BACKGROUND:Poststroke flexed elbow deformity is a frequent and disabling abnormal joint posture that impairs function, hygiene, and quality of life. Despite its clinical impact, assessment strategies and treatment sequencing remain heterogeneous, fragmented across disciplines, and poorly standardized. OBJECTIVES:To establish an international, interdisciplinary expert consensus on the assessment and management of poststroke flexed elbow deformity using a hypothesis-driven Delphi methodology. METHODS:An international Delphi process was conducted involving 28 experts in physical and rehabilitation medicine, orthopedic surgery, and neurosurgery from 12 countries. Three sequential, anonymous rounds of structured online questionnaires were administered. Statements addressed diagnosis, clinical and instrumental assessment, treatment selection, and surgical indications. Experts rated their agreement with each statement. Consensus was predefined as ≥80% agreement among respondents for a given item. RESULTS:Across 3 Delphi rounds, 164 statements were evaluated, of which 61 (38%) reached consensus. Experts, including physical and rehabilitation medicine physicians (n = 13), orthopedic surgeons (n = 10), and neurosurgeons (n = 1) agreed that functional impact assessment must precede treatment decisions and that differentiation between muscle overactivity and soft-tissue contracture is essential. Diagnostic motor nerve blocks and radiological imaging were endorsed as complementary tools in selected cases. Botulinum toxin injections combined with rehabilitation were supported as first-line treatment for correctable deformities, whereas surgical intervention was considered appropriate for partially or non-correctable deformities. Preoperative interdisciplinary consultation and formal goal setting were deemed mandatory before intervention. CONCLUSIONS:This Delphi-based international consensus provides structured, interdisciplinary guidance for the evaluation and management of poststroke flexed elbow deformity. By clarifying assessment principles, treatment sequencing, and indications for referral and surgery, this consensus aims to standardize care pathways and improve patient-centered outcomes. REGISTRATION:Not applicable. This study used a Delphi methodology involving expert opinion only, without human participant intervention.

AIMS:To assess 1-year Transcutaneous Tibial Nerve Stimulation (TTNS) treatment persistence in routine clinical care and to explore clinical and urodynamic factors associated with treatment persistence in patients with lower urinary tract dysfunction (LUTD). METHODS:A prospective, monocentric, observational cohort study was conducted between October 2022 and January 2024 (RnIPH 2022-109). Adult patients with LUTD for whom TTNS was prescribed and initiated at home (20 min/day) were consecutively included. Baseline assessment included clinical characteristics, urodynamic findings, and patient-reported outcomes, including the Patient Global Impression of Severity (PGI-S), Patient Global Impression of Improvement (PGI-I), Urinary Symptom Profile (USP), and QUALIVEEN-Short Form (QSF). Treatment persistence and patient-reported outcomes were assessed at 2-4 months, and persistence was reassessed at 12 months. Persistence over time was described using a Kaplan-Meier analysis, and factors associated with time to discontinuation were explored using Cox proportional hazards models. RESULTS:Fifty-six patients initiated TTNS, including 32 (57%) with neurological LUTD. At 1 year, 21/56 patients (38%) remained persistent, including 21/34 (62%) among the device purchasers. Persistence was higher in neurological (56%, 18/32) than in non-neurological patients (13%, 3/24), and neurological etiology was associated with a lower hazard of discontinuation in multivariable Cox analysis (adjusted HR: 0.42, 95% CI: 0.18-0.99, p = 0.047). Lower symptom burden and greater perceived improvement at 2-4 months were associated with both device acquisition and long-term persistence, particularly through lower PGI-S, PGI-I, USP-OAB, and QSF scores. Overactive urethral sphincter was more frequent in neurological patients (p = 0.008) and among persistent purchasers (p = 0.006). TTNS was well tolerated, with only one minor adverse event reported. CONCLUSION:TTNS treatment persistence in routine care appeared to depend on both clinical profile and early patient-reported outcomes. The 2-4-month reassessment emerged as a key decision point for evaluating long-term TTNS treatment persistence. These findings support further investigation into the relationship between neuro-urological phenotypes and long-term TTNS treatment persistence.

BACKGROUND:The efficacy of the different shoulder orthoses available to prevent hemiplegic shoulder complications still remains debatable. OBJECTIVES:To evaluate how wearing a custom-made (CM) shoulder sling affected personal goals and complications among hemiplegic stroke patients undergoing realworld rehabilitation. METHODS:A prospective, single-center, non-randomized, pilot study on patients having a stroke within the last 6 months with hemiplegic shoulder pain/subluxation >5 mm. The primary outcome was achievement in three personal goals according to Goal Attainment Scaling one month after (week 5) compared to before (day 7) sling wearing. RESULTS:Twenty-two patients were included: 60 % male, 56.4 ± 12.1 years old. ≥1 goal was achieved by 90.5 % of patients after sling wearing (week 5) versus 36 % of patients before. VAS pain score (-1.3 ± 2.3; p = 0.01) and subluxation distance (-0.41±0.42 cm; p = 0.0001) were reduced at week 5. Both the Chedoke Arm and Hand Activity Inventory score (+9.0 ± 13.1; p = 0.0003) and Fugl-Meyer upper-extremity score (+9.5 ± 9.5; p = 0.00002) were improved after sling wearing. CONCLUSION:We observed improvements in patient-desired outcomes, complications, and upper-limb functional recovery after CM sling wearing for 1-month. TRIAL REGISTRATION:NCT04028999.

User task descriptions are the cornerstone of User-Centered Design (UCD) approaches. In user-centered design, they support the description of users’ work and the identification of users’ needs. Arguably, an exhaustive description of the tasks makes it possible to assess the complexity of the work to be performed, identification of potential user errors, the cost of recovering from errors, or the training needs of users. Early task description notations provided high-level descriptions of tasks focusing on hierarchical structuring of goals and tasks, knowledge required to perform the tasks, and collaborative aspects. Some notations, like HTA, support the description of user tasks in a generic way, while CTT refines them into user, system, interaction, or abstract tasks. However, like in most real-life cases, the task descriptions should be precise enough to allow human factors experts to perform the desired analysis. HAMSTERS notation refines CTT user tasks into perceptive, cognitive, and motor tasks. This paper presents three extensions to HAMSTERS, allowing more precise and detailed descriptions of each of these user tasks. For each extension, we present the rationale, the extension itself, and its application to a concrete example in the domain of exercises for post-stroke rehabilitation. These extensions are generic and can also be applied to any type of user tasks when fine details about task performance have to be described. As the task models increase in size when details are added, we present how the extensions have been added to the HAMSTERS tool, which is publicly available.

BackgroundIndividuals with poststroke hemiplegia often develop spasticity, which increases disability. Antispastic treatments such as baclofen and botulinum toxin are commonly prescribed in poststroke recovery. However, their impact on motor recovery, especially when administered within the first 2 months after stroke, remains unclear. ObjectiveThis study aims to compare the motor recovery effects of botulinum toxin versus oral baclofen. The hypothesis is that botulinum toxin is more supportive of motor recovery than baclofen and enhances functional recovery. MethodsThe study is a multicenter, controlled phase IV, comparative, prospective, randomized, double-blind, double-dummy, superiority trial to compare the toxin and baclofen, and a noninferiority trial to compare the toxin and the placebo. It focuses on the time course of the Fugl-Meyer Motor Assessment (FMA) as the primary outcome. The main inclusion criterion is patients with a single stroke in the past 2 months. Treatment comprises 1 intramuscular injection at treatment initiation and oral tablets for 4 months. Randomized patients are allocated to 3 arms: botulinum toxin with placebo baclofen, baclofen with placebo botulinum toxin, and placebo baclofen with placebo botulinum toxin. FMA scores are assessed at pretreatment, 1 month, and 3 months later. Spasticity, functional abilities, activities of daily living, pain, and quality of life are also evaluated. Adverse effects are monitored. A positive difference of 13 points in the FMA time course between the botulinum toxin and baclofen groups is considered a relevant effect. The data analysis plan involves linear regression models to compare primary and secondary outcomes, with adjustments for covariates such as age, center, and associated treatments. Subgroup analyses will examine proportional recovery profiles, and missing data in Fugl-Meyer scores will be addressed using imputation methods. ResultsA total of 179 participants were randomized across 18 centers, with inclusions delayed due to the COVID-19 pandemic. As of December 2024, the data manager currently has all the data, and a review of data quality is in progress. No statistical analysis has been conducted so far, and the blind will be lifted after the analysis. ConclusionsThis study identifies the most suitable spasticity treatment, considering the specificities of the stroke and constraints during the recovery phase. It will provide recommendations for the primary treatment of early spasticity post stroke. Trial RegistrationClinicalTrials.gov NCT02462317; https://clinicaltrials.gov/study/NCT02462317; European clinical trials (EudraCT) 2010-022881-28; https://www.clinicaltrialsregister.eu/ctr-search/trial/2010-022881-28/FR International Registered Report Identifier (IRRID)DERR1-10.2196/62951

There is limited published guidance available to help less experienced practitioners assess and manage shoulder conditions, including spasticity, after acquired central nervous system (CNS) lesions. To address this gap, 11 spasticity and dystonia experts convened in a 2023 meeting to build on existing guidance, provide consensus on best treatment practice, and develop expert recommendations to guide the diagnosis and treatment of complications of shoulder conditions following CNS lesions. Presentations by each expert on diagnosis and management were followed by discussion; consensus on assessment and treatment practices was identified and recommendations developed. The expert panel recommended an assessment approach structured using the following components: patient history, including interpretation of reported symptoms; observation of postures and pain responses; clinical examination with targeted tests for specific signs; diagnostic tests; and assessment of upper limb impairment, activity limitations, and participation restrictions. This assessment process and the recommended measures recognize the importance of identifying shoulder involvement in upper limb spasticity as part of the diagnostic process in shoulder conditions following CNS lesions. These recommendations provide a practical approach to diagnosis and treatment for clinicians who are less experienced in evaluating and treating such conditions, simplifying otherwise complicated clinical scenarios.

Objective: To evaluate functional outcomes of surgery of spastic hip adductor muscles (obturator neurotomy with or without adductor longus tenotomy) in ambulatory and non-ambulatory patients, using preoperatively defined personalized goals. Design: Retrospective observational descriptive study. Patients: Twenty-three patients with adductor spasticity who underwent obturator neurotomy between May 2016 and May 2021 at the Clinique des Cèdres, Cornebarrieu, France, were included. Methods: Postoperative functional results were evaluated in accordance with the Goal Attainment Scaling method. Patients were considered “responders” if their score was ≥ 0. Secondary outcomes included spasticity, strength, hip range of motion and change in ambulatory capacity. When data were available, a comparison of pre- and postoperative 3-dimensional instrumented gait analysis was also performed. Results: Among the 23 patients only 3 were non-walkers. Seventeen/22 patients achieved their main goal and 14/23 patients achieved all their goals. Results were broadly similar for both walking goals (inter-knee contact, inter-feet contact, fluidity, walking perimeter, toe drag) and non-walking goals (intimacy, transfer, pain, posture, dressing). Conclusion: Surgery of spastic hip adductor muscles results in functional improvement in ambulation, hygiene, dressing and posture and can be offered to patients with troublesome adductor overactivity. The use of a motor nerve block is recommended to define relevant goals before the surgery.

OBJECTIVE:To report on preoperative outcomes that guide the choice of surgical techniques to correct equinovarus foot in adults with brain injury.METHODS:Four databases (PubMed, MEDLINE, Cochrane, PEDro) were searched according to the PRISMA guidelines. Studies were included regardless of their level of proof, with no limitation on date of publication, and their quality was assessed with the Methodological Index for Non-Randomized Studies score.RESULTS:We analysed 61 studies (n = 2,293 participants); 523 participants underwent neurotomy, 437 calf musculotendinous lengthening, and 888 tibialis anterior transfer or alternative anterior transfers with the flexor digitorum/hallucis longus (n = 249), the extensor hallucis longus (n = 102), the tibialis posterior (n = 41) and the peroneus longus (n = 41). Two studies were dedicated to osteoarticular surgeries (n = 12 participants). Ankle dorsiflexors motricity was assessed before 70% of neurotomies as compared with 29% before isolated calf lengthening studies, their strength being at least 3/5 in 33% and 50% of the studies concerned, respectively. Passive ankle dorsiflexion was assessed before surgery in 87% of neurotomy studies, with 62% of studies investigating non-retracted spastic equinovarus foot. Before anterior tendon transfer with the tibialis anterior or another muscle, passive ankle dorsiflexion was reported in only 20% and 46% of studies, respectively, and dynamic tibialis anterior activation during gait in 46% and 56%. Although voluntary recruitment of the tibialis anterior produced a better functional result, the presence/correction of varus justified its transfer in 60% of studies as compared with 30% in other transfers, which were justified by hyperactivity or voluntary recruitment of transferred muscle.CONCLUSIONS:This review highlights the poor level of preoperative assessment and the absence of formal criteria to indicate the different surgical approaches in the management of equinovarus foot. It reinforces the interest of a systematic standardized preoperative assessment such as selective motor block and dynamic electromyography to choose the most suitable surgical procedure.

BACKGROUND:In post-stroke hemiparetic subjects, a systematic and quantified description of the shortening default and compensatory movements during the swing phase of gait is essential to guide treatments and assess the impact of therapeutic interventions. However, such a systematic approach does not exist in the current clinical practice.AIM:The aim of this study was to present a method improving the quantification and visualization of the kinematics of both lower limbs during the swing phase of gait, more specifically the origin of shortening default and the weight of compensations, based on a tool specifically developed: ToulGaitViz.DESIGN:Observational cohort study.SETTING:Three-dimensional kinematic gait analyses of outpatients evaluated in Toulouse university hospital.POPULATION:ToulGaitViz was applied to 151 post-stroke hemiparetic participants and 48 healthy control participants.METHODS:ToulGaitViz is a standalone software allowing to compute 1) limb clearance as the sum of the shortening related to hip, knee and ankle flexion in the sagittal plane; 2) compensations related to the abduction of the limb and hip hiking at mid-swing. Both centimetric and angular values of the clearance were reported as well as their correlations with walking speed.RESULTS:Overall, the contribution of compensations in clearance was higher in post-stroke hemiparetic subjects than in healthy control participants with both centimetric (130% vs. 33%; P<0.001) and angular methods (23% vs. 1.4%; P<0.001). The centimetric method better represents the specific contribution of each segment to the clearance than the angular method. Symbolically, mean kinematic data from the cohort supports the claim that 2° of pelvic obliquity is equivalent to 10° of knee flexion to increase clearance by 1 cm, emphasizing the non-proportionality between the angular values and the actual contribution to the shortening. ToulGaitViz allows visualization of clearance, segmental shortening and compensation evolution before and after any therapeutic intervention with quantitative and comprehensive data.CONCLUSIONS:The ToulGaitViz could be systematically used in clinical practice to extract relevant kinematic data from the origin of shortening default and the weight of compensations.CLINICAL REHABILITATION IMPACT:This tool allows better understanding of the mechanisms of action of treatments to better link them to the subjects' needs.

Purpose: To propose a consensus-based definition and framework for motor rehabilitation after stroke. Methods: An expert European working group reviewed the literature, attaining internal consensus after external feedback. Findings: Motor rehabilitation is defined as a process that engages people with stroke to benefit their motor function, activity capacity and performance in daily life. It is necessary for people with residual motor disability whose goal is to enhance their functioning, independence and participation. Motor rehabilitation operates through learning- and use-dependent mechanisms. The trajectory of motor recovery varies across patients and stages of recovery. Early behavioral restitution of motor function depends on spontaneous biological mechanisms. Further improvements in activities of daily living are achieved by compensations. Motor rehabilitation is guided by regular assessment of motor function and activity using consensus-based measures, including patient-reported outcomes. Results are discussed with the patient and their carers to set personal goals. During motor rehabilitation patients learn to optimize and adapt their motor, sensory and cognitive functioning through appropriately dosed repetitive, goal-oriented, progressive, task- and context-specific training. Motor rehabilitation supports people with stroke to maximize health, well-being and quality of life. The framework describes the International Classification of Functioning, Disability and Health in the context of stroke, describes neurobiological mechanisms of behavioral restitution and compensation, and summarizes recommendations for clinical assessment, prediction tools, and motor interventions with strong recommendations from clinical practice guidelines (2016–2022). Conclusions: This definition and framework may guide clinical educators, inform clinicians on current recommendations and guidelines, and identify gaps in the evidence base.

Objective: To establish international recommendations for the management of spastic equinovarus foot deformity.Design: Delphi method. Setting: International study.Participants: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). Interventions: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity.Main Outcome Measures: A consensus was established when at least 80% of experts agreed on a statementResults: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery.Conclusion: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy. Archives of Physical Medicine and Rehabilitation 2023;104:372-9 & COPY; 2022 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine

Paired associative stimulation (PAS) is an intervention that modulates cortical plasticity. Motor imagery (MI) is used in the rehabilitation of stroke patients. We aimed to evaluate the possible synergistic effect of associating both interventions for potentiating motor recovery poststroke. MIPAS is a single-center, randomized controlled trial that enrolled 24 hemiparetic poststroke participants. Three single-session interventions were tested in a crossover design: PAS/MI, PAS, and ShamPAS/MI during which the affected Extensor Carpi Radialis (ECR) muscle was targeted. During MI, the participants were instructed to imagine extending their paretic wrist. We used Sham, subthreshold stimulation during ShamPAS. Changes in ECR Motor-Evoked Potential (MEP) areas and paretic wrist Range of Motion (aROM) during active extension were compared between the interventions. We observed no significant superior effect of any intervention, neither on MEP nor on wrist aROM. A time of assessment effect was highlighted for both outcome measures, with MEP- and aROM-measured post-interventions significantly higher than those measured pre-intervention. Despite the beneficial effect of each intervention on participant paretic wrist motor function, not always associated with MEP change, our results do not highlight a specific advantage in combining PAS and MI interventions in post-stroke motor rehabilitation.

The aim of our prospective single-center study was to assess the loss of bone mineral density (BMD) in the year following stroke with hemiplegia. We evaluated functional disability and bone mineral density (BMD) in 18 patients immediately following and at 1 year of stroke with hemiplegia. The most significant variation in BMD concerns the femoral neck on the hemiplegic side: -0.0551±0.0548g/cm2: -6.85%. This loss is correlated with the functional motor score (Fugl-Meyer Assessment) (r=0.7573; P=0.0004). During follow-up, 11/18 patients fell and 2/18 had a fracture.

Spontaneous alpha oscillations (~10 Hz) have been associated with various cognitive functions, including perception. Their phase and amplitude independently predict cortical excitability and subsequent perceptual performance. Yet, the causal role of alpha phase-amplitude tradeoffs on visual perception remains ill-defined. We aimed to fill this gap and tested two clear predictions from the Pulsed Inhibition theory according to which alpha oscillations are associated with periodic functional inhibition. (1) High alpha amplitude induces cortical inhibition at specific phases, associated with low perceptual performance, while at opposite phases, inhibition decreases (potentially increasing excitation) and perceptual performance increases. (2) Low alpha amplitude is less susceptible to these phasic (periodic) pulses of inhibition, leading to overall higher perceptual performance. Here, cortical excitability was assessed in humans using phosphene (illusory) perception induced by single pulses of transcranial magnetic stimulation (TMS) applied over visual cortex at perceptual threshold, and its post-pulse evoked activity recorded with simultaneous electroencephalography (EEG). We observed that pre-pulse alpha phase modulates the probability to perceive a phosphene, predominantly for high alpha amplitude, with a non-optimal phase for phosphene perception between −π/2 and −π/4. The pre-pulse non-optimal phase further leads to an increase in post-pulse evoked activity (ERP), in phosphene-perceived trials specifically. Together, these results show that alpha oscillations create periodic inhibitory moments when alpha amplitude is high, leading to periodic decrease of perceptual performance. This study provides strong causal evidence in favor of the Pulsed Inhibition theory. Visual Abstract Significance Statement The Pulsed Inhibition theory predicts that the functional inhibition induced by high alpha oscillations’ amplitude is periodic, with specific phases decreasing neural firing and perceptual performance. In turn, low alpha oscillations’ amplitude is less susceptible to phasic moments of pulsed inhibition leading to overall higher perceptual performance. Using TMS with simultaneous EEG recordings in humans, we found that specific phases of spontaneous alpha oscillations (~10 Hz) decrease cortical excitability and the subsequent perceptual outcomes predominantly when alpha amplitude is high. Our results provide strong causal evidence in favor of the Pulsed Inhibition theory.

Spastic equinus foot is a common deformity in neurologic patients who compromise walking ability. It is related to the imbalance between weak dorsiflexion and overactive plantar flexor muscles. To achieve the best functional results after surgical management, the challenge is to identify the relevant components involved in the deformity using several methods, namely, examination in the supine position, motor nerve blocks allowing transient anesthesia of suspected overactive muscles, and kinematic and electromyographic data collected during an instrumented 3D gait analysis. The procedure is not standardized; its use varies from one team to another. Access to gait analysis laboratories is limited, and some teams do not perform motor nerve blocks. When both examinations are available, instrumental data from the instrumented 3D gait analysis can be used to specify muscle targets for motor blocks, but data collected from both examinations are sometimes considered redundant. This retrospective cohort analysis compared examination in the supine position, temporary motor nerve blocks, and instrumented 3D gait analysis data in 40 adults after brain or spinal cord injuries. Clinical data collected before motor nerve block was not associated with instrumental data to assess calf muscle's overactivity and tibialis anterior function. Improvement of ankle dorsiflexion in the swing phase after tibial motor nerve block was associated with soleus spastic co-contraction during this phase corroborating its involvement in ankle dorsiflexion defects. This study showed the relevance of tibial motor nerve block to remove spastic calf dystonia and facilitate the assessment of calf contracture. It also underlined the need for complementary and specific analyses of the tibialis anterior abnormal activation pattern after motor nerve block to confirm or deny their pathological nature.