[Sports-related concussions in youths]. / Commotions cérébrales chez le jeune sportif.

Mild head trauma can be associated with concussion, defined as transient brain function impairment without radiological findings. Sports-related concussion is also reported in pediatrics (rugby, ice hockey, football, boxing, etc.). Misdiagnosis can lead to persistent neurocognitive signs with athletic and academic problems. Consensual tools are available, but they are not well-known by first-line doctors, coaches, and patients or parents. Concussed players should not be allowed to return to the field on the same day. Return to play should be gradual over 3weeks or more. School activities may need to be modified to favor cognitive rest. Prevention is based on risk information and knowledge transfer, rule changes, and protective helmets, whose effectiveness is not always proven.

[Postexercise duplex ultrasound to diagnose external iliac endofibrosis]. / Endofibrose de l'artère iliaque externe diagnostiquée par écho-doppler post-effort.

Arterial endofibrosis is a disease of recent discovery which concerns high-performance athletes, predominantly competitive cyclists. The preferential location is the external iliac artery. The symptoms are diverse (pain, edema, paresthesia), always linked to an effort. The diagnosis may be delayed due to atypical symptoms in athletes. Complementary tests are measure of the systolic pressure index after exercise, duplex ultrasound, CT angiography, MR angiography and arteriography. We report a case of endofibrosis where late diagnosis was established with postexercise duplex ultrasound, while CT angiography and arteriography failed to reveal characteristic abnormalities.

Peroneus quartus and functional ankle instability.

INTRODUCTION: Physical and rehabilitation medicine physicians commonly see patients with chronic functional ankle instability. The main anatomical structures involved in ankle stability are the peroneus (fibularis) brevis and peroneus longus muscles. Several anatomical muscle-tendon variations have been described in the literature as being sometimes responsible for this instability, the peroneus quartus muscle being the most frequent. The objective of this clinical study is to discuss the implication of the bilateral peroneus quartus muscle in functional ankle instability. CLINICAL CASE: This 26-year-old patient was seen in PM&R consultation for recurrent episodes of lateral ankle sprains. The clinical examination found a moderate hyperlaxity on the right side in bilateral ankle varus. We also noted a bilateral weakness of the peroneus muscles. Additional imaging examinations showed a supernumerary bilateral peroneus quartus. The electroneuromyogram of the peroneus muscles was normal. DISCUSSION: In the literature the incidence of a supernumerary peroneus quartus muscle varies from 0 to 21.7%. Most times this muscle is asymptomatic and is only fortuitously discovered. However some cases of chronic ankle pain or instability have been reported in the literature. It seems relevant to discuss, around the clinical case of this patient, the impact of this muscle on ankle instability especially when faced with lingering weakness of the peroneus brevis and longus muscles in spite of eccentric strength training and in the absence of any neurological impairment. One of the hypotheses, previously described in the literature, would be the overcrowding effect resulting in a true conflict by reducing the available space for the peroneal muscles in the peroneal sheath.

An assessment of patient satisfaction for a short-stay program in a physical and rehabilitation medicine day hospital.

INTRODUCTION: The aim of the Physical and Rehabilitation Medicine (PRM) day hospital's short-stay program is to propose a one- or two-day medical and psychosocial assessment to patients with disabilities. The day hospital is run by an interprofessional team, using interdisciplinary cooperation and a hospital/community network. OBJECTIVES: To describe a tool for assessing patient satisfaction and to present the results of our survey. PATIENTS AND METHODS: A self-administered questionnaire about patient satisfaction was created and given to patients coming to the PRM day hospital. The questionnaire included 27 multiple-choice questions, two visual analogic scales, and one free-response question. The survey was conducted over two months. For the 603 annual day hospital sessions, 143 questionnaires on 143 sessions were filled out. RESULTS: Patients found the questionnaire easy to use, but a few needed help to fill it out. It permitted us to highlight the places where the short-stay program performed unsatisfactorily. CONCLUSIONS: The self-administered questionnaire seems to be appropriate for assessing patient satisfaction. The highest scores helped to emphasize where the program was functioning correctly, and the lowest scores allowed us to identify the points that needed to be improved.

Eccentric reinforcement of the ankle evertor muscles after lateral ankle sprain.

To compare two methods of ankle evertor muscle reinforcement after ankle sprain: concentric vs eccentric reinforcement. Eighteen subjects practising sport with first episode of ankle sprain. The first randomized group underwent conventional physical therapy including concentric reinforcement of the evertor ankle muscles [concentric group (CG)]. The second randomized group underwent eccentric reinforcement [eccentric group (EG)]. At the end of the physical therapy, the strength of the evertor muscles was tested using an isokinetic dynamometer. The measurements were peak torques in the concentric and eccentric modes; ankle strength deficits, expressed as percentages of the healthy ankle values recorded in the concentric and eccentric modes; ratios between concentric/eccentric values. After the concentric reinforcement, in the CG group, there is both significant concentric strength deficit and an eccentric strength deficit on the injured side in comparison with the healthy side. After the eccentric reinforcement in the EG group, the muscle strength was significantly greater during concentric movements. Eccentric rehabilitation therefore restored the strength of the injured evertor muscles. These results show the value of this method, especially as the weakness of these muscles after sprains is one of the main risk factors contributing to instability and the recurrence of sprains.

Should European PRM residents be taught in English? The experience of the European school Marseille.

OBJECTIVE: To assess the level of comprehension of the courses taught in English at the annual European school on Physical and Rehabilitation Medicine (PRM) (European School Marseille). MATERIALS AND METHODS: The English level of 37 students, mainly from European countries, was tested using three written questionnaires: an initial test of English grammar, a questionnaire about comprehension at the end of a basic PRM class taught in English by a French specialist and a final multiple-choice test (MCT) on the contents of the course. RESULTS: We found a difference between the level of English given by the residents and the level shown by the initial test. The overall level of English comprehension of the group was good, an average of 8.2/10 (S.D.: 2.1) on a Visual Analogue Scale. The mean MCT score on the contents of the course was good, an average of 6.1/10 (S.D.: 2.2). For residents with lower levels of English, the level of comprehension for courses taught in English by the French specialist was greater than the level of comprehension for courses taught by native English speakers (p=0.033). CONCLUSION: The level of comprehension of most European PRM residents for courses taught in English by French PRM specialists and by English-speaking specialists is good. The level of comprehension is, of course, influenced by the English level of European residents. It thus appears worthwhile to organize programmes taught in English for European PRM residents. Nonetheless, it is important to assess the language skills of the residents and to use specific tools to help the small number of trainees whose English level is to low.

Comparative study of clinical and ultrasonographic evaluation of lateral collateral ligament sprains of the ankle.

AIM: Clinical examination is sometimes insufficient to assess the severity of lateral collateral ligament (LCL) sprain of the ankle, making it difficult to choose the most appropriate treatment. The aim of this study was to compare the assessment of clinical signs and the ultrasonographic findings in recent LCL sprain of the ankle. METHODS: This was a retrospective cross-sectional study. Spearman's rank correlation test and multiple regression analysis were used to assess correlations between clinical signs and type of ligament injury. Fisher's linear discriminant analysis was used to determine most contributive signs in ligament tear diagnosis. RESULTS: No single clinical sign was correlated with the severity of ligament injury as revealed by ultrasonography in the 34 patients analyzed. Careful assessment of all the usual clinical signs of severity seems to better guide the diagnosis of the presence or absence of ligament tearing. CONCLUSIONS: These results confirm the lack of correlation between clinical examination and the anatomic injury in distension or partial tearing of the anterior talofibular ligament. They raise questions about the usefulness of clinical classifications and suggest a broadening of the indications for ultrasonographic exam in ambiguous situations, particularly for athletes showing few signs of severe injury, in order to ensure optimal treatment and a faster recovery.

Orthopedic shoes improve gait in Friedreich's ataxia: a clinical and quantified case study.

Our aim was to evaluate with modern tools the efficacy of orthopedic shoes on gait disorders in Friedreich's ataxia. The case of a 26-year-old woman with Friedreich's ataxia is described. She mainly complained of fatigability, ankle instability, frequent falls and pain. Impairments involved a cerebellar syndrome, a proprioceptive deficit, an upper motor neurone syndrome and osteoarticular deformities. Gait disabilities included ataxia and requirement of a cane. Handicap concerned outings, altering quality of life. Orthopedic shoes combined with physical therapy were prescribed. Assessment of treatment was planned after one month. Self-assessment by the patient was noted. Clinical assessment was provided by physical examination and clinical gait analysis supported by video. Quantified assessment was performed with a Gaitrite system recording spatiotemporal gait parameters. Our results demonstrated that orthopedic shoes improved gait disorders in this patient with Friedreich's ataxia. Pain decreased, walking distance increased, falls were less frequent, going out became possible, stability was better, speed, step length and cadence increased. Both clinical and quantified assessment confirmed functional improvement felt by the patient. In conclusion complete medical and social assessment determines quality of prescription in physical and rehabilitation medicine.

Orthopaedic shoes improve gait in a Charcot-Marie-Tooth patient: a combined clinical and quantified case study.

The aim of this study was to assess the extent to which orthopaedic shoes improved gait in a patient with Charcot-Marie-Tooth (CMT) disease and to show how the latest gait analysis tools available can help to assess and quantify the efficacy of this treatment. The case of a 55-year-old woman with CMT disease is described. She complained mainly of pain and frequent falling. The physical examination and the clinical gait analysis showed the presence of bilateral foot drop, high-stepping and varus. Treatment based on physical therapy and orthopaedic shoes was prescribed. In order to assess the clinical efficacy of the treatment, a complete physical examination was carried out after the patient had been wearing the orthopaedic shoes for one month. The quantified assessment was performed with a Gaitrite system, which can be used to record the spatio-temporal parameters of gait. It was concluded that orthopaedic shoes provide specialists in physical and rehabilitation medicine with an excellent means of treating gait disabilities in patients with CMT disease. With the made-to-measure orthopaedic shoes used, the falling and pain disappeared; the patient's walking speed increased and the foot support base decreased in size. Both the clinical and quantified data confirmed the subjective improvement perceived by the patient. The latest tools available for performing quantified gait analysis in clinical practice provide useful means of objectively assessing the success of treatment.

[Influence of treatment with botulinum toxine after stroke to control posture]. / Influence sur le contrôle postural du traitement par toxine botulique chez les sujets cérébrolésés.

OBJECTIVE: To investigate modification of postural control after treatment with botulinum toxine in leg muscles of stroke patients. METHODS: We performed a retrospective study of stroke patients who benefitted from injection of botulinum toxine in leg muscles between June 2003 and October 2004. The assessment before and after the injection relied on clinical examination and on posturographic recording on 2 force plates with the patient standing, with eyes open performing or not a double task consisting of an arithmetic test and with eyes closed. We also compared patients to healthy subjects. RESULTS: Eight patients were included in the study. Botulinum toxine injection in the leg muscles significantly decreased the triceps spasticity, with no change in clinical assessment of balance control (Fugl-Meyer scale). The posturographic data show a decrease in the area of centre of pressure displacement in the double-task situation after the injection. CONCLUSION: Thanks to the posturographic recording in the double-task situation, we showed a modification of postural control after treatment with botulinum toxine in leg muscles of stroke patients.

[Isokinetic dynamometer measurement of shoulder rotational strength in healthy elite athletes (swimming, volley-ball, tennis): comparison between dominant and nondominant shoulder]. / Mesure de la force des muscles rotateurs de l'épaule chez des sportifs sains de haut niveau (natation, volley-ball, tennis) par dynamomètre isocinétique: comparaison entre épaule dominante et non dominante.

OBJECTIVE: To compare lateral rotator (LR) and medial rotator (MR) muscle strength of both shoulders in a sport involving asymmetrical movements (tennis), symmetrical movements (swimming), and symmetrical and asymmetrical movements (volley-ball). MATERIALS AND METHODS: Retrospective study of 42 healthy elite athletes (18 women: 14 tennis players, 19 swimmers and 9 volleyball players. We evaluated the strength of LR and MR of both shoulders by Cybex Norm isokinetic dynamometer, in the concentric mode, in the modified Davies position, at 2 different speeds (60 degrees and 180 degrees s(-1)) and analysed peak torque of LR and MR and LR/MR ratios. RESULTS: TENNIS: The MR peak torque of the dominant shoulder was significantly higher than that of the non-dominant shoulder. The LR/MR ratio of the dominant shoulder was significantly lower than the non dominant shoulder in women. SWIMMING: The LR strength and LR/MR ratio of the dominant shoulder was higher than the non dominant side in men at 60 degrees/second. Both shoulders showed comparable strength in women. VOLLEYBALL: Shoulder muscular strength was symmetrical. CONCLUSION: The higher strength of MR muscles in the dominant shoulder of tennis players (asymmetrical movements) has been reported in the literature. Athletes show asymmetrical shoulder strength in swimming, a symmetrical sport and similar LR and MR strength in both shoulders in volleyball, a sport with asymmetrical movements. To our knowledge, these results have never been reported before.

Sensori-motor adaptation to knee osteoarthritis during stepping-down before and after total knee replacement.

BACKGROUND: Stepping-down is preceded by a shift of the center of mass towards the supporting side and forward. The ability to control both balance and lower limb movement was investigated in knee osteoarthritis patients before and after surgery. It was hypothesized that pain rather than knee joint mobility affects the coordination between balance and movement control. METHODS: The experiment was performed with 25 adult individuals. Eleven were osteoarthritic patients with damage restricted to one lower limb (8 right leg and 3 left leg). Subjects were recruited within two weeks before total knee replacement by the same orthopedic surgeon using the same prosthesis and technics of surgery. Osteoarthritic patients were tested before total knee replacement (pre-surgery session) and then, 9 of the 11 patients were tested one year after the surgery when re-educative training was completed (post-surgery session). 14 adult individuals (men: n = 7 and women: n = 7) were tested as the control group. RESULTS: The way in which the center of mass shift forward and toward the supporting side is initiated (timing and amplitude) did not vary within patients before and after surgery. In addition knee joint range of motion of the leading leg remained close to normal before and after surgery. However, the relative timing between both postural and movement phases was modified for the osteoarthritis supporting leg (unusual strategy for stepping-down) before surgery. The "coordinated" control of balance and movement turned to be a "sequential" mode of control; once the body weight transfer has been completed, the movement onset is triggered. This strategy could be aimed at shortening the duration-time supporting on the painful limb. However no such compensatory response was observed. CONCLUSION: The change in the strategy used when supporting on the arthritis and painful limb could result from the action of nociceptors that lead to increased proprioceptor thresholds, thus gating the proprioceptive inputs that may be the critical afferents in controlling the timing of the coordination between balance and movement initiation control.

[Temporal, kinetic and kinematic asymmetry in gait initiation in one subject with hemiplegia]. / Asymétries chronométriques, cinétiques et cinématiques de l'initiation de la marche chez un sujet hémiplégique.

OBJECTIVE: To investigate the temporal, kinetic and kinematic asymmetry of gait initiation in one subject with hemiplegia with an equinus varus foot. MATERIAL AND METHODS: A kinetic analysis with two AMTI force plates and a kinematic analysis with an ELITE optoelectronic system of gait initiation were performed in one subject with hemiplegia. RESULTS: The duration of the gait initiation phases was asymmetrical. The monopodal phase was shorter when the affected lower limb was supporting than when the healthy one was supporting. The propulsion resulted from the force exerted on the healthy lower limb. The distribution of body weight on the lower limbs was asymmetrical. Body weight support was more important on the healthy side than on the affected side. Maximal extension of the ankle on the hemiplegic side occurred during the swing phase. Ground clearance was increased by elevating the knee higher on the affected side than on the healthy side during the swing phase. Initial contact with the floor was performed with the foot flat on the affected side. CONCLUSION: This preliminary study has shown that gait initiation in one subject with hemiplegia was asymmetrical in kinetics and kinematics. The results concerning kinematics have not been reported previously for gait initiation in subjects with hemiplegia. The study of gait initiation should allow for better understanding postural and movement control strategies developed by patients with hemiplegia.

[Posture and movement analysis and sports medicine]. / Analyse de la posture et du mouvement et médecine du sport.

The use of posture and movement analysis methods has developed during the past 15 years. These methods are of special interest in the field of sport sciences and have allowed to improve the understanding of physiology of posture and movement in athletes. More recently these methods have been used in the field of sport medicine. In some cases, they have helped to identify abnormalities which cannot be seen on standard clinical examination and to understand the mechanism of lesions occurring during sport activities. For the future these methods should provide useful information for understanding the physiopathology of lesions, for developing prevention of pathologies related to sport and for elaborating and assessing new treatment protocols in the field of sport medicine.