Evaluating self-reported pressure ulcer prevention measures in persons with spinal cord injury using the revised Skin Management Needs Assessment Checklist: reliability study.

STUDY DESIGN: Cross-cultural adaptation and reliability study. OBJECTIVE: To translate, evaluate the reliability and cross-culturally adapt the Skin Management Needs Assessment Checklist (SMnac), a questionnaire evaluating the knowledge on pressure ulcer (PU) prevention measures in persons with spinal cord injury (SCI). SUBJECTS: 138 persons with SCI, mean age 45.9 years, mean time since injury 94 months. MATERIAL AND METHOD: The study was carried out in two stages. First, the questionnaire went through a forward-backward translation process and was cross-culturally adapted, according to a validated methodology for self-reported measures. Then, the test-retest reliability was evaluated on a population of persons with SCI. RESULTS: The standardized back-translation and cross-cultural adaptation led to the revised Smack grid, with the addition of seven items representing an update of PU prevention measures. The reliability was excellent (intraclass correlation coefficient: 0.899). CONCLUSION: The revised SMnac is an adaptation of the SMnac, including therapeutic education frameworks and the latest PU prevention practices. It appears to be a reliable tool for assessing the knowledge and benefits of PU prevention in persons with SCI. Further studies are needed to explore its validity and responsiveness to change.

Using an analytical hierarchy process (AHP) for weighting items of a measurement scale: a pilot study.

BACKGROUND: Many clinical scales contain items that are scored separately prior to being compiled into a single score. However, if the items have different degrees of importance, they should be weighted differently before being compiled. The principal aims of this study were to show how the "analytic hierarchy process" (AHP), which has never been used for this purpose, can be applied to weighting the six items of the "London handicap scale", and to compare the AHP to the "conjoint analysis" (CA), which was previously implemented by Harwood et al. (1994) [1]. DESIGN: In order to assess the relative importance of the six items, we submitted AHP and CA to a group of 10 physiatrists. We compared the methods in terms of item ranking according to importance, assessment of fictitious patients based on weights determined by each method, and perceived difficulty by the physiatrist. RESULTS: For both techniques, "Physical independence" (PHY) was the best-weighted item, but other ranks varied depending on the technique. AHP was better than CA in terms of accuracy (global assessment of the clinical status) and perceived difficulty. CONCLUSION: AHP may be used to reveal the importance that experts assign to the items of a multidimensional scale, and to calculate the appropriate weights for specific items. For this purpose, AHP seems to be more accurate than CA.

Pressure ulcer risk factors in persons with spinal cord injury part 2: the chronic stage.

INTRODUCTION: Pressure ulcers (PUs) are a common complication following spinal cord injury (SCI). Prevalence for persons in the chronic SCI stage varies between 15 and 30%. The risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed for designing an SCI-specific assessment tool. The first results seem quite disappointing, probably because of the level of evidence of the risk factors used. OBJECTIVE: To determine PU risk factors correlated to the chronic stage of SCI. MATERIALS AND METHODS: Systematic review of the literature. RESULTS: There are several PU risk factors for chronic SCI stage: socio-demographics, neurological, medical or behavioral. The level of evidence varies: it is quite high for the socio-demographics and neurological factors and low for behavioral factors. DISCUSSION AND CONCLUSION: Behavioral risk factors (relieving the pressure, careful skin monitoring, smoking) are probably the ones for which a preventive strategy can be established. It is important to develop specific assessment tools for these behavioral risk factors to determine their relevance and evaluate the effect of therapeutic educational programs on persons with SCI.

[Mitochondrial cardiomyopathy in an adult: a case history]. / Cardiomyopathie mitochondriale de l'adulte: à propos d'un cas.

We report an original case of mitochondrial cardiomyopathy discovered in a young woman during an episode of cardiac decompensation. The diagnosis was suspected from the echocardiographic appearances of granite-like heterogeneous hypertrophic cardiomyopathy. It was confirmed by endomyocardial biopsies. The clinical evolution was favourable with classical treatment. Mitochondrial cardiomyopathy is a rare cause of cardiomyopathy, generally observed in children, with multisystemic localisation. The pathophysiology and genetics are complex. Cardiac involvement is observed in 25% of cases, with the principal manifestation being hypertrophic cardiomyopathy. In the absence of any specific clinical or paraclinical signs, echocardiography and MRI are the techniques of choice for morphological evaluation. Diagnosis relies upon myocardial biopsy, which should be readily advocated in every unexplained case of cardiomyopathy in a young subject. The prognosis is poor and no specific treatment is available.

[Bickerstaff's syndrome presenting with coma, tetraplegia and blindness]. / Coma, tétraplégie flasque et cécité révélant un syndrome de Bickerstaff.

INTRODUCTION: Bickerstaff brainstem encephalitis is characterized by the occurrence of ataxia, ophthalmoplegia, motor weakness with areflexia and central nervous system symptoms, with drowsiness, pyramidal syndrome and sensorial symptoms. Diagnosis is based on MR findings and GQ1b antibodies. Treatment is not well known. OBSERVATION: We report a patient aged 39 years native of Laos who presented weakness, loss of reflexes, and drowsiness. Brain MR showed hyperintense signals in the brain stem. GQ1b antibodies were positive. The course was characterized by decrease of the weakness, normalization of MR and negativity of GQ1b antibodies. DISCUSSION: This observation underlines common features of Bickerstaff brainstem encephalitis, Miller Fisher syndrome and Guillain Barre syndrome. A favorable course and GQ1b antibodies are shared by these syndromes.

[Influence of acute aggravations on the development of long-term handicap in relapsing remitting multiple sclerosis: a clinical study in 99 patients]. / Influence des poussées sur la survenue d'un handicap au long cours dans la sclérose en plaques de forme rémittente: étude observationnelle de 99 patients.

INTRODUCTION: Rate of relapse occurring during the first 5 years of MS-RR is a prognosis factor of occurrence of disability or secondary progressive (SP) phase. Progressive phase, related to chronic axonal loss, is mainly considered as the principal factor of disability progression. Influence of acute relapses during the relapsing-remitting phase on disability development is not known as a prognosis factor. OBJECTIVES: To determine the influence of the exacerbations among patients with RR-MS after the second clinical event on the disability occurrence. METHODS: Diagnosis of multiple sclerosis was established according to Poser's classification. Disability measurement was made with the use of the Expanded Disability Status Scale (EDSS). The patients included in the study were classified as clinically definite RR-MS, with an EDSS score500 m. The study began at the time of the second clinical event and ended when an EDSS score of 4.0 was reached or when a SP phase was beginning or at the last follow-up visit date if these two stages were not reached. The primary outcome measure was the comparison of the risk and the average time to reach an EDSS>or=4.0 or a SP form according to the annual exacerbation rate (AER) using Kaplan-Meier survival curve. RESULTS: Among the 238 ms patients of the database, 136 patients were classified as having a definite RR-MS. Among these 136 patients, 99 patients could be included in the study according to the inclusion criteria. The median follow up of the patients since the first clinical event was 9.8 years (range 4 to 44). The average EDSS score was 0.7 at the beginning of the study and 2.3 at the end. 20.2p.cent of patients (n=20) reached an EDSS score of 4.0 or a SP-MS. The median AER was 0.4 and the average 0.62 (range 0 to 6.1). The time to reach the primary end point for 25p.cent of the population was 17.8 years in group with an AER<0.4 (group A) and 6.9 years in group with an AER>0.4 (group B) (logrank; p<0.0001). The relative risk for patients of the group B compared to group A to reach an EDSS of 4.0 or a SP form was 8.01 (IC-95p.cent: 2.74-23.46; p=0.0001). CONCLUSIONS: In spite of a limited number of patients, this study gives evidence that a high rate of acute exacerbations in RR-MS patients after the second clinical event may be an independent predictive factor of long-term residual disability progression. High relapse rate leads to a more frequent and faster SP or EDSS>4.0 occurrence.

[Family study allows more optimistic prognosis and genetic counselling in a child with a deletion of exons 50-51 of the dystrophin gene]. / Impact de l'étude familiale sur le pronostic et le conseil génétique chez un enfant porteur d'une délétion des exons 50-51 du gène de la dystrophine.

INTRODUCTION: In frame deletions of exons encoding the central rod domain of dystrophin have been associated with a highly variable phenotype, including asymptomatic individuals. The lack of family history impairs accurate genetic counselling. OBSERVATION: We report on a 4-year-old child suffering from transient episodes of limping at the age of 2 and several episodes of fall since the age of 3. Clinical examination did not show muscle weakness. CPK levels were increased (1300 UI). EMG was normal. Muscle histology showed a rhabdomyolysis without features of muscular dystrophy. Immunolabelling for dystrophin, merosin and dysferlin were normal. Western blot analysis of muscular proteins showed reduced-size dystrophin bands and a slightly reduced intensity for dystrophin, alpha and gamma-sarcoglycan. Multiplex PCR of the dystrophin gene showed an in-frame deletion of exons 50-51, predicted to be associated to a Becker type of dystrophinopathy. Intragenic markers and quantitative PCR suggested maternal inheritance. This was confirmed by testing the maternal grand-parents, revealing that the asymptomatic 69-year-old grand father was a carrier. Three additional healthy males, whose ages ranged from 28 to 55 years and who were asymptomatic, also carried the mutation. The proband became spontaneously asymptomatic and cardiac echography was normal. In light of these data, genetic counselling was more reassuring and the mutation carrier maternal aunt, who was pregnant, decided to continue the pregnancy. CONCLUSION: This case report emphasizes the importance of family molecular analysis, especially in males from the maternal lineage, for genetic counselling of dystrophinopathies associated to atypical features or to an isolate increase of muscular enzymes level in a young boy with no positive family history.

[Complex regional pain syndrome of the knee: early and beneficial action of diphosphonates on pain and function]. / Algodystrophie de genou: effet précoce et spectaculaire des biphosphonates sur la douleur et la fonction.

We report the case of a 24-years-old man with parcellar Complex Regional Pain Syndrome I (CRPS I) of the patella, responsible for major functional limitation. The diagnosis was based on physical exam and X-ray, in the absence of other articular or peri-articular diseases. The patient received two pamidronate perfusions over a week, with a spectacular decrease of pain, which allowed him to follow the rehabilitation program in good conditions. He was therefore able to go back to work. The place of this treatment in CRPS I is discussed.

[Does the quality of Web sites related to low back pain meet patients expectations? A systematic review]. / La qualité de l'information disponible sur Internet concernant la lombalgie est-elle adaptée aux attentes des patients? Revue systématique.

INTRODUCTION: An assessment of 36 back-pain-related French-language Web sites, miming a patient search strategy, was previously done by use of evidence-based items. Medical information quality was poor, as already noted about English-language Web sites. Thus, patients' expectations may exceed that provided by Web sites with simple medical information. OBJECTIVES: To study whether French-language Web sites related to low back pain meet patients expectations and to valid a rating scale including patients' expectations. MATERIALS AND METHOD: First we reviewed French-language Web sites with new keywords and medical gateways. Second, we systematically double assessed back pain-related Web sites with a health care professional and patient-centered scale. RESULTS: We found 30 additional Web sites not found with the previous search, 7 focusing on patient information. The rating scale is valid, and its use on a Web site sample leads to results different from those generated by an evidence-based medicine rating scale but close to a more global assessment. DISCUSSION: French-language Web sites related to low back pain do not meet patients' expectations. Patients participation in Web site assessment or construction could help to close the gap between the expectations of people with low back pain and information delivered by doctors.

Qualitative evaluation of the expectations of low back pain patients with regard to information gained through semi-directed navigation on the Internet.

OBJECTIVES: To make a qualitative analysis of the expectations of chronic low back pain (LBP) sufferers with regard to information gained using semi-directed Internet navigation on a sample of French LBP-related websites, and to compare the results with those of physical medicine and rehabilitation (PMR) medical doctors (MD). MATERIAL AND METHODS: Twenty-seven hospitalised chronic LBP sufferers assessed in ecological conditions a sample of seven LBP-related websites. The sites were assessed using a simplified version of a rating scale of patients' expectations. Analysis of the relative importance of the different kinds of information delivered was done using a point sharing method. RESULTS: In a comfortable environment, patients gave high scores for medical and extra-medical information, but low scores for website design. Overall quality assessment was similar for patients and MDs. The relative importance of medical and extra-medical information, and design quality, was similar for Chronic LBP patients and MDs. CONCLUSION: PMR MD seemed able to correctly evaluate the overall expectations of chronic LBP patients with regard to information, but their opinions on the different qualities of websites were different. Doctors and patients should collaborate in order to create or validate high quality websites concerned with LBP.

[Camptocormia disclosing Parkinson's disease]. / Camptocormie révélatrice d'une maladie de Parkinson.

Camptocormia is characterised as an extreme bent-forward posture of the trunk that disappears in the recumbent position. On X-ray, trunk flexion appears without vertebral rotation as in scoliosis. The condition is a well-known complication of Parkinson's disease (PD) at the late stage. The authors present the case of a 77-year-old woman affected by severe camptocormia, which appeared and worsened in less than 6 months and hindered gait. Despite no signs of PD, neuro-imaging (DAT-Scan) showed an L-Dopa transducer decrease in putamens. A few weeks later, bradykinesia appeared and the clinical diagnosis of PD became more obvious. L-Dopa improved bradykinesia but did not change the bent-spine posture. A 1-year follow-up showed no other signs of PD other than bradykinesia, but the camptocormia was unchanged.

[About two big buttocks: an erysipelas with lymphoedema after pelvis surgery]. / A propos de deux grosses fesses: un érysipèle sur lymphoedème après chirurgie du pelvis.

We report the case of a 58-year-old man with erysipelas of both buttocks secondary to lymphoedema after pelvis surgery for prostatic cancer and multiple vascular interventions for iliofemoral thrombosis. The diagnosis was based on clinical examination and lymphoscintigraphy. This location of lymphoedema, limited to the buttocks, is uncommon; lower limbs are usually affected. This location needs a specific curative and preventive treatment, including antibiotic therapy, lymphatic drainage and contention to abate the condition and prevent a relapse.

[The role of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain. A randomized controlled trial in a rehabilitation unit]. / Un simple livret d'information peut contribuer à réduire l'incapacité fonctionnelle de patients lombalgiques subaigus et chroniques. Etude contrôlée randomisée en milieu de rééducation.

OBJECTIVES: To compare the efficacy of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain referred to a rehabilitation department. METHODS: An alternate-month design was used for 142 patients with subacute or chronic low back pain who were hospitalized for treatment. Seventy-two patients received written standardized information about back pain (the "back book") and usual physical therapy (intervention group), and 70 received usual physical therapy only along with nonstandardized oral information (control group). The main outcome measure was disability (measured on the Quebec back-pain disability scale), and secondary outcome measures were pain intensity (measured on a visual analog scale), fear-avoidance beliefs (measured on the Fear-Avoidance Beliefs Questionnaire [FABQ] Physical component), and knowledge of the relation of back pain to physical activity assessed at baseline, just before discharge from the hospital and 3 months after discharge. Satisfaction related to the information received was assessed on the day of discharge. RESULTS: Receiving the "back book" had a significant impact on disability at 3 months, from 48.40+/-14.55 to 34.57+/-18.42 in the intervention group and from 52.17+/-16.88 to 42.40+/-14.95 in the control group (p=0.03). Receipt of the book also had a significant impact on patients' knowledge and satisfaction about information but a nonsignificant effect on fear-avoidance beliefs. CONCLUSIONS: Providing an information booklet about back pain to patients with subacute and chronic low back pain referred to a rehabilitation unit contributes to reduced disability in these patients.

[Giant vascular tumour in an adult: tufted angioma or kaposiform hemangioendothelioma]. / Tumeur vasculaire géante de l'adulte: angiome en touffe ou hémangioendothéliome kaposiforme.

INTRODUCTION: Tufted angioma and kaposiform hemangioendothelioma are two rare benign but aggressive vascular tumours that occur mainly in children. OBSERVATION: A 72 year-old man consulted for a 50 cm wide vascular tumour of the right shoulder which was increasing for 10 years. On histological examination there were features of tufted angioma and kaposiform hemangioendothelioma. DISCUSSION: The tumour of this patient was atypical because of its big size never described before. The histological association of aspects which could correspond to tufted angioma and kaposiform hemangioendothelioma seems to confirm recent publications which support the hypothesis that these two tumours are two evolutive stages of one and only entity.

MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

[The assessment of autonomy in elderly people]. / Evaluation de l'autonomie de la personne âgée.

The assessment of autonomy in elderly people relies on various instruments that aim to evaluate and follow up patients, to measure the burden of care for the medical staff, or to properly distribute health budgets. In this article, we describe 3 clinical scales traditionally employed by gerontologists and specialists in geriatric rehabilitation. We intentionally left out generic scales such as the Barthel index and the Functional Independence Measure, which are well known by physiatrists. The Katz index is a scale of Activities of Daily Living, and the Lawton test is a scale of Instrumental Activities of Daily Living. We paid special attention to the AGGIR classification, which is the actual legal instrument for evaluating dependency in elderly in France, and whose first application is health resources management.

[What is the place of diphosphonates in the treatment of complex regional pain syndrome I?]. / Quelle est la place des biphosphonates dans le traitement de l'algodystrophie sympathique réflexe? Analyse critique de la littérature.

OBJECTIVES: To evaluate the efficacy of biphosphonates (BPs) in complex regional pain syndrome I or reflex sympathetic dystrophy and to specify their place in this chronic painful syndrome. METHODS: A literature review of Medline and Embase with use of a combination of 3 key words: biphosphonates therapy, reflex sympathetic dystrophy, complex regional pain syndrome I, controlled study. Each article was classified by 2 independent reviewers according to Aguilar's method into high, middle or low quality. RESULTS: Three second-generation BPs were tested in the treatment of reflex sympathetic dystrophy: pamidronate, alendronate and clodronate. Many open studies investigated pamidronate, but only 2 were randomised and controlled: a low-quality trial comparing pamidronate with placebo and a middle-quality trial comparing pamidronate with calcitonine. Two high-quality trials were performed, 1 with alendronate and 1 with clodronate. Middle-quality trial and high-quality trials reported positive effects on pain with BPs in recent reflex sympathetic dystrophy (disease duration less than eight months). Side effects (fever, asymptomatic hypocalcemia) were observed frequently but disappeared quickly. CONCLUSION: BPs can be used in recent reflex sympathetic dystrophy when calcitonin is inefficient or when calcitonin injections are not well tolerated.

[Assessment of idiopathic Parkinson's disease in physical medicine and rehabilitation]. / Evaluation de la maladie de Parkinson dans le contexte de la médecine physique et de réadaptation.

Parkinson's disease (PD) is a chronic disease associated with motor impairments (bradykinesia, rigidity, tremor and postural disorders), cognitive disorders and dysautonomia. Most symptoms are greatly improved by dopatherapy during the first stages, then signs of treatment ineffectiveness or intolerance occur that signal the beginning of motor and cognitive decline. This evolution signified the need to develop an effective tool to measure the effectiveness of drugs or surgery in PD and has had the Movement Disorder Society to propose 20 years ago a tool to assess such patients: the Unified Parkinson's Disease Rating Scale (UPDRS). This scale has a good internal consistency and a good interrater reliability. Yet, some impairments, especially of cognitive origin, are evaluated too succinctly and need complementary scales. As well, other disorders such as bladder disorders are not included, nor is quality of life studied despite the impact of PD on daily life. Specific scales have been proposed. UPDRS may be well-adapted to PD follow-up in the physical medicine and rehabilitation context by measuring treatment effectiveness, detecting Dopa ineffectiveness or complications and assessing patients' handicap in daily activities. The evolution of UPDRS will improve the qualities of the scale and contribute to better determining the various stages of the disease.

[Incidence, circumstances and consequences of falls in patients undergoing rehabilitation after a first stroke]. / Incidence, circonstances et conséquences des chutes chez les patients en rééducation après un premier accident vasculaire cérébral.

OBJECTIVES: To describe the incidence, circumstances, and consequences of falls in patients admitted in a rehabilitation ward after a stroke. METHODS: Prospective monitoring of falls over four years in a neurological rehabilitation unit. Use of fall registry. INCLUSION CRITERIA: age < 75 years, admission < 45 days after stroke onset, single stroke of 1 cerebral hemisphere (nonlacunar) or of the brain stem. Only falls due to loss of balance were considered; falls caused by a seizure or syncope were not considered. RESULTS: Of 217 consecutive patients with the inclusion criteria, 34 had fallen at least once (15.7%) and 10 twice (4.1%). Fall incidence, defined as the number of falls per patient per day was 2.2 per thousand. Half of the patients fell the first three weeks after admission. Most falls involved getting to or from the wheelchair or the bed; 1 patient had recovered minimal postural abilities at the gym but was not independent. Traumatic lesions were noted in 13 patients: they were minor in nine and severe in four, including three fractures. CONCLUSION: Falls due to loss of balance are a major problem in patients undergoing rehabilitation after a stroke. Getting to and from wheelchairs in the bedroom and bathroom by patients who are not allowed to do so play a key role in many falls. Prevention programs should consider this information.

[Feet insoles and knee osteoarthritis: evaluation of biomechanical and clinical effects from a literature review]. / Orthèses plantaires et gonarthrose: évaluation des effets biomécaniques et cliniques à partir d'une revue de la littérature.

OBJECTIVE: To determine the biomechanical and clinical effectiveness of foot insoles in patients with knee osteoarthritis. MATERIALS AND METHODS: A systematic review of the literature (Medline, Pascal and Embase) using the MESH words knee, and insole and plantar orthosis for the biomechanical part and osteoarthritis, and insole and plantar orthosis for the clinical part. Clinical studies were classified by 2 independent readers using the Jadad scale. RESULTS: Two biomechanical theories were found: the adduction moment theory, which explains the effect of heel wedging, and articular chain theory, which explains the effect of lateral wedged insoles. The clinical effect was explained more by an anti-algesic effect than an anatomic or functional effect: the treated group consumed fewer nonsteroidal anti-inflammatory drugs than the placebo group for up to 2-years of treatment. Evidence is lacking because of methodological weakness and few clinical trials. The information on side effects is limited. DISCUSSION: Laterally wedged foot insoles are proposed for the treatment of knee medial compartment osteoarthritis. The clinical effect is probably limited, but the treatment may reduce the digestive and renal side effects of prolonged use of nonsteroidal anti-inflammatory drugs. Foot insoles could be recommended in clinical practice despite the lack of evidence in comparing the effectiveness of other therapeutics in knee osteoarthritis. CONCLUSION: Use of foot insoles is a nonpharmacologic treatment of osteoarthritis of the knee medial compartment.