A pilot rating system to evaluate the quality of goal attainment scales used as outcome measures in rehabilitation.

Goal Attainment Scaling (GAS) is a method for writing person-centred approach evaluation scales that can be used as an outcome measure in clinical or research settings in rehabilitation. To be used in a research setting, it requires a high methodological quality approach. The aim of this study was to explore the feasibility and reliability of the GAS quality rating system, to ensure that GAS scales used as outcome measures are valid and reliable. Secondary objectives were: (1) to compare goal attainment scores' reliability according to how many GAS levels are described in the scale; and (2) to explore if GAS scorings are influenced by who scores goal attainment. The GAS scales analysed here were set collaboratively by 57 cognitively impaired adults clients and their occupational therapist. Goals had to be achieved within an inpatient one-month stay, during which clients participated in an intervention aimed at improving planning skills in daily life. The GAS quality rating system proved to be feasible and reliable. Regarding GAS scores, interrater reliability was higher when only three of the five GAS levels were described, i.e., "three milestone GAS" (0.74-0.92), than when all five levels were described (0.5-0.88), especially when scored by the clients (0.5 -0.88).

Goal Attainment Scaling in rehabilitation: An educational review providing a comprehensive didactical tool box for implementing Goal Attainment Scaling.

CONTEXT: Goal Attainment Scaling (GAS) is a person-centered and collaborative approach, allowing to assess the effectiveness of an intervention on personally relevant goals. However, GAS is not a "scale" but a heterogeneous group of methodologies, including many variations and lack of consensus on high quality GAS. OBJECTIVE: The aim of this communication is to: 1. provide updated didactical information on GAS use in PRM practice and research; 2. increase awareness of GAS methodological challenges; 3. guide use of GAS as an integrated process of rehabilitation after goal setting and; 4. provide updated resources for self-directed learning and extensive supplemental material to increase knowledge and practical skills in GAS use. METHODS: Educational literature review about current GAS applications relevant to PRM fields. RESULTS: Practical advice is provided regarding clinical challenges in GAS: definition of 0 level, time-frame and means employed to attain the goal, dealing with unforeseen pattern of improvement, synthesizing the numerous significations of "SMART" goal acronym to guide best use of GAS, and thinking flexibility on the type of relevant goals that can be set. Challenges with GAS in rehabilitation research are presented in order to promote researcher's and reviewer's awareness on reliable use of GAS and encouraging best-use of GAS.

Charlie Chaplin and gesture training in severe aphasia: A controlled double-blind single-case experimental design.

BACKGROUND: Aphasia following a stroke is a frequent and disabling condition that decreases quality of life. The use of gesture has been proposed as a way to enhance aphasia recovery. OBJECTIVE: We aimed to explore whether 2 types of gesture interventions could improve communication in individuals with severe aphasia. METHODS: This was a pilot study performed at home in routine care by an outreach team. The study had a controlled double-blind single-case experimental design (SCED): a controlled multiple baseline design across 3 participants and 2 behaviors (gesture and naming). Three male patients with stroke-induced severe chronic aphasia, non-functional perseverative speech and severe associated impairments underwent a passive gesture intervention, in which participants watched movies selected for their intensive use of gesture, and an active gesture intervention, in which they actively practiced gestures by using visual action therapy. The main outcome measures were naming score, gesture score and nonverbal subscale score of the Lillois Test of Communication, with 3-month follow-up. RESULTS: In all 3 participants, gesture interventions improved the ability to gesture a list of words (Tau-U=0.38-0.67 for combined gesture intervention effect) and increased nonverbal communication activity. Benefits were maintained at 3-month follow-up. CONCLUSIONS: Mute films that use intensive nonverbal communication may be a useful add-on to speech therapy for individuals with aphasia. Improving naming in severe and chronic aphasia may not be feasible, and more effort could be devoted to improving gesture-based and nonverbal communication.

High-intensity downhill running exacerbates heart rate and muscular fatigue in trail runners.

This study explores the cardiorespiratory and muscular fatigue responses to downhill (DR) vs uphill running (UR) at similar running speed or similar oxygen uptake (⩒O2). Eight well-trained, male, trail runners completed a maximal level incremental test and three 15-min treadmill running trials at ±15% slope: i) DR at ~6 km·h-1 and ~19% ⩒O2max (LDR); ii) UR at ~6 km·h-1 and ~70% ⩒O2max (HUR); iii) DR at ~19 km·h-1 and ~70% ⩒O2max (HDR). Cardiorespiratory responses and spatiotemporal gait parameters were measured continuously. Maximal isometric torque was assessed before and after each trial for hip and knee extensors and plantar flexor muscles. At similar speed (~6 km·h-1), cardiorespiratory responses were attenuated in LDR vs HUR with altered running kinematics (all p < 0.05). At similar ⩒O2 (~3 l·min-1), heart rate, pulmonary ventilation and breathing frequency were exacerbated in HDR vs HUR (p < 0.01), with reduced torque in knee (-15%) and hip (-11%) extensors and altered spatiotemporal gait parameters (all p < 0.01). Despite submaximal metabolic intensity (70% ⩒O2max), heart rate and respiratory frequency reached maximal values in HDR. These results further our understanding of the particular cardiorespiratory and muscular fatigue responses to DR and provide the bases for future DR training programs for trail runners.

Trail Runners Cannot Reach V˙O2max during a Maximal Incremental Downhill Test.

PURPOSE: The purpose of this study was twofold: (i) determine if well-trained athletes can achieve similar peak oxygen uptake (V˙O2peak) in downhill running (DR) versus level running (LR) or uphill running (UR) and (ii) investigate if lower limb extensor muscle strength is related to the velocity at V˙O2peak (vV˙O2peak) in DR, LR, and UR. METHODS: Eight athletes (V˙O2max = 68 ± 2 mL·min·kg) completed maximal incremental tests in LR, DR (-15% slope), and UR (+15% slope) on a treadmill (+1, +1.5, and +0.5 km·h every 2 min, respectively) while cardiorespiratory responses and spatiotemporal running parameters were continuously measured. They were also tested for maximal voluntary isometric strength of hip and knee extensors and plantar flexors. RESULTS: Oxygen uptake at maximal effort was approximately 16% to 18% lower in DR versus LR and UR (~57 ± 2 mL·min·kg, 68 ± 2 mL·min·kg, and 70 ± 3 mL·min·kg, respectively) despite much greater vV˙O2peak (22.7 ± 0.6 km·h vs 18.7 ± 0.5 km·h and 9.3 ± 0.3 km·h, respectively). At vV˙O2peak, longer stride length and shorter contact time occurred in DR versus LR and UR (+12%, +119%, -38%, and -61%, respectively). Contrary to knee extensor and plantar flexor, hip extensor isometric strength correlated to vV˙O2peak in DR, LR, and UR (r = -0.86 to -0.96, P < 0.05). At similar V˙O2, higher heart rate and ventilation emerged in DR versus LR and UR, associated with a more superficial ventilation pattern. CONCLUSIONS: This study demonstrates that well-trained endurance athletes, accustomed to DR, achieved lower V˙O2peak despite higher vV˙O2peak during DR versus LR or UR maximal incremental tests. The specific heart rate and ventilation responses in DR might originate from altered running gait and increased lower-limb musculotendinous mechanical loading, furthering our understanding of the particular physiology of DR, ultimately contributing to optimize trail race running performance.

Cardiorespiratory Responses to Downhill Versus Uphill Running in Endurance Athletes.

PURPOSE: Mountain running races are becoming increasingly popular, although our understanding of the particular physiology associated with downhill running (DR) in trained athletes remains scarce. This study explored the cardiorespiratory responses to high-slope constant velocity uphill running (UR) and DR. METHOD: Eight endurance athletes performed a maximal incremental test and 2 15-min running bouts (UR, +15%, or DR, -15%) at the same running velocity (8.5 ± 0.4 km·h-1). Oxygen uptake ([Formula: see text]O2), heart rate (HR), and ventilation rates ([Formula: see text]E) were continuously recorded, and blood lactate (bLa) was measured before and after each trial. RESULTS: Downhill running induced a more superficial [Formula: see text]E pattern featuring reduced tidal volume (p < .05, ES = 6.05) but similar respiratory frequency (p > .05, ES = 0.68) despite lower [Formula: see text]E (p < .05, ES = 5.46), [Formula: see text]O2 (p < .05, ES = 12.68), HR (p < .05, ES = 6.42), and bLa (p < .05, ES = 1.70). A negative slow component was observed during DR for [Formula: see text]O2 (p < .05, ES = 1.72) and HR (p < .05, ES = 0.80). CONCLUSIONS: These results emphasize the cardiorespiratory responses to DR and highlight the need for cautious interpretation of [Formula: see text]O2, HR, and [Formula: see text]E patterns as markers of exercise intensity for training load prescription and management.

High-intensity interval training combined with resistance training improves physiological capacities, strength and quality of life in multiple sclerosis patients: a pilot study.

BACKGROUND: Numerous studies have shown that mild-to-moderate intensity or resistance exercise training improves physical capacities such as, peak oxygen consumption, maximal tolerated power and strength in multiple sclerosis patients. However, few studies have evaluated the effects of high-intensity interval training (HIIT) associated to with resistance training. Only few studies have analyzed difference between men and women before and after combined training. Moreover, the evaluation of exercise between ambulatory multiple sclerosis patients without disability (Expanded Disability Status Score [EDSS] 0-3) and patients with disabilities (EDSS 3.5-5) was not largely published. AIM: The main objective of our study was to determine if HIIT combined with resistance training improved aerobic and strength capacities as well as quality of life in multiple sclerosis patients and if gender and disabilities play a role in these changes. DESIGN: This study was an open-label uncontrolled study. SETTING: The study was performed outside from conventional care facilities and including homebased training. POPULATION: Twenty-six multiple sclerosis patients have completed the program (19 women, 7 men; mean age 44.6±7.9 years, EDSS 2 [0-5]). METHODS: We conducted a 12-week program of high-intensity interval training combined with resistance training at body weight. Peak oxygen consumption, maximal tolerated power, lactates, isokinetic strength of quadriceps and hamstrings (at 90°/s, 180°/s, and 240°/s) and quality of life were evaluated before and after the program. RESULTS: Peak oxygen consumption and maximum tolerated power improved by 13.5% and 9.4%, respectively. Isokinetic muscle strength increased in both quadriceps and hamstrings at each speed, with a rebalancing of strength between the two legs in quadriceps. Quality of life was also enhanced in three domains. Women showed better improvements than men in V̇O2peak, maximal tolerated power, lactates at the end of test, and heart rate peak, strength in both quadriceps and hamstrings mostly at low speed, and quality of life. The two EDSS groups increased V̇O2peak and strength. CONCLUSIONS: Our study has shown that HIIT combined with resistance exercise training induced an improvement in physical capacity and quality of life. Moreover, this study allowed patients, irrespective of their sex or EDSS score, to resume exercise autonomously. CLINICAL REHABILITATION IMPACT: The results of the study showed that aerobic training at moderate intensity is not the single type of training tolerated by multiple sclerosis patients. High-intensity interval training is well tolerated too and can be used in clinical rehabilitation with resistance training, in both men and women with and without disabilities.

Lasting relief of chronic anterior knee pain in young adult after ten weekly inductive physiotherapy sessions: A case report.

BACKGROUND: Patellofemoral pain syndrome particularly impairs quality of life in young, physically active subjects. The exact etiology remains unknown, and so this syndrome is a challenging condition to treat. Some patients continue to experience pain and dysfunction after receiving one or more guidelines-compliant conservative treatments. Reducing the likelihood of patellofemoral pain syndrome is an important way of preventing the onset of debilitating anterior knee pain at all ages of life. CASE: A 24-year-old sportswoman with a 15-month history of anterior knee pain and failure of previous guidelines-compliant treatments. We treated this patient with techniques derived from the paradigm of inductive physiotherapy, in which tone disorders with a central origin may contribute to musculoskeletal disorders. One distinctive feature of inductive physiotherapy relates to the fact that the painful area is not manipulated directly. RESULTS: The effects of physiotherapy were evaluated after ten weekly sessions and then 15 months later. The changes in the visual analogue pain scale score and the Knee Lequesne Index were clinically significant. We also observed an unexpected reduction in the static varus misalignment. CONCLUSION: This case could pave the way to an innovative neurological approach to the management of patellofemoral pain syndrome in the young adult.

Comparative assessment of knee extensor and flexor muscle strength measured using a hand-held vs. isokinetic dynamometer.

[Purpose] To compare measurements of knee extensor and flexor muscle strength performed using a hand-held dynamometer and an isokinetic dynamometer in apparently healthy subjects. [Subjects and Methods] Thirty adult volunteers underwent knee muscle strength evaluation using an isokinetic or a hand-held dynamometer. [Results] Strong positive correlations were found between the 2 methods, with correlation coefficients r ranging from 0.72 (95% confidence interval [CI], 0.48-0.86) to 0.87 (95% CI, 0.75-0.94), depending on the muscle group and the isokinetic evaluation mode. The reproducibility of the hand-held dynamometer findings was good, judged by a coefficient of variation of 3.2-4.2%. However, the correlation between the 2 methods for the assessment of flexor/extensor ratios ranged from -0.04 to 0.46. [Conclusion] Knee extensor and flexor muscle strength recorded with a hand-held dynamometer is reproducible and significantly correlated with the isokinetic values, indicating that this method may in some cases be a useful replacement for isokinetic strength measurement. However, for strength ratio assessment, and when judged against the isokinetic standard, a hand-held dynamometer is not a valid option.

High-Force Versus Low-Force Lumbar Traction in Acute Lumbar Sciatica Due to Disc Herniation: A Preliminary Randomized Trial.

OBJECTIVE: This study compared the effects of high-force versus low-force lumbar traction in the treatment of acute lumbar sciatica secondary to disc herniation. METHODS: A randomized double blind trial was performed, and 17 subjects with acute lumbar sciatica secondary to disc herniation were assigned to high-force traction at 50% body weight (BW; LT50, n = 8) or low force traction at 10% BW (LT10, n = 9) for 10 sessions in 2 weeks. Radicular pain (visual analogue scale [VAS]), lumbo-pelvic-hip complex motion (finger-to-toe test), lumbar-spine mobility (Schöber-Macrae test), nerve root compression (straight-leg-raising test), disability (EIFEL score), drug consumption, and overall evaluation of each patient were measured at days 0, 7, 1, 4, and 28. RESULTS: Significant (P < .05) improvements were observed in the LT50 and LT10 groups, respectively, between day 0 and day 14 (end of treatment) for VAS (-44% and -36%), EIFEL score (-43% and -28%) and overall patient evaluation (+3.1 and +2.0 points). At that time, LT50 specifically improved in the finger-to-toe test (-42%), the straight-leg-raising test (+58), and drug consumption (-50%). No significant interaction effect (group-by-time) was revealed, and the effect of traction treatment was independent of the level of medication. During the 2-week follow-up at day 28, only the LT10 group improved (P < .05) in VAS (-52%) and EIFEL scores (-46%). During this period, no interaction effect (group-by-time) was identified, and the observed responses were independent of the level of medication. CONCLUSIONS: For this preliminary study, patients with acute lumbar sciatica secondary to disc herniation who received 2 weeks of lumbar traction reported reduced radicular pain and functional impairment and improved well-being regardless of the traction force group to which they were assigned. The effects of the traction treatment were independent of the initial level of medication and appeared to be maintained at the 2-week follow-up.

Mitochondrial function following downhill and/or uphill exercise training in rats.

INTRODUCTION: The goal of this study was to compare the effects of downhill (DH), uphill (UH), and UH-DH exercise training, at the same metabolic rate, on exercise capacity and skeletal muscle mitochondrial function. METHODS: Thirty-two Wistar rats were separated into a control and 3 trained groups. The trained groups exercised for 4 weeks, 5 times per week at the same metabolic rate, either in UH, DH, or combined UH-DH. Twenty-four hours after the last training session, the soleus, gastrocnemius, and vastus intermedius muscles were removed for assessment of mitochondrial respiration. RESULTS: Exercise training, at the same metabolic rate, improved maximal running speed without specificity for exercise modalities. Maximal fiber respiration was enhanced in soleus and vastus intermedius in the UH group only. CONCLUSIONS: Exercise training, performed at the same metabolic rate, improved exercise capacity, but only UH-trained rats enhanced mitochondrial function in both soleus and vastus intermedius skeletal muscle. Muscle Nerve 54: 925-935, 2016.

Effect of a kneeling chair on lumbar curvature in patients with low back pain and healthy controls: A pilot study.

BACKGROUND: The concept of an ideal sitting posture is often used in practice but lacks a basis in evidence. OBJECTIVE: We designed a cross-sectional, comparative, matched study to determine the effects of chair and posture on lumbar curvature in 10 patients with chronic non-specific low back pain (CLBP; mean pain duration 24 ± 18 months) and 10 healthy matched controls. METHODS: Pelvic incidence, sacral slope and lumbar curvature were measured on computed radiographs by 2 blinded clinicians for subjects in 2 postures (upright vs slumped sitting) and on 2 chairs (usual flat chair vs kneeling chair). RESULTS: The reliability of measures was excellent (intraclass correlation coefficient>0.9). As hypothesized, the expected sacral slope and lumbar lordosis changed between standing and sitting on a kneeling chair as compared with a usual chair (P<0.0001) and less in patients than controls (P=0.046) for lordosis only. In addition, as expected, changes were more pronounced with slumped than upright sitting (P<0.0001). An interaction between chairs and postures for lumbar lordosis (P=0.02) indicated more pronounced effects of the chair in slumped sitting. Therefore, lumbar lordosis was reduced less when sitting on a kneeling chair as compared with a usual chair. CONCLUSIONS: Although healthy subjects showed more reduction in lordosis between standing and sitting, the chair effect was found in both CLBP patients and healthy subjects.

Botulinum toxin as a treatment for functional popliteal artery entrapment syndrome.

PURPOSE: Functional popliteal artery entrapment syndrome is responsible for exercise-induced muscle leg pain. This syndrome is caused, in most of the cases, by the excessive size of the gastrocnemius muscles. Currently, its treatment is based only on surgery with variable results. METHODS: We report the case of a young professional soldier in a combat unit with bilateral functional popliteal artery entrapment syndrome that was confirmed by dynamic arteriography, magnetic resonance angiography, and ultrasonography and did not improve after bilateral popliteal arteriolysis without resection of the gastrocnemius medial head. Treatment by injecting botulinum toxin in the proximal part of the gastrocnemius muscles was proposed and carried out. RESULTS: Regular follow-up (from 1 month to 3 yr after botulinum toxin treatment) showed the disappearance of exercise-induced pain and the improvement of the patient's physical and sports performance. Results of follow-up ultrasonography during dynamic maneuvers at 2.5 months and 2 yr after botulinum toxin injection were normal. Neither adverse effects nor motor deficit of the gastrocnemius muscles was reported. CONCLUSIONS: This case report suggests that botulinum toxin treatment could be an alternative to surgery for patients with functional popliteal artery entrapment syndrome. Botulinum toxin could reduce functional compression and, consequently, exercise-induced pain by decreasing the volume of the gastrocnemius muscle.

Effect of eccentric versus concentric exercise training on mitochondrial function.

INTRODUCTION: The effect of eccentric (ECC) versus concentric (CON) training on metabolic properties in skeletal muscle is understood poorly. We determined the responses in oxidative capacity and mitochondrial H2 O2 production after eccentric (ECC) versus concentric (CON) training performed at similar mechanical power. METHODS: Forty-eight rats performed 5- or 20-day eccentric (ECC) or concentric (CON) training programs. Mitochondrial respiration, H2 O2 production, citrate synthase activity (CS), and skeletal muscle damage were assessed in gastrocnemius (GAS), soleus (SOL) and vastus intermedius (VI) muscles. RESULTS: Maximal mitochondrial respiration improved only after 20 days of concentric (CON) training in GAS and SOL. H2 O2 production increased specifically after 20 days of eccentric ECC training in VI. Skeletal muscle damage occurred transiently in VI after 5 days of ECC training. CONCLUSIONS: Twenty days of ECC versus CON training performed at similar mechanical power output do not increase skeletal muscle oxidative capacities, but it elevates mitochondrial H2 O2 production in VI, presumably linked to transient muscle damage.

Cryopreservation with dimethyl sulfoxide prevents accurate analysis of skinned skeletal muscle fibers mitochondrial respiration.

Impact of cryopreservation protocols on skeletal muscle mitochondrial respiration remains controversial. We showed that oxygen consumption with main mitochondrial substrates in rat skeletal muscles was higher in fresh samples than in cryopreserved samples and that this difference was not fixed but grow significantly with respiration rates with wide fluctuations around the mean difference. Very close results were observed whatever the muscle type and the substrate used. Importantly, the deleterious effects of ischemia-reperfusion observed on fresh samples vanished when cryopreserved samples were studied. These data demonstrate that this technic should probably be performed only extemporaneously.

Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study.

BACKGROUND: Botulinum toxin A (BoNT-A) is used in the treatment of muscle hypertrophy but has never been used in chronic exertional compartment syndrome (CECS). The objective diagnostic criterion in this condition is an abnormally elevated intramuscular pressure (IMP) in the compartment. In this study, the IMP was measured 1 minute (P1) and 5 minutes (P5) after the exercise was stopped before and after BoNT-A injection. HYPOTHESIS: Botulinum toxin A reduces the IMP (P1 and P5) and eliminates the pain associated with CECS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Botulinum toxin A was injected into the muscles of moderately trained patients with an anterior or anterolateral exertional compartment syndrome of the leg. The BoNT-A dose (mean ± SD) ranged from 76 ± 7 to 108 ± 10 U per muscle, depending on which of the 5 muscles in the 2 compartments were injected. The primary end point was IMP (P1, P5). Secondary end points were exertional pain, muscle strength, and safety. Follow-up was conducted up to 9 months. RESULTS: A total of 25 anterior compartments and 17 lateral compartments were injected in 16 patients. The time interval (mean ± SD) between the BoNT-A injection and after BoNT-A injection IMP measurement was 4.4 ± 1.6 months (range, 3-9 months). In the anterior compartment, P1 and P5 fell by 63% ± 17% (P < .00001) and 59% ± 24% (P < .0001), respectively; in the lateral compartment, P1 and P5 fell by 68% ± 21% (P < .001) and 63% ± 21% (P < .01), respectively. Exertional pain and muscle strength were monitored, based on the Medical Research Council score. The exertional pain was completely eliminated in 15 patients (94%). In 5 patients (31%), the strength of the injected muscles remained normal. In 11 patients (69%), strength decreased from 4.5 (out of 5) to 3.5 (P < .01), although without functional consequences. In the conditions of this study, BoNT-A showed a good safety profile in patients with CECS. CONCLUSION: In this case series, BoNT-A reduced the IMP and eliminated exertional pain in anterior or anterolateral CECS of the leg for up to 9 months after the intervention. The mode of action of BoNT-A is still unclear. A randomized controlled study should be carried out to determine whether BoNT-A can be used as a medical alternative to surgical treatment.

Eccentric exercise training: modalities, applications and perspectives.

Eccentric (ECC) exercise is classically used to improve muscle strength and power in healthy subjects and athletes. Due to its specific physiological and mechanical properties, there is an increasing interest in employing ECC muscle work for rehabilitation and clinical purposes. Nowadays, ECC muscle actions can be generated using various exercise modalities that target small or large muscle masses with minimal or no muscle damage or pain. The most interesting feature of ECC muscle actions is to combine high muscle force with a low energy cost (typically 4- to 5-times lower than concentric muscle work) when measured during leg cycle ergometry at a similar mechanical power output. Therefore, if caution is taken to minimize the occurrence of muscle damage, ECC muscle exercise can be proposed not only to athletes and healthy subjects, but also to individuals with moderately to severely limited exercise capacity, with the ultimate goal being to improve their functional capacity and quality of life. The first part of this review article describes the available exercise modalities to generate ECC muscle work, including strength and conditioning exercises using the body's weight and/or additional external loads, classical isotonic or isokinetic exercises and, in addition, the oldest and newest specifically designed ECC ergometers. The second part highlights the physiological and mechanical properties of ECC muscle actions, such as the well-known higher muscle force-generating capacity and also the often overlooked specific cardiovascular and metabolic responses. This point is particularly emphasized by comparing ECC and concentric muscle work performed at similar mechanical (i.e., cycling mechanical power) or metabolic power (i.e., oxygen uptake, VO2). In particular, at a similar mechanical power, ECC muscle work induces lower metabolic and cardiovascular responses than concentric muscle work. However, when both exercise modes are performed at a similar level of VO2, a greater cardiovascular stress is observed during ECC muscle work. This observation underlines the need of cautious interpretation of the heart rate values for training load management because the same training heart rate actually elicits a lower VO2 in ECC muscle work than in concentric muscle work. The last part of this article reviews the documented applications of ECC exercise training and, when possible, presents information on single-joint movement training and cycling or running training programs, respectively. The available knowledge is then summarized according to the specific training objectives including performance improvement for healthy subjects and athletes, and prevention of and/or rehabilitation after injury. The final part of the article also details the current knowledge on the effects of ECC exercise training in elderly populations and in patients with chronic cardiac, respiratory, metabolic or neurological disease, as well as cancer. In conclusion, ECC exercise is a promising training modality with many different domains of application. However, more research work is needed to better understand how the neuromuscular system adapts to ECC exercise training in order to optimize and better individualize future ECC training strategies.

Factitious torsion dystonia in rehabilitation: a singular new case and literature review.

We report a case of a 29-year-old woman suffering from chronic factitious disorder (FD) with torsion dystonia. For nearly five years, she traveled widely over the country, going from one hospital to another, taking serious medical risk in order to prolong her illness. After several admissions to Rehabilitation Units and multiple explorations, we find convincing evidence for factitious origin and the diagnosis of Munchausen syndrome was evoked. Such a clinical presentation is infrequent in Munchausen's syndrome. Indeed, most often the clinical picture is characterized by acute abdominal pain, fainting, hemoptysis, precordialgia, hematemesis or dermatological lesions. Physicians should be aware of this rare and potentially critical form of FD. Awareness in identifying these patients may lead to prevent unnecessary medical and/or surgical interventions.

Sciatica, disk herniation, and neuroborreliosis. A report of four cases.

We report four cases of sciatica in patients with same-level disk herniation confirmed by computed tomography and a final diagnosis of acute radiculitis caused by Borrelia burgdorferi, with a favorable response to ceftriaxone therapy. The neurological manifestations of Lyme disease are protean, and a potential contribution of concomitant disk disease to sciatica can lead to diagnostic wanderings. Disk lesions and infectious conditions that can cause sciatica are discussed. Whether a favorable response to antibiotic therapy should be taken as proof of B. burgdorferi radiculitis deserves discussion. In practice, in a patient with clinical manifestations suggesting disk-related nerve root pain and residing or having traveled to an endemic area, B. burgdorferi infection should be looked for, as both etiologies can coexist.