head-to-head comparisons are lacking. METHODS: DIRECTION is an international, randomized, double-blind, crossover study comparing the safety and efficacy of abobotulinumtoxinA with onabotulinumtoxinA in the management of upper limb spasticity at doses at or near maximum recommended in product labelling. Participants (18-75 years) will be randomized (1:1) to either one cycle of abobotulinumtoxinA (900U) followed by onabotulinumtoxinA (360U) or vice versa. To maintain blinding, a fixed volume (3.6 ml) will be injected into the target upper limb muscles (four wrist and finger flexors and biceps brachii). The second treatment cycle will begin at Week 12 if retreatment criteria are fulfilled, and if not, they will be reassessed every 4 weeks until they meet retreatment parameters. PLANNED OUTCOMES: The primary hypothesis is that there is comparable safety between products; non-inferiority will be tested based on treatment-emergent adverse event (TEAE) rates from injection to Week 12. A secondary hypothesis is that abobotulinumtoxinA has longer duration of effect than onabotulinumtoxinA. This hypothesis will be tested with secondary efficacy endpoints, including injection cycle duration, Modified Ashworth Scale, Disability Assessment Scale and Physician Global Assessment. TRIAL REGISTRATION: EudraCT ( http://eudract.ema.europa.eu ): 2021-000161-32 and Clinicaltrials.gov ( http://clinicaltrials.gov ): NCT04936542. Overview of the study protocol by the principal investigator (MP4 185265 KB).

A Randomized Comparison of the Biomechanical Effect of Two Commercially Available Rocker Bottom Shoes to a Conventional Athletic Shoe During Walking in Healthy Individuals.

Rocker bottom shoes have recently gained considerable popularity, likely in part because of the many purported benefits, including reducing joint loading and toning muscles. Scientific inquiry about these benefits has not kept pace with the increased usage of this shoe type. A fundamental premise of rocker bottom shoes is that they transform hard, flat, level surfaces into more uneven ones. Published studies have described a variety of such shoes-all having a somewhat rounded bottom and a cut heel region or a cut forefoot region, or both (double rocker). Despite the fundamentally similar shoe geometries, the reported effects of rocker bottom shoes on gait biomechanics have varied considerably. Ten healthy subjects agreed to participate in the present study and were given appropriately sized Masai Barefoot Technology (St. Louis, MO), Skechers(™) (Manhattan Beach, CA), and New Balance (Boston, MA) conventional walking shoes. After a 12-day accommodation period, the subjects walked wearing each shoe while 3-dimensional motion and force data were collected in the gait laboratory. The key findings included (1) increased trunk flexion, decreased ankle plantarflexion range, and reduced plantarflexion moment in the early stance; (2) increased ankle dorsiflexion and knee flexor moment in the midstance; (3) decreased peak ankle plantarflexion in the late stance; and (4) decreased ankle plantarflexion and decreased hip flexor and knee extensor moments in the pre-swing and into swing phase. The walking speed was unconstrained and was maintained across all shoe types. A biomechanical explanation is suggested for the observed changes. Suggestions for cautions are provided for using rocker bottom shoes in patients with neuromuscular insufficiency.

Evidence-based review and assessment of botulinum neurotoxin for the treatment of urologic conditions.

Botulinum neurotoxin (BoNT) can be injected to achieve therapeutic benefit across a large range of clinical conditions. To assess the efficacy and safety of BoNT injections for the treatment of certain urologic conditions, including detrusor sphincter dyssynergia (DSD), lower urinary tract symptoms due to benign prostatic hyperplasia (BPH), and detrusor overactivity (both neurogenic [NDO] and idiopathic [IDO]), an expert panel reviewed evidence from the published literature. Data sources included English-language studies identified via MEDLINE, EMBASE, CINAHL, Current Contents, and the Cochrane Central Register of Controlled Trials. Evidence tables generated in the 2008 Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) review of the use of BoNT for autonomic disorders were also reviewed and updated. The panel evaluated evidence at several levels, supporting BoNT as a class, for the serotypes BoNT-A and BoNT-B, as well as for the four individual commercially available formulations: abobotulinumtoxinA (A/Abo), onabotulinumtoxinA (A/Ona), incobotulinumtoxinA (A/Inco), and rimabotulinumtoxinB (B/Rima). The panel ultimately made recommendations on the use of BoNT for the management of these urologic conditions based upon the strength of clinical evidence and following the AAN classification scale. For the treatment of DSD, the evidence supported a Level B recommendation for the use of A/Ona; A/Abo, A/Inco, and B/Rima received a Level U recommendation. For the treatment of NDO, there was sufficient clinical evidence to support a Level A recommendation for BoNT-A as well as for both A/Ona and A/Abo; no published data were identified for either A/Inco or B/Rima (Level U). For the treatment of IDO, the evidence supported a Level A recommendation for A/Ona; A/Inco, A/Abo, and B/Rima received a Level U recommendation. For the management of BPH, the evidence supported a Level B recommendation for BoNT and A/Ona; no published studies were identified for A/Abo, A/Inco, or B/Rima, warranting a Level U recommendation for these three formulations. Further studies are needed to evaluate the efficacy and safety of BoNT for the management of urologic conditions.

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration.

PURPOSE: The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation. RESULTS: Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper. CONCLUSION: It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.

Evaluation and management of spastic gait in patients with traumatic brain injury.

Damage to the corticospinal system after brain injury interferes with activities of daily living, mobility, and communication. The chief cause of this interference has to do with impairment to produce and regulate voluntary movement accompanied by the presence of spasticity. This review advocates that the evaluation of "spasticity" should focus on 3 issues: (1) identifying the clinical pattern of motor dysfunction and its source; (2) identifying the patient's ability to control muscles involved in the clinical pattern; and (3) the differential role of muscle stiffness and contracture as it relates to the functional problem. We have identified and described 6 clinical patterns of motor dysfunction affecting the lower limbs during gait, found in patients with traumatic brain injury and residual from upper motor neuron lesions. We have presented the use of dynamic electromyography to identify the voluntary and spastic characteristics of individual muscles in gait and the use of anesthetic nerve blocks to identify properties of stiffness and contracture in particular muscle groups. Treatment algorithms for these problems include identification of the muscles that contribute to the deformity across a joint; the stage of patient recovery; and most important, the clinical goals applicable to the patient. The treatment strategies based on the algorithm included in this article were focused on the use of chemodenervation of targeted muscles, neuro-orthopedic surgery, and other therapeutic strategies.

The influence of dynamic polyelectromyography in formulating a surgical plan in treatment of spastic elbow flexion deformity.

OBJECTIVE: To determine the influence of motor-control analysis with dynamic electromyography on surgical planning in patients with spastic elbow flexion deformity. DESIGN: Prospective observational design. SETTING: A Traumatic Brain Injury Model Systems-affiliated specialty referral center for the evaluation and treatment of mobility problems associated with neurologic injury and disease. PARTICIPANTS: Twenty-one patients with spastic elbow flexion deformity. INTERVENTIONS: Two surgeons each formulated a detailed surgical plan for each individual muscle-tendon unit. Patients then underwent motor-control analysis in which kinetic and polyelectromyographic data were collected by using a standard protocol. Each surgeon formulated another surgical plan after independently reviewing the laboratory study. MAIN OUTCOME MEASURES: The frequency of change and degree of agreement in the surgical plans after review of the laboratory data were used as measures of the effect of the laboratory studies. RESULTS: Fifty-seven percent of the surgical plans were changed after the motor-control study. The frequency of change did not differ by clinical experience. There was a trend toward higher agreement between surgeons after the study than before. CONCLUSIONS: Detailed electromyographic motor-control analysis alters surgical planning for patients with spastic elbow flexion deformity. Clinical assessment alone does not accurately identify the muscles responsible for the deformity or dysfunction. More clinical experience does not result in greater accuracy. Motor-control analysis produces higher agreement between surgeons in planning surgery.

The impact of instrumented gait analysis on surgical planning: treatment of spastic equinovarus deformity of the foot and ankle.

BACKGROUND: Despite the logic behind instrumented gait analysis, its specific contribution to clinical and surgical decision making is not well known. Our purpose in this study was to determine the influence of gait analysis with dynamic electromyography upon surgical planning in patients with upper motor neuron syndrome and gait dysfunction. METHODS: Two surgeons prospectively evaluated 36 consecutive adult patients with a spastic equinovarus deformity of the foot and ankle. After an initial history and physical exam, each surgeon independently formulated a surgical plan. Surgical treatment options for each individual muscle/tendon unit crossing the ankle included lengthening, transfer, release or no surgery. After the initial clinical evaluation and surgical planning, all patients then underwent instrumented gait analysis collecting kinetic, kinematic and poly-EMG data using a standard protocol by a single experienced physiatrist. Each surgeon reviewed the gait studies and patients independently and again formulated a surgical plan. The surgical plans were compared for each surgeon before and after gait study. The agreement between the two surgeon's surgical plans was also compared before and after gait study. Each patient was evaluated for the clinical outcome of surgery. RESULTS: Overall a change was made in 64% of the surgical plans after the gait study. The frequency of changing the surgical plan was not significantly different between the more and less experienced surgeons. The agreement between surgeons increased from 0.34 to 0.76 (p=0.009) after the gait study. The number of surgical procedures planned by each surgeon converged after the gait studies. Correction of the varus deformity was seen in all patients that underwent surgical treatment. CONCLUSION: Instrumented gait analysis alters surgical planning for patients with equinovarus deformity of the foot and ankle and can produce higher agreement between surgeons in surgical planning. CLINICAL RELEVANCE: The equinovarus deformity is due to a variety of deforming forces and a single, best operation does not exist to correct all equinovarus deformities. Rather, a muscle specific approach that identifies the deforming forces will produce the best outcomes when treating the spastic equinovarus deformity.