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Facciorusso S, Spina S, Picelli A, Baricich A, Francisco GE, Molteni F, Wissel J, Santamato A. The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis. Toxins (Basel) 2024; 16:184. [PMID: 38668609 PMCID: PMC11053519 DOI: 10.3390/toxins16040184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024] Open
Abstract
Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.
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Affiliation(s)
- Salvatore Facciorusso
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy;
| | - Alessio Baricich
- Physical Medicine and Rehabilitation, Department of Health Sciences, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Gerard E. Francisco
- Department of Physical Medicine & Rehabilitation, University of Texas Health McGovern Medical School, Houston, TX 77030, USA;
| | - Franco Molteni
- Villa Beretta Rehabilitation Center, Valduce Hospital Como, 23845 Costa Masnaga, Italy;
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Andrea Santamato
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
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Vu PD, Conselman C, Hernandez I, Francisco GE. Headaches in Spinal Cord Injury: A Differential Diagnosis. Am J Phys Med Rehabil 2024; 103:e15-e17. [PMID: 37903598 DOI: 10.1097/phm.0000000000002360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Affiliation(s)
- Peter D Vu
- From the McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (PDV, CC, IH, GEF); and TIRR Memorial Hermann, Houston, Texas (PDV, IH, GEF)
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Bavikatte G, Esquenazi A, Dimyan MA, Dashtipour K, Feng W, Mayadev A, Fanning K, Musacchio T, Zuzek A, Francisco GE. Safety and real-world dosing of onabotulinumtoxinA for the treatment of adult spasticity: post hoc analysis of the Adult Spasticity International Registry study. Am J Phys Med Rehabil 2024:00002060-990000000-00390. [PMID: 38206635 DOI: 10.1097/phm.0000000000002410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVE To evaluate the safety of onabotulinumtoxinA treatment for spasticity across dose ranges in real-world practice. DESIGN Adult Spasticity International Registry (ASPIRE) was a multicenter, prospective, observational study (NCT01930786) of onabotulinumtoxinA treatment for adult spasticity over 2 years. Adverse events (AEs), serious AEs (SAEs), treatment-related AEs (TRAEs), and TRSAEs were sorted into 5 categories (≤200 U, 201-400 U, 401-600 U, 601-800 U, ≥801 U) based on cumulative dose per session. RESULTS In 3103 treatment sessions (T), 730 patients received ≥1 dose of onabotulinumtoxinA. Dose categories included: ≤200 U (n = 312; t = 811), 201-400 U (n = 446, t = 1366), 401-600 U (n = 244, t = 716), 601-800 U (n = 69, t = 149), ≥801 U (n = 29, t = 61). Of these patients, 261 reported 827 AEs, 94 reported 195 SAEs, 20 reported 23 TRAEs, and 2 patients treated with 201-400 U onabotulinumtoxinA reported 3 TRSAEs. TRAEs reported: ≤200 U (8 TRAEs/811, 0.9%); 201-400 U (7/1366, 0.5%); 401-600 U (6/716, 0.8%); 601-800 U (1/149, 0.7%); ≥801 U (1/61, 1.6%). CONCLUSIONS In this post hoc analysis, most treatment sessions were performed with 201-400 U onabotulinumtoxinA. Patients treated with 201-400 U onabotulinumtoxinA had an AE profile consistent with onabotulinumtoxinA package inserts globally (eg, United States, European Union, United Kingdom, Canada). No new safety signals were identified.
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Affiliation(s)
| | | | | | | | - Wuwei Feng
- Duke University School of Medicine, Durham, NC, USA
| | | | | | | | | | - Gerard E Francisco
- University of Texas McGovern Medical School and TIRR Memorial Hermann, Houston, TX, USA
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Kinney CL, Pruitt DW, Francisco GE, Raddatz MM, Sabharwal S. Current practice focus trends in physical medicine and rehabilitation. PM R 2023. [PMID: 38115622 DOI: 10.1002/pmrj.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/12/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Physical medicine and rehabilitation (PM&R) is a diverse specialty, growing and evolving over a variety of subspecialty and practice focus areas. Accurate data regarding practice patterns of physiatrists are essential for updating requirements in training and certification, particularly as the Accreditation Council for Graduate Medical Education begins its process to update of the PM&R core residency training requirements. This study analyzes practice trends for nearly 98% of physiatrists in active practice, the largest study to date. OBJECTIVE To update current demographics of physicians specializing in PM&R, including current areas of practice focus, to analyze the alignment of practice focus with subspecialty certification, and to determine the extent that electromyography is a component of current physiatric practice. DESIGN Retrospective analysis of deidentified responses from American Board of Physical Medicine and Rehabilitation (ABPMR) board-certified PM&R physicians (diplomates) on annual enrollment in the ABPMR Continuing Certification program. PARTICIPANTS A total of 9543 ABPMR diplomates. MAIN OUTCOME MEASURES Demographics - age, gender, years in practice, practice setting(s) and area(s). Practice focus, subspecialty certifications. RESULTS The majority of practicing physiatrists are men (62%) although the percentage of women in the field is growing (38%). Nearly 80% of physiatrists report more than one practice focus area, with pain medicine and sports medicine/musculoskeletal practices most commonly reported. CONCLUSIONS This study confirms the growth trends in PM&R in pain and sports medicine but also highlights the substantial number of physiatrists focusing their practices in areas related to neurorehabilitation and medical rehabilitation. The large majority of physiatrists incorporate multiple focus areas into their practices. Electromyography is a focus for a declining percentage of practicing physiatrists.
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Affiliation(s)
- Carolyn L Kinney
- American Board of Physical Medicine and Rehabilitation, Rochester, Minnesota, USA
- Mayo Clinic, Phoenix, Arizona, USA
| | - David W Pruitt
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Gerard E Francisco
- University of Texas Health Science Center, McGovern Medical School, TIRR Memorial Herman Hospital, Houston, Texas, USA
| | - Mikaela M Raddatz
- American Board of Physical Medicine and Rehabilitation, Rochester, Minnesota, USA
| | - Sunil Sabharwal
- Harvard Medical School, Boston VA Health Care System, Boston, Massachusetts, USA
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Li S, Ghuman J, Gonzalez-Buonomo J, Huang X, Malik A, Yozbatiran N, Francisco GE, Wu H, Frontera WR. Does Spasticity Correlate With Motor Impairment in the Upper and Lower Limbs in Ambulatory Chronic Stroke Survivors? Am J Phys Med Rehabil 2023; 102:907-912. [PMID: 37026840 PMCID: PMC10522784 DOI: 10.1097/phm.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
OBJECTIVE This study aimed to explore correlations between spasticity and motor impairments in the upper and lower limbs in ambulatory chronic stroke survivors. DESIGN We performed clinical assessments in 28 ambulatory chronic stroke survivors with spastic hemiplegia (female: 12; male: 16; mean ages = 57.8 ± 11.8 yrs; 76 ± 45 mos after stroke). RESULTS In the upper limb, spasticity index and Fugl-Meyer Motor Assessment showed a significant correlation. Spasticity index for the upper limb showed a significant negative correlation with handgrip strength of the affected side ( r = -0.4, P = 0.035) while Fugl-Meyer Motor Assessment for the upper limb had a significant positive correlation ( r = 0.77, P < 0.001). In the LL, no correlation was found between SI_LL and FMA_LL. There was a significant and high correlation between timed up and go test and gait speed ( r = 0.93, P < 0.001). Gait speed was positively correlated with Spasticity index for the lower limb ( r = 0.48, P = 0.01), and negatively correlated with Fugl-Meyer Motor Assessment for the lower limb ( r = -0.57, P = 0.002). Age and time since stroke showed no association in analyses for both upper limb and lower limb. CONCLUSIONS Spasticity has a negative correlation on motor impairment in the upper limb but not in the lower limb. Motor impairment was significantly correlated with grip strength in the upper limb and gait performance in the lower limb of ambulatory stroke survivors.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston
- TIRR Memorial Hermann Hospital, Houston
| | | | | | - Xinran Huang
- Department of Biostatistics and Data Science, The University of Texas Health Science Center, Houston
| | - Aila Malik
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston
- TIRR Memorial Hermann Hospital, Houston
| | - Nuray Yozbatiran
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston
- TIRR Memorial Hermann Hospital, Houston
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston
- TIRR Memorial Hermann Hospital, Houston
| | - Hulin Wu
- Department of Biostatistics and Data Science, The University of Texas Health Science Center, Houston
| | - Walter R Frontera
- Department of Physical Medicine, Rehabilitation, and Sports Medicine, Department of Physiology, University of Puerto Rico School of Medicine, PR
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Craik A, González-España JJ, Alamir A, Edquilang D, Wong S, Sánchez Rodríguez L, Feng J, Francisco GE, Contreras-Vidal JL. Design and Validation of a Low-Cost Mobile EEG-Based Brain-Computer Interface. Sensors (Basel) 2023; 23:5930. [PMID: 37447780 DOI: 10.3390/s23135930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023]
Abstract
Objective: We designed and validated a wireless, low-cost, easy-to-use, mobile, dry-electrode headset for scalp electroencephalography (EEG) recordings for closed-loop brain-computer (BCI) interface and internet-of-things (IoT) applications. Approach: The EEG-based BCI headset was designed from commercial off-the-shelf (COTS) components using a multi-pronged approach that balanced interoperability, cost, portability, usability, form factor, reliability, and closed-loop operation. Main Results: The adjustable headset was designed to accommodate 90% of the population. A patent-pending self-positioning dry electrode bracket allowed for vertical self-positioning while parting the user's hair to ensure contact of the electrode with the scalp. In the current prototype, five EEG electrodes were incorporated in the electrode bracket spanning the sensorimotor cortices bilaterally, and three skin sensors were included to measure eye movement and blinks. An inertial measurement unit (IMU) provides monitoring of head movements. The EEG amplifier operates with 24-bit resolution up to 500 Hz sampling frequency and can communicate with other devices using 802.11 b/g/n WiFi. It has high signal-to-noise ratio (SNR) and common-mode rejection ratio (CMRR) (121 dB and 110 dB, respectively) and low input noise. In closed-loop BCI mode, the system can operate at 40 Hz, including real-time adaptive noise cancellation and 512 MB of processor memory. It supports LabVIEW as a backend coding language and JavaScript (JS), Cascading Style Sheets (CSS), and HyperText Markup Language (HTML) as front-end coding languages and includes training and optimization of support vector machine (SVM) neural classifiers. Extensive bench testing supports the technical specifications and human-subject pilot testing of a closed-loop BCI application to support upper-limb rehabilitation and provides proof-of-concept validation for the device's use at both the clinic and at home. Significance: The usability, interoperability, portability, reliability, and programmability of the proposed wireless closed-loop BCI system provides a low-cost solution for BCI and neurorehabilitation research and IoT applications.
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Affiliation(s)
- Alexander Craik
- Department of Electrical and Computer Engineering, University of Houston, Houston, TX 77004, USA
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
| | - Juan José González-España
- Department of Electrical and Computer Engineering, University of Houston, Houston, TX 77004, USA
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
| | - Ayman Alamir
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
- Department of Biomedical Engineering, University of Houston, Houston, TX 77004, USA
- Department of Electrical Engineering, Jazan University, Jazan 45142, Saudi Arabia
| | - David Edquilang
- Department of Industrial Design, University of Houston, Houston, TX 77004, USA
| | - Sarah Wong
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
- Department of Industrial Design, University of Houston, Houston, TX 77004, USA
| | - Lianne Sánchez Rodríguez
- Department of Electrical and Computer Engineering, University of Houston, Houston, TX 77004, USA
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
| | - Jeff Feng
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
- Department of Industrial Design, University of Houston, Houston, TX 77004, USA
| | - Gerard E Francisco
- Department of Physical Medicine & Rehabilitation, University of Texas Health McGovern Medical School, Houston, TX 77030, USA
- The Institute for Rehabilitation and Research (TIRR) Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Jose L Contreras-Vidal
- Department of Electrical and Computer Engineering, University of Houston, Houston, TX 77004, USA
- Noninvasive Brain-Machine Interface Systems Laboratory, NSF Industry-University Cooperative Research Center for Building Reliable Advances and Innovations in Neurotechnology (IUCRC BRAIN) Center, University of Houston, Houston, TX 77004, USA
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Francisco GE, Engineer N, Dawson J, Kimberley TJ, Cramer S, Prudente CN, Pierce D, Tarver BW, Hinds RHA, Winckel AVD, Yozbatiran N. Vagus Nerve Stimulation Paired with Upper-Limb Rehabilitation After Stroke: Two- and Three-Year Follow-up from the Pilot Study. Arch Phys Med Rehabil 2023:S0003-9993(23)00147-8. [PMID: 37001842 DOI: 10.1016/j.apmr.2023.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 01/27/2023] [Accepted: 02/08/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To assess whether a long-term home-based intervention using Paired VNS therapy is feasible and whether the benefits of Paired VNS therapy are maintained beyond 1 year. DESIGN A long-term follow-up study. SETTING Three centers in the United States and 1 in the United Kingdom. PARTICIPANTS Adults with chronic ischemic stroke (n=15) with moderate to severe arm and hand impairment. INTERVENTIONS Participants were implanted with a VNS device followed by 6 weeks of in-clinic therapy with Paired (Active) or control VNS followed by home-based rehabilitation through day 90 (blinded phase). The control VNS group then crossed over to receive 6 weeks of in-clinic Active VNS. Participants in both groups then continued a long-term home exercise program with self-administered Active VNS. MAIN OUTCOME MEASURES Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and Wolf Motor Function Test (WMFT) Functional scores were evaluated at the end of in-clinic therapy and day 90. Since both groups were subsequently receiving home-based rehabilitation with Active VNS during the long term, follow-up outcome assessments were pooled for the analyses at 6, 9, and 12 months, as previously reported. Here, we report pooled analysis of outcomes beyond 1 year. RESULTS One year after Paired VNS therapy, FMA-UE improved by an average of 9.2±8.2 points, as previously reported. Overall, the 2- and 3-year FMA-UE gain from baseline was 11.4±8.7 (P<.001) and 14.8±10.2 points (P<.001), respectively. At years 2 and 3, FMA-UE improved by an additional 2.9 (P=.03 for change vs year 1, n=14) and 4.7 (P=.02 for change vs year 1, n=14) points, respectively. At year 1, 73% (11/15) of participants were responders (FMA-UE change ≥6) and by year 3, 85.7% (12/14) were responders. At years 2 and 3, the WMFT score improved by an additional 0.21 points (P=.03 for change vs year 1, n=15) and 0.42 points (P=.01 for change vs year 1, n=13), respectively. Responder rate (WMFT change ≥0.4) was 46.6% (7/15), 73.3% (11/15), and 69.2% (9/13) at years 1, 2, and 3, respectively. Long-term significant improvements were also observed for Motor Activity Log (MAL) and Stroke Impact Scale, Hand section (SIS-Hand). There were no serious long-term adverse events from the stimulation. CONCLUSIONS Significant effects of Paired VNS therapy at 1 year were maintained at years 2 and 3, and further improvements in both impairment and function were observed in years 2 and 3. These changes were associated with improvements in measures of activity and participation.
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Sabharwal S, Kinney CL, Raddatz MM, Driscoll SW, Francisco GE, Robinson LR, Geis C, Micheo W. Current status and trends in subspecialty certification in physical medicine and rehabilitation. PM R 2023; 15:212-221. [PMID: 35038251 DOI: 10.1002/pmrj.12763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/08/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is a need to better understand the overall state of sub-specialization in physical medicine and rehabilitation (PM&R). OBJECTIVE To examine the status and trends in subspecialty certification for each of the seven subspecialties approved for American Board of Physical Medicine and Rehabilitation (ABPMR) diplomates. DESIGN/SETTING Retrospective analysis of deidentified information from the ABPMR database. PARTICIPANTS Physicians certified by ABPMR through 2019. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES For each subspecialty, we examined: (1) the number of certificates issued to ABPMR diplomates; (2) the recertification rate; (3) the yearly trends for total active, new, and expired certificates; and (4) for ABPMR-administered subspecialties, recertification rates for those entering the subspecialty through fellowship completion versus a "grandfathered" practice pathway. RESULTS Of 11,421 ABPMR diplomates in the United States in 2019, a total of 3560 (31.2%) had 3985 active subspecialty certificates. Pain Medicine (PM) was the most common subspecialty certification (15.5% of all ABPMR diplomates) followed by Sports Medicine (SM, 6.6%), Brain Injury Medicine (BIM, 4.8%), Spinal Cord Injury Medicine (SCIM, 4.2%), Pediatric Rehabilitation Medicine (PRM, 2.5%), Neuromuscular Medicine (NMM, 0.7%), and Hospice and Palliative Medicine (HPM, 0.5%). For diplomates with more than one subspecialty certification, PM and SM was the most frequent combination. Both the recertification rate and the end of practice track eligibility influenced certification trends differently for individual subspecialties. The average number of new certificates added annually for every subspecialty was higher before than after the temporary practice track-based eligibility ended; the difference was statistically significant (p < .05) for SCIM, PM, SM, and NMM. The recertification rate for all subspecialties combined was 73.4%. For the subspecialties (SCIM, PRM) for which these data were available, fellowship candidates had higher recertification rates than those grandfathered through a practice track. CONCLUSION This report informs stakeholders about the state and evolution of subspecialty certification in PM&R over time.
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Affiliation(s)
- Sunil Sabharwal
- Harvard Medical School, Boston, Massachusetts, USA.,VA Boston Health Care System, Boston, Massachusetts, USA
| | - Carolyn L Kinney
- American Board of Physical Medicine & Rehabilitation, Rochester, Minnesota, USA.,Mayo Clinic, Phoenix, Arizona, USA
| | - Mikaela M Raddatz
- American Board of Physical Medicine & Rehabilitation, Rochester, Minnesota, USA
| | | | - Gerard E Francisco
- University of Texas Health Science Center McGovern Medical School, Houston, Texas, USA.,TIRR Memorial Hermann Hospital, Houston, Texas, USA
| | - Lawrence R Robinson
- University of Toronto, St. John's Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Carolyn Geis
- University of Florida, Gainesville, Florida, USA
| | - William Micheo
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Sivan M, Negrini S, Kiekens C, Khan F, Francisco GE, Gimigliano F. The INFORM (International Framework for Rehabilitation Medics) Project to Strengthen the Medical Specialty. Adv Rehabil Sci Pract 2023; 12:27536351231167482. [PMID: 37152355 PMCID: PMC10161326 DOI: 10.1177/27536351231167482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/18/2023] [Indexed: 05/09/2023]
Affiliation(s)
- Manoj Sivan
- British Society of Physical and Rehabilitation Medicine, London, UK
- Academic Department of Rehabilitation Medicine, University of Leeds, Leeds, UK
- Manoj Sivan, Academic Department of Rehabilitation Medicine, University of Leeds, Leeds, UK.
| | - Stefano Negrini
- Department of Biomedical, Surgical and Dental Sciences, University ‘La Statale’, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Carlotte Kiekens
- Physical and Rehabilitation Medicine, IRCCS MultiMedica, Milan, Italy
| | - Fary Khan
- Director Rehabilitation Royal Melbourne Hospital, Melbourne, Australia
| | - Gerard E. Francisco
- Department of Physical Medicine and Rehabilitation, UTHealth McGovern Medical School, and TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Francesca Gimigliano
- Department of Mental and Physical Health and Preventive Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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Gimigliano F, Francisco GE, Khan F, Li L, Schiappacasse C, Laffont I, Melvin J, Stucki G, Lains J, Frontera WR. Comment on: "Fostering a uniform global name for the specialty of physicians working in rehabilitation". Eur J Phys Rehabil Med 2022; 58:793-795. [PMID: 36472557 PMCID: PMC10081483 DOI: 10.23736/s1973-9087.22.07790-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Francesca Gimigliano
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland - .,Department of Mental and Physical Health and Preventive Medicine, Luigi Vanvitelli University of Campania, Naples, Italy -
| | - Gerard E Francisco
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, USA.,Neurorecovery Research Center, TIRR Memorial Hermann, Houston, TX, USA
| | - Fary Khan
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Department of Rehabilitation, Royal Melbourne Hospital, Parkville, Australia.,Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, University of Melbourne, Parkville, Australia
| | - Leonard Li
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Division of Rehabilitation, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Carolina Schiappacasse
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,British Hospital, Las Araucarias Rehabilitation Clinic, San Martin University, Buenos Aires, Argentina
| | - Isabelle Laffont
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Department of Physical Medicine and Rehabilitation, CHU Montpellier, University of Montpellier, Montpellier, France
| | - John Melvin
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gerold Stucki
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Department of Health Sciences and Health Policy, Center for Rehabilitation in Global Health Systems, University of Lucerne, Lucerne, Switzerland.,Swiss Paraplegic Research (SPF), Guido A. Zaech Institute, Nottwil, Switzerland
| | - Jorge Lains
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Walter R Frontera
- The International Society of Physical and Rehabilitation Medicine, Geneva, Switzerland.,Department of Physical Medicine, Rehabilitation and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Dawson J, Engineer ND, Cramer SC, Wolf SL, Ali R, O'Dell MW, Pierce D, Prudente CN, Redgrave J, Feng W, Liu CY, Francisco GE, Brown BL, Dixit A, Alexander J, DeMark L, Krishna V, Kautz SA, Majid A, Tarver B, Turner DL, Kimberley TJ. Vagus Nerve Stimulation Paired With Rehabilitation for Upper Limb Motor Impairment and Function After Chronic Ischemic Stroke: Subgroup Analysis of the Randomized, Blinded, Pivotal, VNS-REHAB Device Trial. Neurorehabil Neural Repair 2022:15459683221129274. [PMID: 36226541 PMCID: PMC10097830 DOI: 10.1177/15459683221129274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Vagus Nerve Stimulation (VNS) paired with rehabilitation improved upper extremity impairment and function in a recent pivotal, randomized, triple-blind, sham-controlled trial in people with chronic arm weakness after stroke. OBJECTIVE We aimed to determine whether treatment effects varied across candidate subgroups, such as younger age or less injury. METHODS Participants were randomized to receive rehabilitation paired with active VNS or rehabilitation paired with sham stimulation (Control). The primary outcome was the change in impairment measured by the Fugl-Meyer Assessment Upper Extremity (FMA-UE) score on the first day after completion of 6-weeks in-clinic therapy. We explored the effect of VNS treatment by sex, age (≥62 years), time from stroke (>2 years), severity (baseline FMA-UE score >34), paretic side of body, country of enrollment (USA vs UK) and presence of cortical involvement of the index infarction. We assessed whether there was any interaction with treatment. FINDINGS The primary outcome increased by 5.0 points (SD 4.4) in the VNS group and by 2.4 points (SD 3.8) in the Control group (P = .001, between group difference 2.6, 95% CI 1.03-4.2). The between group difference was similar across all subgroups and there were no significant treatment interactions. There was no important difference in rates of adverse events across subgroups. CONCLUSION The response was similar across subgroups examined. The findings suggest that the effects of paired VNS observed in the VNS-REHAB trial are likely to be consistent in wide range of stroke survivors with moderate to severe upper extremity impairment.
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Affiliation(s)
- Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Steven C Cramer
- Department of Neurology, David Geffen School of Medicine at UCLA, and California Rehabilitation Institute; Los Angeles, CA, USA
| | - Steven L Wolf
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rushna Ali
- Department of Neurosciences, Spectrum Health, Grands Rapids, MI, USA
| | - Michael W O'Dell
- Clinical Rehabilitation Medicine, Weill Cornell Medicine, New York City, NY, USA
| | | | | | - Jessica Redgrave
- Sheffield Institute for Neurological Sciences (SITraN), Sheffield, UK
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Charles Y Liu
- USC Neurorestoration Center and Department of Neurological Surgery, USC Keck School of Medicine, Los Angeles, CA, USA, and Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, and The Institute for Rehabilitation and Research (TIRR) Memorial Hermann Hospital; Houston, TX, USA
| | - Benjamin L Brown
- Department of Neurosurgery, Ochsner Neuroscience Institute, Covington, Los Angeles, USA
| | - Anand Dixit
- Stroke Service, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jen Alexander
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Vibor Krishna
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC, USA
| | - Steven A Kautz
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA and Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA
| | - Arshad Majid
- Sheffield Institute for Neurological Sciences (SITraN) and Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | - Teresa J Kimberley
- Department of Physical Therapy, MGH Institute of Health Professions, Boston, MA, USA
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Chang SH, Tseng SC, Su H, Francisco GE. Editorial: How can wearable robotic and sensor technology advance neurorehabilitation? Front Neurorobot 2022; 16:1033516. [DOI: 10.3389/fnbot.2022.1033516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
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Li S, Gonzalez-Buonomo J, Ghuman J, Huang X, Malik A, Yozbatiran N, Magat E, Francisco GE, Wu H, Frontera WR. Aging after stroke: how to define post-stroke sarcopenia and what are its risk factors? Eur J Phys Rehabil Med 2022; 58:683-692. [PMID: 36062331 PMCID: PMC10022455 DOI: 10.23736/s1973-9087.22.07514-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Sarcopenia, generally described as "aging-related loss of skeletal muscle mass and function", can occur secondary to a systemic disease. AIM This project aimed to study the prevalence of sarcopenia in chronic ambulatory stroke survivors and its associated risk factors using the two most recent diagnostic criteria. DESIGN A cross-sectional observational study. SETTING A scientific laboratory. POPULATION Chronic stroke. METHODS Twenty-eight ambulatory chronic stroke survivors (12 females; mean age=57.8±11.8 years; time after stroke=76±45 months), hand-grip strength, gait speed, and appendicular skeletal muscle mass (ASM) were measured to define sarcopenia. Risk factors, including motor impairment and spasticity, were identified using regression analysis. RESULTS The prevalence of sarcopenia varied between 18% and 25% depending on the diagnostic criteria used. A significant difference was seen in the prevalence of low hand grip strength on the affected side (96%) when compared to the contralateral side (25%). The prevalence of slow gait speed was 86% while low ASM was present in 89% of the subjects. Low ASM was marginally negatively correlated with time since stroke and gait speed, but no correlation was observed with age, motor impairment, or spasticity. ASM loss, bone loss and fat deposition were significantly greater in the affected upper limb than in the affected lower limb. Regression analyses showed that time since stroke was a factor associated with bone and muscle loss in the affected upper limb, spasticity had a protective role for muscle loss in the affected lower limb, and walking had a protective role for bone loss in the lower limb. CONCLUSIONS The prevalence of sarcopenia in stroke survivors is high and is a multifactorial process that is not age-related. Different risk factors contribute to muscle loss in the upper and lower limbs after stroke. CLINICAL REHABILITATION IMPACT Clinicians need to be aware of high prevalence of sarcopenia in chronic stroke survivors. Sarcopenia is more evident in the upper than lower limbs. Clinicians also need to understand potential protective roles of some factors, such as spasticity and walking for the muscles in the lower limb.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA -
- NeuroRecovery Research Center, TIRR Memorial Hermann Hospital, Houston, TX, USA -
| | | | | | - Xinran Huang
- Department of Biostatistics and Data Science, University of Texas Health Science Center, Houston, TX, USA
| | - Aila Malik
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
- NeuroRecovery Research Center, TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Nuray Yozbatiran
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
- NeuroRecovery Research Center, TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Elaine Magat
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
- NeuroRecovery Research Center, TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
- NeuroRecovery Research Center, TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Hulin Wu
- Department of Biostatistics and Data Science, University of Texas Health Science Center, Houston, TX, USA
| | - Walter R Frontera
- Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
- Department of Physiology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Frontera WR, Stucki G, Engkasan JP, Francisco GE, Gutenbrunner C, Hasnan N, Lains J, Yusof YM, Negrini S, Omar Z, Battistella LR, Sowa G, Stam H, Bickenbach J. Advancing Academic Capacity in Physical and Rehabilitation Medicine to Strengthen Rehabilitation in Health Systems Worldwide: A Joint Effort by the European Academy of Rehabilitation Medicine, the Association of Academic Physiatrists, and the International Society of Physical and Rehabilitation Medicine. Am J Phys Med Rehabil 2022; 101:897-904. [PMID: 35777886 PMCID: PMC9377495 DOI: 10.1097/phm.0000000000002067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Layne CS, Malaya CA, Ravindran AS, John I, Francisco GE, Contreras-Vidal JL. Distinct Kinematic and Neuromuscular Activation Strategies During Quiet Stance and in Response to Postural Perturbations in Healthy Individuals Fitted With and Without a Lower-Limb Exoskeleton. Front Hum Neurosci 2022; 16:942551. [PMID: 35911598 PMCID: PMC9334701 DOI: 10.3389/fnhum.2022.942551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022] Open
Abstract
Many individuals with disabling conditions have difficulty with gait and balance control that may result in a fall. Exoskeletons are becoming an increasingly popular technology to aid in walking. Despite being a significant aid in increasing mobility, little attention has been paid to exoskeleton features to mitigate falls. To develop improved exoskeleton stability, quantitative information regarding how a user reacts to postural challenges while wearing the exoskeleton is needed. Assessing the unique responses of individuals to postural perturbations while wearing an exoskeleton provides critical information necessary to effectively accommodate a variety of individual response patterns. This report provides kinematic and neuromuscular data obtained from seven healthy, college-aged individuals during posterior support surface translations with and without wearing a lower limb exoskeleton. A 2-min, static baseline standing trial was also obtained. Outcome measures included a variety of 0 dimensional (OD) measures such as center of pressure (COP) RMS, peak amplitude, velocities, pathlength, and electromyographic (EMG) RMS, and peak amplitudes. These measures were obtained during epochs associated with the response to the perturbations: baseline, response, and recovery. T-tests were used to explore potential statistical differences between the exoskeleton and no exoskeleton conditions. Time series waveforms (1D) of the COP and EMG data were also analyzed. Statistical parametric mapping (SPM) was used to evaluate the 1D COP and EMG waveforms obtained during the epochs with and without wearing the exoskeleton. The results indicated that during quiet stance, COP velocity was increased while wearing the exoskeleton, but the magnitude of sway was unchanged. The OD COP measures revealed that wearing the exoskeleton significantly reduced the sway magnitude and velocity in response to the perturbations. There were no systematic effects of wearing the exoskeleton on EMG. SPM analysis revealed that there was a range of individual responses; both behaviorally (COP) and among neuromuscular activation patterns (EMG). Using both the OD and 1D measures provided a more comprehensive representation of how wearing the exoskeleton impacts the responses to posterior perturbations. This study supports a growing body of evidence that exoskeletons must be personalized to meet the specific capabilities and needs of each individual end-user.
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Affiliation(s)
- Charles S. Layne
- University of Houston, Houston, TX, United States
- Center for Neuromotor and Biomechanics Research, College of Liberal Arts and Social Sciences, University of Houston, Houston, TX, United States
- *Correspondence: Charles S. Layne
| | - Christopher A. Malaya
- Center for Neuromotor and Biomechanics Research, College of Liberal Arts and Social Sciences, University of Houston, Houston, TX, United States
| | - Akshay S. Ravindran
- Noninvasive Brain-Machine Interface System Laboratory, Department of Electrical and Computer Engineering, University of Houston, Houston, TX, United States
| | - Isaac John
- Center for Neuromotor and Biomechanics Research, College of Liberal Arts and Social Sciences, University of Houston, Houston, TX, United States
| | - Gerard E. Francisco
- TIRR Memorial Hermann and Department of PMR, University of Texas Health Sciences Center, Houston, TX, United States
| | - Jose Luis Contreras-Vidal
- Noninvasive Brain-Machine Interface System Laboratory, Department of Electrical and Computer Engineering, University of Houston, Houston, TX, United States
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Frontera WR, Stucki G, Engkasan JP, Francisco GE, Gutenbrunner C, Hasnan N, Lains J, Yusof YM, Negrini S, Battistella LR, Sowa G, Stam H, Bickenbach J. Advancing Academic Capacity in Physical and Rehabilitation Medicine to Strengthen Rehabilitation in Health Systems Worldwide: A Joint Effort by the European Academy of Rehabilitation Medicine, the Association of Academic Physiatrists, and the International Society of Physical and Rehabilitation Medicine. J Rehabil Med 2022; 54:jrm00310. [PMID: 35796075 PMCID: PMC9272549 DOI: 10.2340/jrm.v54.3510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Not available.
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Affiliation(s)
- Walter R Frontera
- Department of Physical Medicine, Rehabilitation and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico.
| | - Gerold Stucki
- Center for Rehabilitation in Global Health Systems, Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland; Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julia P Engkasan
- Department of Rehabilitation Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center, Houston, Texas; NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, Texas
| | | | - Nazirah Hasnan
- Department of Rehabilitation Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Jorge Lains
- Centro de Medicina de Reabilitação da Região Centro, Tocha, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | | | - Stefano Negrini
- Department of Biomedical, Surgical and Dental Sciences, University "La Statale," Milan, Italy; IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | | | - Gwen Sowa
- Center for Rehabilitation in Global Health Systems, Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland; Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Henk Stam
- Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jerome Bickenbach
- Center for Rehabilitation in Global Health Systems, Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland
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Driscoll SW, Raddatz MM, Sabharwal S, Francisco GE, Nguyen V, Kinney CL. American Board of Physical Medicine and Rehabilitation Diplomate Customization Choices on the Longitudinal Assessment for Physical Medicine and Rehabilitation: A First-Year Experience. Am J Phys Med Rehabil 2022; 101:S21-S25. [PMID: 35706114 DOI: 10.1097/phm.0000000000001991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The American Board of Physical Medicine and Rehabilitation began administering the longitudinal assessment for physical medicine and rehabilitation for continuing certification in 2020. The longitudinal assessment for physical medicine and rehabilitation digitally delivers quarterly short assessments of content and repeats missed items to facilitate learning as well as serve as a summative certification assessment. With a goal of offering content relevant to an individual's practice and learning needs, diplomates choose how to customize the domains or topic areas of their question content on an annual basis. This report describes the first year of experience with customization of longitudinal assessment for physical medicine and rehabilitation. The American Board of Physical Medicine and Rehabilitation diplomate customization data are grouped and compared in a variety of ways to ascertain whether there are differences in customization choices. While customization choices were similar across several domains, significant differences were seen when comparing groups with specific areas of practice or subspecialty certification. Smaller differences were also seen when comparing question domain allocation choice between sexes, age groups, and practice setting. The results from this first full year of experience confirm an alignment of this innovative assessment approach to individual physician practice, a significant step in improving the relevance of continuing certification overall for participating physicians.
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Affiliation(s)
- Sherilyn W Driscoll
- From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota (SWD); American Board of Physical Medicine and Rehabilitation, Rochester, Minnesota (MMR, CLK); Department of Physical Medicine and Rehabilitation, Harvard Medical School, VA Boston Health Care System, Boston, Massachusetts (SS); Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, McGovern Medical School, TIRR Memorial Hermann, Houston, Texas (GEF); Department of Physical Medicine and Rehabilitation, The University of Alabama at Birmingham, Birmingham, Alabama (VN); and Department of Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona (CLK)
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Sabharwal S, Kinney CL, Raddatz MM, Driscoll SW, Francisco GE, Robinson LR. Key Findings From Peer-Reviewed Published Research by the American Board of Physical Medicine and Rehabilitation in Review. Am J Phys Med Rehabil 2022; 101:S35-S39. [PMID: 35706117 DOI: 10.1097/phm.0000000000002015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Recognizing the dearth of published research on board certification in physical medicine and rehabilitation and its subspecialties, the American Board of Physical Medicine and Rehabilitation has increased efforts to conduct and disseminate research in this area. This report summarizes key findings of peer-reviewed studies published by American Board of Physical Medicine and Rehabilitation staff and leadership in the past 6 yrs, including those conducted in partnership with other entities. The reported studies are organized in three main categories: initial certification, continuing certification, and subspecialty certification in physical medicine and rehabilitation. Related findings are further grouped into subsections that include psychometric evaluation of certification examinations, association of candidate characteristics with certification performance, relationship of certification performance to other measures, and candidate reaction and feedback. Collectively, the summarized results provide evidence that the board certification process is reliable, statistically valid, and predictive of the risk of disciplinary action in subsequent years. These studies also describe facets of our specialty including degree of subspecialization, burnout, and how people maintain certification over time. We hope that physical medicine and rehabilitation trainees, diplomates, institutions, programs, and other stakeholders find this information useful and look forward to continuing research in these and other areas in the spirit of constant evidence-based improvement and feedback to our specialty.
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Affiliation(s)
- Sunil Sabharwal
- From the Harvard Medical School, Boston, Massachusetts (SS); VA Boston Health Care System, Boston, Massachusetts (SS); American Board of Physical Medicine and Rehabilitation, Rochester, Minnesota (CLK, MMR); Mayo Clinic, Phoenix, Arizona (CLK); Mayo Clinic, Rochester, Minnesota (SWD); University of Texas Health Science Center, McGovern Medical School, Houston, Texas (GEF); TIRR Memorial Hermann Hospital, Houston, Texas (GEF); and University of Toronto, St John's Rehabilitation Hospital, Toronto, Ontario, Canada (LRR)
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Sujatha Ravindran A, Malaya C, John I, Francisco GE, Layne C, Contreras-Vidal JL. Decoding Neural Activity Preceding Balance Loss During Standing with a Lower-limb Exoskeleton using an Interpretable Deep Learning Model. J Neural Eng 2022; 19. [PMID: 35508113 DOI: 10.1088/1741-2552/ac6ca9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/04/2022] [Indexed: 11/11/2022]
Abstract
Falls are a leading cause of death in adults 65 and older. Recent efforts to restore lower-limb function in these populations have seen an increase in the use of wearable robotic systems; however, fall prevention measures in these systems require early detection of balance loss to be effective. Prior studies have investigated whether kinematic variables contain information about an impending fall, but few have examined the potential of using electroencephalography (EEG) as a fall-predicting signal and how the brain responds to avoid a fall. To address this, we decoded neural activity in a balance perturbation task while wearing an exoskeleton. We acquired EEG, electromyography (EMG), and center of pressure (COP) data from 7 healthy participants during mechanical perturbations while standing. The timing of the perturbations was randomized in all trials. We found perturbation evoked potentials (PEP) components as early as 75-134 ms after the onset of the external perturbation, which preceded both the peak in EMG (∼ 180 ms) and the COP (∼ 350 ms). A convolutional neural network trained to predict balance perturbations from single-trial EEG had a mean F-score of 75.0 ± 4.3 %. Clustering GradCAM-based model explanations demonstrated that the model utilized components in the PEP and was not driven by artifacts. Additionally, dynamic functional connectivity results agreed with model explanations; the nodal connectivity measured using phase difference derivative was higher in the occipital-parietal region in the early stage of perturbations, before shifting to the parietal, motor, and back to the frontal-parietal channels. Continuous-time decoding of COP trajectories from EEG, using a gated recurrent unit model, achieved a mean Pearson's correlation coefficient of 0.7 ± 0.06. Overall, our findings suggest that EEG signals contain short-latency neural information related to an impending fall, which may be useful for developing brain-machine interface systems for fall prevention in robotic exoskeletons.
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Affiliation(s)
- Akshay Sujatha Ravindran
- Department of Electrical and Computer Engineering, University of Houston, 4800 calhoun road, E413, Cullen Engineering Building 1, University of Houston, Houston, Texas, 77204, UNITED STATES
| | - Christopher Malaya
- Health and Human Performance, University of Houston, 4800 calhoun road, Houston, Houston, Texas, 77204, UNITED STATES
| | - Isaac John
- Health and Human Performance, University of Houston, 4800 calhoun road, Houston, Houston, Texas, 77204, UNITED STATES
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, 7000 Fannin St, Houston, Texas, 77030, UNITED STATES
| | - Charles Layne
- Health and Human Performance, University of Houston, 4800 calhoun road, Houston, Houston, Texas, 77204, UNITED STATES
| | - Jose Luis Contreras-Vidal
- Electrical and Computer Engineering, University of Houston, N308 Engineering Building I, Houston, Texas, 77204-4005, UNITED STATES
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Afzal T, Zhu F, Tseng SC, Lincoln JA, Francisco GE, Su H, Chang SH. Evaluation of Muscle Synergy during Exoskeleton-assisted Walking in Persons with Multiple Sclerosis. IEEE Trans Biomed Eng 2022; 69:3265-3274. [PMID: 35412969 DOI: 10.1109/tbme.2022.3166705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Gait deficit after multiple sclerosis (MS) can be characterized by altered muscle activation patterns. There is preliminary evidence of improved walking with a lower limb exoskeleton in persons with MS. However, the effects of exoskeleton-assisted walking on neuromuscular modifications are relatively unclear. The objective of this study was to investigate the muscle synergies, their activation patterns and the differences in neural strategies during walking with (EXO) and without (No-EXO) an exoskeleton. METHODS Ten subjects with MS performed walking during EXO and No-EXO conditions. Electromyography signals from seven leg muscles were recorded. Muscle synergies and the activation profiles were extracted using non-negative matrix factorization. RESULTS The stance phase duration was significantly shorter during EXO compared to the No-EXO condition (p<0.05). Moreover, typically 3-5 modules were extracted in each condition. The module-1 (comprising Vastus Medialis and Rectus Femoris muscles), module-2 (comprising Soleus and Medial Gastrocnemius muscles), module-3 (Tibialis Anterior muscle) and module-4 (comprising Biceps Femoris and Semitendinosus muscles) were comparable between conditions. During EXO condition, Semitendinosus and Vastus Medialis emerged in module-5 in 7/10 subjects. Compared to No-EXO, average activation amplitude was significantly reduced corresponding to module-2 during the stance phase and module-3 during the swing phase during EXO. CONCLUSION Exoskeleton-assistance does not alter the existing synergy modules, but could induce a new module to emerge, and alters the control of these modules, i.e., modifies the neural commands indicated by the reduced amplitude of the activation profiles.
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Dragojlovic N, Romanoski NL, Verduzco-Gutierrez M, Francisco GE. Prevalence and Treatment Characteristics of Spastic Hypertonia on First-Time Admission to Acute Inpatient Rehabilitation. Am J Phys Med Rehabil 2022; 101:348-352. [PMID: 34121067 DOI: 10.1097/phm.0000000000001823] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to report the prevalence of spasticity and treatment patterns during first-time admission to inpatient rehabilitation after acute stroke, traumatic brain injury, and spinal cord injury. DESIGN This is a retrospective cohort study. METHODS A review of 285 adult patients consecutively admitted to inpatient rehabilitation was conducted. Patients with a history of spasticity and inpatient rehabilitation course and those younger than 18 yrs were excluded. Main outcome measures are as follows: admitting diagnosis, length of stay, time from injury to admission, acute transfer rate, prevalence and severity of spasticity using Modified Ashworth Scale at admission and discharge, Functional Independence Measure scores at admission and discharge, Functional Independence Measure efficiency, and treatments for spasticity. RESULTS Stroke patients had the highest prevalence of spasticity: 68% on admission and 50% at discharge. In traumatic brain injury, spasticity prevalence was 55% on admission and 30% at discharge. In spinal cord injury, spasticity prevalence was 48% on admission and 46% at discharge. Patients with spinal cord injury received the most medications to control spasticity, whereas those with traumatic brain injury and stroke received the most procedural interventions. CONCLUSIONS Spasticity is a common sequela of upper motor neuron injury for patients admitted to inpatient rehabilitation. Early recognition and management are essential to prevent contractures, minimize pain, and maximize functional recovery.
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Affiliation(s)
- Nikola Dragojlovic
- From the Department of Physical Medicine and Rehabilitation, McGovern Medical School at UTHealth, Houston, Texas (ND, GEF); Department of Physical Medicine and Rehabilitation, Penn State Health, Hershey, Pennsylvania (NLR); and Department of Physical Medicine and Rehabilitation, UTHealth San Antonio, San Antonio, Texas (MV-G)
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Stampas A, Hook M, Korupolu R, Jethani L, Kaner MT, Pemberton E, Li S, Francisco GE. Evidence of treating spasticity before it develops: a systematic review of spasticity outcomes in acute spinal cord injury interventional trials. Ther Adv Neurol Disord 2022; 15:17562864211070657. [PMID: 35198042 PMCID: PMC8859674 DOI: 10.1177/17562864211070657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/13/2021] [Indexed: 12/09/2022] Open
Abstract
Introduction: Spasticity is a common consequence of spinal cord injury (SCI), estimated to affect up to 93% of people living with SCI in the community. Problematic spasticity affects around 35% people with SCI spasticity. The early period after injury is believed to be the most opportune time for neural plasticity after SCI. We hypothesize that clinical interventions in the early period could reduce the incidence of spasticity. To address this, we evaluated the spasticity outcomes of clinical trials with interventions early after SCI.Methods: We performed a systematic review of the literature between January 2000 and May 2021 to identify control trials, in humans and animals, that were performed early after SCI that included measures of spasticity in accordance with PRISMA guidelines.Results: Our search yielded 1,463 records of which we reviewed 852 abstracts and included 8 human trial peer-reviewed publications and 9 animal studies. The 9 animal trials largely supported the hypothesis that early intervention can reduce spasticity, including evidence from electrophysiological, behavioral, and histologic measures. Of the 8 human trials, only one study measured spasticity as a primary outcome with a sample size sufficient to test the hypothesis. In this study, neuromodulation of the spinal cord using electric stimulation of the common peroneal nerve reduced spasticity in the lower extremities compared to controls.Conclusion: Given the prevalence of problematic spasticity, there is surprisingly little research being performed in the early period of SCI that includes spasticity measures, and even fewer studies that directly address spasticity. More research on the potential for early interventions to mitigate spasticity is needed.
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Affiliation(s)
| | | | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lavina Jethani
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mahmut T. Kaner
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Erinn Pemberton
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- TIRR Memorial Hermann, Houston, TX, USA
| | - Gerard E. Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- TIRR Memorial Hermann, Houston, TX, USA
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23
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Dawson J, Liu C, Francisco GE, Cramer SC, Wolf SL, Dixit A, Alexander J, Ali R, Brown B, Feng W, DeMark L, Kautz S, Majid A, O'Dell MW, Pierce D, Prudente C, Redgrave J, Turner D, Tarver B, Engineer N, Kimberley TJ. Abstract 1: Vagus Nerve Stimulation Paired With Rehabilitation For Upper Limb Motor Function After Ischaemic Stroke: Sub-group Analysis Of The Randomised, Blinded, Pivotal, Vns-Rehab Device Trial. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Vagus Nerve Stimulation (VNS) paired with rehabilitation improved upper extremity impairment and function in a recent pivotal, randomised, blinded, sham-controlled trial. Here we report post-hoc sub-group analyses from the VNS Rehab trial. We aimed to determine whether treatment effects were consistent across subgroups.
Methods:
VNS Rehab included 108 participants with moderate to severe arm /hand weakness, at least nine months after ischaemic stroke. They were randomised to receive rehabilitation paired with active VNS or rehabilitation paired with sham stimulation (Control). The primary outcome was the change in iFugl-Meyer Assessment Upper Extremity (FMA-UE) score on the first day after completion of in-clinic therapy. The trial was registered on
ClinicalTrials.gov
(NCT03131960). We explored the effect of VNS treatment by sex (n=70 males; n=38 females), age (≤ 65 or >65 years)), time from stroke (median time, 2 years) and baseline FMA-UE score (<=33 severe, >33 moderate). We assessed whether there was any interaction with treatment. No hypotheses were specified prior to this analysis and no formal adjustment was made for multiplicity.
Findings:
On the first day after completion of in-clinic therapy, the mean (±SD) FMA-UE score increased by 5.0 points (SD 4.4) in the VNS group and by 2.4 points (SD 3.8) in the Control group (p=0.001, between group difference 2.6, 95% CI 1.03 to 4.2). The between group difference was similar across all subgroups (figure). No significant treatment interactions were observed with baseline characteristics.
Interpretation:
Participants with moderate to severe arm and hand impairment after ischaemic stroke showed clinically meaningful improvements in motor impairment and function with rehabilitation paired with VNS compared to rehabilitation with sham VNS. The response appeared similar across pre-defined subgroups of interest.
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Affiliation(s)
| | - Charles Liu
- USC Neurorestoration Cntr and Dept of Neurological Surgery, USC Keck Sch of Medicine, Los Angeles, CA
| | | | | | | | - Anand Dixit
- The Newcastle Upon Tyne Hosps NHS Foundation Trust, Newcastle, United Kingdom
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24
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Janela D, Costa F, Molinos M, Moulder RG, Lains J, Francisco GE, Bento V, Cohen SP, Correia FD. Asynchronous and Tailored Digital Rehabilitation of Chronic Shoulder Pain: A Prospective Longitudinal Cohort Study. J Pain Res 2022; 15:53-66. [PMID: 35035234 PMCID: PMC8755939 DOI: 10.2147/jpr.s343308] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/22/2021] [Indexed: 12/21/2022] Open
Abstract
Background Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs. Purpose Present the results of a fully remote digital care program (DCP) for chronic SP. Patients and Methods Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement. Results From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean −13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6). Conclusion This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.
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Affiliation(s)
- Dora Janela
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Fabíola Costa
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Maria Molinos
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Robert G Moulder
- Institute for Cognitive Science, University of Colorado Boulder, Boulder, CO, USA
| | - Jorge Lains
- Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, and TIRR Memorial Hermann, Houston, TX, USA
| | - Virgílio Bento
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA
| | - Steven P Cohen
- Departments of Anesthesiology & Critical Care Medicine, Physical Medicine and Rehabilitation, Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Departments of Anesthesiology and Physical Medicine and Rehabilitation and Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Fernando Dias Correia
- SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA.,Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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25
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Costa F, Janela D, Molinos M, Lains J, Francisco GE, Bento V, Dias Correia F. Telerehabilitation of acute musculoskeletal multi-disorders: prospective, single-arm, interventional study. BMC Musculoskelet Disord 2022; 23:29. [PMID: 34983488 PMCID: PMC8728982 DOI: 10.1186/s12891-021-04891-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022] Open
Abstract
Background Acute musculoskeletal (MSK) pain is very common and associated with impaired productivity and high economic burden. Access to timely and personalized, evidence-based care is key to improve outcomes while reducing healthcare expenditure. Digital interventions can facilitate access and ensure care scalability. Objective Present the feasibility and results of a fully remote digital care program (DCP) for acute MSK conditions affecting several body areas. Methods Interventional single-arm study of individuals applying for digital care programs for acute MSK pain. Primary outcome was the mean change between baseline and end-of-program in self-reported Numerical Pain Rating Scale (NPRS) score and secondary outcomes were change in analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI-GH) and engagement. Results Three hundred forty-three patients started the program, of which 300 (87.5%) completed the program. Latent growth curve analysis (LGCA) revealed that changes in NPRS between baseline and end-of-program were both statistically (p < 0.001) and clinically significant: 64.3% reduction (mean − 2.9 points). Marked improvements were also noted in all secondary outcomes: 82% reduction in medication intake, 63% reduction in surgery intent, 40% in fear-avoidance beliefs, 54% in anxiety, 58% in depression and 79% recovery in overall productivity. All outcomes had steeper improvements in the first 4 weeks, which paralleled higher engagement in this period (3.6 vs 3.2 overall weekly sessions, p < 0.001). Mean patient satisfaction score was 8.7/10 (SD 1.26). Strengths and limitations This is the first longitudinal study demonstrating the feasibility of a DCP for patients with acute MSK conditions involving several body areas. Major strengths of this study are the large sample size, the wide range of MSK conditions studied, the breadth of outcomes measured, and the very high retention rate and adherence level. The major limitation regards to the absence of a control group. Conclusions We observed very high completion and engagement rates, as well as clinically relevant changes in all health-related outcomes and productivity recovery. We believe this DCP holds great potential in the delivery of effective and scalable MSK care. Trial registration NCT, NCT04092946. Registered 17/09/2019; Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04891-5.
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Affiliation(s)
| | - Dora Janela
- SWORD Health Technologies, Inc, Draper, UT, USA
| | | | - Jorge Lains
- Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, and TIRR Memorial Hermann, Houston, TX, USA
| | | | - Fernando Dias Correia
- SWORD Health Technologies, Inc, Draper, UT, USA. .,Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal.
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26
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Correia FD, Molinos M, Neves C, Janela D, Carvalho D, Luis S, Francisco GE, Lains J, Bento V. Digital Rehabilitation for Acute Ankle Sprains: Prospective Longitudinal Cohort Study. JMIR Rehabil Assist Technol 2021; 8:e31247. [PMID: 34499038 PMCID: PMC8517823 DOI: 10.2196/31247] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 07/30/2021] [Indexed: 12/21/2022] Open
Abstract
Background Ankle sprains are one of the most prevalent soft-tissue injuries worldwide. Physical therapy, especially progressive exercise, has proven effective in improving function, while preventing recurrence. Objective We aim to present the results of a fully remote and digitally guided rehabilitation program for acute ankle sprains. Methods We performed a prospective longitudinal cohort study of individuals eligible for workers’ compensation, who were referred for digital rehabilitation therapy for a sprained ankle. Therapeutic exercise sessions were to be performed independently by the patient at home using the biofeedback device provided by SWORD Health. Primary endpoints were the change in self-reported Numerical Pain Rating Scale (NPRS) and Foot and Ankle Ability Measure–activities of daily living (FAAM–ADL) and FAAM–Sports scores. Participants were assessed at baseline, end of the program, and 6 months after program completion. Secondary outcomes included digital therapy dosage, pain and fatigue during sessions, and satisfaction. Results In total, 93 (89.4%) patients completed the program and 79 (76.0%) were available for follow-up. Changes in the primary outcomes between baseline and the 6-month follow-up were both significant (P<.001) and clinically meaningful: mean difference of –2.72 points (95% CI –3.31 to –2.13) on the NPRS (49.8% reduction), 21.7 points (95% CI 17.13-26.27) on the FAAM–ADL (41.1% increase), and 37.8 points (95% CI 30.45-45.15) on the FAAM-Sports (151.8% increase). Longer waiting periods between the accident date and treatment initiation were found to negatively impact functional status at baseline and at the end of the program, triggering an extension in the program duration. The total training volume (12.5 hours, SD 10.5 hours) was similar to that of other interventions for ankle sprains, but the dosage per week was much higher (2.4 hours per week, SD 0.87 hours per week). The mean patient satisfaction score was 8.8 (SD 1.57) out of 10. Among program completers, 83.9% attained full recovery and were discharged with no residual disability. Conclusions Being far less demanding in terms of human resources, the digital program presented constituted a viable, clinically effective, and convenient solution for ankle sprain rehabilitation, particularly during the pandemic. This is the first study presenting a fully remote home-based rehabilitation program for acute ankle sprains, with patients achieving sustained long-term results. This was a prospective cohort study and, as such, did not include a control group, but the results appear comparable to those published for face-to-face interventions. Trial Registration ClinicalTrials.gov NCT04819022; https://clinicaltrials.gov/ct2/show/NCT04819022
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Affiliation(s)
- Fernando D Correia
- Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Escola de Medicina, Universidade do Minho, Braga, Portugal
| | - Maria Molinos
- SWORD Health Technologies, Inc, Draper, UT, United States
| | - Carlos Neves
- SWORD Health Technologies, Inc, Draper, UT, United States
| | - Dora Janela
- SWORD Health Technologies, Inc, Draper, UT, United States
| | - Diana Carvalho
- SWORD Health Technologies, Inc, Draper, UT, United States
| | - Sara Luis
- SWORD Health Technologies, Inc, Draper, UT, United States
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, United States.,TIRR Memorial Hermann, Houston, TX, United States
| | - Jorge Lains
- Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Virgilio Bento
- SWORD Health Technologies, Inc, Draper, UT, United States
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27
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Nolan KJ, Karunakaran KK, Roberts P, Tefertiller C, Walter AM, Zhang J, Leslie D, Jayaraman A, Francisco GE. Utilization of Robotic Exoskeleton for Overground Walking in Acute and Chronic Stroke. Front Neurorobot 2021; 15:689363. [PMID: 34539371 PMCID: PMC8442911 DOI: 10.3389/fnbot.2021.689363] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Stroke commonly results in gait deficits which impacts functional ambulation and quality of life. Robotic exoskeletons (RE) for overground walking are devices that are programmable to provide high dose and movement-impairment specific assistance thus offering new rehabilitation possibilities for recovery progression in individuals post stroke. The purpose of this investigation is to present preliminary utilization data in individuals with acute and chronic stroke after walking overground with an RE. Secondary analysis on a subset of individuals is presented to understand the mechanistic changes due to RE overground walking. Thirty-eight participants with hemiplegia secondary to stroke were enrolled in a clinical trial conducted at eight rehabilitation centers. Data is presented for four sessions of overground walking in the RE over the course of 2 weeks. Participants continued their standard of care if they had any ongoing therapy at the time of study enrollment. Gait speed during the 10 Meter Walk Test, Gait deviations and the Functional Ambulation Category (FAC) data were collected before (baseline) and after (follow-up) the RE walking sessions. Walking speed significantly increased between baseline and follow-up for participants in the chronic (p <0.01) and acute (p < 0.05) stage of stroke recovery. FAC level significantly improved (p < 0.05) and there were significantly fewer (p < 0.05) gait deviations observed for participants in the acute stages of stroke recovery between baseline and follow-up. Secondary analysis on a subset of eight participants indicated that after four sessions of overground walking with the RE, the participants significantly improved their spatial symmetry. The walk time, step count and ratio of walk time to up time increased from first session to the last session for participants in the chronic and acute stages of stroke. The RE was effectively utilized for overground walking for individuals with acute and chronic stroke with varying severity levels. The results demonstrated an increase in walking speed, improvement in FAC and a decrease in gait deviations (from baseline to follow-up) after four sessions of overground walking in the RE for participants. In addition, preliminary data indicated that spatial symmetry and step length also improved after utilization of an RE for overground walking.
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Affiliation(s)
- Karen J Nolan
- Kessler Foundation, Center for Mobility and Engineering Research, West Orange, NJ, United States.,Rutgers-New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ, United States
| | - Kiran K Karunakaran
- Kessler Foundation, Center for Mobility and Engineering Research, West Orange, NJ, United States.,Rutgers-New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ, United States
| | - Pamela Roberts
- Cedars-Sinai Medical Center, Department of Physical Medicine and Rehabilitation, Los Angeles, CA, United States
| | - Candy Tefertiller
- Craig Hospital, Department of Physical Therapy, Englewood, CO, United States
| | - Amber M Walter
- Sheltering Arms Physical Rehabilitation Centers, Mechanicsville, VA, United States
| | - Jun Zhang
- St. Charles Hospital, Port Jefferson, NY, United States
| | | | - Arun Jayaraman
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, IL, United States.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, United States
| | - Gerard E Francisco
- University of Texas at Houston McGovern Medical School, Houston, TX, United States.,TIRR Memorial Hermann, Houston, TX, United States
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Esquenazi A, Francisco GE, Feng W, Baricich A, Gallien P, Fanning K, Zuzek A, Bandari DS, Wittenberg GF. Real-World Adherence to OnabotulinumtoxinA Treatment for Spasticity: Insights From the ASPIRE Study. Arch Phys Med Rehabil 2021; 102:2172-2184.e6. [PMID: 34245684 DOI: 10.1016/j.apmr.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/19/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify baseline characteristics and treatment-related variables that affect adherence to onabotulinumtoxinA treatment from the Adult Spasticity International Registry (ASPIRE) study. DESIGN Prospective, observational registry (NCT01930786). SETTING International clinical sites. PARTICIPANTS Adults with spasticity (N=730). INTERVENTIONS OnabotulinumtoxinA at clinician's discretion. MAIN OUTCOME MEASURES Clinically meaningful thresholds used for treatment adherent (≥3 treatment sessions during 2-year study) and nonadherent (≤2 sessions). Data analyzed using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Treatment-related variables assessed at sessions 1 and 2 only. RESULTS Of the total population, 523 patients (71.6%) were treatment adherent with 5.3±1.6 sessions and 207 (28.4%) were nonadherent with 1.5±0.5 sessions. In the final model (n=626/730), 522 patients (83.4%) were treatment adherent and 104 (16.6%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=1.84; CI, 1.06-3.21; P=.030) and use of orthotics (OR=1.88; CI, 1.15-3.08; P=.012). Baseline characteristics associated with nonadherence: history of diplopia (OR=0.28; CI, 0.09-0.89; P=.031) and use of assistive devices (OR=0.51; CI, 0.29-0.90; P=.021). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.43; CI, 0.26-0.72; P=.001) and clinician dissatisfaction with onabotulinumtoxinA to manage pain (OR=0.18; CI, 0.05-0.69; P=.012). Of the population with stroke (n=411), 288 patients (70.1%) were treatment adherent with 5.3±1.6 sessions and 123 (29.9%) were nonadherent with 1.5±0.5 session. In the final stroke model (n=346/411), 288 patients (83.2%) were treatment adherent and 58 (16.8%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=2.99; CI, 1.39-6.44; P=.005) and use of orthotics (OR=3.18; CI, 1.57-6.45; P=.001). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.42; CI, 0.21-0.83; P=.013) and moderate/severe disability on upper limb Disability Assessment Scale pain subscale (OR=0.40; CI, 0.19-0.83; P=.015). CONCLUSIONS These ASPIRE analyses demonstrate real-world patient and clinical variables that affect adherence to onabotulinumtoxinA and provide insights to help optimize management strategies to improve patient care.
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Affiliation(s)
| | - Gerard E Francisco
- University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Alessio Baricich
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Philippe Gallien
- Physical Medicine and Rehabilitation, Pôle MPR Saint Hélier, Rennes, France
| | | | - Aleksej Zuzek
- Medical Affairs, Spasticity and Movement Disorders/Urology, Allergan, an AbbVie Company, Irvine, CA
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29
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Gracies JM, Francisco GE, Jech R, Khatkova S, Rios CD, Maisonobe P. Guided Self-rehabilitation Contracts Combined With AbobotulinumtoxinA in Adults With Spastic Paresis. J Neurol Phys Ther 2021; 45:203-213. [PMID: 34039905 PMCID: PMC8191476 DOI: 10.1097/npt.0000000000000359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Guided self-rehabilitation contracts (GSCs) are a diary-based rehabilitation strategy, wherein specific muscles are identified for prescription of high-load, home self-stretching techniques. We assessed the effect of GSCs combined with simultaneous upper limb (UL) and lower limb (LL) abobotulinumtoxinA injections on composite active range of motion (CXA) in adults with chronic spastic paresis. METHODS This was an international, prospective, single-arm, open-label study (ENGAGE, NCT02969356). Personalized GSCs were monitored by phone every other week, alongside 2 consecutive abobotulinumtoxinA injections (1500 U) across UL and LL, over 6 to 9 months. Primary outcomes were responder rates (CXA improvement ≥35° [UL] or ≥5° [LL]) at week 6 cycle 2. Secondary outcomes were active function (UL: Modified Frenchay Scale [MFS]; LL: 10-m barefoot maximal walking speed [WS]) and quality of life (12-item Short Form Health Survey, SF-12). RESULTS Of the 153 treated participants, 136 had primary endpoint data; 72.1% (95% confidence interval [CI], 64.0-78.9) were responders. Mean (SD) CXA changes from baseline to last study visit were +49.3° (63.4) for UL and +20.1° (27.6) for LL. Mean (95% CI) changes from baseline to week 12 cycle 2 were +0.55 (0.43-0.66) in MFS, +0.12 m/s (0.09-0.15) for WS, and +4.0 (2.8-5.2) for SF-12 physical scores. In the safety population (n = 157), 49.7% of participants reported treatment-emergent adverse events (AEs); 12.1% reported 25 serious AEs. DISCUSSION AND CONCLUSIONS GSC combined with simultaneous UL and LL abobotulinumtoxinA injections led to improvements in CXA and function in both limbs, and quality-of-life physical scores. These results suggest the beneficial effect of combined GSC and abobotulinumtoxinA therapy in the management of spastic paresis.Video Abstract available for more insight from the authors (see the Supplementary Video, available at: http://links.lww.com/JNPT/A346).
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Affiliation(s)
- Jean-Michel Gracies
- UR 7377 BIOTN, Université Paris-Est Créteil, Albert Chenevier-Henri Mondor Hospital, Department of Neurorehabilitation, Créteil, France (J.M.G.); Department of Physical Medicine and Rehabilitation, the University of Texas Health Science Center at Houston McGovern Medical School, and the Neurorecovery Research Center at TIRR Memorial Hermann, Houston, Texas (G.E.F.); Department of Neurology, First Faculty of Medicine, Charles University, and General Faculty Hospital, Prague, Czech Republic (R.J.); Neurology Department, Federal State Hospital, Treatments and Rehabilitation, Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia (S.K.); and Ipsen Pharma, Boulogne- Billancourt, France (C.D.R., P.M)
| | - Gerard E. Francisco
- UR 7377 BIOTN, Université Paris-Est Créteil, Albert Chenevier-Henri Mondor Hospital, Department of Neurorehabilitation, Créteil, France (J.M.G.); Department of Physical Medicine and Rehabilitation, the University of Texas Health Science Center at Houston McGovern Medical School, and the Neurorecovery Research Center at TIRR Memorial Hermann, Houston, Texas (G.E.F.); Department of Neurology, First Faculty of Medicine, Charles University, and General Faculty Hospital, Prague, Czech Republic (R.J.); Neurology Department, Federal State Hospital, Treatments and Rehabilitation, Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia (S.K.); and Ipsen Pharma, Boulogne- Billancourt, France (C.D.R., P.M)
| | - Robert Jech
- UR 7377 BIOTN, Université Paris-Est Créteil, Albert Chenevier-Henri Mondor Hospital, Department of Neurorehabilitation, Créteil, France (J.M.G.); Department of Physical Medicine and Rehabilitation, the University of Texas Health Science Center at Houston McGovern Medical School, and the Neurorecovery Research Center at TIRR Memorial Hermann, Houston, Texas (G.E.F.); Department of Neurology, First Faculty of Medicine, Charles University, and General Faculty Hospital, Prague, Czech Republic (R.J.); Neurology Department, Federal State Hospital, Treatments and Rehabilitation, Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia (S.K.); and Ipsen Pharma, Boulogne- Billancourt, France (C.D.R., P.M)
| | - Svetlana Khatkova
- UR 7377 BIOTN, Université Paris-Est Créteil, Albert Chenevier-Henri Mondor Hospital, Department of Neurorehabilitation, Créteil, France (J.M.G.); Department of Physical Medicine and Rehabilitation, the University of Texas Health Science Center at Houston McGovern Medical School, and the Neurorecovery Research Center at TIRR Memorial Hermann, Houston, Texas (G.E.F.); Department of Neurology, First Faculty of Medicine, Charles University, and General Faculty Hospital, Prague, Czech Republic (R.J.); Neurology Department, Federal State Hospital, Treatments and Rehabilitation, Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia (S.K.); and Ipsen Pharma, Boulogne- Billancourt, France (C.D.R., P.M)
| | - Carl D. Rios
- UR 7377 BIOTN, Université Paris-Est Créteil, Albert Chenevier-Henri Mondor Hospital, Department of Neurorehabilitation, Créteil, France (J.M.G.); Department of Physical Medicine and Rehabilitation, the University of Texas Health Science Center at Houston McGovern Medical School, and the Neurorecovery Research Center at TIRR Memorial Hermann, Houston, Texas (G.E.F.); Department of Neurology, First Faculty of Medicine, Charles University, and General Faculty Hospital, Prague, Czech Republic (R.J.); Neurology Department, Federal State Hospital, Treatments and Rehabilitation, Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia (S.K.); and Ipsen Pharma, Boulogne- Billancourt, France (C.D.R., P.M)
| | - Pascal Maisonobe
- UR 7377 BIOTN, Université Paris-Est Créteil, Albert Chenevier-Henri Mondor Hospital, Department of Neurorehabilitation, Créteil, France (J.M.G.); Department of Physical Medicine and Rehabilitation, the University of Texas Health Science Center at Houston McGovern Medical School, and the Neurorecovery Research Center at TIRR Memorial Hermann, Houston, Texas (G.E.F.); Department of Neurology, First Faculty of Medicine, Charles University, and General Faculty Hospital, Prague, Czech Republic (R.J.); Neurology Department, Federal State Hospital, Treatments and Rehabilitation, Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia (S.K.); and Ipsen Pharma, Boulogne- Billancourt, France (C.D.R., P.M)
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Zhu F, Kern M, Fowkes E, Afzal T, Contreras-Vidal JL, Francisco GE, Chang SH. Effects of an exoskeleton-assisted gait training on post-stroke lower-limb muscle coordination. J Neural Eng 2021; 18. [PMID: 33752175 DOI: 10.1088/1741-2552/abf0d5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/22/2021] [Indexed: 11/11/2022]
Abstract
Objective.Powered exoskeletons have been used to help persons with gait impairment regain some walking ability. However, little is known about its impact on neuromuscular coordination in persons with stroke. The objective of this study is to investigate how a powered exoskeleton could affect the neuromuscular coordination of persons with post-stroke hemiparesis.Approach.Eleven able-bodied subjects and ten stroke subjects participated in a single-visit treadmill walking assessment, in which their motion and lower-limb muscle activities were captured. By comparing spatiotemporal parameters, kinematics, and muscle synergy pattern between two groups, we characterized the normal gait pattern and the post-stroke motor deficits. Five eligible stroke subjects received exoskeleton-assisted gait trainings and walking assessments were conducted pre-intervention (Pre) and post-intervention (Post), without (WO) and with (WT) the exoskeleton. We compared their gait performance between (a) Pre and Post to investigate the effect of exoskeleton-assisted gait training and, (b) WO and WT the exoskeleton to investigate the effect of exoskeleton wearing on stroke subjects.Main results.While four distinct motor modules were needed to describe lower-extremity activities during stead-speed walking among able-bodied subjects, three modules were sufficient for the paretic leg from the stroke subjects. Muscle coordination complexity, module composition and activation timing were preserved after the training, indicating the intervention did not significantly change the neuromuscular coordination. In contrast, walking WT the exoskeleton altered the stroke subjects' synergy pattern, especially on the paretic side. The changes were dominated by the activation profile modulation towards the normal pattern observed from the able-bodied group.Significance.This study gave us some critical insight into how a powered exoskeleton affects the stroke subjects' neuromuscular coordination during gait and demonstrated the potential to use muscle synergy as a method to evaluate the effect of the exoskeleton training.This study was registered at ClinicalTrials.gov (identifier: NCT03057652).
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Affiliation(s)
- Fangshi Zhu
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, Houston, TX, United States of America.,Center for Wearable Exoskeletons, NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Marcie Kern
- Center for Wearable Exoskeletons, NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Erin Fowkes
- Center for Wearable Exoskeletons, NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Taimoor Afzal
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, Houston, TX, United States of America.,Center for Wearable Exoskeletons, NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Jose-Luis Contreras-Vidal
- Department of Electrical and Computer Engineering, The University of Houston, Houston, TX, United States of America
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, Houston, TX, United States of America.,Center for Wearable Exoskeletons, NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Shuo-Hsiu Chang
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, Houston, TX, United States of America.,Center for Wearable Exoskeletons, NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
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Li S, Francisco GE, Rymer WZ. A New Definition of Poststroke Spasticity and the Interference of Spasticity With Motor Recovery From Acute to Chronic Stages. Neurorehabil Neural Repair 2021; 35:601-610. [PMID: 33978513 DOI: 10.1177/15459683211011214] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The relationship of poststroke spasticity and motor recovery can be confusing. "True" motor recovery refers to return of motor behaviors to prestroke state with the same end-effectors and temporo-spatial pattern. This requires neural recovery and repair, and presumably occurs mainly in the acute and subacute stages. However, according to the International Classification of Functioning, Disability and Health, motor recovery after stroke is also defined as "improvement in performance of functional tasks," i.e., functional recovery, which is mainly mediated by compensatory mechanisms. Therefore, stroke survivors can execute motor tasks in spite of disordered motor control and the presence of spasticity. Spasticity interferes with execution of normal motor behaviors ("true" motor recovery), throughout the evolution of stroke from acute to chronic stages. Spasticity reduction does not affect functional recovery in the acute and subacute stages; however, appropriate management of spasticity could lead to improvement of motor function, that is, functional recovery, during the chronic stage of stroke. We assert that spasticity results from upregulation of medial cortico-reticulo-spinal pathways that are disinhibited due to damage of the motor cortex or corticobulbar pathways. Spasticity emerges as a manifestation of maladaptive plasticity in the early stages of recovery and can persist into the chronic stage. It coexists and shares similar pathophysiological processes with related motor impairments, such as abnormal force control, muscle coactivation and motor synergies, and diffuse interlimb muscle activation. Accordingly, we propose a new definition of spasticity to better account for its pathophysiology and the complex nuances of different definitions of motor recovery.
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Affiliation(s)
- Sheng Li
- University of Texas Health Science Center-Houston, TX, USA.,TIRR Memorial Hermann, Houston, TX, USA
| | - Gerard E Francisco
- University of Texas Health Science Center-Houston, TX, USA.,TIRR Memorial Hermann, Houston, TX, USA.,World Federation of NeuroRehabilitation, North Shields, UK
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Dawson J, Liu CY, Francisco GE, Cramer SC, Wolf SL, Dixit A, Alexander J, Ali R, Brown BL, Feng W, DeMark L, Hochberg LR, Kautz SA, Majid A, O'Dell MW, Pierce D, Prudente CN, Redgrave J, Turner DL, Engineer ND, Kimberley TJ. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial. Lancet 2021; 397:1545-1553. [PMID: 33894832 PMCID: PMC8862193 DOI: 10.1016/s0140-6736(21)00475-x] [Citation(s) in RCA: 159] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term loss of arm function after ischaemic stroke is common and might be improved by vagus nerve stimulation paired with rehabilitation. We aimed to determine whether this strategy is a safe and effective treatment for improving arm function after stroke. METHODS In this pivotal, randomised, triple-blind, sham-controlled trial, done in 19 stroke rehabilitation services in the UK and the USA, participants with moderate-to-severe arm weakness, at least 9 months after ischaemic stroke, were randomly assigned (1:1) to either rehabilitation paired with active vagus nerve stimulation (VNS group) or rehabilitation paired with sham stimulation (control group). Randomisation was done by ResearchPoint Global (Austin, TX, USA) using SAS PROC PLAN (SAS Institute Software, Cary, NC, USA), with stratification by region (USA vs UK), age (≤30 years vs >30 years), and baseline Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score (20-35 vs 36-50). Participants, outcomes assessors, and treating therapists were masked to group assignment. All participants were implanted with a vagus nerve stimulation device. The VNS group received 0·8 mA, 100 μs, 30 Hz stimulation pulses, lasting 0·5 s. The control group received 0 mA pulses. Participants received 6 weeks of in-clinic therapy (three times per week; total of 18 sessions) followed by a home exercise programme. The primary outcome was the change in impairment measured by the FMA-UE score on the first day after completion of in-clinic therapy. FMA-UE response rates were also assessed at 90 days after in-clinic therapy (secondary endpoint). All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT03131960. FINDINGS Between Oct 2, 2017, and Sept 12, 2019, 108 participants were randomly assigned to treatment (53 to the VNS group and 55 to the control group). 106 completed the study (one patient for each group did not complete the study). On the first day after completion of in-clinic therapy, the mean FMA-UE score increased by 5·0 points (SD 4·4) in the VNS group and by 2·4 points (3·8) in the control group (between group difference 2·6, 95% CI 1·0-4·2, p=0·0014). 90 days after in-clinic therapy, a clinically meaningful response on the FMA-UE score was achieved in 23 (47%) of 53 patients in the VNS group versus 13 (24%) of 55 patients in the control group (between group difference 24%, 6-41; p=0·0098). There was one serious adverse event related to surgery (vocal cord paresis) in the control group. INTERPRETATION Vagus nerve stimulation paired with rehabilitation is a novel potential treatment option for people with long-term moderate-to-severe arm impairment after ischaemic stroke. FUNDING MicroTransponder.
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Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Charles Y Liu
- USC Neurorestoration Center and Department of Neurological Surgery, USC Keck School of Medicine, Los Angeles, CA, USA; Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, Houston, TX, USA; The Institute for Rehabilitation and Research (TIRR) Memorial Hermann Hospital, Houston, Texas, USA
| | - Steven C Cramer
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, Los Angeles, CA, USA
| | - Steven L Wolf
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Dixit
- Stroke Service, The Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle, UK
| | - Jen Alexander
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Rushna Ali
- Department of Neurosciences, Spectrum Health, Grand Rapids, MI, USA
| | - Benjamin L Brown
- Department of Neurosurgery, Ochsner Neuroscience Institute, Covington, LA, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | | | - Leigh R Hochberg
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI, USA; VA RR&D Center for Neurorestoration and Neurotechnology, VA Medical Center, Providence, RI, USA
| | - Steven A Kautz
- Ralph H Johnson VA Medical Center, Charleston, SC, USA; Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, USA
| | - Arshad Majid
- Sheffield Institute for Neurological Sciences (SITraN), University of Sheffield, Sheffield, UK; Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
| | - Michael W O'Dell
- Clinical Rehabilitation Medicine, Weill Cornell Medicine, New York City, NY, USA
| | | | | | - Jessica Redgrave
- Sheffield Institute for Neurological Sciences (SITraN), University of Sheffield, Sheffield, UK
| | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | | | - Teresa J Kimberley
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Physical Therapy, MGH Institute of Health Professions, Boston, MA, USA
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Woo J, Mas MF, Zhang J, Wong B, Stampas A, Francisco GE, Li S. Real-world analysis of botulinum toxin (BoNT) injections in post-stroke spasticity: Higher doses of BoNT and longer intervals in the early-start group. J Neurol Sci 2021; 425:117449. [PMID: 33878656 DOI: 10.1016/j.jns.2021.117449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/06/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Our primary objective was to compare early-start vs. late-start Botulinum toxin (BoNT) injections in post-stroke spasticity management. This is an IRB approved retrospective chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke between January 2014 and December 2018 and received BoNT injections within 15 months. The total dose and interval between consecutive injections were used as objective outcomes. 2367 stroke admissions were reviewed. 189 patients metinclusion criteria. 68 out of 189 patients received BoNT injections within 12 weeks after stroke (EARLY group). 20 patients in the EARLY group who received at least three cycles were included for analysis. Out of 189 patients, 47 patients were categorized into the Early- and Late-start subgroups each by time from stroke onset to first BoNT injection (1st and 4th quartiles of time distribution) for comparisons. In the EARLY group, the first interval (Mean (M) = 7.6 weeks, standard deviation (SD) = 2.14) was significantly shorter than the second interval (M = 23.7, SD = 10.41) and the third interval (M = 20.0, SD = 11.23; p < 0.05). The dose at the first cycle (M = 492 units, SD = 201.5) was significantly lower than the dose at the third cycle (M = 605, SD = 82.6). In comparison between the Early- and Late-start subgroups, the time to first BoNT injection was 6.4 weeks (range: 4.7-8.6) after stroke for the Early-start subgroup and 49.6 weeks (range: 27.4-62.3) after stroke for the Late-start subgroup. The subsequent intervals after the first injection were significantly longer in the Early-start subgroup (M = 23.1 weeks) than in the Late-start subgroup (M = 14.6 weeks) (p = 0.008). The average total dose of BoNT was significantly higher in the Early-start subgroup (M = 561.9 units, SD = 143.1) than the Late-start subgroup (M = 470.0, SD = 164.8) (p = 0.012). The findings showed that higher doses of BoNT were used in the Early-start group, and often resulted in longer intervals between subsequent injections than in the Late-start group.
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Affiliation(s)
- Jean Woo
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States of America
| | - Manuel F Mas
- Physical Medicine, Rehabilitation and Sports Medicine Department, University of Puerto Rico, School of Medicine, United States of America; Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School and the NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Juliana Zhang
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School and the NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Bonny Wong
- St. David's Medical Center, Austin, TX, United States of America
| | - Argyrios Stampas
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School and the NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School and the NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School and the NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, TX, United States of America.
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Zhang B, Darji N, Francisco GE, Li S. The Time Course of Onset and Peak Effects of Phenol Neurolysis. Am J Phys Med Rehabil 2021; 100:266-270. [PMID: 33595939 DOI: 10.1097/phm.0000000000001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to explore the time course of onset and peak effects of phenol neurolysis. DESIGN This is a retrospective chart review. Eleven patients with elbow flexor spasticity after brain injury were enrolled. The resting angle of the elbow joint was measured before and after the injection and up to 6 wks of follow-up. RESULTS Phenol injection was performed to 13 musculocutaneous nerves under ultrasound and electrical stimulation guidance. The resting elbow angles were 84.4° ± 25.8° (before injection), 116.6° ± 20.9° (immediately after injection), 121.2° ± 21.4° (2 hrs after injection), 127.2° ± 19.7° (24 hrs after injection), 145.4° ± 11.8° (7 days after injection), 145.5° ± 10.4° (14 days after injection), and 150.3° ± 12.2° (6 wks after injection; N = 7). The mean resting angle was statistically different among the time points from preinjection to 14 days after (F2.625, 31.505 = 36.805, P < 0.01). Post hoc tests revealed that significant improvements existed immediately after and 7 days after the injection (P < 0.01 for both). The effects seemed to reach its peak in 7 days. The effect sizes immediately and 7 days after the injection were 1.37 and 3.04, respectively. The immediate effect accounted for approximately 60% of the maximal effect. CONCLUSIONS Phenol neurolysis has an immediate effect on spasticity reduction and reaches its peak effect around 1 wk after injection.
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Affiliation(s)
- Bei Zhang
- From the Department of Physical Medicine and Rehabilitation, McGovern Medical School University of Texas Health Science Center-Houston, Texas (BZ, GEF, SL); TIRR Memorial Hermann Hospital, Houston, Texas (BZ, ND, GEF, SL); and H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas (ND)
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Francisco GE. The COVID-19 Pandemic Is an Accelerator of the Evolution of Physiatry. Am J Phys Med Rehabil 2021; 100:S1-S2. [PMID: 33181530 DOI: 10.1097/phm.0000000000001640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Gerard E Francisco
- From the Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School, Houston, Texas; and NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, Texas
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Francisco GE, Yamazaki K, Raddatz M, Sabharwal S, Robinson L, Kinney C, Holmboe E. Do Milestone Ratings Predict Physical Medicine and Rehabilitation Board Certification Examination Scores? Am J Phys Med Rehabil 2021; 100:S34-S39. [PMID: 33048889 DOI: 10.1097/phm.0000000000001613] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The Accreditation Council of Graduate Medical Education developed the Milestones to assist training programs in assessing resident physicians in the context of their participation in Accreditation Council of Graduate Medical Education-accredited training programs. Biannual assessments are done over a resident's entire training period to define the trajectory in achieving specialty-specific competencies. As part of its process of initial certification, the American Board of Physical Medicine and Rehabilitation requires successful completion of two examinations administered approximately 9 mos apart. The Part I Examination measures a single dimensional construct, physical medicine and rehabilitation medical knowledge, whereas Part II assesses the application of medical and physiatric knowledge to multiple domains, including data acquisition, problem solving, patient management, systems-based practice, and interpersonal and communication skills through specific patient case scenarios. This study aimed to investigate the validity of the Milestones by demonstrating its association with performance in the American Board of Physical Medicine and Rehabilitation certifying examinations. A cohort of 233 physical medicine and rehabilitation trainees in 3-yr residency programs (postgraduate year 2 entry) in the United States from academic years 2014-2016, who also took the American Board of Physical Medicine and Rehabilitation Parts I and II certifying examinations between 2016 and 2018, were included in the study. Milestones ratings in four distinct observation periods were correlated with scores in the American Board of Physical Medicine and Rehabilitation Parts I and II Examinations. Milestones ratings of medical knowledge (but not patient care, professionalism, problem-based learning, interpersonal and communication skills, and systems-based practice) predicted performance in subsequent Part I American Board of Physical Medicine and Rehabilitation Examination, but none of the Milestone ratings correlated with Part II Examination scaled scores.
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Affiliation(s)
- Gerard E Francisco
- From the Department of Physical Medicine and Rehabilitation, The University of Texas at Houston McGovern Medical School and TIRR Memorial Hermann, Houston, Texas (GEF); Accreditation Council for Graduate Medical Education (ACGME), Chicago, Illinois (KY, EH); American Board of Physical Medicine and Rehabilitation, Rochester, Minnesota (MR, CK); Harvard Medical School and VA Boston Health Care System, Boston, Massachusetts (SS); and University of Toronto, Ontario, Canada (LR)
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Abstract
ABSTRACT Increasing exposure to the needs of patients with chronic disability is important in fostering confidence and comfort in disability knowledge and management among medical students and residents of all disciplines. The 2013 Association of American Medical Colleges Graduation Survey of graduating medical students revealed that 33% expressed inadequate exposure to disability management and rehabilitative care. To address this, a 3- to 4-wk rehabilitation elective course was modified to include lectures, media-based reflections, and a hands-on wheelchair experience. Responses and reflections from students from November 2015 to February 2019 were analyzed to assess the impact of the intervention on medical student knowledge and clinical practice using a disability pretest and posttest design. Preintervention data revealed limited knowledge of terminology in disability health that improved greatly in the postelective assessment. Medical students also gained knowledge on disability laws, available resources, and improved identification of appropriate accommodations to limit barriers to care. Moreover, this novel, interdisciplinary rehabilitation elective experience increased medical student knowledge and exposure of disability management. Incorporating these changes into the medical school curriculum will be invaluable in training future physicians to close the gap in access to care for persons with disabilities.
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Affiliation(s)
- Glendaliz Bosques
- From the Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center (UTHealth) McGovern Medical School, Houston, Texas (GB, KP, GEF); Pediatric Rehabilitation Program, Shriners Hospital for Children, Houston, Texas (GB); Pediatric Rehabilitation Medicine, TIRR Memorial Hermann Hospital, Houston, Texas (GB); Pediatric Rehabilitation Program, Children's Memorial Hermann Hospital, Houston, Texas (GB); and NeuroRecovery Research Center, TIRR Memorial Hermann, Houston, Texas (GEF)
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Taylor CM, Baer H, Edgar L, Jenkins JG, Harada N, Helkowski WM, Zumsteg JM, Francisco GE, Sabharwal S, Hamilton RG, Mallow M. Improving the Assessment of Resident Competency: Physical Medicine and Rehabilitation Milestones 2.0. Am J Phys Med Rehabil 2021; 100:S45-S50. [PMID: 33252467 DOI: 10.1097/phm.0000000000001650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In 2015, the Accreditation Council for Graduate Medical Education published the Physical Medicine and Rehabilitation Milestones 1.0 as part of the Next Accreditation System. This was the culmination of more than 20 yrs of work on the part of the Accreditation Council for Graduate Medical Education to improve graduate medical education competency assessments. The six core competencies were patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. While providing a good foundation for resident assessment, the Physical Medicine and Rehabilitation Milestones 1.0 was not without faults. With input from program directors, national organizations, and the public, the Physical Medicine and Rehabilitation Milestones 2.0 strives to further advance resident assessment, providing improvements through the integration of the harmonized Milestones and the addition of a supplemental guide.
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Affiliation(s)
- Charles M Taylor
- From the Advanced Healthcare Solutions, Frisco, Texas (CMT); PMR and Neurology, University of Colorado Denver, Denver, Colorado (HB); Accreditation Council for Graduate Medical Education, Chicago, Illinois (LE); Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia (JGJ); Department of Veterans Affairs, Office of Academic Affiliations, UCLA David Geffen School of Medicine, Los Angeles, California (NH); UPMC Department of Physical Medicine and Rehabilitation, Pittsburgh, Pennsylvania (WMH); Department of Rehabilitation Medicine, University of Washington, Seattle, Washington (JMZ); University of Texas Health Science Center McGovern Medical School, TIRR Memorial Hermann, Houston, Texas (GEF); Harvard Medical School, Boston, Massachusetts (SS); Baylor Scott and White Institute for Rehabilitation, Dallas, Texas (RGH); Physical Medicine and Rehabilitation, Baylor University Medical Center, Dallas, Texas (RGH); and Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (MM)
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Zhang C, Chen YT, Liu Y, Magat E, Gutierrez-Verduzco M, Francisco GE, Zhou P, Li S, Zhang Y. Improving Botulinum Toxin Efficiency in Treating Post-Stroke Spasticity Using 3D Innervation Zone Imaging. Int J Neural Syst 2021; 31:2150007. [PMID: 33438529 DOI: 10.1142/s0129065721500076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Spasticity is a common post-stroke syndrome that imposes significant adverse impacts on patients and caregivers. This study aims to improve the efficiency of botulinum toxin (BoNT) in managing spasticity, by utilizing a three-dimensional innervation zone imaging (3DIZI) technique based on high-density surface electromyography (HD-sEMG) recordings. Stroke subjects were randomly assigned to two groups: the control group ([Formula: see text]) which received standard ultrasound-guided injections, and the experimental group ([Formula: see text]) which received 3DIZI-guided injections. The amount of BoNT given was consistent for all subjects. The Modified Ashworth Scale (MAS), compound muscle action potential (CMAP) and muscle activation volume (MAV) from bilateral biceps brachii muscles were obtained at the baseline, 3 weeks, and 3 months after injection. Intra-group and inter-group comparisons of MAS, CMAP amplitude and MAV were performed. An overall improvement in MAS of spastic elbow flexors was observed during the 3-week visit ([Formula: see text]), yet no statistically significant difference found with intra-group or inter-group analysis. Compared to the baseline, a significant reduction of CMAP amplitude and MAV were observed in the spastic biceps muscles of both groups at 3-week post-injection, and returned to approximate baseline value at 12-week post injection. A significantly higher reduction was found in CMAP amplitude ([Formula: see text]% versus [Formula: see text]%, [Formula: see text]) and MAV ([Formula: see text]% versus [Formula: see text]%, [Formula: see text]) in the experimental group compared to the control group. The study has demonstrated preliminary evidence that precisely directing BoNT to the innervation zones (IZs) localized by 3DIZI leads to a significantly higher treatment efficiency improvement in spasticity management. Results have also shown the feasibility of developing a personalized BoNT injection technique for the optimization of clinical treatment for post-stroke spasticity using proposed 3DIZI technique.
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Affiliation(s)
- Chuan Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Yen-Ting Chen
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Yang Liu
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Elaine Magat
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Monica Gutierrez-Verduzco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Ping Zhou
- Institute of Rehabilitation Engineering, The University of Rehabilitation, Qingdao, P. R. China
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA.
- TIRR Memorial Hermann Hospital, Houston, TX, USA.
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA
- TIRR Memorial Hermann Hospital, Houston, TX, USA
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Abstract
Spasticity is one component of the upper motor neuron (UMN) syndrome resulting from a multitude of neurologic conditions, such as stroke, brain injury, spinal cord injury, multiple sclerosis, and cerebral palsy. It is clinically recognized as a phenomenon of velocity-dependent increase in resistance, i.e., hypertonia. Recent advances in the pathophysiology of spasticity improve our understanding of mechanisms underlying this complex phenomenon and its relations to other components of UMN syndrome (weakness and disordered motor control), as well as the resultant clinical problems. This theoretical framework provides a foundation to set up treatment goals and to guide goal-oriented clinical assessment and treatment. Among a spectrum of treatment options, botulinum toxin (BoNT) therapy is the preferred treatment for focal spasticity. The evidence is very robust that BoNT therapy effectively reduces spasticity; however, it does not improve voluntary movement. In this chapter, we highlight a few issues on how to achieve the best clinical outcomes of BoNT therapy, such as dosing, dilution, guidance techniques, adjunctive therapies, early treatment, repeated injections, and central effects, as well as the ways to improve motor function in selected subgroups of patients with spasticity. We also discuss the reasons of poor responses to BoNT therapy and when not to use BoNT therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA.
- TIRR Memorial Hermann Hospital, Houston, TX, USA.
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA
- TIRR Memorial Hermann Hospital, Houston, TX, USA
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Francisco GE, Balbert A, Bavikatte G, Bensmail D, Carda S, Deltombe T, Draulans N, Escaldi S, Gross R, Jacinto J, Ketchum N, Molteni F, Moraleda S, ODell MW, Reebye R, Säterö P, Verduzco-Gutierrez M, Walker H, Wissel J. A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: An international group consensus. J Rehabil Med 2021; 53:jrm00134. [PMID: 33057730 PMCID: PMC8772370 DOI: 10.2340/16501977-2753] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4–25 years; mean 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an extensive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but instead aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this. However, where evidence is not yet conclusive, the group members issued statements and, in some cases, made recommendations based on their clinical experience. LAY ABSTRACT A group of doctors from around the world, who are experts in treating muscle stiffness and spasm (also called spasticity), reviewed the current scientific evidence supporting the effectiveness of using botulinum toxin injections in treatment of spasticity that results from a stroke. When evidence is not available, they discussed and agreed on the best way to treat spasticity using botulinum toxin. The recommendations made by these expert doctors can be used by less-experienced doctors as a guide to how best to use botulinum toxin injection in treating spasticity after a stroke.
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Affiliation(s)
- Gerard E Francisco
- Physical Medicine and Rehabilitation, University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX 77030, USA. E-mail:
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Bhagat NA, Yozbatiran N, Sullivan JL, Paranjape R, Losey C, Hernandez Z, Keser Z, Grossman R, Francisco GE, O'Malley MK, Contreras-Vidal JL. Neural activity modulations and motor recovery following brain-exoskeleton interface mediated stroke rehabilitation. Neuroimage Clin 2020; 28:102502. [PMID: 33395991 PMCID: PMC7749405 DOI: 10.1016/j.nicl.2020.102502] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 01/03/2023]
Abstract
Motor intention based arm training targets activity-dependent neuroplasticity. 80% of stroke participants recovered clinically relevant functional movements. Ipsi-lesional, delta-band EEG activity was highly correlated with motor recovery. Results suggest higher activation of ipsi-lesional hemisphere post-intervention.
Brain-machine interfaces (BMI) based on scalp EEG have the potential to promote cortical plasticity following stroke, which has been shown to improve motor recovery outcomes. However, the efficacy of BMI enabled robotic training for upper-limb recovery is seldom quantified using clinical, EEG-based, and kinematics-based metrics. Further, a movement related neural correlate that can predict the extent of motor recovery still remains elusive, which impedes the clinical translation of BMI-based stroke rehabilitation. To address above knowledge gaps, 10 chronic stroke individuals with stable baseline clinical scores were recruited to participate in 12 therapy sessions involving a BMI enabled powered exoskeleton for elbow training. On average, 132 ± 22 repetitions were performed per participant, per session. BMI accuracy across all sessions and subjects was 79 ± 18% with a false positives rate of 23 ± 20%. Post-training clinical assessments found that FMA for upper extremity and ARAT scores significantly improved over baseline by 3.92 ± 3.73 and 5.35 ± 4.62 points, respectively. Also, 80% participants (7 with moderate-mild impairment, 1 with severe impairment) achieved minimal clinically important difference (MCID: FMA-UE >5.2 or ARAT >5.7) during the course of the study. Kinematic measures indicate that, on average, participants’ movements became faster and smoother. Moreover, modulations in movement related cortical potentials, an EEG-based neural correlate measured contralateral to the impaired arm, were significantly correlated with ARAT scores (ρ = 0.72, p < 0.05) and marginally correlated with FMA-UE (ρ = 0.63, p = 0.051). This suggests higher activation of ipsi-lesional hemisphere post-intervention or inhibition of competing contra-lesional hemisphere, which may be evidence of neuroplasticity and cortical reorganization following BMI mediated rehabilitation therapy.
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Affiliation(s)
- Nikunj A Bhagat
- Non-Invasive Brain Machine Interface Systems Laboratory, University of Houston, Houston, TX 77004, USA.
| | - Nuray Yozbatiran
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, NeuroRecovery Research Center at TIRR Memorial Hermann, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Jennifer L Sullivan
- Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX 77005, USA
| | - Ruta Paranjape
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, NeuroRecovery Research Center at TIRR Memorial Hermann, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Colin Losey
- Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX 77005, USA
| | - Zachary Hernandez
- Non-Invasive Brain Machine Interface Systems Laboratory, University of Houston, Houston, TX 77004, USA
| | - Zafer Keser
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, NeuroRecovery Research Center at TIRR Memorial Hermann, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Robert Grossman
- Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, NeuroRecovery Research Center at TIRR Memorial Hermann, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Marcia K O'Malley
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, NeuroRecovery Research Center at TIRR Memorial Hermann, University of Texas Health Science Center at Houston, TX 77030, USA; Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX 77005, USA
| | - Jose L Contreras-Vidal
- Non-Invasive Brain Machine Interface Systems Laboratory, University of Houston, Houston, TX 77004, USA; Houston Methodist Research Institute, Houston, TX 77030, USA; NSF IUCRC BRAIN, University of Houston, Houston, TX 77004, USA
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Esquenazi A, Bavikatte G, Bandari DS, Jost WH, Munin MC, Tang SFT, Largent J, Adams AM, Zuzek A, Francisco GE. Long-Term Observational Results from the ASPIRE Study: OnabotulinumtoxinA Treatment for Adult Lower Limb Spasticity. PM R 2020; 13:1079-1093. [PMID: 33151636 PMCID: PMC8519010 DOI: 10.1002/pmrj.12517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 09/24/2020] [Accepted: 10/23/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION OnabotulinumtoxinA treatment for spasticity varies according to numerous factors and is individualized to meet treatment goals. OBJECTIVE To explore real-world onabotulinumtoxinA utilization and effectiveness in patients with lower limb spasticity from the Adult Spasticity International Registry (ASPIRE) study. DESIGN Two-year, multicenter, prospective, observational registry (NCT01930786). SETTING Fifty-four international clinical sites. PATIENTS Adults (naïve or non-naïve to botulinum toxin[s] treatment for spasticity, across multiple etiologies) with lower limb spasticity related to upper motor neuron syndrome. INTERVENTIONS OnabotulinumtoxinA administered at the clinician's discretion. MAIN OUTCOME MEASURES OnabotulinumtoxinA treatment utilization, clinician- and patient-reported satisfaction. RESULTS In ASPIRE, 530 patients received ≥1 onabotulinumtoxinA treatment for lower limb spasticity (mean age, 52 years; stroke, 49.4%; multiple sclerosis, 20.4%). Equinovarus foot was treated most often (80.9% of patients), followed by flexed knee (26.0%), stiff extended knee (22.5%), and flexed toes (22.3%). OnabotulinumtoxinA doses ranged between 10 and 1100 U across all presentations. Electromyography (EMG) was most commonly used for injection localization (≥41.1% of treatment sessions). Despite low patient response on the satisfaction questionnaire, clinicians (94.6% of treatment sessions) and patients (84.5%) reported satisfaction/extreme satisfaction that treatment helped manage spasticity, and clinicians (98.3%) and patients (91.6%) would probably/definitely continue onabotulinumtoxinA treatment. These data should be interpreted with care. Twenty-one adverse events (AEs) in 18 patients (3.4%) were considered treatment-related. Sixty-seven patients (12.6%) reported 138 serious AEs; 3 serious AEs in two patients (0.4%) were considered treatment-related. No new safety signals were identified. CONCLUSIONS ASPIRE provides long-term observational data on the treatment of lower limb spasticity with onabotulinumtoxinA. Real-world data from this primary analysis can help to guide the clinical use of onabotulinumtoxinA to improve spasticity management.
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Affiliation(s)
| | | | | | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany.,Parkinson-Klinik Ortenau, Wolfach, Germany
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Simon Fuk Tan Tang
- Department of Physical Medicine and Rehabilitation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Joan Largent
- IQVIA Real-World Evidence Solutions, Cambridge, MA, USA
| | | | | | - Gerard E Francisco
- University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX, USA
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Carda S, Invernizzi M, Bavikatte G, Bensmaïl D, Bianchi F, Deltombe T, Draulans N, Esquenazi A, Francisco GE, Gross R, Jacinto LJ, Moraleda Pérez S, O'Dell MW, Reebye R, Verduzco-Gutierrez M, Wissel J, Molteni F. The role of physical and rehabilitation medicine in the COVID-19 pandemic: The clinician's view. Ann Phys Rehabil Med 2020; 63:554-556. [PMID: 32315802 PMCID: PMC7166018 DOI: 10.1016/j.rehab.2020.04.001] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/12/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Stefano Carda
- Service of Neuropsychology and Neurorehabilitation, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Marco Invernizzi
- University of Eastern Piedmont, Department of Health Sciences, 28100 Novara, Italy
| | - Ganesh Bavikatte
- Neurorehabilitation Medicine, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ United Kingdom
| | - Djamel Bensmaïl
- Physical and Rehabilitation Medicine Department, R.-Pointcaré Hospital, AP-HP Université Paris-Saclay, Team INSERM 1179, UFR de Santé Simone-Veil, Université de Versailles Saint-Quentin, Paris, France
| | - Francesca Bianchi
- Neurophysiology Unit, IRCCS San Raffaele Scientific Institute Milan, Italy
| | - Thierry Deltombe
- Service de Médecine Physique & Réadaptation, CHU UCL Namur site Godinne, 5530 Yvoir, Belgium
| | | | - Alberto Esquenazi
- Department of Physical Medicine & Rehabilitation, MossRehab Gait and Motion Analysis Lab, Elkins Park, PA, USA
| | - Gerard E Francisco
- Department of Physical Medicine & Rehabilitation, UTHealth McGovern Medical School, and TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Raphaël Gross
- Service de MPR Neurologique, CHU de Nantes, Hôpital Saint-Jacques, 44093 Nantes cedex, France; EA 43334 laboratoire Motricité, Interactions, Performance-UFR STAPS Nantes, 44300 Nantes, France
| | - Luis Jorge Jacinto
- Serviço de Reabilitação de Adultos 3, Centro de Medicina de Reabilitação de Alcoitão, Alcabideche, Portugal
| | - Susana Moraleda Pérez
- Physical Medicine & Rehabilitation Department, La Paz University Hopital, Madrid, Spain
| | - Michael W O'Dell
- New York Presbyterian Hospital, Weill-Cornell Medical Centre, New York, NY, USA
| | - Rajiv Reebye
- Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC, Canada
| | - Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, Joe-R.-and-Teresa-Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Jörg Wissel
- Neurological Rehabilitation & Physical Therapy, Department of Neurology with Stroke Unit, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | - Franco Molteni
- Valduce Hospital, Villa Beretta Rehabilitation Centre, Costamasnaga (LC), Italy
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Francisco GE, Bandari DS, Bavikatte G, Jost WH, McCusker E, Largent J, Zuzek A, Esquenazi A. High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE study. Toxicon X 2020; 7:100040. [PMID: 32875289 PMCID: PMC7452133 DOI: 10.1016/j.toxcx.2020.100040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 04/23/2020] [Accepted: 05/14/2020] [Indexed: 11/30/2022] Open
Abstract
Etiology-specific onabotulinumtoxinA utilization to manage spasticity is largely unknown. In this 1-year interim analysis, we evaluated real-world onabotulinumtoxinA utilization and effectiveness across several etiologies from the Adult Spasticity International Registry (ASPIRE) study. ASPIRE is a multicenter, prospective, observational registry (NCT01930786) examining stroke, multiple sclerosis [MS], cerebral palsy [CP], traumatic brain injury [TBI], and spinal cord injury [SCI] patients with spasticity treated with onabotulinumtoxinA at the clinician's discretion. Assessments included onabotulinumtoxinA utilization (each session), clinician (subsequent session)/patient (5±1 weeks post-treatment) satisfaction, and the Disability Assessment Scale (DAS; subsequent session). 730 patients received ≥1 onabotulinumtoxinA treatment, with 37% naïve to botulinum toxin(s) for spasticity. The most common etiology was stroke (n=411, 56%), followed by MS (N=119, 16%), CP (N=77, 11%), TBI (N=45, 6%), and SCI (N=42, 6%). The total body mean cumulative dose (±SD) of onabotulinumtoxinA per session ranged from 296 U (±145) in CP to 406 U (±152) in TBI. The most commonly treated upper limb presentations were clenched fist (stroke, MS, and SCI), flexed wrist (CP), and flexed elbow (TBI). Equinovarus foot was the most commonly treated lower limb presentation in all etiologies. Stroke patients showed improved DAS scores for nearly all subscales in both limbs, indicative of improved global function. All etiologies showed improved lower limb mobility DAS scores. Across all sessions, clinicians (range: 87.4% [SCI]-94.2% [CP]) and patients (range: 67.6% [TBI]-89.7% [SCI]) reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped manage spasticity, and clinicians (range: 94.6% [TBI]-98.8% [CP]) and patients (range: 88.4% [stroke]-91.2% [TBI]) would definitely/probably continue treatment. Treatment-related adverse events (TRAEs) and treatment-related serious adverse events (TRSAEs) were reported as follows: stroke: 10 TRAEs (2.2% patients), 3 TRSAEs (0.5%); MS: 5 TRAEs (4.2%), 0 TRSAEs; CP: 0 TRAEs, 0 TRSAEs; TBI: 1 TRAEs (2.2%), 0 TRSAEs; SCI: 0 TRAEs, 0 TRSAEs. No new safety signals were identified. High clinician- and patient-reported satisfaction were observed following individualized onabotulinumtoxinA treatment, as well as improved global function. Interim results from ASPIRE demonstrate etiology-specific similarities and differences in clinical approaches to manage spasticity. ASPIRE found etiology-specific similarities and differences in real-world onabotulinumtoxinA utilization for spasticity. Across all etiologies, there was high clinician- and patient-reported satisfaction with onabotulinumtoxinA treatment. In DAS, all etiologies showed improved global function in lower limb mobility following onabotulinumtoxinA treatment. Adverse event data varied by etiology of spasticity; however, no new safety signals were identified. ASPIRE data may guide clinical strategies and educational programs to improve onabotulinumtoxinA spasticity management.
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Affiliation(s)
- Gerard E Francisco
- The University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX, USA
| | - Daniel S Bandari
- Multiple Sclerosis Center of California & Research Group, Newport Beach, CA, USA
| | | | - Wolfgang H Jost
- University of Freiburg, Department of Neurology, Freiburg im Breisgau, Germany.,Parkinson-Klinik Ortenau, Wolfach, Germany
| | | | - Joan Largent
- IQVIA Real-World Evidence Solutions, Cambridge, MA, USA
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Chen YT, Zhang C, Liu Y, Magat E, Verduzco-Gutierrez M, Francisco GE, Zhou P, Zhang Y, Li S. The Effects of Botulinum Toxin Injections on Spasticity and Motor Performance in Chronic Stroke with Spastic Hemiplegia. Toxins (Basel) 2020; 12:toxins12080492. [PMID: 32751970 PMCID: PMC7472282 DOI: 10.3390/toxins12080492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 02/01/2023] Open
Abstract
Spastic muscles are weak muscles. It is known that muscle weakness is linked to poor motor performance. Botulinum neurotoxin (BoNT) injections are considered as the first-line treatment for focal spasticity. The purpose of this study was to quantitatively investigate the effects of BoNT injections on force control of spastic biceps brachii muscles in stroke survivors. Ten stroke survivors with spastic hemiplegia (51.7 ± 11.5 yrs; 5 men) who received 100 units of incobotulinumtoxinA or onabotulinumtoxinA to the biceps brachii muscles participated in this study. Spasticity assessment (Modified Ashworth Scale (MAS) and reflex torque) and muscle strength of elbow flexors, as well as motor performance assessment (force variability of submaximal elbow flexion) were performed within one week before (pre-injection) and 3~4 weeks (3-wk) after BoNT injections. As expected, BoNT injections reduced the MAS score and reflex torque, and elbow flexor strength on the spastic paretic side. However, motor performance remained within similar level before and after injections. There was no change in muscle strength or motor performance on the contralateral arm after BoNT injections. The results of this study provide evidence that BoNT injections can reduce spasticity and muscle strength, while motor performance of the weakened spastic muscle remains unchanged.
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Affiliation(s)
- Yen-Ting Chen
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-T.C.); (E.M.); (M.V.-G.); (G.E.F.)
- TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- Department of Health and Kinesiology, Northeastern State University, Broken Arrow, OK 74014, USA
| | - Chuan Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204, USA; (C.Z.); (Y.L.); (Y.Z.)
| | - Yang Liu
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204, USA; (C.Z.); (Y.L.); (Y.Z.)
| | - Elaine Magat
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-T.C.); (E.M.); (M.V.-G.); (G.E.F.)
- TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Monica Verduzco-Gutierrez
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-T.C.); (E.M.); (M.V.-G.); (G.E.F.)
- TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Gerard E. Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-T.C.); (E.M.); (M.V.-G.); (G.E.F.)
- TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Ping Zhou
- Guangdong Provincial Work Injury Rehabilitation Center, Guangzhou 510000, China;
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204, USA; (C.Z.); (Y.L.); (Y.Z.)
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-T.C.); (E.M.); (M.V.-G.); (G.E.F.)
- TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-797-7125
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Awad LN, Esquenazi A, Francisco GE, Nolan KJ, Jayaraman A. The ReWalk ReStore™ soft robotic exosuit: a multi-site clinical trial of the safety, reliability, and feasibility of exosuit-augmented post-stroke gait rehabilitation. J Neuroeng Rehabil 2020; 17:80. [PMID: 32552775 PMCID: PMC7301475 DOI: 10.1186/s12984-020-00702-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/21/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Atypical walking in the months and years after stroke constrain community reintegration and reduce mobility, health, and quality of life. The ReWalk ReStore™ is a soft robotic exosuit designed to assist the propulsion and ground clearance subtasks of post-stroke walking by actively assisting paretic ankle plantarflexion and dorsiflexion. Previous proof-of-concept evaluations of the technology demonstrated improved gait mechanics and energetics and faster and farther walking in users with post-stroke hemiparesis. We sought to determine the safety, reliability, and feasibility of using the ReStore™ during post-stroke rehabilitation. METHODS A multi-site clinical trial (NCT03499210) was conducted in preparation for an application to the United States Food and Drug Administration (FDA). The study included 44 users with post-stroke hemiparesis who completed up to 5 days of training with the ReStore™ on the treadmill and over ground. In addition to primary and secondary endpoints of safety and device reliability across all training activities, an exploratory evaluation of the effect of multiple exposures to using the device on users' maximum walking speeds with and without the device was conducted prior to and following the five training visits. RESULTS All 44 study participants completed safety and reliability evaluations. Thirty-six study participants completed all five training days. No device-related falls or serious adverse events were reported. A low rate of device malfunctions was reported by clinician-operators. Regardless of their reliance on ancillary assistive devices, after only 5 days of walking practice with the device, study participants increased both their device-assisted (Δ: 0.10 ± 0.03 m/s) and unassisted (Δ: 0.07 ± 0.03 m/s) maximum walking speeds (P's < 0.05). CONCLUSIONS When used under the direction of a licensed physical therapist, the ReStore™ soft exosuit is safe and reliable for use during post-stroke gait rehabilitation to provide targeted assistance of both paretic ankle plantarflexion and dorsiflexion during treadmill and overground walking. TRIAL REGISTRATION NCT03499210. Prospectively registered on March 28, 2018.
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Affiliation(s)
- Louis N Awad
- Department of Physical Therapy & Athletic Training, Boston University, Boston, MA, USA.
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA.
- Department of PM&R, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA.
| | - Alberto Esquenazi
- Department of PM&R, MossRehab and Einstein Healthcare Network, Elkins Park, PA, USA
| | - Gerard E Francisco
- Department of PM&R, University of Texas McGovern Medical School, TIRR Memorial Hermann, Houston, TX, USA
| | - Karen J Nolan
- Center for Mobility and Rehabilitation Engineering, Kessler Foundation, West Orange, NJ, USA
- Department of PM&R, Rutgers New Jersey Medical School, Kessler Rehabilitation, Newark, NJ, USA
| | - Arun Jayaraman
- Department of PM&R, Northwestern University, Chicago, IL, USA.
- Shirley Ryan AbilityLab, Chicago, IL, USA.
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Carda S, Invernizzi M, Bavikatte G, Bensmaïl D, Bianchi F, Deltombe T, Draulans N, Esquenazi A, Francisco GE, Gross R, Jacinto LJ, Moraleda Pérez S, O'dell MW, Reebye R, Verduzco-Gutierrez M, Wissel J, Molteni F. COVID-19 pandemic. What should Physical and Rehabilitation Medicine specialists do? A clinician's perspective. Eur J Phys Rehabil Med 2020; 56:515-524. [PMID: 32434314 DOI: 10.23736/s1973-9087.20.06317-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
COVID-19 pandemic is rapidly spreading all over the world, creating the risk for a healthcare collapse. While acute care and intensive care units are the main pillars of the early response to the disease, rehabilitative medicine should play an important part in allowing COVID-19 survivors to reduce disability and optimize the function of acute hospital setting. The aim of this study was to share the experience and the international perspective of different rehabilitation centers, treating COVID-19 survivors. A group of Physical Medicine and Rehabilitation specialists from eleven different countries in Europe and North America have shared their clinical experience in dealing with COVID-19 survivors and how they have managed the re-organization of rehabilitation services. In our experience the most important sequelae of severe and critical forms of COVID-19 are: 1) respiratory; 2) cognitive, central and peripheral nervous system; 3) deconditioning; 4) critical illness related myopathy and neuropathy; 5) dysphagia; 6) joint stiffness and pain; 7) psychiatric. We analyze all these consequences and propose some practical treatment options, based on current evidence and clinical experience, as well as several suggestions for management of rehabilitation services and patients with suspected or confirmed infection by SARS-CoV-2. COVID-19 survivors have some specific rehabilitation needs. Experience from other centers may help colleagues in organizing their services and providing better care to their patients.
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Affiliation(s)
- Stefano Carda
- Service of Neuropsychology and Neurorehabilitation, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Lausanne, Switzerland -
| | - Marco Invernizzi
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Ganesh Bavikatte
- Neurorehabilitation Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Djamel Bensmaïl
- Department of Physical and Rehabilitation Medicine, R. Pointcaré Hospital, AP-HP Université Paris-Saclay, Team INSERM 1179, UFR de Santé Simone Veil, Université de Versailles Saint-Quentin, Versailles, France
| | | | - Thierry Deltombe
- Service of Physical Medicine and Rehabilitation, CHU UCL Namur site Godinne, Yvoir, Belgium
| | | | - Alberto Esquenazi
- Department of Physical Medicine and Rehabilitation, MossRehab Gait and Motion Analysis Lab, Elkins Park, PA, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, UTHealth McGovern Medical School, and TIRR Memorial Hermann Hospital, Houston, TX, USA
| | - Raphaël Gross
- Service de MPR Neurologique, CHU Nantes Hôpital Saint Jacques, Nantes cedex / EA 43334 laboratoire Motricité, Interactions, Performance - UFR STAPS Nantes, Nantes, France
| | - Luis J Jacinto
- Service of Rehabilitation for Adults 3, Centro de Medicina de Reabilitação de Alcoitão, Alcabideche, Portugal
| | - Susana Moraleda Pérez
- Department of Physical Medicine and Rehabilitation, La Paz University Hospital, Madrid, Spain
| | - Michael W O'dell
- New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Rajiv Reebye
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada
| | | | - Jörg Wissel
- Unit of Neurological Rehabilitation and Physical Therapy, Department of Neurology with Stroke Unit, Vivantes Hospital Spandau, Berlin, Germany
| | - Franco Molteni
- Valduce Hospital, Villa Beretta Rehabilitation Center, Costamasnaga, Lecco, Italy
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50
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Afzal T, Tseng SC, Lincoln JA, Kern M, Francisco GE, Chang SH. Exoskeleton-assisted Gait Training in Persons With Multiple Sclerosis: A Single-Group Pilot Study. Arch Phys Med Rehabil 2020; 101:599-606. [DOI: 10.1016/j.apmr.2019.10.192] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/18/2019] [Accepted: 10/29/2019] [Indexed: 11/30/2022]
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