Rotura do peitoral maior: relato de caso de uma rotura incomum / Pectoralis major rupture: case report of an unusual rupture / Rotura del pectoral mayor: informe de un caso de rotura inusual

Apesar de não muito frequente, nos últimos 20 anos, houve um aumento significativo dos relatos sobre rotura do peitoral maior, normalmente associadas à prática de atividade física em que ocorre contração intensa e/ou uso de cargas pesadas exercendo resistência sobre o músculo. Neste relato de caso temos um paciente de 51 anos referindo dor no tórax à direita e no braço direito há 3 dias após tentar consertar o guidão da moto. Apresentava assimetria dos peitorais, perda de força do membro superior direito, dificuldade de movimentação e hematoma. A ressonância magnética demonstrou rotura completa da junção miotendínea do peitoral maior, com tendinopatia com fissuras insercionais e intrasubstanciais infraespinhal e tendinopatia com rotura parcial do tendão subescapular. Foi indicado por médico ortopedista o acompanhamento com o uso de medicação analgésica.

Although not very common, in the last 20 years, there has been a significant increase in reports of rupture of the pectoralis major, normally associated with the practice of physical activity in which intense contraction occurs and/or the use of heavy loads exerting resistance on the muscle. In this case report we have a 51-year-old patient reporting pain in his right chest and right arm for 3 days after trying to fix his motorcycle's handlebars. He had asymmetry of the pectorals, loss of strength in the right upper limb, difficulty moving and hematoma. Magnetic resonance imaging demonstrated complete rupture of the myotendinous junction of the pectoralis major, with tendinopathy with insertional and intrasubstantial infraspinatus fissures and tendinopathy with partial rupture of the subscapularis tendon. An orthopedic doctor recommended follow-up with the use of analgesic medication.

Aunque no es muy común, en los últimos 20 años se ha observado un aumento significativo en los reportes de rotura del pectoral mayor, normalmente asociado a la práctica de actividad física en la que se produce una contracción intensa y/o al uso de cargas pesadas ejerciendo resistencia sobre el mismo. el músculo. En este caso clínico tenemos un paciente de 51 años que refiere dolor en el pecho derecho y en el brazo derecho durante 3 días después de intentar arreglar el manillar de su motocicleta. Presentó asimetría de pectorales, pérdida de fuerza en miembro superior derecho, dificultad de movimiento y hematoma. La resonancia magnética demostró rotura completa de la unión miotendinosa del pectoral mayor, con tendinopatía con fisuras de inserción e intrasustancial del infraespinoso y tendinopatía con rotura parcial del tendón subescapular. Un médico ortopédico recomendó seguimiento con el uso de medicación analgésica.

High-frequency magnetic paired associated stimulation promotes motor function recovery in ischemic stroke patients: a study protocol for single-center, sham stimulation randomized controlled trials (H2MPAS).

BACKGROUND: Numerous studies have validated the clinical effectiveness of electromagnetic pairing-associated stimulation. Building upon this foundation, we have developed a novel approach involving high-frequency magnetic paired-associated stimulation, aiming to enhance clinical applicability and potentially improve efficacy. However, the clinical effectiveness of this approach remains unclear. Our objective is to demonstrate the therapeutic efficacy of this novel approach by employing high-frequency pairing to intervene in patients experiencing motor dysfunction following a stroke. METHODS: This is a single-center, single-blind, sham stimulation controlled clinical trial involving patients with upper limb motor dysfunction post-stroke. The intervention utilizes paired magnetic stimulation, combining peripheral and central magnetic stimulation, in patients with Brunnstrom stage III-V stroke lasting from 3 months to 1 year. Evaluation of patients' upper limb motor function occurred before the intervention and after 3 weeks of intervention. Follow-up visits will be conducted after 5 weeks and 3 months of intervention. The primary outcome measure is the Action Research Arm Test, with secondary measures including the Fugl-Meyer Assessment-upper, Modified Barthel Index, modified Tardieu scale, functional near-infrared spectroscopy, and neuroelectrophysiology. DISCUSSION: The high-frequency magnetic paired associative stimulation used in this study combined high-frequency magnetic stimulation with paired stimulation, potentially facilitating both cortical excitation through high-frequency stimulation and specific circuit enhancement through paired stimulation. As dual-coil magnetic stimulation equipment becomes increasingly popular, magnetic-magnetic paired associated stimulation may offer patients improved clinical outcomes at reduced costs. TRIAL REGISTRATION: Chinese Clinical Trial Registry,ChiCTR2400083363. Registered on 23 April 2024.

Enhancing Upper Limb Function and Motor Skills Post-Stroke Through an Upper Limb Rehabilitation Robot.

Cerebrovascular accidents, commonly known as strokes, represent a prevalent neurological event leading to significant upper limb disabilities, thereby profoundly affecting individuals' activities of daily living and diminishing their quality of life. Traditional rehabilitation methods for upper limb recovery post-stroke are often hindered by limitations, including therapist and patient fatigue, reliance on singular training methodologies, and lack of sustained motivation. Addressing these challenges, this study introduces an upper limb rehabilitation robot, which uses intelligent feedback motion control to improve therapeutic outcomes. The system is distinguished by its capability to adjust the direction and magnitude of force feedback dynamically, based on the detection of spastic movements during exercises, thereby offering a tailored therapeutic experience. This system is equipped with four distinct training modes, intelligent assessment of joint range of motion, and the ability to personalize training programs. Moreover, it provides an immersive interactive gaming experience coupled with comprehensive safety measures. This multifaceted approach not only elevates the engagement and interest of participants beyond traditional rehabilitation protocols but also demonstrates significant improvements in upper limb functionality and the activities of daily living among hemiplegic patients. The system exemplifies an advanced tool in upper limb rehabilitation, offering a synergistic blend of precision, personalization, and interactive engagement, thereby broadening the therapeutic options available to stroke survivors.

Validity of Valor Inertial Measurement Unit for Upper and Lower Extremity Joint Angles.

Inertial measurement units (IMU) are increasingly utilized to capture biomechanical measures such as joint kinematics outside traditional biomechanics laboratories. These wearable sensors have been proven to help clinicians and engineers monitor rehabilitation progress, improve prosthesis development, and record human performance in a variety of settings. The Valor IMU aims to offer a portable motion capture alternative to provide reliable and accurate joint kinematics when compared to industry gold standard optical motion capture cameras. However, IMUs can have disturbances in their measurements caused by magnetic fields, drift, and inappropriate calibration routines. Therefore, the purpose of this investigation is to validate the joint angles captured by the Valor IMU in comparison to an optical motion capture system across a variety of movements. Our findings showed mean absolute differences between Valor IMU and Vicon motion capture across all subjects' joint angles. The tasks ranged from 1.81 degrees to 17.46 degrees, the root mean squared errors ranged from 1.89 degrees to 16.62 degrees, and interclass correlation coefficient agreements ranged from 0.57 to 0.99. The results in the current paper further promote the usage of the IMU system outside traditional biomechanical laboratories. Future examinations of this IMU should include smaller, modular IMUs with non-slip Velcro bands and further validation regarding transverse plane joint kinematics such as joint internal/external rotations.

Decoding Multi-Class Motor Imagery From Unilateral Limbs Using EEG Signals.

The EEG is a widely utilized neural signal source, particularly in motor imagery-based brain-computer interface (MI-BCI), offering distinct advantages in applications like stroke rehabilitation. Current research predominantly concentrates on the bilateral limbs paradigm and decoding, but the use scenarios for stroke rehabilitation are typically for unilateral upper limbs. There is a significant challenge to decoding unilateral MI of multitasks due to the overlapped spatial neural activities of the tasks. This study aims to formulate a novel MI-BCI experimental paradigm for unilateral limbs with multitasks. The paradigm encompasses four imagined movement directions: top-bottom, left-right, top right-bottom left, and top left-bottom right. Forty-six healthy subjects participated in this experiment. Commonly used machine learning techniques, such as FBCSP, EEGNet, deepConvNet, and FBCNet, were employed for evaluation. To improve decoding accuracy, we propose an MVCA method that introduces temporal convolution and attention mechanism to effectively capture temporal features from multiple perspectives. With the MVCA model, we have achieved 40.6% and 64.89% classification accuracies for the four-class and two-class scenarios (top right-bottom left and top left-bottom right), respectively. Conclusion: This is the first study demonstrating that motor imagery of multiple directions in unilateral limbs can be decoded. In particular, decoding two directions, right top to left bottom and left top to right bottom, provides the best accuracy, which sheds light on future studies. This study advances the development of the MI-BCI paradigm, offering preliminary evidence for the feasibility of decoding multiple directional information from EEG. This, in turn, enhances the dimensions of MI control commands.

A systematic review and meta-analysis on effect of different exercise training on grip strength and upper extremity muscle strength in patients with type 2 diabetes mellitus.

BACKGROUND: Individuals with type 2 diabetes mellitus (T2DM) are prone to musculoskeletal complications, particularly in the upper extremities (UE), which can significantly impair their grip strength and UE muscle strength. This review will provide valuable insights for developing optimized exercise interventions aimed at enhancing upper limb functionality and improving patient outcomes. AIM: To determine the effect of different exercise training on grip strength & UE muscle strength in patients suffering from T2DM. METHODOLOGY: A comprehensive search from electronic databases was performed based on the selection criteria and 13 randomized controlled trials (RCT's) were included in the study. Mean changes in grip strength and UE muscle strength were the primary outcome measures. Included studies ranked high on the PEDro rating scale and eta-analysis was performed by Rev Man 5.4 software. RESULTS: Meta-analysis results indicated that there was a statistically significant improvement in UE muscle strength of experimental group when compared to control group (mean differences [MD] = 2.91, 95% confidence interval = 0.12, 5.71; p = 0.04) with moderate heterogeneity (I2 = 49%, p < 0.07). Grip strength improved significantly in the experimental group when compared to the control group with (MD = 2.93, 95% CL = -0.00, 5.86; p = 0.05) and moderate heterogeneity (I2 = 66%, p < 0.08). CONCLUSION: This review indicated a positive role of supervised resistance & aerobic exercises on UE muscle strength in patients with T2DM. Due to lack of RCT's, grip strength needs to be explored by further investigations in these patients.

Spanish translation and cross-cultural adaptation of the Box and Block Test: a pilot study in adults with chronic acquired brain injury.

Background The Box and Block Test (BBT) is a highly recommended outcome measure to assess unilateral gross motor activity of the upper limbs. The BBT has not previously been available in a version adapted to the Spanish context. Thus, this study aimed to cross-culturally adapt and translate the BBT's instructions and pilot test the Spanish version of BBT in adults with acquired brain injury (ABI). Methods The BBT was translated and cross-culturally adapted following standard procedures. An expert committee approved the final Spanish version of BBT and it was conceptually validated by four therapists with expertise in ABI. The tool was tested on 14 adults with ABI. Results The Spanish version of BBT included a new section of materials for the test and a record to count the number of blocks transferred from one compartment of the box to the other. Following the pilot study, a modification in terminology was implemented for referring to the dominant and non-dominant hands. Conclusions Our results suggest that the Spanish version of BBT is suitable for assessing manual dexterity in Spanish-speaking adults with ABI.

Effects of high-definition tDCS targeting individual motor hotspot with EMG-driven robotic hand training on upper extremity motor function: a pilot randomized controlled trial.

BACKGROUND: Delivering HD-tDCS on individual motor hotspot with optimal electric fields could overcome challenges of stroke heterogeneity, potentially facilitating neural activation and improving motor function for stroke survivors. However, the intervention effect of this personalized HD-tDCS has not been explored on post-stroke motor recovery. In this study, we aim to evaluate whether targeting individual motor hotspot with HD-tDCS followed by EMG-driven robotic hand training could further facilitate the upper extremity motor function for chronic stroke survivors. METHODS: In this pilot randomized controlled trial, eighteen chronic stroke survivors were randomly allocated into two groups. The HDtDCS-group (n = 8) received personalized HD-tDCS using task-based fMRI to guide the stimulation on individual motor hotspot. The Sham-group (n = 10) received only sham stimulation. Both groups underwent 20 sessions of training, each session began with 20 min of HD-tDCS and was then followed by 60 min of robotic hand training. Clinical scales (Fugl-meyer Upper Extremity scale, FMAUE; Modified Ashworth Scale, MAS), and neuroimaging modalities (fMRI and EEG-EMG) were conducted before, after intervention, and at 6-month follow-up. Two-way repeated measures analysis of variance was used to compare the training effect between HDtDCS- and Sham-group. RESULTS: HDtDCS-group demonstrated significantly better motor improvement than the Sham-group in terms of greater changes of FMAUE scores (F = 6.5, P = 0.004) and MASf (F = 3.6, P = 0.038) immediately and 6 months after the 20-session intervention. The task-based fMRI activation significantly shifted to the ipsilesional motor area in the HDtDCS-group, and this activation pattern increasingly concentrated on the motor hotspot being stimulated 6 months after training within the HDtDCS-group, whereas the increased activation is not sustainable in the Sham-group. The neuroimaging results indicate that neural plastic changes of the HDtDCS-group were guided specifically and sustained as an add-on effect of the stimulation. CONCLUSIONS: Stimulating the individual motor hotspot before robotic hand training could further enhance brain activation in motor-related regions that promote better motor recovery for chronic stroke. TRIAL REGISTRATION: This study was retrospectively registered in ClinicalTrials.gov (ID NCT05638464).

Effect of Upper Limb Repetitive Facilitative Exercise on Gait of Stroke Patients based on Artificial Intelligence and Computer Vision Evaluation.

OBJECTIVE: This study aims to assess how enhancing upper limb function on the affected side of stroke influences the gait of the lower limb. METHODS: Forty eligible stroke patients were randomly assigned to either a control group or a treatment group, with 20 patients in each group. Both groups underwent dynamic evaluation using artificial intelligence and computer vision before treatment. This evaluation focused on analyzing the range of motion of the shoulder and elbow during the gait cycle, as well as various gait parameters (such as step length, step speed, and percentage of stance phase) on the affected side. Following evaluation, the control group received routine rehabilitation treatment. RESULTS: The results indicated that there was no significant difference between the two groups before treatment. However, following treatment, there was a notable improvement in the motion of the shoulder and elbow joints on the affected side among patients in the treatment group (p<0.05), whereas the control group showed only slight improvement, which was not statistically significant (p>0.05). CONCLUSION: The improvement in upper limb function on the affected side also appears to positively influence gait recovery. However, it's important to note that the observation period was relatively short. Further studies are needed to confirm whether this effect is sustained over the long term.

Assessment of inter-rater and intra-rater reliability of the Luna EMG robot as a tool for assessing upper limb proprioception in patients with stroke-a prospective observational study.

Background: The aim of the study was to assess the inter-rater and intra-rater agreement of measurements performed with the Luna EMG (electromyography) multifunctional robot, a tool for evaluation of upper limb proprioception in individuals with stroke. Methods: The study was conducted in a group of patients with chronic stroke. A total of 126 patients participated in the study, including 78 women and 48 men, on average aged nearly 60 years (mean = 59.9). Proprioception measurements were performed using the Luna EMG diagnostic and rehabilitation robot to assess the left and right upper limbs. The examinations were conducted by two raters, twice, two weeks apart. The results were compared between the raters and the examinations. Results: High consistency of the measurements performed for the right and the left hand was reflected by the interclass correlation coefficients (0.996-0.998 and 0.994-0.999, respectively) and by Pearson's linear correlation which was very high (r = 1.00) in all the cases for the right and the left hand in both the inter-rater and intra-rater agreement analyses. Conclusions: Measurements performed by the Luna EMG diagnostic and rehabilitation robot demonstrate high inter-rater and intra-rater agreement in the assessment of upper limb proprioception in patients with chronic stroke. The findings show that Luna EMG is a reliable tool enabling effective evaluation of upper limb proprioception post-stroke.

Temporal localization of upper extremity bilateral synergistic coordination using wearable accelerometers.

Background: The human upper extremity is characterized by inherent motor abundance, allowing a diverse array of tasks with agility and adaptability. Upper extremity functional limitations are a common sequela to Stroke, resulting in pronounced motor and sensory impairments in the contralesional arm. While many therapeutic interventions focus on rehabilitating the weaker arm, it is increasingly evident that it is necessary to consider bimanual coordination and motor control. Methods: Participants were recruited to two groups differing in age (Group 1 (n = 10): 23.4 ± 2.9 years, Group 2 (n = 10): 55.9 ± 10.6 years) for an exploratory study on the use of accelerometry to quantify bilateral coordination. Three tasks featuring coordinated reaching were selected to investigate the acceleration of the upper arm, forearm, and hand during activities of daily living (ADLs). Subjects were equipped with acceleration and inclination sensors on each upper arm, each forearm, and each hand. Data was segmented in MATLAB to assess inter-limb and intra-limb coordination. Inter-limb coordination was indicated through dissimilarity indices and temporal locations of congruous movement between upper arm, forearm, or hand segments of the right and left limbs. Intra-limb coordination was likewise assessed between upper arm-forearm, upper arm-hand, and forearm-hand segment pairs of the dominant limb. Findings: Acceleration data revealed task-specific movement features during the three distinct tasks. Groups demonstrated diminished similarity as task complexity increased. Groups differed significantly in the hand segments during the buttoning task, with Group 1 showing no coordination in the hand segments during buttoning, and strong coordination in reaching each button with the upper arm and forearm guiding extension. Group 2's dissimilarity scores and percentages of similarity indicated longer periods of inter-limb coordination, particularly towards movement completion. Group 1's dissimilarity scores and percentages of similarity indicated longer periods of intra-limb coordination, particularly in the coordination of the upper arm and forearm segments. Interpretation: The Expanding Procrustes methodology can be applied to compute objective coordination scores using accessible and highly accurate wearable acceleration sensors. The findings of task duration, angular velocity, and peak roll angle are supported by previous studies finding older individuals to present with slower movements, reduced movement stability, and a reduction of laterality between the limbs. The theory of a shift towards ambidexterity with age is supported by the finding of greater inter-limb coordination in the group of subjects above the age of thirty-five. The group below the age of thirty was found to demonstrate longer periods of intra-limb coordination, with upper arm and forearm coordination emerging as a possible explanation for the demonstrated greater stability.

Restoring of Interhemispheric Symmetry in Patients With Stroke Following Bilateral or Unilateral Robot-Assisted Upper-Limb Rehabilitation: A Pilot Randomized Controlled Trial.

Bilateral robotic rehabilitation has proven helpful in the recovery of upper limb motor function in patients with stroke, but its effects on the cortical reorganization mechanisms underlying recovery are still unclear. This pilot Randomized Controlled Trial (RCT) aimed to evaluate the effects on the interhemispheric balance of unilateral or bilateral robotic treatments in patients with subacute stroke, using Quantitative Electroencephalography (qEEG). 19 patients with ischemic stroke underwent a 30-session upper limb neurorehabilitation intervention using a bilateral upper limb exoskeleton. Each patient was randomly assigned to the bilateral (BG, n=10) or unilateral treatment group (UG, n=9). EEG evaluations were performed before (T0) and right after (T [Formula: see text] the first treatment session, after 30 treatment sessions (T1), and at 1-week follow-up (T2), in both eyes open and eyes closed conditions. From the acquired EEG data, the pairwise-derived Brain Symmetry Index (pdBSI) was computed. In addition, clinical evaluation was performed at T0 and T1 with validated clinical scales. After the treatment, a significant improvement in clinical and EEG evaluations was observed for both groups, but only the BG showed reduced pdBSI in delta and theta bands. In the cluster of sensorimotor channels, there was no significant difference between groups. The observed changes were not maintained at follow-up. No significant changes were observed in the pdBSI after a single rehabilitation session. Results suggest that balancing of interhemispheric symmetry comes along with a clinical improvement in the upper extremity and that the pdBSI can be used to investigate the mechanisms of neuronal plasticity involved in robotic rehabilitation after stroke.

The use of accelerometers to assess upper limb function in patients with obstetric brachial plexus palsy.

For half a century, the Mallet Scale (MS) has been utilized to assess upper limb function in patients with obstetric brachial plexus palsy (OBPP). However, the correct use of the MS requires trained personnel and the MS does not measure compensatory movements. For this reason, new methods are needed to compensate for these weaknesses. This study introduces an innovative method for objective functional motion analysis using accelerometers to measure upper limb movements in thirty patients with obstetric brachial plexus lesions. Five triaxial accelerometers were positioned on the chest and each upper limb. They recorded acceleration signals during repetitive everyday tasks: hand-to-mouth (HM), hand-to-neck (HN), and hand-to-spine (HS). From these signals, 54 features were extracted and subjected to linear correlation tests to identify 5 suitable features. An algorithm was then developed to categorize patients into five groups and compute an individual movement performance score (iMPScore) assessing the patient's upper extremity function. By using the iMPScore more than 75% of all participants have been classified correctly with respect to their MS category. Identification of MS I category patients in general and assessing upper extremity function of MS I to III in HS tasks were most challenging. We conclude that the introduced approach is a valuable tool for gauging movement limitation of upper limbs in patients with obstetric brachial plexus palsy. Compared to other clinically established methods, it becomes possible to record and even quantify the extent of compensatory movements. In this way, an objective, user- and patient-friendly method is offered, which supports significantly physicians and therapists in their evaluation of OBPP.

Side differences in upper quarter mobility/stability are not related to serve velocity in tennis players with different levels of training experience.

OBJECTIVE: Tennis is characterised by repetitive serves and strokes predominately performed with one arm. This can lead to differences in upper quarter mobility/stability between the stroke and non-stroke arm, which could even enlarge with increasing training experience and negatively affect serve velocity. Thus, we determined side differences (i.e., limb symmetry index) in upper quarter mobility/stability and their association with flat and slice serve velocity in advanced (ITN ≤ 4) female and male tennis players (N = 42, mean age = 23.9 ± 9.3 years) with different levels of training experience (< 2 years: n = 14, 2-5 years: n = 17, 6-8 years: n = 11). RESULTS: Y Balance Test-Upper Quarter (YBT-UQ) side difference (i.e., composite score) and performances (i.e., medial reach) were largest in players with the lowest level of training experience (i.e., < 2 years). Further, YBT-UQ performances (i.e., medial reach and composite score) but not side differences were significantly correlated with flat and slice serve velocity, particularly in less experienced players. Our results suggest that significant side differences in upper quarter mobility/stability occur in less experienced players (indicative of increased injury risk) but they are not related to tennis-specific performance (i.e., serve velocity).

Assessment of the Impact of Sensor-Based Ischemic Preconditioning with Different Cycling Periods on Upper Limb Strength in Bodybuilding Athletes.

Objective: This study designed experiments to explore the effects of ischemic preconditioning (IPC) intervention with different cycling periods on the upper limb strength performance of college male bodybuilding athletes. Methods: Ten bodybuilding athletes were recruited for a randomized, double-blind, crossover experimental study. All subjects first underwent pre-tests with two sets of exhaustive bench presses at 60% of their one-repetition maximum (1RM) to assess upper limb strength performance. They then experienced three different IPC intervention modes (T1: 1 × 5 min, T2: 2 × 5 min, T3: 3 × 5 min), as well as a non-IPC intervention mode (CON), followed by a retest of the bench press. An Enode pro device was used to record the barbell's velocity during the bench press movement (peak velocity (PV), mean velocity (MV)); power (peak power (PP), mean power (MP)); and time under tension (TUT) to evaluate upper limb strength performance. Results: PV values: T1 showed significant increases compared to pre-tests in the first (p = 0.02) and second (p = 0.024) tests, and were significantly greater than the CON (p = 0.032); T2 showed a significant increase in PV in the first test (p = 0.035), with no significant differences in other groups. MV values: T1 showed a significant increase in MV in the first test compared to the pre-test (p = 0.045), with no significant differences in other groups. PP values: T1 showed a highly significant increase in PP in the first test compared to the pre-test (p = 0.001), and was significantly higher than the CON (p = 0.025). MP values: T1 showed highly significant increases in MP in both the first (p = 0.004) and second (p = 0.003) tests compared to the pre-test; T2 showed a highly significant increase in MP in the first test (p = 0.039) and a significant increase in the second test (p = 0.039). T1's MP values were significantly higher than the CON in both tests; T2's MP values were significantly higher than the CON in the first (p = 0.005) and second (p = 0.024) tests. TUT values: T1 showed highly significant increases in TUT in the first (p < 0.001) and second (p = 0.002) tests compared to the pre-test, and were significantly higher than the CON. Conclusions: (1) Single-cycle and double-cycle IPC interventions both significantly enhance upper limb strength performance, significantly improving the speed and power in exhaustive bench press tests, with the single-cycle IPC intervention being more effective than the double-cycle IPC intervention. (2) The triple-cycle IPC intervention does not improve the upper limb strength performance of bodybuilding athletes in exhaustive bench presses.

Use of Botulinum Toxin in Upper-Limb Tremor: Systematic Review and Perspectives.

BACKGROUND: Tremor is the most common movement disorder, with significant functional and psychosocial consequences. Oral medications have been disappointing or limited by side effects. Surgical techniques are effective but associated with risks and adverse events. Botulinum toxin (BT) represents a promising avenue but there is still no double-blind evidence of efficacy on upper limb function. A systematic review on the effects of BT in upper-limb tremor was conducted. METHODS: A systematic search of the literature was conducted up to July 2023, including the keywords "botulinum toxin" and "tremor". All randomized controlled trials (RCTs) and open-label studies were analyzed. Independent reviewers assessed their methodological quality. RESULTS: There were only eight published RCTs and seven published open-label studies, with relatively small sample sizes. This review suggests that BT is more effective when injections are patient-tailored, with analyses based on clinical judgement or kinematics. Subjective and objective measures frequently improve but transient weakness may occur after injections, especially if wrist or fingers extensors are targeted. A number of studies had methodological limitations. CONCLUSIONS: The authors discuss how to optimize tremor assessments and effects of BT injection. Controlled evidence is still lacking but it is suggested that distal "asymmetric" BT injections (targeting flexors/pronators while sparing extensors/supinators) and proximal injections, involving shoulder rotators when indicated, may avoid excessive weakness while optimizing functional benefit.

Using Wavelet Analysis of Blood Flow Oscillations to Investigate Differences in Skin Blood Flow Regulations Between the Upper and Lower Limbs.

BACKGROUND: The objective of this study was to investigate the differences in skin blood flow regulations between the upper and lower limbs in healthy adults using wavelet analysis of skin blood oscillations. To the best of our knowledge, this is the first study investigating the dominant skin blood flow control of the upper and lower limbs in healthy adults. METHODS: Skin blood flow of the forearm and leg was simultaneously measured by laser Doppler flowmetry (LDF) in 17 healthy adults. Skin blood flow oscillations were analyzed using wavelet analysis to assess the dominant control among the metabolic endothelial (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), myogenic (0.05-0.15 Hz), respiratory (0.15-0.4 Hz), and cardiac (0.4-2 Hz) origins. RESULTS: Skin blood flow in the leg (11.13 ± 4.90 perfusion unit) was significantly higher than in the forearm (6.90 ± 2.50 perfusion unit, p < 0.001). The metabolic endothelial control is more dominant in the forearm (1.19 ±0.51 au) compared to the leg (0.73 ± 0.41 au, p < 0.01). The myogenic control is more dominant in the leg (1.18 ± 0.28 au) compared to the forearm (0.96±0.18 au, p < 0.05). CONCLUSION: Through wavelet analysis of skin blood flow oscillations, the results indicate that metabolic endothelial control is more dominant in the forearm (upper limbs) and myogenic control is more dominant in the leg (lower limbs).

Efficacy of a new video observational training method (intensive visual simulation) for motor recovery in the upper limb in subacute stroke: a feasibility and proof-of-concept study.

OBJECTIVE: To demonstrate the feasibility and efficacy  of a new video-observation training method (intensive visual simulation) to improve upper limb function. DESIGN: Small sample, randomized, evaluator-blind, monocentric study. PATIENTS: Seventeen early subacute ischaemic stroke patients with complete hemiplegia were  randomly assigned to the therapeutic group (n = 8) or control group (CG, n = 9). METHODS: Thirty sessions of intensive visual simulation combined with corrected visual feedback (therapeutic group) or uncorrected visual feedback (control group) were performed over 6 weeks on top of a standard rehabilitation programme. MAIN OUTCOME MEASURE: 400-point hand assessment test (400p-HA). SECONDARY OUTCOME MEASURES: Box and Blocks (B&B), Purdue Pegboard test, Minnesota. RESULTS: The 400p-HA test improved significantly from T0 to 6 months for both groups, with a significant difference between groups at 3 months (MW-UT p = 0.046) and 4 months (MW-UT p = 0.046) in favour of the therapeutic group. One-phase exponential modelling of 400p-HA showed a greater plateau for the therapeutic group (F test p = 0.0021). There was also faster recovery of the ability to perform the B&B tests for the therapeutic group (log-rank test p = 0.03). CONCLUSION: This study demonstrated the feasibility and potential efficacy of an intensive visual simulation training programme to improve upper limb  function in subacute stroke patients. A larger study is needed to confirm these results.

Enhancing upper extremity muscle strength in individuals with spinal cord injury using low-intensity blood flow restriction exercise.

OBJECTIVES: This study explores the feasibility and effects of low-intensity blood flow restriction exercise on forearm muscle strength and function in individuals with spinal cord injury. STUDY DESIGN: Pilot randomized clinical trial. PATIENTS AND METHODS: Ten male and female adult participants with chronic cervical and thoracic spinal cord injury underwent an 8-week low-intensity blood flow restriction exercise programme that targeted forearm muscles. Each participant's contralateral forearm served as the control. Grip strength was the primary outcome measure, and participants also provided qualitative feedback on their experiences. RESULTS: The study revealed a significant increase in participants' forearm muscle strength on the experimental side engaged in low-intensity blood flow restriction training, with an average strength gain of 7.5 ± 0.36 kg after 16 exercise sessions (Cohen's d = -6.32, 95% CI -8.34, -6.68). In comparison, the control side, following a conventional high- intensity exercise regimen without BFR, showed a more modest strength increase of 4.4 ± 0.67 kg. A mean Patient's Global Impression of Change score of 2.2 reflected overall improvements in participants' daily activities and health status. CONCLUSION: This study highlights the feasibility and effectiveness of low-intensity blood flow restriction exercise as a safe and promising approach to enhancing forearm muscle strength in individuals with spinal cord injury. The observed positive outcomes, coupled with a high level of participant satisfaction, underscore the potential of this innovative method to significantly improve limb muscle strength, thereby contributing to greater functional independence in this population.

Enhancing stroke rehabilitation with whole-hand haptic rendering: development and clinical usability evaluation of a novel upper-limb rehabilitation device.

INTRODUCTION: There is currently a lack of easy-to-use and effective robotic devices for upper-limb rehabilitation after stroke. Importantly, most current systems lack the provision of somatosensory information that is congruent with the virtual training task. This paper introduces a novel haptic robotic system designed for upper-limb rehabilitation, focusing on enhancing sensorimotor rehabilitation through comprehensive haptic rendering. METHODS: We developed a novel haptic rehabilitation device with a unique combination of degrees of freedom that allows the virtual training of functional reach and grasp tasks, where we use a physics engine-based haptic rendering method to render whole-hand interactions between the patients' hands and virtual tangible objects. To evaluate the feasibility of our system, we performed a clinical mixed-method usability study with seven patients and seven therapists working in neurorehabilitation. We employed standardized questionnaires to gather quantitative data and performed semi-structured interviews with all participants to gain qualitative insights into the perceived usability and usefulness of our technological solution. RESULTS: The device demonstrated ease of use and adaptability to various hand sizes without extensive setup. Therapists and patients reported high satisfaction levels, with the system facilitating engaging and meaningful rehabilitation exercises. Participants provided notably positive feedback, particularly emphasizing the system's available degrees of freedom and its haptic rendering capabilities. Therapists expressed confidence in the transferability of sensorimotor skills learned with our system to activities of daily living, although further investigation is needed to confirm this. CONCLUSION: The novel haptic robotic system effectively supports upper-limb rehabilitation post-stroke, offering high-fidelity haptic feedback and engaging training tasks. Its clinical usability, combined with positive feedback from both therapists and patients, underscores its potential to enhance robotic neurorehabilitation.