The Concept of Guided Self-Rehabilitation Contracts in the Treatment of Deforming Spastic Paresis
Conventional community-based therapy is quantitatively insufficient in most health systems and thus lacks meaningful functional efficacy in chronic deforming spastic paresis. In the past decades, medicine, constraint-induced or robot-assisted therapies have not emphasized treatment of the muscle disorder inherent to the syndrome of deforming spastic paresis. [1,2] To address both the muscle disorder (“spastic myopathy”, part of the soft tissue contracture) and the neural disorder (stretch-sensitive paresis in agonists and spastic cocontraction in antagonists) two basic techniques may be involved in proportions that will depend on the respective coefficients of shortening and of weakness around each joint.
Prolonged self-administered stretch postures for overactive and shortened antagonists with high coefficients of shortening, potentially in combination with focal weakening agents, such as botulinum toxin or alcohol. These stretch postures may gradually lengthen muscles and reduce their stiffness and spindle sensitivity.
Intensive motor training, using high daily numbers of unassisted alternating maximal efforts or rapid alternating movements of maximal amplitude, involving the less overactive muscles as agonists, when there are high coefficients of weakness against the antagonists around the joint. These unassisted rapid alternating movements of maximal amplitude, gradually reduce cocontraction by restoring reciprocal inhibition between antagonists during motor command.
While current health systems cannot provide for daily high-intensity stretch and training over protracted periods, the recently developed system of Guided Self-rehabilitation Contracts (GSC; the patient practices and documents; the therapist coaches, in infrequent but thorough and long teaching sessions) have been conceived as a strategy to generate or increase patient and therapist motivation, therefore rendering the combination of daily intensity and long-term duration of the rehabilitation work realistic. Using a specifically-designed manual,  retrospective studies will be reviewed that have suggested substantial functional improvements in chronic stages, and a large scale, randomized controlled trial is currently underway to compare Guided Self-rehabilitation Contracts with conventional community-based physical therapy. Complementing the manual, a multi-lingual application for tablets and cell-phones – i-GSC – will be presented as an easy-to-use tool to increase patient long-term engagement and to facilitate progress monitoring, program adjustments and communication with the therapist.
 Gracies JM, Blondel R, Gault-Colas C, Bayle N. Contrat d'Autorééducation Guidée dans la parésie spastique. De Boeck éditions, ©Association Neurorééducation en Mouvement, Paris 2013, 108 p, ISBN 978 – 2-35327 – 169 – 6
 Meimoun M, Bayle N, Baude M, Gracies JM. [Intensity in the neurorehabilitation of spastic paresis.]. Rev Neurol (Paris). 2015 Feb;171(2):130 – 40