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Objective: Aphasia recovery depends on neural reorganization, which can be enhanced by speech-language therapy and noninvasive brain stimulation. Several studies suggested that transcranial direct current stimulation (tDCS) associated with speech-language therapy may improve verbal performance evaluated by analytic tests, but none focused on spontaneous speech. We explored the effect of bihemispheric tDCS on spontaneous speech in patients with poststroke aphasia., Methods: In this multicentric controlled randomized cross-over double-blind study, we included 10 patients with poststroke aphasia (4 had aphasia >6 months and 6 with aphasia <6 months). We combined the sessions of speech-language therapy and bihemispheric tDCS (2 mA, 20 min). After three baseline speech evaluations (1/week), two different conditions were randomly consecutively proposed: active and sham tDCS over 3 weeks with 1 week of washout in between. The main outcome measure was the number of different nouns used in 2 min to answer the question "what is your job.", Results: There was no significant difference between conditions concerning the main outcome measure (p = .47) nor in the number of verbs, adjectives, adverbs, pronouns, repetitions, blank ideas, ideas, utterances with grammatical errors or paraphasias used. Other cognitive functions (verbal working memory, neglect, or verbal fluency) were not significantly improved in the tDCS group. No adverse events occurred., Conclusion: Our results differed from previous studies using tDCS to improve naming in patients with poststroke aphasia possibly due to bihemispheric stimulation, rarely used previously. The duration of the rehabilitation period was short given the linguistic complexity of the measure. This negative result should be confirmed by larger studies with ecological measures.

Study Design: Randomised controlled trial., Objectives: To evaluate the impact of two different word prediction software (WPS) training protocols on text input speed (TIS) in people with tetraplegia and to determine which was the most effective., Setting: Rehabilitation department, Garches, France., Methods: Participants with neurological levels between C6 and C8 were allocated to one of three different groups. The REHAB group underwent training with an occupational therapist. The SELF group carried out a standardised home self-training with a written training guide. The CONTROL group had no training. Participants were assessed at day 15 (D15) and day 30 (D30). The primary outcome was a copying task with and without WPS (WITH and WITHOUT)., Results: Forty-two participants (mean age ± SD of 39.8 ± 12) were included and 38 completed the study. At D30, the mean (95% confidence interval) difference in TIS between the CONTROL and SELF groups was 3.8 [-1.7 to 9.4] characters per minute (cpm) (p = 0.23), between the REHAB and SELF groups was 12.9 [7.4 to 18.4] cpm (p < 0.001), and between the REHAB and CONTROL groups was 9.1 [3.5 to 14.6] cpm (p < 0.001)., Conclusions: The results of this study showed that occupational therapist-supervised training improved TIS but word prediction software did not increase TIS. These results suggest that supervised training should be provided to all individuals who are prescribed with devices and systems to facilitate computer access in order to increase their TIS.

Three-dimensional gait analysis is the gold standard for gait-assessment in patients with stroke. This technique is commonly used to assess the effect of treatment on gait parameters. In clinical practice, three gait analyses are usually carried out (baseline, after treatment and follow-up), the objectives were to define the reproducibility and the Minimum Detectable Change (MDC) for gait parameters in stance and swing measured using 3D-gait analysis, and to assess changes in MDC across three repeated 3D-gait analyses. Three gait analyses (V1, V2 and V3) were performed at 7-day intervals in twenty-six patients with chronic stroke. Kinematic data (in the sagittal plane, during swing and stance) and spatiotemporal data were evaluated for the paretic limb. Reliability was tested using repeated measures ANOVA with a Tukey post hoc test, and the MDC values were calculated for each parameter. Only the range of hip motion during swing changed significantly between V1 and V2, but no other kinematic parameters changed. No significant differences were observed for the spatiotemporal parameters. MDC values were always higher during the V1vsV2 comparison for both kinematic and spatiotemporal parameters. This is the first study to evaluate the MDC for kinematic and spatiotemporal parameters during stance and swing. Reliability of kinematic and spatiotemporal data across sessions was very good over the three sessions. MDC values were the lowest between V2 and V3 for most parameters. Use of the MDC will allow clinicians to more accurately determine the effect of treatments., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Plantar-flexor muscles are key muscles in the control of postural sway. Older fallers present lower maximal plantar-flexor performance than older non-fallers; however, the mechanisms underlying this motor impairment remain to be elucidated. This study aimed to determine whether muscular and neural factors are both involved in the lower maximal plantar-flexor performance of older fallers. The maximal voluntary contraction (MVC) torque, resting twitch torque, voluntary activation level (VAL), and electromyographic (EMG) activities for the soleus, gastrocnemius medialis, gastrocnemius lateralis and tibialis anterior during plantar-flexor MVCs were recorded in 23 older non-fallers (age: 83.3 ± 3.9 years) and 25 older fallers (age: 84.0 ± 4.1 years). The maximal plantar-flexor Hoffmann reflex normalized to the maximal motor potential (H max /M max ) was measured to assess the efficacy of spinal transmission from the Ia-afferent fibers to the α-motoneurons. Older fallers presented lower plantar-flexor MVC torque, resting twitch torque, VAL and EMG activity (P < 0.05). No significant differences between older fallers and non-fallers were found for the H max /M max ratio and dorsi-flexor coactivation. The current findings showed for the first time that both neural and muscular factors associated with the plantar-flexors contributed to the specific alteration of maximal motor performance in older fallers. The lack of a difference in the H max /M max ratio indicated that the efficacy of spinal transmission from the Ia-afferent fibers to the α-motoneurons was not involved in the lower voluntary muscle activation of older fallers. This suggests that supraspinal centers are likely to be involved in the lower voluntary muscle activation observed in older fallers., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: After stroke, spasticity of the rectus femoris (RF) and triceps surae (TS) muscles frequently alters the gait pattern. Knee flexion and ankle dorsiflexion in swing are often reduced, respectively called Stiff Knee Gait (SKG) and equinus. A preliminary uncontrolled study suggested that botulinum toxin type A (BTX-A) injections could improve muscle length and force generated during gait, improving inter-segmental coordination. The aim of this randomised controlled study is thus to evaluate changes in the length of the RF and TS muscles during gait 1 month after either BTX-A or placebo injection in patients with chronic stroke, SKG and spastic equinus. The secondary aims are to evaluate peak length and peak force generated during gait, as well inter-segmental coordination assessed using the continuous relative phase method initially described by Barela et al. in patients with stroke., Methods: This is a prospective, three-centre, randomised, placebo-controlled, triple blind study over 3 months with 4 visits. Forty patients will be included. During visits V1, V3 and V4, length and force generated by RF and TS during gait will be assessed using musculoskeletal models (MSM). Muscle force will also be assessed using an isokinetic dynamometer. Inter segmental coordination will be evaluated using 3D gait analysis and functional tests will be performed. During V2, patients will receive either an injection of BTX-A in the RF and TS muscles or a placebo injection of saline solution., Discussion: We expect an increase in peak length and a decrease in peak force generated by the RF and TS muscles in the BTX-A group 1 month post injection. Moreover, we expect these parameters to be more improved in the BTX-A than the Control group. This is the first study to assess these parameters in a randomised, controlled trial using instrumented methods (isokinetic evaluation and 3D gait analysis). The results should help to improve understanding of the mechanism(s) underlying improvements in inter-segmental coordination that have been found in many previous uncontrolled studies., Trial Registration: ClinicalTrials.gov: NCT01821573 , First received: March 27, 2013 Last updated: September 14, 2016 Last verified: September 2016 Other Study ID Numbers: P110136 AOM11223.

Objective: To assess temporal congruence (the difference in performance-time and time to imagine) between the sub-tasks of the Expanded Timed Up and Go (ETUG) and imagined ETUG (iETUG) tests in patients with hemiparesis following unilateral hemispheric stroke, and to compare the results with those for with healthy subjects., Design: Case-controlled study. Subject/patients: Twenty patients with chronic stroke and 20 healthy subjects., Methods: TUG, ETUG and iETUG test performance times were recorded for all participants. Temporal congruence was calculated with the following formula: (ETUG-iETUG)/[(ETUG+iETUG)/2]*100., Results: Patients' performances were slower than those of healthy subjects for all 5 sub-tasks of the TUG, ETUG and iETUG tests. However, there was no significant difference in temporal congruence between healthy subjects and patients. Intragroup analysis showed significant differences between the executed and the imagined conditions for both groups for the "walking", "turn around" and "sitting" phases (healthy subjects p = 0.01, p = 0.03, p = 0.03, and patients p = 0.01, p = 0.003, p = 0.003, respectively)., Conclusion: Temporal congruence was similar for healthy subjects and patients for all sub-tasks of the ETUG test. Moreover, temporal congruence was reduced for the same sub-tasks of the ETUG test in patients and healthy subjects. This suggests that the motor imagery involved the same cerebral structures in both groups, probably including the cerebellum, since it was intact in all patients.

Introduction: This study aimed to determine the intra- and inter-session reliability of neuromuscular assessment of plantar flexor (PF) muscles at three knee angles., Methods: Twelve young adults were tested for three knee angles (90°, 30° and 0°) and at three time points separated by 1 hour (intra-session) and 7 days (inter-session). Electrical (H reflex, M wave) and mechanical (evoked and maximal voluntary torque, activation level) parameters were measured on the PF muscles. Intraclass correlation coefficients (ICC) and coefficients of variation were calculated to determine intra- and inter-session reliability., Results: The mechanical measurements presented excellent (ICC>0.75) intra- and inter-session reliabilities regardless of the knee angle considered. The reliability of electrical measurements was better for the 90° knee angle compared to the 0° and 30° angles., Conclusions: Changes in the knee angle may influence the reliability of neuromuscular assessments, which indicates the importance of considering the knee angle to collect consistent outcomes on the PF muscles.

Because maximal voluntary strength of the knee extensor muscles can be facilitated by the concomitant application of neuromuscular electrical stimulation (NMES) to the contralateral homologous muscle, we aimed to determine whether this was associated with an enhanced neural drive to the agonist muscles. A secondary goal of this study was to examine the potential dose-response relationship between NMES intensity and contralateral facilitation. Twelve healthy men (age: 30 ± 7 yr) completed several maximal voluntary contractions (MVC) of the left knee extensors while the right quadriceps received low-intensity NMES (10% MVC), high-intensity NMES (30% MVC) or no NMES. Supramaximal paired stimuli were delivered to the left quadriceps muscle during and immediately after the MVCs to assess voluntary activation. The EMG activity of vastus lateralis (VL) and biceps femoris (BF) was recorded. MVC torque, voluntary activation and VL EMG activity were higher for both low-intensity and high-intensity NMES compared to no NMES (P < .05), with no difference between the two NMES conditions. The acute application of NMES to the right quadriceps facilitated MVC strength of the contralateral homonymous muscle by enhancing its efferent neural drive. No evident dose-response relationship between NMES intensity and contralateral facilitation was observed., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Following stroke, patients are often left with hemiparesis that reduces balance and gait capacity. A recent, non-invasive technique, transcranial direct current stimulation, can be used to modify cortical excitability when used in an anodal configuration. It also increases the excitability of spinal neuronal circuits involved in movement in healthy subjects. Many studies in patients with stroke have shown that this technique can improve motor, sensory and cognitive function. For example, anodal tDCS has been shown to improve motor performance of the lower limbs in patients with stroke, such as voluntary quadriceps strength, toe-pinch force and reaction time. Nevertheless, studies of motor function have been limited to simple tasks. Surprisingly, the effects of tDCS on the locomotion and balance of patients with chronic stroke have never been evaluated. In this study, we hypothesise that anodal tDCS will improve balance and gait parameters in patients with chronic stroke-related hemiparesis through its effects at cortical and spinal level., Methods/design: This is a prospective, randomised, placebo-controlled, double-blinded, single-centre, cross-over study over 36 months. Forty patients with chronic stroke will be included. Each patient will participate in three visits: an inclusion visit, and two visits during which they will all undergo either one 30-min session of transcranial direct current stimulation or one 30-min session of placebo stimulation in a randomised order. Evaluations will be carried out before, during and twice after stimulation. The primary outcome is the variability of the displacement of the centre of mass during gait and a static-balance task. Secondary outcomes include clinical and functional measures before and after stimulation. A three-dimensional gait analysis, and evaluation of static balance on a force platform will be also conducted before, during and after stimulation., Discussion: These results should constitute a useful database to determine the aspects of complex motor function that are the most improved by transcranial direct current stimulation in patients with hemiparesis. It is the first essential step towards validating this technique as a treatment, coupled with task-oriented training., Trial Registration: ClinicalTrials.gov, ID: NCT02134158 . First received on 18 December 2013; last updated on 14 September 2016. Other study ID numbers: P120135 / AOM12126, 2013-A00952-43.

Background: Motor imagery (MI) capacity may be altered following stroke. MI is evaluated by measuring temporal congruence between the timed performance of an imagined and an executed task. Temporal congruence between imagined and physical gait-related activities has not been evaluated following stroke. Moreover, the effect of cognitive dysfunction on temporal congruence is not known., Objective: To assess temporal congruence between the Timed Up and Go test (TUG) and the imagined TUG (iTUG) tests in patients with stroke and to investigate the role played by cognitive dysfunctions in changes in temporal congruence., Methods: TUG and iTUG performance were recorded and compared in twenty patients with chronic stroke and 20 controls. Cognitive function was measured using the Montreal Cognitive Assessment (MOCA), the Frontal Assessment Battery at Bedside (FAB) and the Bells Test., Results: The temporal congruence of the patients with stroke was significantly altered compared to the controls, indicating a loss of MI capacity (respectively 45.11 ±35.11 vs 24.36 ±17.91, p = 0.02). Furthermore, iTUG test results were positively correlated with pathological scores on the Bells Test (r = 0.085, p = 0.013), likely suggesting that impairment of attention was a contributing factor., Conclusion: These results highlight the importance of evaluating potential attention disorder in patients with stroke to optimise the use of MI for rehabilitation and recovery. However further study is needed to determine how MI should be used in the case of cognitive dysfunction., Competing Interests: The authors have declared that no competing interests exist.

Background: The benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a cluster-randomized trial of intensive care unit (ICU) admission for critically ill elderly patients., Methods: We designed an interventional open-label cluster-randomized controlled trial in 24 centres in France. Clusters were healthcare centres with at least one emergency department (ED) and one ICU. Healthcare centres were randomly assigned either to recommend a systematic ICU admission (intervention group) or to follow standard practices regarding ICU admission (control group). Clusters were stratified by the number of ED annual visits (<44,616 or >44,616 visits), the presence or absence of a geriatric ward and the geographical area (Paris area vs other regions in France). All elderly patients (≥75 years of age) who got to the ED were assessed for eligibility. Patients were included if they had one of the pre-established critical conditions, a preserved functional status as assessed by an ADL scale ≥4 (0 = very dependent, 6 = independent), a preserved nutritional status (subjectively assessed by physicians) and without active cancer. Exclusion criteria were an ED stay >24 h, a secondary referral to the ED and refusal to participate. The primary outcome was the mortality at 6 months calculated at the individual patient level. Secondary outcomes were ICU and hospital mortality, as well as ADL scale and quality of life (as assessed by the SF-12 Health Survey) at 6 months., Results: Between January 2012 and April 2015, 3036 patients were included in the trial, 1518 patients in 11 clusters allocated to intervention group and 1518 patients in 13 clusters allocated to standard care. There were 51 protocol violations., Conclusions: The ICE-CUB 2 trial was deemed feasible and ethically acceptable. The ICE-CUB 2 trial will be the first cluster-randomized trial to assess the benefits of ICU admission for selected elderly patients on long-term mortality. Trial registration Clinical trials.gov identifier: NCT01508819.

Study Design: This is a prospective clinical study., Objectives: The objectives of this study were to determine text input speed (TIS) in persons with cervical spinal cord injury (SCI) and to study the influence of personal characteristics and type of computer access device on TIS., Setting: This study was conducted in the Rehabilitation Department, Garches, France., Methods: People with cervical SCI were included if their level of injury was between C4 and C8 Asia A or B, and if they were computer users. In addition, able-bodied people were recruited from the hospital staff. Each participant underwent a single evaluation using their usual computer access devices. TIS was evaluated during a 10- min copying task. The relationship between the characteristics of participants with cervical SCI, type of computer access device and TIS were analyzed using a Scheirer-Ray-Hare test (nonparametric test similar to a two-way analysis of variance)., Results: Thirty-five participants with cervical SCI and 21 able-bodied people were included. Median TIS of participants with cervical SCI was 11 (6; 14) words per minute (w.p.m.) and of able-bodied participants was 19 (14; 24) w.p.m. (P=0.001). Median TIS of participants with lesions at or above C5 was 12 (4; 13) w.p.m. and of those with lesions below C5 was 10 (9; 18) w.p.m. (P=0.38) [corrected]. The Scheirer-Ray-Hare test showed that only the type of computer access device significantly influenced TIS. Surprisingly, none of the person's characteristics, including the level of cervical lesion, affected TIS., Conclusion: This is the first study to analyze TIS in a group of participants with cervical SCI. The results showed that only the type of computer access device influenced TIS.

It is known that the somatomedins exist in human serum complexed to specific binding proteins. The existence of unbound somatomedins in serum has never unequivocally been demonstrated. We have characterized the distribution of insulin-like growth factor (IGF) I in different fractions after gel filtration of serum through Sephadex G-200 in neutral buffer. IGF-I was measured by RIA after acid extraction. Seventy-two percent of serum IGF-I was associated with large complexes with an estimated size of about 150,000 daltons and 25% was associated with smaller complexes of about 50,000 daltons. No unbound IGF-I was detected. Ultracentrifugation of 10 ml fresh serum was carried out at 106,000 X g for 17 h, after which the tube was aspirated in 1-ml fractions beginning at the top. IGF-I by RIA in fractions 2 and 3 sedimented with albumin; in fractions 4 to 7, the sedimentation pattern approached that of immunoglobulin G. This shift is consistent with the size distribution of IGF-I complexes demonstrated by gel filtration. The failure to find any significant increase in the concentration of IGF-I relative to albumin in the top 30% of the tube (fractions 1-3) after centrifugation argues against the presence of measurable free IGF-I in these fractions. The ability of upper fractions to bind added [125I]IGF-II proved to closely approximate the binding of the initial serum, indicating little sedimentation of the accessible binding protein. The relative binding of [125I]IGF-II by serum aliquots proved to be markedly concentration dependent. At concentrations above 5% serum, the incremental increase of binding as a function of serum concentration was much reduced. We interpret this to indicate that with dilution there is a dissociation of complexes and an increase in accessible binding sites. This phenomenon may modify tissue delivery of somatomedins in interstitial fluid. The data suggest that in undiluted serum there is no significant concentration of free somatomedins but at the dilution of serum that exists in the interstitial fluid, dissociation of bound somatomedins may be facilitated.

The sucking disk of Giardia is supported by a large, plate-like organelle: the ventral disk cytoskeleton. Extraction by Triton-X 100 of Giardia trophozoites from the mouse gut, or of G. duodenalis or G. lamblia grown from cultures, yields cell-free disk cytoskeletons. Up to 8 flagellar axonemes may be attached to an isolated disk. Disks are seen in the electron microscope to be composed of concentrically coiled microtubules bonded to microribbons. Microribbons are large, laminated structures, linked by dense networks of crossbridges. They are made up of regularly arranged subunits. Microtubules and microribbons are preserved in Triton for long periods, but crossbridges are slowly dissolved. Whereas the addition of ATP causes axonemes to resume bending, active movements were not detected in disks. It seems more likely that a disk is a passive effector, which may be acted upon by other contractile structures of the cytoplasm. It is highly specialized and quintessential cytoskeleton. Disks and axonemes will dissolve in sodium dodecyl sulphate (SDS), and after SDS-gel electrophoresis 2 prominent bands are apparent. One, corresponding to tubulin, migrates in low ionic strength, high pH buffers as 2 closely spaced bands of equal staining density. The other, a smaller protein, is a complex polypeptide band of molecular weight 30 000 Daltons. Allowing for staining differences, the 2 proteins are probably present in cytoskeletons in roughly equal amounts. Because of their size microribbons account for at least 75% of the structured material stained by electron stains in pellets of cytoskeletons. Disk and axoneme microtubules comprise the minority fraction. This result suggests that, like microtubules, microribbons are a source of structural tubulin and probably also contain the 30 000 mol. wt protein.

1. Acanthamoeba lactic dehydrogenase (D-lactate specific, EC 1.1.1.28) has been studied through the use of polyacrylamide gel electrophoresis (PAGE) and isoelectric focusing (PAGIEF). 2. Data from PAGE showed the presence of only a single macromolecular form of the enzyme in trophozoites, but PAGIEF data demonstrated that at least three LDH species occur. 3. Molecular weight determinations indicated a tetrameric assembly state for the enzyme. 4. Multiple molecular forms of the enzyme (isoenzymes) are encoded either by genes at two loci or by two alleles at a single LDH locus.