Quantification of push-off and collision work during step-to-step transition in amputees walking at self-selected speed: Effect of amputation level.

Maintaining forward walking during human locomotion requires mechanical joint work, mainly provided by the ankle-foot in non-amputees. In lower-limb amputees, their metabolic overconsumption is generally attributed to reduced propulsion. However, it remains unclear how altered walking patterns resulting from amputation affect energy exchange. The purpose of this retrospective study was to investigate the impact of self-selected walking speed (SSWS) on mechanical works generated by the ankle-foot and by the entire lower limbs depending on the level of amputation. 155 participants, including 47 non-amputees (NAs), 40 unilateral transtibial amputees (TTs) and 68 unilateral transfemoral amputees (TFs), walked at their SSWS. Positive push-off work done by the trailing limb (WStS+) and its associated ankle-foot (Wankle-foot+), as well as negative collision work done by the leading limb (WStS-) were analysed during the transition from prosthetic limb to contralateral limb. An ANCOVA was performed to assess the effect of amputation level on mechanical works, while controlling for SSWS effect. After adjusting for SSWS, NAs produce more push-off work with both their biological ankle-foot and trailing limb than amputees do on prosthetic side. Using the same type of prosthetic feet, TTs and TFs can generate the same amount of prosthetic Wankle-foot+, while prosthetic WStS+ is significantly higher for TTs and remains constant with SSWS for TFs. Surprisingly and contrary to theoretical expectations, the lack of propulsion at TFs' prosthetic limb did not affect their contralateral WStS-, for which a difference is significant only between NAs and TTs. Further studies should investigate the relationship between the TFs' inability to increase prosthetic limb push-off work and metabolic expenditure.

Toe walking in children with cerebral palsy: a possible functional role for the plantar flexors.

Equinus and toe walking are common locomotor disorders in children with cerebral palsy (CP) walking barefoot or with normal shoes. We hypothesized that, regardless of the type of footwear, the plantar flexors do not cause early equinus upon initial foot contact but decelerate ankle dorsiflexion during weight acceptance (WA). This latter action promoted by early flat-foot contact is hypothesized to be functional. Hence, we performed an instrumented gait analysis of 12 children with CP (Gross Motor Function Classification System class: I or II; mean age: 7.2 yr) and 11 age-matched typically developing children. The participants walked either barefoot, with unmodified footwear (4° positive-heel shoes), or with 10° negative-heel shoes (NHSs). In both groups, wearing NHSs was associated with greater ankle dorsiflexion upon initial foot contact, and greater tibialis anterior activity (but no difference in soleus activity) during the swing phase. However, the footwear condition did not influence the direction and amplitude of the first ankle movement during WA and the associated peak negative ankle power. Regardless of the footwear condition, the CP group displayed 1) early flattening of the foot and ample dorsiflexion (decelerated by the plantar flexors) during WA and 2) low tibialis anterior and soleus activities during the second half of the swing phase (contributing to passive equinus upon foot strike). In children with CP, the early action of plantar flexors (which typically decelerate the forward progression of the center of mass) may be a compensatory mechanism that contributes to the WA's role in controlling balance during gait.NEW & NOTEWORTHY Adaptation to walking in negative-heel shoes was similar in typically developing children and children with cerebral palsy: it featured ankle dorsiflexion upon initial contact, even though (in the latter group) the soleus was always spastic in a clinical examination. Hence, in children with cerebral palsy, the early deceleration of ankle dorsiflexion by the plantar flexors (promoted by early flattening of the foot, and regardless of the type of footwear) may have a functional role.

The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review.

BACKGROUND AND OBJECTIVE: Phantom limb pain (PLP) is a major problem after limb amputation. Mirror therapy (MT) is a non-pharmacological treatment using representations of movement, the efficacy of which in reducing PLP remains to be clarified. Here, we present the first systematic review on MT efficacy in PLP and phantom limb movement (PLM) in amputees (lower or upper limb). METHODS: A search on Medline, Cochrane Database and Embase, crossing the keywords "Phantom Limb" and "Mirror Therapy" found studies which were read and analyzed according the PRISMA statement. RESULTS: Twenty studies were selected, 12 on the subject of MT and PLP, 3 on MT and PLM, 5 on MT and both (PLP and PLM). Among these 20 studies, 5 were randomized controlled trials (163 patients), 6 prospective studies (55 patients), 9 case studies (40 patients) and methodologies were heterogeneous. Seventeen of the 18 studies reported the efficacy of MT on PLP, but with low levels of evidence. One randomized controlled trial did not show any significant effect of MT. As to the effect of MT on PLM, the 8 studies concerned reported effectiveness of MT: 4 with a low level of evidence and 4 with a high level of evidence. An alternative to visual illusion seems to be tactile or auditory stimulation. CONCLUSION: We cannot recommend MT as a first intention treatment in PLP. The level of evidence is insufficient. Further research is needed to assess the effect of MT on pain, prosthesis use, and body representation, and to standardize protocols.

Phantom hand and wrist movements in upper limb amputees are slow but naturally controlled movements.

After limb amputation, patients often wake up with a vivid perception of the presence of the missing limb, called "phantom limb". Phantom limbs have mostly been studied with respect to pain sensation. But patients can experience many other phantom sensations, including voluntary movements. The goal of the present study was to quantify phantom movement kinematics and relate these to intact limb kinematics and to the time elapsed since amputation. Six upper arm and two forearm amputees with various delays since amputation (6months to 32years) performed phantom finger, hand and wrist movements at self-chosen comfortable velocities. The kinematics of the phantom movements was indirectly obtained via the intact limb that synchronously mimicked the phantom limb movements, using a Cyberglove® for measuring finger movements and an inertial measurement unit for wrist movements. Results show that the execution of phantom movements is perceived as "natural" but effortful. The types of phantom movements that can be performed are variable between the patients but they could all perform thumb flexion/extension and global hand opening/closure. Finger extension movements appeared to be 24% faster than finger flexion movements. Neither the number of types of phantom movements that can be executed nor the kinematic characteristics were related to the elapsed time since amputation, highlighting the persistence of post-amputation neural adaptation. We hypothesize that the perceived slowness of phantom movements is related to altered proprioceptive feedback that cannot be recalibrated by lack of visual feedback during phantom movement execution.

Quality of life and satisfaction after multilevel surgery in cerebral palsy: confronting the experience of children and their parents.

OBJECTIVES: If the benefits of single-event multilevel surgery (SEMS) in ambulatory children with cerebral palsy have already been validated, especially in terms of functional outcomes, fewer studies have evaluated SEMS in terms of quality of life and satisfaction with surgical outcomes, especially pertaining to the opinions of children and their family. The objectives of this study were to confront the perceptions of parents and the experience of their operated children in terms of quality of life and surgical outcomes. MATERIALS AND METHODS: This was an observational, descriptive, single-center study conducted in a regional Pediatric Physical Medicine and Rehabilitation (PM&R) center, which is considered a reference center in this region of France. The subjects recruited were ambulatory children with cerebral palsy (CP) who had SEMS between 2009 and 2011, and one of their parents. The specific "child" and "parent" CP-related modules of the DISABKIDS questionnaire were used to assess these children's quality of life post-surgery. Perceptions of parents and children regarding gait evolution and satisfaction with surgical outcomes were analyzed via a questionnaire developed by the author. Regarding quality of life and surgical outcomes, the correlation between the perception of parents and experience of children was estimated using the intraclass correlation coefficient (ICC) or prevalence-adjusted bias-adjusted kappa values (PABAK). RESULTS: Twelve children (83% of them boys) and their parents participated in the study. For the DISABKIDS questionnaire, a moderate correlation was found regarding functional impact (ICC=0.58; P<0.0178) but a high correlation was reported for the communication item of the questionnaire (ICC=0.73; P=0.0025). Regarding satisfaction with surgical outcomes, results showed a good correlation (PABAK=0.64). CONCLUSION: Concerning quality of life and satisfaction with surgical outcomes, our study showed a good or even high correlation between parents' perceptions and their child's experience. It is however essential to privilege the child's opinion whenever possible.

[Rehabilitation following primary repair of flexor tendons in adults]. / Rééducation après réparation primaire des tendons fléchisseurs des doigts chez l'adulte.

Rehabilitation after primary repair of flexor tendons, particularly in the early phase, has changed due to more solid suture repairs. The objectives of this article are to outline the general principles surrounding this rehabilitation, set out the indications for various early mobilization techniques and describe in detail the physiotherapy protocol used by the Physical Medicine and Rehabilitation Department of the Regional Institute of Rehabilitation in collaboration with the Plastic and Reconstructive Surgery Department of the Émile-Gallé Surgical Center in Nancy, France. This protocol is mainly used for adult patients and carried out in four stages over a 12-week period. If there are no contraindications, the patient learns protected early active self-rehabilitation during the first four postoperative weeks. The protocol includes standardized multidisciplinary follow-up until the social and occupational rehabilitation phase to ensure the best chance of functional recovery.

[Rehabilitation after secondary surgery of the flexor tendons of fingers and thumb]. / Rééducation après chirurgie secondaire des tendons fléchisseurs des doigts.

The repair of the finger flexor tendons can be complicated by the appearance of ruptures and peritendinous adhesions. Ruptures are often treated with tendon grafts. Peritendinous adhesions can require tenolysis. Following these two surgical procedures, there is a risk of new adhesions and rupture. Rehabilitation after this secondary surgery consists of a tailored, closely supervised protocol. Protocols used by the team at the Physical Medicine and Rehabilitation Department of the Regional Rehabilitation Institute and the team at the Plastic and Reconstructive Surgery Department of the Emile-Gallé Surgical Center of Nancy (France) are described. A close collaboration between these teams of surgeons and physical therapists is essential. After tendon grafting, protected early motion helps to move the transplant immediately while still protecting it. After tenolysis, immediate (several times a day) and extended rehabilitation ensures that the mobility obtained intraoperatively is maintained. It is performed in a specialized rehabilitation center during the first three postoperative weeks. The goal is to prevent new adhesions from forming while taking into account tendon's fragility.

Non-invasive cerebral stimulation for the upper limb rehabilitation after stroke: a review.

Numerous studies have recently been published on improving upper-limb motor function after stroke. There has been a particular interest in brain stimulation techniques, which could promote brain plasticity. In this review, transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS) are presented as techniques that could be relevant in Physical Medicine and Rehabilitation (PM&R) centers in the future. We are presenting a comprehensive literature review on the studies using tDCS or rTMS for upper-limb rehabilitation after a stroke. Both techniques have shown their ability to modify cortical excitability and to transitorily improve upper-limb function after one single stimulation session. The first placebo-controlled, blinded therapeutic trials, which included repeated daily sessions, seem quite promising, and deserve to be validated by further trials.

Knee kinetic pattern during gait and anterior knee pain before and after rehabilitation in patients with patellofemoral pain syndrome.

Patellofemoral pain is likely due to compressive force acting on the patella related in turn to knee extension moment. The latter variable was assumed to be (i) reduced during short-distance free walking in case of patellofemoral pain syndrome and (ii) increased after therapeutic pain reduction. Peak knee extension moment at beginning of stance phase was recorded by three-dimensional gait analysis in 22 controls and in 23 patients with patellofemoral pain syndrome before and after rehabilitation of knee extensors and flexors to reduce the pain. Pain would occur mainly in stressful activities such as stair negotiation or squatting and was quantified by the anterior knee pain scale. Peak knee extension moment was significantly reduced in all the patients before treatment (n=23) compared to controls, although no one had pain during free walking. In the 17 patients who experienced significant post-rehabilitation pain reduction in their stressful activities, the peak knee extension moment was significantly reduced before treatment compared to controls and significantly increased after treatment, reaching values similar to control values. The peak knee extension moment during free walking appears to be a good kinetic variable related to a compensatory mechanism limiting or avoiding anterior knee pain and may be of interest in assessing knee dynamics alteration in patients with PFPS.

[Reproducibility study of the "400 Points assessment", a measurement of the hand's functional ability]. / Étude de reproductibilité de la cotation du « Bilan 400 points ¼, une mesure de capacité fonctionnelle de la main.

OBJECTIVES: Evaluate the inter-rater and test-retest reproducibility of the "400 Points assessment", a measurement of the functional ability of the hand. The scale included four tests: function of the hand, prehension strengths, handling and displacement of things, and function with both hands. METHODS: Thirty patients with hand injuries were participated. The inter-rate agreements were examinated between three occupational therapists. The First rater was an experienced user of this instrument (observer 1), the second one was a novice user (observer 2), the last rater is a student who had never used it before (observer 3). Subjects were tested twice by the same raters independently, with 30 minutes intervals between tests. Statistical analysis was done by calculating average differences and intraclass correlation coefficient. RESULTS: (i) The difference between the three raters agreements was small for the two measurements, except for function with both hands in the second period. Every intraclass correlation coefficient was higher than 0.95. (ii) Difference between the two measurements was small for every observer. These differences are not significant except for function with both hands. Intraclass correlation coefficients are all higher than 0.82 even than 0.90 for the total score. The difference between the two periods for the overall test is small, from 5% to 10% for seven patients and from 10 to 15% for two patients. Differences at two times had the same agreement for the three observers. CONCLUSION: "400 Points assessment" is reproducible (inter-rater and test-retest reproductibility). The test "function with both hands" requires more experience of the assessment.

Suprascapular nerve entrapment in a patient with a spinal cord injury.

STUDY DESIGN: Case report. OBJECTIVES: To describe a case of suprascapular nerve entrapment (SNE) in a patient with a spinal cord injury (SCI) as a cause of shoulder pain. SETTING: Physical Medicine and Rehabilitation Institute, Nancy, France. REPORT: Six months after the occurrence of acute paraplegia T9 ASIA, a 45-year-old man complained of pain in the posterior and lateral areas of the left shoulder. A clinical assessment found an atrophy of the infraspinatus muscle and a muscular weakness during external shoulder rotation. SNE was suggested as a cause of pain and confirmed by nerve conduction recording. Magnetic resonance imaging excluded any compressive cyst. SNE at the spinoglenoid notch, related to upper limb overuse, was suggested. A gluco-corticoid injection in the proximity of the suprascapular nerve eliminated the pain in a few hours. Two months after the injection, the pain had not reappeared, the infraspinatus muscle atrophy was resolved, and supraspinal nerve conduction was normalized. CONCLUSION: Shoulder pain is common in individuals with paraplegia, but this is the first time that SNE has been reported as a cause of pain. This micro-traumatic pathology, well known in athletes, is probably under-diagnosed in patients with SCI who overuse their upper limbs for wheelchair propulsion and body transfers.

[Functional outcome of tuberculous arthiritis of the knee in a male Moroccan patient]. / Regard fonctionnel sur l'arthrite tuberculeuse de genou, chez un homme d'origine marocaine.

PURPOSE: The purpose of this article is to present a case of tuberculous arthritis of the knee and discuss the importance of early diagnosis and rehabilitatin in management outcome. CASE REPORT: A 57-year-old Moroccan man with no medical history presented with a mass in the left knee associated with pain and fever. Analysis of aspirated fluid demonstrated sterile inflammatory liquid. Presumptive antibiotic therapy was ineffective. Diagnosis of tuberculous arthritis was made based on positive tuberculin skin test and interferon-release assays. Diagnosis was confirmed by arthroscopic biopsy. Physiotherapy allowed improvement in both function and analytical test findings. DISCUSSION: Tuberculous arthritis is rare occurring in only 2 to 5% of people with tuberculosis. It can be very destructive. Diagnosis is often delayed leading to joint pain, tissue damage, and functional disability (e.g. inability to walk). Since prompt treatment (antibiotics then physiotherapy) can limit complications, early diagnosis is necessary and often requires deep biopsy, except endemic zones. In the acute phase, immobilization of the extremity in a functional position is necessary. When inflammatory signs subside, physiotherapy can be undertaken in short but frequent sessions without excessive weight or resistance. CONCLUSION: The functional outcome of tuberculous arthritis depends on early multidisciplinary care involving the rheumatologist, infectious disease specialist, orthopedic surgeon and attending physician.

Assessment of compliance with prescribed activity by hemiplegic stroke patients after an exercise programme and physical activity education.

UNLABELLED: Although post-stroke exercise training programmes improve aerobic capacity and functional capacities in the short-term, the impact on exercise performance at home has not been established. OBJECTIVES: To assess compliance with prescribed physical activity by hemiplegic stroke patients. To compare the patients' stated activity with their actual activity. PATIENTS AND METHODS: This was a prospective pilot study of nine hemiplegic patients following an exercise training programme. Each patient's activity was measured using an activity monitor (the ActivPAL) before, during and immediately after the programme and then 3months after the end of the programme. The activity actually performed was compared with the levels recommended after a stroke (at least 30minutes of non-stop activity three times a week). Three months after the end of the programme, the patient's stated and actual activities (in terms of frequency and duration) were compared. RESULTS: Activity patterns changed immediately after the end of the programme. Short-term compliance was good for four patients. However, 3months later, only one patient was performing regular activity in accordance with the guidelines. Hence, medium-term compliance was poor. Most patients overestimated both the duration and frequency of their activity sessions. CONCLUSION: Three months after the end of the supervised training programme, compliance with physical activity guidelines was low. The ActivPAL activity monitor is easy to use and performs satisfactorily. It can be used as a tool for activity assessment and education intervention. The use of an actimeter may increase the efficacy of health education interventions, which promote physical activity.

Care protocol for persistent vegetative states (PVS) and minimally conscious state (MSC) in Lorraine: retrospective study over an 18-year period.

OBJECTIVES: Retrospective analysis of the efficiency of a protocol for care of chronic vegetative states (CVS) and minimally conscious state (MCS) in Lorraine. MATERIAL AND METHOD: Two indicators are used: protocol activity (number of patients hospitalized between 1988 and 2006, number of admissions per year, of requests per year, origin of requests, waiting time) and the epidemiological data (age, sex ratio, etiology, length of stay, geographic origin, number of deaths, number of hospital discharges). The number of CVS and MCS and patients having progressed towards arousal is specified as well as the technical procedures (orthopedic surgery, number of tracheotomies). RESULTS: Forty-seven patients (30 males and 17 females) were hospitalized in a 12-bed unit. The number of admissions per year was 2.4, and the annual number of requests varied between five and 15. Hospitalization times ranged from six to 18 months. The average length of hospitalization was 41 months. Eighty-eight percent of the cases were residents of Lorraine. The etiology was traumatic (53%), vascular (38% including 12% anoxia), miscellaneous (9%). Fifteen percent rate of return to arousal (average time period: 28.41 months, traumatic etiology) with hospital discharge in four cases. CONCLUSION: The protocol is managed as part of a local scheme and enables an appropriate response to a specific clinical profile by providing up-to-date multidiscipline follow-up care and a rapid solution should intercurrent events occur (signs of arousal, orthopedic deterioration, change of environment). Typical limitations are geographical remoteness and difficulties with family support care.

Compensatory mechanism involving the hip joint of the intact limb during gait in unilateral trans-tibial amputees.

Hip dynamics in the intact limb during the beginning of stance phase in unilateral trans-tibial amputees (TTA) was studied to evaluate its contribution to compensatory function. We hypothesized (1) an increase in hip total work during H1 power phase (0-30% of gait cycle) including an initial negative phase and (2) an intensification of the hip work in response to uncomfortable gait induced by prosthesis misalignment. Three-dimensional gait analysis was conducted in 17 unilateral TTA and 15 healthy subjects walking at the same self-selected speed in three prosthetic alignments: initial alignment (IA); IA altered either by 6 degrees of internal rotation (IR) or by 6 degrees of external rotation. Patients reported best comfort of gait in IA condition and discomfort mainly in IR condition. During the H1 power phase, in intact limbs a consistent initial flexion movement of the hip (0-8% gait cycle) was associated to negative work and was followed by hip extension and positive work whereas in both prosthetic and control limbs only hip extension and positive work occurred (except in one healthy individual). Absolute value of hip work during H1 phase was significantly higher in intact and prosthetic limbs compared to control limbs in IA condition and was further significantly increased in IR condition only in intact limbs demonstrating a compensatory function of the latter. In intact limbs, early hip negative work contributed to energy absorption in addition to the knee joint probably to compensate the lower energy absorption exerted by the prosthetic limbs.

[Muscles of the below-knee amputees]. / Les muscles de l'amputé tibial.

OBJECTIVE: The objective of this article is to review anatomical, histological and physiological muscle changes following below-knee amputation. MATERIALS AND METHODS: We searched the PubMed and Reedoc databases for studies evaluating modifications of the below-knee stump and changes over time in its anatomy, volume and histology. We also looked at postamputation modifications in gait and balance. RESULTS: Below-knee amputees show muscular atrophy on both the amputated side and nonamputated side, with fewer and smaller muscle fibres (particularly slow-twitch fibres). This amyotrophy varies in magnitude and distribution and can reach about 25% for the quadriceps (predominantly on the medial side), but is nonsignificant for the hamstrings. This amyotrophy results from the anatomical consequences of the surgical act. The loss of one or more of a muscle's insertions or reimplantation into a nonphysiological site prompts greater atrophy. Changes in muscle activation patterns also lead to atrophy. The hamstrings replace the triceps as the main muscles for propulsion and the remaining stump muscles contract so as to ensure a good fit with the prosthesis. The below-knee amputee must adapt to a new muscular state: gait symmetry is altered, energy expenditure for walking is higher and training is needed in order to achieve optimal balance control.

Compensatory mechanism involving the knee joint of the intact limb during gait in unilateral below-knee amputees.

This study evaluated the asymmetry of knee kinetics during uncomfortable gait induced by prosthesis misalignment to further demonstrate the compensatory function of the knee joint of the intact limb during gait. Three-dimensional gait analysis including knee kinematics and kinetics at the beginning of stance phase was conducted in 15 healthy subjects and 17 unilateral trans-tibial amputees (TTA) walking at self-selected speed in three conditions of prosthetic alignment: initial alignment (IA); initial alignment altered either by 6 degrees of internal rotation (IR) or by 6 degrees of external rotation (ER) applied on the pylon. Patients reported best comfort of gait in IA condition and discomfort mainly in IR condition. Maximum knee flexion and knee total work at power phases K0-K2 were significantly higher in intact limbs compared to prosthetic and control limbs. In intact limbs, these variables had significantly higher values (+10-35%, p<0.05) in IR condition than IA condition whereas these were not altered across conditions in prosthetic limbs. In trans-tibial amputees, inducing uncomfortable gait by internally rotating the prosthetic foot did not alter the knee kinetics of the prosthetic limb, which suggests a protective mechanism. Knee kinetics of the intact limb did alter, which suggests a compensatory mechanism.

Different flavonoids present in the micronized purified flavonoid fraction (Daflon 500 mg) contribute to its anti-hyperpermeability effect in the hamster cheek pouch microcirculation.

AIM: This study evaluated microcirculatory effects of the flavonoid substances that constitute the micronized purified flavonoid fraction (MPFF) (Daflon 500 mg) in comparison to diosmin. METHODS AND RESULTS: In groups of 3 male hamsters, oral treatment with MPFF or diosmin (15 min before anesthesia) did not alter blood pressure. At 10 or 30 mg/kg, both MPFF and diosmin significantly decreased the leaky sites caused by ischemia/reperfusion (I/R) (30 min) in the hamster cheek pouch; the effect was significantly higher with MPFF (39+/-1% and 52+/-1%, respectively) than diosmin (18+/-1% and 37+/-3%, respectively). Eight groups of 3 hamsters each were treated with the components of MPFF. Diosmetin only decreased the number leaky sites at 30 mg/kg (decrease: 15+/-2%). The decrement at 10 and 30 mg/kg averaged at: 17+/-3% and 44+/-1%, respectively, for hesperidin; 19+/-1% and 46+/-2%, respectively, for linarin; and 30+/-1% and 44+/-1%, respectively, for isorhoifolin. Hesperidin, linarin, and isorhoifolin each displayed an anti-leakage effect comparable to or greater than diosmin. MPFF decreases permeability more than any of its single constituents, suggesting that the flavonoids present in its formulation have a synergistic action. CONCLUSION: These results illustrate that MPFF is more potent than single diosmin in this model of hyperpermeability and that each of the flavonoid substances present in MPFF contribute to its action.

[Exercise training for lower limb amputees]. / Le réentraînement à l'effort chez l'amputé de membre inférieur.

Lower limb amputee have lower exercise capacities, proportionally to the delay necessary to use their well-fitted prosthesis. Exercise training is a valid therapeutic to improve local factors (residual limb), muscle strength and endurance, locomotor performance and to decrease the cardiovascular risk factors. The programs for exercise training used for amputees are derivate from the vascular diseases and adapted (upper limb ergometer, cycloergometer with intact limb, pharmacological stress). Exercise training must be personalised because the population with lower limb amputation is very heterogeneous for deficiency and capacity (orthopaedic, vascular and cardiac) and for their socioprofessional project.