Pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminary study.

Acetabular cup orientation (inclination and anteversion) is a fundamental topic in orthopaedics and depends on pelvis tilt (positional parameter) emphasising the notion of a safe range of pelvis tilt. The hypothesis was that pelvic incidence (morphologic parameter) could yield a more accurate and reliable assessment than pelvis tilt. The aim was to find out a predictive equation of acetabular 3D orientation parameters which were determined by pelvic incidence to include in the model. The second aim was to consider the asymmetry between the right and left acetabulae. Twelve pelvic anatomic specimens were measured with an electromagnetic Fastrak system (Polhemus Society) providing 3D position of anatomical landmarks to allow measurement of acetabular and pelvic parameters. Acetabulum and pelvis data were correlated by a Spearman matrix. A robust linear regression analysis provided prediction of acetabulum axes. The orientation of each acetabulum could be predicted by the incidence. The incidence is correlated with the morphology of acetabula. The asymmetry of the acetabular roof was correlated with pelvic incidence. This study allowed analysis of relationships of acetabular orientation and pelvic incidence. Pelvic incidence (morphologic parameter) could determine the safe range of pelvis tilt (positional parameter) for an individual and not a group.

Systems medicine approaches for the definition of complex phenotypes in chronic diseases and ageing. From concept to implementation and policies.

Chronic diseases are diseases of long duration and slow progression. Major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, rheumatologic diseases and mental health) represent the predominant health problem of the Century. The prevention and control of NCDs are the priority of the World Health Organization 2008 Action Plan, the United Nations 2010 Resolution and the European Union 2010 Council. The novel trend for the management of NCDs is evolving towards integrative, holistic approaches. NCDs are intertwined with ageing. The European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has prioritised NCDs. To tackle them in their totality in order to reduce their burden and societal impact, it is proposed that NCDs should be considered as a single expression of disease with different risk factors and entities. An innovative integrated health system built around systems medicine and strategic partnerships is proposed to combat NCDs. It includes (i) understanding the social, economic, environmental, genetic determinants, as well as the molecular and cellular mechanisms underlying NCDs; (ii) primary care and practice-based interprofessional collaboration; (iii) carefully phenotyped patients; (iv) development of unbiased and accurate biomarkers for comorbidities, severity and follow up of patients; (v) socio-economic science; (vi) development of guidelines; (vii) training; and (viii) policy decisions. The results could be applicable to all countries and adapted to local needs, economy and health systems. This paper reviews the complexity of NCDs intertwined with ageing. It gives an overview of the problem and proposes two practical examples of systems medicine (MeDALL) applied to allergy and to NCD co-morbidities (MACVIA-LR, Reference Site of the European Innovation Partnership on Active and Healthy Ageing).

Effect of coordination biofeedback on (re)learning preferred postural patterns in post-stroke patients.

After stroke, ankle-hip coordination during stance is characterized by changes in the postural system dynamics, specifically the disappearance of the in-phase pattern and the reduced stability of the anti-phase pattern. This study was conducted to assess the success of a coordination visual biofeedback for the (re)learning of the two preferred patterns, and to explore the effect of this treatment on postural and functional abilities. Twenty four patients were randomly assigned to one of two experimental groups or to a control group. During one month, patients from experimental groups followed a training protocol on the two preferred postural patterns using the biofeedback device. These two groups improved their in-phase coordination after the (re)learning compared with control group, and showed a related improvement of the functional independence measure. Results suggest that (re)learning the in-phase pattern is possible and seems to improve independence in poststroke patients.

Heterogeneous assessment of shoulder disorders: validation of the Standardized Index of Shoulder Function.

OBJECTIVE: Although 40 assessment tools are described in the literature, very few of them have been correctly validated. The Standardized Index of Shoulder Function (FI2S) encompasses pain, mobility, strength and function. The aim of this work is to describe the FI2S and to study its construct validity, reliability and responsiveness to change. PATIENTS: Fifty-nine patients with non-surgical (rotator cuff lesions, frozen shoulders, osteoarthritis) or post-surgical (acromioplasty, repairs of rotator cuff tears, arthroplasty) shoulder disorders were included. METHODS: The FI2S was compared with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), with the Constant-Murley Score (CMS), and with a visual analogue scale for pain. RESULTS: Inter-test reliability and inter-rater reliability are excellent, with intra-class correlation coefficient of 0.93 (0.88-0.96) and 0.94 (0.90-0.96), respectively. Under a convergent hypothesis, the Spearman's correlation coefficients with the CMS and DASH score are 0.91 (p < 0.0001) and -0.64 (p < 0.0001), respectively. Correlations between the FI2S and the CMS are excellent for mobility and strength, but moderate for pain and functional capacities. Under a divergent hypothesis, no correlation is observed between the FI2S total score and age. Responsiveness to change is excellent. CONCLUSION: The FI2S appears to be a proper assessment tool for pain, mobility, strength and function in shoulder disorders, easy to administer and of good metric value.

Changes in preferred postural patterns following stroke during intentional ankle/hip coordination.

We compared the spatio-temporal postural organization between stroke patients and healthy controls in a bipedal standing task where participants had to intentionally produce two specific ankle/hip coordination patterns: in-phase and anti-phase. The pattern to reproduce was visually represented by a ankle-hip Lissajous figure, and a real-time biofeedback displayed the current coordination sur-imposed to the expected coordination. Contrary to the healthy participants who were successful at reproducing the two patterns, stroke patients were unable to produce the in-phase pattern. In addition, when the anti-phase pattern was required, a reduction of stability was observed for the stroke group. The impairment of postural capacities following stroke was thus accompanied by a disappearance of one of the two preferred patterns found in healthy participants, a result that have consequences for understanding the etiology of postural pattern formation and the elaboration of rehabilitation programs.

The management of stroke patients. Conference of experts with a public hearing. Mulhouse (France), 22 October 2008.

The objective is to define as early as possible appropriate criteria for managing patients who have had a cerebrovascular accident (CVA), or stroke, beginning in the Neurovascular and Acute Care Services, in order to facilitate the patient's return home (or the equivalent of home) or continuing care in the most appropriate health care facility.

Sensitivity to change of two depression rating scales for stroke patients.

OBJECTIVE: To assess the sensitivity to change of two depression scales for stroke patients: the Aphasic Depression Rating Scale (ADRS), which is a 9-item external assessment, and the Visual Analog Mood Scale (VAMS), which is a visual self-assessment scale. PATIENTS: Forty-nine stroke patients admitted to two rehabilitation units. METHODS: Symptoms of depression were assessed twice at a one-month interval (D0-D30) using the ADRS, the VAMS, and by a trained psychologist (PSY). Sensitivity to change was assessed by effect size and standardized response mean. A one-way ANOVA on ranks was performed to determine if the scales distinguished between deteriorated, stable and improved patient status. Spearman's correlation coefficient (r) was used to assess the relationship between changes in PSY and changes in the ADRS and the VAMS between D0 and D30. RESULTS: Mean depression scores at D0 and D30 were 2.6 +/- 1.8 and 2.4 +/- 1.7 (ADRS/10), 3.1 +/- 2.9 and 3.0 +/- 3.2 (VAMS/10), 2.9 +/- 2.3 and 2.4 +/- 2.4 (PSY/10). Percentages of deteriorated, stable and improved patient status were 22%, 45% and 33% (ADRS); 41%, 22% and 37% (VAMS); and 20%, 41% and 39% (PSY). Changes in PSY correlated with the ADRS (r = 0.72, P<10( -6)) and the VAMS (r = 0.41, P<10(- 2)). The ADRS was better than the VAMS in terms of effect size, standardized response mean and ability to discriminate between deteriorated, stable and improved patient status. This result was partly due to the difficulty encountered by nine (19%) patients in understanding directions to complete the VAMS. CONCLUSIONS: The ADRS is more sensitive than the VAMS for detecting changes in post-stroke depression. The VAMS is less appropriate in very cognitively impaired stroke patients.

Painful camptocormia: the relevance of shaking your patient's hand.

Camptocormia is an abnormal posture with marked flexion of thoracolumbar spine that abates in the recumbent position. Camptocormia has been described in various neurological (Parkinsonism), muscular (myopathy), psychogenic or orthopedic disorders. There are several hypotheses that can explain this impaired posture but they are usually related to the concomitant pathologies. We report the first case of a patient with confirmed myotonic dystrophy addressed to our medical center for impaired posture who underwent extensive medical exams and explorations because of a myotonic hand. Axial weakness and muscle atrophy, validated by CT-scan imaging, are discussed independent of the concomitant pathology (Parkinson, myopathy).

Influence of back muscle fatigue on lumbar reflex adaptation during sudden external force perturbations.

There is still conflicting evidence about the influence of fatigue on trunk reflex activity. The aim of this study was to measure response latency and amplitude changes of lumbar and abdominal muscles after heavy external force perturbation applied to the trunk in the sagittal plane before and after back muscle fatigue, in expected and unexpected conditions. Ten healthy subjects in a semi-seated position, torso upright in a specific apparatus performed an intermittent back muscle fatigue protocol. EMG reflex activity of erector spinae (ES) and external oblique muscles were recorded in unexpected and in expected (self pre-activation) conditions. After fatigue, the normalized reflex amplitude of ES increased in expected and unexpected conditions (P<0.05) while ES response latency was slightly decreased. Reflexes latencies for ES were systematically shorter (P<0.05) of 25% in expected compared to unexpected conditions. These findings suggest that a large external force perturbation would elicit higher paraspinal magnitude responses and possible earlier activation in order to compensate the loss of muscular force after fatigue. Because of the seated position the postural adjustments were probably not triggered and thus explain the lack of abdominal activation. The self-anticipated pre-activation in order to counteract perturbations was not affected by fatigue illustrating the natural muscular activation to maintain trunk stability.

Muscle oxygenation and intramuscular pressure related to posture and load in back muscles.

BACKGROUND CONTEXT: There is little information about the simultaneous changes of intramuscular pressure (IMP) and oxygen saturation (StO(2)) of the paraspinal muscle under various conditions of posture and load. PURPOSE: To measure simultaneously and compare IMP and StO(2) across a range of static trunk postures commonly observed during normal work tasks. STUDY DESIGN: A prospective study using a repeated-measure design in clinical setting. PATIENT SAMPLE: Sixteen healthy young men with no history of back pain. OUTCOME MEASURES: Simultaneous measurements of IMP by a flexible slit catheter and StO(2) by near infrared spectroscopy of the multifidus muscle were performed. METHODS: The two measures were taken in six static posture tasks: standing upright and bending forward with and without load (20kg), bending backward and during a sustained isometric contraction (ie, Sorensen test). To compare the influence of the tasks on IMP and StO(2) variables, a one-way variance analysis with repeated measures was used. Spearman's rank correlation coefficient (rho) was determined between the two variables for each posture task. RESULTS: We observed only a moderate but significant correlation between IMP and StO(2) values in upright standing and a trend in bending forward positions with load (p<.05). IMP increased in the bending backward position and showed the greatest increase during the Sorensen test. StO(2) decreased significantly during the Sorensen test, in the bending forward position with and without load bearing but did not in bending backward. CONCLUSION: The simultaneous recording of IMP and StO(2) of the multifidus muscle allows a deeper insight of physiological events during various trunk postures. In the mutifidus muscle, there is no evident linear relationship between IMP and StO(2) values in various static postures of the trunk in young males. This preliminary study shows that IMP may play a role on StO(2) only in some circumstances, such as a prolonged endurance test or in a bending forward position with a significant load bearing.

Reproducibility of transcutaneous oxygen pressure measurements in persons with spinal cord injury.

OBJECTIVES: To assess the reproducibility and the effects of the subjects' characteristics on the reproducibility of transcutaneous oxygen pressure (TcPO2) measurements in the sacral area in persons with spinal cord injury during loading in the supine position. DESIGN: Test-retest study. SETTING: Physical medicine and rehabilitation center. PARTICIPANTS: Thirty spinal cord-injured American Spinal Injury Association grade A subjects. MAIN OUTCOME MEASURES: Two TcPO2 monitoring sessions in the sacral area during loading in the supine position were performed at 24-hour intervals, including the measurement of absolute resting sacral and chest TcPO2 values and the calculation of regional perfusion index (RPI) and delta from rest oxygen pressure, taking into account systemic TcPO2 changes. RESULTS: The intraclass coefficient of the sacral TcPO2 absolute resting value, RPI, and delta from rest oxygen pressure was .787 and .798, .704 and .635, .760 and .465, respectively, at 20 and 40 minutes. The only characteristic with an influence on RPI reproducibility was the subject's smoking status, whereas age, weight, time since injury, lesion level, and presence of pressure ulcer showed no influence. CONCLUSIONS: TcPO2 measurement is a reproducible method for assessing cutaneous microcirculation during loading over 20-minute monitoring sessions, with RPI exhibiting better reproducibility than delta from rest oxygen pressure at 40 minutes.

Perineal descent predicted by a pelvic bone factor: the pelvic incidence angle.

PURPOSE: By measuring the pelvic incidence angle, we assessed the relationship between pelvic floor disorders and pelvic morphology, which allowed us to document for the first time the hypothesis that pelvic incidence may be a predictive factor of perineal descent. METHODS: In a retrospective study of 197 women, the perineal descent at rest and during straining was assessed by defecography. The pelvic incidence angle (53 degrees +/- 9 degrees , independent of the subject position) was defined as the angle between the line perpendicular to the sacral plate at its midpoint and the line connecting this point to the middle of the femoral heads axis. The pelvic incidence angle was correlated with the incidence of pelvic floor descent. RESULTS: In those with pelvic floor descent at rest compared with those without, pelvic incidence angle was significantly larger (64 degrees vs. 53 degrees , P < 10E-06). As a predictive factor of perineal descent at rest, a great pelvic incidence (>62 degrees ) had a sensitivity (73 percent), specificity (82 percent), positive predictive value (81 percent), and negative predictive value (75 percent). CONCLUSIONS: A large pelvic incidence (>62 degrees ) may be a predictive factor of perineal descent at rest before the apparition of other acquired factors. With pelvic incidence >62 degrees , a large overhang between the insertions increases the strains on the perineum, which is rather horizontal.

[Peripheral nerve blocks and spasticity. Why and how should we use regional blocks?]. / Prise en charge des spasticités douloureuses: pourquoi et comment utiliser les blocs locorégionaux?

Muscle spasticity causes pain, disability, and difficulties in the rehabilitation of patients with cerebrovascular lesions, head, brain or spine trauma, coma, or neurologic diseases such as multiple sclerosis, amyotrophic lateral sclerosis, or cerebral palsy. Regional blocks have a threefold use in patients with painful spasticity: diagnostic, prognostic, and therapeutic. Blocks are feasible on an outpatient or day-hospital basis. Blocks are applied most often to 4 peripheral sites: the pectoral nerve loop, median, obturator, and tibial nerves. The main indication is debilitating or painful spasticity. Peripheral blocks with local anesthetics are used as tests, to mimic the effects of motor blocks and determine their potential adverse effects, transiently and reversibly. Peripheral neurolytic blocks are easy to perform, effective, and inexpensive.

Is there an evidence-based efficacy for the use of foot orthotics in knee and hip osteoarthritis? Elaboration of French clinical practice guidelines.

OBJECTIVE: To develop clinical practice guidelines for the use of foot orthotics (FO) in the treatment of knee and hip osteoarthritis. METHOD: The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating a systematic review of the literature, input from every day clinical practice and external review by a multidisciplinary expert committee, was used. The selected analysis criteria were pain, disability, medications used and X-ray evolution of osteoarthritis. The recommendations are classified according to the level of proof in Grade A, B or C according to the French National Agency for Health Accreditation and Evaluation (NAHAE). RESULTS: In medial knee osteoarthritis, foot pronation orthotics--when there are no contraindications--can be proposed for their symptomatic impact, especially in the decrease of NSAIDs consumption (Grade B). To this day, there is no evidence of a structural or functional impact on osteoarthritis (Grade B). Outside of this specific clinical framework, there is no validated indication for prescribing foot orthotics in the treatment of knee or hip OA (Grade C). CONCLUSION: It is necessary to have further randomized controlled trials to better define the indication of Foot orthotics (severity of knee OA, genu varum), test the efficacy of other orthoses such as cushioning FO. The long-term side effects, mainly on the external femorotibial compartment could also be assessed. A medical and economical assessment of FO prescriptions is also quite necessary.

Contribution of each lower limb to upright standing in stroke patients.

BACKGROUND AND PURPOSE: To analyze the postural behavior of standing stroke patients: (1) To differentiate between postural impairment attributable to the neurological condition (deficits attributable to the cerebral lesion) and postural impairment attributable to new mechanical constraints caused by body weight asymmetry; (2) To assess the involvement of each limb in the postural impairment; (3) To better understand which clinical deficits underlie the postural impairment. METHODS: The posturographic characteristics of each limb in 41 stroke patients (first hemispheric stroke: 16 left, 25 right cerebral lesions) required to stand in their preferred posture were compared to those in 40 matched healthy individuals required to stand asymmetrically. RESULTS: Compared to normal individuals in a similar asymmetrical posture, stroke patients were more unstable. The weight bearing asymmetry and the lateral postural instability were mainly related to spatial neglect. The paretic limb was unable to bring into play a normal longitudinal pattern of the center of pressure, which reflects an impaired stabilization control. Overall postural instability occurred when the strong limb was unable to compensate for the postural impairment of the paretic limb. CONCLUSIONS: The weight bearing asymmetry of standing stroke patients is not the primary cause of their postural imbalance, which is rather the consequence of impaired control of postural stabilization involving both limbs. Weight bearing asymmetry may not be the principle target of rehabilitation programs aiming at restoring standing balance after stroke. Instead it is suggested that more account should be taken of the compensatory role of the strong limb.

Analysis of low back pain in adults with scoliosis.

STUDY DESIGN: Prospective study of self-assessed symptom severity. OBJECTIVES: To carry out a comparative semiological analysis of pain in scoliotic and nonscoliotic adults with low back pain, and to study the factors that correlate with the severity of pain in scoliotic patients. SUMMARY OF BACKGROUND DATA: Low back pain is a frequent complaint in subjects with adult lumbar scoliosis. Few studies have taken an interest in the semiological specificities of lumbar pain in such patients. METHODS: Fifty adults with lumbar scoliosis and suffering from chronic low back pain and 50 nonscoliotic adults with chronic low back pain, matched for age and gender underwent a standard examination. The characteristics of the pain described in the 2 groups were compared. Relationships between the features of the scoliosis and the intensity of the pain were sought. RESULTS: There was no difference between the 2 groups with regard to pain severity (duration and intensity). The pain evolved more steadily in scoliotic patients. Inguinal pain (P < 0.001) and cruralgia (P < 0.05) were particularly associated with scoliosis. In scoliotics, the severity of the low back pain correlated well with the radiologic aspects: Cobb angle (P < 0.05), vertebral rotation (P < 0.05) and rotatory olisthesis (P < 0.05). Cruralgia was significantly associated with the presence of rotatory dislocation (P < 0.01). CONCLUSION: The pain felt by scoliotic adults has several semiological features, in particular the frequency of inguinal pain and cruralgia. Lumbar scoliosis with a great curvature and/or rotatory olisthesis increases the intensity of low back pain in adults. These findings suggest that the magnitude of the curvature and the existence of rotatory olisthesis must be targeted for prevention and treatment of the chronic low back pain in subjects with a lumbar scoliosis.

Use of the Faces Pain Scale by left and right hemispheric stroke patients.

No pain scale is available for stroke patients due to the presence of language or cognitive disorders. However, the Faces Pain Scale (FPS), which was initially developed for children, has been used with success in adults with cognitive impairments. The aim of this study is to test whether the FPS could be used in left or right hemispheric stroke patients (LHSP, RHSP). One hundred twenty-seven stoke patients and 21 controls were recruited in 2 rehabilitation units. Construct validity of FPS was assessed by rating and ranking facial expressions. FPS was correlated to a Visual Analog Scale (VAS) and to a Verbal Rating Scale (VRS) for the assessment of shoulder pain. Reliability was determined by test-retest procedures. Performances of RHSP in the ranking and rating procedures were very poor compared to LHSP and to controls. However, in the assessment of patients' shoulder pain, FPS scores were highly correlated with VAS and VRS in both stroke groups (r=0.65-0.82, p<10(-3)). FPS was more reliable in LHSP than in RHSP. It was preferred to VAS and VRS in LHSP, while in RHSP VAS was the preferred scale. The present study provides preliminary support for the validity and the reliability of FPS in LHSP. However, we do not recommend its sole use in stroke patients. Further studies are needed to determine whether FPS can be used in stroke patients for assessing changes in severity of pain over time.

Three-dimensional study of pelvic asymmetry on anatomical specimens and its clinical perspectives.

The aim of this study was to assess pelvic asymmetry (i.e. to determine whether the right iliac bone and the right part of the sacrum are mirror images of the left), both quantitatively and qualitatively, using three-dimensional measurements. Pelvic symmetry was described osteologically using a common reference coordinate system for a large sample of pelvises. Landmarks were established on 12 anatomical specimens with an electromagnetic Fastrak system. Seventy-one paired variables were tested with a paired t-test and a non-parametric test (Wilcoxon). A Pearson correlation matrix between the right and left values of the same variable was applied exclusively to values that were significantly asymmetric in order to calculate a dimensionless asymmetry index, ABGi, for each variable. Fifteen variables were significantly asymmetric and correlated with the right vs. left sides for the following anatomical regions: sacrum, iliac blades, iliac width, acetabulum and the superior lunate surface of the acetabulum. ABGi values above a threshold of +/- 4.8% were considered significantly asymmetric in seven variables of the pelvic area. Total asymmetry involving the right and the left pelvis seems to follow a spiral path in the pelvis; in the upper part, the iliac blades rotate clockwise, and in the lower part, the pubic symphysis rotates anticlockwise. Thus, pelvic asymmetry may be evaluated in clinical examinations by measuring iliac crest orientation.

A comparison of gait in spinal muscular atrophy, type II and Duchenne muscular dystrophy.

This study investigated and compared the gait of two patients with spinal muscular atrophy, type II (SMA II) and two patients with Duchenne muscular dystrophy (DMD). These diseases cause a progressive and proximal to distal muscular weakness resulting in the loss of ambulation. The DMD cases had comparable muscle weakness with the SMA II cases on manual muscle testing and patients were assessed using kinematics, kinetics, electromyography and video analysis. SMA II and DMD patients employed different gait strategies for forward movement. SMA II patients used pelvic rotation initiated by the upper body to propel the leg forward and produce the necessary step-length whereas the DMD patients tended to use hip flexion and plantar flexion. Management of SMA II patients would include preservation of hip abductor and flexor strength to maintain mobility.

Validation of the aphasic depression rating scale.

BACKGROUND AND PURPOSE: The Aphasic Depression Rating Scale (ADRS) was developed to detect and measure depression in aphasic patients during the subacute stage of stroke. METHODS: Six experts selected an initial sampling of behavioral items from existing depression rating scales. Stroke patients (aphasic and nonaphasic) were assessed with these items by the rehabilitation staff, with the Hamilton Depression Rating Scale (HDRS) for nonaphasic patients only, by a psychiatrist, and by the rehabilitation staff with Visual Analog Scales (VAS). A second item selection was conducted after a regression algorithm was run including VAS as independent variables (criterion validity) and after their factorial structure was analyzed with a principal component analysis (factorial validity). The construct validity was evaluated with respect to the other depression assessments. A threshold for the diagnosis of depression was computed with respect to the psychiatrist's diagnosis. Interrater and test-retest reliability were assessed in 2 additional groups of aphasic patients. RESULTS: Eighty patients participated in the study (59 aphasic). Fifteen behavioral items from existing depression rating scales were selected, and 9 were retained after the validation process. ADRS correlated highly with VAS and HDRS (r=0.60 to 0.78, P=10(-4) to 10(-6)). With respect to the psychiatrist's diagnosis, the sensitivity and specificity of ADRS were 0.83 and 0.71, respectively, when the threshold was set at 9/32. Its factorial structure was comparable to HDRS structure. Interrater and test-retest reliability were high (average kappa coefficient of the 9 items=0.69). CONCLUSIONS: ADRS is a valid, reliable, sensitive, and specific tool for the evaluation of depression in aphasic patients during the stroke subacute phase.