Search Results (18)

Shoulder spasticity is a common consequence of upper motor neuron lesions and may be associated with soft tissue contractures, limiting functional recovery. While both cryoneurolysis and tendon lengthening procedures are used individually in refractory cases, their combined effect has not been clearly established. It is consequently necessary to assess the efficacy of combining cryoneurolysis and percutaneous pectoral tenotomy in reducing shoulder spasticity and improving passive range of motion in patients with refractory shoulder spasticity and contracture. This retrospective, single-centre cohort study included 15 adults (≥19 years) with chronic shoulder spasticity and clinically confirmed musculotendinous contracture, previously treated with botulinum toxin injections without sufficient functional response, and free of pharmacological effects (last injection >4 months prior). All patients underwent cryoneurolysis targeting motor branches to the pectoral muscles. Outcomes included Modified Ashworth Scale (MAS) and shoulder Passive Range Of Motion (PROM). The combined approach provided significant improvements in spasticity severity for shoulder flexion (p < 0.01) and abduction (p < 0.01), and significant improvements in maximum PROM for shoulder flexion (p < 0.0001) and abduction (p < 0.0001). Combining cryoneurolysis and pectoral tenotomy appears feasible, safe, and clinically beneficial in selected patients with both spasticity and tendon contracture. Cryoneurolysis addresses the neural component, while tenotomy may restore mechanical excursion. This sequential diagnostic and therapeutic approach may enhance personalized management of mixed spastic–contracture shoulder limitations and could be applicable to other joints. Full article

Spasticity, a complex consequence of upper motor neuron lesions, poses challenges for clinical assessment due to its neural and mechanical origins. Traditional scales like the Modified Ashworth and Tardieu Scales provide subjective, context-limited insights, often missing spasticity’s dynamic nature. Neuromusculoskeletal (NMS) modeling offers objective, quantitative insights by integrating patient-specific muscle–tendon properties, reflex dynamics, and multi-joint biomechanics. This scoping review examines advancements in spasticity modeling, comparing mechanical, neurological, and integrated approaches, and their applications in conditions like cerebral palsy and stroke. We highlight barriers to clinical translation, including computational demands and regulatory challenges, and propose future directions, such as real-time simulation and machine learning integration, to enhance personalized assessment and treatment. Full article

Spasticity of the distal lower limb substantially impairs stance, gait, and quality of life in patients with upper motor neuron lesions. Although ultrasound-guided botulinum toxin A (BoNT-A) injections are increasingly employed, structured, muscle-specific visual guidance for the distal lower limb remains limited. This study provides a comprehensive guide for ultrasound-guided BoNT-A injections across ten key distal lower limb muscles: gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, flexor digitorum longus, tibialis anterior, extensor hallucis longus, flexor digitorum brevis, flexor hallucis brevis, and extensor digitorum longus. For each muscle, we present (1) Anatomical positioning relative to osseous landmarks; (2) Sonographic identification cues and dynamic features; (3) Zones of intramuscular neural arborization optimal for injection; (4) Practical injection protocols derived from literature and clinical experience. High-resolution ultrasound images and dynamic videos illustrate real-life muscle behavior and guide injection site selection. This guide facilitates precise targeting by correlating sonographic signs with optimal injection zones, addresses common spastic patterns—including equinus, varus, claw toe, and hallux deformities—and integrates fascial anatomy with motor-point mapping. This article completes the Elias University Hospital visual series, providing clinicians with a unified framework for effective spasticity management to improve gait, posture, and patient autonomy. Full article

Spasticity is a common complication after spinal cord injury (SCI) that significantly diminishes quality of life and complicates daily management. As a hallmark of upper motor neuron lesions, spasticity emerges through a complex post-injury process involving the resolution of spinal shock, an imbalance between excitatory and inhibitory signaling, and maladaptive neuronal plasticity, leading to hyperreflexia and chronic spasticity. Severe spasticity frequently results in pain, sleep disturbances, and marked functional impairments. This review systematically integrates motor neuron alterations with corresponding muscle manifestations, providing a comprehensive analysis of the brain–spinal cord–muscle pathway in spasticity pathogenesis. Through an in-depth analysis of the pathological and physiological changes in motor neurons post-SCI, this review offers a novel perspective that unveils the intrinsic mechanisms underlying spasticity formation, thereby establishing a robust theoretical foundation for developing targeted therapeutic strategies. Full article

Background: Although various theories have been developed to explain ipsilateral hemiparesis, the causes behind this clinical phenomenon are still poorly understood. The main pathophysiological hypotheses include the anatomical variations in decussation of the corticospinal tract, the theory of diaschisis, the Kernohan-Woltman notch phenomenon, and Ectors’ syndrome. The current article aims to report the case of a 43-year-old woman diagnosed with ipsilateral hemiparesis following a right pterional meningioma, later treated by surgery. The different theories behind this paradoxical clinical phenomenon are discussed to elucidate the most likely mechanism behind it. Methods: A 43-year-old right-handed woman with a history of splenomegaly and iron deficiency anemia was admitted to our hospital for refractory headache, right-sided hemiparesis, and generalized tonic-clonic seizures. Clinical examination revealed a right upper motor neuron syndrome, with a grade 4 MRCS muscle strength for the upper and lower limbs. The contrast-enhanced brain MRI revealed an extra-axial right pterional mass lesion with a broad dural base, well-defined margins, and intense post-contrast enhancement, suggestive of meningioma. The patient was surgically treated for the brain lesion. Results: After a Simpson grade I resection with complete removal of the tumor and affected dura, the patient had a favorable local and neurological evolution, and after three weeks, total remission of the symptoms was achieved. Conclusions: To assess the mechanism behind ipsilateral hemiparesis, thorough clinical examination and further research in neuroimaging assessment and functional studies are essential. Full article

Background: Central facial palsy (CFP), resulting from upper motor neuron lesions in the corticofacial pathway, is traditionally characterized by the sparing of the upper facial muscles. However, reports of upper facial weakness in CFP due to acute ischemic stroke have challenged this long-held assumption. This study aimed to determine the prevalence of upper facial weakness in CFP and identify its associated clinical factors. Methods: In this cross-sectional study, we evaluated consecutive patients with acute ischemic stroke admitted to a university hospital in Thailand from January 2022 to June 2023. Full-face video recordings were analyzed using the Sunnybrook Facial Grading System. Upper facial weakness was defined as asymmetry in at least one upper facial expression. Multivariable logistic regression was performed to identify factors associated with upper facial weakness. Results: Of 108 patients with acute ischemic stroke, 92 had CFP, and among these, 70 (76%) demonstrated upper facial weakness. Tight eye closure (force and wrinkle formation, both 42%) was the most sensitive indicator for detecting upper facial weakness. Greater stroke severity, as reflected by higher NIHSS scores (adjusted odds ratio [aOR], 1.42; 95% CI 1.07–1.88) and the presence of lower facial weakness (aOR, 6.56; 95% CI 1.85–23.29) were significantly associated with upper facial involvement. Although upper facial weakness was generally milder than lower facial weakness, its severity correlated with increasing lower facial asymmetry during movement. Conclusions: Contrary to traditional teaching, upper facial weakness is common in CFP due to acute ischemic stroke. The severity of stroke and the presence of lower facial weakness are key predictors of upper facial involvement. These findings underscore the need for clinicians to reconsider the diagnostic paradigm, recognizing that upper facial weakness can occur in CFP. Enhanced awareness may improve diagnostic accuracy, inform treatment decisions, and ultimately lead to better patient outcomes. Full article

Moyamoya disease is a cerebrovascular pathology characterized by progressive stenosis of the internal carotid arteries and their branches, leading to ischemic and/or hemorrhagic disorders of the cerebral circulation, primarily affecting children and young adults. We present a case of a 23-year-old woman with a history of recurrent cerebrovascular accidents since childhood. Despite experiencing focal motor seizures and transient ischemic attacks, her condition remained undiagnosed until 2006, when, at the age of 7, a digital subtraction angiography revealed characteristic bilateral internal carotid artery occlusions. Subsequent diagnostic challenges and treatments preceded a worsening of symptoms in adulthood, including generalized tonic–clonic seizures. Upon presentation to our clinic, the patient exhibited upper motor neuron syndrome and occipital lobe syndrome, consistent with the disease’s pathophysiology, neuroimaging, and clinical manifestations. Imaging studies confirmed multiple ischemic lesions throughout the cerebral vasculature. Treatment adjustments were made due to the increased incidence of seizures, and the dose of her anti-seizure medication—divalproex sodium—was increased. This case underscores the diagnostic complexities and challenges in managing moyamoya disease, emphasizing the importance of early recognition and prompt intervention. Full article

Anxiety and depression are two of the most impactful diseases on quality of life and cause significant disability to patients. It burdens the medical system even as a stand-alone pathology or a secondary condition. These conditions can occur secondarily after a patient suffers from other illnesses, such as upper motor neuron lesions. Binaural beats are a new and emerging type of technology that can be used as an adjunct therapy for anxiety and depression as well as in neurologic conditions to some extent. We searched through the MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, and ICTRP databases to identify studies using binaural beats as therapy for anxiety and depression. Twelve articles were declared eligible to be included in this review. Binaural beats, whether used in the form of pure beats or masked by another sound, have shown better results in alleviating symptoms of anxiety and depression compared to control conditions such as no music or the use of noise-canceling headphones alone. The results suggest that using binaural beats could be a promising and easy-to-use method to help alleviate the symptoms of anxiety and depression. Full article

Background: People with spinal cord injuries (SCIs) often have trouble remaining active because of paralysis. In the past, exercise recommendations focused on the non-paralyzed muscles in the arms, which provides limited benefits. However, recent studies show that electrical stimulation can help engage the paralyzed extremities, expanding the available muscle mass for exercise. Methods: The authors provide an evidence-based approach using expertise from diverse fields, supplemented by evidence from key studies toward the management of electrical stimulation therapies in individuals with SCIs. Literature searches were performed separately using the PubMed, Medline, and Google Scholar search engines. The keywords used for the searches included functional electrical stimulation cycling, hybrid cycling, neuromuscular electrical stimulation exercise, spinal cord injury, cardiovascular health, metabolic health, muscle strength, muscle mass, bone mass, upper limb treatment, diagnostic and prognostic use of functional electrical stimulation, tetraplegic hands, and hand deformities after SCI. The authors recently presented this information in a workshop at a major rehabilitation conference. Additional information beyond what was presented at the workshop was added for the writing of this paper. Results: Functional electrical stimulation (FES) cycling can improve aerobic fitness and reduce the risk of cardiovascular and metabolic diseases. The evidence indicates that while both FES leg cycling and neuromuscular electrical stimulation (NMES) resistance training can increase muscle strength and mass, NMES resistance training has been shown to be more effective for producing muscle hypertrophy in individual muscle groups. The response to the electrical stimulation of muscles can also help in the diagnosis and prognosis of hand dysfunction after tetraplegia. Conclusions: Electrical stimulation activities are safe and effective methods for exercise and testing for motor neuron lesions in individuals with SCIs and other paralytic or paretic conditions. They should be considered part of a comprehensive rehabilitation program in diagnosing, prognosing, and treating individuals with SCIs to improve function, physical activity, and overall health. Full article

Amyotrophic lateral sclerosis (ALS) is a fatal form of neuromuscular disease. The aim of this study was to assess changes in the blink reflex (BR) parameters as a valid and easy-to-use tool in ALS patients. We assessed the BR test in patients with a definitive diagnosis of ALS, healthy volunteers, and patients with diseases affecting the peripheral nervous system. The BR was studied in 29 patients who met the Awaji criteria. Latencies were compared with our healthy controls (N = 50) and other diseases of the peripheral nervous system (N = 61). The ALS Functional Rating Scale—Revised (ALSFRS-R) was used to evaluate functional status. Significantly prolonged R2i and R2c latencies were found in the ALS group compared with the healthy control group (p < 0.001). The latencies of R1, R2i, R2c were all increased in the bulbar subtype compared to the limb-onset subtype (p < 0.05). According to our results, BR examination might be a promising tool to monitor the course of the disease or serve as a prognostic biomarker in patients with ALS, but it should be assessed in further studies. The abnormalities detected through BR might help perform earlier interventions in ALS patients and might be useful in other diseases affecting the peripheral nervous system. Full article

Foot drop during the swing phase of gait and at initial foot contact is a current kinematic abnormality that can occur following an upper motor neuron (UMN) lesion. Functional electrical stimulation (FES) of the common peroneal nerve through an assistive device is often used in neuro-rehabilitation to help patients regain mobility. Although there are FES-specific guideline recommendations, it remains a challenge for clinicians to appropriately select patients eligible for the daily use of FES devices, as very few health insurance systems cover its cost in Europe. In Luxembourg, since 2018, successfully completing an FES clinical pathway called CHECGAIT is a prerequisite to receiving financial coverage for FES devices from the national health fund (Caisse Nationale de Santé—CNS). This study describes the structure and steps of CHECGAIT and reports our experience with a cohort of 100 patients enrolled over a three-year period. The clinical and gait outcomes of all patients were retrospectively quantified, and a specific analysis was performed to highlight differences between patients with and without an FES device prescription at the end of a CHECGAIT. Several significant gait differences were found between these groups. These results and CHECGAIT may help clinicians to better select patients who can most benefit from this technology in their daily lives. In addition, CHECGAIT could provide significant savings to public health systems by avoiding unnecessary deliveries of FES devices. Full article

Sustained involuntary muscle activity (IMA) is a highly disabling phenomenon that arises in the acute phase of an upper motor neuron lesion (UMNL). Wearable probes for long-lasting surface EMG (sEMG) recordings have been recently recommended to detect IMA insurgence and to quantify its evolution over time, in conjunction with a complex algorithm for IMA automatic identification and classification. In this study, we computed sensitivity (Se), specificity (Sp), and overall accuracy (Acc) of this algorithm by comparing it with the classification provided by two expert assessors. Based on sample size estimation, 6020 10 s-long sEMG epochs were classified by both the algorithm and the assessors. Epochs were randomly extracted from long-lasting sEMG signals collected in-field from 14 biceps brachii (BB) muscles of 10 patients (5F, age range 50–71 years) hospitalized in an acute rehabilitation ward following a stroke or a post-anoxic coma and complete upper limb (UL) paralysis. Among the 14 BB muscles assessed, Se was 85.6% (83.6–87.4%); Sp was 89.7% (88.6–90.7%), and overall Acc was 88.5% (87.6–89.4%) and ranged between 78.6% and 98.7%. The presence of IMA was detected correctly in all patients. These results support the algorithm’s use for in-field IMA assessment based on data acquired with wearable sensors. The assessment and monitoring of IMA in acute and subacute patients with UMNL could improve the quality of care needed by triggering early treatments to lessen long-term complications. Full article

Disabling limb spasticity can result from stroke, traumatic brain injury or other disorders causing upper motor neuron lesions such as multiple sclerosis. Clinical studies have shown that abobotulinumtoxinA (AboBoNT-A) therapy reduces upper and lower limb spasticity in adults. However, physicians may administer potentially inadequate doses, given the lack of consensus on adjusting dose according to muscle volume, the wide dose ranges in the summary of product characteristics or cited in the published literature, and/or the high quantity of toxin available for injection. Against this background, a systematic literature review based on searches of MEDLINE and Embase (via Ovid SP) and three relevant conferences (2018 to 2020) was conducted in November 2020 to examine AboBoNT-A doses given to adults for upper or lower limb muscles affected by spasticity of any etiology in clinical and real-world evidence studies. From the 1781 unique records identified from the electronic databases and conference proceedings screened, 49 unique studies represented across 56 publications (53 full-text articles, 3 conference abstracts) were eligible for inclusion. Evidence from these studies suggested that AboBoNT-A dose given per muscle in clinical practice varies considerably, with only a slight trend toward a relationship between dose and muscle volume. Expert-based consensus is needed to inform recommendations for standardizing AboBoNT-A treatment initiation doses based on muscle volume. Full article

Langerhans cells represent the first immune cells that sense the entry of external molecules and microorganisms at the epithelial level in the skin. In this pilot case-study, we evaluated Langerhans cells density and progression of epidermal atrophy in permanent spinal cord injury (SCI) patients suffering with either lower motor neuron lesions (LMNSCI) or upper motor neuron lesions (UMNSCI), both submitted to surface electrical stimulation. Skin biopsies harvested from both legs were analyzed before and after 2 years of home-based Functional Electrical Stimulation for denervated degenerating muscles (DDM) delivered at home (h-bFES) by large anatomically shaped surface electrodes placed on the skin of the anterior thigh in the cases of LMNSCI patients or by neuromuscular electrical stimulation (NMES) for innervated muscles in the cases of UMNSCI persons. Using quantitative histology, we analyzed epidermal thickness and flattening and content of Langerhans cells. Linear regression analyses show that epidermal atrophy worsens with increasing years of LMNSCI and that 2 years of skin electrostimulation reverses skin changes, producing a significant recovery of epidermis thickness, but not changes in Langerhans cells density. In UMNSCI, we did not observe any statistically significant changes of the epidermis and of its content of Langerhans cells, but while the epidermal thickness is similar to that of first year-LMNSCI, the content of Langerhans cells is almost twice, suggesting that the LMNSCI induces an early decrease of immunoprotection that lasts at least 10 years. All together, these are original clinically relevant results suggesting a possible immuno-repression in epidermis of the permanently denervated patients. Full article

Spasticity is a common sequala of the upper motor neuron lesions. For instance, it often occurs in the first 4 weeks after stroke and is seen in more than one-third of stroke survivors after 12 months. In recent years, extracorporeal shock wave therapy (ESWT) has been recognized as a safe and effective method for reducing muscle spasticity. Possible/relevant mechanisms include nitric oxide production, motor neuron excitability reduction, induction of neuromuscular transmission dysfunction, and direct effects on rheological properties. There are two types of ESWT, focused and radial, with the radial type more commonly applied for treating muscle spasticity. Concerning the optimal location for applying ESWT, the belly muscles and myotendinous junction seem to produce comparable results. The effects of ESWT on spasticity are known to last at least four to six weeks, while some studies report durations of up to 12 weeks. In this review, the authors will focus on the current evidence regarding the effectiveness of ESWT in spasticity, as well as certain technical parameters of ESWT, e.g., the intensity, frequency, location, and number of sessions. The pertinent literature has been reviewed, with an emphasis on post-stroke upper limbs, post-stroke lower limbs, cerebral palsy, and multiple sclerosis. In short, while ESWT has positive effects on parameters such as the modified Ashworth scale, mixed results have been reported regarding functional recovery. Of note, as botulinum toxin injection is one of the most popular and effective pharmacological methods for treating spasticity, studies comparing the effects of ESWT and botulinum toxin injections, and studies reporting the results of their combination, are also reviewed in this paper. Full article