Guided Self-rehabilitation Contracts Research Articles

Exceptional improvement in chronic stroke through Guided Self-rehabilitation Contract: a case report study

A 44-year-old woman suffered a carotid dissection causing a deep and superficial right middle cerebral artery stroke in October 2013, despite undergoing thrombolysis and thrombectomy. Sixteen months later, massive left upper extremity impairment persisted. She then agreed to embark upon a guided self-rehabilitation contract (GSC). This GSC is a moral contract where the physician or therapist identifies specific muscles, particularly hypo-extensible and disabling that act as antagonists to functional activities. The physician or therapist then teaches and prescribes quantified daily high-load self-stretch postures for these muscles, alternating with repeated maximal amplitude movement exercises against their resistance. In turn, the patient commits to practicing the prescribed program and to delivering a diary of the stretch postures and alternating movement exercises performed each day. Over 4 years of GSC, the patient practiced upon prescription against a total of seven upper limb antagonists to common functional movements: shoulder extensors, shoulder internal rotators, elbow flexors, elbow pronators, wrist and finger flexors, and interossei muscles. She manually filled up her diary 99% of the days. Each day, she practiced an average of 20 min of high-load static self-stretch per muscle, alternating with about 50 maximal active efforts against the resistance of each targeted muscle's resistance. Overall, her mean static self-stretch time was 81 ± 2 (mean ± SEM) min/day, and her mean number of active maximal efforts was 285 ± 78/day, for a total daily self-rehabilitation time of over 2 h a day. Five years after her stroke, she had recovered all left upper extremity use in daily activities and resumed her previous job as a nurse's aide. She now spontaneously uses her left hand in most tasks. Functional MRI (March 2020) demonstrated bilateral primary motor and motor supplementary area activation upon left-hand exercise. Prolonged static self-stretch increased muscle extensibility (muscle plasticity) while maximal amplitude, alternating movement training reduced co-contraction in these muscles (neural plasticity). The Modified Frenchay Scale assessment was video-recorded by the clinician at each visit, allowing qualitative and quantitative evaluation of the functional capacities. The two videos of the first and last clinic visits have been uploaded and are available.

Guided Self-rehabilitation Contract vs conventional therapy in chronic peripheral facial paresis: VISAGE, a multicenter randomized controlled trial

BackgroundOne year after persistent peripheral facial paresis (PFP), prescriptions of conventional rehabilitation are often downgraded into maintenance rehabilitation or discontinued, the patient entering what is seen as a chronic stage. This therapeutic choice is not consistent with current knowledge about behavior-induced plasticity, which is available all life long and may allow intense sensorimotor rehabilitation to remain effective. This prospective, randomized, multicenter single-blind study in subjects with chronic unilateral PFP evaluates changes in facial motor function with a Guided Self-rehabilitation Contract (GSC) vs. conventional therapy alone, carried out for six months.MethodsEighty-two adult subjects with chronic unilateral PFP (> 1 year since facial nerve injury) will be included in four tertiary, maxillofacial surgery (2), otolaryngology (1) and rehabilitation (1) centers to be randomized into two rehabilitation groups. In the experimental group, the PM&R specialist will implement the GSC method, which for PFP involves intensive series of motor strengthening performed daily on three facial key muscle groups, i.e. Frontalis, Orbicularis oculi and Zygomatici. The GSC strategy involves: i) prescription of a daily self-rehabilitation program, ii) teaching of the techniques involved in the program, iii) encouragement and guidance of the patient over time, in particular by requesting a quantified diary of the work achieved to be returned by the patient at each visit. In the control group, participants will benefit from community-based conventional therapy only, according to their physician’s prescription. The primary outcome measure is the composite score of Sunnybrook Facial Grading System. Secondary outcome measures include clinical and biomechanical facial motor function quantifications (Créteil Scale and 3D facial motion analysis through the Cara system), quality of life (Facial Clinimetric Evaluation and Short-Form 12), aesthetic considerations (FACE-Q scale) and mood representations (Hospital Anxiety and Depression scale). Participants will be evaluated every three months by a blinded investigator, in addition to four phone calls (D30/D60/D120/D150) to monitor compliance and tolerance to treatment.DiscussionThis study will increase the level of knowledge on the effects of intense facial motor streng- Facial paralysisthening prescribed through a GSC in patients with chronic peripheral facial paresis.Trial registrationClinicalTrials.gov, NCT04074018. Registered 29 August 2019.Protocol versionVersion N°4.0—04/02/2021.

Guided Self-rehabilitation Contracts Combined With AbobotulinumtoxinA in Adults With Spastic Paresis.

Guided self-rehabilitation contracts (GSCs) are a diary-based rehabilitation strategy, wherein specific muscles are identified for prescription of high-load, home self-stretching techniques. We assessed the effect of GSCs combined with simultaneous upper limb (UL) and lower limb (LL) abobotulinumtoxinA injections on composite active range of motion (CXA) in adults with chronic spastic paresis. This was an international, prospective, single-arm, open-label study (ENGAGE, NCT02969356). Personalized GSCs were monitored by phone every other week, alongside 2 consecutive abobotulinumtoxinA injections (1500 U) across UL and LL, over 6 to 9 months. Primary outcomes were responder rates (CXA improvement ≥35° [UL] or ≥5° [LL]) at week 6 cycle 2. Secondary outcomes were active function (UL: Modified Frenchay Scale [MFS]; LL: 10-m barefoot maximal walking speed [WS]) and quality of life (12-item Short Form Health Survey, SF-12). Of the 153 treated participants, 136 had primary endpoint data; 72.1% (95% confidence interval [CI], 64.0-78.9) were responders. Mean (SD) CXA changes from baseline to last study visit were +49.3° (63.4) for UL and +20.1° (27.6) for LL. Mean (95% CI) changes from baseline to week 12 cycle 2 were +0.55 (0.43-0.66) in MFS, +0.12 m/s (0.09-0.15) for WS, and +4.0 (2.8-5.2) for SF-12 physical scores. In the safety population (n = 157), 49.7% of participants reported treatment-emergent adverse events (AEs); 12.1% reported 25 serious AEs. GSC combined with simultaneous UL and LL abobotulinumtoxinA injections led to improvements in CXA and function in both limbs, and quality-of-life physical scores. These results suggest the beneficial effect of combined GSC and abobotulinumtoxinA therapy in the management of spastic paresis.Video Abstract available for more insight from the authors (see the Supplementary Video, available at: http://links.lww.com/JNPT/A346).

Rehabilitation and Biomarkers of Stroke Recovery: Study Protocol for a Randomized Controlled Trial.

Background: Stroke is a leading cause of disability. Nonetheless, the care pathway for stroke rehabilitation takes partially into account the needs of chronic patients. This is due in part to the lack of evidence about the mechanisms of recovery after stroke, together with the poor knowledge of related and influencing factors. Here we report on the study protocol “Rehabilitation and Biomarkers of Stroke Recovery,” which consists of 7 work-packages and mainly aim to investigate the effects of long-term neurorehabilitation on stroke patients and to define a related profile of (clinical-biological, imaging, neurophysiological, and genetic-molecular) biomarkers of long-term recovery after stroke. The work-package 1 will represent the main part of this protocol and aims to compare the long-term effects of intensive self-rehabilitation vs. usual (rehabilitation) care for stroke.Methods: We planned to include a total of 134 adult subacute stroke patients (no more than 3 months since onset) suffering from multidomain disability as a consequence of first-ever unilateral ischemic stroke. Eligible participants will be randomly assigned to one of the following groups: intensive self-rehabilitation (based on the principles of “Guided Self-Rehabilitation Contract”) vs. usual care (routine practice). Treatment will last 1 year, and patients will be evaluated every 3 months according to their clinical presentation. The following outcomes will be considered in the main work-package: Fugl-Meyer assessment, Cognitive Oxford Screen Barthel Index, structural and functional neuroimaging, cortical excitability, and motor and somatosensory evoked potentials.Discussion: This trial will deal with the effects of an intensive self-management rehabilitation protocol and a related set of biomarkers. It will also investigate the role of training intensity on long-term recovery after stroke. In addition, it will define a set of biomarkers related to post-stroke recovery and neurorehabilitation outcome in order to detect patients with greater potential and define long-term individualized rehabilitation programs.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04323501.

Ultrasound Structural Changes in Triceps Surae After a 1-Year Daily Self-stretch Program: A Prospective Randomized Controlled Trial in Chronic Hemiparesis

Introduction. The effects of long-term stretching (>6 months) in hemiparesis are unknown. This prospective, randomized, single-blind controlled trial compared changes in architectural and clinical parameters in plantar flexors of individuals with chronic hemiparesis following a 1-year guided self-stretch program, compared with conventional rehabilitation alone. Methods. Adults with chronic stroke-induced hemiparesis (time since lesion >1 year) were randomized into 1 of 2, 1-year rehabilitation programs: conventional therapy (CONV) supplemented with the Guided Self-rehabilitation Contract (GSC) program, or CONV alone. In the GSC group, specific lower limb muscles, including plantar flexors, were identified for a diary-based treatment utilizing daily, high-load, home self-stretching. Blinded assessments included (1) ultrasonographic measurements of soleus and medial gastrocnemius (MG) fascicle length and thickness, with change in soleus fascicle length as primary outcome; (2) maximum passive muscle extensibility (XV1, Tardieu Scale); (3) 10-m maximal barefoot ambulation speed. Results. In all, 23 individuals (10 women; mean age [SD], 56 [±12] years; time since lesion, 9 [±8] years) were randomized into either the CONV (n = 11) or GSC (n = 12) group. After 1 year, all significant between-group differences favored the GSC group: soleus fascicle length, +18.1mm [9.3; 29.9]; MG fascicle length, +6.3mm [3.5; 9.1]; soleus thickness, +4.8mm [3.0; 7.7]; XV1 soleus, +4.1° [3.1; 7.2]; XV1 gastrocnemius, +7.0° [2.1; 11.9]; and ambulation speed, +0.07m/s [+0.02; +0.16]. Conclusions. In chronic hemiparesis, daily self-stretch of the soleus and gastrocnemius over 1 year using GSC combined with conventional rehabilitation increased muscle fascicle length, extensibility, and ambulation speed more than conventional rehabilitation alone.

Guided Self-rehabilitation Contract vs conventional therapy in chronic stroke-induced hemiparesis: NEURORESTORE, a multicenter randomized controlled trial

BackgroundAfter discharge from hospital following a stroke, prescriptions of community-based rehabilitation are often downgraded to “maintenance” rehabilitation or discontinued. This classic therapeutic behavior stems from persistent confusion between lesion-induced plasticity, which lasts for the first 6 months essentially, and behavior-induced plasticity, of indefinite duration, through which intense rehabilitation might remain effective. This prospective, randomized, multicenter, single-blind study in subjects with chronic stroke-induced hemiparesis evaluates changes in active function with a Guided Self-rehabilitation Contract vs conventional therapy alone, pursued for a year.MethodsOne hundred and twenty four adult subjects with chronic hemiparesis (> 1 year since first stroke) will be included in six tertiary rehabilitation centers. For each patient, two treatments will be compared over a 1-year period, preceded and followed by an observational 6-month phase of conventional rehabilitation. In the experimental group, the therapist will implement the diary-based and antagonist-targeting Guided Self-rehabilitation Contract method using two monthly home visits. The method involves: i) prescribing a daily antagonist-targeting self-rehabilitation program, ii) teaching the techniques involved in the program, iii) motivating and guiding the patient over time, by requesting a diary of the work achieved to be brought back by the patient at each visit. In the control group, participants will benefit from conventional therapy only, as per their physician’s prescription.The two co-primary outcome measures are the maximal ambulation speed barefoot over 10 m for the lower limb, and the Modified Frenchay Scale for the upper limb. Secondary outcome measures include total cost of care from the medical insurance point of view, physiological cost index in the 2-min walking test, quality of life (SF 36) and measures of the psychological impact of the two treatment modalities. Participants will be evaluated every 6 months (D1/M6/M12/M18/M24) by a blinded investigator, the experimental period being between M6 and M18. Each patient will be allowed to receive any medications deemed necessary to their attending physician, including botulinum toxin injections.DiscussionThis study will increase the level of knowledge on the effects of Guided Self-rehabilitation Contracts in patients with chronic stroke-induced hemiparesis.Trial registrationClinicalTrials.gov: NCT02202954, July 29, 2014.

Modern aspects of the pathophysiology of walking disorders and their rehabilitation in post-stroke patients

The problem of rehabilitation of post-stroke patients with motor deficit remains relevant with growing prevalence of disability and decreasing mortality, despite all measures aimed at stroke prevention and morbidity reduction. One of the most common consequences of stroke is gait impairment as a result of spastic paresis of the lower limb (decreased gait velocity, shortened step, excessive loading of intact limb etc.), which leads to significant maladaptation, increased risk of falls, decrease in quality of life. The article presents a detailed review of motor action in normal and pathologic conditions, analysis of neuronal structures involved into a movement act in healthy individuals and in stroke patients, current aspects of gait pathophysiology, characteristics of post-stroke gait (speed and asymmetry of gain, balance control impairment). A separate paragraph is devoted to gait recovery after stroke with analysis of existing and developing strategies of rehabilitation, aimed at the improvement of vertical posture, balance control and movement, condition, tone and functioning of skeletal muscles. Authors also analyze new research information on the efficacy of botulinum toxin preparations and programs of Guided Self-Rehabilitation Contracts (GSC), present the results of clinical trials demonstrating the efficacy of combination of these two methods.

Projects of distant rehabilitation in neurology. The website of in-home rehabilitation in the territory of Krasnoyarsk Region

At the present time, distant rehabilitation is a relevant direction in restorative medicine. The article considers existing projects in remote rehabilitation, including a self-rehabilitation method developed by academician K.V. Lyadov, the Guided Self-Rehabilitation Contracts system (GSC) etc. The authors present an original project of a remote rehabilitation website 'NeuroHouse' designed for the restoration of balance and gait functions, wrist fine motor skills and speech, spasticity management in patients with neurological diseases. The project combines proprietary rehabilitation methods and classical exercise therapy. This website will make it possible to implement the third ambulatory stage of medical rehabilitation at home.

Simultaneous upper and lower limb abobotulinumtoxinA injections and guided self-rehabilitation contracts in spastic hemiparesis: Baseline data from the engage study

Guided self-rehabilitation contracts (GSC) are a diary-based and antagonist-targeting strategy, in which therapists identify muscles against which to prescribe patients daily, home-based self-stretching and active training programmes. Patients record a diary of exercises performed between visits. The ENGAGE study assesses effects of abobotulinumtoxinA (aboBoNT-A) on voluntary movements, following co-injection of upper (UL) and lower limbs (LL), alongside GSC in patients with chronic hemiparesis resulting from acquired brain injury. An interim analysis of ENGAGE baseline data is presented here. International phase 3b/4, prospective, single-arm, open-label study ( NCT02969356 ). Patients, stratified with UL or LL as primary treatment target (PTT), receive two consecutive injections of aboBoNT-A 1500 U, together with personalised GSC. Primary efficacy endpoint is the proportion of responders (improvement in composite active range of motion [CX A ] of ≥ 35° or 5° in UL or LL, respectively) in the PTT at Cycle 2 Week 6. Baseline data were analysed for 157 patients (data cut-off December 2017). Baseline characteristics are presented in Table 1 ; 91% of patients had experienced stroke; mean time since brain injury was 79.5 months. PTT split was 52% versus 48% for UL and LL, respectively. Twenty-seven percent of patients were naïve to botulinum toxin (BoNT) for both UL and LL spasticity (34% UL-naïve; 58% LL-naïve), and 74% were naïve to GSC. Baseline BoNT doses administered are shown in Table 2 . Degree of CX A in UL or LL at baseline are presented in Table 3 . The ENGAGE study will provide insights into the safety and efficacy of the combination of GSC with aboBoNT-A, simultaneously injected into UL and LL, in adults with spastic hemiparesis.

Effect on Voluntary Movements of Simultaneous Upper and Lower Limb AbobotulinumtoxinA Injections in Conjunction with Guided Self-Rehabilitation Contracts in Adults with Spastic Hemiparesis: Methodology of the ENGAGE Study (P5.013)

Effect on Voluntary Movements of Simultaneous Upper and Lower Limb AbobotulinumtoxinA Injections in Conjunction with Guided Self-Rehabilitation Contracts in Adults with Spastic Hemiparesis: Methodology of the ENGAGE Study (P5.013)

Effect on Passive Range of Motion and Functional Correlates After a Long-Term Lower Limb Self-Stretch Program in Patients With Chronic Spastic Paresis

BackgroundIn current health care systems, long-duration stretching, performed daily, cannot be obtained through prescriptions of physical therapy. In addition, the short-term efficacy of the various stretching techniques is disputed, and their long-term effects remain undocumented. ObjectiveTo evaluate changes in extensibility in 6 lower limb muscles and in ambulation speed after a ≥1-year self-stretch program, the Guided Self-rehabilitation Contract (GSC), in individuals with chronic spastic paresis. DesignRetrospective study. SettingNeurorehabilitation clinic. ParticipantsPatients diagnosed with hemiparesis or paraparesis at least 1 year before the initiation of a GSC and who were then involved in the GSC program for at least 1 year. InterventionsFor each patient, specific muscles were identified for intervention among the following: gluteus maximus, hamstrings, vastus, rectus femoris, soleus, and gastrocnemius. Prescriptions and training for a daily, high-load, prolonged, home self-stretching program were primarily based on the baseline coefficient of shortening, defined as CSH = [(XN –XV1)/XN] (XV1 = PROM, passive range of motion; XN = normally expected amplitude). Main Outcome MeasurementsSix assessments were performed per year, measuring the Tardieu XV1 or maximal slow stretch range of motion angle (PROM), CSH, 10-m ambulation speed, and its functional ambulation category (Perry’s classification: household, limited, or full). Changes from baseline in self-stretched and nonself-stretched muscles were compared, with meaningful XV1 change defined as ΔXV1 >5° for plantar flexors and >10° for proximal muscles. Correlation between the composite XV1 (mean PROM for the 6 muscles) and ambulation speed also was evaluated. ResultsTwenty-seven GSC participants were identified (14 women, mean age 44 years, range 29-59): 18 with hemiparesis and 9 with paraparesis. After 1 year, 47% of self-stretched muscles showed meaningful change in PROM (ΔXV1) versus 14% in nonself-stretched muscles (P < .0001, χ2). ΔCSH was –31% (95% confidence interval [95% CI] –41.5 to –15.2) in self-stretched versus –7% (95% CI –11.9 to –2.1) in nonself-stretched muscles (P < .0001, t-test). Ambulation speed increased by 41% (P < .0001) from 0.81 m/s (95% CI 0.67-0.95) to 1.15 m/s (95% CI 1.01-1.29). Eight of the 12 patients (67%) who were in limited or household categories at baseline moved to a higher functional ambulation category. There was a trend for a correlation between composite XV1 and ambulation speed (r = 0.44, P = .09) in hemiparetic patients. ConclusionTherapists should consider prescribing and monitoring a long-term lower limb self-stretch program using GSC, as this may increase muscle extensibility in adult-onset chronic paresis. Level of EvidenceIII

Beliefs of rehabilitation professionals towards guided self-rehabilitation contracts for post stroke hemiparesis

PurposeTo investigate the beliefs of physiotherapy students (ST), professionals (PT) and physicians (MD) about engaging patients with post-stroke hemiparesis into Guided Self-Rehabilitation Contracts (GSC), to increase their exercise intensity and responsibility level.MethodA survey examining beliefs about post-stroke rehabilitation was completed by first (n = 95), second (n = 105), and third (n = 48) year STs; PTs (n = 129) and MDs (n = 65) in France.ResultsThe belief about whether a patient may exercise alone varied between the professional groups with more STs and MDs finding it acceptable: 62% of PTs vs. 74% of STs (p = 0.005) and 79% of MDs (p = 0.02). For 93% of therapists (STs and PTs together), the caregiver may take part in physical therapy sessions. The appropriate weekly duration of exercises in chronic hemiparesis should be over 5 h for 19% of PTs, 37% of STs, and 51% of MDs (MDs vs. PTs, p < 0.005). After stroke, functional progress through rehabilitation is possible all lifelong for 11% of STs, 19% of PTs (p < 0.05, STs vs. PTs), and 29% of MDs (MD vs. PT, NS).ConclusionsThe strategy of asking patients to perform exercises alone, in the practice or at home, is still not accepted by a large proportion of physical therapy professionals as compared with students or with physicians. Most therapists still see a <5-h weekly duration of exercise as sufficient after stroke. Few therapists are ready to utilize the persistence of behavior-induced brain plasticity regardless of age or delay after the lesion.

Guided self-rehabilitation and ambulation capacities in spastic paresis: Stretching postures vs. neuronal training vs. combined program. A randomized study

In chronic spastic paresis, intensity in rehabilitation programs leads to possible improvements in patients walking capacities. However, the implementation of intensive rehabilitation is limited by time and financial constraints of conventional physiotherapy programs. Thus, the use Guided Self-Rehabilitation Contract (GSC) programs makes it possible to overcome these disadvantages. GSC have proven their impact on functional activities using two rehabilitation technics: prolonged static stretch postures and motor training with fast alternating movements of maximal amplitude. The objective of this study was to compare the effects of 3 programs using GSC during 2 months on ambulation capacities in chronic spastic paresis: a program with prolonged static stretch postures, a motor training program with fast alternating movements of maximal amplitude and a combined program with prolonged static stretch postures and fast alternating movements of maximal amplitude. Eleven patients with spastic hemiparesis were included in this prospective randomized simple-blinded study from January to June 2016. They had no botulinum toxin injection in the last 2 months. Each patient followed a 60-minutes working per day program using GSC for 2 months targeting the antagonists of active ankle dorsiflexion, knee flexion and hip flexion in the stretching group, the training group or the combined group. The primary outcome was the comparison of the maximal speed barefoot in the 10-meter ambulation test at D-15 and D60. The median daily working duration was 39 ± 18 minutes. No difference was found between groups on the maximal speed barefoot on the 10-meter ambulation test after 2 months of programs using GSC. The whole population increased its maximal speed barefoot on the 10-meter ambulation test (from 0.89 ± 0.38 m/s to 0.99 ± 0.43 m/s; P = 0.006, Wilcoxon). The combined group and the training group increased their maximal speed on the 10-meter ambulation test barefoot by 16%, contrary to the stretching group which increased its maximal speed only by 5%. No difference between the 3 programs was found although tendencies seems to be in favor of the combined group. A larger prospective study should be planned in order to confirm these tendencies.

Structural changes in the muscle-tendon complex of triceps surae after a daily self-stretch program in chronic hemiparesis: A one-year randomized controlled trial

The effects of long-term (> 6 months) stretching in spastic paresis are unknown. The objective of this study was to compare the architectural and clinical changes in plantar flexors in patients with chronic hemiparesis following a one-year daily self-stretch program vs. standard rehabilitation. Twenty-three patients with chronic hemiparesis (8 W; mean age, 56 [12]; time since lesion 9 [8]) participated in a one-year randomized controlled trial involving either conventional therapy (CONV) or a daily self-stretch program within a Guided Self-rehabilitation Contract (GSC). Assessments involved: (i) soleus and medial gastrocnemius (MG) fascicle length, pennation angle, thickness, tendon length, measured by ultrasonography; (ii) XV1, angle of arrest at slow stretch in soleus (XV1SOL), gastro-soleus complex (XV1GAS), gluteus maximus (XV1GM) and rectus femoris (XV1RF); (iii) 10-meter maximal ambulation speed. Correlations (Pearson's) between architectural parameters and XV1 were also explored. After one year, soleus fascicle length increased by +16.6 mm (CI95 [+10.3; +22.9]; +42%), in the GSC group vs. −0.1 mm (CI95 [−7.3; +7.1]; −3.7%), in the CONV group ( P = 0.005, Rank-Ancova), MG fascicle length increased by +5.2 mm (CI95 [+2.75; +7.65]; +13%), in the GSC group vs. +1.2 mm (CI95 [−2.0; +4.4]; +7%), in the CONV group ( P = 0.01), soleus thickness increased by +4.3 mm (CI95 [+2.7; +5.9]; +33%), vs. −0.3 mm (CI95 [−2.4; +1.8]; −0.8%), in the CONV group ( P = 0.005). Changes in XV1 involved XV1SOL, +2.4° (CI95 [+0.9; +4.0]; +2.4%), in the GSC group vs. +0.1° (CI95 [−2.7; +2.8]; +0.1%), in the CONV group ( P = 6.9 E-05); XV1GAS, +7.4° (CI95[+5.0; +9.8]; +8%) vs. +1.5° (CI95 [−3.3; +6.3]; +1.5%; P = 0.003); XV1GM, +5.3° (CI95[+2.7; + 7.9]; 4.2%) vs. +1.5° (CI95[+0.1; +5.4]; +1.2%; P = 0.025); XV1RF, +10.5° (CI95 [+5.8; + 16.4]; +3.4%) vs. +1.5° (CI95 [−3.75; +6.65]; +1.9%; P = 0.08). Walking speed increased by +0.08 m/s (CI95 [+0.04; +0.12]; +14%, P = 0.006, t -test) in the GSC group vs. +0.04 m/s (CI95[0.0; +0.08]; +5%, NS) in the CONV group. At baseline, XV1SOL correlated negatively with soleus tendon length ( R = −0.74, P = 0.0003) and positively with muscle thickness ( R = 0.68, P = 0.015). In patients with chronic hemiparesis, a daily self-stretch program of soleus and medial gastrocnemius through Guided Self-rehabilitation Contract over one year increased muscle fascicle length and thickness more than conventional rehabilitation.

Treatment of hypermetric tremors using motor strengthening combined with muscle weakening with botulinum toxin

Essential tremor and other cerebellar tremors are characterized by iterative hypermetria, which causes limb oscillations triggered by the slightest voluntary muscle activity. Classically, these tremors are treated with synaptic depressors (e.g. propranolol). However, questions are raised whether such systemic depressors may not actually worsen tremors in the long-term. We combined botulinum toxin injections and motor strengthening programs directed to the muscles involved in the tremor, with gradual systemic synaptic depressor withdrawal. In this retrospective study, inclusion criteria were: hypermetric upper limb tremor followed for ≥ 1 year with handwriting speed, maximal frequency of small alternating movements, and 30-s and five-hand-and-mouth volumetric tests (90-mm cup) performed at each clinic visit. Patients were treated with motor strengthening program (guided self-rehabilitation contract) associated with repeated botulinum toxin injections in the muscle groups responsible for the tremor. Twelve patients were included. The level of water remaining in the cup on the 30-s volumetric test improved from 34.1 mm to 47.0 mm ( P = 0.035, Wilcoxon) on the more affected side and from 45.4 to 67.3 mm ( P = 0.02) on the less affected side, with similar results on the five-hand-and-mouth volumetric test improved. Other changes included +0.6 mm/s ( P = 0.22) in handwriting speed and +0.2 Hz ( P = 0.8) on the more affected side and +2.6 Hz ( P = 0.21) on the less affected side in the frequency of small alternating movements. In cases of hypermetric tremors, volumetric tests improved after one year of treatment combining motor strengthening and botulinum toxin injections in the muscles involved with systemic depressor withdrawal.

Poster 62: Effect on Voluntary Movements of Simultaneous Upper and Lower Limb AbobotulinumtoxinA Injections in Conjunction with Guided Self-Rehabilitation Contracts in Adults with Spastic Hemiparesis: Methodology of the ENGAGE Study

PM&RVolume 9, Issue 9S1 p. S157-S157 Neurological Rehabilitation Poster Hall: Original Research Poster 62: Effect on Voluntary Movements of Simultaneous Upper and Lower Limb AbobotulinumtoxinA Injections in Conjunction with Guided Self-Rehabilitation Contracts in Adults with Spastic Hemiparesis: Methodology of the ENGAGE Study Jean-Michel Gracies MD, Jean-Michel Gracies MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorGerard E. Francisco MD, Gerard E. Francisco MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorRobert Jech MD, Robert Jech MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorFrancois Constant Boyer MD, Francois Constant Boyer MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorPascal Maisonobe MD, Pascal Maisonobe MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorJovita Balcaitiene MD, Jovita Balcaitiene MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this author Jean-Michel Gracies MD, Jean-Michel Gracies MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorGerard E. Francisco MD, Gerard E. Francisco MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorRobert Jech MD, Robert Jech MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorFrancois Constant Boyer MD, Francois Constant Boyer MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorPascal Maisonobe MD, Pascal Maisonobe MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this authorJovita Balcaitiene MD, Jovita Balcaitiene MD EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, Créteil, FranceSearch for more papers by this author First published: 19 September 2017 https://doi.org/10.1016/j.pmrj.2017.08.019Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume9, Issue9S12017 AAPM&R Annual Assembly AbstractsSeptember 2017Pages S157-S157 RelatedInformation

Muscle lengthening and structural changes in the muscle-tendon complex of triceps surae after 1 year of rehabilitation including a daily self-stretch program in patients with chronic hemiparesis

To explore changes in muscle architectural parameters of the muscle-tendon unit of soleus and medial gastrocnemius (GM) in patients with chronic hemiparesis, after 1 year of rehabilitation. In this prospective study, 20 chronic hemiparetic patients (8 W, mean age: 56 [12], time since lesion 9 [8]) were evaluated. Muscle architectural parameters including muscle fascicle length, pennation angle, thickness, tendon and muscle belly lengths were evaluated in vivo using ultrasonography in passive condition (verified by electromyographic recording) in a seated patient with ankle, knee and hip on the paretic side at 90°. Following the biomechanical analysis, each patient benefited from the Five Step Assessment (FSA), involving the measure of XV1, angle of arrest at slow and strong stretch, which estimates soft tissue extensibility around each muscle. Four muscles of interest in the lower limb were selected for this measure: soleus (XV1Sol), medial gastro-soleus complex (XV1GSC), gluteus maximus (XV1GM) and rectus femoris (XV1RF). Biomechanical and clinical analyses were performed at the beginning and after 1 year of treatment. Two treatments were implemented: – conventional rehabilitation (50%); – guided Self-rehabilitation contract (GSC, 50%). Patients in the GSC group were prescribed a daily self-stretch program with static (> 10 min/muscle/day) and eccentric stretch. Changes in architectural parameters and clinical muscle extensibility of overall patients before and after 1 year of rehabilitation were analyzed (Student's). After 1 year, muscle fascicle length and thickness increased respectively by 6.1 mm (14.2%, P = 0.05), 1.8 mm (13.6%, P = 0.06) in soleus, and by 2.9 mm (9.1%, P = 0.04) and 1.7 mm (13.2%, P = 0.03) in MG. Muscle belly length of MG increased by 2.9 cm (17%, P = 0.0001) and its tendon length decreased by 0.82 cm (5%, P = 0.04). XV1GSC increased by 4.8° (3.3%, P = 0.07), XV1GM by 4.1° (3.3%, P = 0.0004) and XV1RF by 7.2° (6%, P = 0.02). Stretch of soleus and medial gastrocnemius practiced over the long term in patients with spastic hemiparesis allowed structural changes, increasing muscle fascicle length and thickness. Muscle belly length of medial gastrocnemius also increased significantly while its tendon length decreased, suggesting that the tendon may adapt its length to the muscle length changes.

Daily static and eccentric self-stretching program and changes in muscle functional length in chronic spastic paresis after one year of Guided Self-rehabilitation Contract's practice

To evaluate the impact of a daily self-stretching program within a Guided Self-rehabilitation Contract (GSC), on functional muscle length in patients with chronic spastic paresis. Retrospective chart review of 16 chronic paretic patients (7 W, age 40 ± 8 years, time since lesion 57 ± 35 months) who consecutively participated to a Guided Self-rehabilitation Contract for at least one year (2 years follow-up for 10 of them). By this contract, patients were committed to clinicians to achieve every day a self-stretching program based on self-stretching postures (> 10 mn/muscle/day) and excentric stretching exercises on some selected muscles (“self-stretched” muscles). Each program was specific for each patient. Functional muscle length X V1 (angle of arrest after slow and strong stretch) measured by the clinician at every visit on 5 key muscles of the lower limb (soleus, gastrocnemius, hamstrings, vastus, rectus femoris), they have been selected or not for the self-stretching program, was the main outcome measure. Coefficient of shortening (CS) was calculated CR = (X N –X V1 )/X N (X N , normal passive amplitude). After one and two years, muscles has been considered as responders if, from baseline, ΔX V1 > 10° for hamstrings, vastus and rectus femoris, and > 5° for soleus and gastrocnemius. In retrospect, at baseline, CS for the non-stretched muscles group was 0.12 ± 0.03 (mean ± SD) vs 0.20 ± 0.02 in the self-stretched muscles group ( P = 0,028, t test). The percent of responders in the self-stretched muscles group was significantly higher than in the non-stretched muscles group after one and two years of GSC (42% vs 20%, P = 0.025; 50% vs 20%, P = 0.035 respectively, Chi 2 ). After one year, the CS of the self-stretched muscles group decreased about 18%, vs 5% for the non-stretched muscles group ( P = 0.028, Mann-Whitney). Regarding individual muscles data, raw functional lengthening after two years of daily self-stretched ( n = 10) were: hamstrings, +9 ± 6; vastus, +6 ± 2; rectus femoris, +13 ± 7; soleus, +2 ± 2; gastrocnemius, +3 ± 1. A customized program of self-stretching daily practiced by chronic paretic patients for at least one year within a Guided Self-rehabilitation Contract might allow a significant functional muscle lengthening. These results need to be confirmed by a prospective controlled study.

Comparative shortening of different muscles in patients with chronic hemiparesis treated in guided self-rehabilitation contracts

Muscle contracture is one of the main factors of motor impairment in spastic paresis, and particularly in hemiparesis. We aimed to quantify the degree of contracture in 8 key muscles at a chronic stage after the lesion. Four independent raters assessed 18 adults with chronic hemiparesis (age: 50 ± 14, mean ± SD; time since lesion 5.3 ± 2.4 years) treated with guided self-rehabilitation contracts (GSC) [1] , using the 5-step clinical assessment [2] previously described, of which step 2 evaluates passive range of motion (angle of arrest at slow speed, X V1 ) and step 3 measures the angle of catch at fast speed (X V3 ). Data from the 4 investigators were averaged. Coefficients of shortening (C SH = (X N − X V1 )/X N ; X N , normal expected amplitude) and of spasticity (C SP = (X V1 − X V3 )/X V1 ) were derived. Muscles assessed were shoulder extensors (SE), elbow flexors (EF), wrist flexors (WF), finger flexors (FF), gluteus maximus (GM), rectus femoris (RF), soleus (SO) and gastrocnemius muscles (GM). Mean values were: SE, C SH : 0.21 ± 0.03; C SP : 0.25 ± 0.03; EF, C SH : 0.04 ± 0.02; C SP : 0.27 ± 0.04; WF, C SH : 0.07 ± 0.02; C SP : 0.24 ± 0.04; FF, C SH : 0.16 ± 0.04; C SP : 0.32 ± 0.04; GM, C SH : 0.16 ± 0.03; C SP : 0.13 ± 0.02; RF, C SH : 0.09 ± 0.01; C SP : 0.26 ± 0.03; SO, C SH : 0.15 ± 0.02; C SP : 0.10 ± 0.01; GM, C SH : 0.21 ± 0.01; C SP : 0.12 ± 0.01. There was a suggestion of negative correlation between C SH and C SP (Pearson's r = −0.37, NS). In chronic hemiparesis, plantar flexors and shoulder extensors are the most shortened muscles, followed by gluteus maximus and finger flexors. This might represent an incentive to promote more aggressive posturing in the acute stages to maintain length of these important muscle groups.

Degree of muscle shortening in chronic hemiparesis in patients not treated with guided self-rehabilitation contracts (GSC)

Antagonist muscle resistance, including due to muscle contracture, is a fundamental factor of motor impairment in spastic paresis. We aimed to quantify the degree of shortening in the main muscles involved in chronic hemiparesis (>1 year post-lesion), in patients following a conventional system of rehabilitation. From their first clinic visit in the neurorehabilitation unit of the PM&R department we retrospectively collected the assessments of passive range of motion (X V1 ) – based on the 5-step clinical assessment, including the Tardieu Scale – against 8 key antagonists in the lower limb ( n = 19 patients with chronic hemiparesis, age: 48 ± 13, mean ± SD; time since lesion 3.7 ± 3.8 years) and 13 antagonists in the upper limb ( n = 13 patients, age: 39 ± 13, mean ± SD; time since lesion 5.2 ± 3.9 years), then derived coefficients of shortening (C SH ) by referring them to the normal expected amplitude (X N ), C SH = (X N -X V1 )/X N . The higher coefficients of shortening were: vertical adductors (latissimus dorsi – pectoralis major – teres major), 36 ± 3%; shoulder extensors with flexed elbow (long head of triceps; latissimus dorsi) 33 ± 4%; horizontal adductors (pectoralis major), 23 ± 1%; gastrocnemius, 20 ± 1%; soleus, 15 ± 2%; gluteus maximus, 16 ± 3%; rectus femoris, 12 ± 1% and pronator teres, 12 ± 4%. Shoulder extensors, plantar flexors and gluteus maximus in patients untreated with self-stretching postures have undergone major muscle shortening in chronic hemiparesis. A future study could assess the effectiveness of stretching postures taught and applied from the early phase of stroke on shortening of these muscles.