Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke.

Brain-computer interfaces (BCI) are used in stroke rehabilitation to translate brain signals into intended movements of the paralyzed limb. However, the efficacy and mechanisms of BCI-based therapies remain unclear. Here we show that BCI coupled to functional electrical stimulation (FES) elicits significant, clinically relevant, and lasting motor recovery in chronic stroke survivors more effectively than sham FES. Such recovery is associated to quantitative signatures of functional neuroplasticity. BCI patients exhibit a significant functional recovery after the intervention, which remains 6-12 months after the end of therapy. Electroencephalography analysis pinpoints significant differences in favor of the BCI group, mainly consisting in an increase in functional connectivity between motor areas in the affected hemisphere. This increase is significantly correlated with functional improvement. Results illustrate how a BCI-FES therapy can drive significant functional recovery and purposeful plasticity thanks to contingent activation of body natural efferent and afferent pathways.

Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: brief report.

BACKGROUND: Whenever oral treatment or botulinum toxin injections fail to control severe spasticity, a trial with intrathecal baclofen is recommended no earlier than 1 year after brain injury. When irreversible contractures are to be avoided, such a trial might be done earlier. Some have briefly reported cognitive modifications with this treatment. METHODS: During the trial period, intrathecal baclofen is continuously infused by a portable external pump through an intrathecal catheter. The daily dose is adjusted according to the clinical response. If the expected response is obtained by reduction of spasticity, a programmable pump is then implanted. Throughout the procedure, close neuropsychological follow-up is pursued. RESULTS: Two persons with extremely severe brain injury and spasticity received a programmable pump less than 10 months after trauma. Unexpectedly, one emerged from the minimally conscious state and the other from post-traumatic amnesia. CONCLUSIONS: Intrathecal baclofen should be considered within the first year after brain injury whenever spasticity does not respond to medication. ITB lessens the degree of spasticity which in turn facilitates care and, thus, has the potential to limit contractures. After severe brain injury, this treatment might trigger recovery from altered states of consciousness, improve cognition and facilitate rehabilitation.

Clinical evaluation of BrainTree, a motor imagery hybrid BCI speller.

OBJECTIVE: While brain-computer interfaces (BCIs) for communication have reached considerable technical maturity, there is still a great need for state-of-the-art evaluation by the end-users outside laboratory environments. To achieve this primary objective, it is necessary to augment a BCI with a series of components that allow end-users to type text effectively. APPROACH: This work presents the clinical evaluation of a motor imagery (MI) BCI text-speller, called BrainTree, by six severely disabled end-users and ten able-bodied users. Additionally, we define a generic model of code-based BCI applications, which serves as an analytical tool for evaluation and design. MAIN RESULTS: We show that all users achieved remarkable usability and efficiency outcomes in spelling. Furthermore, our model-based analysis highlights the added value of human-computer interaction techniques and hybrid BCI error-handling mechanisms, and reveals the effects of BCI performances on usability and efficiency in code-based applications. SIGNIFICANCE: This study demonstrates the usability potential of code-based MI spellers, with BrainTree being the first to be evaluated by a substantial number of end-users, establishing them as a viable, competitive alternative to other popular BCI spellers. Another major outcome of our model-based analysis is the derivation of a 80% minimum command accuracy requirement for successful code-based application control, revising upwards previous estimates attempted in the literature.

Work in inflammatory and degenerative joint diseases.

This article focuses on work disability and sick leave and their cost; it also discusses the value of vocational rehabilitation programmes in rheumatic conditions such as rheumatoid arthritis, ankylosing spondylitis, hip and knee osteoarthritis. It acknowledges the importance of work not only for the worker who has one of these diseases but also for the public purse. Much can be done to improve the health of the persons and reduce their disability and its impact in the workplace which will have an important effect on their and their family's quality of life. It is important that neither rehabilitation nor vocational rehabilitation are regarded as bolt-on activities after drug treatment but are seen as an integral part of effective management. Publications dealing with return to work are relatively common in rheumatoid arthritis, less common in ankylosing spondylitis and relatively rare in osteoarthritis. Vocational rehabilitation programmes should aim to facilitate job retention or, failing that, to improve the ability to return to work. The process must be started with in the health arena and it has to be recognised that slow or poor practice in the health service can jeopardise the patient's work potential.

Vocational rehabilitation: a multidisciplinary intervention.

Vocational rehabilitation is by definition a multidisciplinary intervention in a process linked to the facilitation of return to work or to the prevention of loss of the work. Clinical staff in contact with a person who has lost his job (general practitioner, specialized physician) must promote vocational rehabilitation. Medical rehabilitation for those with disabilities, whether new or old, has to be followed without delay by vocational rehabilitation. It is even better if these two intertwined processes are overlapping. They involve many professionals including physiotherapists, occupational therapists, psychologists, vocational trainers, job counsellors, teachers, case-managers, job placement agencies. Vocational rehabilitation has a financial cost, borne by many state organizations (security, social system, social affairs) as well as by employers and private insurances, which are in case of accident, concerned by this process. However, the evidence suggests that this is recouped 2- to 10-fold as suggested by the British Society of Rehabilitation Medicine.

[Spinal cord injury: potential for neurologic and functional recovery]. / Le traumatisme médullaire: potentiel de récupération neurologique et fonctionnel.

Since antiquity, spinal cord injury was recognised mortal. At the beginning of the 19th century, the situation had hardly changed and the mortality rate remained high. Since the Second World War the care of the spinal man evolved considerably. Over the last past years, promising experiments on the neurological recovery in animals were achieved. While waiting for their application to the human being, global rehabilitation in specialised centres offers to spinal cord injured patient the possibility of functional recovery with social and professional reinsertion.

Symptoms of recurrent intrathecal baclofen withdrawal resulting from drug delivery failure: a case report.

A 24-yr-old, completely (T8) paraplegic male patient presenting with severe spasticity had a drug administration device implanted in April 1991 for continuous intrathecal administration of baclofen. After a period of remarkable improvement in both the spasticity level and his quality of life, the patient experienced several short-lasting episodes of increased spasticity, with severe spasms. Among the possible causes of these deleterious episodes were microcrystalluria, obstipation, a decubitus ulcer, a foreign body in the buttocks, drug tolerance to baclofen, electromagnetic interference, and erroneous filling and programing of the pump. The catheter was the most common source of intrathecal baclofen withdrawal symptoms and had to be changed four times in 5 yr. Intrathecal baclofen administered through an implantable drug administration device is a highly effective but complex and expensive procedure that requires careful patient selection and close monitoring by highly qualified and well-trained health professional. Withdrawal symptoms may be related to noncompliance on the part of the patient, erroneous filling or programing of the pump, depletion of the battery, random component failure, concomitant illness, drug tolerance, or advancement of the disease itself. When failure of the device is suspected, substitution with oral baclofen is recommended until a full work-up is performed to determine the defect.

Parenchymatous cerebral neurocysticercosis in a quadriplegic patient.

OBJECTIVE: To present and discuss a case of cerebral neurocysticercosis in a quadriplegic patient. DESIGN: Case report of a case of neurocysticercosis in a high level spinal cord injury (SCI) patient who developed episodes of autonomic dysreflexia and orthostatic hypotension associated with transient neurologic deficits and seizures. SETTING: Spinal Cord Unit of the University Hospital of Geneva, Switzerland. SUBJECT: Single patient case report. MAIN OUTCOME MEASURE: Clinical and radiological magnetic resonance imaging follow-up of the patient between July 1995 and October 1997. RESULTS: Treatment of cysticercosis with praziquantel relieved the patient from autonomic dysreflexia, symptomatic orthostatic hypotension, transitory neurological deficits and seizures. CONCLUSION: Diagnosis of neurocysticercosis in a quadriplegic patient might be difficult because of frequent overlaps with some usual symptoms occurring in high level SCI, mostly autonomic dysreflexia and orthostatic hypotension. Neurocysticercosis should be kept in mind when a SCI patient living in, or coming from endemic zones presents with new neurological abnormalities and seizures. Magnetic resonance imaging appears to be more sensitive than computerised tomography to confirm the diagnosis of active cysticercosis. Treatment with praziquantel associated with cimetidine to increase the drug bioavailability and prednisone to reduce the inflammatory reaction gives good results.

Has botulinum toxin type A a place in the treatment of spasticity in spinal cord injury patients?

OBJECTIVE: To present and discuss treatment of severe spasms related to spinal cord injury with botulinum toxin type A. DESIGN: A 2-year follow-up study of an incomplete T12 paraplegic patient, who was reluctant to undergo intrathecal baclofen therapy, presenting severe painful spasms in his lower limbs treated with intramuscular injections of botulinum toxin type A. SETTING: Department of Physical Medicine and Rehabilitation, Hôpital de Gravelone, Sion, Switzerland. SUBJECT: Single patient case report. MAIN OUTCOME MEASURE: Spasticity, spasms and pain measured with the modified Ashworth scale, spasm frequency score and visual analogue scale. RESULTS: Treatment of spasticity with selective intramuscular injections of botulinum toxin type A resulted in subjective and objective improvement. CONCLUSION: Botulinum toxin type A has its place in the treatment of spasticity in spinal cord injury patients. This treatment is expensive and its effect is reversible. It can complement intrathecal baclofen in treating upper limb spasticity in tetraplegic patients. Tolerance does occur to the toxin. Although high doses of the product are well tolerated, the quantity should be tailored to the patient's need. The minimal amount necessary to reach clinical effects should be adhered to and booster doses at short period intervals should be avoided.

Iliopsoas bursitis and pseudogout of the knee mimicking L2-L3 radiculopathy: case report and review of the literature.

We report the case of a 74-year-old woman who presented with acute-onset right groin pain irradiating to the thigh anteriorly after having suffered for a few weeks from slight knee pain. As a CT scan showed multiple herniated intervertebral discs and spinal stenosis at the L3-L4 level, she was referred to a neurosurgical unit with the tentative diagnosis of L2-L3 radicular pain. Investigations (MR, myelography with CT scan) showed severe acquired lumbar canal stenosis. Decompression surgery was finally postponed because of the patient's serious cardiac medical history and she was referred to us for conservative treatment. She was found to have iliopsoas bursitis with chondrocalcinosis of the knee. Local steroid injections of the two sites abolished her symptoms. We draw attention to the possible pitfalls that the radiographic appearance and one of the multiple clinical presentations of this unrare pathology may represent. Whenever a patient comes walking with crutches, avoids putting weight on his or her leg, and radicular pain is suspected, we advise consideration of other extra-spinal causes for the pain.

[Open laser surgery on the locomotor apparatus]. / Offene Laserchirurgie am Bewegungsapparat.

The first applications of laser in surgery of the locomotor apparatus in the early 1980s used the haemostatic properties of laser to diminish the amount of substitution of coagulation factors in haemophiliac patients. Only since the early 1990s has a device been available in corporating the pulsed holmium:YAG laser which works in a fluid medium without relevant side effects. Apart from haemostasis, the cutting function and tissue ablation, together with the thermal shrinking effect, are exploited in arthroscopy and percutaneous disc decompression. Now that the biophysical mechanisms of action have been elucidated, nothing stands in the way of the use of infrared lasers in open surgery of the locomotor apparatus in some indications. In a prospective clinical study we included 30 consecutive patients who underwent open laser surgery from November 1992 to August 1994, for the following indications: the sparing haemostatic tissue ablation was used for synovectomy or for bony resection in osteophytes and osteochondromas of different locations, an osteoid osteoma and a painful sacral hyperplasia in the presence of incomplete sacral meningomyelocele. With bleeding eliminated, the shaping was much easier. The non-ablative shrinking produced less tissue loss and a stabilizing strengthening of tissue at the margins of soft tissue resections, e.g. in jumper's knee, tennis elbow and Achilles tendon cysts. All laser functions that are useful in open surgery have also been used in sequestered disc herniations that are inaccessible a percutaneous procedure and, in spinal decompression, for remodelling of the posterior spine contour. An analgesic effect of laser limited the postoperative administration of analgesic drugs to an average of 3 days. No complications related to the laser treatment were observed. At follow-up 12-21 months after operation, 25 of the 30 patients in this heterogeneous population showed complete or near-total healing of the operated pathological finding, and a further 3 patients showed significant improvement. To what extent these very encouraging results will persist will be shown by long-term observation.

Adenomyosis--an unusual cause of sciatic pain.

We report the case of a female patient who presented with a 5-month history of sciatic pain. She was referred to us for investigation and eventual surgical treatment of a suspected herniated lumbar intervertebral disc. Because of an ill-defined clinical picture at admission, she was treated conservatively. After 2 weeks without any improvement, imaging of the spine by MR was performed. No signs of a herniated disc or intraspinal, space-occupying lesion were apparent, but a right paramedian pelvic mass was seen. Ultrasonography confirmed an enlarged, irregular uterus. Hysterectomy abolished the symptoms.