[Incidence, circumstances and consequences of falls in patients undergoing rehabilitation after a first stroke]. / Incidence, circonstances et conséquences des chutes chez les patients en rééducation après un premier accident vasculaire cérébral.

OBJECTIVES: To describe the incidence, circumstances, and consequences of falls in patients admitted in a rehabilitation ward after a stroke. METHODS: Prospective monitoring of falls over four years in a neurological rehabilitation unit. Use of fall registry. INCLUSION CRITERIA: age < 75 years, admission < 45 days after stroke onset, single stroke of 1 cerebral hemisphere (nonlacunar) or of the brain stem. Only falls due to loss of balance were considered; falls caused by a seizure or syncope were not considered. RESULTS: Of 217 consecutive patients with the inclusion criteria, 34 had fallen at least once (15.7%) and 10 twice (4.1%). Fall incidence, defined as the number of falls per patient per day was 2.2 per thousand. Half of the patients fell the first three weeks after admission. Most falls involved getting to or from the wheelchair or the bed; 1 patient had recovered minimal postural abilities at the gym but was not independent. Traumatic lesions were noted in 13 patients: they were minor in nine and severe in four, including three fractures. CONCLUSION: Falls due to loss of balance are a major problem in patients undergoing rehabilitation after a stroke. Getting to and from wheelchairs in the bedroom and bathroom by patients who are not allowed to do so play a key role in many falls. Prevention programs should consider this information.

[Standing-up/sitting-down movement. Electromyographic analysis of 4 muscles of lower limb and the erector spinae muscle: study of anticipatory postural adjustments]. / Mouvement debout-assis. Analyse électromyographique de quatre muscles du membre pelvien et du muscle erector spinae: recherche d'ajustements posturaux anticipateurs.

This study was conducted to evaluate the activity of the Erector Spinae and four other muscles of the lower limb during the 1500 first milliseconds of the sitting movement. Electromyographic activities of the Soleus, Tibialis Anterior, Biceps Femoris, Vastus Lateralis, and Erector Spinae muscles were recorded together with cinematic and kinematic data. An inhibition of the Erector Spinae activity was found at the beginning of the movement. It preceded the displacement of the first mobile kinematic marker in 8 of 15 trials. This muscular inhibition created a postural forward movement before the voluntary backward movement. This inhibition of the Erector Spinae could be considered as an anticipatory adjustment movement because of its postural function and its precocity. These results, obtained in healthy young people, should be compared with results in old people, especially with people who suffer from psychomotor dysadaptation syndrome, in whom this inhibition of the Erector Spinae seems to be absent.

Healing of open stump wounds after vascular below-knee amputation: plaster cast socket with silicone sleeve versus elastic compression.

OBJECTIVE: To assess the effect of a plaster cast socket on the healing of open wounds and on temporary prosthesis fitting after below-knee amputation because of arterial occlusive disease. DESIGN: Randomized controlled trial. SETTING: Rehabilitation center, university hospital. PATIENTS: All included patients had undergone recent (in the previous 3 months) below-knee amputation because of arterial disease and initially had an open stump. Patients were randomly assigned to two groups of 28 subjects each. The sizes of the amputation scars were 8 to 24 cm2. Ischemia of the stump was eliminated as a probable cause of delayed wound healing by the inclusion criterion of transcutaneous oxygen tension (TcPO2) of >35 mmHg. The average age in group I (the experimental group) was 65.2 +/- 12.4 (SD) years and in group II (the control group) 66.8 +/- 10.8 years (not significant). INTERVENTION: A plaster cast (supracondylar-type) socket was fitted on the stumps of group I patients, interposed with a silicone sleeve. The patients were gradually trained to wear this cast for up to 5 hours a day. They were provided with elastic compression bandages for the remainder of the time. Patients in group II wore elastic compression bandages, which were only removed for dressing changes. MAIN OUTCOME MEASURES: Time required for stump healing, length of time between amputation and ability to walk wearing a contact socket, and length of hospital stay. RESULTS: Group I had a quicker average healing time (71.2 +/- 31.7 [SD] days compared to the control group's 96.8 +/- 54.9 days) and a shorter average length of hospital stay (99.8 +/- 22.4 days compared to the control group's 129.9 +/- 48.3 days). CONCLUSION: Use of a plaster cast socket leads to more rapid healing of the open stump and to a shorter hospitalization. If there is no stump ischemia, this plaster cast technique is safe.

Nuclear magnetic resonance evidence of different muscular adaptations after resistance training.

OBJECTIVE: To evaluate muscle bioenergetics, muscle cross-sectional area (CSA), and soreness when the gastrocnemius was subjected to concentric and concentric/eccentric resistance training modes. DESIGN: Prospective study, before and after training. The subjects served as their own controls. SETTING: Rehabilitation center and nuclear magnetic resonance spectroscopy unit of a university hospital. PARTICIPANTS: Sixteen healthy young volunteers from the local physiotherapist school. INTERVENTION: Two distinct resistive training programs were evaluated on the gastrocnemius: a protocol consisting of concentric contractions only and a mixed concentric/eccentric program. MAIN OUTCOME MEASURES: Maximal isometric resistance was measured after each training session. Before and after training, muscle CSA was appreciated using magnetic resonance imaging, whereas changes in muscle pH, phosphorus metabolite ratios, maximal oxidative power (Pmax), and oxidative phosphorylation were studied using 31P nuclear magnetic resonance spectroscopy at rest and during an incremental exercise protocol. RESULTS: Magnetic resonance imaging revealed a significant increase (7.1%) in the gastrocnemius CSA in the concentric-eccentric group only. The PCr/Pi (8.3 +/- 0.9 vs 10.4 +/- 1.7) and PCr/ATP (3.68 +/- .36 vs 4.07 +/- .27) resting ratios increased significantly (p = .008) after concentric-eccentric resistance training. Pmax was significantly improved in the concentric-eccentric group (7.0 +/- 2.1W vs 8.4 +/- 1.8W: p < .02). This mixed protocol also reduced the incidence of muscular soreness. CONCLUSION: The data suggest that the improved oxidative mechanical power output could be due mainly to a greater muscle cross-section in the concentric-eccentric group, with circumstantial evidence suggesting a relatively higher type IIa fiber activity.

Effects of low-frequency electrical stimulation of quadriceps and calf muscles in patients with chronic heart failure.

PURPOSE: The aim of this preliminary study was to evaluate the effects of low-frequency electrical stimulation of quadriceps and calf muscles on global exercise capacities, skeletal muscle metabolism, calf muscle volume, and cardiac output in patients with chronic heart failure. METHODS: Fourteen patients with chronic heart failure (mean age of 56.4 years +/- 9.1 SD; mean radionuclide left ventricular ejection fraction of 22.3% +/- 8.8 SD) underwent 5 weeks (1 hour per day, 5 days per week) of low-frequency electrical stimulation of quadriceps and calf muscles. RESULTS: Low-frequency electrical stimulation was well tolerated. Exercise capacity and the calf muscles volumes increased significantly after rehabilitation in comparison with prior rehabilitation (the peak oxygen consumption increased from 17.2 mL/(kgmin) +/- 5.3 SD to 19.6 mL/(kgmin) +/- 5.9 SD; the anaerobic threshold increased from 12.3 mL/(kgmin) +/- 3.2 SD to 15.2 mL/(kgmin) +/- 3.3 SD; the 6-minute walking test increased from 419 m +/- 122 SD to 459 m +/- 114.3 SD; the gastrocnemius volume increased from 259.4 cm3 +/- 58 SD to 273.4 cm3 +/- 74 SD, and the soleus volume increased from 319 cm3 +/- 42.9 SD to 338 cm3 +/- 52.5 SD). The New York Heart Association class was improved after rehabilitation. The P-31 nuclear magnetic resonance spectroscopy of gastrocnemius muscle data were not significantly modified after rehabilitation, thereby inferring that no significant improvement of the muscle metabolism occurred. These data reinforce the hypothesis of an increased muscle mass during stimulation. It is noteworthy that the electrical stimulation did not increase cardiac output at any stage; an enormous asset in favor of this mode of rehabilitation. CONCLUSION: These results suggest that low-frequency muscular electrical stimulation is well tolerated, induces an increased exercise capacity in patients with chronic heart failure, without an undesirable increase in cardiac output.

A kinematic comparison between elderly and young subjects standing up from and sitting down in a chair.

BACKGROUND AND AIMS: The transfer from sitting to standing and back to sitting as the two phases of the same task has never been studied in elderly people. The purposes of this study were to analyse and compare kinematic features of the whole task (standing up and sitting down) and to determine whether there are age-related differences upon movement kinematics in healthy elderly persons during the whole sequence (standing up and sitting down). METHODS: The movements of various parts of the body were measured with a 100 Hz television image analyser that computed the co-ordinates of small reflective markers glued onto the skin of the subjects. The task was conducted using an armless chair set to 100% of knee height under four conditions: at normal speed in light, at normal speed in the dark, at fast speed in light and at fast speed in the dark. TYPE OF STUDY: Laboratory study. RESULTS: In young subjects, the task was characterized by similar acromion trajectories and angular displacement of trunk in standing up and sitting down and by a stabilization of the head in space during the two phases. However, the time required to achieve the movement was found to be greater in sitting down than in standing up, and an adjustment of velocity appeared in final part of the movement before reaching the chair. In sitting down, as in carrying out a pointing task of upper limb, an adjustment was required to achieve accuracy. This feature was not found in standing up. Age-related differences appeared to be more important during sitting down than during standing up. Moreover, deterioration of head stability was found in elderly subjects, particularly when the task was achieved rapidly and in darkness. CONCLUSION: There is a relationship between changes in the motor control of the task, which appeared during periods of potential postural instability, and the effects of ageing on postural stability.

Muscle metabolism changes with training in the nonamputated limb after vascular amputation: interest of phosphorus 31 NMR spectroscopy.

OBJECTIVE: To determine by 31P nuclear magnetic resonance (NMR) spectroscopy the efficacy of training in improving aerobic metabolism of calf muscle in nonamputated limb after recent vascular amputation; to assess the possible associated microcirculatory changes; and to evaluate the need for noninvasive monitoring techniques during training in the nonamputated limb after recent vascular amputation. DESIGN: Prospective study, before and after training. Subjects served as their own controls and were compared with a control group. SETTING: Rehabilitation center of a university hospital. PATIENTS: Ten unilateral vascular amputated patients were included with ankle systolic index between 0.5 and 0.8 in the nonamputated limb, and 10 control subjects without cardiovascular disease or risk factors of atherosclerosis with ankle systolic index of >.95. INTERVENTION: Walking with prosthesis at self-selected velocity over increasing walking distance, arm training at a workload of 60% of a maximal arm test, and analytical exercises of the nonamputated leg (dynamic contractions against low resistance). Subjects received training as inpatients, 5 days a week. MAIN OUTCOME MEASURES: Before and after training, ankle systolic index, forefoot transcutaneous oxygen tension (TcPO2) and veno-arteriolar reflex, and digital plethysmography of the second toe with reactive hyperemia test were studied. Changes in calf muscle pH, phosphocreatine (PCr), and inorganic phosphate (Pi) were measured by 31P NMR spectroscopy at rest and during a plantar flexion-type incremental protocol. RESULTS: There was no significant difference in ankle systolic index (.63 +/- .10 vs .64 + .07) or in TcPO2 (42 +/- 11 vs 44 +/- 10mmHg), and there was reappearance of veno-arteriolar reflex in 3 cases, of a plethysmographic signal in 2 cases, and of the positivity of the reactive hyperemia test in 3 cases. No differences were found with 31P NMR spectroscopy at rest before and after training. At the same workload (1 watt) the difference of the ratio (PCr/(PCr + Pi)) of rest to effort (PCr depletion) was significantly increased in the amputated patients (.423 +/- .159 vs .145 +/- .058; p < .01). This difference of ratio was lower after training (.360 +/- .158 vs .423 +/- .159; p < .05). The pH was less acid between the two periods. CONCLUSION: Vascular monitoring with systolic index and TcPO2 is necessary to follow and to prevent serious ischemia of the nonamputated limb. Claudication is often not detected because of early exhaustion during walking. Training after recent vascular amputation improves the skeletal muscle oxidative capacity.

Relationship between increased peak oxygen uptake and modifications in skeletal muscle metabolism following rehabilitation after myocardial infarction.

PURPOSE: Rehabilitation after myocardial infarction produces an increased peak oxygen uptake (VO2peak). This study investigates the relationship between the modifications in skeletal muscle metabolism and the modification in VO2peak induced by a standard program of physical training following a myocardial infarction. METHODS: Seventeen patients (14 male, 3 female) were studied by phosphorus 31(31P) magnetic resonance spectroscopy after the acute phase of a myocardial infarction and after 2 months of rehabilitation. Changes in calf muscle pH, phosphocreatine, and inorganic phosphates were measured at rest and during a plantar flexion-type incremental workload protocol. Calf muscle pH, phosphocreatine/(phosphocreatine + inorganic phosphates), and inorganic phosphates/phosphocreatine ratios were compared at the highest identical workload attained in both studies. The VO2peak (mL/kg/min) was determined during a cycle stress test. RESULTS: At the highest identical workload attained in both tests, the ratio phosphocreatine/(phosphocreatine + inorganic phosphates) was significantly higher (0.48 +/- 0.15 to 0.57 +/- 0.18: P < .001), and the ratio inorganic phosphates/phosphocreatine was lower (1.38 +/- 1.14 to 0.99 +/- 0.87: P < .01). After rehabilitation, no difference was observed for the pH at stress (6.83 +/- 0.16 to 6.91 +/- 0.14: not significant [NS]). The increase in the VO2peak was significant after rehabilitation (24 +/- 9 to 29 +/- 11 mL/kg/min: P < .001). The VO2peak improvement induced by the physical training was correlated with the increase in the phosphocreatine/(phosphocreatine + inorganic phosphates) (r = 0.818, P < .001). CONCLUSIONS: The reduction in phosphocreatine depletion indicated that the oxidative capacity of the skeletal muscle was improved during the rehabilitation. The good correlation between the indexes of skeletal muscle metabolism and VO2peak suggests the peripheral effect of training.

Bioenergetic comparison of a new energy-storing foot and SACH foot in traumatic below-knee vascular amputations.

In this study, the metabolic performances of a new energy-storing foot (Proteor) and of the solid-ankle cushion heel (SACH) are compared. Twelve patients with traumatic below-knee amputations (mean age: 50.0 +/- 19.9 years) and 12 patients with vascular below-knee amputations (mean age: 73 +/- 7 years) were studied. Oxygen uptake (VO2) was measured in all the subjects on a walkway at a self-selected velocity; only the subjects with traumatic amputation were tested on a level treadmill (progressive speed: 2.4-4 and 6 km/h), and then in two randomized trials: incline (+5%) and decline walking treadmill test at 4 km/h. Vascular explorations were done in the vascular patients: distal pressure measurements, pulse plethysmography, transcutaneous oxygen tension. Free walking was improved in subjects with traumatic amputation using the energy-storing foot (+6%), with a better bioenergetic efficiency (0.24 +/- 0.4mL/kg.m vs 0.22 +/- 0.04mL/kg.m). However, in subjects with vascular amputation, this foot did not produce an increased free velocity nor an improved energy cost. During the level treadmill test, the traumatic amputee subjects showed a decrease of energy expenditure with the new prosthetic foot, more significant at sufficient speed (4 km/h): 17.00 +/- 3.42 vs 14.67 +/- 2.05 mL/kg/min (p < .05). The same effect is shown during the incline (19.31 +/- 2.80 vs 16.79 +/- 2.32 mL/kg/min-p < .02) and decline walking tests (14.13 +/- 3.64 vs 11.81 +/- 1.54mL/kg/min-p < .02). There is no significant difference in cardiocirculatory effects between the two types of prosthetic foot. Despite a lower velocity, the subjects with vascular amputation exceed 70% of the maximal heart rate, with the cardiocirculatory factor being the main cause of walking restriction. The energy-storing foot should be reserved for active and fast walkers, whereas the SACH foot seems more suitable for elderly patients with amputation with a slow walk.

[Cortico-basal degeneration: a new entity]. / Dégénérescence cortico-basale: une nouvelle entité.

Cortico-basal degeneration is a progressive disease comprisong characteristic features concerning both cortical and basal ganglionic dysfunction. Manifestations include akineto-rigid syndrome and apraxia strictly limited at disease onset to one hemibody, especially the left. Myoclonus, chorea a alien limb syndrome can begin within the clinicalcome. Functional exploration of the brain shows an asymmetric hypometabolism affecting both cortical and basal structures. Neuropathologic studies show pathological features including neuronal loss, gliosis and neuronal achromasia affecting the cortex (frontal and parietal), basal ganglia and locus niger. Further evaluation of this disease is needed to understand its links with the other neurological degenerative diseases especially progressive aphasia and Pick's disease.

[Medical and technical compensation of disabilities]. / Compensation médico-technique des handicaps.

Thanks to technological advances handicaps can be treated in a better way by physicians. This real Metrology of Handicap constitutes a preliminary stage to medical decision. Functional repercussions of a lesion can thus be accurately assessed before the well adapted compensatory means are conceived, prescribed and applied. A better understanding of physiopathological mechanisms involving lesion, deficit and handicap and of compensatory procedures used by disabled people depends from this assessment. Some examples will be reported such as energy expenditure, 3-dimensional biomechanical analysis of daily activities and the correlation between both approaches. Likewise, efficiency of therapeutics can be assessed such as the analysis of gait with appliances with different types of prosthetic feet or effects on muscle of various training programs. Besides, sophisticated orthesis, prosthesis and living aids can be developed with the help of data processing, robotics and electrostimulation. This new type of devices will be added to the range of standard devices developed at little cost by occupational therapists. As for the future, caution is imperative. "Repaired" man turning "robotised" is an image provided by media that might bring disillusions. On one hand, numerous social, economic and personal factors intervene in the determination of the plan for life by the individual and his family. Thereby, all the possibilities offered by technological advances might not be studied in the choice of plan of life. On the other hand, priorities in aims of an increasingly demanding individual economy will be dictated by collective economy focused on cost management. However, the concept of increase in life expectancy without disability will be relevant in the determination of health policy and the role of rehabilitation physicians will be all the more important because they are the only one to be able to coordinate a team qualified to choose and apply the best therapeutics. Times are over when below-knee amputees were directly referred to the orthoprosthetist after segmentation, At the present time, psychologists cannot decide alone on the re-orientation of patients with brain trauma and, Domoticians will never organize the life place of tetraplegic subjects.

[Effect of rehabilitation after myocardial infarction on muscular metabolism. Contribution of phosphorus 31 NMR spectroscopy]. / Effets sur le métabolisme musculaire de la réadaptation après infarctus du myocarde. Apport de la spectroscopie RMN du phosphore 31.

P 31 NMR spectroscopy is a recent technique which allows a non-invasive and direct analysis of oxidative metabolism and pH changes, an indicator of acidosis due to lactic acid accumulation in the skeletal muscles. The authors investigated oxidative muscular metabolism of the sural triceps in 10 patients after myocardial infarction by performing a study after the acute phase and repeating the study after a programme of physical training. At rest, there were no significant differences. On the other hand, for the same level of maximal effort, the depletion in phosphocreatinine (PCr) and the accumulation of inorganic phosphate (Pi) were significantly lower after physical training: the PCr/PCr + Pi increased from 0.467 +/- 0.179 to 0.538 +/- 0.20 (p < 0.02) and the Pi/PCr ratio decreased from 1.570 +/- 1.440 to 1.181 +/- 1.069 (p < 0.05). The pH at the same level of maximal exercise did not change significantly between the two periods: 6.85 +/- 0.16 vs 6.88 +/- 0.15 (NS). The peak oxygen consumption (VO2) measured during bicycle ergometry increased significantly from 23.4 +/- 10.5 to 28.3 +/- 12.14 ml/min/kg after exercise training (p < 0.01). In addition, a correlation was observed between the improvement of the peripheral parameters (PCr/PCr + Pi) and the increase in VO2 max (r = 0.757, p < 0.01). The authors results confirm the effects of physical training on oxidative metabolisms of the peripheral muscles and its influence on improvement of global performance of coronary patients.

The energetic cost of some daily activities: a comparison in a young and old population.

We compared the energetic costs of some daily activities in two groups, 10 young people (24.3 +/- 2.8 years) and 10 old people (74.4 +/- 2.2 years): rising and sitting back down on a seat, getting up from and lying down on a bed and getting up from the floor. We measured the oxygen consumption and the time necessary for the activities. The results showed a noteworthy economical energetic procedure when rising and sitting back down on a seat among the older group. The values of the energy expenditure were respectively 3.9 +/- 1.3 cal/kg in the older group and 5.8 +/- 1.6 in the younger one with a standard seat (45 cm) and 2.7 +/- 1.2 vs 5.2 +/- 1.5 with a raised seat (60 cm). The activities did not vary significantly in time in the two age groups. This procedure could be understood as an adaptation of the energy expenditure to the reduced aerobic capacity with ageing. Conversely, getting up from and lying down on the floor or a standard hospital bed involved the same energy expenditure in the older and younger group, but performing these activities took significantly longer for the older people (+60% for getting up from the floor, +33% from the bed). As these activities revealed no economical energetic procedure in the older group, they appeared responsible for a strong factor of dependence. The importance of a learning process particularly for the most usual movements in everyday life is discussed.

Transcutaneous oxygen pressure. An effective measure for prosthesis fitting on below-knee amputations.

After amputation for arterial occlusive disease of the lower limbs, healing and local adaptation to a prosthesis depend on the oxygen ratio in the tissue. Transcutaneous oxygen tension (TcPO2) is a noninvasive microcirculatory exploration. Forty six below-knee stumps were selected without any prosthetic problem excepting vascular, with a follow-up mean duration of 23 months. They were classified into different prosthetic categories. The first was the worst because it required further amputation on the thigh and the fourth the best, which displayed complete adaptation to a socket contact. These groups were related to their TcPO2 values on the anterior and exterior face of the stumps in both reclined and seated positions. It seems that it is impossible to achieve healing when the TcPO2 value is lower than 15 mm Hg in lying position. However, healing is possible above 20 mm Hg but socket contact is not possible when TcPO2 values are under 40 mm Hg. When TcPO2 values are above 40 mm Hg, a good prosthesis fitting is possible when no problems are encountered other than vascular ones.

Lung function in advanced age: study of ambulatory subjects aged over 75 years.

Spirometric parameters including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and various parietal parameters (superior and inferior rib cage and abdominal maximal expansion amplitudes) were measured in 65 ambulatory subjects aged over 75 years. The population was divided into three age groups: group 1: 75-79; group 2; 80-84, group 3: 85 and older. A marked decrease in clinical and spirometric results was observed between groups 1 and 2, and 1 and 3, but there was no difference between groups 2 and 3. Such findings might be attributed to a survival effect. There was a high correlation between the parietal parameters and FVC and FEV1. In clinical practice, this simple parietal assessment may be of value in the identification of elderly subjects at risk of acute respiratory distress.

Effects of increased heart work on release of norepinephrine and ventricular arrhythmias following reperfusion in the isolated rat heart.

The influence of increasing left atrial pressures (0.5, 1.0, and 2.0 kPa) on the incidence of ventricular arrhythmias and the liberation of prelabeled norepinephrine (3H-NE) was investigated in the isolated working rat heart. Acute regional myocardial ischemia (30 min) was produced by ligature of the left main coronary artery with subsequent release of the ligature to achieve reperfusion, which consistently provoked ventricular arrhythmias. The magnitude of regional ischemia was measured by microspheres, and the efflux of 3H-labeled NE compounds was measured in the coronary effluent. Our data show that an increase in atrial pressure enhanced reperfusion arrhythmias, but the magnitude of NE release was not directly related to the occurrence of arrhythmias. It is proposed that increased heart work has an arrhythmogenic effect by enhancing the severity of regional ischemia.