Swallowing Disorders in Severe Brain Injury in the Arousal Phase.

The objective of this study was to determine the clinical characteristics of swallowing disorders in severe brain injury in the arousal phase after coma. Between December 1, 2013 and June 30, 2014, eleven patients with severe acquired brain injury who were admitted to rehabilitation center (Male 81.8 %; 40.7 ± 14.6 years) were included in the study. Evaluation of swallowing included a functional examination, clinical functional swallowing test, and naso-endoscopic swallowing test. All patients had swallowing disorders at admission. The first functional swallowing test showed oral (77.8 %) and pharyngeal (66.7 %) food bolus transport disorders; and alterations in airway protection mechanisms (80 %). Swallowing test under endoscopic control showed a disorder in swallowing coordination in 55.6 % of patients tested. Seven (63.6 %) patients resumed oral feeding within an average of 6 weeks after admission to rehabilitation center and 14 weeks after acquired brain injury. Six (85.7 %) of these seven patients continued to require modified solid and liquid textures. Swallowing disorders are a major concern in severe brain injury in the arousal phase. Early bedside assessment of swallowing is essential for detection of swallowing disorders to propose appropriate medical rehabilitation care to these patients in a state of altered consciousness.

What are the perspectives for ventilated tetraplegics? A French retrospective study of 108 patients with cervical spinal cord injury.

OBJECTIVE: Tetraplegic patients are often difficult to manage in intensive care units (ICU). The aim of our study was to calculate the incidence of patients in ICU with cervical spinal cord injury with special focus on tetraplegic patients on ventilation support and their future perspectives. MATERIALS AND METHODS: This retrospective study included patients with cervical spinal cord injury in Upper Normandy, between 2002 and 2012. Data analyzed included age, sex, past medical history, date of onset of quadriplegia, level of neurological involvement, AIS grade, and ventilatory status. RESULTS: One hundred and eight patients were included (49.0 ± 21.1 years). The most common etiology was fall (50 patients [46.3%]). Incidence was calculated at 12.7 per one million inhabitants. Tracheotomy was performed in 40.7% of patients. Long-term mechanical ventilation was required for 6.5%. At the end of the study, 9 patients (9.6%) were permanently hospitalized, 61 patients (64.9%) had returned home but none of the four ventilated patients had been discharged. CONCLUSION: The conclusion of this work is that the future of highly tetraplegic patients is compromised, especially for those who remain reliant on mechanical ventilation.

Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs.

Physical and rehabilitation medicine (PRM) care pathways: "spinal cord injury".

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. The patients after spinal cord injury are divided into five categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.

[Continent cystostomy: monocentric experience]. / Cystostomies continentes : expérience monocentrique.

AIMS: To evaluate the feasibility, the efficiency, the results of continent cystostomy in adult population. MATERIAL AND METHODS: Retrospective study of patients who underwent a continent cystostomy between 1987 and 2011. RESULTS: Forty-three patients underwent a continent cystostomy (13 men and 30 women). The mean age at surgery was 53.4±14.6years. The mean BMI was 25kg/m(2). No death in relation with the cystostomy was reported. Thirty-two patients had a neurological pathology (74.4%), 11 a pathology other than neurological (25.6%). A retention bladder was reported for 12 patients (27.9%), 17 (39.5%) were incontinent, and 14 (32.6%) had a mixed symptomatology. All patients had urodynamics and an evaluation of the urinary tract. Nineteen appendicovesicostomy were made, 15 double Monti-procedure, six simple Monti-procedure, three channels were made of an association of ileon and appendix. Seventeen patients underwent an augmentation cystoplasty in combination with the continent catheterizable conduit. The mean follow-up was 47.6±29months. Continence was achieved in 37 patients (86%), two patients underwent a Bricker. Stomal stenosis occurred in eight patients (18.6%), with a median time of 16.1±20.4 months. Leakage occurred after bladder neck closure for two patients (4.6%). Clean intermittent catheterization were performed by 30 patients, catheterization by a care giver for four patients, seven did not use their stomy because of the evolution of their causal pathology, or because of an intercurrent pathology. No difference between the channels (Mitrofanoff versus Monti) was reported. CONCLUSION: Continent catherizable cystostomy were a feasible method of continent urinary diversion in an adult population. This study demonstrated their feasibility in an adult population and their long-term efficiency with a mean follow-up of 47.6months and 127months for one of them. With a rate of continence upper than 80%, it was an effective technique of urinary diversion associated with intermittent catheterization.

Dynamic cardiorespiratory changes in obese women.

AIM: This study examined the effects of an exercise training program on ventilatory function at rest and the exercise cardiorespiratory pattern in relation to body composition in obese individuals (53.4±7.6 years; 158.6±6.7 cm). METHODS: After initial tests (exercise testing and anthropometric assessment), ten women participated in a 12-week training program combining strength exercise and aerobic exercise at the ventilatory threshold, three times per week for 90 minutes. RESULTS: The post-training mean ventilatory efficiency (ΔE/ΔCO(2)) and cardiac efficiency (ΔHR/ΔO(2)) were improved (P<0.05, respectively). Decreased fat mass (-1.2 kg, P<0.01), increased lean body mass (+1 kg, P<0.01), and decreased waist and hip circumferences (-5.5 cm and -5 cm, respectively, P<0.05) were also obtained after training. CONCLUSION: The program significantly improved a number of physiological variables in our obese patients, although not to sedentary healthy levels. The results show that a functional exercise program has the potential to improve physiological variables and dynamic cardiorespiratory response to exercise in obese women.

Direct neurectomy of the motor branches of the tibial nerve in hemiplegic adults: an assessment with a mean follow-up period of 11 years.

INTRODUCTION: Neurectomy of the tibial nerve plays a major role in the relief of disabling spasticity, which is refractory to drug treatment and physiotherapy. Although the immediate postoperative results are generally satisfactory, few evaluations of the procedure's long-term efficacy have been published. OBJECTIVE: To estimate the long-term efficacy of total or partial neurectomy of the motor branches of the tibial nerve (combined with additional orthopaedic surgery in some cases). METHOD: A descriptive, retrospective study of 25 brain-damaged patients having undergone neurectomy at least 4 years ago. RESULTS: The mean post-neurectomy follow-up period was 11 years. Twenty patients became less dependent on the use of walking aids. Of the 18 patients unable to walk barefoot before surgery, 11 could do so after surgery. Of the 12 patients unable to walk on uneven ground before surgery, seven could do so afterwards. The walking distance increased for 20 patients. In 22 cases, the spasticity disappeared immediately after the operation and did not reappear in the long-term. In three other cases, spasticity persisted postoperatively and, in the long-term, affected the soleus (the denervation of which had been incomplete or not performed). Eighty-three percent of the patients were satisfied with the operation's outcome. CONCLUSIONS: The observed maintenance of the benefits of total or partial neurectomy after an average follow-up period of 11 years confirms the value of this procedure. The few mediocre outcomes (observed in cases of partial neurectomy of the soleus) are in agreement with literature reports and emphasize the role of the soleus in this pathology.

Oncology and physical medicine and rehabilitation.

INTRODUCTION: Cancer patients are living longer with deficiencies and functional impairments requiring often typically a care in physical medicine and rehabilitation (PMR). OBJECTIVE: To examine the care of cancer patients in PMR. METHOD: Investigation made with a questionnaire diffused from the e-mail listing of the Société Française de Médecine Physique et de Réadaptation. RESULTS: Sixty-seven answers received. Fifty-seven centers take care of cancer patients. On average, 4% of cancer patients are hospitalised in PMR. Spinal cord injuries and hemiplegias are the most common impairments. Forty-two percent of the PMR units take the patients in all the stages of cancer treatment. Working relationships between PMR and oncology units are formalized only eight times out of 52. In case of health degradation, relationships with a palliative care unit are frequent but not generalized. Eighty-five percent of the centers think that PMR is not enough developed in oncology. CONCLUSIONS: In spite of its limited character, this investigation shows that the PMR units take these patients. Situations where PMR has an important role in the follow-up of cancer patients are multiple and publications have showed its interest, especially on the limitations of activities. It is important to make better known the interest of PMR in oncology units but also to develop specific care within PMR units.

[Characteristics of patients suffering from multiple sclerosis according to professional situation]. / Caractéristiques des personnes atteintes d'une sclérose en plaques selon la situation professionnelle.

AIM: To describe the health and professional status of multiple sclerosis patients of working age and to compare a group of patients in work (group T1) with a group of unemployed patients (group T2). MATERIALS AND METHODS: A case-controlled study was performed. In the course of a specific consultation with a neurologist, demographic, medical and professional data were gathering using a questionnaire. Descriptive and comparative statistical analyses were then performed. RESULTS: A total of 76 patients were included in the study: 54 were in work (group T1) and 22 were unemployed (group T2). Hence, the employment rate was 71%, with an average time since disease onset of nine years at the time of the study. Low educational level (p=0.02), disease progression (p=0.0001), the presence of motor symptoms (p=0.01), cerebellar symptoms (p=0.02) or cognitive symptoms (p=0.03), a worse EDSS (p=0.0001) and a job requiring force (p=0.05) or manual dexterity (p=0.05) were found to be negative factors. Employment in the public sector (p=0.003) or large companies (p=0.03) were found to be protective factors. Access to the workplace was better for currently employed patients (p=0.03). CONCLUSION: This study shows that differences exist within the MS patient population according to the professional situation. It underlines the importance of clinical and demographics variables as determinants of differences in employment status. Not surprisingly, unemployed patients are more likely to have been classified as handicapped workers. Factors linked to work-induced constraints did not emerge from the survey because the questionnaire items were not appropriate for addressing this latter issue.

[Assessment of anorectal disorders with paraplegia]. / Evaluation à distance des troubles anorectaux chez les paraplégiques.

INTRODUCTION: Functional anorectal disorders in paraplegia are frequent; few studies evaluate the effect of these disorders on quality of life. OBJECTIVE: Assessment of the functional anorectal disorders in a homogeneous group of patients with total paraplegia in terms of quality of life. METHODS: During a global follow-up consultation, patients answered questions on a systematic questionnaire about anorectal disorders and a specific quality-of-life autoquestionnaire about functional digestive disorders: Functional Digestive Disorders Quality of Life (FDDQL) questionnaire; score 0 to 100 (100 corresponding to no effect on quality of life). RESULTS: Twenty-three patients with a mean age of 44.3 years who had been paraplegic for 10 years participated. Two had a colostomy because of bedsores. Fourteen underwent daily rectal examination, 10 with an evacuation aim; the time given to defecation was, on average, 36 minutes. One patient had clinical constipation. Twelve had had one or more episodes of incontinence. The mean global FDDQL score was 69.7. This score was not related to incontinence; only the "comfort" domain among the 8 domains was related to incontinence. DISCUSSION: Anorectal disorders are frequent in paraplegia; the duration and the methods of defecation represent a great worry to patients. More than half of the patients already had faecal incontinence; the effect of even occasional incontinence on quality of life is significant. Since the FDDQL scale is not specific to patients with paraplegia, its interest should be checked on a greater number of patients. For certain patients, it is important not to dismiss more complex surgical treatment methods.

[Postural biofeedback and locomotion reeducation in stroke patients]. / Barobiofeedback et rééducation de la marche de l'hémiplégique.

AIMS: To compare, in post-acute hemiparetic patients, gait improvement after conventional physical therapy alone or with a specialised balance retraining program. PATIENTS: Twenty-six patients within 3 months of onset of stroke were randomised to receive physical therapy (control group) or therapy and retraining (experimental group), most of the patients in both groups with left hemiplegia. The experimental group was significantly older than the control group. METHOD: Thirteen patients received early conventional therapy, and 13 received therapy combined with standing balance training by biofeedback (BPM Monitor). Clinical measures were collected at entry (J0), once when subjects began to walk (JM) and 30 days later (JM + 30). Gait spatiotemporal parameters were collected by use of the Vicon system at JM and JM + 30. RESULTS: Whatever the method of rehabilitation, the clinical scores improved significantly between J0 and JM + 30, except for spasticity. The time between stroke and the beginning of walking was not significantly different between both groups. Gait velocity increased significantly between JM and JM + 30 in both groups, with no difference between groups. The walking pattern was improved for both groups, with a significant increase of the duration of the paretic limb single stance. The experimental group significantly improved the duration of the reception double stance on the paretic limb between JM and JM + 30 compared with the control group (P = 0.03). CONCLUSION: Both groups demonstrated improvement in the rehabilitation unit. The benefits of visual biofeedback by forceplate system training suggest particular improvement of anticipation equilibrium with conventional therapy.

[Evaluation after four years of exercise therapy for chronic low back pain]. / Evaluation à quatre ans d'un programme de reconditionnement à l'effort pour lombalgie chronique.

OBJECTIVE: To assess at four years follow-up the efficiency of exercise therapy for chronic low back pain in terms of pain, physical ability, quality of life and return to work. MATERIALS AND METHODS: Patients who graduated from a functional restoration program between April 1997 and June 1999, answered a questionnaire at one year follow-up. The patients who had answered this questionnaire were evaluated 48 months later: they first answered another questionnaire and then most underwent a clinical examination assessing pain on a visual analogue scale, flexibility by use of the Schöber index and the finger-ground distance test, endurance of abdominal and spinal muscles, and quality of life as assessed by the Dallas pain questionnaire. RESULTS: Thirty-four patients graduated from the program; 26 were studied at four-year follow-up. Pain intensity was significantly reduced. Improvement in flexibility after the program remained at four-year follow-up, whereas improvement in endurance did not. Scores on the Dallas pain questionnaire remained as improved as those at one-year follow-up. Initially, 23 of the 26 patients had a job; 19 were on sick leave for an average of 35 weeks. At four-year follow-up, 16 patients were still working, and 56% had changed jobs. Six patients pursued a regular activity before entering the program; at four-year follow-up, 17 were regularly active. No significant relationship was found between the pursuit of physical activity and return to work. Nevertheless, a significant relationship was found between having a regular physical activity and improvement of the finger-ground distance and endurance of spinal muscles. This observation was not true for the Dallas pain questionnaire scores. CONCLUSION: Despite the lack of a control group, this study seems to favour a benefit in the functional restoration program.

[Aging with spinal cord injury]. / Vieillissement chez les blessés médullaires.

OBJECTIVE: Literature review of the data on aging with spinal cord injury. METHOD: Interrogation on Medline using the following keywords: aging, spinal cord injuries, paraplegia, quadriplegia, mortality, morbidity, quality of life, survival, health status. RESULTS: The expectation of life of the spinal cord injury patients improved even though it remains even lower than that of the general population. The effects of aging add to the specific complications which are numerous and alter almost every function. Respiratory complications became the first cause of death especially for tetraplegics. Urinary and cutaneous complications remain important as well as osteo-articular pathologies (particular upper limbs) whose consequences can be serious on the functional capacities. Studies on the quality of life show that adaptation to the handicap is done in a continuous way and a long time after the initial phase of rehabilitation. They underline the importance of professional resources, psychological reactions and previous experiences of the spinal cord injury patients in appreciating the quality of life after the traumatism. CONCLUSION: The specificities of the aging of the spinal cord injury patients require to be well known and underline the importance and the necessity of an adequate and specific follow-up. On a more general plan, they imply a reflection on the strategies of initial rehabilitation, not to compromise the future of these spinal cord injury patients.

[Isolated truncular paralysis of the musculocutaneous nerve of the upper limb]. / Paralysies tronculaires isolées du nerf musculocutané au membre supérieur.

Isolated palsy of the musculocutaneous nerve, terminal branch of the lateral cord of the brachial plexus, is rare. It is responsible for sensory loss of the distal forearm and weakness of elbow flexion. It occurs after shoulder or clavicle surgery, trauma (fracture, dislocation, blows on the shoulder), violent exercice or extension of the forearm, prolonged positioning of the shoulder in extension-abduction-external rotation and phlebotomy. Different mechanisms such as stretching, compression or direct nerve injury are encountered. We report 5 cases with isolated musculocutaneous nerve palsy, including bilateral palsy caused by violent forearm extension. In other cases, mechanisms were an extensive stretching during surgery and compression caused by prolonged supine position. Different injury locations and causes described in literature are reviewed.

Isolated musculocutaneous nerve palsy in a spinal cord injury.

Isolated musculocutaneous nerve palsy is rare. We report one case of a bilateral palsy of this nerve following a road accident which led to a complete thoracic level paraplegia.

External anal sphincter function in spinal patients. Electromyographic and manometric study.

Six patients with complete transection of the spinal cord and six healthy volunteers were examined by using anorectal manometry together with electromyographic (EMG) recording of the external anal sphincter composed of striated muscle. Anal pressure and EMG activity of the external anal sphincter were continuously recorded at rest and during gradual rectal distention (10, 20, 30, 40, and 50 ml) by means of an air-filled balloon eliciting a rectoanal inhibitory reflex (RAIR) at the upper part, and an inflation reflex (IR) at the lower part of the anal canal. All patients and controls had a RAIR for each rectal distention volume. A relationship between the duration of the RAIR and the rectal distention volume was present in controls only. In controls the IR was present for each rectal distention volume, whereas it was present in only one patient for a 40-ml volume. During the resting period, all controls showed continuous tonic EMG activity of the external anal sphincter, but after 30 minutes all the patients showed a decrease and ultimately in five cases a disappearance of the tonic EMG activity of the external anal sphincter. In spinal patients, the presence or absence of EMG activity of the external anal sphincter did not modify the anal canal pressure. These results indicate that: 1) the tonic EMG activity of the external anal sphincter seems to be under the control of supraspinal structures, because in spinal patients it disappears in the absence of sensitive inputs toward the spinal cord; 2) the absence of EMG activity at rest indicates that the external anal sphincter is not implicated in the RAIR disturbances observed in spinal patients; 3) the IR is not a spinal reflex but is under voluntary control, because it is not present in spinal humans; 4) in spinal humans the tonic EMG activity of the external anal sphincter does not play a role in the maintenance of the anal pressure at rest.

Colonic transit time and anorectal manometric anomalies in 19 patients with complete transection of the spinal cord.

In order to determine the relative importance of sympathetic and parasympathetic centers in the control of colorectal motility, colonic transit and anorectal motility were studied in 19 patients with complete spinal cord transection: group 1 (n = 5) where transection was above T9; group 2 (n = 6) where transection was between T9 and L2; group 3 (n = 8) where transection involved S2-S4. Colonic transit time was calculated by the radiopaque markers. Methods and results were compared with those of eight controls, all bedridden for non-digestive surgery. Anorectal motility was investigated by anorectal manometry, and results were compared with those of 17 healthy controls. Both mean right and left colonic transit times were not different in the three groups of patients and the bedridden control group. Mean rectosigmoid and total transit time increased in groups 2 and 3. In five patients of group 3 the mean anal canal (lower part) pressure was higher than in controls. Recto-anal inhibitory reflex was present in all patients, but their was no correlation in group 3 between the volume of rectal distension and both amplitude and duration of the recto-anal inhibitory reflex, and in group 1 between rectal distension and the duration of the recto-anal inhibitory reflex. Rectosigmoid transit time increased when sympathetic and parasympathetic spinal centers are injured, suggesting the importance of this extrinsic nervous control; right and left colonic transit are not affected by spinal cord lesion suggesting that the distal colon but not the proximal colon, is under spinal cord nervous control.(ABSTRACT TRUNCATED AT 250 WORDS)

Anorectal manometric anomalies in seven patients with frontal lobe brain damage.

We studied the anorectal manometric and urodynamic pattern of seven patients who had right and/or left frontal lobe injury to investigate the possibility that the frontal lobe area plays an important role in control of anorectal motility as it does for the urinary bladder. We found that the disturbances of anorectal manometric recordings were similar to those of urodynamic recordings: (1) lack of urinary bladder filling sensation (two cases), increased perception threshold of rectal distension (two cases); (2) uninhibited detrusor contractions during filling (five cases), spontaneous rectal contractions during the resting step (four cases); (3) absence of micturition (one case), absence of rectoanal inhibitory reflex (one case). Furthermore, in all but one patient, we observed a decrease in the amplitude and duration of the voluntary contraction of the anal canal (six cases). However, in two of the seven patients we found hypertonia in the anal canal (upper part: one case, lower part: one case), but never in the urethral canal. Our results suggest that frontal lobe may be involved in the nervous control of anorectal motility as it is for urinary bladder function. However, the lack of correlation between urinary and anorectal anomalies in individual cases suggests that these functions depend on distinct areas of the frontal lobe.

Radiopaque markers transit and anorectal manometry in 16 patients with multiple sclerosis and urinary bladder dysfunction.

Fecal incontinence and/or constipation are frequent complaints in multiple sclerosis associated with urinary bladder dysfunction, incontinence, and/or retention. Total and segmental colonic transit were studied by determination of radiopaque markers, and anorectal function by anorectal manometry, in 16 multiple sclerosis patients clinically defined (with urinary bladder dysfunction shown by urodynamic examination). Fifteen multiple sclerosis patients had constipation and 14 had increased colonic transit time; ten multiple sclerosis patients had fecal incontinence and five had spontaneous rectal contractions. It is suggested that increased colonic transit and anorectal dysfunction were secondary to neurologic disorders just as urinary bladder dysfunction is due to neurologic disorders in multiple sclerosis.