Exoesqueletos para la recuperación funcional de la marcha en pacientes con patologías del sistema nervioso central como la esclerosis múltiple, ictus y/o lesiones medulares post-traumatismo / Exoskeletons for the functional recovery of walking ability in patients with central nervous system disorders such as multiple sclerosis, stroke, and traumatic spinal injury

INTRODUCCIÓN: La rehabilitación robótica de la marcha, conocida como Robot-Assisted Gait Therapy, ha surgido como una alternativa innovadora a la rehabilitación convencional de la marcha. Esta terapia ofrece un enfoque de rehabilitación controlada, repetitiva e intensiva, permitiendo una evaluación objetiva del progreso de los pacientes. La rehabilitación de la marcha es especialmente relevante en pacientes con trastornos del sistema nervioso central, como la esclerosis múltiple, ictus o lesión medular. Estas condiciones pueden provocar una pérdida significativa de la capacidad motora y afectar la calidad de vida de los pacientes. Los exoesqueletos pueden ser utilizados en la rehabilitación de estos pacientes, buscando mejorar los patrones de marcha y mitigar los síntomas asociados. En resumen, la rehabilitación robótica de la marcha mediante exoesqueletos para las extremidades inferiores ofrece una opción terapéutica innovadora para mejorar la funcionalidad y la independencia en la marcha de los pacientes con trastornos del sistema nervioso central. Este informe busca proporcionar una evaluación completa de estos dispositivos en la rehabilitación de la marcha, centrándose en pacientes con esclerosis múltiple, ictus y lesión medular. OBJETIVOS: 1) Identificar, sintetizar, analizar y evaluar la evidencia científica disponible sobre la efectividad y seguridad de los exoesqueletos para la recuperación

INTRODUCTION: Robot-assisted gait training has emerged as an innovative alternative to conventional gait rehabilitation. The focus of this type of training is highly-controlled intensive repetitive rehabilitation, enabling objective evaluation of patient progress. Gait rehabilitation is key in patients with central nervous system damage such as that associated with multiple sclerosis, stroke, and spinal injury. These conditions can cause significant loss of motor function, and hence, impair patient quality of life. Exoskeletons may be used in the rehabilitation of these patients, seeking to improve gait patterns and ameliorate associated symptoms. In brief, robot-assisted gait rehabilitation using lower-extremity exoskeletons is an innovative treatment option for improving gait function and independence in patients with central nervous system damage. This report aims to provide a complete assessment of these gait rehabilitation devices, with a focus on patients with multiple sclerosis, stroke, or spinal injury. AIMS: 1) To identify, synthetise, analyse and evaluate the scientific evidence available concerning the efficacy/effectiveness and safety of exoskeletons for functional gait recovery in adult patients with central nervous system damage associated with multiple scl

Eficacia y seguridad del sistema robotizado para la rehabilitación de adultos con trastorno de la marcha debido a accidente cerebrovascular / Efficacy and safety of the robotic system for the rehabilitation of adults with gait disorder due to stroke

ANTECEDENTES: En el marco de la metodología ad hoc para evaluar solicitudes de tecnologías sanitarias, aprobada mediante Resolución de Instituto de Evaluación de Tecnologías en Salud e Investigación N° 111 -IETSI-ESSALUD-2021 y ampliada mediante Resolución de Instituto de Evaluación de Tecnologías en Salud e Investigación N° 97-IETSI-ESSALUD2022, se ha elaborado el presente dictamen sobre la evaluación de la eficacia y seguridad del sistema robotizado para la rehabilitación de adultos con trastorno de la marcha debido a accidente cerebrovascular. ASPECTOS GENERALES: El accidente cerebrovascular (ACV) es una afección que se produce cuando se interrumpe el suministro de sangre al sistema nervioso central (cerebro, retina, columna espinal), lo que puede dañar las células cerebrales y provocar discapacidad o la muerte (Sacco et al., 2013). Existen dos tipos principales de ACV: el isquémico, que se produce cuando un coágulo o placa ateroesclerótica bloquea un vaso sanguíneo y deja sin oxígeno a alguna región del sistema nervioso central, y el hemorrágico, que se produce comúnmente tras una vasculopatía que causa una hemorragia (Campbell & Khatri, 2020). El ACV es una condición que afecta a las personas de todas las edades y géneros, siendo la segunda causa de muerte y tercera causa de discapacidad en todo el mundo (Feigin et al., 2021). Se estima que una de cada cuatro personas puede verse afectada por esta condición en algún momento de su vida (Feigin et al., 2018). Además, es especialmente frecuente en personas mayores de 65 años (Rajati et al., 2023). La prevención, la identificación temprana y el tratamiento adecuado son fundamentales para prevenir las complicaciones del ACV y mejorar los resultados del paciente. METODOLOGÍA: Se realizó una búsqueda bibliográfica exhaustiva con el objetivo de identificar la mejor evidencia sobre la evaluación de la eficacia y seguridad del sistema robotizado para la rehabilitación de adultos con trastorno de la marcha debido a accidente cerebrovascular. La búsqueda bibliográfica se llevó a cabo en las bases de datos PubMed, The Cochrane Library, Web of Science y LILACS. Además, se realizó una búsqueda manual en Google y dentro de las páginas web pertenecientes a grupos que realizan evaluaciones de tecnologías sanitarias (ETS) y guías de práctica clínica (GPC), incluyendo el Centro Nacional de Excelencia Tecnológica en Salud (CENETEC), National Institute for Health and Care Excellence (NICE), la Agency for Healthcare Research and Quality's (AH RQ), Scottish I ntercollegiate Guidelines Network (SIGN), The Guidelines International Network (GIN), National Health and Medical Research Council (NHMRC), Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA), Comissáo Nacional de Incorporacáo de Tecnologias no Sistema Único de Saúde (CONITEC), Instituto de Evaluación Tecnológica en Salud (IETS), Instituto de Efectividad Clínica y Sanitaria (IECS), Scottish Medicines Consortium (SMC), Canadian Agency for Drugs and Technologies in Health (CADTH), Instituto de Calidad y Eficiencia en la Atención de la Salud (IQWiG, por sus siglas en alemán), y Hauté Autorité de Santé (HAS). Asimismo, se realizó una búsqueda de GPC en las páginas web de las principales sociedades o instituciones especializadas en el manejo del accidente cerebrovascular o trastorno de la marcha, tales como: American Heart Association/American Stroke Association (AHA/ASA), European Stroke Organisation, Academy of Neurologic Physical Therapy (APTA). Finalmente, se realizó una búsqueda de estudios en curso aún no publicados en las páginas web de ClinicalTrials.gov y la International Clinical Trials Registry Platform. RESULTADOS: La búsqueda bibliográfica se realizó el 16 de marzo de 2023 y se identificaron cinco guías de práctica clínica (GPC) que contenían recomendaciones acerca del dispositivo en evaluación para la población objetivo (Haute Autorité de Santé, 2022; Hornby et al., 2020; National Institute for Health and Care Excellence, 2013; Teasell et al., 2020; Winstein et al., 2016). También se incluyeron cinco revisiones sistemáticas (RS) con metaanálisis (MA) que realizaron comparaciones directas de la intervención y comparador de la pregunta PICO planteada (Baronchelli et al., 2021; Calafiore et al., 2022; Loro et al., 2023; Mehrholz et al., 2020; Wang et al., 2021). Sin embargo, una de las RS evaluó como intervención la combinación del sistema robotizado y la fisioterapia, lo que limitó la evaluación del efecto aislado del sistema robotizado (Mehrholz et al., 2020). Durante la revisión de los ensayos clínicos aleatorizados (ECA) en la fase de texto completo, se encontró que la mayoría de ellos ya habían sido considerados en los análisis cualitativos y cuantitativos de las RS, por lo que se decidió no incluirlos en el análisis final. Además, se incluyó un protocolo de ECA (University Hospital Ostrava, 2022) en el que planea determinar el efecto de la rehabilitación de la marcha con Lokomat en comparación con la terapia convencional con un protocolo de tratamiento definido. CONCLUSIÓN: Por lo expuesto, el Instituto de Evaluación de Tecnologías en Salud e Investigación- 'ETS' no aprueba el uso del sistema robotizado para la rehabilitación de adultos con trastorno de la marcha debido a accidente cerebrovascular. Se recomienda a los especialistas que, en caso de identificar nueva evidencia que responda a la población de la PICO de interés, envíen sus propuestas para ser evaluadas en el marco de la Directiva N° 001-IETSI-ESSALUD-2018.

Balance and mobility in geriatric patients : Assessment and treatment of neurological aspects.

BACKGROUND: Personal autonomy in advanced age critically depends on mobility in the environment. Geriatric patients are often not able to walk safely with sufficient velocity. In many cases, multiple factors contribute to the deficit. Diagnostic identification of single components enables a specific treatment. OBJECTIVE: This article describes the most common neurological causes of imbalance and impaired gait that are relevant for a pragmatic approach for the assessment of deficits in clinical and natural environments taking into account the physiology of balance and gait control, typical morbidities in older people and the potential of innovative assessment technologies. MATERIAL AND METHODS: Expert opinion based on a narrative review of the literature and with reference to selected research topics. RESULTS AND DISCUSSION: Common neurological causes of impaired balance and mobility are sensory deficits (reduced vision, peripheral neuropathy, vestibulopathy), neurodegeneration in disorders with an impact on movement control and motoric functions (Parkinsonian syndromes, cerebellar ataxia, vascular encephalopathy) and functional (psychogenic) disorders, particularly a fear of falling. Clinical tests and scores in laboratory environments are complemented by the assessment in the natural environment. Wearable sensors, mobile smartphone-based assessment of symptoms and functions and adopted strategies for analysis are currently emerging. Use of these data enables a personalized treatment. Furthermore, sensor-based assessment ensures that effects are measured objectively.

Impact of instrumental analysis of stiff knee gait on treatment appropriateness and associated costs in stroke patients.

BACKGROUND: Stiff Knee Gait (SKG) in stroke patients is typically treated by the inhibition of the rectus femoris (RF) with botulinum toxin (BoNT) after clinical evaluation, obtaining an average pooled recovery in knee flexion (KF) of 7 degrees. PURPOSE: Our hypothesis is that this limited recovery after BoNT could depend on the inadequacy in the selection of patients to be treated. The aim of this study was to assess the percentage of inappropriate treatments (PIT) that can be avoided when instrumental gait analysis (GA) is used, and to estimate the associated cost savings. METHODS: We retrospectively analyzed GA data from chronic stroke patients with SKG and clinically assessed knee extensors spasticity referred to our laboratory over a five-year period. Gait kinematics and dynamic electromyography data were used. Patients were considered unsuitable for RF inhibition when: their SKG was determined by inadequate ankle push-off (APO) rather than by a brake from knee extensors, based on a previously published algorithm using gait kinematics (PITKIN); when RF was not active during KF (PITEMG); and when a proximal braking mechanism was found, if this was not due to RF activity (PITGA). RESULTS: 160 patients, age 20-87 years, gait speed 9-77%height/s, KF peak -4-44 degrees, were included. Of these, in 119 cases poor APO was the main cause of SKG, thus leading to PITKIN = 74%. In 48 out of 107 non-obese subjects, RF spasticity was not involved in SKG, resulting in PITEMG = 45%. Finally, patients with a braking activity as the main cause and concurrent RF activity were 20/107 = 19%, resulting in PITGA = 81% SIGNIFICANCE: When treating SKG, proper use of GA can reduce the percentage of inappropriate treatments by BoNT at the RF up to 81%. Savings are in the order of €100k/year when considering centers treating 100 or more patients/year.

Kin-FOG: Automatic Simulated Freezing of Gait (FOG) Assessment System for Parkinson's Disease.

Parkinson's disease (PD) is one of the leading neurological disorders in the world with an increasing incidence rate for the elderly. Freezing of Gait (FOG) is one of the most incapacitating symptoms for PD especially in the later stages of the disease. FOG is a short absence or reduction of ability to walk for PD patients which can cause fall, reduction in patients' quality of life, and even death. Existing FOG assessments by doctors are based on a patient's diaries and experts' manual video analysis which give subjective, inaccurate, and unreliable results. In the present research, an automatic FOG assessment system is designed for PD patients to provide objective information to neurologists about the FOG condition and the symptom's characteristics. The proposed FOG assessment system uses an RGB-D sensor based on Microsoft Kinect V2 for capturing data for 5 healthy subjects who are trained to imitate the FOG phenomenon. The proposed FOG assessment system is called "Kin-FOG". The analysis of foot joint trajectory of the motion captured by Kinect is used to find the FOG episodes. The evaluation of Kin-FOG is performed by two types of experiments, including: (1) simple walking (SW); and (2) walking with turning (WWT). Since the standing mode has features similar to a FOG episode, our Kin-FOG system proposes a method to distinguish between the FOG and standing episodes. Therefore, two general groups of experiments are conducted with standing state (WST) and without standing state (WOST). The gradient displacement of the angle between the foot and the ground is used as the feature for discriminating between FOG and standing modes. These experiments are conducted with different numbers of FOGs for getting reliable and general results. The Kin-FOG system reports the number of FOGs, their lengths, and the time slots when they occur. Experimental results demonstrate Kin-FOG has around 90% accuracy rate for FOG prediction in both experiments for different tasks (SW, WWT). The proposed Kin-FOG system can be used as a remote application at a patient's home or a rehabilitation clinic for sending a neurologist the required FOG information. The reliability and generality of the proposed system will be evaluated for bigger data sets of actual PD subjects.

Walking assessment after lumbar puncture in normal-pressure hydrocephalus: a delayed improvement over 3 days.

OBJECTIVE The determination of gait improvement after lumbar puncture (LP) in idiopathic normal-pressure hydrocephalus (iNPH) is crucial, but the best time for such an assessment is unclear. The authors determined the time course of improvement in walking after LP for single-task and dual-task walking in iNPH. METHODS In patients with iNPH, sequential recordings of gait velocity were obtained prior to LP (time point [TP]0), 1-8 hours after LP (TP1), 24 hours after LP (TP2), 48 hours after LP (TP3), and 72 hours after LP (TP4). Gait analysis was performed using a pressure-sensitive carpet (GAITRite) under 4 conditions: walking at preferred velocity (STPS), walking at maximal velocity (STMS), walking while performing serial 7 subtractions (dual-task walking with serial 7 [DTS7]), and walking while performing verbal fluency tasks (dual-task walking with verbal fluency [DTVF]). RESULTS Twenty-four patients with a mean age of 76.1 ± 7.8 years were included in this study. Objective responder status moderately coincided with the self-estimation of the patients with subjective high false-positive results (83%). The extent of improvement was greater for single-task walking than for dual-task walking (p < 0.05). Significant increases in walking speed were found at TP2 for STPS (p = 0.042) and DTVF (p = 0.046) and at TP3 for STPS (p = 0.035), DTS7 (p = 0.042), and DTVF (p = 0.044). Enlargement of the ventricles (Evans Index) positively correlated with early improvement. Gait improvement at TP3 correlated with the shunt response in 18 patients. CONCLUSIONS Quantitative gait assessment in iNPH is important due to the poor self-evaluation of the patients. The maximal increase in gait velocity can be observed 24-48 hours after the LP. This time point is also best to predict the response to shunting. For dual-task paradigms, maximal improvement appears to occur later (48 to 72 hours). Assessment of gait should be performed at Day 2 or 3 after LP.

Gait and Balance Assessment.

Gait and balance deficits are commonly experienced by individuals with a variety of neurologic disorders. These deficits can be particularly frustrating because they often profoundly impact a person's quality of life. The author applies information about gait and balance based on the neurologic examination and summarizes important relationships among common impairment measures of gait and balance deficits. She also provides an interpretation of these relationships to assist the clinician in how to identify and manage gait and balance deficits.

Toe walking: causes, epidemiology, assessment, and treatment.

PURPOSE OF REVIEW: The present review includes the most up-to-date literature on the causes, epidemiology, diagnosis, and treatment of toe walking. RECENT FINDINGS: The prevalence of toe walking at age 5.5 years is 2% in normally developing children, and 41% in children with a neuropsychiatric diagnosis or developmental delays. A recent systematic review concluded that there is good evidence for casting and surgery in the treatment of idiopathic toe walking, with only surgery providing long-term results beyond 1 year. Botox combined with casting does not provide better outcomes compared with casting alone. Ankle-foot-orthoses restrict toe walking when worn, but children revert to equinus gait once the orthosis is removed. SUMMARY: Toe walking can occur because of an underlying anatomic or neuromuscular condition, but in the majority of cases toe walking is idiopathic, without a discernable underlying cause. For some families, toe walking may simply be a cosmetic concern, whereas in other cases it can cause pain or functional issues. Treatment for toe walking is based on age, underlying cause, and the severity of tendon contracture. Described treatments include casting, chemical denervation, orthotics, physical therapy, and surgical lengthening of the gastroc-soleus-Achilles complex. A careful history, clinical exam, and selective diagnostic testing can be used to differentiate between different types of toe walking and determine the most appropriate treatment for each child.

Reducing The Cost of Transport and Increasing Walking Distance After Stroke: A Randomized Controlled Trial on Fast Locomotor Training Combined With Functional Electrical Stimulation.

Background Neurorehabilitation efforts have been limited in their ability to restore walking function after stroke. Recent work has demonstrated proof-of-concept for a functional electrical stimulation (FES)-based combination therapy designed to improve poststroke walking by targeting deficits in paretic propulsion. Objectives To determine the effects on the energy cost of walking (EC) and long-distance walking ability of locomotor training that combines fast walking with FES to the paretic ankle musculature (FastFES). Methods Fifty participants >6 months poststroke were randomized to 12 weeks of gait training at self-selected speeds (SS), fast speeds (Fast), or FastFES. Participants' 6-minute walk test (6MWT) distance and EC at comfortable (EC-CWS) and fast (EC-Fast) walking speeds were measured pretraining, posttraining, and at a 3-month follow-up. A reduction in EC-CWS, independent of changes in speed, was the primary outcome. Group differences in the number of 6MWT responders and moderation by baseline speed were also evaluated. Results When compared with SS and Fast, FastFES produced larger reductions in EC (Ps ≤.03). FastFES produced reductions of 24% and 19% in EC-CWS and EC-Fast (Ps <.001), respectively, whereas neither Fast nor SS influenced EC. Between-group 6MWT differences were not observed; however, 73% of FastFES and 68% of Fast participants were responders, in contrast to 35% of SS participants. Conclusions Combining fast locomotor training with FES is an effective approach to reducing the high EC of persons poststroke. Surprisingly, differences in 6MWT gains were not observed between groups. Closer inspection of the 6MWT and EC relationship and elucidation of how reduced EC may influence walking-related disability is warranted.

A microcontroller platform for the rapid prototyping of functional electrical stimulation-based gait neuroprostheses.

Functional electrical stimulation (FES) has been used over the last decades as a method to rehabilitate lost motor functions of individuals with spinal cord injury, multiple sclerosis, and post-stroke hemiparesis. Within this field, researchers in need of developing FES-based control solutions for specific disabilities often have to choose between either the acquisition and integration of high-performance industry-level systems, which are rather expensive and hardly portable, or develop custom-made portable solutions, which despite their lower cost, usually require expert-level electronic skills. Here, a flexible low-cost microcontroller-based platform for rapid prototyping of FES neuroprostheses is presented, designed for reduced execution complexity, development time, and production cost. For this reason, the Arduino open-source microcontroller platform was used, together with off-the-shelf components whenever possible. The developed system enables the rapid deployment of portable FES-based gait neuroprostheses, being flexible enough to allow simple open-loop strategies but also more complex closed-loop solutions. The system is based on a modular architecture that allows the development of optimized solutions depending on the desired FES applications, even though the design and testing of the platform were focused toward drop foot correction. The flexibility of the system was demonstrated using two algorithms targeting drop foot condition within different experimental setups. Successful bench testing of the device in healthy subjects demonstrated these neuroprosthesis platform capabilities to correct drop foot.

The long-term cost-effectiveness of the use of Functional Electrical Stimulation for the correction of dropped foot due to upper motor neuron lesion.

OBJECTIVE: Functional Electrical Stimulation (FES) for correction of dropped foot has been shown to increase mobility, reduce the incidence of falls and to improve quality of life. This study aimed to determine how long the intervention is of benefit, and the total cost of its provision. DESIGN: Retrospective review of medical records. PARTICIPANTS: One hundred and twenty-six people with spastic dropped foot (62 stroke, 39 multiple sclerosis, 7 spinal cord injury, 3 cerebral palsy, 15 others) who began treatment in the year 1999. METHOD: All received common peroneal nerve stimulation, producing dorsiflexion and eversion time to the swing phase of gait using a heel switch. Device usage, 10 m walking speed and Functional Walking Category (FWC) were recorded. RESULTS: The median time of FES use was 3.6 years (mean 4.9, standard deviation 4.1, 95% confidence interval 4.2-5.6) with 33 people still using FES after a mean of 11.1 years. People with stroke walked a mean of 45% faster overall, including a 24% training effect with 52% improving their FWC. People with multiple sclerosis did not receive a consistent training effect but walked 29% faster when FES was used with 40% increasing their FWC. The average treatment cost was £3,095 per patient resulting in a mean cost per Quality Adjusted Life Years of £15,406. CONCLUSION: FES is a practical, long-term and cost-effective treatment for correction of dropped foot.

Gait assessment during the initial fitting of customized selective laser sintering ankle foot orthoses in subjects with drop foot.

BACKGROUND: Recently, additive fabrication has been proposed as a feasible engineering method for manufacturing of customized ankle foot orthoses (AFOs). Consequently, studies on safety, comfort and effectiveness are now carried out to assess the performance of such devices. OBJECTIVE: Evaluate the clinical performance of customized (selective laser sintering) SLS-AFOs on eight subjects with unilateral drop foot gait and compare to clinically accepted (polypropylene) PP-AFOs. STUDY DESIGN: Active control trial. METHODS: For each subject two customized AFOs were fabricated: one SLS-AFO manufactured following an additive fabrication framework and one thermoplastic PP-AFO manufactured according to the traditional handcraft method. Clinical performance of both AFOs was evaluated during gait analysis. RESULTS: A significant beneficial effect of both custom-moulded PP-AFO and customized SLS-AFO in terms of spatial temporal gait parameters and ankle kinematic parameters compared to barefoot gait of adults with drop foot gait are observed. No statistically significant difference between the effect of PP-AFO and of SLS-AFO was found in terms of spatial temporal gait parameters and ankle kinematic parameters. CONCLUSION: AFOs manufactured through the SLS technique show performances that are at least equivalent to the handcrafted PP-AFOs commonly prescribed in current clinical practice. Clinical relevance Manufacturing personalized AFOs with selective laser sintering (SLS) in an automated production process results in decreased production time and guarantees the consistency of shape and functional characteristics over different production time points compared to the traditional manufacturing process. Moreover, it reduces the dependency of the appliance on the experience and craftsmanship of the orthopaedic technician.

Assessing competency in spasticity management: a method of development and assessment.

This project endeavored to create an educational module including methodology to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients with spasticity and other sequelae of the upper motor neuron syndrome. It further sought to verify acquired competencies in spasticity management through objective evaluation methodology. A physical medicine and rehabilitation board-certified physician with 10 yrs clinical experience in spasticity management trained 16 residents using a standardized competency-based module. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. The 16 residents successfully demonstrated proficiency in every segment of the evaluation module by the end of the Postgraduate Year 3 spasticity management rotation. Objective measures compared resident scores on an institution-specific standardized test administered before and after training. Resident proficiency in the skills and knowledge pertaining to spasticity management was objectively verified after completion of the standardized educational module. Validation of the assessment tool is evidenced by significantly improved postrotational institution-specific standardized test scores (mean pretest score, 61.1%; mean posttest score, 95.4%) as well as oral testing. In addition, the clinical development tool was validated by residents being individually observed performing skills and deemed competent by a board-certified physical medicine and rehabilitation physician specializing in spasticity management. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical skill area of spasticity management.

Office assessment of gait and station.

Gait and station disorders are among the most common reasons patients seek outpatient neurologic consultation. A careful assessment of gait and station provides the clinician with an overview of the integrity of a patient's central and peripheral nervous systems. Therefore, clinicians may consider performing a gait and station examination as the prelude to their formal neurologic examination of the patient, regardless of their chief complaint, to gain insight into which areas of the remainder of the neurologic examination they should particularly focus on, to localize the patient's neurologic dysfunction. In this review, the author describes how a structured gait and station examination may be performed in the ambulatory setting, without any special equipment. Then, the precise mechanics of each component of normal gait and station are discussed, so that the potential localizations and significance of abnormalities, which may occur during various phases of the gait cycle, can be highlighted. In particular, some less common findings are emphasized, which may be mistaken as psychogenic in etiology.

Freezing of gait in older people: associated conditions, clinical aspects, assessment and treatment.

Freezing of gait (FOG) is a disabling condition in older people. It is common in Parkinson's disease (PD) and other parkinsonian syndromes. The assessment of this condition poses challenges due to its episodic and transient nature and its frequent association with cognitive impairment. The pathophysiology of FOG is complex and poorly understood. Morphological brain imaging is of limited value in the evaluation of FOG, and functional imaging techniques are currently being developed to study the phenomenon. The treatment of 'off' time FOG in PD is relatively straight forward, but 'on' freezing in PD and FOG associated with other conditions may be difficult to treat. FOG is a strong risk factor for falls and adversely affects the quality of life of patients and carers. A multidisciplinary team approach is essential for optimum management.

[Assessment of gait disorders in older people]. / Evaluer les troubles de la marche des personnes âgées au cabinet.

Gait disorders are frequent and important to assess in older people because they provide unique diagnostic and prognostic information. Gait disorders can be regarded as a marker of frailty because they are associated with several adverse consequences, including falls, cognitive disorders, functional decline, institutionalization, hospitalization, and death. Using structured instruments, gait assessment could be performed in primary care practice to classify the level of sensorimotor deficit and provide the necessary information to decide how to best intervene to improve gait performances, prevent falls as well as functional decline.

Quantitative assessment of anaesthetic nerve block and neurotomy in spastic equinus foot: a review of two cases.

OBJECTIVE: To quantitatively evaluate the effect of motor nerve branch block and neurotomy of the soleus nerve on triceps surae spasticity, reviewing 2 cases. METHODS: Beside clinical assessment, we carried out a quantitative measurement of the stiffness of the ankle flexor muscles. The path length of the phase diagram between elastic and viscous stiffness quantifies the reflex response to movement and reflects the importance of the spasticity. The assessments were carried out before and 30 min after motor nerve branch block of the upper soleus nerve and more than 7 months after neurotomy. RESULTS: Both patients presented with pronounced ankle plantar flexor spasticity: their path lengths were more than 6 times greater than normal values at baseline (#1: 354 N m rad(-1); #2: 409 N m rad(-1)). Motor nerve branch block and neurotomy allowed a near-normalization of elastic and viscous stiffness of ankle plantar flexor muscles in the 2 patients. Their path length was almost similarly improved by motor nerve branch block (#1: 127 N m rad(-1); #2: 231 N m rad(-1)) and neurotomy (#1: 60 N m rad(-1); #2: 162 N m rad(-1)). CONCLUSION: These case reports highlight the fundamental role of the soleus muscle in triceps surae spasticity in our patients, the predictivity of motor nerve branch block in the preoperative assessment, and the effectiveness of soleus neurotomy in spastic equinus foot.