[Comparison of two electrical stimulation protocols on quadriceps muscle after anterior cruciate ligament surgery. Feasability study]. / Etude comparative de deux protocoles d'électrostimulation du quadriceps après chirurgie du ligament croisé antérieur. Etude de faisabilité.

OBJECTIVES: To evaluate the feasibility of a study comparing the effects of two protocols of electrical stimulation of the quadriceps femoris after anterior cruciate ligament surgery. MATERIAL: Seven sportsmen with a mean age of 26 yrs were randomly grouped in two: a 20 Hz stimulated group (4 patients) and a 80 Hz stimulated group (3 patients). After surgery all patients received electrical stimulation of the quadriceps femoris, five days a week, for 12 weeks, and had a standard program of voluntary contractions. The main outcome assessed before and three months after surgery were: quadriceps and hamstring peak torque at 90, 180 and 240 degrees /second, maximal isometric quadriceps at 75 degrees of flexion and muscle and subcutaneous fat volumes of the thigh using MRI. RESULTS: After 12 weeks of rehabilitation, the thigh muscle volume deficit of the operated limb was between 3 and 9% in the 20 Hz stimulated group and between 1 and 2% in the 80 Hz stimulated group. Quadriceps peak torque deficit was less than 30% except for two patients in the 20 Hz stimulated group. Maximal isometric quadriceps deficit of the operated limb was higher than 30% except for two patients in the 20 Hz stimulated group. CONCLUSION: The study showed that comparison of two protocols of electrical stimulation of the quadriceps femoris after anterior cruciate ligament surgery is possible if stimulation period is not more than four weeks.

[3D preliminary analysis gait in stroke patients: knee flexion in compensatory strategies]. / Analyse préliminaire 3D de la marche de l'hémiplégique: rôle de la flexion du genou dans la stratégie de récupération fonctionnelle.

OBJECTIVE: The aim of this preliminary study was to assess strategies of walking a stride in stroke patients with spastic right hemiplegia. MATERIAL AND METHODS: Gait was recorded in 3D in seven patients without other locomotion disorders. Kinematics data were studied only on the sagittal plane. The position and trajectory markers on the right side were studied during the swing phase in comparison with static standing position. Results were confronted with angular data. RESULTS: Three walking models were defined: 1) near normal gait with normal mobility in the knee; 2) gait with hicking while the flexion of the knee was reduced; 3) gait with a "talus" foot without motor recovery necessitating a pendular movement. DISCUSSION: The second pathological group was characterized with insufficient flexion in the knee in lifting the foot from the floor. In this group, patients adopted a compensation strategy with hicking in making the stride without touching the floor. We raised the question of limiting this adaptive strategy in order to enhance their remaining mobility. CONCLUSION: A 3D strategy gait analysis, before therapeutic choices, seems to confirm the value of analysing kinematic data in stroke patients with hemiplegia. The amplitude of knee mobility and hip compensation strategy can be specifically studied to improve the effectiveness of therapeutic strategies (orthesis, selective tibial neurotomy, botulinum toxin).

Clinical approach to erectile dysfunction in spinal cord injured men. A review of clinical and experimental data.

Despite the many developments in the area of sexual dysfunction, rehabilitation settings seldom investigate the remaining sexual function following spinal cord injury, or offer differential diagnoses of sexual dysfunction in spinal cord injured men. This article attempts to show how sexual rehabilitation should begin with a thorough assessment of the sexual function of paraplegic and tetraplegic men. Assessment includes a basic neurological examination of the perineal area and an extended clinical interview on sexual function and visceral function. The interpretation of patient evaluation is discussed in terms of a classification system adapted to sexual purposes and in terms of the differential diagnoses between sexual dysfunctions of organic, and those of predominantly psychogenic origin in the spinal cord injured patient. The organic or psychogenic contribution is discussed in terms of sophisticated procedures, where assessment of nocturnal penile tumescence (NPT) is critically evaluated and where alternatives such as urodynamic findings and skin potentials are discussed. Treatment strategies, such as intracavernous injections and cognitive-behavioural strategies adapted to different lesion types, are discussed.

Restoration of gait by functional electrical stimulation for spinal cord injured patients.

In this clinical study, we report the results of functional electrical stimulation for the ambulation of paraplegic patients without long leg braces (LLB), according to the Parastep approach. Of 13 SCI patients with complete neurological lesions included in this trial, 12 progressed to independent ambulation with the aid of the Parastep. The average walking distance was 76 m, with a maximum of 350 m, and the mean speed 0.2 m s-1. Compared to the situation with long leg braces, which in fact are given up by most paraplegic patients, long term home use seems to be much more important. Tolerance of this method is satisfactory. The psychological benefits of the device are remarkable. From this experience, it is concluded that this method is valuable for the restoration of standing and walking in the long term management of spinal cord injury patients.

Cardiac output during exercise in paraplegic subjects.

The purpose of this study was to measure the cardiac output using the CO2 rebreathing method during submaximal and maximal arm cranking exercise in six male paraplegic subjects with a high level of spinal cord injury (HP). They were compared with eight able bodied subjects (AB) who were not trained in arm exercise. Maximal O2 consumption (VO2max) was lower in HP (1.11.min, SD 0.1; 17.5 ml.min-1.kg-1, SD 4) than in AB (2.5 l.min-1, SD 0.6; 36.7 ml.min-1.kg, SD 10.7). Maximal cardiac output was similar in the groups (HP, 14 l.min-1, SD 2.6; AB, 16.8 l.min-1, SD 4). The same result was obtained for maximal heart rate (fc,max) (HP, 175 beats.min-1, SD 18; AB, 187 beats.min-1, SD 16) and the maximal stroke volume (HP, 82 ml, SD 13; AB, 91 ml, SD 27). The slopes of the relationship fc/VO2 were higher in HP than AB (P less than 0.025) but when expressed as a %VO2max there were no differences. The results suggest a major alteration of oxygen transport capacity to active muscle mass in paraplegics due to changes in vasomotor regulation below the level of the lesion.

Multi-centre, double-blind trial of a novel antispastic agent, tizanidine, in spasticity associated with multiple sclerosis.

A multi-centre, double-blind study was carried out in 100 patients suffering from chronic spasticity due to multiple sclerosis to compare the effectiveness of tizanidine hydrochloride with that of baclofen. Patients were allocated at random to receive treatment initially with daily doses of either 6 mg tizanidine or 15 mg baclofen and the dose was increased during the first 2 weeks up to a maximum of 24 mg tizanidine or 60 mg baclofen per day. Patients were then treated with the optimum dose for 6 weeks. Efficacy and tolerability parameters were evaluated after 2 and 8 weeks. Tizanidine and baclofen improved the functional status of patients in 80% and 76% of cases, respectively, but there were no significant differences between the two drugs. The antispastic efficacy of tizanidine was greater after 8 weeks than after 2 weeks, whereas the efficacy of baclofen decreased slightly with time. Both drugs showed good overall tolerability in more than 60% of patients. Thus, tizanidine is a well tolerated and effective muscle relaxant, the antispastic efficacy of which is well maintained over time, and it promises to be particularly useful in the treatment of spasticity due to multiple sclerosis.

A multi-centre, double-blind trial of tizanidine, a new antispastic agent, in spasticity associated with hemiplegia.

A double-blind study was carried out in 105 patients with chronic spasticity associated with hemiplegia in order to compare the efficacy and tolerability of tizanidine with that of diazepam. Dosage was increased progressively, if tolerated, to a maximum of 24 mg tizanidine or 30 mg diazepam per day at the end of 2 weeks. The optimum dosage was then maintained for 6 weeks. Efficacy and tolerability parameters were assessed after 2 and 8-weeks' therapy. Patients on tizanidine but not those on diazepam showed a statistically significant improvement in functional status, as assessed by walking distance on flat ground. Analysis of the stretch reflex in four groups of muscles showed that both tizanidine and diazepam reduced the duration of contractions and increased the angle at which contraction occurred, but there were no significant differences between the two drugs. Clonus of the triceps surae resolved in 48% of tizanidine and 40% of diazepam patients. Evaluation of the effect of therapy revealed an improvement with each drug in approximately 83% of patients, with the overall evaluation being slightly (but non-significantly) in favour of tizanidine. There were fewer discontinuations of treatment in the tizanidine group as a result of side-effects. It would appear, therefore, that tizanidine is an effective and well-tolerated drug in the treatment of cerebral spasticity.

Aerobic performance capacity in paraplegic subjects.

To determine adaptation to prolonged exercise in paraplegics, maximal O2 uptake (VO2max) and lactate threshold (LT) were evaluated during an arm cranking exercise in nine patients (P) and nine able-bodied (AB) subjects. Mean VO2max averaged 25.1 and 31.6 ml X min-1 X kg-1 in P and AB groups respectively. VO2max in P was found to be directly related to the level of spinal injury: the higher the lesion the lower the uptake. Lactate threshold expressed as a percentage of VO2max was higher in P (59%) than in AB (43%), and close to that observed in arm-trained athletes. Since training has less effect on VO2max in paraplegics than in able-bodied subjects, attributable to a deficiency in the circulatory adaptation of paraplegics to exercise, the observed differences between AB and P in lactate threshold and submaximal exercise indicate that the possible effect of training in paraplegics is located at the level of intracellular chemistry, with a diminution in glycogenolysis (higher LT) and a higher rate of lipid utilization (lower RQ).

[Value of studying spinal evoked potentials in patients with thoracolumbar spinal cord lesions]. / Intérêt de l'étude des potentiels évoqués spinaux chez des sujets porteurs de lésions médullaires dorso-lombaires.

31 control subjects and 14 patients with dorso-lumbar spinal cord lesions were studied using the spEP (spinal evoked response). The presented responses were recorded by subcutaneous needle electrodes following stimulation of the peroneal nerve. Results from control subjects are presented first (triphasic negative potential, latency increasing with level of recording). The 14 patients were grouped according to their clinical symptoms. The prognostic value of the spEP response was considered. Results were as follow: flaccid paraplegia with no motor response to stimulation: no spEP was recorded; complete anatomoclinical paraplegia: the spEP was normal caudal to the lesion and negative rostral to the lesion; complete paraplegia with minor anatomical lesions: prognosis was good when spEP rostral to the lesion was recorded and poor when no response was detected; motor paraplegia: the spEPs rostral and caudal to the lesion were normal. In all cases, the levels of the lesions were in accordance with the upper level at which changes in spEPs were observed.

[Treatment of spastic foot by selective neurotomy of the tibial nerve. Results of a series of 31 cases]. / Traitement du pied spastique par la neurotomie sélective du nerf tibial. Résultats sur une série de 31 cas.

A large number of patients suffering from various neurological diseases remain disabled because of spastic disorders in their foot. These disorders--which are responsible for abnormal postures and painful disturbances for walking and standing--can be corrected by an effective procedure: the so-called Selective Neurotomy of the Tibial Nerve (T.N.), developed in its modern form by Gros in 1972. The procedure aims at sectioning the T.N. branches corresponding to the muscles, the spasticity of which is considered harmful, i.e. the soleus (and/or gastrocnemius) nerves for equinus and ankle clonus, the posterior tibialis branch for varus, and the flexor fascicles for tonic flexion of the toes. After dissection of each T.N. branches at the lower part of the popliteal region and their identification with bipolar electro-stimulation, the selected nerves are sectioned partially (about two-third of their caliber) under the operative microscope. The present series consists of 37 operations--performed 25 times unilaterally and 6 bilaterally--in 31 patients, 17 to 68 year old (39 on average). In 11 patients spasticity was from spinal cord origin and in the 20 others from vascular or traumatic cerebral damages. The spastic disorders--installed for 2 to 17 years (4 on average)--were due to one, several or all the following components: equinus, ankle clonus, varus, flexion of the toes. Surgery obtained complete suppression of the disabling spastic components, total pain relief and consequently improvement of the residual voluntary movements by achieving balance between agonist and antagonist muscles, in 33 out of the 37 cases, i.e. in 91% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The female paraplegic: a statistical survey.

From November 1969 to December 1979, 1234 patients with spinal cord lesions were treated at the Henry Gabrielle Hospital. Of these 386 were from medical causes and 848 from trauma. The computer study of these cases brings out statistical differences between the sexes as the overall incidence in females is 30 per cent and even lower if one considers traumatic cases only 22.4 per cent out of the 848 cases. Furthermore, the average female paraplegic is two years older and it was noted that more females are married. In females the causes of spinal cord injuries are more frequently car accidents and suicidal falls from high places, whereas in males the causes are related to direct blows, that is sport injuries, motorcycle accidents and industrial falls. Clinical symptoms are similar in the two groups with the exception that there is less heterotopic ossifications and fewer bladder stones in females. The duration of hospitalisation is shorter in females. A well equipped household is more important for the handicapped females than for males.

Life expectancy following spinal cord injury: a ten-years survey in the Rhône-Alpes Region, France, 1969-1980.

A ten years survey of 848 patients having sustained traumatic spinal cord injury between 1969 and 1979 was conducted in the Rhône-Alpes Region, France. All patients had been referred to the spinal cord injury unit, Hôpital Henry Gabrielle. 48 deaths were recorded: 36 patients admitted early to the Unit, and 12 patients injured before 1969 but followed-up in the Unit. The deceased patients were older and more frequently male and tetraplegic than the rest of the group. In 75 per cent of the deceased patients, the survival time was less than 1/5 of the theoretical life expectancy. In 59 per cent, it was less than 1/10. Twenty tetraplegics died of respiratory complications. Three patients committed suicide, the rest died of urinary complications. The results appear to determine a secondary period with high mortality rate, after the initial high mortality of these patients. About one year post-injury, the life expectancy in our series appears to tend towards the values observed in the French population.

[Isolated tonic ambulatory flexion of the foot (author's transl)]. / Flexion tonique plantaire isolée.

A tonic ambulatory foot response developed one year after clamping of an aneurysm of the contralateral carotid artery in a young adult. No motor deficiency was noted during the postoperative period, but spasm of the carotid bifurcation branches were present on arteriograms. Clinical examination and deep reflexes tests excluded pyramidal lesions. Cortical somatesthetic evoked potential recordings confirmed the absence of sensory disturbances. CT scan suggested the presence of an infarct in the territory of the anterior choroidal artery. The present findings are compared with previous reports. The etiological data and CT scan results in the present case allow reconsideration of the physiopathology of tonic ambulatory foot response in the light of current knowledge of locomotor function in animals. The tonic flexion, an "extension" dystonia of the toes, electively provoked by walking, occurring one year after the neurological accident without any pyramidal signs, could arise from a coordination synkinesis due to lesions limited to the efferent extrapyramidal system.