The use of visual and proprioceptive feedback is a key property of motor rehabilitation techniques. This feedback can be used alone, for example, for vision in mirror or video therapy, for proprioception in focal tendon vibration therapy, or in combination, for example, in robot-assisted training. This Electroencephalographic (EEG) study in healthy subjects explored the distinct neurophysiological impact of adding visual (video therapy), proprioceptive (focal tendinous vibration), or combined feedback (video therapy and focal tendinous vibration) to a motor imagery task. Sixteen healthy volunteers performed 20 mental imagery (MI) tasks involving right wrist extension and flexion under four conditions: MI alone (IA), MI + video feedback observation (IO), MI + vibratory feedback (IV), and MI + observation + vibratory feedback (IOV). Brain activity was monitored with EEG, and time-frequency neurophysiological markers of movement were computed. The emotions of the patients were also measured during the task. In the alpha band, we observed bilateral ERD in the visual feedback conditions (IO, IOV). In the beta band, the ERD was bilateral in the IA, IV and IOV but more lateralized in the IV and IOV. After movement, we observed strong ERS in the IO and IOV but not in the IA or IV. Embodiment was stronger in conditions with vibratory feedback (IOV > IV > IA and IO) Conditions with visual feedback (IO, IOV) recruit the mirror neurons system (alpha ERD) and provide more accurate feedback of the task than IA and IV, which triggers motor validation pathways (beta rebound analysis). Vibratory feedback enhances the recruitment of the left sensorimotor areas, with a synergistic effect in the IOV (beta ERD analysis), thus maximizing embodiment. Visual and vibratory feedback recruits the sensorimotor cortex during motor imagery in different ways and can be combined to maximize the benefits of both techniques https://clinicaltrials.gov/study/NCT04449328 .

A 49-year-old male experienced right traumatic brachial plexus C5-C7 avulsion in a motorcycle accident. He underwent unsuccessful neurotization surgery and was chronically suffering from traumatic brachial plexus (TBP) avulsion for 4 years. His clinical examination revealed residual severe neuropathic chronic pain with tingling sensations, numbness, distal itching, dorsal anaesthesia, palmar hypoesthesia, and recurrent painful electric shocks even with daily medication intake. After several therapeutic failures, sequential therapy comprising 12 sessions of anodal transcranial direct current stimulation and video-feedback observation therapy was proposed. The patient experienced significant pain relief after the protocol, with sustained benefits at follow-up. Only a few studies have reported such sequential strategies, and the results appear to be promising. Although TBP avulsion is a relatively rare condition, it mostly affects young adults whose pain relief is a major challenge to their quality of life.

Background Disability is experienced by approximately 1.3 billion individuals worldwide. Therefore, people with disabilities (PWD) are part of every physician's patient base, regardless of specialty. Specific educational programs are needed, as medical students and physicians still report discomfort in taking histories, performing clinical examinations and making differential diagnoses when dealing with PWD. Objective We hypothesized that participation in a one-week disability awareness training, including theoretical sessions, practical workshops with PWD, and 3-day immersive training courses, would significantly improve the quantitative and qualitative outcomes of medical students toward PWD. Methods We conducted a monocentric prospective mixed-methods study targeting 3rd year medical students, using quantitative measurements through repeated synchronous surveys, evaluating disability attitudes in health care (DAHC) scores and performed qualitative explorations through individual semidirected interviews, evaluating students’ feelings and attitudes toward PWD. Results A total of 218 students (mean age: 21.1 ± 1.4 years) were included in the study. While 60 % of the participants reported no prior working experience with PWD, there was a significant improvement in paired-DAHC scores 3 months after the training (+1.32, p = 0.003). Improvements were predominantly observed in comfort levels during interaction and in discriminatory attitudes. This practical experience was positively reported in the semidirected interviews, in which a facilitated transition from unfamiliarity to informed empathy and knowledge was reported. Conclusions The implementation of disability awareness trainings in compulsory medical curricula should be prioritized to improve future physician's skills and attitudes when caring for PWD.

PURPOSE:Although most patients recover well from COVID-19 infection, this may not be the case of those who experienced severe dysfunction after being admitted to intensive care unit (ICU). This study aimed to assess the recovery of patients who experienced severe multiple dysfunctions after being admitted to ICU for COVID-19 infection. METHODS:Forty-seven patients hospitalized and mechanically ventilated in ICU for SARS-CoV-2 infection underwent evaluations at 4 to 8 wk (T1) and 6 months (T2) post-ICU discharge. Evaluations included questionnaires, lung function tests, incremental cardiopulmonary exercise testing, and neuromuscular function tests. RESULTS:From T1 to T2, the percentage of patients classified as fatigued decreased from 56% to 21% whereas forced vital capacity and the forced expiratory volume in 1 s increased by 13% and 8% ( P < 0.05) to reach 93% and 95% of predicted values at T2, respectively. Peak work rate also increased from 97 to 135 W (+35 ± 32%, P < 0.001). Likewise, V̇O 2peak increased from 18.3 to 21.6 mL·min -1 ·kg -1 (+18 ± 27%, P < 0.001) to reach 72% of predicted values. Maximal strength and the number of contractions during the fatigability test increased between T1 and T2 by 41% and 39%, respectively (both P < 0.001). CONCLUSIONS:Six months of recovery improved patients' physical function and reduced fatigue.

Objective: To demonstrate the feasibility and efficacy of a new video-observation training method (intensive visual simulation) to improve upper limb function. Design: Small sample, randomized, evaluator-blind, monocentric study. Patients: Seventeen early subacute ischaemic stroke patients with complete hemiplegia were randomly assigned to the therapeutic group (n = 8) or control group (CG, n = 9). Methods: Thirty sessions of intensive visual simulation combined with corrected visual feedback (therapeutic group) or uncorrected visual feedback (control group) were performed over 6 weeks on top of a standard rehabilitation programme. Main outcome measure: 400-point hand assessment test (400p-HA). Secondary outcome measures: Box and Blocks (B&B), Purdue Pegboard test, Minnesota. Results: The 400p-HA test improved significantly from T0 to 6 months for both groups, with a significant difference between groups at 3 months (MW-UT p = 0.046) and 4 months (MW-UT p = 0.046) in favour of the therapeutic group. One-phase exponential modelling of 400p-HA showed a greater plateau for the therapeutic group (F test p = 0.0021). There was also faster recovery of the ability to perform the B&B tests for the therapeutic group (log-rank test p = 0.03). Conclusion: This study demonstrated the feasibility and potential efficacy of an intensive visual simulation training programme to improve upper limb function in subacute stroke patients. A larger study is needed to confirm these results.

Acquired deforming hypertonia (ADH) affects the daily care of numerous nursing home residents. The aim of this study was to analyze the practice, aims, and effectiveness of botulinum toxin injections (BTxis) in the treatment of older patients with contractures, an indication for which BTxis are still underused. Data were extracted retrospectively from medical records regarding population, contractures, and injections. A prospective analysis was conducted to evaluate treatment goals set by goal attainment scaling (GAS) at T0 and at T1, to evaluate the therapeutic effects. We also recorded the occurrence of side effects, using a telephone questionnaire. This study included 41 patients older than 70 years who had received one or more BTxis for the first time between January 2018 and December 2021. Most of the older people we included lived in an institution (66%), manifested severe dependence, and presented significant morbi-mortality (37% of the patients died in the year after the last injection). The main objectives of these injections were purely comfort, without any functional goals. The GAS scores suggested effectiveness for comfort GAS scores. No complications were recorded. This study highlights the BTxis potential to address the needs of a larger number of older patients with ADH.

Percutaneous needle tenotomies constitute a promising approach that enables direct access to tendons through minimally invasive interventions. They can be performed rapidly without need for large incisions or general anaesthesia. However, the reported procedures are heterogeneous and currently conducted without guidelines. We aimed to determine the indications for percutaneous needle tenotomies described in the current literature. Our secondary aim was to identify the different procedures reported, as well as their efficacy and their safety. A systematic review following PRISMA guidelines was conducted to identify original articles that mentioned percutaneous needle tenotomy in humans and reported its application, description, effectiveness or adverse events. Non-percutaneous tendinous surgical procedures and ineligible designs were excluded. The Downs and Black checklist was used to assess the risk of bias. A total of 540 studies were identified from the MEDLINE, Embase, Cochrane Library, and PEDro databases. Fourteen clinical studies met the inclusion criteria and were found to have an acceptable quality (674 individuals, 1664 tenotomies). Our results indicated a wide variety of indications for percutaneous needle tenotomies in children and in adults. We highlighted 24 tendons as eligible targets in the upper and lower limbs. Tenotomies were performed with either 16- or 18-Ga needles, lasted from 1 to 30 min, and were performed using various procedures. Their efficacy was mainly assessed through clinical outcomes highlighting tendon discontinuity on palpation after the procedure. Passive range-of-motion gains after tenotomy were reported for both upper and lower limbs with an estimated 5 % complication rate. This is the first review to systematically synthesize all the available evidence on the indications, procedures, efficacy and safety of percutaneous tenotomies exclusively performed with needles. Current evidence suggests that procedures are safe and effective for treating various deformities. CRD42022350571

Purpose: Approximately 30% of people infected with COVID-19 require hospitalization, and 20% of them are admitted to an intensive care unit (ICU). Most of these patients experience symptoms of fatigue weeks post-ICU, so understanding the factors associated with fatigue in this population is crucial. Methods: Fifty-nine patients (38-78 yr) hospitalized in ICU for COVID-19 infection for 32 (6-80) d, including 23 (3-57) d of mechanical ventilation, visited the laboratory on two separate occasions. The first visit occurred 52 +/- 15 d after discharge and was dedicated to questionnaires, blood sampling, and cardiopulmonary exercise testing, whereas measurements of the knee extensors neuromuscular function and performance fatigability were performed in the second visit 7 +/- 2 d later. Results: Using the FACIT-F questionnaire, 56% of patients were classified as fatigued. Fatigued patients had worse lung function score than non-fatigued (i.e., 2.9 +/- 0.8 L vs 3.6 +/- 0.8 L; 2.4 +/- 0.7 L vs 3.0 +/- 0.7 L for forced vital capacity and forced expiratory volume in 1 s, respectively), and forced vital capacity was identified as a predictor of being fatigued. Maximal voluntary activation was lower in fatigued patients than non-fatigued patients (82% +/- 14% vs 91% +/- 3%) and was the only neuromuscular variable that discriminated between fatigued and non-fatigued patients. Patient-reported outcomes also showed differences between fatigued and non-fatigued patients for sleep, physical activity, depression, and quality of life (P < 0.05). Conclusions: COVID-19 survivors showed altered respiratory function 4 to 8 wk after discharge, which was further deteriorated in fatigued patients. Fatigue was also associated with lower voluntary activation and patient-reported impairments (i.e., sleep satisfaction, quality of life, or depressive state). The present study reinforces the importance of exercise intervention and rehabilitation to counteract cardiorespiratory and neuromuscular impairments of COVID-19 patients admitted in ICU, especially individuals experiencing fatigue.

BACKGROUND:Video-feedback observational therapy (VOT) is an intensive rehabilitation technique based on movement repetition and visualization that has shown benefits for motor rehabilitation of the upper and lower limbs. Despite an increase in recent literature on the neurophysiological effects of VOT in the upper limb, there is little knowledge about the cortical effects of visual feedback therapies when applied to the lower limbs. The aim of our study was to better understand the neurophysiological effects of VOT. Thus, we identified and compared the EEG biomarkers of healthy subjects undergoing lower limb VOT during three tasks: passive observation, observation and motor imagery, observation and motor execution. METHODS:We recruited 38 healthy volunteers and monitored their EEG activity while they performed a right ankle dorsiflexion task in the VOT. Three graded motor tasks associated with action observation were tested: action observation alone (O), motor imagery with action observation (OI), and motor execution synchronized with action observation (OM). The alpha and beta event-related desynchronization (ERD) and event-related synchronization (or beta rebound, ERS) rhythms were used as biomarkers of cortical activation and compared between conditions with a permutation test. Changes in connectivity during the task were computed with phase locking value (PLV). RESULTS:During the task, in the alpha band, the ERD was comparable between O and OI activities across the precentral, central and parietal electrodes. OM involved the same regions but had greater ERD over the central electrodes. In the beta band, there was a gradation of ERD intensity in O, OI and OM over central electrodes. After the task, the ERS changes were weak during the O task but were strong during the OI and OM (Cz) tasks, with no differences between OI and OM. CONCLUSION:Alpha band ERD results demonstrated the recruitment of mirror neurons during lower limb VOT due to visual feedback. Beta band ERD reflects strong recruitment of the sensorimotor cortex evoked by motor imagery and action execution. These results also emphasize the need for an active motor task, either motor imagery or motor execution task during VOT, to elicit a post-task ERS, which is absent during passive observation. Trial Registration NCT05743647.

Background: Percutaneous needle tenotomies constitute a promising approach that enables direct access to tendons through minimally invasive interventions. They can be performed rapidly without need for large incisions or general anaesthesia. However, the reported procedures are heterogeneous and currently conducted without guidelines. Objectives: We aimed to determine the indications for percutaneous needle tenotomies described in the current literature. Our secondary aim was to identify the different procedures reported, as well as their efficacy and their safety. Methods: A systematic review following PRISMA guidelines was conducted to identify original articles that mentioned percutaneous needle tenotomy in humans and reported its application, description, effectiveness or adverse events. Non-percutaneous tendinous surgical procedures and ineligible designs were excluded. The Downs and Black checklist was used to assess the risk of bias. Results: A total of 540 studies were identified from the MEDLINE, Embase, Cochrane Library, and PEDro databases. Fourteen clinical studies met the inclusion criteria and were found to have an acceptable quality (674 individuals, 1664 tenotomies). Our results indicated a wide variety of indications for percutaneous needle tenotomies in children and in adults. We highlighted 24 tendons as eligible targets in the upper and lower limbs. Tenotomies were performed with either 16- or 18-Ga needles, lasted from 1 to 30 min, and were performed using various procedures. Their efficacy was mainly assessed through clinical outcomes highlighting tendon discontinuity on palpation after the procedure. Passive range -ofmotion gains after tenotomy were reported for both upper and lower limbs with an estimated 5 % complication rate. Conclusion: This is the first review to systematically synthesize all the available evidence on the indications, procedures, efficacy and safety of percutaneous tenotomies exclusively performed with needles. Current evidence suggests that procedures are safe and effective for treating various deformities. PROSPERO registration: CRD42022350571 (c) 2024 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY -NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Background The locked-in syndrome (LIS), due to a lesion in the pons, impedes communication. This situation can also be met after some severe brain injury or in advanced Amyotrophic Lateral Sclerosis (ALS). In the most severe condition, the persons cannot communicate at all because of a complete oculomotor paralysis (Complete LIS or CLIS). This even prevents the detection of consciousness. Some studies suggest that auditory brain–computer interface (BCI) could restore a communication through a « yes–no» code. Methods We developed an auditory EEG-based interface which makes use of voluntary modulations of attention, to restore a yes–no communication code in non-responding persons. This binary BCI uses repeated speech sounds (alternating “yes” on the right ear and “no” on the left ear) corresponding to either frequent (short) or rare (long) stimuli. Users are instructed to pay attention to the relevant stimuli only. We tested this BCI with 18 healthy subjects, and 7 people with severe motor disability (3 “classical” persons with locked-in syndrome and 4 persons with ALS). Results We report online BCI performance and offline event-related potential analysis. On average in healthy subjects, online BCI accuracy reached 86% based on 50 questions. Only one out of 18 subjects could not perform above chance level. Ten subjects had an accuracy above 90%. However, most patients could not produce online performance above chance level, except for two people with ALS who obtained 100% accuracy. We report individual event-related potentials and their modulation by attention. In addition to the classical P3b, we observed a signature of sustained attention on responses to frequent sounds, but in healthy subjects and patients with good BCI control only. Conclusions Auditory BCI can be very well controlled by healthy subjects, but it is not a guarantee that it can be readily used by the target population of persons in LIS or CLIS. A conclusion that is supported by a few previous findings in BCI and should now trigger research to assess the reasons of such a gap in order to propose new and efficient solutions. Clinical trial registrations : No. NCT02567201 (2015) and NCT03233282 (2013).

16 Background: The locked-in syndrome (LIS), due to a lesion in the pons, impedes communication. This situation can also be

Les états de conscience altérée (ECA) prolongés sont définis par une absence de communication fonctionnelle au-delà de 28 jours après une lésion cérébrale aigue grave. L’étiologie, la typologie des lésions et la sévérité de l’état de conscience altérée sont des éléments pronostiques essentiels. L’évaluation précise de ces patients est donc fondamentale. Pour cela, l’échelle clinique CRS-R (Coma Recovery Scale – Revised) et les explorations électroneurophysiologiques sont utilisées. L’IRM cérébrale multimodale permet en particulier d’identifier des lésions thalamo-mésencéphaliques susceptibles d’altérer durablement la vigilance. La tomographie par émission de positons (TEP) a une valeur pronostique péjorative lorsqu’elle révèle un hypométabolisme cortical dans le réseau du mode par défaut (support de la conscience de soi) et dans le réseau fronto-pariétal externe (support de la conscience du monde extérieur). Cependant, ces explorations conventionnelles peuvent être prises en défaut d’où un intérêt croissant pour les techniques avancées d’analyse de la morphométrie et de la connectivité cérébrales. L’amantadine et le zolpidem sont les molécules les plus utilisées pour accélérer la restauration de la conscience, mais seule l’amantadine a une autorisation temporaire d’utilisation dans l’ECA traumatique. Leur mode d’action pharmacologique commun soutient l’hypothèse du « mesocircuit » reliant l’altération de conscience à une réduction de la connectivité thalamo-corticale et thalamo-striatale.

INTRODUCTION:Muscle changes after stroke cannot be explained solely on the basis of corticospinal bundle damage. Muscle-specific changes contribute to limited functional recovery but have been poorly characterized.EVIDENCE ACQUISITION:We conducted a systematic review of muscular changes occurring at the histological, neuromuscular and functional levels during the first year after the onset of post-stroke hemiplegia. A literature search was performed on PubMed, Embase and CINHAL databases up to November 2022 using a keyword combination comprising cerebral stroke, hemiplegic, atrophy, muscle structure, paresis, skeletal muscle fiber type, motor unit, oxidative stress, strength, motor control.EVIDENCE SYNTHESIS:Twenty-seven trial reports were included in the review, out of 12,798 articles screened. Structural modifications described on the paretic side include atrophy, transformation of type II fibers into type I fibers, decrease in fiber diameter and apparent myofilament disorganization from the first week post-stroke up to the fourth month. Reported biochemical changes comprise the abnormal presence of lipid droplets and glycogen granules in the subsarcolemmal region during the first month post-stroke. At the neurophysiological level, studies indicate an early decrease in the number and activity of motor units, correlated with the degree of motor impairment. All these modifications were present to a lesser degree on the non-paretic side. Although only sparse data concerning the subacute stage are available, these changes seem to appear during the first two weeks post-stroke and continue up to the third or fourth month.CONCLUSIONS:Considering these early pathophysiological changes on both the paretic and non-paretic sides, it seems crucial to promptly stimulate central and also peripheral muscular activation after stroke through specific rehabilitation programs focused on the maintenance of muscle capacities associated with neurological recovery or plasticity.

Background: The time-course response after a single injection of botulinum toxin (BoNT) for post-stroke spasticity is debated. We addressed this issue by conducting a systematic review and a pharmacodynamic model based meta-analysis.Methods: We searched Medline, PeDro and Google Scholar databases up to March 2020, selecting randomized controlled trials of post-stroke and traumatic brain injury patients with arm or leg muscle hypertonia, comparing BoNT to placebo, or different BoNT preparations. The main outcome was change in Modified Ashworth Scale (MAS) score. A non-linear mixed effect model was used to estimate maximal toxin and placebo effects (Emax and EPlacebo), the effect disappearance half-life (T1/2off) of BoNT and the doses achieving 50 and 80% of Emax (D50 and D80). The equivalence ratios between different BoNT preparations were calculated from D50 values. Adverse events were recorded.Results: Altogether, 2,236 unique records were screened by 2 independent reviewers: 35 eligible trials including 3011 patients (95% post-stroke) were identified. For all BoNT preparations, the BoNT Emax of-1.11 (95% credible interval-1.31;-0.29) was reached at 5 weeks; the maximal placebo effect was-0.30 (-0.37;-0.22). Both D50 and D80 differed significantly by muscle volume. At D50, the equivalence ratio was signifi-cantly higher for abobotulinumtoxinA (3.35) than onabotulinumtoxinA and lower for letibotulinumtoxinA (0.41). T1/2off was longer for abobotulinumtoxinA than for onabotulinumtoxinA and the other preparations (13.1 weeks [95% credible interval 7.7; 19.3] vs 8.6 weeks [7.1; 10.1]). Adverse events were minor, with a weak, but significant, dose-response relation for muscle weakness.Conclusions: This first pharmacodynamic model-based meta-analysis of individuals with stroke revealed that for all BoNT-A preparations, BoNT-A injections to treat spasticity have maximal effect at 5 weeks. The T1/2off was longer for abobotulinumtoxinA than other preparations. Differences between certain BoNT unit scales were also confirmed.(c) 2021 Elsevier Masson SAS. All rights reserved.

Interface pressure applied by compression bandages is the therapeutic action of the treatment of some venous or lymphatic pathologies. The so-called Static Stiffness Index, which quantifies the pressure increase from supine to standing position, is usually used to differentiate compression bandages. It was hypothesized that this pressure increase was the consequence of a change in leg geometry (blood and muscle falling down) and a change in calf soft tissue mechanical properties (muscles contraction). Calf soft tissue global stiffness of both legs of 25 patients was characterized in a sitting and standing position. This characterization was combined with interface pressure measurements applied by six different bandages. Though soft tissue mechanical properties significantly increased from sitting to standing position, no correlation was observed with the corresponding pressure increase. Thus, pressure increase is mainly attributed to a change in leg geometry.