I. Laffont

The contribution of kinematics in the assessment of upper limb motor recovery early after stroke.

Background. Kinematic assessment of upper limb motor recovery after stroke may be related to clinical scores while being more sensitive and reliable than clinical evaluation alone. Objective. To identify the potential of kinematics in assessing upper limb recovery early poststroke. Methods. Thirteen patients were included within 1 month poststroke and evaluated once a week for 6 weeks and at 3 months with (a) the Fugl-Meyer Assessment (FMA) and (b) kinematic analysis of reach-to-grasp movements. The link between clinical and kinematic data was identified using mixed model with random coefficient analysis. Results. Movement time, trajectory length, directness, smoothness, mean and maximum velocity of the hand were sensitive to change over time and distinguished between movements of paretic, nonparetic, and healthy control limbs. The FMA score increased with movement smoothness over time, explaining 62.5% of FMA variability. Conclusion. Kinematic analysis of reach-to-grasp movements is relevant to assess upper limb recovery early poststroke, and is linked to the FMA. Kinematics could provide more accurate real-time indicators of patients’ recovery as compared with the sole use of clinical scores, although it remains challenging to establish the universality of the reaching model in relation to motor recovery after stroke.

How to extend the elbow with a weak or paralyzed triceps: control of arm kinematics for aiming in C6-C7 quadriplegic patients.

This study aims to investigate how quadriplegic patients with a C6-C7 spinal lesion coordinate their upper limb to extend the elbow despite the paralysis or weakness of the triceps brachii, and what is the effect of a surgical musculotendinous transfer. For this purpose, aiming movements in a wide workspace were recorded in seven healthy subjects and in patients with incomplete (five cases) or complete (eight cases) triceps paralysis and after musculotendinous transfer (eight cases). We used four electromagnetic field sensors to quantify hand trajectory and to compute the angles describing the rotations at the scapula, glenohumeral joint, elbow and wrist (10 degrees of freedom). Extent and smoothness of the hand trajectories and hand velocity profiles were surprisingly similar between healthy subjects and quadriplegic patients. The reduction of elbow extension observed in patients was compensated by rotations distributed across several degrees of freedom including the scapula. Principal components analysis showed that the joint rotations could be summarized by an additive combination of two synergies, respectively orientating and stretching out the limb, which explained similar amounts of variance in healthy subjects and in patients. The participations of degrees of freedom in the synergies were roughly similar in the different groups of subjects, the main difference concerning scapular medial-lateral rotation, which seems to be critical in patients with a complete triceps paralysis. This demonstrates that elbow extension in quadriplegic patients is due to anticipated mechanical interaction coupling between upper limb segments. We propose that the persisting (incomplete paralysis) or restored (musculotendinous transfer) elbow extensor strength may act by stabilizing the elbow. This counterintuitive preservation of limb kinematics for horizontal aiming movements in quadriplegic patients despite the drastic changes in muscle action provoked by paralysis and/or by surgery strongly suggests that the motor system does not primarily control forces but the morphological aspects of movement, via joint rotation synergies.

Prevention of urinary tract infection in six spinal cord-injured pregnant women who gave birth to seven children under a weekly oral cyclic antibiotic program

BACKGROUND Pregnancies in spinal cord-injured (SCI) patients present unique clinical challenges. Because of the neurogenic bladder and the use of intermittent catheterization, chronic bacteriuria and recurrent urinary tract infection (UTI) is common. During pregnancy the prevalence of UTI increases dramatically. Recurrent UTI requires multiple courses of antibiotics and increases the risks of abortion, prematurity, and low birth weight. A weekly oral cyclic antibiotic (WOCA) program was recently described for the prevention of UTI in SCI patients. OBJECTIVE To test the impact of WOCA in six SCI pregnant women (four paraplegic, two tetraplegic). DESIGN This was a prospective observational study. WOCA consists of the alternate administration of one of two antibiotics once per week. RESULTS We observed a significant reduction of UTI (6 UTI/patient/year before pregnancy to 0.4 during pregnancy and under WOCA; p<0.001) and no obstetric complications. Infant outcomes were good. CONCLUSION The WOCA regimen could be useful for UTI prophylaxis in SCI pregnant women.

Post-polio syndrome: Pathophysiological hypotheses, diagnosis criteria, medication therapeutics

Post-polio syndrome (PPS) refers to a clinical disorder affecting polio survivors with sequelae years after the initial polio attack. These patients report new musculoskeletal symptoms, loss of muscular strength or endurance. PPS patients are tired, in pain and experience new and unusual muscular deficits, on healthy muscles as well as deficient muscles initially affected by the Poliovirus. Once a clinical diagnosis is established, the therapeutic options can be discussed. Some pathophysiological mechanisms have been validated by research studies on PPS (inflammatory process in cerebrospinal fluid [CSF] and cytokines of the immune system). Several studies have been conducted to validate medications (pyridostigmine, immunoglobulin, coenzyme Q10) or physical exercises protocols. This article focuses on the relevance and efficacy that can be expected from these therapeutics. Very few studies reported some improvements. Medications combined to individual and supervised exercise training programs are promising therapeutic strategies for PPS patients care management.

Evaluation of a Stair-Climbing Power Wheelchair in 25 People With Tetraplegia

OBJECTIVE To compare the performance of a power wheelchair with stair-climbing capability (TopChair) and a conventional power wheelchair (Storm3). DESIGN A single-center, open-label study. SETTING A physical medicine and rehabilitation hospital. PARTICIPANTS Patients (N=25) who required power wheelchairs because of severe impairments affecting the upper and lower limbs. INTERVENTIONS Indoor and outdoor driving trials with both devices. Curb-clearing and stair-climbing with TopChair. MAIN OUTCOME MEASURES Trial duration and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) tool; number of failures during driving trials and ability to climb curbs and stairs. RESULTS All 25 participants successfully completed the outdoor and indoor trials with both wheelchairs. Although differences in times to trial completion were statistically significant, they were less than 10%. QUEST scores were significantly better with the Storm3 than the TopChair for weight (P=.001), dimension (P=.006), and effectiveness (P=.04). Of the 25 participants, 23 cleared a 20-cm curb without help, and 20 climbed up and down 6 steps. Most participants felt these specific capabilities of the TopChair--for example, curb clearing and stair climbing-were easy to use (22/25 for curb, 21/25 for stairs) and helpful (24/25 and 23/25). A few participants felt insecure (4/25 and 6/25, respectively). CONCLUSIONS The TopChair is a promising mobility device that enables stair and curb climbing and warrants further study.

Intermittent positive-pressure breathing effects in patients with high spinal cord injury.

OBJECTIVE To determine whether intermittent positive-pressure breathing (IPPB) improved lung compliance, work of breathing, and respiratory function in patients with recent high spinal cord injury (SCI). DESIGN An unblinded randomized crossover trial. SETTING Rehabilitation hospital. PARTICIPANTS Patients (N=14) with SCI caused by trauma within the last 6 months and located between C5 and T6. INTERVENTION Two months of IPPB and 2 months of conventional treatment were evaluated prospectively in random order in patients with SCI. MAIN OUTCOME MEASURES Noninvasive lung function tests and arterial blood gas measurements were obtained repeatedly in all patients. Repeated measurements of dynamic lung compliance and work of breathing as measured by computing the area enclosed between the inspiratory esophageal pressure-tidal volume curve, and the theoretical chest wall static pressure-volume curve were performed in 7 patients. RESULTS IPPB had no long-term effects on vital capacity (52.1%+/-11.3% vs 54.5%+/-12.5%, after conventional treatment and IPPB, respectively; P=.27), lung compliance (66.4+/-48.9 mL/cmH(2)O vs 70.3+/-38.4 mL/cmH(2)O; P=.56), or other lung function tests. IPPB did not exert short-term effects on lung compliance or work of breathing. CONCLUSIONS IPPB produced no immediate or long-term improvements in lung function or ventilatory mechanics in patients with recent SCI. (ClinicalTrials.gov identifier: NCT00476866.).

Somatosensory-Related Limitations for Bimanual Coordination After Stroke

Background. Bimanual coordinated movements may be impaired after stroke, so an assessment of causes is necessary to optimize rehabilitation strategies. Objective. We assessed the role of afference-based sources of coordination, including phase entrainment and error correction based on visual and somatosensory feedback. Methods. In all, 10 persons with unilateral chronic stroke and 8 age-matched controls participated in a kinesthetic tracking protocol, in which the hemiparetic upper limb was passively driven by the machine. The task consisted of matching the trajectory of the driven limb as accurately as possible with the freely moving limb in 2 conditions: eyes closed and eyes open. We analyzed the continuous relative phase (CRP), the mean absolute difference between positions (ADP) between the positions of the 2 limbs, and the jerk of the matching limb. Results. Coordination instability (CRP standard deviation) and mean ADP were significantly higher for patients with eyes closed, compared with patients with eyes open, controls with eyes closed, and controls with eyes open. Moreover, the jerk was higher for the nonparetic limb of patients than for the control group. Thus, the nonparetic limb did not produce optimally smooth movements even as the motor-driven paretic limb did. Conclusion. Besides deficits caused by interhemispheric competition and motor execution of the paretic limb, somatosensory feedback is a limiting factor in bimanual coordination after stroke. The findings have clinical implications pertaining to the design and individualization of efficient bimanual movement therapy.

Motor recovery of the ipsilesional upper limb in subacute stroke.

OBJECTIVE To investigate the time-related changes in motor performance of the ipsilesional upper limb in subacute poststroke patients by using clinical and kinematic assessments. DESIGN Observational, longitudinal, prospective, monocentric study. SETTING Physical medicine and rehabilitation department. PARTICIPANTS Stroke patients (n=19; mean age, 62.9y) were included less than 30 days after a first unilateral ischemic/hemorrhagic stroke. The control group was composed of age-matched, healthy volunteers (n=9; mean age, 63.1y). INTERVENTIONS Clinical and kinematic assessments were conducted once a week during 6 weeks and 3 months after inclusion. Clinical measures consisted of Fugl-Meyer Assessment, Box and Block Test (BBT), Nine-Hole Peg Test (9HPT), and Barthel Index. We used a 3-dimensional motion recording system during a reach-to-grasp task to analyze movement smoothness, movement time, and peak velocity of the hand. Healthy controls performed both clinical (BBT and 9HPT) and kinematic evaluation within a single session. MAIN OUTCOME MEASURES BBT and 9HPT. RESULTS Recovery of ipsilesional upper arm capacities increased over time and leveled off after a 6-week period of rehabilitation, corresponding to 9 weeks poststroke. At study discharge, patients demonstrated similar ipsilesional clinical scores to controls but exhibited less smooth reaching movements. We found no effect of the hemispheric side of the lesion on ipsilesional motor deficits. CONCLUSIONS Our findings provide evidence that ipsilesional motor capacities remain impaired at least 3 months after stroke, even if clinical tests fail to detect the impairment. Focusing on this lasting ipsilesional impairment through a more detailed kinematic analysis could be of interest to understand the specific neural network underlying ipsilesional upper-limb impairment.

Reproducibility of isokinetic peak torque assessments of the hip flexor and extensor muscles.

OBJECTIVES Isokinetic assessment is currently the reference method for measuring dynamic muscle strength. We have sought to evaluate the reproducibility over time of isokinetic testing of the hip flexor (FI) and extensor (Ext) muscles and to establish whether there is a significant difference in peak torque (PT) between the left and right hips. PATIENTS AND METHODS Ten adults were tested once a week for 3 weeks by the same investigator and according to the same protocol, with two velocities (60 degrees /s and 180 degrees /s) for the hip FI and Ext in concentric tests and one velocity (30 degrees /s) for the Ext only in eccentric tests. The reproducibility of the measured PT was analyzed by using the intraclass correlation coefficient (ICC) and a Bland and Altman plot. The difference in PT between the right and left hips was tested using Students T test. RESULTS The ICC for the observed PT values revealed very good reproducibility (with a value of between 0.75 and 0.96) for the hip FI and Ext measurements (regardless of the body side, test velocity or contraction mode). We did not observe any significant PT differences between the right and left hips. CONCLUSION The isokinetic assessment of the concentric and eccentric PT values generated by the hip FI and Ext is highly reproducible. There is no difference between dominant and nondominant body sides, which enables the use of the contralateral limb as a reference.

Breathlessness associated with abdominal spastic contraction in a patient with C4 tetraplegia: a case report.

A tetraplegic patient with C4 cervical cord injury reported breathlessness during episodes of spastic contraction of the abdominal muscles. To determine the mechanism, we performed electrophysiologic testing of the phrenic nerves. We measured abdominal pressure, esophageal pressure, and transdiaphragmatic pressure (Pdi) during a maximal inspiratory effort (Pdi max), a maximal sniff maneuver (sniff Pdi) during resting breathing, and during the episodes of breathlessness. Electrophysiologic testing of the phrenic nerves showed axonal neuropathy on the left. Sniff Pdi and Pdi max were 38cmH(2)O and 42cmH(2)O, respectively. Transient spastic contractions of abdominal muscles were associated with an increase in abdominal pressure greater than 30cmH(2)O, with a decrease in abdominal volume; this rise in abdominal pressure was transmitted to the esophageal pressure. Inspiration became effective only when esophageal pressure fell below the resting baseline value. Achieving this decrease required an increase in inspiratory effort, characterized by swings in esophageal pressure and Pdi of 30cmH(2)O and 40cmH(2)O (approximately 100% of Pdi max), respectively. During these periods, minute ventilation was markedly reduced. This is the first report that spastic abdominal muscle contractions can impose a significant load on the diaphragm, uncovering moderate diaphragmatic weakness. This has important clinical implications; abolition of the spastic abdominal muscle contraction in this patient completely resolved her intermittent respiratory symptoms.