Medication by Physical Exercise of the Upper Limb in Deforming Spastic Paresis (Stroke); Conventional Physiotherapy Versus Supervised Self- rehabilitation: A Multicentre Prospective, Controlled and Randomized, Single-blind Study over a Period of One Year

Background: Some patients who have had a stroke develop paresis. With time it can become spastic and even distorting. Spastic deforming paresis is often accentuated in the upper limb. It is a real brake in the performance of daily activities, with a psychological impact. The physical therapy of the upper limb today, appears like a real sea snake. Hence the strategies of physical medication must be thought out, studied and developed on a daily basis to overcome this unsightly condition. Objective: Is conventional physiotherapy more effective than supervised self-rehabilitation, in terms of functional recovery in deforming spastic paresis after stroke of the upper limb? This was the major question / objective of this study. Methods: Our study was a multicenter, prospective, interventional, controlled, and randomized, single-blind study. Comparing conventional physiotherapy versus supervised self-rehabilitation over a 12-month period. We recruited 37 patients in France and Spain more than 6 months after their stroke. The judgment tool used during all phases (1st day; 6 months; 9 months and 12 months) of the assessment was the modified Frenchay scale (MFS). Results: The mean age of our cohort was 69 ± 7 years and the mean mounts after stroke was 11,9 ± 5 months. Supervised self-rehabilitation was significantly superior to conventional physiotherapy during the three evaluations carried out on the modified Frenchay scales. At 6 months: 5.99 ± 4.7 Vs 6.97 ± 2.1 (P <0.5). At 9 months: 6.71 ± 9.4; against 7.83 ± 4.1 (P <0.5). Three months after the follow up, we reassessed the patients to see the residual effect, the retention of acquired knowledge and behavioral adaptation after the protocol: 6.57 ± 11, Vs 7.9 ± 6 (P= 0,14). Conclusion: Supervised self-rehabilitation is more effective than conventional physiotherapy. Because from 6 months, and 9 months, a statistically significant difference is demonstrated. this difference persists even 3 months after stopping the follow-up. For the techniques used in the supervised self-rehabilitation group: learning a motor skill could strengthen the circuits of spinal interneurons that facilitate movement. We realized that learning a simple and reciprocating movement, associated with activo-dynamic stretching, done several times a day on target muscles (antagonists were more significant than traditional physiotherapy which, it was rather holistic and nonspecific) would produce an influence in the spinal cord. And, over time, would promote reciprocal inhibition between antagonist and agonist muscles. All the same, further studies with a larger cohort must be carried out in order to conclude on this mentioned neurophysiological hypothesis.

Case Report: HTLV-1–Induced Adult T-Cell Leukemia and Tropical Spastic Paresis

Human T-lymphotropic virus type 1 (HTLV-1) is a retrovirus endemic in many areas around the world. HTLV-1 can induce the development of adult T-cell leukemia (ATL) or myelopathy/tropical spastic paraparesis (HAM/TSP). We report a patient who presented to our outpatient clinic with massive splenomegaly, weight loss, urinary retention, and lower extremity weakness for the previous 3 years. The patient was found to have positive HTLV-1 by ELISA and Western blot from peripheral blood. Evaluation of the spleen demonstrated T-cell large granular lymphocyte leukemia consistent with ATL. In addition to progressive lower extremity weakness, hyperreflexia and clonus, cerebral spinal fluid was positive for HTLV-1 by ELISA and had a reversed CD4-to-CD8 ratio consistent with HAM/TSP. These findings suggest HTLV-1 induced ATL and HAM/TSP presenting simultaneously in the same patient.

Current trends in the rehabilitation of patients with spastic paresis with focal brain damage

Spasticity is one of the most frequent movement disorders and its development is associated with such CNS lesions as stroke, multiple sclerosis, cerebral palsy, craniocerebral and spinal injuries, CNS tumors, neurodegenerative diseases. Post-stroke spasticity develops in about 40% of patients, and about 15% of patients have severe and disabling spasticity. According to statistics, after TBI, about 75% of patients develop spasticity, and half of them require treatment.Spasticity worsens walking, complicates hygiene, dressing, complicates rehabilitation measures, and reduces the quality of life of patients and his family members. In recent years, this movement disorder has been actively studied, new data have appeared on the pathophysiology of spastic paresis and encouraging data on improving function in patients receiving botulinum toxin injections as part of multidisciplinary rehabilitation.The article presents data from the latest systematic reviews on the effectiveness of various rehabilitation technologies for the treatment of spasticity.The use of botulinum neurotoxin for the treatment of spastic paresis of the upper and lower extremities is the preferred method of complex multidisciplinary rehabilitation of patients with spasticity and has the highest level of evidence.Currently, there is no doubt that botulinum toxin should be used as early as possible in patients with an emerging pathological movement pattern, which can contribute to pattern change and muscle length maintenance. But the question remains: which rehabilitation technology is most effective for enhancing and prolonging the action of botulinum neurotoxin. To date, there is no clear answer to this question.

Motor rehabilitation of the spastic paresis and proprioceptive disorders of the upper limb after focal CNS lesion (case report)

Motor disorders (i.e., spastic paresis of the upper limb) are among the most common complications of a stroke. Motor deficiency (muscle weakness/paresis), increased muscle tone, proprioceptive loss, and lesions of muscles, joints, and surrounding tissues develop in the limb. As a result, its functional rehabilitation is a challenging, long-term, and labor-intensive process. This paper addresses factors that directly affect the functional recovery of the upper limb after stroke. The authors emphasize the importance of timely diagnosis of all lesions using assessment scales, optimal rehabilitation programs, including techniques to recover sensitivity and muscle tone, and current rehabilitation techniques with biofeedback. This rehabilitation allows for adapting patients (particularly younger patients of working age) to society and daily life. This case report describes a 22-year-old man with cerebral infarction in the right temporoparietal in whom relevant diagnostic tools and personalized rehabilitation programs provided an excellent functional outcome. These methods are crucial for motor rehabilitation of patients with spastic paresis of the upper limb and proprioceptive disorders after focal CNS lesion. KEYWORDS: stroke, paresis, spasticity, prognosis, proprioception, rehabilitation, botulinum toxin therapy, biofeedback. FOR CITATION: Khat’kova S.E., Nikolaev E.A., Pogorel’tseva O.A. et al. Motor rehabilitation of the spastic paresis and proprioceptive disorders of the upper limb after focal CNS lesion (case report). Russian Medical Inquiry. 2021;5(10):674–682 (in Russ.). DOI: 10.32364/2587-6821- 2021-5-10-674-682.

Frameshift Variant in Novel Adenosine-A1-Receptor Homolog Associated With Bovine Spastic Syndrome/Late-Onset Bovine Spastic Paresis in Holstein Sires

Since their first description almost 100 years ago, bovine spastic paresis (BSP) and bovine spastic syndrome (BSS) are assumed to be inherited neuronal-progressive diseases in cattle. Affected animals are characterized by (frequent) spasms primarily located in the hind limbs, accompanied by severe pain symptoms and reduced vigor, thus initiating premature slaughter or euthanasia. Due to the late onset of BSP and BSS and the massively decreased lifespan of modern cattle, the importance of these diseases is underestimated. In the present study, BSP/BSS-affected German Holstein breeding sires from artificial insemination centers were collected and pedigree analysis, genome-wide association studies, whole genome resequencing, protein–protein interaction network analysis, and protein-homology modeling were performed to elucidate the genetic background. The analysis of 46 affected and 213 control cattle revealed four significantly associated positions on chromosome 15 (BTA15), i.e., AC_000172.1:g.83465449A&gt;G (–log10P = 19.17), AC_000172.1:g.81871849C&gt;T (–log10P = 8.31), AC_000172.1:g.81872621A&gt;T (–log10P = 6.81), and AC_000172.1:g.81872661G&gt;C (–log10P = 6.42). Two additional loci were significantly associated located on BTA8 and BTA19, i.e., AC_000165.1:g.71177788T&gt;C and AC_000176.1:g.30140977T&gt;G, respectively. Whole genome resequencing of five affected individuals and six unaffected relatives (two fathers, two mothers, a half sibling, and a full sibling) belonging to three different not directly related families was performed. After filtering, a homozygous loss of function variant was identified in the affected cattle, causing a frameshift in the so far unknown gene locus LOC100848076 encoding an adenosine-A1-receptor homolog. An allele frequency of the variant of 0.74 was determined in 3,093 samples of the 1000 Bull Genomes Project.

Gastrocnemius Medialis Muscle Geometry and Extensibility in Typically Developing Children and Children With Spastic Paresis Aged 6–13 Years

Gait of children with spastic paresis (SP) is frequently characterized by a reduced ankle range of motion, presumably due to reduced extensibility of the triceps surae (TS) muscle. Little is known about how morphological muscle characteristics in SP children are affected. The aim of this study was to compare gastrocnemius medialis (GM) muscle geometry and extensibility in children with SP with those of typically developing (TD) children and assess how GM morphology is related to its extensibility. Thirteen children with SP, of which 10 with a diagnosis of spastic cerebral palsy and three with SP of unknown etiology (mean age 9.7 ± 2.1 years; GMFCS: I–III), and 14 TD children (mean age 9.3 ± 1.7 years) took part in this study. GM geometry was assessed using 3D ultrasound imaging at 0 and 4 Nm externally imposed dorsal flexion ankle moments. GM extensibility was defined as its absolute length change between the externally applied 0 and 4 Nm moments. Anthropometric variables and GM extensibility did not differ between the SP and TD groups. While in both groups, GM muscle volume correlated with body mass, the slope of the regression line in TD was substantially higher than that in SP (TD = 3.3 ml/kg; SP = 1.3 ml/kg, p &lt; 0.01). In TD, GM fascicle length increased with age, lower leg length and body mass, whereas in SP children, fascicle length did not correlate with any of these variables. However, the increase in GM physiological cross-sectional area as a function of body mass did not differ between SP and TD children. Increases in lengths of tendinous structures in children with SP exceeded those observed in TD children (TD = 0.85 cm/cm; SP = 1.16 cm/cm, p &lt; 0.01) and even exceeded lower-leg length increases. In addition, only for children with SP, body mass (r = −0.61), height (r = −0.66), muscle volume (r = − 0.66), physiological cross-sectional area (r = − 0.59), and tendon length (r = −0.68) showed a negative association with GM extensibility. Such negative associations were not found for TD children. In conclusion, physiological cross-sectional area and length of the tendinous structures are positively associated with age and negatively associated with extensibility in children with SP.

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

Repeated injection cycles with abobotulinumtoxinA, a botulinum toxin type A, are recommended in current clinical guidelines as a treatment option for adults with upper limb spastic paresis. However, the magnitude of the maximal therapeutic effect of repeated abobotulinumtoxinA treatment across different efficacy parameters and the number of injection cycles required to reach maximal effect remain to be elucidated. Here we present a post hoc exploratory analysis of a randomised, double-blind, placebo-controlled trial (12–24 weeks; NCT01313299) and open-label extension study (up to 12 months; NCT0131331), in patients aged 18–80 years with hemiparesis for ≥6 months following stroke/traumatic brain injury. Two inferential methods were used to assess changes in efficacy parameters after repeat abobotulinumtoxinA treatment cycles: Mixed Model Repeated Measures analysis and Non-Linear Random Coefficients analysis. Using the latter model, the expected maximal effect size (not placebo-controlled) and the number of treatment cycles to reach 90% of this maximal effect were estimated. Treatment responses in terms of passive and perceived parameters (i.e. modified Ashworth scale in primary target muscle group, disability assessment scale for principal target for treatment or limb position, and angle of catch at fast speed) were estimated to reach near-maximal effect in 2–3 cycles. Near-maximal treatment effect for active parameters (i.e. active range of motion against the resistance of extrinsic finger flexors and active function, assessed by the Modified Frenchay Scale) was estimated to be reached 1–2 cycles later. In contrast to most parameters, active function showed greater improvements at Week 12 (estimated maximal change from baseline modified Frenchay scale overall score: +0.8 (95% confidence interval [CI] 0.6; 1.0) than at Week 4 (+0.6 [95% CI 0.4; 0.8]). Overall, the analyses suggest that repeated treatment cycles with abobotulinumtoxinA in patients chronically affected with upper limb spastic paresis allow them to relearn how to use the affected arm with now looser antagonists. Future studies should assess active parameters as primary outcome measures over repeated treatment cycles, and assess efficacy at the 12-week time-point of each cycle, as the benefits of abobotulinumtoxinA may be underestimated in studies of insufficient duration.