Archive for October, 2015
[ARTICLE] Economic modeling of the use of botulinum toxin A in a homogenous patient population based on real-life clinical practice: ULIS-II (The Upper Limb International Spasticity Study); the French perspective
To evaluate the real life practice of the use of botulinum toxin A (BoNT-A) in post-stroke upper limb spasticity and the economic consequences of fair comparisons of the dosing between either abobotulinumtoxinA (Dysport®) or onabotulinumtoxinA (Botox®) or incobotulinumtoxinA (Xeomin®) in France.
ULIS-II is an 18-month, observational, prospective study, conducted in 84 centers in 22 countries. France was the major contributor with 14 centers. Of 456 adults with post-stroke upper limb spasticity presenting for treatment with BoNT-A, 193 patients with the same injected limb segments “upper arm and lower arm” were analyzed for the dose injected for one cycle of BoNT-A. Treatment and concomitant interventions were in accordance with routine local clinical practice. Sample size, mean (SD)/median dose (min–max) in Unit for each BoNT-A and annual cost per patient were calculated using the median dose administered and considering no vial sharing. An injection interval of 12 weeks was simulated for all BoNT-A treatments and the France listed public price was used to ascertain annual cost.
For the abobotulinumtoxinA group (n = 141) a mean (SD)/median (min–max) dose of 665 U (280)/500 U (150–1500) was injected, for the onabotulinumtoxinA group (n = 37) a mean (SD)/median dose of 183 U (99)/200 U (50–500) was injected and for incobotulinumtoxinA (n = 15), a mean (SD)/median dose of 235 U (108)/200 U (100-440) was injected. Based on a BoNT-A injection interval of 12 weeks, the annual cost per patient in France would be 1123 € for abobotulinumtoxinA, 1784 € for onabotulinumtoxinA and 1784 € for incobotulinumtoxinA (based on median doses).
Considering the real life practice of BoNT-A injections and the comparison of treatment groups treated for the same limb segment, this analysis suggests that the use of abobotulinumtoxinA would result potentially in a reduction in the healthcare cost for the treatment of spasticity (−37%) and that more patients could be treated with abobotulinumtoxinA with a given budget.
Source: Economic modeling of the use of botulinum toxin A in a homogenous patient population based on real-life clinical practice: ULIS-II (The Upper Limb International Spasticity Study); the French perspective
[ARTICLE] Transcranial Direct Current Stimulation of the Leg Motor Cortex Enhances Coordinated Motor Output During Walking With a Large Inter-Individual Variability
- tDCS can enhance the coordinated motor output during walking in healthy subjects, but there is large inter-individual variability in response.
- Dual-hemispheric tDCS tends to have a larger effect on the coordinated motor output than uni-hemispheric tDCS.
- tDCS did not result in improved coordinated motor output in the paretic leg of chronic stroke survivors.
Background: Transcranial direct current stimulation (tDCS) can augment force generation and control in single leg joints in healthy subjects and stroke survivors. However, it is unknown whether these effects also result in improved force production and coordination during walking and whether electrode configuration influences these effects.
Objective: We investigated the effect of tDCS using different electrode configurations on coordinated force production during walking in a group of healthy subjects and chronic stroke survivors.
Methods: Ten healthy subjects and ten chronic stroke survivors participated in a randomized double-blinded crossover study. Subjects walked on an instrumented treadmill before and after 10 minutes of uni-hemispheric (UNI), dual-hemispheric (DUAL) or sham tDCS applied to the primary motor cortex.
Resultst: DCS responses showed large inter-individual variability in both subject populations. In healthy subjects tDCS enhanced the coordinated output during walking as reflected in an increased positive work generation during propulsion. The effects of DUAL tDCS were clearer but still small (4.4% increase) compared to UNI tDCS (2.8% increase). In the chronic stroke survivors no significant effects of tDCS in the targeted paretic leg were observed.
Conclusionst: DCS has potential to augment multi-joint coordinated force production during walking. The relative small contribution of the motor cortex in controlling walking might explain why the observed effects are rather small. Furthermore, a better understanding of the inter-individual variability is needed to optimize the effects of tDCS in healthy but especially stroke survivors. The latter is a prerequisite for clinical applicability.
Source: Transcranial Direct Current Stimulation of the Leg Motor Cortex Enhances Coordinated Motor Output During Walking With a Large Inter-Individual Variability – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation
BACKGROUND: Power walking, i.e. walking with emphasized arm swing, increases energy expenditure. To characterize this moderate aerobic fitness exercise, the associated activation patterns of upper limb and trunk muscles need to be known.
AIM: To describe the amount and pattern of EMG activity of upper limb and trunk muscles during power walking and compare it to normal walking and jogging.
METHOD: Twenty volunteers were examined on a treadmill at 6 km/h during (a) normal walking, (b) power walking, (c) jogging. EMG data were collected for the trapezius (TRAP), anterior (AD) and posterior deltoid (PD), biceps (BIC), triceps (TRI), latissimus dorsi (LD) and erector spinae (ES) muscles.
RESULTS: Activity of four muscles (AD, BIC, PD, TRAP) was three- to fivefold stronger during power walking than normal walking (p<0.01). Further significant increases (p<0.01) involved the TRI, LD and ES. Two muscles (AD, TRAP) were more active during power walking than jogging (p<0.05). Normal walking and power walking involved similar EMG patterns of PD, LD, ES.
CONCLUSION: Emphasizing arm swing during power walking triples the EMG activity of upper limb muscles, compared to normal walking. Similar basic temporal muscle activation patterns in both modes of walking suggest a common underlying motor program.
AT A GLANCE
Power walking, i.e. walking with emphasized arm swing, is a moderate aerobic exercise. Compared to normal walking, the EMG activity of upper limb muscles is tripled during power walking. Similar activation patterns of some muscles in both modes of walking suggest a common underlying motor program. Two shoulder muscles are even more active during power walking than during slow running (jogging)
In this article, the motion control problem of a robotic EXOskeletal WRIST (EXOWRIST) prototype is considered. This novel robotic appliance’s motion is achieved via pneumatic muscle actuators, a pneumatic form of actuation possessing crucial attributes for the development of an exoskeleton that is safe, reliable, portable and low-cost. The EXOWRIST’s properties are presented in detail and compared to the recent wrist exoskeleton technology, while its two degrees-of-freedom movement capabilities (extension-flexion, ulnar-radial deviation) are experimentally evaluated on a healthy human volunteer via an advanced nonlinear PID-based control algorithm.
[ARTICLE] Monitoring of Upper Limb Rehabilitation and Recovery after Stroke: An Architecture for a Cloud-Based Therapy Platform
Amongst the therapies available to stroke sufferers, one that is gaining attention is the application of video games to encourage therapeutic movement. The Limbs Alive project at Newcastle University has developed a system that gathers therapeutic game data from patients, uses statistical tools to estimate a number of performance metrics and presents the results to patients and clinicians via web applications. This paper describes the architecture of this system and outlines the various technical challenges that were overcome, including in security and deployment.
[ARTICLE] Effects of Functional Limb Overloading on Symmetrical Weight Bearing, Walking Speed, Perceived Mobility, and Community Participation among Patients with Chronic Stroke – Full Text HTML
Background. Stroke is a leading cause for long-term disability that often compromises the sensorimotor and gait function accompanied by spasticity. Gait abnormalities persist through the chronic stages of the condition and only a small percentage of these persons are able to walk functionally in the community.
Material and Method. Patients with chronic stroke were recruited from outpatient rehabilitation unit at Department of Neurology & Neurosurgery, All India Institute of Medical Sciences, having a history of first stroke at least six months before recruitment, with unilateral motor deficits affecting gait. The patients were randomly assigned to either the functional limb overloading (FLO) or Limb Overloading Resistance Training (LORT) group and provided four weeks of training.
Result. We found that there was an improvement in gait performance, weight bearing on affected limb, and perceived mobility and community participation.
Conclusion. To the best of our knowledge, this is the first study that has evaluated the effects of functional limb overloading training on symmetric weight bearing, walking ability, and perceived mobility and participation in chronic hemiplegic population. The study demonstrated a beneficial effect of training on all the outcomes, suggesting that the functional limb overloading training can be a useful tool in the management of gait problems in chronic stroke patients.
Stroke is becoming a rapidly increasing problem and an important cause of disability and deaths worldwide. Incidence and prevalence of strokes in Saudi Arabia are comparatively lower than western countries, which could be because of the predominance of the younger age groups in this region . The annual stroke incidence ranged from 27.5 to 63 per 100,000 population and prevalence ranged from 42 to 68 per 100,000 population .
Stroke is a leading cause for long-term disability due to compromised sensorimotor function. Approximately 85% of stroke survivors learn to walk independently by 6 months after stroke, but gait abnormalities persist throughout the chronic stages of the condition. Only a small percentage of stroke survivors are able to walk functionally in the community [3, 4].
The objective of stroke rehabilitation is to enable individual patients to maximize benefits from training in order to attain the highest possible degree of physical and psychological performance. The ultimate goals for many stroke patients are to achieve a level of functional independence necessary for returning home and to integrate as fully as possible into community life.
Ng and Hui-Chan  have noted that weakness in hemiplegic stroke patients is sometimes overshadowed over concerns about treatment of spasticity and synergistic movements. Studies have revealed positive correlations between the strength of specific muscle groups and a variety of functional attributes . Furthermore, a nonlinear relationship between walking performance and muscle strength in the lower extremities has been suggested . However, as the protocols were multifaceted, it was not possible to determine the precise role that the strength-training component may have played in improving walking function.
A number of studies have shown that task specificity and intensity of training are the main determinants of functional improvement after stroke [6, 8, 9]. Moreover, there is growing evidence suggesting that intensive task-oriented practice can induce greater improvement in walking competency than usual practice in stroke survivors [10–12].
Yang et al.  in their study on stroke patients undergoing progressive lower limb strengthening using functional weight bearing activities found moderate increases in walking speed. Sullivan et al.  found that task-specific training with body-weight support is more effective in improving walking speed but lower limb strength training did not provide any added benefit to walking outcomes.
A major limitation to the conclusions from these studies and systematic reviews is the lack of consistency in the intervention and specified protocols [15–17]. Despite the number of studies dedicated to task-oriented training, none of these studies had combined functional task training with prolonged resistance in the form of limb overloading applied 90% of the awake time. Therefore, we designed this study to address the evidence related to our training protocol to enhance symmetric weight bearing and walking speed and its impact on perceived mobility and community participation in patients with chronic stroke.
We hypothesized that intervention programs that combine lower limb overload with functional task training would be more effective at improving walking outcomes and community participation than lower limb overload training alone.
The design of our study was influenced by the literature on lower extremity strength training and task-specific locomotor training [14, 18, 19]. The use of this design should provide…
Traumatic brain injury (TBI) is a major cause of death and disability in the United States, contributing to about 30 percent of all injury deaths, according to The Center for Disease Control and Prevention. People who survive a TBI can face a wide range of side effects, ranging from ones that may last a few days to lifelong disabilities.
The Mighty worked with the Traumatic Brain Injury Support Facebook page to ask people affected by TBI what they wish others understood about their conditions.
This is what they had to say:
1. “People need to learn to not judge you because of it. It makes it more difficult for us to keep moving on in the right direction.” — Erin Fox
2. “I am still capable of doing lots of things. I have worked really, really hard to overcome my injury and although I now suffer from epilepsy and use a seizure alert dog, I am still the smart, capable, funny uncommonly kind person I’ve always been. Stop telling me I can’t and start helping me reach my next goal.” — Kat Mac Kenzie
Stroke Rehabilitation Clinician Handbook
2. Brain Reorganization, Recovery and Organized Care
Robert Teasell MD, Norhayati Hussein MBBS MRehabMed
For people in wheelchairs, finding convenient ways to get around is a huge obstacle. But Kenguru, a new electric car manufactured in the U.S., promises to give disabled people some much-needed independence.
The Kenguru measures 7 feet long and 5 feet high, making it smaller than a Smart Car. It has no seats — drivers simply roll a wheelchair in from a pop-up back door. Designed for use on local roads, the vehicle goes up to 25 miles per hour, with an estimated range of 60 miles. The Kenguru will cost about $25,000, but green energy and mobility tax incentives can bring that price down for qualified buyers.
Kenguru has a long, courageous back story. The original concept, developed by Istvan Kissaroslaki from Hungary many years ago, hadn’t been able to go to market without substantial financial backing. But in 2010, Stacy Zoern, an American lawyer disabled from a muscle disease, came across the Kenguru online and thought it was just what she needed. Zoern eventually convinced Kissaroslaki to move the company to Austin, Texas. The pair has been aggressively pursuing investors ever since.
Last month, the company announced Kenguru is finally going into production in the U.S. Interested buyers can reserve one online, and the first cars are expected to be ready in 12 to 18 months.
Check out this yellow Kenguru hitting the road.