ToulGaitViz: a tool for the systematic description of lower limb clearance during the swing phase of hemiparetic gait after stroke. A cohort study.

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.

Motor rehabilitation after stroke: European Stroke Organisation (ESO) consensus-based definition and guiding framework.

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.

Selection criteria for surgical correction of equinovarus foot in adults with brain damage: A systematic scoping review.

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.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi.

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 statement RESULTS: 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.

Respective Contributions of Instrumented 3D Gait Analysis Data and Tibial Motor Nerve Block on Presurgical Spastic Equinus Foot Assessment: A Retrospective Study of 40 Adults.

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.

α Phase-Amplitude Tradeoffs Predict Visual Perception.

Spontaneous α oscillations (∼10 Hz) have been associated with various cognitive functions, including perception. Their phase and amplitude independently predict cortical excitability and subsequent perceptual performance. However, the causal role of α 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 α oscillations are associated with periodic functional inhibition. (1) High-α 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-α 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 postpulse evoked activity recorded with simultaneous electroencephalography (EEG). We observed that prepulse α phase modulates the probability to perceive a phosphene, predominantly for high-α amplitude, with a nonoptimal phase for phosphene perception between -π/2 and -π/4. The prepulse nonoptimal phase further leads to an increase in postpulse-evoked activity [event-related potential (ERP)], in phosphene-perceived trials specifically. Together, these results show that α oscillations create periodic inhibitory moments when α amplitude is high, leading to periodic decrease of perceptual performance. This study provides strong causal evidence in favor of the pulsed inhibition theory.

When can maximal efficacy occur with repeat botulinum toxin injection in upper limb spastic paresis?

Repeated injection cycles with abobotulinumtoxinA, a botulinum toxin type A, are recommended in current clinical guidelines as a treatment option for adults with upper limb spastic paresis. However, the magnitude of the maximal therapeutic effect of repeated abobotulinumtoxinA treatment across different efficacy parameters and the number of injection cycles required to reach maximal effect remain to be elucidated. Here, we present a post hoc exploratory analysis of a randomized, double-blind, placebo-controlled trial (12-24 weeks; NCT01313299) and open-label extension study (up to 12 months; NCT0131331), in patients aged 18-80 years with hemiparesis for ≥6 months after stroke/traumatic brain injury. Two inferential methods were used to assess the changes in efficacy parameters after repeat abobotulinumtoxinA treatment cycles: Mixed Model Repeated Measures analysis and Non-Linear Random Coefficients analysis. Using the latter model, the expected maximal effect size (not placebo-controlled) and the number of treatment cycles to reach 90% of this maximal effect were estimated. Treatment responses in terms of passive and perceived parameters (i.e. modified Ashworth scale in primary target muscle group, disability assessment scale for principal target for treatment or limb position, and angle of catch at fast speed) were estimated to reach near-maximal effect in two to three cycles. Near-maximal treatment effect for active parameters (i.e. active range of motion against the resistance of extrinsic finger flexors and active function, assessed by the Modified Frenchay Scale) was estimated to be reached one to two cycles later. In contrast to most parameters, active function showed greater improvements at Week 12 (estimated maximal change from baseline-modified Frenchay Scale overall score: +0.8 (95% confidence interval, 0.6; 1.0) than at Week 4 (+0.6 [95% confidence interval, 0.4; 0.8]). Overall, the analyses suggest that repeated treatment cycles with abobotulinumtoxinA in patients chronically affected with upper limb spastic paresis allow them to relearn how to use the affected arm with now looser antagonists. Future studies should assess active parameters as primary outcome measures over repeated treatment cycles, and assess efficacy at the 12-week time-point of each cycle, as the benefits of abobotulinumtoxinA may be underestimated in the studies of insufficient duration. Abbreviated summary In this post hoc analysis of repeated abobotulinumtoxinA injection cycles in upper limb spastic paresis, Gracies et al. used statistical modelling to elucidate the maximal therapeutic effect of abobotulinumtoxinA. Notably, the number of injections required to reach this maximal effect was higher for active (e.g. active function) compared with passive (e.g. tone) parameters.

Controlling for lesions, kinematics and physiological noise: impact on fMRI results of spastic post-stroke patients.

Functional magnetic resonance imaging (fMRI) is a widely used technique for assessing brain function in both healthy and pathological populations. Some factors, such as motion, physiological noise and lesion presence, can contribute to signal change and confound the fMRI data, but fMRI data processing techniques have been developed to correct for these confounding effects. Fifteen spastic subacute stroke patients underwent fMRI while performing a highly controlled task (i.e. passive extension of their affected and unaffected wrists). We investigated the impact on activation maps of lesion masking during preprocessing and first- and second-level analyses, and of adding wrist extension amplitudes and physiological data as regressors using the Statistical Parametric Mapping toolbox (SPM12). We observed a significant decrease in sensorimotor region activation after the addition of lesion masks and movement/physiological regressors during the processing of stroke patients' fMRI data. Our results demonstrate that:•The unified segmentation routine results in good normalization accuracy when dealing with stroke lesions regardless of their size;•Adding a group lesion mask during the second-level analysis seems to be a suitable option when none of the patients have lesions in target regions. Otherwise, no masking is acceptable;•Movement amplitude is a significant contributor to the sensorimotor activation observed during passive wrist extension in spastic stroke patients;•Movement features and physiological noise are relevant factors when interpreting for sensorimotor activation in studies of the motor system in patients with brain lesions. They can be added as nuisance covariates during large patient groups' analyses.

Kinematic parameters obtained with the ArmeoSpring for upper-limb assessment after stroke: a reliability and learning effect study for guiding parameter use.

BACKGROUND: After stroke, kinematic measures obtained with non-robotic and robotic devices are highly recommended to precisely quantify the sensorimotor impairments of the upper-extremity and select the most relevant therapeutic strategies. Although the ArmeoSpring exoskeleton has demonstrated its effectiveness in stroke motor rehabilitation, its interest as an assessment tool has not been sufficiently documented. The aim of this study was to investigate the psychometric properties of selected kinematic parameters obtained with the ArmeoSpring in post-stroke patients. METHODS: This study involved 30 post-stroke patients (mean age = 54.5 ± 16.4 years; time post-stroke = 14.7 ± 26.7 weeks; Upper-Extremity Fugl-Meyer Score (UE-FMS) = 40.7 ± 14.5/66) who participated in 3 assessment sessions, each consisting of 10 repetitions of the 'horizontal catch' exercise. Five kinematic parameters (task and movement time, hand path ratio, peak velocity, number of peak velocity) and a global Score were computed from raw ArmeoSpring' data. Learning effect and retention were analyzed using a 2-way repeated-measures ANOVA, and reliability was investigated using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC). RESULTS: We observed significant inter- and intra-session learning effects for most parameters except peak velocity. The measures performed in sessions 2 and 3 were significantly different from those of session 1. No additional significant difference was observed after the first 6 trials of each session and successful retention was also highlighted for all the parameters. Relative reliability was moderate to excellent for all the parameters, and MDC values expressed in percentage ranged from 42.6 to 102.8%. CONCLUSIONS: After a familiarization session, the ArmeoSpring can be used to reliably and sensitively assess motor impairment and intervention effects on motor learning processes after a stroke. Trial registration The study was approved by the local hospital ethics committee in September 2016 and was registered under number 05-0916.

Cross-Modal Functional Connectivity of the Premotor Cortex Reflects Residual Motor Output After Stroke.

Stroke is known to cause widespread activation and connectivity changes resulting in different levels of functional impairment. Recovery of motor functions is thought to rely mainly on reorganizations within the sensorimotor cortex, but increasing attention is being paid to other cerebral regions. To investigate the motor task-related functional connectivity (FC) of the ipsilesional premotor cortex (PMC) and its relation to residual motor output after stroke in a population of mostly poorly recoverd patients. Twenty-four stroke patients (23 right handed, mean age = 52.4 ± 12.6 years) with varying levels of motor deficits underwent functional magnetic resonance imaging while performing different motor tasks (passive mobilization, motor execution, and motor imagery of an extension movement of the unaffected hand [UH] or affected hand [AH]). For the different motor tasks, analyses of cerebral activation and task-related FC of the ipsilesional lateral sensorimotor network (SMN), and particularly the premotor cortex (PMC), were performed. Compared with UH data, FC of the ipsilesional lateral SMN during the passive or active motor tasks involving the AH was decreased with regions of the ipsilesional SMN and was increased with regions of the bilateral frontal and the ipsilesional posterior parietal cortices such as the precuneus (Pcu). During passive wrist mobilization, FC between the ipsilesional PMC and the contralesional SMN was negatively correlated with residual motor function, whereas that with nonmotor regions such as the bilateral Pcu and the contralesional dorsolateral prefrontal cortex was positively correlated with the residual motor function. Cross-modal FC of the ipsilesional PMC may reflect compensation strategies after stroke. The results emphasize the importance of the PMC and other nonmotor regions as prominent nodes involved in reorganization processes after a stroke.

Spastic co-contraction is directly associated with altered cortical beta oscillations after stroke.

OBJECTIVE: Spastic co-contraction is a motor-disabling form of muscle overactivity occurring after a stroke, contributing to a limitation in active movement and a certain level of motor impairment. The cortical mechanisms underlying spastic co-contraction remain to be more fully elucidated, the present study aimed to investigate the role of the cortical beta oscillations in spastic co-contraction after a stroke. METHOD: We recruited fifteen post-stroke participants and nine healthy controls. The participants were asked to perform active elbow extensions. In the study, multimodal analysis was performed to combine the evaluation of three-dimensional elbow kinematics, the elbow muscles electromyographic activations, and the cortical oscillatory activity. RESULTS: The movement-related beta desynchronization was significantly decreased in post-stroke participants compared to healthy participants. We found a significant correlation between the movement-related beta desynchronization and the elbow flexors activation during the active elbow extension in post-stroke participants. When compared to healthy participants, post-stroke participants exhibited significant alterations in the elbow kinematics and greater muscle activation levels. CONCLUSIONS: Cortical beta oscillation alterations may reflect an important neural mechanism underlying spastic co-contraction after a stroke. SIGNIFICANCE: Measuring the cortical oscillatory activity could be useful to further characterize neuromuscular plasticity induced by recovery or therapeutic interventions.

Impact of the EMG normalization method on muscle activation and the antagonist-agonist co-contraction index during active elbow extension: Practical implications for post-stroke subjects.

Electromyographic (EMG) raw signals are sensitive to intrinsic and extrinsic factors. Consequently, EMG normalization is required to draw proper interpretations of standardized data. Specific recommendations are needed regarding a relevant EMG normalization method for participants who show atypical EMG patterns, such as post-stroke subjects. This study compared three EMG normalization methods ("isometric MVC", "isokinetic MVC", "isokinetic MVC kinematic-related") on muscle activations and the antagonist-agonist co-contraction index. Fifteen post-stroke subjects and fifteen healthy controls performed active elbow extensions, followed by isometric and isokinetic maximum voluntary contractions (MVC). Muscle activations were obtained by normalizing EMG envelopes during active movement using a reference value determined for each EMG normalization method. The results showed no significant difference between the three EMG normalization methods in post-stroke subjects on muscle activation and the antagonist-agonist co-contraction index. We highlighted that the antagonist-agonist co-contraction index could underestimate the antagonist co-contraction in the presence of atypical EMG patterns. Based on its practicality and feasibility, we recommend the use of isometric MVC as a relevant procedure for EMG normalization in post-stroke subjects. We suggest combined analysis of the antagonist-agonist co-contraction index and agonist and antagonist activations to properly investigate antagonist co-contraction in the presence of atypical EMG patterns during movement.

Contribution of FEF to Attentional Periodicity during Visual Search: A TMS Study.

Visual search, looking for a target embedded among distractors, has long been used to study attention. Current theories postulate a two-stage process in which early visual areas perform feature extraction, whereas higher-order regions perform attentional selection. Such a model implies iterative communication between low- and high-level regions to sequentially select candidate targets in the array, focus attention on these elements, and eventually permit target recognition. This leads to two independent predictions: (1) high-level, attentional regions and (2) early visual regions should both be involved periodically during the search. Here, we used transcranial magnetic stimulation (TMS) applied over the frontal eye field (FEF) in humans, known to be involved in attentional selection, at various delays while observers performed a difficult, attentional search task. We observed a periodic pattern of interference at ∼6 Hz (theta) suggesting that the FEF is periodically involved during this difficult search task. We further compared this result with two previous studies (Dugué et al., 2011, 2015a) in which a similar TMS procedure was applied over the early visual cortex (V1) while observers performed the same task. This analysis revealed the same pattern of interference, i.e., V1 is periodically involved during this difficult search task, at the theta frequency. Past V1 evidence reappraised for this paper, together with our current FEF results, confirm both of our independent predictions, and suggest that difficult search is supported by low- and high-level regions, each involved periodically at the theta frequency.

Botuloscope: 1-year follow-up of upper limb post-stroke spasticity treated with botulinum toxin.

BACKGROUND: Botuloscope is a cohort study supported by a French public grant and aiming to evaluate a 1-year treatment of the post-stroke spastic upper limb with botulinum toxin type A (BoNT-A) in terms of individual satisfaction with respect to personalized goals and quality of life. METHODS: This was an open-label prospective, multicentric study (11 French centres) that followed 330 adults [mean (SD) age 53.7 (13.7) years] over 1 year; participants had ranked 5 therapeutic goals at inclusion [mean (SD) 5.1 (7.3) years post-stroke], had severe hemiparesis [median motricity index (MI) 40 (Q1-Q3 24 to 60)], and were assessed at inclusion (M0) and at month 3 (M3) and M12. Outcome criteria were: spasticity, range of motion, pain [visual analog scale (VAS)], motor function [Modified Ashworth Scale (MAS)] and activities (MI; Frenchay Arm Test), and overall satisfaction with the achievement of each goal (VAS) and quality of life (Reintegration to Normal Life Index). Criteria at M0 and M12 were compared. Adverse effects were also collected, as were medication changes. RESULTS: The primary goal was comfort and activities for 63% of participants and motor function for 36%. Participants underwent a mean of 2.4 injection sessions, 19% causing adverse effects. The greatest spasticity attenuation occurred with wrist flexors (median decrease in MAS -2 [Q1-Q3; -2 to -1], P<10-3). Fewer individuals took oral anti-spastic drugs (56% at M12 vs 50% at M0; P<10-2). Range of motion increased by 16°, on average (13 to 19; P<10-3) for wrist extension. Pain prevalence decreases at rest (29% at M0 vs. 19% at M12; P<10-4) and during mobilization (64% vs. 43%; P<10-4), and fewer participants took analgesics (25% vs. 17%; P<10-3). Satisfaction was high for the goals "hand hygiene" and "pain release" and moderate for "improvement in upper limb function". However, function was more improved for participants who selected this goal as the first priority than others (P<10-2). Overall, 22% had the goal "improving gait and balance", which was reasonably achieved at M12. Quality of life improved markedly [median 8 (4 to 11) vs. 6 (3 to 10); P<10-4]. Prevalence of complete dissatisfaction with the first objective was 10% to 15%. CONCLUSION: This is the first long-term follow-up of BoNT-A treatment for upper limb spasticity involving a large cohort independent of industry. Quality of life was improved by treating upper limb spasticity with BoNT-A, even at 5 years post-stroke. Personalizing objectives of the treatment amplified its efficacy. BoNT-A was a powerful analgesic when pain was spasticity-related. Treating the spastic upper limb also improved balance and gait abilities.

Supraspinal Control of Recurrent Inhibition during Anisometric Contractions.

PURPOSE: Increase in recurrent inhibition was observed during eccentric compared with isometric and concentric maximal voluntary contractions but the neural mechanisms involved in this specific control of the Renshaw cell activity are unknown. This study was designed to investigate the supraspinal control of the recurrent inhibition during anisometric contractions of the plantar flexor muscles. METHODS: To that purpose, the paired Hoffmann-reflex (H-reflex) technique permitted to assess changes in homonymous recurrent pathway by comparing the modulations of test and conditioning H-reflexes (H' and H1, respectively) in the soleus (SOL) muscle during maximal and submaximal isometric, concentric and eccentric contractions. Submaximal contraction intensity was set at 50% of the SOL electromyographic activity recorded during maximal isometric contraction. Fourteen volunteer subjects participated in an experimental session designed to assess the activity of the recurrent inhibition pathway. RESULTS: The results indicate that the amplitude of H1 normalized to the maximal M-wave were similar (P > 0.05) regardless of the muscle contraction type and intensity. Whatever the contraction intensity, the ratio between H' and H1 amplitudes was significantly decreased (P < 0.05) during eccentric compared with isometric and concentric contractions. Furthermore, this ratio was significantly smaller (P < 0.05) during submaximal compared with maximal contractions whatever the muscle contraction type. CONCLUSION: Together, the current results confirm the supraspinal control of the Renshaw cell activity when muscle contraction intensity is modulated and show that this control remains similar for isometric, concentric and eccentric contractions. Data further suggest that recurrent inhibition pathway may serve as variable gain regulator at motoneuronal level to improve resolution in the control of motor output for the SOL during eccentric contractions.

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study.

INTRODUCTION: Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke. METHODS AND ANALYSIS: 220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored. ETHICS AND DISSEMINATION: Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients. TRIAL REGISTRATION NUMBER: NCT02944929.