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.

Kinematic parameters obtained with the ArmeoSpring for upper-limb assessment after stroke: a reliability and learning effect study for guiding parameter use.

BACKGROUND: After stroke, kinematic measures obtained with non-robotic and robotic devices are highly recommended to precisely quantify the sensorimotor impairments of the upper-extremity and select the most relevant therapeutic strategies. Although the ArmeoSpring exoskeleton has demonstrated its effectiveness in stroke motor rehabilitation, its interest as an assessment tool has not been sufficiently documented. The aim of this study was to investigate the psychometric properties of selected kinematic parameters obtained with the ArmeoSpring in post-stroke patients. METHODS: This study involved 30 post-stroke patients (mean age = 54.5 ± 16.4 years; time post-stroke = 14.7 ± 26.7 weeks; Upper-Extremity Fugl-Meyer Score (UE-FMS) = 40.7 ± 14.5/66) who participated in 3 assessment sessions, each consisting of 10 repetitions of the 'horizontal catch' exercise. Five kinematic parameters (task and movement time, hand path ratio, peak velocity, number of peak velocity) and a global Score were computed from raw ArmeoSpring' data. Learning effect and retention were analyzed using a 2-way repeated-measures ANOVA, and reliability was investigated using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC). RESULTS: We observed significant inter- and intra-session learning effects for most parameters except peak velocity. The measures performed in sessions 2 and 3 were significantly different from those of session 1. No additional significant difference was observed after the first 6 trials of each session and successful retention was also highlighted for all the parameters. Relative reliability was moderate to excellent for all the parameters, and MDC values expressed in percentage ranged from 42.6 to 102.8%. CONCLUSIONS: After a familiarization session, the ArmeoSpring can be used to reliably and sensitively assess motor impairment and intervention effects on motor learning processes after a stroke. Trial registration The study was approved by the local hospital ethics committee in September 2016 and was registered under number 05-0916.

Predictive position computations mediated by parietal areas: TMS evidence.

When objects move or the eyes move, the visual system can predict the consequence and generate a percept of the target at its new position. This predictive localization may depend on eye movement control in the frontal eye fields (FEF) and the intraparietal sulcus (IPS) and on motion analysis in the medial temporal area (MT). Across two experiments we examined whether repetitive transcranial magnetic stimulation (rTMS) over right FEF, right IPS, right MT, and a control site, peripheral V1/V2, diminished participants' perception of two cases of predictive position perception: trans-saccadic fusion, and the flash grab illusion, both presented in the contralateral visual field. In trans-saccadic fusion trials, participants saccade toward a stimulus that is replaced with another stimulus during the saccade. Frequently, predictive position mechanisms lead to a fused percept of pre- and post-saccade stimuli (Paeye et al., 2017). We found that rTMS to IPS significantly decreased the frequency of perceiving trans-saccadic fusion within the first 10min after stimulation. In the flash grab illusion, a target is flashed on a moving background leading to the percept that the target has shifted in the direction of the motion after the flash (Cavanagh and Anstis, 2013). In the first experiment, the reduction in the flash grab illusion after rTMS to IPS and FEF did not reach significance. In the second experiment, using a stronger version of the flash grab, the illusory shift did decrease significantly after rTMS to IPS although not after rTMS to FEF or to MT. These findings suggest that right IPS contributes to predictive position perception during saccades and motion processing in the contralateral visual field.

Assessment of a program to encourage the multidisciplinary management of urinary disorders in multiple sclerosis.

AIMS: Urinary disorders (UD) secondary to multiple sclerosis (MS) are common and can be responsible for complications. Since 2004, we organized in our region their management through a neuro-urological activity and a care network that established and distributed an algorithm for screening and first line care. The objective was to assess the effects of this organization on the management of UD and its impact for patients. METHODS: Between January 2004 and December 2009, 328 patients were seen in neuro-urological consultation. The data of a group of 168 patients consulting during the deployment of our organization (before January 2007: group 1) were compared to those of 160 patients taken when the organization was well established (from January 2007: group 2). In parallel, the modification of the prescription rate of the first-line examination patients was evaluated. RESULTS: The two groups were significantly different concerning age, duration of MS, EDSS score (Group 1 vs. Group 2 respectively 51.6 ± 12.6 vs. 48 ± 11.8 years, P = 0.008; 19 ± 9.7 vs. 13.8 ± 10.5 years, P < 0.0001; 5.8 ±2.0 vs. 5.1 ± 2.1, P = 0.008). The occurrence of urinary complications in group 1 was more frequent than in group 2 (66.3% vs. 40%, P < 0.0001). The rate of first-line examinations rose from 1/16 patient seen in January 2006 to 9/12 patients in January 2008. CONCLUSION: The multidisciplinary management of UD in MS led to patients being cared for sooner in the evolution of MS, with fewer complications and to an improvement in the rate of prescription of first-line examinations. Neurourol. Urodynam. 36:706-709, 2017. © 2016 Wiley Periodicals, Inc.

Intradetrusor injections of onabotulinum toxin A (Botox®) 300 U or 200 U versus abobotulinum toxin A (Dysport®) 750 U in the management of neurogenic detrusor overactivity: A case control study.

AIMS: To compare the outcomes of the first intradetrusor injections of abobotulinum toxin 750 U and onabotulinum toxin 200 and 300 U in patients with neurogenic detrusor overactivity (NDO). METHODS: A retrospective case-control study was conducted including 211 NDO patients treated in three consecutives eras with onabotulinum toxin 300 U (2004-2006; 80 patients), abobotulinum toxin 750 U (2007-2011; 78 patients) or onabotulinum toxin 200 U (2011-2014; 53 patients). Urodynamic and clinical parameters were compared between groups. The primary endpoint was the rates of success defined as the combination of urgency, urinary incontinence, and detrusor overactivity resolution. RESULTS: When comparing abobotulinum toxin to onabotulinum toxin any doses (200 or 300 U; n = 133), success rates were similar (65.4% vs. 55.6%; P = 0.16). Patients treated with abobotulinum toxin 750 U had higher success rate (65.4% vs. 41.5%; P = 0.007) compared to those who received onabotulinum toxin 200 U. In contrast, there were similar success rates in abobotulinum toxin 750 U and onabotulinum toxin 300 U groups (65.4% vs. 65%; P = 0.91) but with a trend towards longer interval between the first and the second injection in the onabotulinum toxin 300 U group (12.4 vs. 9.3 months; P = 0.09). CONCLUSIONS: Intradetrusor injections of abobotulinum toxin 750 U for NDO provided better outcomes than injections of onabotulinum toxin 200 U. Success rates of abobotulinum toxin 750 U and onabotulinum toxin 300 U were similar but interval between injections tended to be longer with onabotulinum toxin 300 U. Neurourol. Urodynam. 36:734-739, 2017. © 2016 Wiley Periodicals, Inc.

Adverse drug reactions of botulinum neurotoxin type A in children with cerebral palsy: a pharmaco-epidemiological study in VigiBase.

AIM: The aim of this study was to assess the risk of adverse drug reactions (ADRs) with botulinum neurotoxin type A (BoNT-A) in children with cerebral palsy (CP) using the World Health Organization global individual case safety report (ICSR) database, VigiBase. METHOD: We extracted all children ICSRs for ADRs with BoNT-A used as anti-spastic drug in CP recorded between 1995 and 2015 in VigiBase. We also performed a case/non-case method (disproportionality analysis) to assess the link between exposure to BoNT-A and each ADR of interest in children and adults, calculating reporting odds ratios (RORs). RESULTS: In VigiBase, 162 ICSRs were registered. They involved mainly males (n=95, 59%) and mean (SD) age was 7 years 11 months (4y 4mo). The most frequent ADR was dysphagia (27 ICSRs, 17%) followed by asthenia and muscular weakness (25 ICSRs each, 16%). Nineteen ICSRs (12%) were lethal. There was a significant association between BoNT-A and death in children (ROR=11.1 95%, confidence interval [CI] 7.0-17.7) but not in adults. INTERPRETATION: In children with CP, most ADRs seem to be linked to a systemic spread of BoNT-A. Our study suggests a higher risk of ADRs with BoNT-A in children than in adults.

Efficacy and safety of the first and repeated intradetrusor injections of abobotulinum toxin A 750 U for treating neurological detrusor overactivity.

PURPOSE: To assess clinical and urodynamic efficacy of the first and repeated intradetrusor injections of abobotulinum toxin A (Dysport(®), Ipsen(®), France) in patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergic treatment. METHODS: A single-center retrospective study was conducted in 81 consecutive patients who had never received any botulinum toxin intradetrusor injections. They were treated with at least one 750 U intradetrusor injection of abobotulinum toxin A. All patients performed clean intermittent self-catheterization (CIC) before injections. Success was defined as a combination of no incontinence episode, a number of catheterization <8 reported in a 3-day bladder diary and the lack of detrusor overactivity. RESULTS: Six weeks after the first injection, the success rate was 64.2 %. The proportion of continent patients was 80.2 %, the mean number of CIC per 24 h reduced (-3.55, p < 0.0001) and the mean catheterization volume increased (+237.3 ml, p < 0.0001). Regarding urodynamics, mean maximum cystometric capacity and mean volume at the first uninhibited contraction increased (+132.7 ml, p < 0.0001 and +180 ml, p < 0.0001, respectively) and mean maximum bladder pressure decreased significantly (-21.5 cm H2O, p < 0.0001). Mean reinjection number was 3.9 and mean interval between reinjection was 8.8 ± 3 months. The clinical efficacy rate after each reinjection (up to fourteen) was at least 86.7 %. Out of 55 patients who underwent repeated injections, secondary resistance was noted in 2 (3.6 %). CONCLUSION: The results of the present study are in favor of a long-term safety and efficacy of abobotulinum toxin A 750 U for NDO.

Preliminary results of botulinum toxin A switch after first detrusor injection failure as a treatment of neurogenic detrusor overactivity.

AIMS: To assess the results of onabotulinum toxin detrusor injections when abobotulinum toxin detrusor injection failed. METHODS: Twenty-six patients, 15 women and 11 men, mean age 40.8 ± 12.7 years old, in whom a first injection of 750 U abobotulinum toxin in 20 sites failed in treating neurogenic detrusor overactivity, received onabotulinum toxin 300 U detrusor injections in 30 sites. Neurologic conditions were spinal cord injury in 14 cases, multiple sclerosis in nine, myelomeningocele in two and myelitis in one. Mean time between the two injections was 5.6 ± 1.4 months. Before and 6 weeks after each injection, patients carried out a 3-day bladder diary and had urodynamics. The success was defined as the combination of a clean intermittent self-catheterization number under 8 per 24 hr, urgency, urinary incontinence and detrusor overactivity relief. RESULTS: Out of 26 patients, the second injection was successful in 15 (57.7%). While the first injection of 750 U abobotulinum toxin had no impact at all, after 300 U onabotulinum toxin injection, the number of clean intermittent self-catheterization decreased significantly (11.3 ± 2.1 vs. 6.4 ± 1.9, P = 0.01), 17/26 (65.4%) patients achieved continence, urgency was relieved in 18/26 (69.2%) and detrusor overactivity in 15/26 (57.7%). CONCLUSIONS: In case of failure after a first detrusor injection of abobotulinum toxin, switching for onabotulinum toxin is efficient. Further investigations should be performed to assess whether the replacement of onabotulinum toxin by abobotulinum toxin provides the same results.

Neural adaptations to submaximal isokinetic eccentric strength training.

PURPOSE: This study investigated the neural adaptations following submaximal isokinetic eccentric strength training of the plantar flexors. The modulation of electromyographic (EMG) activity and spinal excitability were compared in the soleus muscle (SOL) during isometric, concentric and eccentric maximal voluntary contractions (MVC) before and after submaximal isokinetic eccentric training. METHODS: Eighteen healthy subjects were divided into a training group (n = 8) and a control group (n = 10). The training protocol consisted of sixteen sessions of isokinetic eccentric strength training during 8 weeks. Normalized EMG was used to assess the activity of SOL and medial gastrocnemius muscle (MG). For SOL, maximal Hoffmann reflex (H-reflex) and compound motor potential were evoked during isometric, concentric and eccentric actions at rest (Hmax and Mmax, respectively) and during MVC (Hsup and Msup, respectively). RESULTS: The results showed that the torque and normalized EMG of SOL significantly increased after training during eccentric (+20.5 and +28.8 %, respectively) and isometric (+18.2 and +23.0 %, respectively) MVC (p < 0.05). Hmax/Mmax and Hsup/Msup ratios were not significantly modified after training for SOL (p > 0.05), and remained significantly depressed during eccentric compared to isometric and concentric actions (p < 0.05). In contrast, no significant difference was observed on normalized EMG of MG (p > 0.05). CONCLUSIONS: These results suggested that the increase in voluntary torque after submaximal isokinetic eccentric training can be at least partly ascribed to enhanced neural drive for SOL that does not affect the H-reflex pathway.

Theta oscillations modulate attentional search performance periodically.

Visual search--finding a target element among similar-looking distractors--is one of the prevailing experimental methods to study attention. Current theories of visual search postulate an early stage of feature extraction interacting with an attentional process that selects candidate targets for further analysis; in difficult search situations, this selection is iterated until the target is found. Although such theories predict an intrinsic periodicity in the neuronal substrates of attentional search, this prediction has not been extensively tested in human electrophysiology. Here, using EEG and TMS, we study attentional periodicities in visual search. EEG measurements indicated that successful and unsuccessful search trials were associated with different amounts of poststimulus oscillatory amplitude and phase-locking at ∼6 Hz and opposite prestimulus oscillatory phase at ∼6 Hz. A trial-by-trial comparison of pre- and poststimulus ∼6 Hz EEG phases revealed that the functional interplay between prestimulus brain states, poststimulus oscillations, and successful search performance was mediated by a partial phase reset of ongoing oscillations. Independently, TMS applied over occipital cortex at various intervals after search onset demonstrated a periodic pattern of interference at ∼6 Hz. The converging evidence from independent TMS and EEG measurements demonstrates that attentional search is modulated periodically by brain oscillations. This periodicity is naturally compatible with a sequential exploration by attention, although a parallel but rhythmically modulated attention spotlight cannot be entirely ruled out.

Urinary complications and risk factors in symptomatic multiple sclerosis patients. Study of a cohort of 328 patients.

AIMS: Lower urinary tract dysfunctions (LUTD) are very common in Multiple Sclerosis (MS), have a significant social impact, while the organic impact is discussed. We studied urinary complications and their risk factors in our cohort of MS patients, in order to improve the management of LUTD in MS. METHODS: Between 2004 and 2009, all patients affected by MS and managed for LUTD were included in a retrospective study. We studied the epidemiological data (age, gender), the clinical data (duration of MS, EDSS score, progression of MS) and the paraclinical data (urinary creatinine clearance, urine culture, urinary tract ultrasonography and in some cases urodynamic assessment and cystography). We then identified the urinary complications and their risk factors. RESULTS: Three hundred twenty eight patients, mean age 49.9 ± 12.3 years, with a MS for 14.3 ± 10 years on average and with a median EDSS score equal to 6 (1-9), were managed for LUTD. One hundred seventy eight (54%) patients developed one or more urinary complications. We identified duration of MS greater than 8.5 years and an EDSS above 7 as risk factors. CONCLUSION: Urinary complications are common in symptomatic MS, these results imply screening and specialized care to limit the impact on the quality of life but also to prevent urinary complications.

Failure of botulinum toxin injection for neurogenic detrusor overactivity: Switch of toxin versus second injection of the same toxin.

OBJECTIVES: To evaluate the efficacy of a second injection of the same toxin versus switching to a different botulinum toxin A after failure of a first detrusor injection in patients with neurogenic detrusor overactivity. METHODS: The charts of all patients who underwent detrusor injections of botulinum toxin A (either abobotulinumtoxinA or onabotulinumtoxinA) for the management of neurogenic detrusor overactivity at a single institution were retrospectively reviewed. Patients in whom a first detrusor injection had failed were included in the present study. They were managed by a second injection of the same toxin at the same dosage or by a new detrusor injection using a different botulinum toxin A. Success was defined as a resolution of urgency, urinary incontinence and detrusor overactivity in a patient self-catheterizing seven times or less per 24 h. RESULTS: A total of 58 patients were included for analysis. A toxin switch was carried out in 29 patients, whereas the other 29 patients received a reinjection of the same toxin at the same dose. The success rate was higher in patients who received a toxin switch (51.7% vs. 24.1%, P = 0.03). Patients treated with a switch from abobotulinumtoxinA to onabotulinumtoxinA and those treated with a switch from onabotulinumtoxinA to abobotulinumtoxinA had similar success rates (52.9% vs. 50%, P = 0.88). CONCLUSION: After failure of a first detrusor injection of botulinum toxin for neurogenic detrusor overactivity, a switch to a different toxin seems to be more effective than a second injection of the same toxin. The replacement of onabotulinumtoxin by abobotulinumtoxin or the reverse provides similar results.

Between-day reliability of centre of pressure measures for balance assessment in hemiplegic stroke patients.

BACKGROUND: Stroke patients have impaired postural balance that increases the risk of falls and impairs their mobility. Assessment of postural balance is commonly carried out by recording centre of pressure (CoP) displacements, but the lack of data concerning reliability of these measures compromises their interpretation. The purpose of this study was to investigate the between-day reliability of six CoP-based variables, in order to provide i) reliability data for monitoring postural sway and weight-bearing asymmetry of stroke patients in clinical practice and ii) consistent assessment method of measurement error for applications in physical medicine and rehabilitation. METHODS: Postural balance of 20 stroke patients was assessed in quiet standing on a force platform, in two sessions, 7 days apart. Six CoP-based variables were collected in eyes open and eyes closed conditions: postural sway was assessed with mean and standart deviation of CoP-velocity, CoP-velocity along the mediolateral and anteroposterior axes, and confidence ellipse area (CE(AREA)); weight-bearing asymmetry was assessed with mean CoP position along the mediolateral axis (CoP(ML)). The intraclass correlation coefficient (ICC) was used to determine the level of agreement between test-retest. Small real difference (SRD), corresponding to the smallest change that indicates a real improvement for a single individual, was used to determine the extent of measurement error. RESULTS: ICCs were satisfactory (>0.9) for all CoP-based variables, except for CE(AREA) in eyes open condition and CoP(ML) (<0.8). The SRDs (eyes open/closed conditions) were: 6.1/9.5 mm.s(-1) for mean velocity; 12.3/12.2 mm.s(-1) for standard deviation of CoP-velocity; 3.6/5.5 mm.s(-1) and 4.9/7.3 mm.s(-1) for CoP-velocity in mediolateral and anteroposterior axes, respectively; 17.4/21.4 mm for CoP(ML). Because CE(AREA) showed heteroscedasticity of measurement error distribution, SRD (eyes open/closed conditions) was expressed as a percentage (121/75%) and a ratio (3.68/2.16) obtained after log-antilog procedure. CONCLUSIONS: In clinical practice, the CoP-based velocity variables should be prefer to CE(AREA) to assess and monitor postural sway over time in hemiplegic stroke patients. The poor reliability of CoP(ML) compromises its use to assess weight-bearing asymmetry. The procedure we used could be applied in reliability studies concerning other CoP-based variables or other biological variables in the field of physical medicine and rehabilitation.

Selection criteria for surgical correction of equinovarus foot in adults with brain damage: A systematic scoping review.

OBJECTIVE: To report on preoperative outcomes that guide the choice of surgical techniques to correct equinovarus foot in adults with brain injury. METHODS: Four databases (PubMed, MEDLINE, Cochrane, PEDro) were searched according to the PRISMA guidelines. Studies were included regardless of their level of proof, with no limitation on date of publication, and their quality was assessed with the Methodological Index for Non-Randomized Studies score. RESULTS: We analysed 61 studies (n = 2,293 participants); 523 participants underwent neurotomy, 437 calf musculotendinous lengthening, and 888 tibialis anterior transfer or alternative anterior transfers with the flexor digitorum/hallucis longus (n = 249), the extensor hallucis longus (n = 102), the tibialis posterior (n = 41) and the peroneus longus (n = 41). Two studies were dedicated to osteoarticular surgeries (n = 12 participants). Ankle dorsiflexors motricity was assessed before 70% of neurotomies as compared with 29% before isolated calf lengthening studies, their strength being at least 3/5 in 33% and 50% of the studies concerned, respectively. Passive ankle dorsiflexion was assessed before surgery in 87% of neurotomy studies, with 62% of studies investigating non-retracted spastic equinovarus foot. Before anterior tendon transfer with the tibialis anterior or another muscle, passive ankle dorsiflexion was reported in only 20% and 46% of studies, respectively, and dynamic tibialis anterior activation during gait in 46% and 56%. Although voluntary recruitment of the tibialis anterior produced a better functional result, the presence/correction of varus justified its transfer in 60% of studies as compared with 30% in other transfers, which were justified by hyperactivity or voluntary recruitment of transferred muscle. CONCLUSIONS: This review highlights the poor level of preoperative assessment and the absence of formal criteria to indicate the different surgical approaches in the management of equinovarus foot. It reinforces the interest of a systematic standardized preoperative assessment such as selective motor block and dynamic electromyography to choose the most suitable surgical procedure.

ToulGaitViz: a tool for the systematic description of lower limb clearance during the swing phase of hemiparetic gait after stroke. A cohort study.

BACKGROUND: In post-stroke hemiparetic subjects, a systematic and quantified description of the shortening default and compensatory movements during the swing phase of gait is essential to guide treatments and assess the impact of therapeutic interventions. However, such a systematic approach does not exist in the current clinical practice. AIM: The aim of this study was to present a method improving the quantification and visualization of the kinematics of both lower limbs during the swing phase of gait, more specifically the origin of shortening default and the weight of compensations, based on a tool specifically developed: ToulGaitViz. DESIGN: Observational cohort study. SETTING: Three-dimensional kinematic gait analyses of outpatients evaluated in Toulouse university hospital. POPULATION: ToulGaitViz was applied to 151 post-stroke hemiparetic participants and 48 healthy control participants. METHODS: ToulGaitViz is a standalone software allowing to compute 1) limb clearance as the sum of the shortening related to hip, knee and ankle flexion in the sagittal plane; 2) compensations related to the abduction of the limb and hip hiking at mid-swing. Both centimetric and angular values of the clearance were reported as well as their correlations with walking speed. RESULTS: Overall, the contribution of compensations in clearance was higher in post-stroke hemiparetic subjects than in healthy control participants with both centimetric (130% vs. 33%; P<0.001) and angular methods (23% vs. 1.4%; P<0.001). The centimetric method better represents the specific contribution of each segment to the clearance than the angular method. Symbolically, mean kinematic data from the cohort supports the claim that 2° of pelvic obliquity is equivalent to 10° of knee flexion to increase clearance by 1 cm, emphasizing the non-proportionality between the angular values and the actual contribution to the shortening. ToulGaitViz allows visualization of clearance, segmental shortening and compensation evolution before and after any therapeutic intervention with quantitative and comprehensive data. CONCLUSIONS: The ToulGaitViz could be systematically used in clinical practice to extract relevant kinematic data from the origin of shortening default and the weight of compensations. CLINICAL REHABILITATION IMPACT: This tool allows better understanding of the mechanisms of action of treatments to better link them to the subjects' needs.

Motor rehabilitation after stroke: European Stroke Organisation (ESO) consensus-based definition and guiding framework.

PURPOSE: To propose a consensus-based definition and framework for motor rehabilitation after stroke. METHODS: An expert European working group reviewed the literature, attaining internal consensus after external feedback. FINDINGS: Motor rehabilitation is defined as a process that engages people with stroke to benefit their motor function, activity capacity and performance in daily life. It is necessary for people with residual motor disability whose goal is to enhance their functioning, independence and participation. Motor rehabilitation operates through learning- and use-dependent mechanisms. The trajectory of motor recovery varies across patients and stages of recovery. Early behavioral restitution of motor function depends on spontaneous biological mechanisms. Further improvements in activities of daily living are achieved by compensations. Motor rehabilitation is guided by regular assessment of motor function and activity using consensus-based measures, including patient-reported outcomes. Results are discussed with the patient and their carers to set personal goals. During motor rehabilitation patients learn to optimize and adapt their motor, sensory and cognitive functioning through appropriately dosed repetitive, goal-oriented, progressive, task- and context-specific training. Motor rehabilitation supports people with stroke to maximize health, well-being and quality of life. The framework describes the International Classification of Functioning, Disability and Health in the context of stroke, describes neurobiological mechanisms of behavioral restitution and compensation, and summarizes recommendations for clinical assessment, prediction tools, and motor interventions with strong recommendations from clinical practice guidelines (2016-2022). CONCLUSIONS: This definition and framework may guide clinical educators, inform clinicians on current recommendations and guidelines, and identify gaps in the evidence base.

The phase of ongoing oscillations mediates the causal relation between brain excitation and visual perception.

Why does neuronal activity in sensory brain areas sometimes give rise to perception, and sometimes not? Although neuronal noise is often invoked as the key factor, a portion of this variability could also be due to the history and current state of the brain affecting cortical excitability. Here we directly test this idea by examining whether the phase of prestimulus oscillatory activity is causally linked with modulations of cortical excitability and with visual perception. Transcranial magnetic stimulation (TMS) was applied over human visual cortex to induce illusory perceptions (phosphenes) while electroencephalograms (EEGs) were simultaneously recorded. Subjects reported the presence or absence of an induced phosphene following a single pulse of TMS at perceptual threshold. The phase of ongoing alpha (∼10 Hz) oscillations within 400 ms before the pulse significantly covaried with the perceptual outcome. This effect was observed in occipital regions around the site of TMS, as well as in a distant frontocentral region. In both regions, we found a systematic relationship between prepulse EEG phase and perceptual performance: phosphene probability changed by ∼15% between opposite phases. In summary, we provide direct evidence for a chain of causal relations between the phase of ongoing oscillations, neuronal excitability, and visual perception: ongoing oscillations create periodic "windows of excitability," with sensory perception being more likely to occur at specific phases.

α Phase-Amplitude Tradeoffs Predict Visual Perception.

Spontaneous α oscillations (∼10 Hz) have been associated with various cognitive functions, including perception. Their phase and amplitude independently predict cortical excitability and subsequent perceptual performance. However, the causal role of α phase-amplitude tradeoffs on visual perception remains ill-defined. We aimed to fill this gap and tested two clear predictions from the pulsed inhibition theory according to which α oscillations are associated with periodic functional inhibition. (1) High-α amplitude induces cortical inhibition at specific phases, associated with low perceptual performance, while at opposite phases, inhibition decreases (potentially increasing excitation) and perceptual performance increases. (2) Low-α amplitude is less susceptible to these phasic (periodic) pulses of inhibition, leading to overall higher perceptual performance. Here, cortical excitability was assessed in humans using phosphene (illusory) perception induced by single pulses of transcranial magnetic stimulation (TMS) applied over visual cortex at perceptual threshold, and its postpulse evoked activity recorded with simultaneous electroencephalography (EEG). We observed that prepulse α phase modulates the probability to perceive a phosphene, predominantly for high-α amplitude, with a nonoptimal phase for phosphene perception between -π/2 and -π/4. The prepulse nonoptimal phase further leads to an increase in postpulse-evoked activity [event-related potential (ERP)], in phosphene-perceived trials specifically. Together, these results show that α oscillations create periodic inhibitory moments when α amplitude is high, leading to periodic decrease of perceptual performance. This study provides strong causal evidence in favor of the pulsed inhibition theory.

Respective Contributions of Instrumented 3D Gait Analysis Data and Tibial Motor Nerve Block on Presurgical Spastic Equinus Foot Assessment: A Retrospective Study of 40 Adults.

Spastic equinus foot is a common deformity in neurologic patients who compromise walking ability. It is related to the imbalance between weak dorsiflexion and overactive plantar flexor muscles. To achieve the best functional results after surgical management, the challenge is to identify the relevant components involved in the deformity using several methods, namely, examination in the supine position, motor nerve blocks allowing transient anesthesia of suspected overactive muscles, and kinematic and electromyographic data collected during an instrumented 3D gait analysis. The procedure is not standardized; its use varies from one team to another. Access to gait analysis laboratories is limited, and some teams do not perform motor nerve blocks. When both examinations are available, instrumental data from the instrumented 3D gait analysis can be used to specify muscle targets for motor blocks, but data collected from both examinations are sometimes considered redundant. This retrospective cohort analysis compared examination in the supine position, temporary motor nerve blocks, and instrumented 3D gait analysis data in 40 adults after brain or spinal cord injuries. Clinical data collected before motor nerve block was not associated with instrumental data to assess calf muscle's overactivity and tibialis anterior function. Improvement of ankle dorsiflexion in the swing phase after tibial motor nerve block was associated with soleus spastic co-contraction during this phase corroborating its involvement in ankle dorsiflexion defects. This study showed the relevance of tibial motor nerve block to remove spastic calf dystonia and facilitate the assessment of calf contracture. It also underlined the need for complementary and specific analyses of the tibialis anterior abnormal activation pattern after motor nerve block to confirm or deny their pathological nature.

Prospective study of the impact on quality of life of cystectomy with ileal conduit urinary diversion for neurogenic bladder dysfunction.

OBJECTIVES: Neurogenic bladder dysfunction has a negative impact on the patient's quality of life (QoL). Cystectomy with ileal conduit urinary diversion is a treatment option in patients in failure after conservative management. The objective of this study was to evaluate the impact of ileal conduit urinary diversion on the QoL of patients with neurogenic bladder dysfunction. MATERIALS AND METHODS: From March 2004 to November 2010, 48 patients (36 women and 12 men with a mean age of 50.6 ± 11.8 years) treated by cystectomy with ileal conduit urinary diversion for neurogenic bladder dysfunction, prospectively completed, before and after surgery, two self-administered QoL questionnaires. Neurological diseases were multiple sclerosis in 38 cases, spinal cord injury in 7 cases, and other neurological disease in 3 cases. Cystectomy was performed by laparoscopy in all patients. QoL was measured by using two self-administered questionnaires, one questionnaire specific for urinary disorders validated in neurological patients, Qualiveen®, and the generic SF36-v2® questionnaire. Data were compared by Student's t test. RESULTS: Comparison of the Qualiveen® self-administered questionnaire scores and indices before and after surgery showed that, after surgery, patients presented a significant reduction of limitations (0.57 ± 0.64 vs. 1.55 ± 1.35, P < 0.001), constraints (2.12 ± 0.83 vs. 2.64 ± 1.12, P = 0.046) scores and the SIUP index (1.29 ± 0.65 vs. 1.79 ± 0.95, P = 0.015). No significant change in SF36-v2® scores was observed postoperatively. CONCLUSIONS: Ileal conduit urinary diversion improves the urinary QoL of patients with neurogenic bladder dysfunction by decreasing limitations and constraints induced by urinary disorders, but has no impact on general QoL.