The aim is to present an integrated multidisciplinary approach for spasticity assessment, by providing
information about accurate and valid methods that are suitable for the clinic.
An instrumented assessment of spasticity developed for routine clinical practice can assist clinicians
to make more goal directed decisions about the treatment pathways for their patients, to choose the
most efficient and cost effective management option for the individual patient and to verify the
efficacy of various procedures. Crucial in the instrumented spasticity assessment is the
multidisciplinary approach to the problem by aiming for an optimal combination of the
biomechanical, neurophysiological and clinical aspects of the problem. Three groups of signals during
standardised passive isolated movements in different lower limb joints, which are (1) stretch
characteristics (joint angle parameters), (2) reactive resistance and (3) muscle activity, are integrated
to provide objective spasticity parameters. Clinically meaningful parameters for spasticity assessment
are described and relations between biomechanical and neurophysiological characters of the reflex
responses and velocity of lengthening are highlighted. These associations between parameters, as
well as innovative parameters describing additional phenomena of spasticity, can be used to unify all
multidisciplinary knowledge in an integrated clinical spasticity assessment, illustrated by clinical
cases.
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for treatment fine-tuning
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for treatment fine-tuning
Outline
A velocity dependent increase in tonic stretch reflex (muscle tone) with exaggerated tendon jerks,
Resulting from hyper excitability of the stretch reflex,As one component of the upper motor neurone
syndrome
Lance 1980
sSpasticity definitions
3
0 1 1+ 2 3 4
Scoring the resistance felt in a specificmuscle group by passively moving a limb
at one velocity
Bohannon and Smith 1987
Clinical grading of spasticity
Modified Ashworth Scale
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Clinical grading of spasticity
Related to muscle activity
CP Increased resistance to passive motion
Related to passive structures
E.g. Spasticity
Stiffness
Viscosity
Inertia
Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for treatment fine-tuning
1.3Instrumented spasticity assessmentInstrumented Spasticity Assessment (ISA) Instrumented spasticity assessment
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Reactiveresistance
Muscle length/lengthening velocity
Tonic stretch reflex
Spasticity assessment
Reactiveresistance
Tonic stretch reflex
Spasticity assessment
Joint angles/velocity(muscle length/lengthening velocity)
Reactiveresistance
Spasticity assessment
Joint angles/velocity(muscle length/lengthening velocity)
EMG (Tonic stretch reflex)
Torque (reactiveResistance)
Spasticity assessment
Joint angles/velocity(muscle length/lengthening velocity)
EMG (Tonic stretch reflex)
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Signals measured simultaneously
Manually performed passive stretches
Three stretch velocities
Signal integration
Electromyography (EMG)
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2-0.2
-0.1
0
0.1
0.2
0.3
0.4
Time (s)
Raw
EMG (m
V)
-4 -3 -2 -1 0 1 2-20
0
20
40
60
80
100
120
140
160
Ang
lula
r ve
loci
ty (°
/s)
Time (s)
Angles and angular velocity Torque
torq
ue(N
m)
Joint angle (°)
Bar-On et al. 2013
Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for treatment fine-tuning
Protocol: Instrumented Spasticity assessment (ISA)
Manually performed passive stretches
Three stretch velocities
Signal integration
Bar-On et al. 2013
• Manually performed passive stretches
• Three stretch velocities: • Low (5sec), Medium (1s), High (as fast as possible)
• 3 good repetitions
• 7 seconds rest between stretches
Data acquisition and sensor processing
Overview
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Data acquisition and sensor processing
OverviewMeasuring the Velocity of Stretch
Inertial Measurement Units (IMU) sensors
1. placed arbitrarily 2. joint motions/positions calibrated during measurement protocol
Gyroscope: angular velocity
Accelerometer: gravity and acceleration
Force/Torque-sensor
Interaction force therapist-patient
– 3 forces– 3 torques
Specific adaptors to attach sensor to limb.
Foot-piece:Triceps
Calf-piece:Hamstrings Knee extensors
Measuring the torque
1. Standard electrode placement (SENIAM)
2. Maximal Voluntary Contraction (MVC)
3. EMG in rest
Wireless EMG
Measuring Muscle Activity
(Hermens et. al. 2000)
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Data acquisition and sensor processing
Overview
sEMG
Motion capturingsystem
Interaction force
Clinical informationand context.
Synchronized acquisition andGrafical User Interface (GUI)
Synchronous
Data acquisition and sensor processing
Acquisition set‐up
Data acquisition and sensor processing
Overview
Clinical ProtocolCalibration motion sensors
• Ankle• Neutral position• Move to plantar flexion
• Knee• Full extension• Move to knee flexion
• Hip• Neutral ab/adduction• No motion
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Calculating the net internal joint torque
Taking into account:
• Forces in non-perpendicular directions
• Moments exerted by the therapist
• Inertia
• Gravity
(Anthropometric models of Drillis 1964, and Jensen 1986)
Data acquisition and sensor processing
Overview
Four lower‐limb muscles
27
Manually performed passive stretches
Three stretch velocities
Signal integration
Bar-On et al. 2013
Adductors Gastrocnemius
RectusFemoris
Hamstrings
Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for Treatment fine-tuning
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Comparison between velocities
-2 -1 0 1 2 3 4 5-40
-20
0
20
Time [s]
-2 -1 0 1 2 3 4 50
50
100
150
Time [s]
-2 -1 0 1 2 3 4 50
0,02
0,04
-2 -1 0 1 2 3 4 50
10
20
Time [s]
Position
Velocityn
RMS-EMGn
Torquen
Low velocity
Time (s)
Comparison between velocities
-2 -1 0 1 2 3 4 5-40
-20
0
20
Time [s]
-2 -1 0 1 2 3 4 50
50
100
150
Time [s]
-2 -1 0 1 2 3 4 50
0,02
0,04
-2 -1 0 1 2 3 4 50
10
20
Time [s]
Positionn
Velocityn
RMS-EMGn
Torquen
Time (s)
Low velocityHigh velocity
Comparison between velocities
-2 -1 0 1 2 3 4 5-40
-20
0
20
Time [s]
-2 -1 0 1 2 3 4 50
50
100
150
Time [s]
-2 -1 0 1 2 3 4 50
0,02
0,04
-2 -1 0 1 2 3 4 50
10
20
Time [s]
Positionn
Velocityn
RMS-EMGn
Torquen
Time (s)
Low velocityHigh velocity
Muscle Activity
32
Raw EMG
Stretch at high velocityStretch at low velocity
Example of patient
Example of typical subject
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Muscle Activity
Raw EMG
Stretch at high velocity
rms EMG
Muscle Activity
Start: 200 msec prior to the time of max velocityEnd: at 90% of total range of motion
Muscle Activity
• Average of EMG Area under rms EMG-time curve divided by
time and expressed as % of MVC
• Knee angle and angular velocity at EMG onset
Three stretch velocities
1. Slow (ROM)
2. Medium (Ashworth-like)
3. High (Tardieu-like)
Period of interest
Change between velocities
Low Medium HighAver
aged
nor
mal
ised
rms
EMG
Comparison between velocities
-2 -1 0 1 2 3 4 5-40
-20
0
20
Time [s]
-2 -1 0 1 2 3 4 50
50
100
150
Time [s]
-2 -1 0 1 2 3 4 50
0,02
0,04
-2 -1 0 1 2 3 4 50
10
20
Time [s]
Positionn
Velocityn
RMS-EMGn
Torquen
Time (s)
Low velocityHigh velocity
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Torque at 70° knee flexion To
rque
(Nm
)
Position (°)
Low velocity
Torque
High velocity
Torque at 70° knee flexion
Torque
Torq
ue (N
m)
Position (°)
Low velocity
Torque at 70° knee flexion
Torque
Position (°)
Change between Low and High
Torq
ue(N
m)
Work
From maximum velocity until 90% of the ROM
Position (°)
Torq
ue(N
m)
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Change between High and Low
Work
From maximum velocity until 90% of the ROM
Position (°)
Torq
ue(N
m)
Work
Three stretch velocities
1. Slow (ROM)
2. Medium (Ashworth-like)
3. High (Tardieu-like)
Work
Change between velocities
Work
43
Three stretch velocities
1. Slow (ROM)
2. Medium (Ashworth-like)
3. High (Tardieu-like)
Work
Change between velocities
Low Medium High0
1
2
3
4
5
6
7
8
Wor
k [J
]
Instrumented spasticity assessment
• Spatisticity parameters are reliable• Instrumented spasticity has discriminative validity
(between CP and TD)• Parameters can distinguish different levels of spasticity
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for Treatment fine-tuning
Quantification of the spastic catch
• Subjective• Inaccurate
Haugh et al. 2006; Van de Noort 2010
Modified Tardieu Scale
Maximum change in torque (dT/dt)AOC 1
Maximum decelerationAOC 2
ISOLATED BIOMECHANICAL SIGNALSVan de Noort 2010; Wu et al. 2010
Quantitative definitions
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Velocity dependence of the catch angle
Wu et al. 2010
The faster the stretch, the later the catch?!
We assume that the earlier the catch, the more severe the spasticityBUT
Problem with the AOC!
Angle of catch (AOC)
Joint angular position
Time (s)
Joint angular velocity
EMG
Torque
Quantification of angle of catch
-2 -1 0 1 2 3
0
1
2
3
4
5
Time [s]
Pow
er [W
]
POWER (ω*T)
-2 -1 0 1 2 3-1
0
1
2
3
4
5
6
7
Time [s]
Torq
ue [N
m]
-2 -1 0 1 2 3 4-20
0
20
40
60
80
100
120
140
160
180
Time [s]
Velo
city
[deg
/s]
TORQUE (T) VELOCITY (ω)
AOC 3 = min. (ω*T)
INTEGRATED SIGNAL
Integration of signalsQuantification of the spastic catch
Spastic Catch conclusions
The AOC depends on the velocity of stretch. AOC best defined by integrating signals. The intensity at which the catch occurs should additionally
be considered.
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for Treatment fine-tuning
CP (n=31), Hamstrings muscles (n=40)
Average age 9 years
Male/female 18 male, 13 female
Paralysis injury11 unilateral involvement
20 bilateral involvement
GMFCS Range I - IV
Timing of pre-btx measurement 9 ± 15 days before
Timing of post-btx measurement 43 ± 16 days afterAssessment
Sensitivity to BTX-A treatment
Instrumented parameters pre vs. post BTXp
RMS-EMG (mV) *<0.001
Torque at 70˚ (Nm) *<0.001
Torque at VMAX (Nm) *0.009
Work (J) *<0.001
AOC (%) *<0.001
AOC power (W) *<0.001
Spasticity parameters are sensitive to the effect of BTX
Sensitivity to BTX-A treatment2.3
ElineBTX dosage
Pre Ashworth
Post Ashworth
PreTardieu
PostTardieu
GAS 3U/Kg 1+ 1+ -15° -15°
MEH 4U/Kg 1+ 1+ -50° -50°
Yana
GAS 3U/Kg 1+ 1+ -15° -10°MEH 1U/Kg 1+ 1+ -50° -70°
Clinical cases: Eline and YanaBTX‐dosage and clinical results
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Instrumented spasticity assessmentEffect of botulinum toxin
• Spatisticity parameters are sensitive in measuring the effect of BTX-A in the hamstrings
• Instrumented spasticity is more responsive than clinical scales
• Torque is less sensitive to BTX than EMG
Outline
• Introduction
• Instrumented Spasticity Assessmento Protocolo Spasticity parameterso Angle Of Catch (AOC)o Treatment
• Advanced data-analysis for treatment fine-tuning
How can we explain the variation in response to treatment?
• Advanced analysis of EMG
• Advanced analysis of torqueTime (s)
SLOW stretch
RMS‐EM
G (mV)
RMS‐EM
G (mV) FAST stretch
Time (s)
Gastrocnemius
Advanced analysis of EMG
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Time (s)
RMS‐EM
G (mV)
RMS‐EM
G (mV)
Time (s)
Gastrocnemius
RMS‐EM
G (mV)
RMS‐EM
G (mV)
Time (s)Time (s)
Hamstrings
EMG
SLOW stretch FAST stretch
SLOW stretch FAST stretch
EMG
-4 -2 0 2 4 6 8 10-40
-30
-20
-10
0
10
20
30
Time [s]
Posi
tion
[deg
]
90% ROM
63.33% ROM
36.66% ROM
10% ROM
Position zones
P1 P2 P3
12
3
1
2
3
0
5
10
Fast stretch
Slow stretch
More muscle length
Aver
age
norm
aliz
ed
RM
S-EM
G (%
)
More muscle lengthening velocity
Medium stretch
Average normalized RMS-EMG
Position zones
More muscleactivation
12
3
1
2
3
0
20
40
60
80
velocity categories
zones
Avg
. nor
m. r
ms
emg
med
. ham
. [%
]
Low velocity dependent1
23
1
2
3
0
5
10
15
20
velocity categories
zones
Avg
. nor
m. r
ms
emg
med
. ham
. [%
]
Mixed pattern
Visual classification of EMG patterns
Study Results (N = 54 children with CP)
12
3
1
2
3
0
5
10
Mixed more velocity Mixed more low velocity dependent
Velocity dependent1
23
1
2
3
0
1
2
3
4
5
Gastrocnemius
Rectus Femoris
Adductors
Medial Hamstrings
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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12
3
1
2
3
0
5
10
Parameter development
EMG parameters
Fast stretch
Slow stretch
Aver
age
norm
aliz
ed
RM
S-EM
G (%
)
Medium stretch
Position zones
Study Results
Normalized RMS-EMG (%)
Nor
mal
ized
RM
S-E
MG
(%)
Pilot studySpastic hamstring muscles (n=9)
Botulinum Toxin-A
Normalized RMS-EMG (%)
Nor
mal
ized
RM
S-E
MG
(%)
Study Results
More position dependent
More velocity dependent
Pilot study
Conclusions
• Differences between musclesHamstrings and adductors => low velocity-dependentGastrocnemius and Rectus femoris => velocity dependent
• Differences between patients
Pattern definition may help to fine-tune patient specific treatment
Bar-On 2013, 2014
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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Advanced analysis of torque
Is it stiff or is it spastic?
Stiff SpasticASSESS
?Neural causes
Hyper-active stretch reflexNon-neural causes
Muscle and joint structure
Stiffness
Viscosity
Muscle activation
Inertia
Increased joint torque
Alibiglou et al. 2008Harlaar et al. 2000 De Vlugt et al. 2012
Computational models and motor-driven systems
Motor-driven systems
Stiff or Spastic?
Related to passive structures
Stiffness
Viscosity
Inertia
Torque decomposition
Anthropometric parameters
measured and estimated
(Drillis 1964 and Jensen 1986)
torque(Nm
)
Joint angle (°)
(De Vlugt et al. 2010)
1
EMG (mV)
Time(s)
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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-30 -20 -10 0 10 20 30 40
0
2
4
6
8
Non-neural
Stiffness
Viscosity
Inertia
Anthropometric parameters
measured and estimated
(Drillis 1964 and Jensen 1986)
Joint angle (°)
torq
ue(N
m)
-30 -20 -10 0 10 20 30 40
0
2
4
6
8
torq
ue(N
m)
Joint angle (°)
SLOW stretch
Resulting torque
(De Vlugt et al. 2010)
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2-0.2
-0.1
0
0.1
0.2
0.3
0.4
-30 -20 -10 0 10 20 30 40
0
2
44
6
8
Joint angle (°)
torq
ue(N
m)
Time (s)
EMG
(mv)
Time (s)
-30 -20 -10 0 10 20 30 40
0
2
44
6
8
-30 -20 -10 0 10 20 30 40
0
2
44
6
8
-30 -20 -10 0 10 20 30 40
0
2
4
6
8
torq
ue(N
m)
Joint angle (°)-30 -20 -10 0 10 20 30 40
0
2
4
6
8
Non-neural
Stiffness
Viscosity
Inertia
Anthropometric parameters
measured and estimated
(Drillis 1964 and Jensen 1986)
Joint angle (°)
torq
ue(N
m)
Joint angle (°)
torq
ue(N
m)
Joint angle (°)
torq
ue(N
m)
FAST stretch
SLOW stretch
Resulting torque
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2-0.2
-0.1
0
0.1
0.2
0.3
0.4
-30 -20 -10 0 10 20 30 40
0
2
44
6
8
-30 -20 -10 0 10 20 30 40
0
2
44
6
8
-30 -20 -10 0 10 20 30 40
0
2
4
6
8
torq
ue(N
m)
Joint angle (°)-30 -20 -10 0 10 20 30 40
0
2
4
6
8
Non-neural
Stiffness
Viscosity
Inertia
Anthropometric parameters
measured and estimated
(Drillis 1964 and Jensen 1986)
Joint angle (°)
torq
ue(N
m)
Joint angle (°)
torq
ue(N
m)
Joint angle (°)
torq
ue(N
m)
FAST stretch
SLOW stretch
Resulting torque
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2-0.2
-0.1
0
0.1
0.2
0.3
0.4
What part in the curve is not explained by stiffness or viscosity?
Neural
Muscle activationMuscle
activation
Fitting error
= 0.44 Nm
-30 -20 -10 0 10 20 30 40
0
2
4
6
8
joint position [deg]
mom
ent [
Nm
]
-30 -20 -10 0 10 20 30 40
0
2
4
6
8
joint position [deg]
mom
ent [
Nm
]
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
joint position [deg]
mom
ent [
Nm
]
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
joint position [deg]
mom
ent [
Nm
]
Joint angle (°)
Torq
ue (N
m)
Joint angle (°)
Torq
ue (N
m) SLOW stretchFAST stretch
Model deviation
Fitting error
= 0.04 NmModel deviation
Slow stretch is well explained by stiffness curve
Large deviation from stiffness during fast stretch
>
Searching for maximum fitting error
Deviation from the model
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
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-30 -20 -10 0 10 20 30 400
0.005
0.01
0.015
0.02
0.025
0.03
Joint position [deg]
RM
S-EM
G (m
V)
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
joint position [deg]
mom
ent [
Nm
]
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
joint position [deg]
mom
ent [
Nm
]
Joint angle (°)
Torq
ue (N
m)
Joint angle (°)
RM
S-E
MG
(mV
)
NeuralNon-neural
Stiffness
Viscosity
InertiaMuscle
activation
FAST stretch
Muscle activation
Processed EMG
Deviation from the model and EMG onset
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
joint position [deg]
mom
ent [
Nm
]
Non-neural
Stiffness
Viscosity
InertiaNeural
Muscle activation
Non-neural
Stiffness
Viscosity
InertiaNeural
Muscle activation
Joint angle (°)
Torq
ue (N
m)
0.44 Nm
Bar-On 2014
Joint angle (°)
Torq
ue (N
m)
-30 -20 -10 0 10 20 30 40-2
0
2
4
6
8
10
Joint angle (°)
Torq
ue (N
m)
1.99 J
Work
VComparison of parameters
Model deviation
CP TD p-value
Model Deviation (Nm) 2.70 (1.06) 0.90 (0.63) <0.001*
Work deviation (J) 2.07 (1.06) 0.53 (0.33) <0.001*Work (J) 2.99 (1.29) 1.21 (0.55) <0.001*
ICC SEM MDC
Model Deviation (Nm) 0.96 0.36 0.84
Work deviation (J) 0.96 0.31 0.72Work (J) 0.97 0.35 0.82
Results
Reliability
Discriminate validity
Pre-BTX Post-BTX p-value
Model Deviation (Nm) 2.74 (1.01) 1.80 (0.80) 0.006*
Work deviation (J) 2.02 (0.86) 0.53 (0.33) 0.012*Work (J) 3.17 (1.46) 2.67 (1.53) 0.183
Sensitivity
Conclusions
• Neural component of torque is sensitive to treatment
• Non-neural component of torque is not sensitive to treatment
Torque decomposition may help to fine-tune patient specific treatment
September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat
References
Bar‐On, L., Aertbeliën, E., Molenaers, G., Desloovere, K. (2014). Muscle activation patterns when passively stretching spastic lower limb muscles of children with cerebral palsy. PLoS One, art.nr. doi:10.1371/journal.pone.0091759.
Bar‐On, L., Aertbeliën, E., Molenaers, G., Desloovere, K. (2014). Manually controlled instrumented spasticity assessments: a systematic review of psychometric properties. Developmental Medicine and Child Neurology, art.nr. DOI: 10.1111/dmcn.12419.
Bar‐On, L., Van Campenhout, A., Desloovere, K., Aertbeliën, E., Huenaerts, C., Vandendoorent, B., Nieuwenhuys, A., Molenaers, G. (2014). Is an instrumented spasticity assessment an improvement over clinical spasticity scales in assessing and predicting the response to integrated Botulinum Toxin‐A treatment in children with Cerebral Palsy?. Archives of Physical Medicine and Rehabilitation, 95 (3), 515‐523.
Bar‐On, L., Aertbeliën, E., Molenaers, G., Van Campenhout, A., Vandendoorent, B., Nieuwenhuys, A., Jaspers, E., Hunaerts, C., Desloovere, K. (2014). Instrumented assessment of the effect of Botulinum Toxin‐A in the medial hamstrings in children with cerebral palsy. Gait & posture, 39 (1), 17‐22.
Bar‐On, L., Desloovere, K., Molenaers, G., Harlaar, J., Thalia, K., Aertbeliën, E. (2014). Identification of the neural component of torque during manually‐applied spasticity assessments in children with cerebral palsy. Gait & Posture.
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September 10, 2014 AACPDM 2014 GCMAS Symposium Desloovere Kaat