Motion analysis for the evaluation of muscle overactivity: A point of view.

Muscle overactivity is a general term for pathological increases in muscle activity such as spasticity. It is caused by damage to the central nervous system at the cortical, subcortical or spinal levels, leading to an upper motor neuron syndrome. In routine clinical practice, muscle overactivity, which induces abnormal muscle tone, is usually evaluated by using the Modified Ashworth Scale or the Tardieu Scale. However, both of these scales involve testing in passive conditions that do not always reflect muscle activity during dynamic tasks such as gait or reaching. To determine appropriate treatment strategies, muscle overactivity should be evaluated by using objective measures in dynamic conditions. Instrumental motion analysis systems that include 3-D motion analysis and electromyography are very useful for this purpose. The method can be used to identify patterns of abnormal muscle activity that can be related to abnormal kinematic patterns. It allows for objective and accurate assessment of the effects of treatments to reduce muscle overactivity on the movement to be improved. The aim of this point-of-view article is to describe the utility of instrumental motion analysis and to outline both its numerous advantages in evaluating muscle overactivity and to present the current limitations for its use (e.g., cost, the need for an engineer, errors relating to marker placement and cross talk between electromyography sensors).

Correction to: Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies.

The original article [1] contains a small mistake concerning the ARTIC Team members mentioned in the Acknowledgements. The team member, Rocco Salvatore Calabrò had their name presented incorrectly. This has now been corrected in the original article.

International consensus statement for the use of botulinum toxin treatment in adults and children with neurological impairments--introduction.

Botulinum neurotoxin (BoNT) is most commonly used to reduce focal over-activity in skeletal muscle, although newer indications such as management of drooling, pain and tremor are emerging. Treatment of spasticity incorporating BoNT is usually part of an integrated multidisciplinary rehabilitation programme. Prior to initiating this therapy, specific functional limitations, goals and expected outcomes of treatment should be discussed with the patient/carers. Muscle selection and the order/priority of treatment should be agreed. Treatment goals may involve increasing active or passive function or the avoidance of secondary complications or impairment progression. This paper describes the basic science mechanisms of the action of BoNT and subsequent nerve recovery and introduces a supplement comprising the best available evidence and expert opinion from international panels on questions of assessment, indications, BoNT regimen, adjunctive therapy, expected outcomes and recommended monitoring. Speciality areas reviewed include Paediatric Lower Limb Hypertonicity, Paediatric Upper Limb Hypertonicity, Adult Lower Limb Hypertonicity, Adult Upper Limb Hypertonicity, Cervical Dystonia, Drooling and Pain and Niche Indications. There is good quality scientific evidence to support the efficacy of BoNT to reduce muscle over-activity in the limbs secondary to central nervous system disorders in adults and children, to address primary or secondary cervical dystonia, to reduce saliva flow and to treat some pain syndromes. There is emergent evidence for the efficacy of BoNT to reduce focal tremor, to treat other types of pain including neuropathic pain and also to improve function following treatment of focal muscle over-activity.

Botulinum toxin assessment, intervention and aftercare for lower limb disorders of movement and muscle tone in adults: international consensus statement.

Lower limb disorders of movement and muscle tone in adults significantly impact quality of life. The management of the patient with hypertonia is complex and requires a multidisciplinary team working with the patient and family/carers. Botulinum neurotoxin type A (BoNT-A) has been used as a component of this management to reduce lower limb hypertonia, increase passive range of motion and reduce associated pain and requirements for bracing. Adjunctive treatments to augment the effect of BoNT-A include electrical muscle stimulation of the injected muscles and stretching. When determining suitability for injection, the patient's main goals for intervention need to be established. Muscle overactivity must be distinguished from contracture, and the effect of underlying muscle weakness taken into account. Explanation of the injection process, potential adverse effects and post-injection interventions is essential. Assessment at baseline and post-treatment of impairments such as hypertonia, range of motion and muscle spasm are appropriate; however, the Goal Attainment Scale and other validated patient-centred scales can also be useful to assess therapy outcomes. In the future, initiatives should be directed towards examining the effectiveness of BoNT treatment to assist with achievement of functional and participation goals in adults with hypertonia and dystonia affecting the lower limb.

Improvements in healthcare and cost benefits associated with botulinum toxin treatment of spasticity and muscle overactivity.

Spasticity is a widespread, disabling form of muscle overactivity affecting patients with central nervous system damage resulting in upper motor neurone syndrome. There is a range of effective therapies for the treatment of spasticity (e.g. physical, anaesthetic, chemodenervation and neurolytic injections, systemic medication and surgery), but all therapies must be based on an individualized, multidisciplinary programme targeted to achieve patient goals. Appropriate therapy should be based on the extent and severity of spasticity, but spasticity and its consequences, regardless of presentation or cause, are commonly treated with systemic agents. This may be ill-advised as systemic treatment is associated with many undesirable effects. In particular, elderly patients with post-stroke spasticity are at risk from the central adverse effects of systemic medication (e.g. sedation and gait disturbance), which make them more susceptible to falling, with an associated increased risk of fracture. The rising costs of fracture care and its sequelae are fast becoming an international problem contributing to high healthcare expenditure. Botulinum toxin type-A (BoNT-A) treatment is highly effective for some of the more common forms of spasticity and muscle overactivity, and has a favourable profile when compared with systemic agents and other focal treatments. Therefore, the clinical benefits of BoNT-A treatment outweigh the apparent high costs of this intervention, showing it to be a cost-effective treatment.

Factors associated with poor outcomes in patients with lupus nephritis.

The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome (P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 +/- 6 versus 5 +/- 5, P < 0.05), chronicity index (CI) score (4 +/- 3 versus 2 +/- 2 unit, P < 0.025), higher baseline mean arterial pressure (MAP) (111 +/- 21 versus 102 +/- 14 mmHg, P < 0.025) and serum creatinine (1.9 +/- 1.3 versus 1.3 +/- 1.0 mg/dL, P < 0.025), but lower baseline hematocrit (29 +/- 6 versus 31 + 5%, P < 0.025) and complement C3 (54 +/- 26 versus 65 + 33 mg/dL, P < 0.025) compared to controls. More patients reaching the composite outcome had nephrotic range proteinuria compared to controls (74% versus 56%, P < 0.025). By multivariate analysis, CI (hazard ratio [95% CI] 1.18 [1.07-1.30] per point), MAP (HR 1.02 [1.00-1.03] per mmHg), and baseline serum creatinine (HR 1.26 [1.04-1.54] per mg/dL) were independently associated with the composite outcome. We concluded that hypertension and elevated serum creatinine at the time of the kidney biopsy as well as a high CI are associated with an increased the risk for chronic renal failure or death in patients with lupus nephritis.

Laboratory analysis and dynamic polyEMG for assessment and treatment of gait and upper limb dysfunction in upper motoneuron syndrome.

Multiple muscle agonists and antagonists acting for all the joint movements in the upper and lower limb exist. This redundancy of motor control is very valuable in normal physiology, but when a central nervous system injury with resulting upper motor neuron syndrome takes place, the source of the functional impairment may be difficult to localize. In this paper we discuss the use of gait and motor control analysis studies as a tool particularly useful in determining the specific muscles that may be producing limb dysfunction. We present the most frequent patterns of upper motor neuron dysfunction that affect the upper and lower limb as a result of upper motor neuron syndrome. A case description of the features, the electromyographic patterns, and their functional implications are used. Our objective is to clarify the understanding of these patterns of dysfunction and their focal cause with the intent to improved care of the patient with upper motor neuron syndrome.

Botulinum toxin for the management of muscle overactivity and spasticity after stroke.

Stroke is a major cause of disability involving the arm and leg. This disability results from the upper motoneuron syndrome (UMN) evident after stroke. It is commonly associated with spasticity and muscle overactivity, which can lead to abnormal limb posturing that interferes with active and passive function. The origin of limb deformity in patients with UMN is based on the concept of unbalanced agonist and antagonist muscle forces acting across joints. In the past decade, botulinum toxin A (BTX-A) a new medication that modifies muscle force and, hence, can treat muscle imbalance, has become available and has renewed interest in the management of muscle overactivity and spasticity after stroke. A reduction in muscle tone, painful spasms, and improved functionality can be obtained. Research and clinical reports support the concept that chemodenervation with BTX-A is an excellent intervention for treating focal muscle overactivity and spasticity secondary to stroke. Many muscles differing in size, shape, and location have been injected, and clinical effectiveness is particularly notable in elbow flexors, ankle plantar flexors, and smaller limb muscles, such as intrinsics of the hand and wrist. Smaller muscles are readily accessible for injection and require smaller amounts of toxin.

Rehabilitation after amputation.

The principles of amputee rehabilitation, from preamputation to reintegration into the work force and community, are reviewed. The authors discuss exercise techniques, training programs, and environmental modifications that have been found to be helpful in the rehabilitation of the amputee. The exercise programs presented here are divided into four main components: flexibility, muscle strength, cardiovascular training, and balance and gait. The programs include interventions by the physical, occupational, and recreational therapist under the supervision and guidance of a physician.

Changes in strength over time among polio survivors.

OBJECTIVE: To study changes in the strength of different muscle groups in polio survivors over a period of approximately 9 months. DESIGN: Longitudinal study. SETTING: Moss Rehabilitation Research Institute. PARTICIPANTS: One hundred twenty subjects (57 men, 63 women) were studied on three occasions, each 3 to 5 months apart. Subjects were recruited through the Einstein-Moss Post-Polio Management Program. newspaper advertisements, and polio support groups. MAIN OUTCOME MEASURES: Isometric strength of 30 muscle groups (16 in upper extremities, 14 in lower extremities) was measured, using a hand-held dynamometer. RESULTS: Data were analyzed in two separate groups: upper-extremity muscles and lower-extremity muscles. Results for the upper-extremity muscles revealed evidence of a significant deterioration in strength. The amount of deterioration differed among muscles and increased with age. There was also evidence of deterioration in strength in the flexor muscles in the ankle, hip, and knee. However, the rate of deterioration in these muscles was not strongly related to age, time since polio, gender, symptom status, or history of residual weakness. CONCLUSIONS: Strength is deteriorating among polio survivors at a rate higher than that associated with normal aging. This deterioration is not occurring in the extensor, or so-called "weight-bearing" muscles, but is occurring in many of the upper-extremity muscle groups and in the flexor muscles in the lower extremities.

The relation between lower extremity strength and shoulder overuse symptoms: a model based on polio survivors.

OBJECTIVE: To determine the relation between lower extremity weakness and shoulder overuse symptoms among polio survivors. We predicted that individuals with moderate weakness in their leg extensor muscles would use their arms to help compensate for this weakness and would be at high risk for developing symptoms of shoulder overuse. DESIGN: A cohort study of polio survivors recruited from the Einstein-Moss Postpolio Management Program (Philadelphia), the community, and the surrounding region. SETTING: A research laboratory at Moss Rehabilitation Research Institute, Philadelphia, PA. PARTICIPANTS: One hundred ninety-four polio survivors. Demographic and medical history data, symptom data, and strength data were obtained for each. MAIN OUTCOME MEASURES: Presence or absence of shoulder symptoms and ratings of pain by visual analogue scale were recorded. Strength was measured using a hand-held dynamometer and manual muscle testing. RESULTS: Shoulder symptoms could be grouped into two distinct clusters based on the type of testing used for assessment. Symptoms elicited by palpation were present in 26% of the subjects and were strongly related to knee extensor strength and weight. These symptoms were more common among women than men (42% and 10%, respectively). Symptoms elicited by resistance tests were present in 33% of the subjects and were seen with equal frequency in both sexes. These symptoms were also related to lower extremity strength, but the specific relationship was not as clear as for the palpation-related symptoms. CONCLUSIONS: Lower extremity weakness predisposes individuals to shoulder overuse symptoms. Sex and body weight are contributing factors. These results may be generalized to other populations with lower extremity weakness, including the elderly.

Gait analysis in rehabilitation medicine: a brief report.

Gait analysis can be a powerful tool for rehabilitation research and clinical practice. However, there has been little coordinated effort to set goals for the application of gait analysis in rehabilitation. Therefore, a priority setting process was engaged to obtain the opinions of a diverse pool of experts related to human motion analysis. The primary goal of this process was to develop priorities for future research, development, and standardization in gait analysis. A multistep approach was used that included expert testimony, group discussions, individually developed priorities, and a ranking process. Several important priorities emerged from this activity. The highest priority was assigned to research on the efficacy, outcomes, and cost-effectiveness of gait analysis.

Temporal-spatial feature of gait after traumatic brain injury.

The temporal-spatial characteristics of the gait of patients with traumatic brain injury (TBI) were investigated and compared with those of normal gait and the gait of stroke survivors. A slower walking velocity is evident in the TBI population when compared with normal. The average walking speed of TBI survivors is faster than that of stroke patients and is mainly related to a longer step length. TBI survivors produce a gait pattern with a prolonged stance period for the unaffected limb, without prolonged stance period for the affected limb, and a shorter step length for the unaffected limb.

Improving calf muscle strength in patients with spastic equinovarus deformity by transfer of the long toe flexors to the Os calcis.

The split tibialis anterior tendon transfer (SPLATT), Achilles tendon lengthening, and toe flexor release are proven and effective procedures for correcting a spastic equinovarus deformity of the foot. Paresis is a prominent feature of upper motoneuron syndrome. Lengthening the Achilles tendon, although necessary to correct the equinus, further weakens the gastrocnemius-soleus muscle group. The calf paresis commonly results in the need for an ankle-foot orthosis (AFO) during ambulation. Previous studies have shown that despite the correction of the equinovarus deformity, only one third of patients were able to ambulate without an AFO. The need for continued use of an AFO was because of insufficient calf strength to stabilize the tibia during late stance when the body mass is anterior to the ankle joint. This study prospectively evaluated the results of transfer of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) to the os calcis in 30 patients. The transfer was done in an effort to augment the strength of the gastrocnemius-soleus muscle complex. Twenty-five patients in group I (the control group) underwent SPLATT, Achilles tendon lengthening, and toe flexor release. Thirty patients in group II (the study group) underwent the identical procedures plus the additional FHL and FDL transfer to the os calcis. Postoperatively, the varus and toe flexion deformities were corrected in all feet. In group II, two feet had a mild residual equinus that did not interfere with ambulation. Of the 11 patients who were not independent community ambulators in group I, 7 (64%) improved ambulatory status by at least one level after surgery. Of the 15 patients who were not independent community ambulators in group II, 14 (93%) improved ambulatory status by at least one level after surgery. In group I, 10 of 25 (40%) of the patients were brace free at follow-up. In group II, 21 of 30 (70%) were brace free at follow-up (c2, P =.025). These results indicate that the addition of an FHL and FDL transfer to the os calcis at the time of SPLATT, Achilles tendon lengthening, and toe flexor release improves calf strength and allows greater increase in function and less reliance on orthotics.

Common patterns of clinical motor dysfunction.

An upper motor neuron syndrome often leads to the development of stereotypical patterns of deformity secondary to agonist muscle weakness, antagonist muscle spasticity and changes in the rheologic (stiffness) properties of spastic muscles. Identification of the spastic muscles that contribute to deformity across a joint allows therapeutic denervation to be implemented with the maximum likelihood of success. Identifying responsible muscles can be complex, since many muscles may cross the joint involved, and not all muscles with the potential to cause deformity will be spastic. Strategies including polyelectromyography and diagnostic blocks with local anesthetics can be used to test hypotheses regarding the deformity, providing information for more long-term denervation. In this review, we discuss frequently observed patterns of deformity associated with problematic spasticity, paresis, contracture, and impaired voluntary motor control.

Measurement of dynamic pressures at the shoe-foot interface during normal walking with various foot orthoses using the FSCAN system.

Foot orthoses are routinely used in clinical practice to redistribute pressure at the shoe-foot interface, although there is very little scientific evidence to support the efficacy of their use. In this study, the FSCAN sensor (an ultrathin in-shoe transducer) was used to determine the efficacy of pressure redistribution with a Plastizote, Spenco, cork, and a plastic foot orthosis as compared with control (no orthosis). Measurement variations of up to 18% occurred between sensors, and changes in stance time of up to 5% occurred between the orthoses and the control conditions. In spite of these potentially confounding variables, statistically significant differences in peak pressure between the orthotic types and the control condition (range, 9-146%) were noted. We conclude that Plastizote, cork, and plastic foot orthoses can be beneficial in relieving pressure in certain regions of the shoe-foot interface, but that they may do so at the cost of increasing pressure in other areas of the plantar surface.

Rehabilitation in limb deficiency. 4. Limb amputation.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article reviews the phases of amputation rehabilitation from preoperative stages to community reintegration and long-term follow-up. The various indications for artificial limb components for the upper and lower limb amputee and the expected functional levels based on level of amputation are discussed. New concepts of critical pathways are also introduced as guidelines in optimizing the rehabilitation of the amputee. The reader is directed to other relevant literature as well, in an attempt to enhance knowledge in this area of rehabilitation.