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Curved walking in hemiparetic patients
S62
Abstracts / Gait & Posture 33S (2011) S1–S66
Fig. 1. Traces of the finger tip for a healthy subject (left) and an ataxic patient (right) while executing the random test with the dominant limb
progress over time of patients affected by progressive pathologies, such as ataxia, a group of rare genetic diseases whose main symptom is the progressive loss of motor coordination. Previous studies [1,2] analyzed upper limb movements of patients affected by cerebellar ataxia and an objective evaluation (through optoelectronic systems) of the functional limitation in some specific tasks was provided. The aim of our study was to define a new experimental procedure for a quantitative description of upper limb movement and coordination analysis in patients affected by ataxia by introducing visual stimuli given by an electronic board that also allowed us to identify the timing of the movement. Materials and methods The quantitative evaluation was carried out at the Movement Analysis Laboratory through the integration of an optoelectronic system (SMART, BTS Bioengineering, Italy) and a dedicated electronic board that also provides a series of visual stimuli to the subject, developed at the Bioengineering Laboratory of the Institute. 9 adult patients affected by hereditary dominant and recessive ataxias (6 M, 3 F) and 10 healthy volunteers (6 M, 4 F) were recruited for the analysis. 20 passive retroreflective markers were placed on the subject’s upper limb, trunk and head and two types of pointing tests were defined: in the first one, the subjects were asked to reach with the index finger five consecutive times each of the three targets (repetitive test), and in the second test, the subjects were asked to randomly reach the targets with the index finger (random test), according to the stimulation sequence. For the quantitative characterization of the pointing movements, the duration of the movement, the trajectory, the velocity and the smoothness of finger tip and the presence and quantification of hysteresis were considered. In order to evaluate the upper limb motor coordination, the movements of the wrist, elbow, shoulder (both for the arm that was performing the task and the arm that was lying on the table), and head, were considered. In this first part of the study, only kinematic data related to the marker placed on the finger tip will be presented. Results The preliminary results showed that patients affected by ataxia took more time to perform the pointing tests and their trajectories presented a higher degree of hysteresis than healthy subjects (Fig. 1). The velocity profile was less smooth in ataxic subjects and presented different patterns related to the severeness of impairment (Fig. 2). Discussion The new developed experimental procedure seems to be very promising in the quantitative description of upper limb movements of pathological and healthy subjects and it seems to be able to distinguish the impairments due to different levels of ataxia and provide for relevant indexes in order to track the disease progress over time.
Fig. 2. Velocity profiles of a single pointing movement in the going phase (dashed line for a mild ataxic patient, dotted line for a severe ataxic patient continuous line for a healthy subject)
References [1] Topka H, et al. Exp Brain Res 1998;119:483–92. [2] Menegoni F, et al. European Journal of Neurology 2009;16:232–9.
doi:10.1016/j.gaitpost.2010.10.075 P38 Curved walking in hemiparetic patients M. Godi 1 , A. Nardone 1,2 , M. Grasso 1 , M. Schieppati 3,4 1
Posture & Movement Laboratory, Division of Physical and Rehabilitation Medicine, Fondazione Salvatore Maugeri (IRCCS), Veruno (NO), Italy 2 Department of Clinical and Experimental Medicine, University of Eastern Piedmont, Novara, Italy 3 Centro Studi Attività Motorie, Fondazione Salvatore Maugeri (IRCCS), Pavia, Italy 4 Department of Experimental Medicine, University of Pavia, Italy Introduction Curved walking requires complex adaptations, including shift of body weight to counteract the ensuing centrifugal force and production of strides of different length between legs [1,2]. We hypothesized that gait capacities would be more stressed in hemiparetic patients than in healthy subjects when walking along curved than straight trajectories. Matherials and methods Twenty chronic, stabilized stroke patients and 20 healthy subjects walked along straight or curved trajectories. Mean cadence and gait velocity were off-line computed from video recordings. Centre of pressure during standing was recorded by posturography. An electronic walkway detected asymmetry of single support and degree of foot yaw angle at mid-stance. Results Compared to linear, velocity of curved walking was hardly smaller in patients, and independent of affected body side or direction of rotation. It was inversely correlated to paretic limb weakness, asymmetry of single support, and shift of CoP toward the healthy side. External rotation of paretic foot relatively favoured curved walking toward the paretic side. Discussion Curved locomotion is defective in stabilized stroke patients, but impairment is not dependent on direction of rotation, indicating a shared task between legs or occurrence of effective functional adaptation [3]. These findings advocate rehabilitation exercises targeting complex gait adaptations including curved walking.
Abstracts / Gait & Posture 33S (2011) S1–S66
S63
References [1] Courtine G, Schieppati M. Eur J Neurosci 2003;18:177–90. [2] Courtine G, Schieppati M. J Neurophysiol 2004;91:1524–35. [3] Nardone A, et al. Gait Posture 2009;30:5–10.
doi:10.1016/j.gaitpost.2010.10.076 P39 Robot-assisted therapy and botulinum toxin type A: A promising approach for upper limb ataxia rehabilitation G. Berto 1 , P. Marchi 2 , L. Lutzoni 2 , L. Ansaloni 3 , S. Straudi 2 , N. Basaglia 2
Fig. 1. Speed profiles of the wrist during a reaching movement pre- and post treatment
1
School of Medicine, Ferrara University, Italy Department of Physical Medicine & Rehabilitation, Ferrara, Italy 3 School of Physiotherapy, Ferrara University, Italy 2
Introduction Upper limb ataxia is one of the most common motor disorders associated with cerebellar damage. The human cerebellum contains more neurons than any other region in the brain and is a major actor in motor control [1]. The cerebellum is thought to be a primary site of motor learning and individuals with cerebellar lesions are known to have deficits in motor learning [2]. The successful use of botulinum toxin type A (BTX-A) in conditions with muscle overactivity has been established and new areas in the field of movement disorders such as tremor and dysmetria has been explored with promising results. Intensive, repetitive, task-specific practice of the affected upper extremity also improves motor function and can be enhanced using robotics. This case study reports on the outcomes of a six-weeks intervention of robotic-assisted training combined with BTXA administered to a 33-years-old man with disabling ataxia and intention tremor with no meaningful use of the right arm attributable to a brain tumor sequelae. Methods Robotic therapy comprising repetitive, goal-directed reaching tasks was administered two times/week for six weeks (Reo Therapy System, Motorika, Medical Ltd, Israel). Sites and doses of BTX-A (Xeomin) injections were selected empirically and on the basis of physical examination. Injected muscles and doses were as follows: biceps (20 U), triceps (20 U), wrist flexors (20 U) and deltoid (20 U). To test the effects on motor coordination we analyzed 15 multi-planar point-to-point reaching movements with the right arm (VICON motion analysis system). Improvements in upper-limb coordination and motor performance were highlighted throughout kinematic parameters, i.e. mean and max wrist velocity, reaching task duration; as measure of smoothness we calculated the peaks velocity number and the mean jerk (the rate of change of acceleration). Motor Activity Log (MAL) questionnaire indicated the quality and amount of paretic arm use during daily activities at home. Results After this six weeks training program the reaching task duration decreased from 4.4 ± 0.5 s to 3.3 ± 0.5 s (p < 0.002). Max speed (cm/s) decreased from 76.3 ± 24.5 to 58.6 ± 8.4 (p < 0.05). There were no differences in mean speed pre- and post-treatment (25.5 ± 2.6 and 25.6 ± 0.6). Smoothness was improved from 9.733533 cm/s3 to −1.8677 cm/s3 (mean jerk) and the peaks velocity number was reduced from 61.6 ± 14.2 to 5 ± 2.2 (p < 0.002). Fig. 1 shows the typical speed profiles pre- and posttreatment. There were no effects on MAL scores (0.2 pre- and posttreatment).
Discussion BTX-A injections are useful to enhance motor coordination in subjects with upper-extremity ataxia. This preliminary report indicates that robotic therapy may be a useful clinical tool when combined with BTX-A injections for improving coordination and quality of motor performance in subjects with upper limb ataxia. The findings of our study encourage further studies using BTX-A to enhance the effects of rehabilitation techniques and also points out some areas for further research. References [1] Manto M. Mechanisms of human cerebellar dysmetria: experimental evidence and current conceptual bases. J Neuroeng Rehabil 2009;6:10. [2] Morton SM, Bastian AJ. Can rehabilitation help ataxia. Neurology 2009;73(22):1818–9.
doi:10.1016/j.gaitpost.2010.10.077 P40 The comorbidity of the elderly patient: The instrumental approach and evaluation G. Reggiani, C. Cazzola, M. Vanini, I. Miselli, A. Tamborrelli, I. Perona Raquena U.O. Medicina Riabilitativa Ospedale di Carpi ausl di Modena, Italy Introduction The comorbidity of the elderly patient asks for articulated interventions of measurement and clinical evaluation. The evaluation of his/her autonomy and the functional state, in particularly of the cardiovascular system, is important. The information coming from an instrumental neuromechanical approach, even though suitable, could represent only partially the complexity of the elderly patient with comorbidity. Method We have assessed the risk of fall and fracture in 10 patients evaluated in our laboratory. During a first phase of study the following tests have been applied to the patients: the “6mw” test, the UBS test (method of evaluation of the equilibrium, divided in a few sets), the FIM, the VAS and the Charlson Index. Subsequently all the patients have been observed through the different neuromechanical instrumental examinations (isokinetic test, stabilometry test, basography, surface’s emg, stabilometry with platform of strength and with platform of pressure, test of the work). The information coming from the functional and instrumental evaluation has made possible to identify in the patient the point of homeostasis (i.e., there is no risk of fall), the point of crisis (i.e., the fall is possible), the adaptive point (i.e., the patient can answer to more than one set of postural and/or movement eval-
Abstracts / Gait & Posture 33S (2011) S1–S66
Fig. 1. Traces of the finger tip for a healthy subject (left) and an ataxic patient (right) while executing the random test with the dominant limb
progress over time of patients affected by progressive pathologies, such as ataxia, a group of rare genetic diseases whose main symptom is the progressive loss of motor coordination. Previous studies [1,2] analyzed upper limb movements of patients affected by cerebellar ataxia and an objective evaluation (through optoelectronic systems) of the functional limitation in some specific tasks was provided. The aim of our study was to define a new experimental procedure for a quantitative description of upper limb movement and coordination analysis in patients affected by ataxia by introducing visual stimuli given by an electronic board that also allowed us to identify the timing of the movement. Materials and methods The quantitative evaluation was carried out at the Movement Analysis Laboratory through the integration of an optoelectronic system (SMART, BTS Bioengineering, Italy) and a dedicated electronic board that also provides a series of visual stimuli to the subject, developed at the Bioengineering Laboratory of the Institute. 9 adult patients affected by hereditary dominant and recessive ataxias (6 M, 3 F) and 10 healthy volunteers (6 M, 4 F) were recruited for the analysis. 20 passive retroreflective markers were placed on the subject’s upper limb, trunk and head and two types of pointing tests were defined: in the first one, the subjects were asked to reach with the index finger five consecutive times each of the three targets (repetitive test), and in the second test, the subjects were asked to randomly reach the targets with the index finger (random test), according to the stimulation sequence. For the quantitative characterization of the pointing movements, the duration of the movement, the trajectory, the velocity and the smoothness of finger tip and the presence and quantification of hysteresis were considered. In order to evaluate the upper limb motor coordination, the movements of the wrist, elbow, shoulder (both for the arm that was performing the task and the arm that was lying on the table), and head, were considered. In this first part of the study, only kinematic data related to the marker placed on the finger tip will be presented. Results The preliminary results showed that patients affected by ataxia took more time to perform the pointing tests and their trajectories presented a higher degree of hysteresis than healthy subjects (Fig. 1). The velocity profile was less smooth in ataxic subjects and presented different patterns related to the severeness of impairment (Fig. 2). Discussion The new developed experimental procedure seems to be very promising in the quantitative description of upper limb movements of pathological and healthy subjects and it seems to be able to distinguish the impairments due to different levels of ataxia and provide for relevant indexes in order to track the disease progress over time.
Fig. 2. Velocity profiles of a single pointing movement in the going phase (dashed line for a mild ataxic patient, dotted line for a severe ataxic patient continuous line for a healthy subject)
References [1] Topka H, et al. Exp Brain Res 1998;119:483–92. [2] Menegoni F, et al. European Journal of Neurology 2009;16:232–9.
doi:10.1016/j.gaitpost.2010.10.075 P38 Curved walking in hemiparetic patients M. Godi 1 , A. Nardone 1,2 , M. Grasso 1 , M. Schieppati 3,4 1
Posture & Movement Laboratory, Division of Physical and Rehabilitation Medicine, Fondazione Salvatore Maugeri (IRCCS), Veruno (NO), Italy 2 Department of Clinical and Experimental Medicine, University of Eastern Piedmont, Novara, Italy 3 Centro Studi Attività Motorie, Fondazione Salvatore Maugeri (IRCCS), Pavia, Italy 4 Department of Experimental Medicine, University of Pavia, Italy Introduction Curved walking requires complex adaptations, including shift of body weight to counteract the ensuing centrifugal force and production of strides of different length between legs [1,2]. We hypothesized that gait capacities would be more stressed in hemiparetic patients than in healthy subjects when walking along curved than straight trajectories. Matherials and methods Twenty chronic, stabilized stroke patients and 20 healthy subjects walked along straight or curved trajectories. Mean cadence and gait velocity were off-line computed from video recordings. Centre of pressure during standing was recorded by posturography. An electronic walkway detected asymmetry of single support and degree of foot yaw angle at mid-stance. Results Compared to linear, velocity of curved walking was hardly smaller in patients, and independent of affected body side or direction of rotation. It was inversely correlated to paretic limb weakness, asymmetry of single support, and shift of CoP toward the healthy side. External rotation of paretic foot relatively favoured curved walking toward the paretic side. Discussion Curved locomotion is defective in stabilized stroke patients, but impairment is not dependent on direction of rotation, indicating a shared task between legs or occurrence of effective functional adaptation [3]. These findings advocate rehabilitation exercises targeting complex gait adaptations including curved walking.
Abstracts / Gait & Posture 33S (2011) S1–S66
S63
References [1] Courtine G, Schieppati M. Eur J Neurosci 2003;18:177–90. [2] Courtine G, Schieppati M. J Neurophysiol 2004;91:1524–35. [3] Nardone A, et al. Gait Posture 2009;30:5–10.
doi:10.1016/j.gaitpost.2010.10.076 P39 Robot-assisted therapy and botulinum toxin type A: A promising approach for upper limb ataxia rehabilitation G. Berto 1 , P. Marchi 2 , L. Lutzoni 2 , L. Ansaloni 3 , S. Straudi 2 , N. Basaglia 2
Fig. 1. Speed profiles of the wrist during a reaching movement pre- and post treatment
1
School of Medicine, Ferrara University, Italy Department of Physical Medicine & Rehabilitation, Ferrara, Italy 3 School of Physiotherapy, Ferrara University, Italy 2
Introduction Upper limb ataxia is one of the most common motor disorders associated with cerebellar damage. The human cerebellum contains more neurons than any other region in the brain and is a major actor in motor control [1]. The cerebellum is thought to be a primary site of motor learning and individuals with cerebellar lesions are known to have deficits in motor learning [2]. The successful use of botulinum toxin type A (BTX-A) in conditions with muscle overactivity has been established and new areas in the field of movement disorders such as tremor and dysmetria has been explored with promising results. Intensive, repetitive, task-specific practice of the affected upper extremity also improves motor function and can be enhanced using robotics. This case study reports on the outcomes of a six-weeks intervention of robotic-assisted training combined with BTXA administered to a 33-years-old man with disabling ataxia and intention tremor with no meaningful use of the right arm attributable to a brain tumor sequelae. Methods Robotic therapy comprising repetitive, goal-directed reaching tasks was administered two times/week for six weeks (Reo Therapy System, Motorika, Medical Ltd, Israel). Sites and doses of BTX-A (Xeomin) injections were selected empirically and on the basis of physical examination. Injected muscles and doses were as follows: biceps (20 U), triceps (20 U), wrist flexors (20 U) and deltoid (20 U). To test the effects on motor coordination we analyzed 15 multi-planar point-to-point reaching movements with the right arm (VICON motion analysis system). Improvements in upper-limb coordination and motor performance were highlighted throughout kinematic parameters, i.e. mean and max wrist velocity, reaching task duration; as measure of smoothness we calculated the peaks velocity number and the mean jerk (the rate of change of acceleration). Motor Activity Log (MAL) questionnaire indicated the quality and amount of paretic arm use during daily activities at home. Results After this six weeks training program the reaching task duration decreased from 4.4 ± 0.5 s to 3.3 ± 0.5 s (p < 0.002). Max speed (cm/s) decreased from 76.3 ± 24.5 to 58.6 ± 8.4 (p < 0.05). There were no differences in mean speed pre- and post-treatment (25.5 ± 2.6 and 25.6 ± 0.6). Smoothness was improved from 9.733533 cm/s3 to −1.8677 cm/s3 (mean jerk) and the peaks velocity number was reduced from 61.6 ± 14.2 to 5 ± 2.2 (p < 0.002). Fig. 1 shows the typical speed profiles pre- and posttreatment. There were no effects on MAL scores (0.2 pre- and posttreatment).
Discussion BTX-A injections are useful to enhance motor coordination in subjects with upper-extremity ataxia. This preliminary report indicates that robotic therapy may be a useful clinical tool when combined with BTX-A injections for improving coordination and quality of motor performance in subjects with upper limb ataxia. The findings of our study encourage further studies using BTX-A to enhance the effects of rehabilitation techniques and also points out some areas for further research. References [1] Manto M. Mechanisms of human cerebellar dysmetria: experimental evidence and current conceptual bases. J Neuroeng Rehabil 2009;6:10. [2] Morton SM, Bastian AJ. Can rehabilitation help ataxia. Neurology 2009;73(22):1818–9.
doi:10.1016/j.gaitpost.2010.10.077 P40 The comorbidity of the elderly patient: The instrumental approach and evaluation G. Reggiani, C. Cazzola, M. Vanini, I. Miselli, A. Tamborrelli, I. Perona Raquena U.O. Medicina Riabilitativa Ospedale di Carpi ausl di Modena, Italy Introduction The comorbidity of the elderly patient asks for articulated interventions of measurement and clinical evaluation. The evaluation of his/her autonomy and the functional state, in particularly of the cardiovascular system, is important. The information coming from an instrumental neuromechanical approach, even though suitable, could represent only partially the complexity of the elderly patient with comorbidity. Method We have assessed the risk of fall and fracture in 10 patients evaluated in our laboratory. During a first phase of study the following tests have been applied to the patients: the “6mw” test, the UBS test (method of evaluation of the equilibrium, divided in a few sets), the FIM, the VAS and the Charlson Index. Subsequently all the patients have been observed through the different neuromechanical instrumental examinations (isokinetic test, stabilometry test, basography, surface’s emg, stabilometry with platform of strength and with platform of pressure, test of the work). The information coming from the functional and instrumental evaluation has made possible to identify in the patient the point of homeostasis (i.e., there is no risk of fall), the point of crisis (i.e., the fall is possible), the adaptive point (i.e., the patient can answer to more than one set of postural and/or movement eval-