Assessing the impact of a patient education programme on pressure ulcer prevention in patients with spinal cord injuries.

OBJECTIVES: There is currently a low level of evidence for the impact of patient education on the management of patients with chronic neurological disease at risk of developing pressure ulcers. The objective of this study was to assess the impact of a patient education programme on pressure ulcer prevention in patients with chronic spinal cord injuries. MATERIALS AND METHODS: This study included adult patients with any spinal cord injury, regardless of the cause. Participants attended 2 group workshops focusing on pressure ulcer prevention. Various clinical data were gathered during an initial individual interview and at 3, 6 and 12 months, along with rating scale values from the Hospital Anxiety and Depression Scale, Rosenberg self-esteem scale, Schwarzer self-efficacy scale, a quality of life scale (SF-36) and the revised Skin Management Needs Assessment Checklist (Revised SMnac), which was used as the primary endpoint. RESULTS: Twenty patients were included in the study. The mean patient age was 52 years (SD: 9,8). Sixteen patients had traumatic spinal cord injuries, with a median injury duration of 234 months (IQR: 123-407). Seventy-five percent had had a pressure ulcer in the twelve months prior to the study. Patient education was shown to have a significant impact on skin management ability, with a highly significant increase in the overall revised SMnac score at 3 months. These results were stable over time, from 6 to 12 months. Six patients developed a pressure ulcer during the study (30%). CONCLUSION: This study supports the hypothesis that a therapeutic educational program conducted at the chronic phase in spinal cord injured individuals has an impact.

Kienböck's disease and cerebral palsy case report.

INTRODUCTION: Pain is the main problem in patients suffering from cerebral palsy, particularly in adults. The upper limbs are affected in 25% of cases. Here, we report the case of a patient with Kienböck's disease. METHOD: Clinical case and literature review. A 28-year-old man suffering from dystonic quadriplegia consulted for progressively worsening pain in the right wrist. Kienböck's disease was diagnosed and conservative treatment with botulinum toxin in the flexor carpi radialis recommended. A good result was obtained with a decrease in pain. This result was still present two years later. DISCUSSION: Although few references are made to it in literature, Kienböck's disease in cerebral palsy is probably underestimated. Maintenance of the wrist in a permanent flexed position and muscular hypertonia may be risk factors. Knowledge of this particular clinical picture will enable it to be detected promptly and thus enable conservative treatment to be organised with a maximum chance of therapeutic success, preventing the need for surgery.

[Intrasphincteric pharmacological treatments in neurourology]. / B. traitements pharmacologiques intra-sphinctériens en neuro-urologie.

Neurogenic detrusor-sphincter dyssynergia can be treated medically by intrasphincteric injection of lidocaine or botulinum toxin. The indications, practical modalities and results of these two molecules are described in the light of a review of the literature, which indicates that lidocaine injections alone are useless. The results of the various types of transperineal injection of botulinum toxin A with electromyographic or direct endoscopic guidance are described.

Physical training and multiple sclerosis.

For many years, patients with multiple sclerosis (MS) were advised to avoid exercise because of the risk of increased neurological impairment. This article reviews the literature related to MS and physical exercise. Physical exercise depends on patients' physiological tolerance and response to exercise. MS patients can exhibit dysfunction of cardiovascular adjustment accompanied by respiratory involvement, which can alter aerobic capacity. These abnormalities tend to increase with the neurological impairment. Muscle weakness is the consequence of not only altered central motor drive but also disuse. Several studies have shown the benefits of physical training, with improvements in aerobic capacity, gait parameters and fatigue, and an influence on quality of life. Regular aerobic physical activity is necessary to maintain the benefit of physical training.

[Pain in adults with cerebral palsy]. / La douleur chez le sujet adulte infirme moteur cérébral.

INTRODUCTION: Pain is the main problem in patients with cerebral palsy. To improve the quality of life of people with cerebral palsy, a good knowledge of the clinical syndrome is necessary. METHOD: We reviewed the published data of the APIB study. We analysed data about pain, especially its correlation with age, motor handicap, and depressive syndrome. We also reviewed the literature to survey the pain syndrome in such a situation. RESULTS: A total of 562 patients responded to the APIB survey (mean age 36+/-14 years). Of these, 75% complained about physical pain. Pain was significantly associated with age, motor handicap, depressive syndrome, and sleep disorders. DISCUSSION: A study of the literature confirms our results on pain in cerebral palsy from the APIB survey. The main localisations of pain are the spine, and scapular and pelvic girdles. Pain syndromes of the upper and lower limbs are also frequent, with much due to overuse. Some rare causes include heterotopic ossifications. CONCLUSION: A good knowledge of the characteristics of the pain syndromes in people with cerebral palsy is important because of the great prevalence of this problem in this population. Better knowledge will help prevent the pain and improve quality of life.

[Two cases of rehabilitation in Ehler-Danlos syndrome]. / Prise en en charge rééducative de la maladie d'Elhers-Danlos: à propos de deux cas.

PURPOSE: Ehlers-Danlos syndrome is rare and little known. It comprises a heterogeneous group of heritable connective tissue disorders characterized by articular hypermobility, skin extensibility and tissue fragility. Diagnosis may be difficult and often delayed. CASE REPORT: Here we describe 2 cases of women with Ehlers-Danlos syndrome. The first had scoliosis with back pain and joint hypermobility. The second presented with hypermobility and joint dislocation, which increased during pregnancy. In these 2 cases, rehabilitation management produced clinical improvement. DISCUSSION: Orthopaedic complications such joint pain, joint swelling, joint dislocation, back pain, with walking and hand function disability are the main problems in Ehlers-Danos syndrome. Surgery may be necessary to correct dislocated joints but is often not sufficient to resolve the handicap, and physical therapy has an important place in management. CONCLUSION: Ehlers-Danlos syndrome is an evolving disease that can lead to great impairment. Thus, physicians must be aware of this syndrome to offer the best management, with the appropriate use of orthotic devices, specific strengthening routines, education in proper body mechanics and assistive devices, to prevent joint dislocation and subluxations responsible for pain and handicap.

[Multiple sclerosis and physical activities]. / Activité sportive et sclérose en plaques.

INTRODUCTION: Multiple sclerosis (MS) is a neurological disease of the central nervous system that most often affects young people. It is characterized by various debilitating symptoms. The aim of this study was to assess physical activities in patients with MS and how these affect their quality of life. METHODS: Forty-five patients were questioned about their physical activities. The following were taken into account: the characteristics of MS within each patient, the level of disease severity (EDSS score) and the quality of life (on the SEP-59 questionnaire). RESULTS: Fifteen patients had to give up a physical activity because of their illness but more so due to ataxia, fatigue and muscular weakness. Fifteen patients take part in a physical activity, the principal motivation being for their personal well-being. The mean EDSS was 4.2. Answers on the SEP-59 revealed found that patients with MS who took part in a physical activity had significantly better well-being in general. DISCUSSION AND CONCLUSION: Physical activities seem to improve the quality of life of patients with MS who, in general, already have a poor quality of life in relation to the general population. Knowing that muscular function is improved through exercise in patients with an EDSS less than 6, it would seem advantageous for them to take part in a regular physical activity.

Effects of pregnancy and childbirth on the incidence of urinary disorders in multiple sclerosis.

OBJECTIVE: Women with multiple sclerosis frequently pose questions to physicians regarding the potential negative impact of pregnancy, especially on urinary disorders. About 50 to 80% of patients suffer from urinary disorders during the course of the disease. Trauma to the pelvic floor and the urethral sphincter during vaginal delivery may lead to the development of stress urinary incontinence. The purpose of this work was to study the consequences of pregnancy and childbirth on urinary problems. STUDY DESIGN: An inception cohort of 368 consecutive women suffering from multiple sclerosis (MS), according to the Poser criteria, were included in the study between June 1999 and June 2000. For each patient a full urological and obstetrical record was obtained. RESULTS: Two hundred and seventy-three women (74%) had had at least one pregnancy. The parous women were older at the time of the study (mean age: 45.5 years vs 35.5 years), and were older at MS onset (mean age: 32.8 years vs 25.7 years). The nulliparous women were more rapidly disabled, with a shorter time to reach an EDSS score of 3 from MS onset (mean time of 5.9 years versus 8.2 years in parous women). In parous women, 259 (95%) had had at least one vaginal delivery and 14 (5%) had had a caesarean only. Delivery modalities had no influence on urinary disorder frequency or the type of problems. CONCLUSION: On the basis of these data, there is actually no clear argument for systematically performing caesarean section in MS women. Urinary disorders in these women were mostly linked to the duration and the severity of the disease but not to pregnancy or delivery modalities. From our point of view, caesarean section must be decided only on classic obstetrical criteria as for healthy women independently of multiple sclerosis. However our data were open and retrospective.

[Home care and quality of life three years after stroke]. / Maintien à domicile et qualité de vie à distance d'un accident vasculaire cérébral.

INTRODUCTION: Stroke is the most disabling chronic disease among adults. The assessment of quality of life is of great importance to improve the management of patients with stroke sequelae returning to the community. METHOD: A total of 93 patients and their referring clinicians were contacted. Quality of life of patients three years after stroke was assessed by use of the Short-Form Health Survey (SF-36). RESULTS: Thirteen patients died during this period. Fifty participated in the study. The average age was 66.8 years. The patients who died were older and had an initial greater impairment after stroke than survivors. In most of the cases, a life plan, built during the inpatient rehabilitation period, could be achieved. Just six patients had to change their way of life during the three years after stroke. A total of 44% of the patients needed human assistance for basic daily living activities. Patients with stroke had lower scores on the SF-36 than their healthy peers. All subscale scores differed for patients with stroke, as compared with health peers. Initial disability, the occurrence of falls, age and urinary incontinence at the time of the study indicated poor prognosis. DISCUSSION: Our results are close to those previously published: a great number of people who survive stroke live with sequelae that requires assistance in the home and have decreased quality of life. These results stress the importance of follow-up by a rehabilitation team to prevent altered quality of life, with a special care to urinary incontinence and falls, especially in old people with abundant sequelae of stroke.

[Charcot-Marie-Tooth disease associated with syringomyelia revealed by urinary disorders]. / Association de maladie de Charcot-Marie-Tooth et de syringomyélie révélée par la survenue de troubles urinaires.

PURPOSE: Charcot-Marie-Tooth (CMT) disease is characterized by genetic and clinical heterogeneity. The occurrence of urinary disorders is unusual and requires further investigation. CMT disease and syringomyelia are not usually associated. Moreover, primary urinary signs in syringomyelia are not frequent. CASE REPORT: An 11-year-old girl with CMT disease 1A duplication presented with motor deficit of the leg associated with urinary disorders. Urodynamic study revealed neurogenic detrusor overactivity, and magnetic resonance imaging confirmed syringomyelia extending from T11 to an L1 located conus. DISCUSSION: Review of the literature confirmed the possibility of primary urinary signs in syringomyelia, with only one case of CMT and urinary signs described. In this case, the diagnosis was radicullar and medullar compression by a hypertrophic nerve formation called an "onion bulb" reflecting the demyelinisation and remyelinisation cycle. CONCLUSION: Urinary signs in CMT disease are exceptional and require investigation into the possibility of a central lesion.

[Eccentric isokinetic strengthening in hamstrings of patients with multiple sclerosis]. / Renforcement musculaire isocinétique excentrique des ischiojambiers chez des patients atteints de sclérose en plaque.

OBJECTIVE: To assess the benefit of a program of rehabilitation involving eccentric isokinetic muscle strengthening for hamstrings of patient with multiple sclerosis. PATIENTS AND METHODS: A total of 28 patients with multiple sclerosis and abnormalities when walking who underwent a program of rehabilitation involving eccentric isokinetic muscle strengthening associated with classical neurological rehabilitation. Assessment was by use of an isokinetic test, clinical examination and score on a visual analog scale (VAS) about quality of walking at the beginning and end of the rehabilitation program and three months later. The rehabilitation program involved eccentric isokinetic exercises during 12 sessions. RESULTS: Patients with multiple sclerosis and difficulty walking showed weak hamstrings on manual muscular testing. After 12 sessions of isokinetic eccentric rehabilitation, hamstring and quadriceps strength increased, VAS score increased, and recurvatum of the knee improved in 26 cases. Three months later, the score for quality of walking remained the same, but that for strength returned to a previous level. CONCLUSION: Hamstring strength in patients with multiple sclerosis can be improved without complication with use of eccentric isokinetic rehabilitation. This is an interesting way to improve the quality of walking in these patients.

[Influence of temperature changes on clinical symptoms in multiple sclerosis: an epidemiologic study]. / Influence des variations de la température sur la symptomatologie clinique dans la sclérose en plaques: étude épidémiologieque.

UNLABELLED: The effects of the modifications of temperature are well known in patients affected by multiple sclerosis (MS). They are variable and can influence daily living. This sensibility can be used in the management of the disabilities. METHOD: An epidemiological study was realized on a cohort of 191 patients suffering from MS referred to the MS clinic of Rennes (France). All the patients were questioned about the influence of heat and cold on their clinical symptoms (fatigue spasticity, walking disorders, vision, em leader ). Correlations with the main clinical characteristics were studied. POPULATION: One hundred ninety-one patients, 129 women and 62 men with an average age of 47.6 +/- 10 years were interviewed. Average score EDSS was of 5.2 +/- 1.5. The mean duration of MS was 13.5 +/- 10 years. RESULTS: One hundred forty-seven patients (77%) reported a sensibility to the temperature. Heat deteriorated function in 104 cases and 82 patients improved with cold. Paradoxically 20 patients reported to be deteriorated with cold and 19 improved with heat. Fatigue and walking were the most sensitive to temperature fluctuations. No particular clinical profile could be established. Fifty percent of the patients used this sensibility with therapeutic aim in everyday life. DISCUSSION: The clear influence of temperature fluctuations on the clinical symptom was confirmed in this study. However, there is a great variability from one patient to another. Different hypotheses have been evoked to explain this phenomenon. The most likely is an influence on the nervous specific conductivity. In routine practice cold physiotherapy will be proposed on case by case basis and still has an interesting place in the rehabilitation management.

[Interest of visual biofeedback training in rehabilitation of balance after stroke]. / Intérêt de la rééducation par biofeedback visuel sur plateforme de stabilométrie dans la prise en charge des troubles posturaux des hémiplégiques vasculaires.

OBJECTIVE: The aim of this study was the assessment of visual biofeedback in the management of balance disorders after stroke. MATERIAL AND METHODS: This is a prospective randomised trial, which compares visual biofeedback training and traditional balance training. Twenty-seven patients took part in this study: 13 in the first group and 14 in the second group. The rehabilitation program in the first group consists in an association of visual biofeedback and traditional training during 3 weeks. For the second group traditional training was used alone. Clinical, functional and forceplate assessments were performed before and after the program of rehabilitation. RESULTS: All the patients had a clinical and functional improvement. However, patients who have benefited from biofeedback training had a significant improvement of the forceplate parameters with closed eyes. DISCUSSION AND CONCLUSION: Those results confirm the interest of rehabilitation in balance disorders after stroke. The use of biofeedback training incorporated into functional physiotherapy affords added benefits probably by a best integration of proprioceptive informations.

Magnetoencephalography in stroke: a 1-year follow-up study.

Recovery after stroke is closely linked to cerebral plasticity. Magnetoencephalography (MEG) is a non-invasive technique, which allows location of cerebral cells activities. In the present work, a cohort of patients has been studied with MEG. Twelve patients with a recent ischemic or hemorragic stroke were included as soon as possible after onset of stroke. Neurologic assessment, including standard neurologic examination, functional independence measure (FIM) and Orgogozo's scale was performed for 1 year in addition to a study of the somatosensory evoked field (SEF) using a 37-channel Biomagnetometer system. No response could be recorded in five patients at the first SEF exploration. In three cases, no response was ever recorded during the study. All these patients had a bad recovery. The location of the SEF sources was always in the normal non-infarcted cortex of the postcentral gyrus. Sensory recovery seemed to be linked to the reorganization of the persistent functional cortex, which was a limiting factor for recovery. These observations confirm the experimental results obtained in animal models. After stroke it can be assumed that in the case of incomplete lesion, an intensive sensory peripheral stimulation could maximize the use of residual sensory function and then contribute to improve the sensory deficit. In case of total sensory loss other techniques have to be used, such as visual monitoring of hand activity in order to improve hand function.

[Heterotopic ossification in Guillain-Barré syndrome]. / Paraostéoarthropathies dans le syndrome de Guillain-Barré

INTRODUCTION: Heterotopic ossification are frequent in central nervous disease, on the opposite just a few cases have been described in peripheral disorders. PURPOSE: To describe three cases of Guillain-Barré syndrome complicated by heterotopic ossification. METHODS: From the detailed case reports and a review of the literature. RESULTS: The authors report three cases of heterotopic ossification in Guillain-Barré syndrome. Each of them had serious symptom and had to go in intensive care. Two of them had encephalopathy. A patient had compression of ulnar nerve as complication of heterotopic ossification. In all cases the consequence of the heterotopic ossifications lead to a great functional handicap. DISCUSSION: Heterotopic ossification is a frequent complication in central neurologic lesions such spinal cord injury or brain injury. Just a few cases following peripheral nerve disorders have been reported. Serious neurologic deficit and encephalopathy may influence the apparition of heterotopic ossifications in patients suffering from Guillain-Barre syndrome. This possibility of complication must be known by the clinicians who should have a special attention to such patients.

[Hemiplegia and return to domicile]. / Hémiplégie vasculaire et retour à domicile.

OBJECTIVE: We have studied the outcome after a stroke on being discharged from a department of physical medicine and rehabilitation in patients with hemiplegia, and the factors influencing the choice of the orientation. MATERIAL AND METHOD: This prospective study was based on 93 patients. The mode of discharged was patient's domicile, institution, the number of death was also noted. The potentially influential factors studied were age, the side with hemiplegia, the aetiology of the hemiplegia, co-morbidity, the delay in starting rehabilitation, the neurological damage evaluated by the Orgogozo score, the initial functional damage evaluated by Functional Independence Measure (FIM) and by the functional score carried out within the framework PMSI(1) (computerised programme of medical care), the existence of aphasia, the existence of a depressive syndrome, presence of hemineglect, presence of superficial or profound sensory disorders, incontinence at the start of rehabilitation and at one month after the stroke, the existence of cognitive or psychiatric disorders. The tests used were the non-parametric test of Mann and Whitney, the chi(2) test and the correlation test. The threshold of significance used was 0.05. RESULTS: Based on 93 patients (47 women and 46 men, average age 64.8) 81 have gone back to their previous domicile, 11 were oriented toward an institution. One patient died. The predictive factors or those linked to an absence of return to the previous domicile were the age, social situation, the delay in starting rehabilitation, presence of aphasia, the initial and final functional damage, the impossibility to walk, the presence of a depressive syndrome, urinary incontinence. CONCLUSION: The authors stress the importance of familial environment and of functional independence in establishing a prognosis for return to the domicile.

[Fractures of ossified Achilles tendon in cerebral palsy. Apropos of a case]. / Fractures d'ossifications de tendons d'Achille chez un infirme moteur cérébral. A propos d'un cas.

PURPOSE: To describe a case of ossification of the Achilles tendon fracture in cerebral palsy. METHODS: From the detailed case report, review of the literature was performed. RESULTS: A 49 years old patient who have presented a bilaterally pain syndrome of the ankles. Clinical investigations showed a bilaterally ossification of the Achilles tendon, with a fracture on the left side. The evolution was marked by the occurrence of an other fracture on the right side. Both needed surgery. Just a few cases of such ossification have been reported in literature. This ossification are more often asymptomatic. Complications such fracture are rare, no more than 20 cases have been reported, and only one case in cerebral palsy. The etiologic factors are multiple, including partial or complete rupture or surgery, with a probably great importance of tissular hypoxemia. Men older than 40 years old are more often concerned. DISCUSSION: In the majority of case ossification of the Achilles tendon are painless, and fortuitously discovered. In case of ankle pain syndrome, a research of fracture must be done. Standard X-rays and RMI are the more instructive exams for diagnosis. The treatment of these fractures is more often the surgery. Orthopaedic treatments remain rarely used because of the duration of treatment and of a major risk of recurrence. CONCLUSION: In adult cerebral palsy a standard X-rays of the two Achilles tendon must be realised in case of the occurrence of an ankle pain syndrome especially if an antecedent of Achilles tendon lengthening is known.

Influence of urinary management on urologic complications in a cohort of spinal cord injury patients.

OBJECTIVE: To study urologic complications in patients with spinal cord injury (SCI) in relation to their bladder management. DESIGN AND SETTING: A cohort study of patients with SCI in a rehabilitation center. PARTICIPANTS: One hundred eighty-two patients were studied; demographic data, disease characteristics, and urologic history were obtained for each. INTERVENTION: Patients responding to a questionnaire were given a clinical exam. Their medical records were reviewed, with particular attention given to the following urologic complications: lithiasis, urinary infections, orchiepididymitis, urethral trauma, vesicorenal reflux, and renal failure. RESULTS: Results are reported for 123 patients. Time since SCI was 8 years. Intermittent catheterization was the main method of bladder management. Only 32 patients had changed their method of vesical voiding. Urinary complications had developed in 75% of patients. The most common complication was urinary infection. Vesicoureteral reflux occurred in 26% of patients using percussion. Trauma related to catheterization was the main problem with intermittent catheterization, responsible for a high rate of orchiepididymitis. CONCLUSION: Intermittent catheterization is the most-used method of bladder management, but with a nonnegligible rate of urethral trauma in men. Percussion and Credé maneuver appear to be acceptable techniques of bladder management if the patient is closely monitored.