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Botulinum toxin type A is a first-line treatment for post-stroke spasticity, with selective action at nerve endings and minimal effects beyond the injection site. However, concerns about potential adverse reactions due to toxin diffusion and spread can significantly influence physicians' therapeutic decisions in managing post-stroke spasticity. Current evidence shows that while the main formulations of botulinum toxin type A have different molecular weights and sizes, they do not exhibit differing diffusion profiles. Instead, the key factors determining botulinum toxin type A diffusion and spread in post-stroke spasticity management are the dose (i.e., the actual amount of 150 kDa neurotoxin protein injected), dilution, and injection volume. Other injection-related factors, such as the needle gauge and injection speed, have also been suggested to have a secondary influence on botulinum toxin type A diffusion and spread. The needs of patients with post-stroke spasticity may vary, and depending on treatment goals, botulinum toxin type A diffusion and spread can be something to avoid or may offer therapeutic benefits by reaching a greater number of nerve terminals in the target muscle, enhancing the toxin's effect. These factors should be carefully evaluated in spasticity clinics.

Background: Spastic equinus (plantar flexed) foot is a common postural pattern in patients who suffer from post-stroke spasticity. To date, some clinicians use the Silfverskiöld Test in their practice to differentiate between gastrocnemius and soleus muscle overactivity in patients with spastic equinus (plantar flexed) foot. This use of the Silfverskiöld Test goes beyond its original aim, which was to distinguish isolated gastrocnemius contracture in patients with equinus deformity., Aim: The aim of this study was to investigate the Silfverskiöld Test validity for evaluating spastic equinus (plantar flexed) foot (i.e., differentiation between gastrocnemius and soleus muscle overactivity) by checking its outcome against those of selective diagnostic nerve block of tibial motor nerve branches to the soleus, gastrocnemius and tibialis posterior muscles., Design: The design of the study was retrospective observational., Setting: The study was set in a university hospital., Population: Sixty-seven adult stroke patients with spastic equinus (plantar flexed) foot., Methods: Each patient underwent selective diagnostic nerve block of tibial motor nerve branches to the soleus, gastrocnemius and tibialis posterior muscles. All patients were evaluated before diagnostic nerve block by means of the Silfverskiöld Test which was considered positive when ankle joint passive dorsiflexion was greater with the knee flexed than extended. Furthermore, they were assessed before and after nerve block by means of the modified Ashworth Scale and the Tardieu Scale., Results: Our sample included 41 males and 26 females (mean age 57.6 years) suffering from spastic equinus (plantar flexed) foot due to chronic stroke (mean time from onset 2.4 years). Forty-eight patients out of 67 presented with positive Silfverskiöld Test. The χ 2 test showed no association between the Silfverskiöld Test and spastic overactivity of the gastrocnemius (P=0.253), soleus (P=0.605) and tibialis posterior (P=0.462) muscles as evaluated by serial selective diagnostic block of the tibial nerve motor branches., Conclusions: Our findings do not support the Silfverskiöld Test as a valid tool for evaluating spastic equinus (plantar flexed) foot to differentiate between gastrocnemius, soleus and tibialis posterior spastic muscle overactivity in adult patients with stroke., Clinical Rehabilitation Impact: The choice for an appropriate management of spastic equinus (plantar flexed) foot in adults with stroke should not be mainly defined on the base of Silfverskiöld Test.

Introduction: People with poststroke acquired brain injury (ABI) face a complex and often troubled identity reconstruction journey. The literature is rich with studies related to the psychological and neuropsychological components involved in rehabilitation, but it is lacking with respect to the investigation of the existential dimensions and the challenges associated with finding new senses and meanings for one's identity and future perspectives, body and interpersonal relationships., Methods: The aim of this study is to investigate the narrative processes of identity reconstruction after brain damage. Through a qualitative approach, 30 autobiographical narratives about self, body and the relationships with others were collected and analyzed. Semistructured interviews were used for the data collection. Narrative and positioning analysis were applied., Results: Four main positionings emerged: sanctioning a radical break with one's previous life; assuming a sense of salvation and compulsory as well as irreversible adaptation to the limitations associated with one's condition; feeling different and disabled; and considering new possibilities and active constructions of self-being in relationship with others. These results underline the narrative processes of construction of the injury and the identity and delineate possible resources and instruments to improve the clinical practice for health practitioners. They are also valuable for other professionals who deal with neurological services and rehabilitation, such as psychological counselling and support for persons who have experienced ABI and their families., Patient or Public Contribution: This work resulted from a close collaboration between two universities and a hospital neurological rehabilitation department in the Veneto Region (Northern Italy). Three associations of people with stroke and their families living in the same area contributed to designing the research on the basis of the needs expressed by their members with the aim to identify strategies and devices to be implemented in the public service to improve the care pathway. They also participated in the interpretation of the data., (© 2023 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Objective: People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel., Design: This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations., Participants: Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion., Main Measures: The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding 'unsure' responses., Results: Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which 'some agreement' (50%-74% agreement) was achieved and those for which recommendations remain to be clarified were recorded., Conclusions: These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

Background: Physical modalities may be useful to manage poststroke spasticity. Shortwave diathermy has been demonstrated to improve extensibility of the myotendinous tissue. Spasticity may alter morphology of the muscle and its elastic properties. Our main aim was to evaluate the effects of shortwave diathermy on spastic equinus foot in stroke patients., Methods: Ten chronic stroke patients with spastic equinus foot received 10 shortwave diathermy sessions, 5 days/week for 2 consecutive weeks to the spastic calf muscles. Clinical (modified Ashworth Scale and ankle dorsiflexion passive range of motion) and ultrasound (spastic gastrocnemius muscle echo intensity and hardness percentage measured by sonoelastography) evaluation was done before, after treatment, and at two weeks of follow-up., Results: A significant difference in calf muscle spasticity (P=0.004), ankle passive range of motion (P=0.014), and spastic gastrocnemius muscle hardness percentage (P=0.004) was found after treatment. A significant difference in calf muscle spasticity (P=0.004) was found also at the follow-up evaluation., Conclusions: Our preliminary findings support the hypothesis that shortwave diathermy might improve calf muscle tone, ankle passive range of motion, and gastrocnemius muscle elasticity in chronic stroke patients with spastic equinus. This might be due to the deep thermal effects coupled with the rheological direct action of shortwave diathermy on spastic muscles.

While stroke is one of the leading causes of disability, the prediction of upper limb (UL) functional recovery following rehabilitation is still unsatisfactory, hampered by the clinical complexity of post-stroke impairment. Predictive models leading to accurate estimates while revealing which features contribute most to the predictions are the key to unveil the mechanisms subserving the post-intervention recovery, prompting a new focus on individualized treatments and precision medicine in stroke. Machine learning (ML) and explainable artificial intelligence (XAI) are emerging as the enabling technology in different fields, being promising tools also in clinics. In this study, we had the twofold goal of evaluating whether ML can allow deriving accurate predictions of UL recovery in sub-acute patients, and disentangling the contribution of the variables shaping the outcomes. To do so, Random Forest equipped with four XAI methods was applied to interpret the results and assess the feature relevance and their consensus. Our results revealed increased performance when using ML compared to conventional statistical approaches. Moreover, the features deemed as the most relevant were concordant across the XAI methods, suggesting good stability of the results. In particular, the baseline motor impairment as measured by simple clinical scales had the largest impact, as expected. Our findings highlight the core role of ML not only for accurately predicting the individual outcome scores after rehabilitation, but also for making ML results interpretable when associated to XAI methods. This provides clinicians with robust predictions and reliable explanations that are key factors in therapeutic planning/monitoring of stroke patients.

Somatosensory disorders are often present after cerebral stroke. These deficits are associated with patients' disability. Therefore, their rehabilitation takes an importance in recovery program. However, the treatment of sensation remains poorly considered during neurorehabilitation and evidence for active sensory training is limited. Mirror Box Therapy is a simple training used to treat upper extremity motor deficits and pain also in patients with stroke. However, the effects of Mirror Box Therapy on somatosensory impairments in post-stroke patients are not deeply investigated and often exclusively motor exercises are provided during therapy.The aim of the present study was to investigate the effects of Mirror Box Therapy sensory training on somatosensory deficits in a stroke patient presenting upper limb impairment.The patient underwent to four weeks of training, five days a week. Before, during and after the Mirror Box Therapy treatment, the patient was assessed by Rivermead Assessment of Somatosensory Performance. Before and after training also upper limb motor function and performance in activities of daily living were assessed.After training patient showed an improvement in somatosensory performance. The gain was maintained at follow-up.This case report shows the effects of Mirror Box Therapy sensory training on the upper extremity for the improvement of sensation and movement in a patient with a thalamo-capsular hemorrhagic stroke during the subacute phase.

Background: Dysphagia is a primary risk factor for pneumonia and affects around 50% of acute stroke patients. Systematic bedside swallowing screening of acute stroke patients is recommended before oral intake. Currently there is lack of comprehensive dysphagia assessment tools with robust good accuracy, clinical utility and cost-effectiveness. An altered hyoid bone movement may represent a major risk factor for aspiration. Ultrasonography quantitatively measures hyoid-larynx approximation, which was found reduced in stroke patients with dysphagia. Although ultrasonography was suggested for assessing stroke patients with dysphagia, there is lack of evidence about the acute phase of stroke. Thus, our aim was to investigate the use of ultrasonography for bedside screening of dysphagia in acute stroke patients., Methods: Nineteen acute stroke patients were included. Each patient performed clinical bedside screening for dysphagia by means of the Gugging Swallow Screen and the Functional Oral Intake Scale. Furthermore, all patients underwent ultrasonography in order to measure the distance between the thyroid cartilage and hyoid bone during swallowing (water bolus of 3 mL). The hyoid-larynx approximation distance (obtained by subtracting [a-b] the shortest distance between the hyoid bone and thyroid cartilage during swallowing (b) from the initial resting distance (a) and degree {[(a-b)/a]×100} were calculated)., Results: The Functional Oral Intake Scale showed a significant direct association with the hyoid-larynx approximation distance (P=0.011) and degree (P=0.005). Also, the Gugging Swallow Screen showed a significant direct association with the hyoid-larynx approximation distance (P=0.008) and degree (P=0.004). The hyoid-larynx approximation distance and degree were significantly reduced in dysphagic patients., Conclusions: Our findings support the use of ultrasonography in aid of swallowing clinical (non-instrumental) evaluation for the bedside screening of dysphagia in acute stroke patients.

Background: The COVID-19 pandemic has affected health-care systems worldwide, including the outpatient spasticity care with botulinum neurotoxin toxin type A (BoNT-A)., Aim: The aim of this study was to investigate the impact of discontinuation of BoNT-A treatment on patients living with spasticity during the COVID-19 quarantine., Design: A multicentric cross-sectional study., Setting: Outpatients setting., Population: Patients with spasticity after stroke and traumatic brain injury treated with BoNT-A., Methods: A phone-based survey was conducted from March to May, 2020. Based on the International Classification of Functioning, Disability and Health (ICF), an ad hoc questionnaire CORTOX (CORonavirus TOXin survey) was developed to investigate patients' experiences following the discontinuation of their usual treatment for spasticity due to the lockdown and its implication on their health perception. It assessed patients' condition and explored different ICF domains related to spasticity: unpleasant sensations, mobility, self-care, facilitators and psychosocial factors. The sum of those represented the CORTOX score (Max 142). The questionnaire also collected data about the impact of COVID-19 on patients' wellbeing (mood, sleep, relationships, community life, motivation)., Results: A total of 151 participants completed the survey. Most participants (72.2%) experienced a worsening in perceived spasticity, 53% got worse in independence and 70.9% had a negative impact on quality of life. The mean CORTOX score was 52.85±27.25, reflecting a perceived worsening in all ICF domains investigated. Moderate to strong correlations were found between different sub-scores of the questionnaire and severity of spasticity (P<0.001). COVID-19 psychosocial related factors were associated with loss of independence (P<0.05) but only mood was associated with worsening of spasticity (P<0.001). The lack of rehabilitation therapy was significantly associated with the worsening of independence but not with the worsening of spasticity. Finally, respondents reported that BoNT-A was useful to their condition and should not be discontinued., Conclusions: The discontinuation of BoNT-A treatment was associated with worsening of activities and participation and perceived spasticity. COVID-19 related problems and rehabilitation showed an association with loss of independence., Clinical Rehabilitation Impact: This study will provide useful information in the field of spasticity management using a patient's centred approach, with consistent quantitative and qualitative information.

Early management of spasticity may improve stroke outcome. Botulinum toxin type A (BoNT-A) is recommended treatment for post-stroke spasticity (PSS). However, it is usually administered in the chronic phase of stroke. Our aim was to determine whether the length of time between stroke onset and initial BoNT-A injection has an effect on outcomes after PSS treatment. This multicenter, longitudinal, cohort study included stroke patients (time since onset <12 months) with PSS who received BoNT-A for the first time according to routine practice. The main outcome was the modified Ashworth scale (MAS). Patients were evaluated before BoNT-A injection and then at 4, 12, and 24 weeks of follow-up. Eighty-three patients with PSS were enrolled. MAS showed a significant decrease in PSS at 4 and 12 weeks but not at 24 weeks after treatment. Among the patients with a time between stroke onset and BoNT-A injection >90 days, the MAS were higher at 4 and 12 weeks than at 24 weeks compared to those injected ≤90 days since stroke. Our findings suggest that BoNT-A treatment for PSS should be initiated within 3 months after stroke onset in order to obtain a greater reduction in muscle tone at 1 and 3 months afterwards.

This study aims at exploring disability, health-related quality of life (HrQoL), psychological distress, and psychological features in post-stroke patients with chronic pain. An observational cross-sectional study involving 50 post-stroke patients (25 with chronic pain and 25 without pain) was conducted. The primary outcome was the self-reported level of disability and HrQoL which were both assessed through the Stroke Impact Scale 3.0. Both psychological distress and specific psychological features (i.e., self-efficacy, coping strategies, psychological flexibility, perceived social support) were examined. Post-stroke patients with chronic pain reported statistically significant higher levels of disability and worse HrQoL, higher psychological distress and inflexibility, as well as a lower level of self-efficacy and problem-oriented coping strategies than patients without pain ( p < 0.001). Finally, correlation analysis in the group of stroke survivors with pain showed that higher levels of disability were significantly related to higher psychological distress. This study confirms the negative influence of chronic pain on disability and HrQoL in post-stroke patients and presents preliminary insights on the association between chronic pain, disability, HrQoL, psychosocial distress, and the patient's approach in dealing with personal difficulties and emotions. These findings carry further implications for multidisciplinary management of post-stroke patients with chronic pain.

Background: Upper limb motor deficits in patients with severe stroke often remain unresolved over time. Combining transcranial Direct Current Stimulation with robotic therapy is an innovative neurorehabilitation approach that holds promise to improve upper limb impairment after stroke., Objective: To investigate the effects of robotic training in combination with transcranial Direct Current Stimulation for treating poststroke upper limb impairment., Methods: PubMed, MEDLINE, Cochrane Library, and EMBASE electronic databases were searched using keywords, MeSH terms, and strings: "Stroke"[MeSH] AND ("Upper Extremity"[MeSH] OR "upper limb") AND ("Transcranial Direct Current Stimulation" [MeSH] OR "tDCS") AND ("robotics" OR "robotic therapy"). Full-text articles published in English up to October 2020 were included. Each was rated for quality according to the Physiotherapy Database (PEDro) score: eight out of eleven scored more than 8 points; their results were considered reliable for this review., Results: Of the total of 171 publications retrieved, 11 met the inclusion criteria. The results of studies that examined the same outcome measures were pooled to draw conclusions on the effectiveness of transcranial Direct Current Stimulation and robot-assisted training in corticomotor excitability, upper limb kinematics, muscle strength and tone, function, disability, and quality of life after stroke., Conclusions: To date, there is insufficient evidence to support the hypothesis that transcranial Direct Current Stimulation enhances the effects of robot-assisted arm training in poststroke patients. Further studies with more accurate, comparable and standardized methodology are needed in order to better define the effects of robotic training in combination with transcranial Direct Current Stimulation on poststroke upper limb impairment. Therefore, given the scarce resources available to rehabilitation researches, other, more promising approaches should be given attention.

Equinovarus/equinus foot is a pattern most commonly treated with botulinum toxin type A in patients with post-stroke spasticity involving the lower limbs; the gastrocnemius is the muscle most frequently injected. Spastic equinovarus/equinus can present a mixture of conditions, including spasticity, muscle/tendon shortening, muscle weakness and imbalance. In this study, we wanted to determine whether botulinum toxin treatment affects the ultrasonographic characteristics of post-stroke spastic equinus. The same dose of AbobotulinumtoxinA was injected into the gastrocnemius medialis and lateralis of 21 chronic stroke patients with spastic equinus. Clinical (Ashworth scale and ankle range of motion) and ultrasound (conventional and sonoelastography) evaluation of the treated leg was carried out before and 4 weeks after injection. No significant effects of botulinum toxin treatment on the ultrasonographic characteristics of spastic equinus were observed. As expected, there were significant improvements in ankle passive dorsiflexion range of motion and calf muscle spasticity at 1 month after treatment. There was a direct association between Achilles tendon elasticity and calf muscle spasticity at baseline evaluation. Larger studies with a long-term timeline of serial evaluations are needed to further investigate the possible effects of botulinum toxin injection on spastic muscle characteristics in patients with post-stroke spasticity.

Objective: To evaluate the role of diagnostic nerve block in predicting the outcome of subsequent botulinum toxin type A treatment for spastic equinovarus foot due to chronic stroke., Design: Retrospective observational study., Patients: Fifty chronic stroke patients with spastic equinovarus foot., Methods: Each patient was given diagnostic tibial nerve block (lidocaine 2% perineural injection) assessment followed by botulinum toxin type A inoculation into the same muscles as had been targeted by the nerve block. All patients were evaluated before diagnostic nerve block, after the nerve block, and 4 weeks after botulinum toxin injection. Outcomes were ankle dorsiflexion passive range of motion of the affected side, and calf muscle spasticity, measured with the modified Ashworth scale and the Tardieu Scale., Results: Significant improvements were measured after diagnostic nerve block and botulinum toxin injection compared with the baseline condition. Diagnostic nerve block led to significantly greater improvements in all outcomes than botulinum toxin injection., Conclusion: This study confirmed diagnostic nerve block as a valuable screening tool in deciding whether to treat spastic equinovarus with botulinum toxin. However, the results support the evidence that diagnostic nerve block results in a greater reduction in muscle overactivity than does botulinum toxin type A in patients with spastic equinovarus due to stroke.

Objective: To identify the anatomical landmarks of tibial motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot., Design: Observational study., Patients: Twenty-five chronic stroke patients with spastic equinovarus foot., Methods: Motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked in the affected leg, using ultrasonography, and located in the space (vertical, horizontal and deep) according to the position of the fibular head (proximal/distal) and a virtual line from the middle of the popliteal fossa to the Achilles tendon insertion (medial/lateral)., Results: Mean coordinates for the gastrocnemius medialis motor branch were: 1.5 cm (standard deviation (SD) 2.7) vertical (proximal), 1.7 cm (SD 1.3) horizontal (medial), 1.1 cm (SD 0.4) deep; for the gastrocnemius lateralis motor branch: 0.9 cm (SD 2.2) vertical (proximal), 1.8 cm (SD 1.7) horizontal (lateral), 1.0 cm (SD 0.3) deep; for the soleus motor branch: 1.4 cm (SD 1.1) vertical (distal), 1.6 cm (SD 0.7) horizontal (lateral), 2.8 cm (SD 0.7) deep; and for the tibialis posterior motor branch: 4.3 cm (SD 1.5) vertical (distal), 1.9 cm (SD 0.9) horizontal (lateral), 4.2 cm (SD 0.8) deep., Conclusion: These findings may help in the identification of tibial motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot.

Background and objectives: Hemispatial neglect is a common consequence of stroke, with an estimated incidence of 23%. Interventions for treating hemispatial neglect may be categorized as either top-down or bottom-up processing. The aim of top-down approaches is to train the person to voluntarily compensate for their neglect. Such approaches require awareness of the disorder and a high level of active participation by the patient. Differently, bottom-up approaches are based on manipulation of a patient's sensory environment and so require less awareness of behavioral bias. In line with the latter, it is conceivable that elastic therapeutic taping applied to the left neck surface may provide bottom-up inputs that reduce hemispatial neglect symptoms. The aim of this study was to assess the effect of therapeutic neck taping on visuo-spatial abilities, neck motion, and kinesthetic sensibility in chronic stroke patients with hemispatial neglect. Materials and Methods: After randomization, 12 chronic stroke patients with hemispatial neglect received 30 consecutive days of real (treatment group) or sham (control group) neck taping. The outcomes were as follows: Stars Cancellation Test; neck active range of motion; Letter Cancellation Test; Comb and Razor Test; Cervical Joint Position Error Test evaluated before and after one month of taping. Results: Between-group comparison showed significant differences only for the Cervical Joint Position Error Test after treatment ( p = 0.009). Conclusions: Our preliminary findings support the hypothesis that neck taping might improve cervicocephalic kinesthetic sensibility in chronic stroke patients with hemispatial neglect. Further studies are needed to strengthen our results and better investigate the effects of elastic therapeutic taping on visuo-spatial abilities in stroke patients with hemispatial neglect., Competing Interests: The authors declare no conflict of interest.

Background: Restoration of walking function is a primary concern of neurorehabilitation with respect to the aspired social and vocational reintegration. To date, the best practice for improving gait early after stroke is still object of debate. On one hand, repetitive task-specific approaches with higher intensities of walking have been observed to result in greater improvements of gait after stroke. Conversely there is some evidence that conventional gait training would be more effective for facilitating walking ability after stroke., Aim: To compare the effects of an early treatment protocol of add-on robot-assisted gait training with add-on conventional overground physiotherapy for improving locomotion in non-ambulatory adult stroke patients., Design: Single-blind randomized controlled trial., Setting: Neurorehabilitation hospital., Population: Seventy-four subacute patients with first-ever ischemic stroke., Methods: The patients were randomized into two groups. The training program consisted of forty, 2-hour sessions (including 45 minutes basic training, 45 minutes add-on training plus rest periods), 5 days a week, for 8 consecutive weeks. Patients allocated to the add-on robot-assisted gait training were treated by means of the Lokomat. Patients allocated to the add-on conventional overground gait training aimed at improving postural control during gait, body weight transfer, stability during the stance phase, free swing phase, adequate heel contact and gait pattern. Primary outcome was the modified Emory Functional Ambulation Profile. Secondary outcomes were the Rivermead Motor Index, the Mobility Milestones and the Hochzirl Walking Aids Profile., Results: No significant difference was observed between groups with regards to age (P=0.661), time from stroke onset (P=0.413) and the primary outcome (P=0.854) at baseline evaluation. As to the primary outcome, no significant differences were found between groups at the end of the study. As During the 8-week training, within-group comparisons showed significant improvements of mean modified Emory Functional Ambulation Profile in both groups (P<0.001)., Conclusions: Our results support the hypothesis that an early treatment protocol of robot-assisted gait retraining is not superior to add-on conventional gait training intervention for improving locomotion in non-ambulatory stroke patients., Clinical Rehabilitation Impact: This study might help to better understand the role of robot-assisted gait training in early phase stroke rehabilitation.

Botulinum toxin type A (BoNT-A) is considered the gold standard for the treatment of focal post-stroke spasticity (PSS). However, a recently published study estimated that a significant percentage of patients affected by PSS could benefit from higher doses of BoNT-A than those permitted by current directives in the countries studied. Several studies have reported the use of high doses of BoNT-A in the management of patients affected by severe PSS; however, the most important adverse effect of this drug might be systemic diffusion of the toxin, which could potentially be related to its dose. Even if systemic toxicity is a rare event, fear of systemic toxicity is still the most relevant concern regarding use of high doses. The aim of our narrative review was to show the state of the art on the use of high doses of BoNT-A in patients affected by PSS in order to define the safety profile, focusing on both clinical and instrumental assessment of systemic effects. Current evidence from the literature suggests that higher doses of BoNT-A are effective in reducing spasticity of upper and lower limbs after stroke, with rare occurrence of mild adverse effects. The use of high doses seems to be an effective and safe therapeutic option to reduce multifocal or generalized PSS in selected patients. In particular, the potential role of higher doses in order to improve the functional outcome of these patients should be noted.

Even after rehabilitation, post stroke patients remain disabled. The Post Stroke Checklist (PSC) was developed to highlight unmet needs of community-dwelling stroke patients. The present study set out to validate Post Soft Care-App, designed to administer the PSC using smartphones and tablets, in order to monitor unmet needs in chronic patients. Fifty-three patients and fifteen physiotherapists were enrolled. The therapists administered the PSC to patients using the app, and then completed a structured questionnaire on its usability and utility. The Post Soft Care-App highlighted the following unmet needs: increased spasticity (56.6%), reduced independence in activities of daily living (47.2%), reduced mobility (45.3%), absence of secondary prevention (45.3%). Therapists positively evaluated Post Soft Care-App as useful, practical, quick to complete (96.2%), and effective in helping improve communication with patients (75.5%). The Post Soft Care-App can be considered a valid assessment tool for helping therapists to monitor functional outcomes in chronic patients.

Background: Stroke is a major cause of death and long-term disability across the globe. Previous studies have demonstrated the trainability of stroke survivors and documented beneficial effects of aerobic exercises on cardiovascular fitness and gait ability., Aim: The main aim of this study was to compare the effects of a high-intensity treadmill training (HITT) against low-intensity treadmill training (LITT) on gait ability, quality of life, cardiorespiratory fitness and cost of walking in chronic stroke subjects., Design: Randomized, controlled pilot study., Setting: Patients were recruited among Neurorehabilitation Unit outpatient., Population: The sample was composed of 16 subjects suffering from chronic stroke., Methods: Subjects were enrolled and randomly allocated either in the HITT (N.=8) or in the LITT (N.=8). Both groups performed 3-month training, 3 times per week. Subjects were evaluated before starting the training and after the end of the training by mean of clinical scales (Six-Minute Walk Test, Ten-Meter Walk Test, Health Survey Questionnaire SF-36, Stroke Impact Scale) and instrumental tests (gait analysis, VO2peak and walking energy cost)., Results: Fifteen subjects completed the study and no dropouts were observed. One patient in the LITT refused to initiate the training. The HITT group produced greater improvements than LITT group on the Six-Minute Walk Test (HITT: 64.25 meters, LITT: 6 meters; p=0.005) and Ten-Meter Walk Test performances (HITT: -1.7 s, LITT: 0.6 s; P=0.007), stride length (HITT: 3.3 cm, LITT: 0.4 cm, P=0.003), step length non-paretic side (HITT: 0.5 cm, LITT: 2.4 cm, P=0.008), step length paretic side (HITT: 1.8 cm, LITT: 0.7 cm, P=0.004), cadence (HITT: 1.6 step/min, LITT: 0.6 step/min, P=0.021) and symmetry ratio (HITT: 0.04 cm, LITT: 0.01 cm, P=0.004), VO2peak (HITT: 4.6 mL/kg/min, LITT: 0.87 mL/kg/min; P=0.015) and walking energy cost at 100% of self-selected speed (HITT: -30.8 mL/kg∙km, LITT: -20 5 mL/kg∙km; P=0.021). Significant changes were found on Six-Minute Walk Test (P=0.012) and Ten-Meter Walk Test (P=0.042) performances, spatio-temporal gait parameters (stride length P=0.011, step length paretic side P=0.012, cadence P=0.037 and symmetry ratio P=0.012), VO2peak (P=0.025) and cost of walking at 100% of self-selected speed (P=0.018) in the HITT group. In the LITT no significant results were observed., Conclusions: HITT could be considered a feasible training and led to improvement in gait ability and enhanced VO2peak and reduction in cost of walking compared to LITT., Clinical Rehabilitation Impact: Chronic stroke survivors should be encouraged to engage regular aerobic treadmill training at medium/high intensity. HITT is safe and feasible and has positive effects on gait ability, cardiovascular fitness and cost of walking in subjects with stroke in chronic phase.

Background: Bilateral arm training (BAT) has shown promise in expediting progress toward upper limb recovery in chronic stroke patients, but its neural correlates are poorly understood., Objective: To evaluate changes in upper limb function and EEG power after a robot-assisted BAT in chronic stroke patients., Methods: In a within-subject design, seven right-handed chronic stroke patients with upper limb paresis received 21 sessions (3 days/week) of the robot-assisted BAT. The outcomes were changes in score on the upper limb section of the Fugl-Meyer assessment (FM), Motricity Index (MI), and Modified Ashworth Scale (MAS) evaluated at the baseline (T 0 ), posttraining (T 1 ), and 1-month follow-up (T 2 ). Event-related desynchronization/synchronization were calculated in the upper alpha and the beta frequency ranges., Results: Significant improvement in all outcomes was measured over the course of the study. Changes in FM were significant at T 2 , and in MAS at T 1 and T 2 . After training, desynchronization on the ipsilesional sensorimotor areas increased during passive and active movement, as compared with T 0 ., Conclusions: A repetitive robotic-assisted BAT program may improve upper limb motor function and reduce spasticity in the chronically impaired paretic arm. Effects on spasticity were associated with EEG changes over the ipsilesional sensorimotor network.

Background: Preliminary evidence showed additional effects of anodal transcranial direct current stimulation over the damaged cerebral hemisphere combined with cathodal transcutaneous spinal direct current stimulation during robot-assisted gait training in chronic stroke patients. This is consistent with the neural organization of locomotion involving cortical and spinal control. The cerebellum is crucial for locomotor control, in particular for avoidance of obstacles, and adaptation to novel conditions during walking. Despite its key role in gait control, to date the effects of transcranial direct current stimulation of the cerebellum have not been investigated on brain stroke patients treated with robot-assisted gait training., Objective: To evaluate the effects of cerebellar transcranial direct current stimulation combined with transcutaneous spinal direct current stimulation on robot-assisted gait training in patients with chronic brain stroke., Methods: After balanced randomization, 20 chronic stroke patients received ten, 20-minute robot-assisted gait training sessions (five days a week, for two consecutive weeks) combined with central nervous system stimulation. Group 1 underwent on-line cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere + cathodal transcutaneous spinal direct current stimulation. Group 2 received on-line anodal transcranial direct current stimulation over the damaged cerebral hemisphere + cathodal transcutaneous spinal direct current stimulation. The primary outcome was the 6-minute walk test performed before, after, and at follow-up at 2 and 4 weeks post-treatment., Results: The significant differences in the 6-minute walk test noted between groups at the first post-treatment evaluation (p = 0.041) were not maintained at either the 2-week (P = 0.650) or the 4-week (P = 0.545) follow-up evaluations., Conclusion: Our preliminary findings support the hypothesis that cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere in combination with cathodal transcutaneous spinal direct current stimulation might be useful to boost the effects of robot-assisted gait training in chronic brain stroke patients with walking impairment.

The present paper provides practical guidance on the management of adult spasticity with OnabotulinumtoxinA. Advisory Board members reviewed the available evidence and discussed their personal experiences in order to address the unmet needs in the management of spasticity with botulinum toxin type A identified by the recent Italian Real-Life Post-Stroke Spasticity Survey. Stroke patients should be referred to spasticity services that have adequate facilities and multidisciplinary teams with the necessary training, competence and expertise. The current literature shows a strong correlation between the development of post-stroke spasticity and the degree of central sensorimotor system destruction/disorganization. Use of tools such as the Poststroke Checklist may help clinicians in the long-term follow-up of stroke patients. The maximum dose of onabotulinumtoxinA - according to the current literature this ranges from 300U to 400U for upper limb and from 500U to 600U for lower limb aggregate postures - should be re-considered. In addition, there is a need for future consensus (also based on pharmacoeconomic considerations) on consistent clinical care models for the management of patients with post-stroke spasticity.

Background: So far, the development of robotic devices for the early lower limb mobilization in the sub-acute phase after stroke has received limited attention., Aim: To explore the feasibility of a newly robotic-stationary gait training in sub-acute stroke patients. To report the training effects on lower limb function and muscle activation., Design: A pilot study., Setting: Rehabilitation ward., Population: Two sub-acute stroke inpatients and ten age-matched healthy controls were enrolled. Healthy controls served as normative data., Methods: Patients underwent 10 robot-assisted training sessions (20 minutes, 5 days/week) in alternating stepping movements (500 repetitions/session) on a hospital bed in addition to conventional rehabilitation. Feasibility outcome measures were compliance, physiotherapist time, and responses to self-report questionnaires. Efficacy outcomes were bilateral lower limb muscle activation pattern as measured by surface electromyography (sEMG), Motricity Index (MI), Medical Research Council (MRC) grade, and Ashworth Scale (AS) scores before and after training., Results: No adverse events occurred. No significant differences in sEMG activity between patients and healthy controls were observed. Post-training improvement in MI and MRC scores, but no significant changes in AS scores, were recorded. Post-treatment sEMG analysis of muscle activation patterns showed a significant delay in rectus femoris offset (P=0.02) and prolonged duration of biceps femoris (P=0.04) compared to pretreatment., Conclusions: The robot-assisted training with our device was feasible and safe. It induced physiological muscle activations pattern in both stroke patients and healthy controls. Full-scale studies are needed to explore its potential role in post-stroke recovery., Clinical Rehabilitation Impact: This robotic device may enrich early rehabilitation in subacute stroke patients by inducing physiological muscle activation patterns. Future studies are warranted to evaluate its effects on promoting restorative mechanisms involved in lower limb recovery after stroke.

The tibialis posterior muscle is a frequent target for injection of botulinum toxin during the management of spastic equinovarus foot in adults with post-stroke spasticity. Although it is deep-seated, the needle insertion into the tibialis posterior muscle is usually performed using anatomical landmarks and safety information obtained from healthy subjects and cadavers. Our aim was to evaluate the botulinum toxin injection site for the medial approach to the tibialis posterior muscle in chronic stroke patients with spastic equinovarus foot. Forty-six patients were evaluated at the affected middle lower leg medial surface with ultrasonography according to the following parameters: tibialis posterior muscle depth, thickness, and echo intensity. As to the spastic tibialis posterior, we found a mean muscle depth of 26.5 mm and a mean muscle thickness of 10.1 mm. Furthermore we observed a median tibialis posterior muscle echo intensity of 3.00 on the Heckmatt scale. The tibialis posterior muscle thickness was found to be inversely associated with its depth ( p < 0.001) and echo intensity ( p = 0.006). Furthermore, tibialis posterior muscle depth was found to be directly associated with its echo intensity ( p = 0.004). Our findings may usefully inform manual needle placement into the tibialis posterior for the botulinum toxin treatment of spastic equinovarus foot in chronic stroke patients., Competing Interests: The authors declare no conflict of interest.

Spasticity is common in stroke and multiple sclerosis. To treat spasticity we have a wide range of interventions, whose application may depend not only on the severity of spasticity but also on its etiology. Consequently, a better understanding of muscle spasticity in different neurological diseases may inform clinicians as to the more appropriate therapeutic approach. Our aim was to compare the clinical and ultrasonographic features of spastic equinus in patients with chronic stroke and multiple sclerosis. Thirty-eight patients with secondary progressive multiple sclerosis and 38 chronic stroke patients with spastic equinus were evaluated at the affected ankle according to the following outcomes: modified Ashworth scale, Tardieu scale, passive range of motion, spastic gastrocnemius muscle echo intensity and thickness. Affected calf muscles tone was significantly greater in patients with chronic stroke (modified Ashworth scale P=0.008; Tardieu scale angle P=0.004) as well as spastic gastrocnemius muscle echo intensity (P<0.001). Affected ankle range of motion was significantly greater in patients with multiple sclerosis (P<0.001) as well as spastic gastrocnemius muscle thickness (medialis: P=0.003; lateralis: P=0.004). Our findings evidenced that the same pattern of spasticity (equinus foot) has some different features according to its etiology. This may help the management of spasticity., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Hemiplegic shoulder pain is the most common pain condition after stroke. Suprascapular nerve block is an effective treatment for shoulder pain. The aim of this pilot study was to evaluate the effects of suprascapular nerve block on pain intensity, spasticity, shoulder passive range of motion, and quality of life in long-term chronic stroke patients with hemiplegic shoulder pain. Ten chronic stroke patients (over 2 years from onset) with hemiplegic shoulder pain graded ≥30 mm on the Visual Analogue Scale underwent suprascapular nerve block injection with 1 mL of 40 mg/mL methylprednisolone and 10 mL 0.5% bupivacaine hydrochloride. Main outcome was the Visual Analogue Scale evaluated before and after nerve block at 1 h, 1 week, and 1 month. Secondary outcomes were the modified Ashworth scale and the shoulder elevation, abduction, and external rotation passive range of motion evaluated before the nerve block and after 1 h as well as the American Chronic Pain Association Quality of Life Scale evaluated before and after nerve block at 1 month. The Visual Analogue Scale significantly improved after nerve block at 1 h (P = 0.005) and 1 week (P = 0.011). Significant improvements were found at 1 h after nerve block in the modified Ashworth scale (P = 0.014) and the passive range of motion of shoulder abduction (P = 0.026), flexion (P = 0.007), and external rotation (P = 0.017). The American Chronic Pain Association Quality of Life Scale significantly improved at 1 month after nerve block (P = 0.046). Our findings support the use of suprascapular nerve block for treating hemiplegic shoulder pain in long-term chronic stroke patients.

Current guidelines suggested a dosage up to 600units (U) of botulinum toxin type A (BoNT-A) (onabotulinumtoxinA or incobotulinumtoxinA) in reducing spastic hypertonia with low prevalence of complications, although a growing body of evidence showed efficacy with the use of high doses (>800U). The available evidence mainly referred to a single set of injections evaluating the efficacy and safety of the neurotoxin 30days after the treatment. In a prospective, non-randomized, open-label study, we studied the safety of repeated higher doses of incobotulinumtoxinA in post-stroke upper and lower limb spasticity. Two years after the first set of injections, we evaluated in 20 stroke survivors with upper and lower limb spasticity the long-term safety of repeated high doses of incobotulinumtoxinA (up to 840U) for a total of eight sets of injections. Patients reported an improvement of their clinical picture concerning a reduction of spasticity measured with the Asworth Scale (AS) for elbow, wrist, fingers and ankle flexor muscles and disability measured with the Disability Assessment Scale (DAS) 30days after the last set of injections (eighth set) compared to the baseline (p<0.0001). No difference in AS and DAS scores has been found between t 1 (30days after the first injection set) and t 2 (30days after the eighth set of injections), with also similar safety. In a two-year follow-up, repeated high doses of incobotulinumtoxinA, administered for eight sets of injections, appeared to be safe in patients with upper and lower limb spasticity after stroke without general adverse effects., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The present national survey seeking to identify unmet needs in the management of spasticity with botulinum toxin type A focused on the use of OnabotulinumoxinA, since this is the brand with the widest range of licensed indications in Italy. Physicians from twenty-four Italian neurorehabilitation units compiled a questionnaire about "real-life" post-stroke spasticity management. OnabotulinumtoxinA was reported to be used in the following average doses: upper limb 316.7 ± 79.1 units; lower limb 327.8 ± 152.3; upper and lower limb 543.7 ± 123.7 units. Of the physicians surveyed, 37.5% felt that increasing the frequency of OnabotulinumtoxinA injection would improve its efficacy; 70.8% use electrical stimulation/electromyography guidance (one fourth of injections with no instrumental guidance). Instrumental evaluation was used by 41.7% of the physicians. The participants expressed the view that early identification of post-stroke spasticity would be facilitated by the availability of a post-stroke checklist, and that this should be used by physiotherapists (91.7%), physiatrists (58.3%), family doctors (50%), stroke unit physicians (25%), patients and caregivers (79.2%). According to our findings, the management of poststroke spasticity has several unmet needs that, were they addressed, might improve these patients' clinical outcomes and quality of life. These needs concern patient follow-up, where a clearly defined pathway is lacking; furthermore, there is a need to use maximum doses per treatment and to ensure early intervention on post-stroke spasticity.

To date, few studies focused on prediction of functional recovery after cerebellar stroke. The main aim of this prospective pilot study was to determine the association between cerebellar lesion location and functional outcome in adults with acute cerebellar infarction. We examined 14 patients with first-ever unilateral cerebellar ischemic stroke within 7 days and at 90 days from the onset of stroke by means of the International Cooperative Ataxia Rating Scale. Cerebellar lesions were traced from magnetic resonance imaging performed within 72 h since stroke and region of interest were generated. The association between the International Cooperative Ataxia Rating Scale score and lesion location was determined with the voxel-based lesion-symptom mapping methods implemented in the MRIcro software. Colored lesion-symptom maps representing the z statistics were generated and overlaid onto the MNI-ICBM 152 linear probabilistic atlas of the human brain and the Johns Hopkins University white matter templates. Our results documented that injuries to the V, VI, VIIA Crus I, VIIA Crus II, VIIB, VIIIA, and VIIIB lobules and the middle cerebellar peduncle are significantly associated with the International Cooperative Ataxia Rating Scale (ICARS) score at 1 week after the onset of stroke. Furthermore, we found that injuries to the VI, VIIA Crus I, VIIA Crus II, VIIB, VIIIA, and VIIIB lobules, the dentate nucleus, and the middle cerebellar peduncle are significantly associated with the ICARS score at 3 months since the cerebellar stroke onset. The findings of this pilot study might improve prognostic accuracy of functional outcome in patients with acute cerebellar infarction.

Since the increasing update of the biomolecular scientific literature, biomarkers in stroke have reached an outstanding and remarkable revision in the very recent years. Besides the diagnostic and prognostic role of some inflammatory markers, many further molecules and biological factors have been added to the list, including tissue derived cytokines, growth factor-like molecules, hormones, and microRNAs. The literatures on brain derived growth factor and other neuroimmune mediators, bone-skeletal muscle biomarkers, cellular and immunity biomarkers, and the role of microRNAs in stroke recovery were reviewed. To date, biomarkers represent a possible challenge in the diagnostic and prognostic evaluation of stroke onset, pathogenesis, and recovery. Many molecules are still under investigation and may become promising and encouraging biomarkers. Experimental and clinical research should increase this list and promote new discoveries in this field, to improve stroke diagnosis and treatment., Competing Interests: The authors declare that they have no competing interests.

Background: Pusher behavior (PB) is a little-known postural control disorder characterized by alterations in the perception of body orientation in the coronal (roll) plane. Poststroke PB poses many short- and long-term concerns in clinical practice leading to the longer length of hospital stay and slower functional recovery. The literature on specific rehabilitation training in PB is scant. The aim of this pilot study was to compare the outcomes after postural orientation training using visual and somatosensory cues versus conventional physiotherapy in patients with poststroke PB., Methods: Sixteen patients with PB were enrolled. Eight patients received postural orientation training employing visual and somatosensory cues. Seven patients received conventional physiotherapy. Each patient underwent 20 (50 min/d) individual treatment sessions (5 d/week for 4 weeks). Primary outcome measure was the Scale for Contraversive Pushing (SCP). Secondary outcome measures were the European Stroke Scale (ESS), and the Postural Assessment Scale for Stroke (PASS). Outcomes were assessed at admission, after 1 week, post-treatment, and at 1-month follow-up., Results: No significant between-group differences were measured on primary and secondary outcome measures. Significant within-group changes in performance were noted in both groups. The magnitude of the differences between the postural orientation training and the conventional physiotherapy effects, as measured on the SCP and the PASS, suggests the value of the former approach., Conclusions: Training employing visual and somatosensory cues might reduce pusher behavior severity and improve postural control in poststroke pusher behaviour.

Pain is a common and disabling symptom in patients with stroke, multiple sclerosis (MS), cerebral palsy (CP), spinal cord injury (SCI) and other conditions associated with spasticity, but data on its prevalence, and natural history, as well as guidelines on its assessment and treatment in the field of neurorehabilitation, are largely lacking. The Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) searched and evaluated current evidence on the frequency, evolution, predictors, assessment, and pharmacological and non-pharmacological treatment of pain in patients with stroke, MS, CP, SCI and other conditions associated with spasticity. Patients with stroke, MS, CP, and SCI may suffer from pain related to spasticity, as well as nociceptive and neuropathic pain (NP), whose prevalence, natural history, impact on functional outcome, and predictors are only partially known. Diagnosis and assessment of the different types of pain in these patients is important, because their treatment may differ. Botulinum neurotoxin is the first choice treatment for spasticity, while some antidepressant and antiepileptic drugs may be effective on NP, but pharmacological treatment varies according to the underlying disease. In most cases, a single therapy is not sufficient to treat pain, and a multidisciplinary approach, which include pharmacological and non-pharmacological treatments is needed. Further studies, and in particular randomized controlled trials, are needed on these topics.

The development of an innovative functional assessment procedure based on the combination of electroencephalography (EEG) and robot-assisted upper limb devices may provide new insights into the dynamics of cortical reorganization promoted by rehabilitation. The aim of this study was to evaluate changes in event-related synchronization/desynchronization (ERS/ERD) in alpha and beta bands in a patient with pure sensory stroke who underwent a specific rehabilitation program for somatic sensation recovery. A 49-year-old, right-handed woman (time since stroke, 12 months) with severe upper limb somatic sensation deficits was tested using validated clinical scales and a standardized video-EEG system combined with the Bi-Manu-Track robot-assisted arm trainer protocol. The patient underwent a 3-month home-based rehabilitation program for promoting upper limb recovery (1 hour a day for 5 days a week). She was tested before treatment, at 1-month, and at 3-month during treatment. Results showed progressive recovery of upper limb function over time. These effects were associated with specific changes in the modulation of alpha and beta event-related synchronization/desynchronization. This unique study provides new perspectives for the assessment of functional deficits and changes in cortical activity promoted by rehabilitation in poststroke patients., (© EEG and Clinical Neuroscience Society (ECNS) 2014.)

Stroke is a major cause of dysphagia. Few studies to date have reported on standardized multidisciplinary protocolized approaches to the management of post-stroke dysphagia. The aim of this retrospective cohort study was to evaluate the impact of a standardized multidisciplinary protocol on clinical outcomes in patients with post-stroke dysphagia. We performed retrospective chart reviews of patients with post-stroke dysphagia admitted to the neurological ward of Verona University Hospital from 2004 to 2008. Outcomes after usual treatment for dysphagia (T- group) were compared versus outcomes after treatment under a standardized diagnostic and rehabilitative multidisciplinary protocol (T+ group). Outcome measures were death, pneumonia on X-ray, need for respiratory support, and proportion of patients on tube feeding at discharge. Of the 378 patients admitted with stroke, 84 had dysphagia and were enrolled in the study. A significantly lower risk of in-hospital death (odds ratio [OR] 0.20 [0.53-0.78]), pneumonia (OR 0.33 [0.10-1.03]), need for respiratory support (OR 0.48 [0.14-1.66]), and tube feeding at discharge (OR 0.30 [0.09-0.91]) was recorded for the T+ group (N = 39) as compared to the T- group (N = 45). The adjusted OR showed no difference between the two groups for in-hospital death and tube feeding at discharge. Use of a standardized multidisciplinary protocolized approach to the management of post-stroke dysphagia may significantly reduce rates of aspiration pneumonia, in-hospital mortality, and tube feeding in dysphagic stroke survivors. Consistent with the study's exploratory purposes, our findings suggest that the multidisciplinary protocol applied in this study offers an effective model of management of post-stroke dysphagia.

Objective: To investigate the accuracy of manual needle placement for injection of botulinum toxin type A into the forearm muscles of adults with spastic flexed wrist and clenched fist as a consequence of stroke., Design: Prospective clinical study., Patients: A total of 41 adults with chronic stroke who were scheduled to receive botulinum toxin type A injection into the following forearm muscles: flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and flexor digitorum profundus., Methods: According to Huber & Heck's atlas suggestions on treatment of spasticity with botulinum toxin, surface identification of muscles to inject was performed by means of palpation and anatomical landmarks. Accuracy of needle placement and muscle thickness at the site of needle insertion were assessed using ultrasonography., Results: Overall accuracy of manual needle placement evaluated using ultrasonography was 51.2%. Accuracy was significantly higher for the finger flexors than for the wrist flexors (63.4% vs 39.0%). The finger flexors were significantly thicker than the wrist flexors (mean 1.58 vs 0.49 cm)., Conclusion: Instrumental guidance should be used in order to achieve an acceptable accuracy of needle placement when performing botulinum toxin type A injections into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist.

Objective: To find more accurate indices that could affect decisions in spasticity treatment by investigating the relation between ultrasonographic, electromyographic, and clinical parameters of the gastrocnemius muscle in adults with spastic equinus after stroke., Design: Observational study., Setting: University hospitals., Participants: Chronic patients with stroke with spastic equinus (N=43)., Interventions: Not applicable., Main Outcome Measures: Ultrasonographic features were spastic gastrocnemius muscle echo intensity, muscle thickness, and posterior pennation angle of the gastrocnemius medialis (GM) and gastrocnemius lateralis (GL) in both legs. Electromyographic evaluation included compound muscle action potentials (CMAPs) recorded from the GM and GL of both legs. Clinical assessment of the spastic gastrocnemius muscle was performed with the Modified Ashworth Scale (MAS) and by measuring ankle dorsiflexion passive range of motion (PROM)., Results: Spastic muscle echo intensity was inversely associated with proximal (GM and GL: P=.002) and distal (GM and GL: P=.001) muscle thickness, pennation angle (GM: P< .001; GL: P=.01), CMAP (GM: P=.014; GL: P=.026), and ankle PROM (GM: P=.038; GL: P=.024). The pennation angle was directly associated with the proximal (GM and GL: P< .001) and distal (GM: P=.001; GL: P< .001) muscle thickness of the spastic gastrocnemius muscle. The MAS score was directly associated with muscle echo intensity (GM: P=.039; GL: P=.027) and inversely related to the pennation angle (GM and GL: P=.001) and proximal (GM: P=.016; GL: P=.009) and distal (GL: P=.006) muscle thickness of the spastic gastrocnemius., Conclusions: Increased spastic muscle echo intensity was associated with reduced muscle thickness, posterior pennation angle, and CMAP amplitude in the gastrocnemius muscle. Building on previous evidence that these instrumental features are related to botulinum toxin response, these new findings may usefully inform spasticity treatment decisions., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the outcome of manual needle placement, electrical stimulation and ultrasonography-guided techniques for botulinum toxin injection into the forearm muscles of adults with arm spasticity., Design: Randomized controlled trial., Setting: University hospital., Subjects: Sixty chronic stroke patients with wrist and fingers spasticity., Intervention: After randomization into three groups, each patient received botulinum toxin type A in at least two of these muscles: flexor carpi radialis and ulnaris, flexor digitorum superficialis and profundus (no fascicles selection). The manual needle placement group underwent injections using palpation; the electrical stimulation group received injections with electrical stimulation guidance; the ultrasonography group was injected under sonographic guidance. A sole injector was used., Main Measures: All patients were evaluated at baseline and four weeks after injection., Outcomes: Modified Ashworth Scale; Tardieu Scale; wrist and fingers passive range of motion., Results: One month after injection, Modified Ashworth Scale scores improved more in the electrical stimulation group than the manual needle placement group (wrist: P = 0.014; fingers: P = 0.011), as well as the Tardieu angle (wrist: P = 0.008; fingers: P = 0.015) and passive range of motion (wrist: P = 0.004). Furthermore, Modified Ashworth Scale scores improved more in the ultrasonography group than in the manual needle placement group (wrist: P = 0.001; fingers: P = 0.003), as well as the Tardieu angle (wrist: P = 0.010; fingers: P = 0.001) and passive range of motion (wrist: P < 0.001; proximal interphalangeal joints: P = 0.009). No difference was found between the ultrasonography and electrical stimulation groups., Conclusions: Instrumental guidance may improve the outcome of botulinum toxin injections into the spastic forearm muscles of stroke patients.

Association between the site of brain injury and poststroke spasticity is poorly understood. The present study investigated whether lesion analysis could document brain regions associated with the development of severe upper limb poststroke spasticity. A retrospective analysis was conducted on 39 chronic stroke patients. Spasticity was assessed at the affected upper limb with the modified Ashworth scale (shoulder, elbow, wrist, and fingers). Brain lesions were traced from magnetic resonance imaging performed within the first 7 days after stroke and region of interest images were generated. The association between severe upper limb spasticity (modified Ashworth scale ≥ 2) and lesion location was determined with the voxel-based lesion-symptom mapping method implemented in MRIcro software. Colored maps representing the z statistics were generated and overlaid onto the automated anatomical labeling and the Johns Hopkins University white matter templates provided with MRIcron. Thalamic nuclei were identified with the Talairach Daemon software. Injuries to the insula, the thalamus, the basal ganglia, and white matter tracts (internal capsule, corona radiata, external capsule, and superior longitudinal fasciculus) were significantly associated with severe upper limb poststroke spasticity. Further advances in our understanding of the neural correlates of spasticity may lead to early targeted rehabilitation when key regions are damaged.

Objectives: To assess the use of extracorporeal shock wave therapy (ESWT) for the treatment of equinus foot after stroke and to correlate the ESWT effect on spastic plantar-flexor muscles with echo intensity on the Heckmatt scale., Methods: The prospective open-label study examined 23 patients with poststroke lower limb spasticity. Adults with spastic equinus foot after stroke received one ESWT session on hypertonic plantar-flexor muscles. The effect on spasticity, degree of passive ankle dorsiflexion, and neurophysiological values were evaluated. Before treatment, participants underwent a sonography evaluation of calf muscles to identify echo intensity on the Heckmatt scale., Results: Immediately after the session, ESWT induced a statistically significant reduction in muscle tone, increasing passive ankle dorsiflexion motion. At 30 days of follow-up, the effect persisted only in patients with echo intensity of spastic plantar-flexor muscles graded I, II, or III on the Heckmatt scale without any action related to spinal excitability. Mild adverse events were reported after the treatment but were resolved in a few days., Conclusions: ESWT is safe and efficacious for the treatment of poststroke plantar-flexor muscles spasticity, reducing muscle tone and improving passive ankle dorsiflexion motion. The effect was long lasting in subjects with echo intensity of calf muscles graded I, II, or III but was brief for echo intensity graded IV on the Heckmatt scale. The ESWT effect did not appear to be related to spinal excitability.

Objective: The aim of this study was to compare the clinical outcomes of manual needle placement, electrical stimulation, and ultrasonography-guided techniques for botulinum toxin injection into the gastrocnemius of adults with spastic equinus after stroke., Design: After randomization into three groups, each patient received the same dose of botulinum toxin type A into the lateral and medial head of the gastrocnemius muscle (OnabotulinumtoxinA, 100U per head) of the affected leg. The manual needle placement group (n = 15) underwent injections using anatomic landmarks and palpation; the electrical stimulation group (n = 15) received injections with electrical stimulation guidance; and the ultrasonography group (n = 17) was injected under sonographic guidance. The modified Ashworth scale, the Tardieu scale, and the ankle passive range of motion were measured at baseline and 1 mo after injection. Nonparametric statistical analysis was used., Results: One month after injection, the modified Ashworth scale improved better in the ultrasonography group than in the manual needle placement group (P = 0.008). The ankle passive range of motion improved better in the ultrasonography group than in the electrical stimulation (P = 0.004) and manual needle placement (P < 0.001) groups. No difference was found between groups for the Tardieu scale., Conclusions: Ultrasonography-guided injection technique could improve the clinical outcome of botulinum toxin injections into the gastrocnemius of adults with spastic equinus.

Objective: To investigate the relationship between gastrocnemius muscle echo intensity and response to botulinum toxin type A (BoNT-A) in patients with spastic equinus foot resulting from stroke., Design: Cohort study., Setting: University hospital., Participants: Adult patients (N=56) with spastic equinus foot resulting from stroke scheduled to receive BoNT-A injection into the gastrocnemius muscle., Interventions: All patients were injected with BoNT-A (abobotulinumtoxinA) into the gastrocnemius muscle with an ultrasonography-guided, multisite injection technique. The toxin dose was 250U for the gastrocnemius medialis and 250U for the gastrocnemius lateralis (dilution 500U/2mL) in each patient. All patients were evaluated before and 4 weeks after BoNT-A injection., Main Outcome Measures: Spastic gastrocnemius muscle echo intensity visually graded with the Heckmatt scale. Clinical assessment of the spastic gastrocnemius with the Modified Ashworth Scale, Tardieu Scale, and ankle passive range of motion., Results: Postintervention testing at 4 weeks showed overall significant improvements in the clinical assessment of the spastic gastrocnemius muscle. No significant change was observed in the echo muscle intensity of the spastic gastrocnemius after BoNT-A injection. Post hoc comparisons showed that all clinical outcomes were significantly better in those patients with echo muscle intensity of the spastic gastrocnemius graded II on the Heckmatt scale than those with grades III (P<.001) and IV (P<.001) after botulinum toxin injection., Conclusions: These findings support the hypothesis that patients with higher spastic muscle echo intensity have a reduced response to BoNT-A., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Optimal treatment of spasticity requires a combination of pharmacotherapy and muscle lengthening. We evaluated 13 stroke patients with equinovarus foot randomized to treatment with either botulinum toxin A (BTA) injection plus ankle-foot casting (n=6) or BTA alone (n=7). The tibialis posterior and calf muscles (range of BTA injection: 190 to 320 U) were treated in each patient. Castings were worn at night for four months. Each patient was examined before, and at two and four months after BTA injection using the static and dynamic baropodometric tests, the Modified Ashworth Scale and the 10-meter walking test. At two months, therapeutic effects were observed in both groups. At four months, the study group showed further clinical improvement, while the control group returned to baseline performance. Thus, prolonged stretching of spastic muscles after BTA injection affords long-lasting therapeutic benefit, enhancing the effects of the toxin alone.

Background and Purpose: Early prognosis of arm recovery is a major clinical issue in stroke. The aim of this study was to assess the prognostic value of 4 simple bedside tests., Methods: Forty-eight patients with arm paresis/plegia were evaluated on days 7, 14, 30, 90 and 180 after stroke. Assessment included 4 potential predictors of arm recovery (active finger extension, shoulder abduction, shoulder shrug and hand movement scales) and 3 outcome measures evaluating arm function (Nine Hole Peg Test, Fugl-Meyer arm subtest, Motricity Index arm subtest)., Results: The active finger extension scale was the most powerful prognostic factor. Patients with active finger extension scores >3 had a high probability of achieving good performance as assessed by the Motricity Index., Conclusions: Active finger extension is a reliable early predictor of recovery of arm function in stroke patients.

Background: Humans often use co‐speech gestures to promote effective communication. Attention has been paid to the cortical areas engaged in the processing of co‐speech gestures. Aims: To investigate the neural network underpinned in the processing of co‐speech gestures and to observe whether there is a relationship between areas involved in language and gesture processing. Methods & Procedures: We planned to include studies with neurotypical and/or stroke participants who underwent a bimodal task (i.e., processing of co‐speech gestures with relative speech) and a unimodal task (i.e., speech or gesture alone) during a functional magnetic resonance imaging (fMRI) session. After a database search, abstract and full‐text screening were conducted. Qualitative and quantitative data were extracted, and a meta‐analysis was performed with the software GingerALE 3.0.2, performing contrast analyses of uni‐ and bimodal tasks. Main Contribution: The database search produced 1024 records. After the screening process, 27 studies were included in the review. Data from 15 studies were quantitatively analysed through meta‐analysis. Meta‐analysis found three clusters with a significant activation of the left middle frontal gyrus and inferior frontal gyrus, and bilateral middle occipital gyrus and inferior temporal gyrus. Conclusions: There is a close link at the neural level for the semantic processing of auditory and visual information during communication. These findings encourage the integration of the use of co‐speech gestures during aphasia treatment as a strategy to foster the possibility to communicate effectively for people with aphasia. WHAT THIS PAPER ADDS: What is already known on this subject: Gestures are an integral part of human communication, and they may have a relationship at neural level with speech processing. What this paper adds to the existing knowledge: During processing of bi‐ and unimodal communication, areas related to semantic processing and multimodal processing are activated, suggesting that there is a close link between co‐speech gestures and spoken language at a neural level. What are the potential or actual clinical implications of this work?: Knowledge of the functions related to gesture and speech processing neural networks will allow for the adoption of model‐based neurorehabilitation programs to foster recovery from aphasia by strengthening the specific functions of these brain networks. [ABSTRACT FROM AUTHOR]