Loss of bone mineral density in hemiplegic patients after stroke: Prospective single-center study.

The aim of our prospective single-center study was to assess the loss of bone mineral density (BMD) in the year following stroke with hemiplegia. We evaluated functional disability and bone mineral density (BMD) in 18 patients immediately following and at 1 year of stroke with hemiplegia. The most significant variation in BMD concerns the femoral neck on the hemiplegic side: -0.0551±0.0548g/cm2: -6.85%. This loss is correlated with the functional motor score (Fugl-Meyer Assessment) (r=0.7573; P=0.0004). During follow-up, 11/18 patients fell and 2/18 had a fracture.

Serotonin Selective Reuptake Inhibitors (SSRIs) and Stroke.

PURPOSE OF REVIEW: The interest in SSRIs after stroke has increased in the past few years, with better knowledge of post-stroke depression and with the demonstrated capacity of some SSRIs to act on the functional recovery of non-depressed subjects. RECENT FINDINGS: Arguments for the action of SSRIs in favour of post-stroke neurological function recovery have improved through new elements: basic science and preclinical data, positive clinical trials and repeated series of stroke patient meta-analysis, and confirmation of favourable safety conditions in post-stroke patients. Global coherence is appearing, showing that SSRIs improve stroke recovery in non-depressed patients when given for 3 months after the stroke, with highly favourable safety conditions and a favourable benefit/risk ratio. Large series are still needed.

Recurrent inhibition is higher in eccentric compared to isometric and concentric maximal voluntary contractions.

AIM: This study was designed to investigate the influence of muscle contraction type on spinal recurrent inhibition during maximal voluntary contractions (MVC) of the plantar flexor muscles. METHODS: To that purpose, the paired Hoffmann-reflex (H-reflex) technique permitted to assess changes in recurrent pathway by comparing the modulations of test, reference and conditioning H-reflexes (H', Href and H1 respectively) in the soleus muscle during isometric, concentric and eccentric MVC. Twenty-five subjects participated in an experimental session designed to assess the activity of the recurrent inhibition pathway. RESULTS: The results indicate that both the electromyographic activity and the amplitude of H1 normalized to the maximal M-wave (Mmax ) were similar regardless of the muscle contraction type while the ratio between H' and H1 amplitudes was significantly smaller during eccentric compared with isometric and concentric MVC. Furthermore, Href and H' amplitudes did not differ significantly during both isometric and concentric MVCs while H' amplitude was significantly lower than Href amplitude during eccentric MVC. In addition, the V/Mmax ratio was similar for all muscle contraction type and greater H' amplitude was significantly correlated with greater V-wave amplitude regardless of the muscle contraction type. CONCLUSION: Together, the current results indicate that recurrent inhibition is elevated for the soleus muscle during eccentric compared to isometric and concentric MVC. Data further suggest that the Renshaw cell activity is specifically controlled by the descending neural drive and/or peripheral neural mechanisms during eccentric MVC.

Cerebral imaging of post-stroke plasticity and tissue repair.

Six months after stroke onset, 50 % of patients are still disabled and dependent, while many brain mechanisms of recovery remain partially unknown or misunderstood. However, brain imaging and cerebral connectivity analytical techniques have provided invaluable insights into such mechanisms and identified two main patterns of brain reorganization depending on stroke severity. The contralesional primary motor cortex can take over motor function in severely impaired patients, whereas the ipsilesional motor cortex or hemisphere reorganize themselves in good recoverers. These patterns evolve with time after stroke, and highlight ipsilesional and contralesional primary and secondary areas that appear to take over lost functions. The crucial role of these areas has been confirmed by histological tracer studies. In addition, non-invasive techniques can stimulate post-stroke brain plasticity, although appropriate targets first need to be found. Imaging has proved useful for finding such appropriate targets and has also provided biomarkers of efficacy with various therapies. Moreover, it has provided some clues to the mechanisms of action of recovery-enhancing drugs. These imaging techniques have also identified patients who show atypical reorganization and recovery patterns. Thus, it may be necessary to design individualized and targeted therapies.

[Study of the sensitivity of renal ultrasonography as an indirect means of assessing renal function in patients with neurogenic bladder, from a cohort of 103 patients]. / Étude de la sensibilité de l'échographie rénale comme moyen indirect d'évaluation de la fonction rénale chez les patients porteurs d'une vessie neurologique, à partir d'une cohorte de 103 patients.

OBJECTIVES: The assessment of renal function is essential to follow up the patients with neurogenic bladder. The objective of this study was to determine if renal ultrasonography would both evaluate the morphology of the urinary tract and renal function. METHOD: In a retrospective study, all patients followed for neurogenic bladder were included, regardless of their neurological disease. Renal function was estimated by creatinine clearance (Cl24 h), the reference test in neurological patients, the glomerular filtration rate by the MDRD simplified (MDRDs) and CKD-EPI creatinine formula, and we identified renal abnormalities detected on ultrasonography. RESULTS: One hundred and three patients were included (57 men-36 women), mean age 51±13 years. Fifty-nine patients had multiple sclerosis, 23 spinal cord injury. Depending on the method used (Cl24h, MDRDs, CKD-EPI creatinine) respectively 54, 49 and 39 patients had abnormal renal function; eleven patients had abnormal findings on renal ultrasonography. The sensitivity of ultrasonography as an indirect indicator of renal function depending on the method used (Cl24h, MDRDs, CKD-EPI creatinine) was equal respectively to 14%, 8% and 10%. CONCLUSION: Renal ultrasonography, which is essential to follow up the neurogenic bladder, is not enough sensitive to detect abnormal renal function and should continue to be associated with an evaluation of renal function, which is suitable for neurological patients. LEVEL OF EVIDENCE: 4.

Post-stroke hemiplegia rehabilitation: evolution of the concepts.

Stroke rehabilitation has undergone a revolution over the last three decades. Cohort studies have consistently reinforced the importance of post-stroke rehabilitation to stimulate recovery, but the concepts of empirical methods originally proposed by therapists to rehabilitate these patients have not withstood clinical analysis. Functional neuroimaging and animal models have unveiled the mechanisms underlying functional recovery and helped teams understand its limitations and improvement modalities. These neuroscience discoveries constitute the grounds needed to understand the emergence of new technologies: robotics and virtual reality. The objective of this review of the literature was to select key works in this field to better understand current therapeutic possibilities.

An individual rehabilitation program: evaluation by Parkinsonian patients and their physiotherapists.

OBJECTIVES: The purpose of this work was to study the feasibility of an individual Parkinson disease (PD) rehabilitation program based on each patient's prevalent symptoms and to determine the effects of this program on patient's quality of life as well as the level of patient's and physiotherapist's satisfaction with the program. PATIENTS AND METHODS: In association with physiotherapists with expertise in PD, a physical medicine and rehabilitation physician, we elaborated a physical therapy program based on the core areas for physical therapy in PD: transfers; posture; balance and falls; physical capacity and inactivity. Within this program, we selected exercises tailored to each patient's main impairment and proposed this selection to their local physiotherapist for three months. Quality of life was evaluated with PDQ-39 at baseline and after three months of the individualized physical therapy program. We built an anonymous satisfaction questionnaire for patients and physiotherapists that was filled out at the end of the program. RESULTS: One hundred and three individuals with moderately advanced but clinically stable idiopathic PD were included. Significant improvement was found for the emotional well-being, bodily discomfort and stigma domain (P ≤ 0.05). No significant improvement was found for the other PDQ-39 domains. The mean global satisfaction figures for this program were 6.0 ± 2.4 and 7.2 ± 2.1 for patients and physiotherapists respectively. Most of the patients felt improved by the physiotherapy program and especially for transfer, balance, gait, and mobility. CONCLUSION: Our study found evidence of the potential benefits of a patient-tailored physiotherapy program. Such a program was feasible and had a favorable impact on patients' quality of life and on physiotherapists' practices for PD patients. Specific physiotherapy may be effective to limit physical mobility impairment. Our results also pointed out that physiotherapy may be efficient to confine the negative impact of social isolation, pain and emotional reactions. Such a program should be associated with a therapeutic education intervention such as encouraging patients to perform physical therapy exercises alone.

Transcranial magnetic stimulation in brain injury.

OBJECTIVES: Transcranial magnetic stimulations (TMS) have been used for many years as a diagnostic tool to explore changes in cortical excitability, and more recently as a tool for therapeutic neuromodulation. We are interested in their applications following brain injury: stroke, traumatic and anoxic brain injury. DATA SYNTHESIS: Following brain injury, there is decreased cortical excitability and changes in interhemispheric interactions depending on the type, the severity, and the time-lapse between the injury and the treatment implemented. rTMS (repetitive TMS) is a therapeutic neuromodulation tool which restores the interhemispheric interactions following stroke by inhibiting the healthy cortex with frequencies ≤1Hz, or by exciting the lesioned cortex with frequencies between 3 and 50Hz. Results in motor recovery are promising and those in improving aphasia or visuospatial neglect are also encouraging. Finally, the use of TMS is mainly limited by the risk of seizure, and is therefore contraindicated for many patients. CONCLUSION: TMS is a useful non-invasive brain stimulation tool to diagnose the effects of brain injury, to study the mechanisms of recovery and a non-invasive neuromodulation promising tool to influence the post-lesional recovery.

Posterior tibial tendon transfer in the spastic brain-damaged adult does not lead to valgus flatfoot.

BACKGROUND: We studied the possible development of valgus flat foot after transfer of the posterior tibial tendon to the lateral cuneiform, used for surgical restoration of dorsiflexion in brain-damaged adult patients with spastic equinovarus foot. METHODS: Twenty hemiplegic patients were reviewed with a mean postoperative follow-up of 57.9 months. Weightbearing radiographs, static baropodometry analysis and functional evaluation were used to assess postoperatively outcomes. RESULTS: On the operated side, weightbearing radiographs showed an absence of medial arch collapse and a symmetrical and physiological hindfoot valgus; static baropodometric analysis showed a reduced plantar contact surface with a pes cavus appearance. The surgical procedure yielded good functional results. Nineteen patients were satisfied with the outcome of their surgery. CONCLUSIONS: Our findings support that transfer of the posterior tibial tendon does not lead to valgus flat foot in the spastic brain-damaged adult, and is still a current surgical alternative for management of spastic equinovarus foot.

Impact of intermittent catheterization on the quality of life of multiple sclerosis patients.

PURPOSE: Lower urinary tract dysfunction is common in multiple sclerosis (MS). The purpose of this study was to prospectively evaluate the impact of intermittent catheterization (IC) on the quality of life of patients affected by MS. METHODS: Between 2007 and 2009, we admitted 23 patients to teach them the technique of IC. Their quality of life was evaluated before and more than 6 months after the beginning of learning the technique, when the urinary situation was stable. Two questionnaires were used: one specific for urinary disorders (QUALIVEEN(®)) and one general (SF-36(®)). RESULTS: Twenty-two patients followed this different way of bladder emptying. More than 6 months (9.3 ± 3 months on average) after first learning to use IC, the impact of urinary disorders explored by Qualiveen(®) had significantly decreased (the overall quality of life; bother with limitation; fears; feelings; Wilcoxon's test, respectively p = 0.004; 0.007; 0.02; 0.02) while the quality of life was not diminished. CONCLUSION: Intermittent catheterization (IC) in association with overall urinary management, among patients affected by MS, is well accepted and reduces the impact of urinary dysfunction on their quality of life.

[Pathophysiology of spasticity]. / Physiopathologie de la spasticité

The term "spasticity" describes the velocity-dependent increase in tonic stretch reflexes. The symptom is commonly seen in patients with injury to the central nervous system. It is rarely isolated but, instead, part of a set of symptoms that is sometimes confusing. However, the pathophysiology of the symptom has evolved over the past three decades, and it is now considered part of a global process that includes not only spinal reflex loop modifications, but also changes in the biomechanical properties of muscle fibers. Finally, recent studies of changes in the membrane properties of motor neurons and the occurrence of plateau potential have opened new perspectives. This review aims to describe these new pathophysiological models.