Recommendations for Ultrasound Guidance for Diagnostic Nerve Blocks for Spasticity. What Are the Benefits?

The diagnostic nerve block (DNB) for spasticity is the percutaneous application of an anesthetic to an individual peripheral nerve trunk (mixed motor sensory nerve), nerve branch to a muscle or an intramuscular branch. The DNB causes a temporary paralysis to assess the contribution of muscle(s) on the spastic pattern and may unmask a fully or partially increased joint range of motion. The anesthetic literature supports the use of ultrasound (US) guidance to improve nerve blocks for sensory targets. This communication summarizes the potential advantages that support the use of US to improve DNB technique. Nerves are much smaller than muscle targets and have various known innervation patterns. US allows for rapid localization of the target before injection, particularly in complex anatomy patterns. The nerve trunks are typically found adjacent to or encapsulating blood vessels, which can be quickly identified with or without color Doppler, allowing the clinician to scan from the vessels to the target and avoid intravascular injection. Lower stimulation levels can be used as the targeted muscle(s) can be seen stimulating rather than only on the surface. A shorter needle insertion time and lower stimulation levels should cause less discomfort to the patient. Smaller volumes of anesthetic may be used as the fluid is seen reaching its target and cessation of stimulation is observed. Further study is needed to identify evidence supporting US utilization with electrical stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.

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.

Spasticity following brain and spinal cord injury: assessment and treatment.

PURPOSE OF REVIEW: Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS: Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY: Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.

Rehabilitation of somatic sensation and related deficit of motor control by Mirror Box Therapy: a case report.

Somatosensory disorders are often present after cerebral stroke. These deficits are associated with patients' disability. Therefore, their rehabilitation takes an importance in recovery program. However, the treatment of sensation remains poorly considered during neurorehabilitation and evidence for active sensory training is limited. Mirror Box Therapy is a simple training used to treat upper extremity motor deficits and pain also in patients with stroke. However, the effects of Mirror Box Therapy on somatosensory impairments in post-stroke patients are not deeply investigated and often exclusively motor exercises are provided during therapy.The aim of the present study was to investigate the effects of Mirror Box Therapy sensory training on somatosensory deficits in a stroke patient presenting upper limb impairment.The patient underwent to four weeks of training, five days a week. Before, during and after the Mirror Box Therapy treatment, the patient was assessed by Rivermead Assessment of Somatosensory Performance. Before and after training also upper limb motor function and performance in activities of daily living were assessed.After training patient showed an improvement in somatosensory performance. The gain was maintained at follow-up.This case report shows the effects of Mirror Box Therapy sensory training on the upper extremity for the improvement of sensation and movement in a patient with a thalamo-capsular hemorrhagic stroke during the subacute phase.

Effects of deep heating modalities on the morphological and elastic properties of the non-insertional region of achilles tendon: a pilot study.

BACKGROUND: Over the last 20 years, both diathermy and ultrasound have been popular choices for many clinicians in treating musculoskeletal disorders. However, there is a lack of clinical evidence of deep heating modalities to treat tendon pathology, There is no study to investigate the effects of such as physical modalities on morphological and elastic properties on the human tendons. OBJECTIVE: the objective of the present study was to compare the effects of diathermy and ultrasound therapies on cross sectional area, transversal height and hardness percentage of the non-insertional region of the Achilles tendon in able-bodied subjects. METHODS: healthy volunteers were divided in diathermy and ultrasound group received six 15-min treatment sessions. Before and after treatment a sonographic assessment was conducted by mean of ultrasonography and the following parameters were recorded: cross sectional area, transversal height and hardness percentage. RESULTS: thirty-two subjects were enrolled. Between-group comparisons showed a significant change on hardness percentage (p = 0.004) after treatment in diathermy therapy group. Within-group comparison showed a significant improvement in the hardness percentage for the diathermy (p = 0.001) and ultrasound (p = 0.046) after two weeks of treatment. CONCLUSION: this pilot study demonstrated larger effects on morphological and elastic properties of the non-insertional region of the Achilles tendon after diathermy than ultrasound therapy in normal tendons. Diathermy may be a useful deep heat modality for treating non-insertional Achilles tendinopathy.

Effects of Neck Taping in the Treatment of Hemispatial Neglect in Chronic Stroke Patients: A Pilot, Single Blind, Randomized Controlled Trial.

Background and objectives: Hemispatial neglect is a common consequence of stroke, with an estimated incidence of 23%. Interventions for treating hemispatial neglect may be categorized as either top-down or bottom-up processing. The aim of top-down approaches is to train the person to voluntarily compensate for their neglect. Such approaches require awareness of the disorder and a high level of active participation by the patient. Differently, bottom-up approaches are based on manipulation of a patient's sensory environment and so require less awareness of behavioral bias. In line with the latter, it is conceivable that elastic therapeutic taping applied to the left neck surface may provide bottom-up inputs that reduce hemispatial neglect symptoms. The aim of this study was to assess the effect of therapeutic neck taping on visuo-spatial abilities, neck motion, and kinesthetic sensibility in chronic stroke patients with hemispatial neglect. Materials and Methods: After randomization, 12 chronic stroke patients with hemispatial neglect received 30 consecutive days of real (treatment group) or sham (control group) neck taping. The outcomes were as follows: Stars Cancellation Test; neck active range of motion; Letter Cancellation Test; Comb and Razor Test; Cervical Joint Position Error Test evaluated before and after one month of taping. Results: Between-group comparison showed significant differences only for the Cervical Joint Position Error Test after treatment (p = 0.009). Conclusions: Our preliminary findings support the hypothesis that neck taping might improve cervicocephalic kinesthetic sensibility in chronic stroke patients with hemispatial neglect. Further studies are needed to strengthen our results and better investigate the effects of elastic therapeutic taping on visuo-spatial abilities in stroke patients with hemispatial neglect.

Quantification of Upper Limb Motor Recovery and EEG Power Changes after Robot-Assisted Bilateral Arm Training in Chronic Stroke Patients: A Prospective Pilot Study.

Background: Bilateral arm training (BAT) has shown promise in expediting progress toward upper limb recovery in chronic stroke patients, but its neural correlates are poorly understood. Objective: To evaluate changes in upper limb function and EEG power after a robot-assisted BAT in chronic stroke patients. Methods: In a within-subject design, seven right-handed chronic stroke patients with upper limb paresis received 21 sessions (3 days/week) of the robot-assisted BAT. The outcomes were changes in score on the upper limb section of the Fugl-Meyer assessment (FM), Motricity Index (MI), and Modified Ashworth Scale (MAS) evaluated at the baseline (T0), posttraining (T1), and 1-month follow-up (T2). Event-related desynchronization/synchronization were calculated in the upper alpha and the beta frequency ranges. Results: Significant improvement in all outcomes was measured over the course of the study. Changes in FM were significant at T2, and in MAS at T1 and T2. After training, desynchronization on the ipsilesional sensorimotor areas increased during passive and active movement, as compared with T0. Conclusions: A repetitive robotic-assisted BAT program may improve upper limb motor function and reduce spasticity in the chronically impaired paretic arm. Effects on spasticity were associated with EEG changes over the ipsilesional sensorimotor network.

Changes in the sensorimotor system and semitendinosus muscle morphometry after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study with 1-year follow-up.

PURPOSE: To evaluate the time course of sensorimotor integration processes involved in balance capability during 1-year follow-up after arthroscopic anterior cruciate ligament (ACL) reconstruction. To evaluate whether an association exists between balance performance and semitendinosus muscle morphometry features. METHODS: Twenty-seven patients (mean age 29.6 ± 10.8 years) were prospectively followed with stabilometry and ultrasound at 3 months (T0), 6 months (T1), and 1 year (T2) after arthroscopic ACL reconstruction. Body sway and sensorimotor integration processes were evaluated by calculating the percentage difference of sway (PDS) on two surface conditions. RESULTS: A significant difference in PDS was observed over time (p < 0.001). The interaction "Time × Condition" showed significant differences (p = 0.02), with worse performance on the compliant than the firm surface. There was a significant difference in CSA (p < 0.001), MT (p < 0.001), and %HRD (p < 0.001) over time. The interaction "Time*side" was significant for CSA (p = 0.02) and %HRD (p = 0.01). A negative correlation between PDS on compliant surface and CSA was measured at 3- (r = - 0.71, n = 27, p < 0.001) and 6-month post-surgery (r = - 0.47, n = 27, p = 0.013). CONCLUSIONS: Balance was regained within the first 6 months after surgery, while morphometry of the semitendinosus muscle improved mostly between 6 and 12 months in patients who returned to sports activities. Balance capabilities paralleled semitendinosus muscle morphometry improvements. The instrumental assessment of sensorimotor integration processes is relevant in clinical practice as screening tests for primary and secondary prevention of ACL injury. LEVEL OF EVIDENCE: Prospective studies, Level II.

Prognostic Importance of Lesion Location on Functional Outcome in Patients with Cerebellar Ischemic Stroke: a Prospective Pilot Study.

To date, few studies focused on prediction of functional recovery after cerebellar stroke. The main aim of this prospective pilot study was to determine the association between cerebellar lesion location and functional outcome in adults with acute cerebellar infarction. We examined 14 patients with first-ever unilateral cerebellar ischemic stroke within 7 days and at 90 days from the onset of stroke by means of the International Cooperative Ataxia Rating Scale. Cerebellar lesions were traced from magnetic resonance imaging performed within 72 h since stroke and region of interest were generated. The association between the International Cooperative Ataxia Rating Scale score and lesion location was determined with the voxel-based lesion-symptom mapping methods implemented in the MRIcro software. Colored lesion-symptom maps representing the z statistics were generated and overlaid onto the MNI-ICBM 152 linear probabilistic atlas of the human brain and the Johns Hopkins University white matter templates. Our results documented that injuries to the V, VI, VIIA Crus I, VIIA Crus II, VIIB, VIIIA, and VIIIB lobules and the middle cerebellar peduncle are significantly associated with the International Cooperative Ataxia Rating Scale (ICARS) score at 1 week after the onset of stroke. Furthermore, we found that injuries to the VI, VIIA Crus I, VIIA Crus II, VIIB, VIIIA, and VIIIB lobules, the dentate nucleus, and the middle cerebellar peduncle are significantly associated with the ICARS score at 3 months since the cerebellar stroke onset. The findings of this pilot study might improve prognostic accuracy of functional outcome in patients with acute cerebellar infarction.

Diagnosing mild cognitive impairment in Parkinson's disease: which tests perform best in the Italian population?

Mild cognitive impairment (MCI) is common in patients with Parkinson's disease (PD) and should be recognized early because it represents a predictor of PD-related dementia and worse disease course. Diagnostic criteria for PD-related MCI (PD-MCI) have recently been defined by a Movement Disorders Society (MDS) task force. The present study explored which neuropsychological tests perform best for a level II (i.e., comprehensive neuropsychological assessment) diagnosis of PD-MCI according to the MDS task force criteria in Italian-speaking PD patients. To this aim, we assessed a comprehensive 23-item neuropsychological battery, derived the best-performing 10-test battery (i.e., two tests per domain for each of the five cognitive domains), and explored its accuracy for diagnosing PD-MCI in comparison to the full battery in a group of PD patients. A secondary aim was to explore the role of this battery for subtyping PD-MCI according to single-domain vs. multiple-domain involvement. The 10-test battery showed 73% sensitivity and 100% specificity for diagnosing PD-MCI, and 69% sensitivity and 100% specificity for PD-MCI subtyping. In patients older than 70 years, we derived a slightly different 10-test battery with 84% sensitivity and 100% specificity for PD-MCI diagnosis, and 86% sensitivity and 100% specificity for PD-MCI subtyping. These 10-item neuropsychological batteries might represent a good trade-off between diagnostic accuracy and time of application, and their role in PD-MCI diagnosis and subtyping should be further explored in future prospective studies.

Suprascapular nerve block for the treatment of hemiplegic shoulder pain in patients with long-term chronic stroke: a pilot study.

Hemiplegic shoulder pain is the most common pain condition after stroke. Suprascapular nerve block is an effective treatment for shoulder pain. The aim of this pilot study was to evaluate the effects of suprascapular nerve block on pain intensity, spasticity, shoulder passive range of motion, and quality of life in long-term chronic stroke patients with hemiplegic shoulder pain. Ten chronic stroke patients (over 2 years from onset) with hemiplegic shoulder pain graded ≥30 mm on the Visual Analogue Scale underwent suprascapular nerve block injection with 1 mL of 40 mg/mL methylprednisolone and 10 mL 0.5% bupivacaine hydrochloride. Main outcome was the Visual Analogue Scale evaluated before and after nerve block at 1 h, 1 week, and 1 month. Secondary outcomes were the modified Ashworth scale and the shoulder elevation, abduction, and external rotation passive range of motion evaluated before the nerve block and after 1 h as well as the American Chronic Pain Association Quality of Life Scale evaluated before and after nerve block at 1 month. The Visual Analogue Scale significantly improved after nerve block at 1 h (P = 0.005) and 1 week (P = 0.011). Significant improvements were found at 1 h after nerve block in the modified Ashworth scale (P = 0.014) and the passive range of motion of shoulder abduction (P = 0.026), flexion (P = 0.007), and external rotation (P = 0.017). The American Chronic Pain Association Quality of Life Scale significantly improved at 1 month after nerve block (P = 0.046). Our findings support the use of suprascapular nerve block for treating hemiplegic shoulder pain in long-term chronic stroke patients.

Assessed and Emerging Biomarkers in Stroke and Training-Mediated Stroke Recovery: State of the Art.

Since the increasing update of the biomolecular scientific literature, biomarkers in stroke have reached an outstanding and remarkable revision in the very recent years. Besides the diagnostic and prognostic role of some inflammatory markers, many further molecules and biological factors have been added to the list, including tissue derived cytokines, growth factor-like molecules, hormones, and microRNAs. The literatures on brain derived growth factor and other neuroimmune mediators, bone-skeletal muscle biomarkers, cellular and immunity biomarkers, and the role of microRNAs in stroke recovery were reviewed. To date, biomarkers represent a possible challenge in the diagnostic and prognostic evaluation of stroke onset, pathogenesis, and recovery. Many molecules are still under investigation and may become promising and encouraging biomarkers. Experimental and clinical research should increase this list and promote new discoveries in this field, to improve stroke diagnosis and treatment.

Sensory integration balance training in patients with multiple sclerosis: A randomized, controlled trial.

BACKGROUND: Impaired sensory integration contributes to balance disorders in patients with multiple sclerosis (MS). OBJECTIVE: The objective of this paper is to compare the effects of sensory integration balance training against conventional rehabilitation on balance disorders, the level of balance confidence perceived, quality of life, fatigue, frequency of falls, and sensory integration processing on a large sample of patients with MS. METHODS: This single-blind, randomized, controlled trial involved 80 outpatients with MS (EDSS: 1.5-6.0) and subjective symptoms of balance disorders. The experimental group (n = 39) received specific training to improve central integration of afferent sensory inputs; the control group (n = 41) received conventional rehabilitation (15 treatment sessions of 50 minutes each). Before, after treatment, and at one month post-treatment, patients were evaluated by a blinded rater using the Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), Multiple Sclerosis Quality of Life-54, Fatigue Severity Scale (FSS), number of falls and the Sensory Organization Balance Test (SOT). RESULTS: The experimental training program produced greater improvements than the control group training on the BBS (p < 0.001), the FSS (p < 0.002), number of falls (p = 0.002) and SOT (p < 0.05). CONCLUSIONS: Specific training to improve central integration of afferent sensory inputs may ameliorate balance disorders in patients with MS. Clinical Trial Registration (NCT01040117).

Robot-assisted gait training is not superior to balance training for improving postural instability in patients with mild to moderate Parkinson's disease: a single-blind randomized controlled trial.

OBJECTIVE: The main aim was to compare robotic gait training vs. balance training for reducing postural instability in patients with Parkinson's disease. The secondary aim was to compare their effects on the level of confidence during activities of daily living requiring balance, functional mobility and severity of disease. DESIGN: Randomized controlled trial. SETTING: University hospital. SUBJECTS: A total of 66 patients with Parkinson's disease at Hoehn and Yahr Stage 3. INTERVENTION: After balanced randomization, all patients received 12, 45-minute treatment sessions, three days a week, for four consecutive weeks. A group underwent robot-assisted gait training with progressive gait speed increasing and body-weight support decreasing. The other group underwent balance training aimed at improving postural reactions (self and externally induced destabilization, coordination, locomotor dexterity exercises). MAIN MEASURES: Patients were evaluated before, after and one month posttreatment. MAIN OUTCOME MEASURE: Berg Balance Scale. SECONDARY OUTCOMES: Activities-Specific Balance Confidence Scale; Timed Up and Go Test; Unified Parkinson's Disease Rating Scale. RESULTS: No significant differences were found between the groups for the Berg Balance Scale either immediately after intervention (mean score in the robotic training group 51.58 ±3.94; mean score in the balance training group 51.15 ±3.46), or one-month follow-up (mean score in the robotic training group 51.03 ±4.63; mean score in the balance training group 50.97 ±4.28). Similar results were found for all the secondary outcome measures. CONCLUSIONS: Our findings indicate that robotic gait training is not superior to balance training for improving postural instability in patients with mild to moderate Parkinson's disease.

Adhesive taping vs. daily manual muscle stretching and splinting after botulinum toxin type A injection for wrist and fingers spastic overactivity in stroke patients: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of two procedures increasing the botulinum toxin type A effect for wrist and finger flexor spasticity after stroke. DESIGN: A single-blind randomized trial. SUBJECTS: Seventy patients with upper limb post-stroke spasticity. METHODS: Adults with wrist and finger flexor muscles spasticity after stroke were submitted to botulinum toxin type A therapy. After the treatment, the subjects injected were randomly divided into two groups and submitted to adhesive taping (Group A) or daily muscle manual stretching, passive articular mobilization of wrist and fingers, and palmar splint (Group B) for 10 days. We measured spasticity with Modified Ashworth Scale, related disability with Disability Assessment Scale, and fingers position at rest. The measurements were done at baseline, after two weeks, and after one month from the treatment session. RESULTS: After two weeks, subjects in Group A reported a significantly greater decrease in spasticity scores (Modified Ashworth Scale fingers: mean (standard deviation) 1.3±0.6 vs. 2.1±0.6; Modified Ashworth Scale wrist: 1.7 ±0.6 vs. 2.3 ±0.8), and after one month in spasticity and disability scores (Modified Ashworth Scale fingers: mean (standard deviation) 1.9 ±0.7 vs. 2.5 ±0.6; Modified Ashworth Scale wrist: 2.0 ±0.7 vs. 2.6 ±0.6; Disability Assessment Scale: 1.6 ±0.7 vs. 2.1 ±0.7) compared with Group B subjects. Subjects in Group A reported also a significantly improved fingers position at rest compared with Group B subjects after two weeks (2.8 ±0.9 vs. 2.1 ±0.7) and one month (2.3 ±0.7 vs. 1.5 ±0.6). CONCLUSIONS: Adhesive taping of wrist and finger flexor muscles appeared to enhance the effect of botulinum toxin type A therapy more than daily manual muscle stretching combined with passive articular mobilization and palmar splint.

Relationship between ultrasonographic, electromyographic, and clinical parameters in adult stroke patients with spastic equinus: an observational study.

OBJECTIVE: To find more accurate indices that could affect decisions in spasticity treatment by investigating the relation between ultrasonographic, electromyographic, and clinical parameters of the gastrocnemius muscle in adults with spastic equinus after stroke. DESIGN: Observational study. SETTING: University hospitals. PARTICIPANTS: Chronic patients with stroke with spastic equinus (N=43). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ultrasonographic features were spastic gastrocnemius muscle echo intensity, muscle thickness, and posterior pennation angle of the gastrocnemius medialis (GM) and gastrocnemius lateralis (GL) in both legs. Electromyographic evaluation included compound muscle action potentials (CMAPs) recorded from the GM and GL of both legs. Clinical assessment of the spastic gastrocnemius muscle was performed with the Modified Ashworth Scale (MAS) and by measuring ankle dorsiflexion passive range of motion (PROM). RESULTS: Spastic muscle echo intensity was inversely associated with proximal (GM and GL: P=.002) and distal (GM and GL: P=.001) muscle thickness, pennation angle (GM: P< .001; GL: P=.01), CMAP (GM: P=.014; GL: P=.026), and ankle PROM (GM: P=.038; GL: P=.024). The pennation angle was directly associated with the proximal (GM and GL: P< .001) and distal (GM: P=.001; GL: P< .001) muscle thickness of the spastic gastrocnemius muscle. The MAS score was directly associated with muscle echo intensity (GM: P=.039; GL: P=.027) and inversely related to the pennation angle (GM and GL: P=.001) and proximal (GM: P=.016; GL: P=.009) and distal (GL: P=.006) muscle thickness of the spastic gastrocnemius. CONCLUSIONS: Increased spastic muscle echo intensity was associated with reduced muscle thickness, posterior pennation angle, and CMAP amplitude in the gastrocnemius muscle. Building on previous evidence that these instrumental features are related to botulinum toxin response, these new findings may usefully inform spasticity treatment decisions.

Botulinum toxin injection into the forearm muscles for wrist and fingers spastic overactivity in adults with chronic stroke: a randomized controlled trial comparing three injection techniques.

OBJECTIVE: To compare the outcome of manual needle placement, electrical stimulation and ultrasonography-guided techniques for botulinum toxin injection into the forearm muscles of adults with arm spasticity. DESIGN: Randomized controlled trial. SETTING: University hospital. SUBJECTS: Sixty chronic stroke patients with wrist and fingers spasticity. INTERVENTION: After randomization into three groups, each patient received botulinum toxin type A in at least two of these muscles: flexor carpi radialis and ulnaris, flexor digitorum superficialis and profundus (no fascicles selection). The manual needle placement group underwent injections using palpation; the electrical stimulation group received injections with electrical stimulation guidance; the ultrasonography group was injected under sonographic guidance. A sole injector was used. MAIN MEASURES: All patients were evaluated at baseline and four weeks after injection. OUTCOMES: Modified Ashworth Scale; Tardieu Scale; wrist and fingers passive range of motion. RESULTS: One month after injection, Modified Ashworth Scale scores improved more in the electrical stimulation group than the manual needle placement group (wrist: P = 0.014; fingers: P = 0.011), as well as the Tardieu angle (wrist: P = 0.008; fingers: P = 0.015) and passive range of motion (wrist: P = 0.004). Furthermore, Modified Ashworth Scale scores improved more in the ultrasonography group than in the manual needle placement group (wrist: P = 0.001; fingers: P = 0.003), as well as the Tardieu angle (wrist: P = 0.010; fingers: P = 0.001) and passive range of motion (wrist: P < 0.001; proximal interphalangeal joints: P = 0.009). No difference was found between the ultrasonography and electrical stimulation groups. CONCLUSIONS: Instrumental guidance may improve the outcome of botulinum toxin injections into the spastic forearm muscles of stroke patients.

Robot-assisted arm training in patients with Parkinson's disease: a pilot study.

BACKGROUND: Despite the growing diffusion of robotic devices in neurorehabilitation, no previous study investigated the effects of robotic training on arm impairment due to Parkinson's disease. The aim of this pilot study was to evaluate whether robot-assisted arm training might improve upper limb function in patients with Parkinson's disease. FINDINGS: Ten patients with Parkinson's disease (Hoehn and Yahr stage 2.5-3) received ten, 45-minute, treatment sessions, five days a week, for two consecutive weeks. Robot-assisted arm training was performed with the Bi-Manu-Track (Reha-Stim, Berlin, Germany) that provides a computer-controlled, repetitive, bilateral, mirror-like practice of forearm pronation/supination and wrist extension/flexion. Patients were trained according to the following modalities: passive-passive (both arms moved by the machine) and active-active (both arms actively moving against resistance). The dominant upper limb was evaluated before and immediately after treatment as well as at two weeks of follow-up. Outcomes were the nine-hole peg test, the Fugl-Meyer assessment (upper limb section) and the Unified Parkinson's Disease Rating Scale. After treatment, a significant improvement was found in the nine-hole peg test (P = 0.007) as well as in the upper limb section of the Fugl-Meyer assessment (P = 0.012). Findings were confirmed at the 2-week follow-up evaluation only for the nine-hole peg test (P = 0.007). No significant improvement was found in the Unified Parkinson's Disease Rating Scale at both post-treatment and follow-up evaluations. CONCLUSIONS: Our findings support the hypothesis that robot-assisted arm training might be a promising tool in order to improve upper limb function in patients with Parkinson's disease.

Effects of contralesional robot-assisted hand training in patients with unilateral spatial neglect following stroke: a case series study.

BACKGROUND: A reduction of hemispatial neglect due to stroke has been associated with activation of the contralesional hand in the contralesional hemispace. Robot-assisted upper limb training was found to effectively improve paretic arm function in stroke patients. To date no proof of concept of robot-assisted hemispatial neglect therapy has been reported in literature. This study aimed to determine whether robot-assisted left (contralesional) hand activation alone could lead to an improvement in hemispatial neglect following stroke. METHODS: Three stroke patients with right brain injury underwent a 2-week training program of robotic left hand activation with the Gloreha® hand rehabilitation glove, which provides repetitive, passive mobilization of the fingers. Outcomes were assessed using the Line Crossing test, the Bells test, the Sentence Reading test, the Saccadic Training, the Sustained Attention to Response Task, and the Purdue Pegboard test. RESULTS: Changes were observed after treatment as follows. Line Crossing test: all patients showed improved performance (6.7%, 89.5% and 80% increase in lines crossed) with two patients reaching normal performance levels. Bells test: one patient improved performance (50% increase), while one patient showed no change and one patient declined (-10.3% change); no patient reached normal performance levels. Sentence Reading test: all patients showed improved performance (800%, 57.1% and 42.9% increase in number of sentences read) with no patient reaching normal performance level. Saccadic Training: all patients showed improved performance (-62.8%, -15.5% and -9.7% change of the left hemifield reaction time). Sustained Attention to Response Task: all patients showed improved performance (-20.5%, -5.8% and -10% change of the reaction time) with two patients reducing incorrect responses (-42.9% and -73.3%) and one patient increasing them (9.1%). Purdue Pegboard test: all patients showed improved performance (100%, 27.3% and 75% change in the left + right + both hands sub-item score). CONCLUSIONS: Some caution is warranted when interpreting our results, as the responses to the intervention were variable and might have been due to a placebo effect or fluctuating clinical conditions. However, robot-assisted hemispatial neglect therapy might be useful in stroke patients. Larger-scale investigations are needed to confirm our preliminary findings.