Discriminative value of different combinations of tests to detect unilateral neglect in patients with right hemisphere damage.

BACKGROUND AND PURPOSE: This study was undertaken to assess the most sensitive combination of tests to detect peripersonal unilateral neglect (UN) after stroke. METHODS: The present study is a secondary analysis of a previously reported multicentric study of 203 individuals with right hemisphere damage (RHD), mainly subacute stroke, 11 weeks postonset on average, and 307 healthy controls. A battery of seven tests, providing 19 age- and education-adjusted z-scores, were given: the bells test, line bisection, figure copying, clock drawing, overlapping figures test, and reading and writing. Statistical analyses used a logistic regression and a receiver operating characteristic (ROC) curve after adjustment on demographic variables. RESULTS: A combination of four z-scores based on the following three tests provided good discrimination of patients with RHD from matched healthy controls: the starting point and the difference between the number of omissions on left and right sides from the bells test, rightward deviation in bisection of long lines (20 cm), and left-sided omissions in a reading task. The area under the ROC curve was 0.865 (95% confidence interval = 0.83-0.901), with sensitivity = 0.68, specificity = 0.95, accuracy = 0.85, positive predictive value = 0.90, and negative predictive value = 0.82. CONCLUSIONS: The most sensitive and parsimonious combination of tests to detect UN after stroke relies on four scores from three simple tests (bells test, line bisection, and reading). Future study is warranted to assess its ability to account for the functional difficulties of UN in daily life in the patient's actual environment.

Development and Preliminary Validation of the Coma Arousal Communication Scale.

OBJECTIVE: To develop a Coma Arousal Communication Scale and perform preliminary validation. METHODS: A group of experts developed a questionnaire to assess communication between patients emerging from coma and caregiver (participation, communication modes, and themes) and the strategies used to facilitate communication. To assess the scale's psychometric characteristics, it was presented to the caregivers of 40 inpatients admitted to 5 coma units and (to obtain reference data) to 29 control participants. RESULTS: The Coma Arousal Communication Scale displayed good intra- and interrater reliability as judged by intraclass correlation coefficients (between 0.76 and 0.98) and Bland and Altman plots. Cohen κ coefficient revealed moderate to almost perfect levels of agreement for most individual items and slight levels for a few items dealing with compensatory strategies. We observed good internal consistency, relations with the Wessex Head Injury Matrix, and sensitivity to change for patients who had sustained brain injury in the previous 6 months. CONCLUSION: The Coma Arousal Communication Scale provides accurate information about communication skills of individuals emerging from coma. However, some compensatory strategies adopted by caregivers are difficult to characterize.

The long-term nutritional status in stroke patients and its predictive factors.

BACKGROUND: Malnutrition is common in the first few months after stroke and contributes to a poor overall outcome. We analyzed long-term weight changes and their predictive factors. METHODS: A total of 71 first-ever stroke patients were included in the study and examined (1) their weight on admission to the acute stroke unit (usual weight [UW]), on admission to the rehabilitation unit, on discharge from the rehabilitation unit, and then 1 year or more after the stroke (median time: 2.5 years), (2) the presence of malnutrition after stroke, and (3) possible predictive factors, namely, sociodemographic factors, clinical characteristics (concerning the stroke, the patient's current neurologic status and the presence of diabetes mellitus and depression), and the present nutritional state (including eating difficulties, anorexia, and changes in food intake and food preferences). RESULTS: Body weight fell (4.0 kg) during the patients' stay in the stroke unit, increased moderately in the rehabilitation unit (2.0 kg), and returned to the UW by the long-term measurement. However, at the last observation, 40.1% of the patients weighed markedly less than their UW, 38.0% weighed markedly more, and 21.1% were relatively stable. Predictors of weight change were a change in preferences for sweet food products and a change in food intake. Malnutrition was frequent (47.9%) and associated with reduced food intake, residence in an institution, and diabetes mellitus. CONCLUSIONS: Malnutrition was highly prevalent, with an important role of change in food intake and food preferences, which could result from brain lesions and specific regimens. Living in an institution needs consideration, as its negative effects can be prevented.

Construction and pilot assessment of the Upper Limb Assessment in Daily Living Scale.

OBJECTIVE: The upper limb function of hemiplegic patients is currently evaluated using scales that assess physical capacity or daily activities under test conditions. The present scale, the Upper Limb Assessment in Daily Living (ULADL) Scale, was developed to explore the subjective and objective functional capacities of such patients in a proximal to distal sequence. METHODS: A group of experts constructed a scale addressing 17 upper limb functions (five active passive and 12 active) which could be explored by a questionnaire (Q) and a test (T). Reproducibility, internal consistency, concurrent validity (Rivermead Motor Assessment (RMA)) and learning effect were estimated in a multicentre study. RESULTS: 49 stroke patients were each rated three times within 7 days by a total of 21 physicians, yielding a total of 142 ratings. The ULADL took 16±8 min to complete compared with 9±5 min for the RMA. Cronbach's alpha coefficient was 0.95 for Q and 0.97 for the practical tests (T). The global Q and T scores, and in particular the global Q score, were slightly higher at the second rating. The intra-rater intraclass correlation coefficient (ICC) was 0.65 (95% CI (0.44 to 0.79)) for Q and 0.97 (0.95 to 0.98) for T, and the inter-rater ICC was 0.95 for both Q and T. The Bland and Altman method showed good intra- and inter-rater reliability with no systematic trend. Correlation coefficients for ULADL versus RMA were >0.80 for both Q and T. CONCLUSIONS: The ULADL Scale has good psychometric properties and can explore patients with different degrees of upper limb impairment.

Influence of spatial neglect, hemianopia and hemispace on the subjective vertical.

The perception of the vertical is frequently shifted to the contralesional side in patients with hemispheric lesions, and this is amplified by spatial neglect. However, we do not know the specific influence of hemianopia and space of perception on this phenomenon. Here, we analyzed the respective influences of spatial neglect, hemianopia and hemispace on the subjective vertical in patients with right hemispheric stroke. Twelve neglect patients with and 5 without hemianopia were compared to 3 non-neglect patients with and 13 without hemianopia. They had to match a luminous rod to the vertical, either in the mid-sagittal plane or in the right or the left hemispace. Patients showed a counter-clockwise deviation, and this was exaggerated by both neglect and hemianopia. In patients with neglect, the error was greater in the left hemispace. In conclusion, neglect and hemianopia had additive effects on the contralesional bias of the subjective vertical.

Decompressive surgery for malignant middle cerebral artery infarcts: the results of randomized trials can be reproduced in daily practice.

BACKGROUND: In clinical randomized controlled trials (RCTs), decompressive surgery (DS) for malignant middle cerebral artery (MMCA) infarcts leads to a 50% absolute risk reduction in mortality, and improves the 1-year functional outcome. The reproducibility of these results in routine practice has never been evaluated. The purpose of this study was to test the hypothesis that the results of DS for MMCA in practice are similar to those observed in the surgical group of RCTs. METHODS: We prospectively included the first 31 patients who underwent DS for MMCA. They were screened based on similar criteria as in the meta-analysis. The primary outcome was a modified Rankin Scale (mRS) score of ≤4, and secondary outcomes were mRS of ≤3 and death at 1 year. RESULTS: Thirty-one patients underwent DS for MMCA. The 1-year mRS was ≤4 in 22 patients (71.0%) and ≤3 in 16 (51.6%). Seven patients died (22.6%). CONCLUSION: This observational study showed that DS for MMCA in a center without previous experience provides similar results as those obtained in the surgical arm of RCTs.

Effect of early compensation of distal motor deficiency by the Chignon ankle-foot orthosis on gait in hemiplegic patients: a randomized pilot study.

OBJECTIVE: To compare the effect of the Chignon ankle-foot orthosis on gait versus a standard ankle-foot orthosis. METHOD: A multicentre randomized study was conducted in seven rehabilitation centres. Hemiplegic patients were recruited after unilateral stroke lasting less than six months. Exclusion criteria were: impossibility to stand for 10 seconds; ankle passive dorsiflexion <5 degrees with knee flexed to 90 degrees; triceps spasticity ≥3/4 on the Ashworth modified scale; diseases that might impair active participation in the study. Thirteen patients were randomized to the Chignon group and 15 to the control group. Included patients were given a standard ankle-foot orthosis or Chignon ankle-foot orthosis. The Chignon ankle-foot orthosis is an articulated double-stopped custom-made orthosis with elements to assist dorsiflexion and plantar flexion. Gait speed improvement (ten-metre test), kinematic assessment, and functional scales were assessed. RESULTS: Gain ratio of walking speed with the orthosis increased significantly more in the Chignon group than in the control group at day 0 (27.2 ± 36% versus -0.8 ± 17%; P = 0.006), day 30 (39.9 ± 19% versus 7.5 ± 17%; P = 0.0004) and day 90 (44.6 ± 27% versus 17.1 ± 0.3%; P = 0.04). There was also a significant improvement in kinematic parameters and spasticity in the Chignon group. CONCLUSION: Early compensation of distal motor deficiency by the Chignon ankle-foot orthosis improves the immediate gait of hemiplegics more than the standard ankle-foot orthosis and seems to modify motor recovery processes in the legs after stroke.

The pusher syndrome reverses the orienting bias caused by spatial neglect.

Spatial neglect can be accompanied by a pusher syndrome (PS) which is characterized by a postural deviation towards the contralesional side. In this study, the representation of the body orientation in the horizontal plane was evaluated in neglect patients with and without PS. The participants had to align a luminous rod with the straight ahead direction, a method allowing the measure of both horizontal components of subjective straight ahead, i.e. lateral shift and yaw rotation. Eighteen patients with a lesion of the right hemisphere were compared with ten healthy participants. Patients had neglect and PS (P+N+; n=3), neglect only (P-N+; n=10), or neither neglect nor PS (P-N-; n=5). P+N+ patients showed a significant leftward shift contrasting with the rightward shift of P-N+. No shift occurred in patients without neglect and controls. No significant yaw error was recorded in any groups. The original result of this study was an inversion of the sign of the bias in neglect patients with PS. This could be related to the postural disorders characterizing this syndrome, and which are opposite to those usually observed in spatial neglect. Thus, these data suggest a link between disorders of spatial representations and disorders of posture.

Long-term effect of tibial nerve neurotomy in stroke patients with lower limb spasticity.

OBJECTIVES: We investigated the long-term effects and predictive indices of efficacy of tibial nerve neurotomy in a large series of patients with post-stroke hemiplegia. METHODS: Fifty-one patients were prospectively included, who showed disabling lower limb deformity (equinus, varus, clawing toes). The motor branches of the tibial nerve were selected according to the type of deformity, and partially resected at the posterior part of the calf. Patients were regularly assessed, before surgery and from the third month to the second year post surgery, for spasticity (primary outcome measure), motor control, range of active and passive movements, balance, walk, gait parameters, Rivermead Motor Assessment (RMA), subjective improvement and satisfaction. RESULTS: Neurotomy definitely reduced spasticity and improved motor control on antagonist muscles, while improving balance, walk, and the RMA. These effects were clearly perceived in daily living. A discrete decline was at times observed at 2 years. Functional improvement was greater in patients more severely impaired. Side effects, consisting in sensory disorders, were observed following neurotomy of the motor fascicles of the flexor digitorum longus. CONCLUSIONS: Tibial nerve neurotomy showed great and lasting effects, and can be proposed to improve walking and balance in stroke patients with disabling lower limb deformity.

Tibialis posterior transfer for foot drop due to central causes: Long-term hindfoot alignment.

BACKGROUND: Tibialis posterior transfer (TPT) is the treatment most widely used to palliate foot drop due to dorsiflexor palsy. TPT has been extensively studied in patients with peripheral neurological causes of foot drop. In contrast, data are scarce on central foot drop, in which TPT is often blamed for causing flattening of the arches. The primary objective of this study was to assess the impact on foot alignment of TPT in patients with central foot drop. The secondary objective was to determine whether TPT combined with other surgical procedures improved gait. HYPOTHESIS: TTP can induce flattening of the medial arch of the foot. PATIENTS AND METHODS: We retrospectively identified 13 patients managed with TPT (1 foot per patient). Mean follow-up was 65 months (range, 12-108 months). The causes were stroke (n=5), head injury (n=3), spinal cord injury (n=2), cervical spondylotic myelopathy (n=1), cerebral palsy (n=1), and a brain tumour (n=1). The clinical assessment focused chiefly on forefoot alignment and footprint parameters. The following variables were collected from weight-bearing radiographs: Djian-Annonier angle, Méary-Toméno angle, lateral arch angle, and calcaneal pitch angle in the sagittal plane; talo-metatarsal angle in the transverse plane; and rearfoot valgus angle in the coronal plane. RESULTS: Of the 13 feet, 6 had normal footprint parameters and 7 pes cavus. There were no cases of flatfoot. Pronation deformities and supination deformities were each found in 2 patients. Comparing the radiographic parameters between the two feet in each patient identified differences only for the lateral arch angle and calcaneal pitch angle, which indicated pes cavus on the operated side (operated side: 142.7° [range, 136°-156°], p=0.041; and 24° [range, 14°-33°], p=0.028, respectively). DISCUSSION: In contrast to the working hypothesis, we found no evidence of progression to valgus flatfoot after TPT transfer performed to treat central foot drop. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

An evaluation of cognitive disorders after anterior choroidal artery infarction.

Anterior choroidal artery infarction (AChAI) can be the source of aphasia and spatial neglect, but we have no idea of the other possible cognitive disorders. Here, we investigated these disorders in a relatively large cohort of AChAI patients. Twenty patients with relatively recent infarction (left side: 13; mean delay = 47.4 days; 10 men; mean age = 59.6; mean education level, EL = 10.3) were included. We assessed nonspatial attention (alertness, Go Nogo, divided attention and visual vigilance from the computerized test TEA), spatial attention (bell test), language (BDAE) orientation (time, place), short-term memory (forward and backward digit spans, spatial span), executive functioning (WCST, TMT A and B, categorial evocation), delayed memory (Buschke verbal test, Rey figure test), and retrograde memory (questionnaire on famous events). The performance level was compared with that of 20 control subjects matched in age and EL. AChAI patients were impaired in several tests of attention (slowness, increase in omission and error rate), executive functioning (TMT B; categorical evocation) and delayed memory. Conversely, we found preservation of spatial attention, language, orientation, short-term memory, WCST, and retrograde memory. In conclusion, at the secondary phase post-stroke, these patients can present with moderate disorders of attention, memory and executive functioning, which are clearly less severe than what is usually observed following thalamic or cortical lesions.

Ineffectiveness of prism adaptation on spatial neglect signs.

BACKGROUND AND PURPOSE: To evaluate the effect of prism adaptation (PA) on spatial neglect signs. METHODS: Ten patients (hemianopia in 6) and 8 control subjects were included. Tasks were reading single words, nonwords, and a text, bell cancellation, line bisection, and scene drawing, before and after adaptation, with either deviating or neutral prisms. RESULTS: Errors were more frequent in patients but without any specific effect of PA. We found partial improvement at the late sessions, independent of prisms. CONCLUSIONS: We did not confirm the efficacy of PA on spatial neglect.

A battery of tests for the quantitative assessment of unilateral neglect.

PURPOSE: The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of unilateral neglect (UN) after stroke. In addition, dissociations have been reported between performance on traditional paper-and-pencil tests and UN in everyday life situations. METHODS: In this paper, we present the validation studies of a quantitative test battery for UN, including paper-and-pencil tests, an assessment of personal neglect, extinction, and anosognosia, and a behavioural assessment, the Catherine Bergego Scale (CBS). The battery was given to healthy subjects (n=456-476) and to patients with subacute stroke, either of the right or the left hemisphere. RESULTS: In healthy subjects, a significant effect of age, education duration and acting hand was found in several tasks. In patients with right hemisphere stroke, the most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. An important finding was that behavioural assessment was more sensitive than any other single test. Neglect was two to four times less frequent, but also less severe and less consistent after left hemisphere stroke. CONCLUSION: Assessment of UN should rely on a battery of quantitative and standardised tests. Some patients may show clinically significant UN in everyday life while obtaining a normal performance on paper-and-pencil measures. This underlines the necessity to use a behavioural assessment of UN.

Effects of tibial nerve neurotomy on posture and gait in stroke patients: A focus on patient-perceived benefits in daily life.

OBJECTIVE: To evaluate the objective and subjective functional effectiveness of tibial nerve neurotomy (TNN) in post-stroke spastic equinovarus foot (SEF). METHODS: In an open study, 23 hemiplegic patients were assessed immediately before TNN and then 5months after TNN. The main outcome measure was the Lower Limb Function Assessment Scale (LL-FAS), which provided an ecologic assessment of impairments in standing and walking (i.e. kinematic abnormalities) and their impacts on activities of daily living. Patients were also assessed for global clinical impression of change, fear of falling, neuromotor impairments, spatiotemporal and video gait parameters and walking capacities. RESULTS: TNN had a very marked effect on the level of spasticity and the range of motion in dorsiflexion (p<10(-3)). These changes resulted in better foot positioning when standing and walking (particularly in stance), which was perceived very favorably by the patients. There was a clear, patient-perceived improvement in activities performed when standing and walking (LL-FAS (p<0.01)), the global clinical impression of change (p<10(-3)) and the fear of falling (p=0.022) that was not revealed by conventional, objective measurements (New Functional Ambulation Classification, Rivermead Mobility Index). CONCLUSION: TNN is an effective treatment for post-stroke SEF; it is associated with a patient-reported improvement in standing and walking abilities during activities of daily living. Further research must now assess the long-term subjective efficacy of TNN.

Subjective visual vertical in pitch and roll in right hemispheric stroke.

BACKGROUND AND PURPOSE: Patients with right hemispheric stroke usually present an anticlockwise deviation of the subjective visual vertical (SVV) in the frontal (roll) plane. However, the occurrence of a similar disorder in the sagittal (pitch) plane has never been assessed. We investigated the subjective visual vertical in both planes in those patients. METHODS: Eight patients, 4 with spatial neglect (N+) and 4 without neglect (N-), were compared with 4 healthy participants (C). They sat facing a luminous bar adjustable in rotation, either in the roll or in the pitch plane, and had to orient it in a vertical position, in the dark. RESULTS: Compared with N- (-0.1 degrees) and C (+1.1 degrees) groups, N+ patients presented with a significant backward deviation (-4.5 degrees) of the SVV in pitch. In accordance with other studies, they also showed a significant anticlockwise deviation (-8.8 degrees) of the SVV in roll, as compared with N- (-1.9 degrees) and C (+0.4 degrees) subjects. This was associated with an opposite trunk deviation in both planes. CONCLUSIONS: While confirming the anticlockwise deviation already reported in the frontal plane, we showed for the first time to our knowledge a backward deviation of the SVV in neglect patients, which has to be put in relation with their balance disorders.

Effect of posture on the perception of verticality in neglect patients.

BACKGROUND AND PURPOSE: The anticlockwise (ACW) deviation of the visual and visuohaptic subjective verticals (SVs), known to occur in patients with right hemisphere lesion, is amplified by spatial neglect (N). These patients have only been assessed when sitting. We investigated the hypothesis that postural changes modulate visuohaptic SV deviation. METHODS: Eight patients presenting with a right hemisphere lesion and spatial N were compared with 6 matched control subjects (C). In the dark, they had to rotate a luminous rod to put it at the vertical in 4 conditions: (1) sitting with plantar sole support; (2) sitting without plantar sole support; (3) sitting with legs extended on a support; and (4) supine position. RESULTS: N patients showed a significant ACW deviation (-4.5 degrees) of the SV compared with C subjects (+0.01 degrees). The effect of body position depended on the group (P=0.022) because changes had definite effects in the N but not in the C group. In fact, the former showed a reduction of the ACW deviation, from the first to the fourth condition. CONCLUSIONS: Although the possible role of plantar and leg somaesthetic inputs remains to be thoroughly investigated, the modulation of gravitational inputs at trunk or vestibular level influences the SV deviation in N patients. This has to be put in relation with the modulation of N signs reported by other authors when passing from the sitting to the supine position.

The egocentric reference deviation of neglect patients is influenced by visuospatial attention.

The right deviation of the subjective straight-ahead (SSA), representing a deviation of the body centered spatial reference frame (egocentric reference), is a frequent phenomenon in spatial neglect. Little is known about the influence of visuo-spatial attention on this SSA shift. The aim of this study was to investigate the influence of eye direction (overt attention) and perception of the visual background (covert attention) on the SSA pointing. We included 12 patients with right hemisphere stroke. Six were classified as neglect (N+) and compared to the six non neglect (N-) patients and 19 normal control subjects (C). They had to point straight-ahead (right hand) on an horizontal board. Pointing was performed in the light or in darkness, first with spontaneous eye direction, then while fixating a visual target (-15 degrees , 0 degrees , +15 degrees ). A first ANOVA of factors group, eye direction (left, center, right fixation) and visual context (light, darkness) showed a right SSA deviation in N+ patients only, which was more severe in the light than in darkness. In this group, the SSA was shifted in the same direction as the target, while that of N- and C groups was mildly shifted in the opposite direction. The comparison of spontaneous and central fixation conditions also showed an eye direction by group interaction, as the spontaneous right SSA deviation was reduced by central fixation in N+ patients only. These results suggest that, in neglect patients, the egocentric reference deviation is not a fixed phenomenon, and that it can be influenced by manipulation of both overt and covert spatial attention.

The visual vertical in the pusher syndrome: influence of hemispace and body position.

The subjective visual vertical (SVV) was investigated in right brain-damaged (RBD) patients with pusher syndrome (PS) which is thought to stem from an erroneous perception of body orientation. The participants, sitting or lying, had to align a luminous rod with gravity. The task was performed in darkness with the rod centred to the body, or placed in the left (neglected) or in the right hemispace. The error, negligible in the control group (+0.3 degrees; n = 6) and mild in the nonneglect non-pusher patients (-1.8 degrees; n = 6), was clearly clockwise in the pusher neglect patients (N+P+; +7.2 degrees; n = 4), but anticlockwise in the non-pusher neglect patients (-6.6 degrees; n = 6). In both neglect groups, error was greater when the rod was in the left space. In N+P+ patients, the performance was strongly affected by posture (lying: +5.2 degrees ; sitting: +9.2 degrees ). Intra-individual variability was also much greater in this group. This study confirms the contralesional deviation of SVV in RBD patients without PS and suggests the presence of an opposite bias in RBD patients affected by PS.

Variability and predictability of functional efficacy of botulinum toxin injection in leg spastic muscles.

Botulinum toxin injection reduces spasticity level. However, the effects on gait parameters and daily living activities remain controversial, and the prediction of results remains poorly evaluated. The aim of this open study was to investigate these effects, and the predictability of results. Forty-seven injections were given to 47 patients with stroke (males: 24; mean age: 51.7), in the soleus, gastrocnemius, tibialis posterior and anterior, and flexor digitorum longus, with a global dose of 300 U (Botox). Each was evaluated at day 1 (D1), day 15 (D15), month 2 (M2) and month 5 (M5). We observed a significant but moderate reduction in spasticity (Ashworth) of the ankle plantar flexors (0.72/5) and dorsiflexors, which was greater at D15, and an improvement in distal positioning in the upright situation. Upright balance and gait (Functional Ambulation Categories) were improved, especially at M2 and in the barefoot condition. Gait velocity and step length with usual aids (10 m) were discretely increased, and this was especially evident in about 15 patients. We also found improvement in the Rivermead Motor Assessment. Patients reported better foot positioning, facilitation in limb propulsion, and better static and dynamic balance. For each assessment, high variability in the effects was also shown. Improvement in functional tests was partially predicted by age (negative relation), delay since stroke (negative relation), gender (better in men), spasticity of hip adductors and knee extensors (negative relation), active ankle dorsiflexion (positive relation) and heel-ground distance (positive relation). In conclusion, the effects on spasticity, balance and gait were relatively modest, and with a large variability between patients. Functional improvement could be partially predicted by several general or specific factors, the knowledge of which is important in the selection of patients to be injected, and for future trials aiming to demonstrate the efficacy of botulinum toxin injection.

Variability of video-based clinical gait analysis in hemiplegia as performed by practitioners in diverse specialties.

OBJECTIVE: Clinical gait analysis is widely used by different therapists working with hemiplegic patients. The purpose of this study was to assess the reliability of video-based clinical gait assessment, as performed by practitioners in diverse specialties. DESIGN: Five neurologists, 5 physiotherapists, and 5 doctors of physical medicine and rehabilitation (physiatrists) were asked to study a videotape of 6 patients with hemiplegia in the act of walking. This activity was chosen due to the wide use of gait information for therapeutic prescription and medical decision-making during medical consultations, at conventions, or in exchanges between therapists. RESULTS: Results highlighted a certain inconsistency in the use of the gait description indicators. The 15 therapists used 396 different locutions to describe the gaits of the 6 patients. These locutions yielded 60 general indicators, or gait disorders, which were grouped in 5 categories. Eleven of them were classified as "controversial" due to the significant inter-subject variability of the evaluations. CONCLUSION: The study identified a large number of indicators that were used relatively inconsistently by the 3 specialties studied. The results of this study would appear to indicate that greater caution is needed when dealing with some of the "controversial" indicators, as well as with the "unusual" gait patterns observed in some patients.