Jane Burridge

Spasticity: Clinical perceptions, neurological realities and meaningful measurement

The aim of this paper is to review briefly our understanding of the phenomenon of spasticity based in current evidence.

Treadmill training for individuals with multiple sclerosis: a pilot randomised trial

This pilot study investigated whether 4 weeks of aerobic treadmill training in individuals with multiple sclerosis (MS) improved mobility and reduced fatigue. Individuals with MS were recruited to this prospective, randomised controlled trial. Individuals were assessed at baseline, week 7 and 12 with a 10 metre timed walk, a 2 minute walk, the Rivermead Mobility Index, and the Fatigue Severity Scale. After a pre-assessment familiarisation session and a baseline assessment, individuals were randomly allocated to an initial intervention or delayed intervention group. Treadmill training consisted of 4 weeks of supervised aerobic exercise delivered weeks 3–6 in the immediate group and 8–11 in the delayed group. Of the initial 19 recruits, 16 individuals completed the study. There was a significant difference in walking endurance between the delayed and immediate groups at baseline (p<0.05). On reassessment in week 7, decreases in 10 metre walk time were found in both groups, which was significant in the immediate group (p<0.05). The 2 minute walk distance significantly increased in both groups (p<0.05). In the training group, reassessed at week 12 after training ceased, there was a return towards baseline scores. No significant changes in fatigue scores were found. This study showed that in individuals with MS, aerobic treadmill training is feasible and well tolerated. Walking speed and endurance increased following training with no increase in reported fatigue. Detraining occurred in the period following training. A larger randomised clinical trial is warranted.

Iterative Learning Control in Health Care: Electrical Stimulation and Robotic-Assisted Upper-Limb Stroke Rehabilitation

Annually, 15 million people worldwide suffer a stroke, and 5 million are left permanently disabled. A stroke is usually caused when a blood clot blocks a vessel in the brain and acts like a dam, stopping the blood reaching the regions downstream. Alternatively, it may be caused by a hemorrhage, in which a vessel ruptures and leaks blood into surrounding areas. As a result, some of the connecting nerve cells die, and the person commonly suffers partial paralysis on one side of the body, termed hemiplegia. Cells killed in this way cannot regrow, but the brain has some spare capacity and, hence, new connections can be made. The brain is continually and rapidly changing as new skills are learned, new connections are formed, and redundant ones disappear. A person who relearns skills after a stroke goes through the same process as someone learning to play tennis or a baby learning to walk, requiring sensory feedback during the repeated practice of a task. Unfortunately, the problem is that they can hardly move and, therefore, do not receive feedback on their performance.

Can aerobic treadmill training reduce the effort of walking and fatigue in people with multiple sclerosis: a pilot study

Impaired mobility in multiple sclerosis (MS) is associated with high-energy costs and effort when walking, gait abnormalities, poor endurance and fatigue. This repeated measures trial with blinded assessments investigated the effect of treadmill walking at an aerobic training intensity in 16 adults with MS. The intervention consisted of 12 sessions of up to 30 minutes treadmill training (TT), at 55–85% of age-predicted maximum heart rate. The primary outcome measure was walking effort, measured by oxygen consumption (mL/kg per metre), during treadmill walking at comfortable walking speed (CWS). Associated changes in gait parameters using the ‘Gait-Rite’ mat, 10-m time and 2-minute distance, and Fatigue Severity Scale were examined. Following training, oxygen consumption decreased at rest (P = 0.008), CWS increased (P = 0.002), and 10-m times (P = 0.032) and walking endurance (P = 0.020) increased. At increased CWS, oxygen consumption decreased (P = 0.020), with a decreased time spent in stance in the weaker leg (P = 0.034), and a greater stride distance with the stronger leg (P = 0.044). Reported fatigue levels remained the same. Aerobic TT presents the opportunity to alter a motor skill and reduce the effort of walking, whilst addressing cardiovascular de-conditioning, thereby, potentially reducing effort and fatigue for some people with MS.

PHASE II TRIAL TO EVALUATE THE ACTIGAIT IMPLANTED DROP-FOOT STIMULATOR IN ESTABLISHED HEMIPLEGIA

OBJECTIVE To evaluate a selective implantable drop foot stimulator (ActiGait) in terms of effect on walking and safety. DESIGN A phase II trial in which a consecutive sample of participants acted as their own controls. SUBJECTS People who had suffered a stroke at least 6 months prior to recruitment and had a drop-foot that affected walking were recruited from 3 rehabilitation centres in Denmark. METHODS Stimulators were implanted into all participants. Outcome measures were range of ankle dorsiflexion with stimulation and maximum walking speed and distance walked in 4 minutes. Measurements were applied before implantation, at 90 days and at a long-term follow-up assessment. Changes over time and with and without stimulation are reported. Safety was evaluated by nerve conduction velocity and adverse events. RESULTS Fifteen participants were implanted and 13 completed the trial. Long-term improvements were detected in walking speed and distance walked in 4 minutes when stimulated, and the orthotic effect of stimulation showed statistically significant improvement. The device did not compromise nerve conduction velocity and no serious device-related adverse events were reported. Technical problems were resolved by the long-term follow-up assessment at which further improvement in walking was observed. CONCLUSION This trial has evaluated the safety and performance of the device, which was well accepted by patients and did not compromise safety.

Biomechanical approaches applied to the lower and upper limb for the measurement of spasticity: a systematic review of the literature.

Purpose: To review and characterise biomechanical approaches for the measurement of spasticity as one component of the upper motor neurone syndrome. Method: Systematic literature searches based on defined constructs and a four-step review process of approaches used or described to measure spasticity, its association with function or associated phenomena. Most approaches were limited to individual joints and therefore, to reflect this trend, references were grouped according to which body joint(s) were investigated or whether it addressed a functional activity. For each joint, references were further sub-divided into the types of measurement method described. Results: A database of 335 references was established for the review process. The knee, ankle and elbow joints were the most popular, perhaps reflecting the assumption that they are mono-planar in movement and therefore simpler to assess. Seven measurement methods were identified: five involving passive movement (manual, controlled displacement, controlled torque, gravitational and tendon tap) and two involving active movement (voluntary and functional). Generally, the equipment described was in an experimental stage and there was a lack of information on system properties, such as accuracy or reliability. Patient testing was either by cohort or case studies. The review also conveyed the myriad of interpretations of the concept of spasticity. Conclusions: Though biomechanical approaches provide quantitative data, the review highlighted several limitations that have prevented them being established as an appropriate method for clinical application to measure spasticity.

Indices to describe different muscle activation patterns, identified during treadmill walking, in people with spastic drop-foot

This study was concerned with individuals who were unable to effectively dorsiflex their ankle when walking, as a result of a lesion of the central nervous system (CNS). Indices that categorise and quantify different patterns of calf and anterior tibial muscle activation patterns during treadmill walking have been derived from a sample of fifteen individuals with established hemiplegia following stroke and twelve age-matched individuals without impairment. As subjects walked on a treadmill, force sensitive foot-switches under the heel and first metatarsal head allowed EMG signals from the calf and anterior tibial muscles to be related to phases of the gait cycle. Normal activation periods for each muscle group were identified as percentiles of the gait cycle and indices for muscle activation periods were derived using ratios of integrated EMG during selected periods. Indices were derived that identified statistically significant differences, between normal and hemiplegic subjects, in calf activation during both push-off phase (P<0.001) and early stance phase (P<001), but not activation of tibialis anterior during swing (P=0.325) Observation suggested that integrated tibialis anterior activity during swing phase in hemiplegic subjects was not dissimilar to normal subjects, but the profile in hemiplegic subjects tended to lack the normal second peak of activity at initial foot contact. The reasons for drop-foot were shown to be varied and complex. The indices defined may be useful for directing therapy and measuring outcome.

Clinical and Therapeutic Applications of Neuromuscular Stimulation: A Review of Current Use and Speculation into Future Developments

In this paper we present an overview of current research into clinical and therapeutic applications of electrical neuromuscular stimulation (NMS). As this is now such a huge subject we have focused our attention on the therapeutic rather than orthotic uses of stimulation and limited the field almost exclusively to upper limb applications in hemiplegia. The evidence that NMS influences motor re‐learning and how this may be measured is discussed. We have identified the following as the three most important unresolved issues: 1) an understanding of how NMS modifies the interactions within the nervous system, 2) clinical effectiveness of NMS, and 3) inexpensive, simple to insert and reliable controllable implanted systems. We discuss recent research aimed at resolving these issues and based on this we make some suggestions for future research. To resolve these issues we propose: 1) neurophysiologic research into the mechanism through which NMS interacts with the nervous system; 2) large multicenter randomized controlled trials using rigorous methodology that compare different applications of NMs; 3) continued technical development that is closely linked to clinical applications.

Feasibility of Iterative Learning Control Mediated by Functional Electrical Stimulation for Reaching After Stroke

Background. An inability to perform tasks involving reaching is a common problem following stroke. Evidence supports the use of robotic therapy and functional electrical stimulation (FES) to reduce upper limb impairments, but current systems may not encourage maximal voluntary contribution from the participant because assistance is not responsive to performance. Objective. This study aimed to investigate whether iterative learning control (ILC) mediated by FES is a feasible intervention in upper limb stroke rehabilitation. Methods. Five hemiparetic participants with reduced upper limb function who were at least 6 months poststroke were recruited from the community. No participants withdrew. Intervention. Participants undertook supported tracking tasks using 27 different trajectories augmented by responsive FES to their triceps brachii muscle, with their hand movement constrained in a 2-dimensional plane by a robot. Eighteen 1-hour treatment sessions were used with 2 participants receiving an additional 7 treatment sessions. Outcome measures. The primary functional outcome measure was the Action Research Arm Test (ARAT). Impairment measures included the upper limb Fugl— Meyer Assessment (FMA), tests of motor control (tracking accuracy), and isometric force. Results. Compliance was excellent and there were no adverse events. Statistically significant improvements were measured (P ≤ .05) in FMA motor score, unassisted tracking for 3 out of 4 trajectories, and in isometric force over 5 out of 6 directions. Changes in ARAT were not statistically significant. Conclusion. This study has demonstrated the feasibility of using ILC mediated by FES for upper limb stroke rehabilitation.

Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population

Objective: To explore the relationship in individuals with early rheumatoid arthritis (RA) between self-report upper limb function, therapist-assessed upper limb function and therapist-assessed measures of structural impairment (handgrip, active hand motion and metacarpophalangeal (MCP) joint ulnar deviation). Design: Thirty-six patients with early RA were recruited across seven outpatient occupational therapy departments. Outcome measures: Upper limb functional activity and ability was measured using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Grip Ability Test (GAT). Upper limb impairment was assessed by bilateral power handgrip using the MIE Digital Grip Analyser, goniometry measures of bilateral metacarpophalangeal (MCP) joint ulnar deviation and bilateral active motion of the wrist. Results: Strong correlations (>0.7) were seen between the self-report DASH questionnaire and the therapist-rated GAT assessment. Bilateral power handgrips were also strongly correlated with both functional assessments. Dominant ulnar deviation at the MCP joints demonstrated a weak correlation (0.3-0.4) with both self-report and therapist-rated functional ability and a weak to moderate. (0.1-0.5) correlation on the nondominant side. Conclusion: In this early RA population handgrip strength is an accurate indicator of upper limb ability. Ulnar deviation at the MCP joints shows only a weak to moderate association with upper limb functional activity and ability. Although the DASH and the GAT were strongly correlated, the DASH was a more discriminating measure than the GAT in assessing upper limb ability in this sample population.