Clinical Assessment Of Motor Function Research Articles

How to assess the recovery of muscular function following nerve injury: A view from surgeons and patients

Patient experience of motor recovery from denervation paralysis is complex and textured. The Medical Research Council (MRC) system of grading muscle peak volitional force is widely used as a single measure of assessment. However, it is becoming clear that current motor function assessments are not reflecting the patient lived experience of muscle reinnervation. Therefore, this study aimed to engage international expert nerve surgeons in a classical Delphi process to achieve a consensus of opinion on the ideal clinical assessment of motor function. This was compared with patient-reported impairments of reinnervated muscle. Invitations to engage in the Delphi process were extended to expert peripheral nerve surgeons across two international specialist meetings. For comparison, patients who attended a "Nerve Injury Community Day" were invited to complete a questionnaire on patient-reported impairments of reinnervated muscle. Questions were designed on the basis of a literature review and the clinical experiences of a specialist nerve injury unit. A combination of direct yes/no, multiple choice, open-ended and Likert questions were employed throughout the questionnaires. Eighteen surgeons engaged with the Delphi process; 18 and 11 responded to the first and second rounds respectively. Thirty-one patients responded to the questionnaire. It was found that clinicians were strongly biased towards efferent assessments of muscular function, while patients strongly favoured muscular fatigue, co-contraction and pain when monitoring their own recovery. The findings suggest that current clinical assessments of muscular function are inadequate and should embody measurements of afferent muscular function to better reflect the lived experience of muscle reinnervation.

Quantitative clinical assessment of motor function during and following LSVT-BIG\xae therapy

BackgroundLSVT-BIG® is an intensively delivered, amplitude-oriented exercise therapy reported to improve mobility in individuals with Parkinson’s disease (PD). However, questions remain surrounding the efficacy of LSVT-BIG® when compared with similar exercise therapies. Instrumented clinical tests using body-worn sensors can provide a means to objectively monitor patient progression with therapy by quantifying features of motor function, yet research exploring the feasibility of this approach has been limited to date. The aim of this study was to use accelerometer-instrumented clinical tests to quantify features of gait, balance and fine motor control in individuals with PD, in order to examine motor function during and following LSVT-BIG® therapy.MethodsTwelve individuals with PD undergoing LSVT-BIG® therapy, eight non-exercising PD controls and 14 healthy controls were recruited to participate in the study. Functional mobility was examined using features derived from accelerometry recorded during five instrumented clinical tests: 10 m walk, Timed-Up-and-Go, Sit-to-Stand, quiet stance, and finger tapping. PD subjects undergoing therapy were assessed before, each week during, and up to 13 weeks following LSVT-BIG®.ResultsAccelerometry data captured significant improvements in 10 m walk and Timed-Up-and-Go times with LSVT-BIG® (p < 0.001), accompanied by increased stride length. Temporal features of the gait cycle were significantly lower following therapy, though no change was observed with measures of asymmetry or stride variance. The total number of Sit-to-Stand transitions significantly increased with LSVT-BIG® (p < 0.001), corresponding to a significant reduction of time spent in each phase of the Sit-to-Stand cycle. No change in measures related to postural or fine motor control was observed with LSVT-BIG®. PD subjects undergoing LSVT-BIG® showed significant improvements in 10 m walk (p < 0.001) and Timed-Up-and-Go times (p = 0.004) over a four-week period when compared to non-exercising PD controls, who showed no week-to-week improvement in any task examined.ConclusionsThis study demonstrates the potential for wearable sensors to objectively quantify changes in motor function in response to therapeutic exercise interventions in PD. The observed improvements in accelerometer-derived features provide support for instrumenting gait and sit-to-stand tasks, and demonstrate a rescaling of the speed-amplitude relationship during gait in PD following LSVT-BIG®.

Effects of the Integration of Dynamic Weight Shifting Training Into Treadmill Training on Walking Function of Children with Cerebral Palsy: A Randomized Controlled Study.

The aim of the study was to determine whether applying an assistance force to the pelvis and legs during treadmill training can improve walking function in children with cerebral palsy. Twenty-three children with cerebral palsy were randomly assigned to the robotic or treadmill only group. For participants who were assigned to the robotic group, a controlled force was applied to the pelvis and legs during treadmill walking. For participants who were assigned to the treadmill only group, manual assistance was provided as needed. Each participant trained 3 times/wk for 6 wks. Outcome measures included walking speed, 6-min walking distance, and clinical assessment of motor function, which were evaluated before, after training, and 8 wks after the end of training, and were compared between two groups. Significant increases in walking speed and 6-min walking distance were observed after robotic training (P = 0.03), but no significant change was observed after treadmill training only. A greater increase in 6-min walking distance was observed after robotic training than that after treadmill only training (P = 0.01). Applying a controlled force to the pelvis and legs, for facilitating weight-shift and leg swing, respectively, during treadmill training may improve walking speed and endurance in children with cerebral palsy. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) discuss the importance of physical activity at the participation level (sports programs) for children with cerebral palsy; (2) contrast the changes in walking ability and endurance for children in GMFCS level I, II and III following sports programs; and (3) identify the impact of higher frequency of sports program attendance over time on walking ability. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Atypical within- and between-hemisphere motor network functional connections in children with developmental coordination disorder and attention-deficit/hyperactivity disorder.

Developmental coordination disorder (DCD) and attention-deficit hyperactivity disorder (ADHD) are highly comorbid neurodevelopmental disorders; however, the neural mechanisms of this comorbidity are poorly understood. Previous research has demonstrated that children with DCD and ADHD have altered brain region communication, particularly within the motor network. The structure and function of the motor network in a typically developing brain exhibits hemispheric dominance. It is plausible that functional deficits observed in children with DCD and ADHD are associated with neurodevelopmental alterations in within- and between-hemisphere motor network functional connection strength that disrupt this hemispheric dominance. We used resting-state functional magnetic resonance imaging to examine functional connections of the left and right primary and sensory motor (SM1) cortices in children with DCD, ADHD and DCD + ADHD, relative to typically developing children. Our findings revealed that children with DCD, ADHD and DCD + ADHD exhibit atypical within- and between-hemisphere functional connection strength between SM1 and regions of the basal ganglia, as well as the cerebellum. Our findings further support the assertion that development of atypical motor network connections represents common and distinct neural mechanisms underlying DCD and ADHD. In children with DCD and DCD + ADHD (but not ADHD), a significant correlation was observed between clinical assessment of motor function and the strength of functional connections between right SM1 and anterior cingulate cortex, supplementary motor area, and regions involved in visuospatial processing. This latter finding suggests that behavioral phenotypes associated with atypical motor network development differ between individuals with DCD and those with ADHD.

Clinical evidences of brain plasticity in stroke patients

Emerging findings deriving from neuromodulation and neuroradiology are providing us new insights about plas- ticity and functional reorganization of the brain after stroke, but the direct clinical assessment of motor function should still be considered an indispensable tool for the evaluation of the effects of plasticity in stroke patients. Recovery of motor function can be spontaneous or guided by training. Substantial functional recovery can occur spontaneously especially in the first month post-stroke. Instead, the guided recovery may take more time and may rely on a number of rehabilitation techniques which proved to be capable of stimulating cerebral plasticity. Even the time course of these processes is a decisive element. First, it is important to correlate the trends of plasticity after stroke, from the enhancement of earlier periods to the later stages, to the behavioral changes observed. Furthermore, it is crucial to distinguish recovery of function occurring through improvement of motor deficit from compensatory mechanisms, distinction that has also an effect on timing of recovery. Another relevant question is the maintenance over time of the improvements reached with the treatment, feature on which various clinical studies have been conducted in acute and chronic stroke patients. Further studies are needed to allow us to get a more precise definition of the potentiality of functional recovery and of the mechanisms underlying the recovery depending on its levels and timing. Understanding the mechanisms, the effects and the limits of neural plasticity may eventually help enhancing the recovery process in stroke patients, significantly improving the quality of life of these patients. Then, a greater attention towards the clinical implica- tions of the changes related to plasticity can be a crucial element to further improve the therapeutic options used in neurorehabilitation.

A Pharmacokinetic-Pharmacodynamic Model for Duodenal Levodopa Infusion

The purpose of this work was to identify and estimate a population pharmacokinetic- pharmacodynamic model for duodenal infusion of a levodopa/carbidopa gel (Duodopa) to examine pharmacological properties of this treatment. The modeling involved pooling data from 3 studies (on advanced Parkinson disease) and fixing some parameters to values found in literature. The first study involved 12 patients studied on 3 occasions each and was previously published. The second study involved 3 patients on 2 occasions. A bolus dose was given after a washout during night. Plasma samples and motor ratings (clinical assessment of motor function on a 7-point treatment response scale ranging from "very off" to "very hyperkinetic") were collected until the clinical effect returned to baseline. The third study involved 5 patients on 3 occasions receiving 5 different dose levels. Different structural models were evaluated using the nonlinear mixed-effects modeling program NONMEM VI. Population mean parameter values, and interindividual, interoccasion, and residual variabilities were estimated. Absorption of the levodopa/carbidopa gel can be adequately described with first-order absorption with bioavailability and lag time. Estimated population parameter values were a mean absorption time of 28.5 minutes, a lag time of 2.9 minutes, and a bioavailability of 88%. The pharmacodynamic model for motor ratings had the following population values: a half-life of effect delay of 21 minutes, a concentration at 50% effect of 1.55 mg/L, an Emax of 2.39 U on the treatment response scale, and a sigmoidicity of the Emax function of 11.6. For the typical unmedicated subject, it will take 51.4 minutes until the peak levodopa effect is reached after a bolus dose. This delay is, like the magnitude of the effect, highly variable in this patient group. The residual error magnitudes of 20% for levodopa concentrations and 0.92 U (SD) for motor ratings indicate that the models developed provide predictions of a relevant quality. The developed model may be a first step toward model-guided treatment individualization of duodenal infusion of levodopa.

Effects of Gender and Age on Motor Exam in Typically Developing Children

Few studies have contrasted performance of typically developing boys and girls on standardized motor assessment. In the present study, developmental status of the motor system was assessed in 144 typically developing children (72 boys, 72 girls, ages 7–14), using the Physical and Neurological Examination for Subtle Signs (PANESS, Denckla, 1985). Four summary variables were examined: (1) Gaits and Stations, (2) Overflow, (3) Dysrythmia, and (4) Timed Movements. For most variables, gender differences were not significant; however significant gender effects were observed for some subtle signs (involuntary movements), gaits and stations, and timed patterned movements. In all instances, girls showed fewer subtle signs and were faster and more proficient than boys. Significant age-related changes were observed for some subtle signs (dysrythmia and overflow), and for timed movements. In contrast, by age 7, many of the skills assessed by the PANESS have reached “adult” level in typically developing children. Motor development appears to follow a different developmental course in girls than in boys; separate gender and age norms should be used in clinical assessment of motor function in children.

2.220 Duodenal levodopa infusion for advanced Parkinson's disease: 24-month treatment outcome

involved 12 patients on 3 occasions and is described by Nyholm et al. (Clinical Neuropharmacology 2003; 26: 156−63). The second study, PEDAL, involved 3 patients on 2 occasions. A bolus dose (normal morning dose plus 50%) was given after a washout during night. Plasma samples and motor ratings (clinical assessment of motor function from video recordings on a treatment response scale between −3 and 3, where −3 represents severe parkinsonism and 3 represents severe dyskinesia) were repeatedly collected until the clinical effect was back at baseline. At this point, the usual infusion rate was started and sampling continued for another two hours. Different structural absorption models and effect models were evaluated using the value of the objective function in the NONMEM package. Population mean parameter values, standard error of estimates (SE) and if possible, interindividual/interoccasion variability (IIV/IOV) were estimated. Results: Our results indicate that Duodopa absorption can be modelled with an absorption compartment with an added bioavailability fraction and a lag time. The most successful effect model was of sigmoid Emax type with a steep Hill coefficient and an effect compartment delay. Estimated parameter values are presented in the table.

Clinical Assessment of Motor Function: A Processes Oriented Instrument Based on a Speed‐Accuracy Trade‐Off Paradigm

In this study, we developed a digitizing tablet-based instrument for the clinical assessment of human voluntary movements targeting motor processes of planning, programming and execution. The tool was used to investigate an adaptation of Fitts' reciprocal tapping task [10], comprising four conditions, each of them modulated by three indices of difficulty related to the amplitude of movement required. Temporal, spatial and sequential constraints underlying the various conditions allowed the intricate motor processes to be dissociated. Data obtained from a group of elderly healthy subjects (N = 50) were in agreement with the literature on motor control, in the temporal and spatial domains. Speed constraints generated gains in the temporal domain and costs in the spatial one, while spatial constraints generated gain in the spatial domain and costs in the temporal one; finally, sequential constraints revealed the integrative nature of the cognitive operations involved in motor production. This versatile instrument proved capable of providing quantitative, accurate and sensitive measures of the various processes sustaining voluntary movement in healthy subjects. Altogether, analyses performed in this study generated a theoretical framework and reference data which could be used in the future for the clinical assessment of patients with various movement disorders, in particular Parkinson’s disease.

Timed tests in the clinical assessment of motor function in Parkinson's disease.

The clinical evaluation section of the Core Assessment Program for Intracerebral Transplantations (CAPIT) for Parkinson's disease (PD) was developed to standardize the clinical evaluation in cell transplantation trials, but also has been used in other therapeutic trials for PD. An important part of the CAPIT protocol is the standardized timed tests of motor function. In a recent revision of CAPIT, the Core Assessment Program for Surgical Interventional Therapies in Parkinson's Disease (CAPSIT-PD), the timed tests have been modified. There are some practical considerations that need attention when timed tests are used. They should be performed under the same circumstances with the patient in a defined condition and according to the same instructions from one time to another. Also, the examiner should not assist the patient, either directly or indirectly, by cueing. In addition to quantification of motor function as an outcome measure in therapeutic trials and other clinical research, timed tests also can be used for determining dopaminergic responsiveness in differential diagnosis of parkinsonism. Our experience is that timed tests are valuable quantitative and objective measures in scientific as well as clinical assessments of PD. Practical guidelines for and examples of these areas of use are provided.

Behavioral evaluating methods in the objective clinical assessment of motor function after experimental brachial plexus reconstruction in the rat

Unfortunately, the results of brachial plexus surgery have not fulfilled expectations. Although the components of the rat brachial plexus are similar to those of the human plexus, experimental work in this field is limited. No functional test to assess experimental brachial plexus reconstruction has so far been published. We worked out a method of evaluating brachial plexus impairment in rats in the laboratory. It consists of a simple test in which a bowl of water is projected over the animal's head, eliciting grooming movements of the forepaws towards the head. This test is therefore called the ‘grooming test’. A system of scoring the animals' performance is suggested. Rats were also submitted to walking tracks analysis, but this was of limited value in assessing brachial plexus impairment.

Objective clinical assessment of motor function after experimental spinal cord injury in the rat.

A new method was developed for the clinical assessment of motor function in rats after experimental spinal cord injury. The method consists of placing the animal on an inclined plane which can be adjusted to provide a slope of varying grade, and then assessing the maximum angle of the plane at which the animal can maintain its position without falling. The method was used to quantitate motor function in normal rats and in rats subjected to myelectomy, and consistently showed major differences between the two groups. The method has many positive features: the plane is easy to construct and of low cost; and the test is rapid, non-invasive, repeatable, and consistent.