European consensus on the concepts and measurement of the pathophysiological neuromuscular responses to passive muscle stretch.

BACKGROUND AND PURPOSE: To support clinical decision-making in central neurological disorders, a physical examination is used to assess responses to passive muscle stretch. However, what exactly is being assessed is expressed and interpreted in different ways. A clear diagnostic framework is lacking. Therefore, the aim was to arrive at unambiguous terminology about the concepts and measurement around pathophysiological neuromuscular response to passive muscle stretch. METHODS: During two consensus meetings, 37 experts from 12 European countries filled online questionnaires based on a Delphi approach, followed by plenary discussion after rounds. Consensus was reached for agreement ≥75%. RESULTS: The term hyper-resistance should be used to describe the phenomenon of impaired neuromuscular response during passive stretch, instead of for example 'spasticity' or 'hypertonia'. From there, it is essential to distinguish non-neural (tissue-related) from neural (central nervous system related) contributions to hyper-resistance. Tissue contributions are elasticity, viscosity and muscle shortening. Neural contributions are velocity dependent stretch hyperreflexia and non-velocity dependent involuntary background activation. The term 'spasticity' should only be used next to stretch hyperreflexia, and 'stiffness' next to passive tissue contributions. When joint angle, moment and electromyography are recorded, components of hyper-resistance within the framework can be quantitatively assessed. CONCLUSIONS: A conceptual framework of pathophysiological responses to passive muscle stretch is defined. This framework can be used in clinical assessment of hyper-resistance and will improve communication between clinicians. Components within the framework are defined by objective parameters from instrumented assessment. These parameters need experimental validation in order to develop treatment algorithms based on the aetiology of the clinical phenomena.

Towards the definition of a patient-specific rehabilitation program for TKA: A new MRI-based approach for the easy volumetric analysis of thigh muscles.

After Total Knee Arthroplasty (TKA), a global post-operative rehabilitation programme is commonly performed. However, this current program is not always adapted to every patient and it could be improved by deeply reinforcing weaker thigh muscles. To do this, a muscle volume estimation coupled with force evaluation is required to therefore adapt the rehabilitation as a specific patient exercise plan. In this paper, we presented an MRI protocol allowing the acquisition of the whole thigh as well as a semi-automated pipeline to segment two main groups of thigh muscles, i.e., the quadriceps femoris and the hamstrings muscles. The pipeline is based on a few cross-sections manually labelled and a 3D-spline interpolation using directed graphs corresponding points. The seven muscles of ten thighs (70 muscles in total) were segmented and reconstructed in 3D. To assess this pipeline, three types of metrics (volumetric similarity, surface distance, and classical measures) were employed. Furthermore, the inter-muscle overlapping was calculated as an additional metric. The results showed mean DICE was 99.6% (±0.1), Hausdorff Distance was 4.9 mm (±1.8) and Absolute Volume Difference was 2.97 cm3 (±1.94) in comparison to the manual ground truth. The average overlap was 2.05% (±0.54).Clinical Relevance- The proposed segmentation method is fast, accurate and possible to integrate in the clinical workflow of TKA.

[Satisfaction with technological equipment in individuals with tetraplegia following spinal cord injury]. / Enquête de satisfaction sur l'équipement technologique des personnes tétraplégiques par blessure medullaire.

OBJECTIVE: To measure the acquisition, use and satisfaction with high technology equipment by spinal cord injured tetraplegic subjects. DESIGN AND SETTING: A questionnaire was mailed to 102 tetraplegic subjects who were hospitalised in the rehabilitation center of Kerpape (Ploemeur, France) between 1998 and 2004, and 59 subjects responded. The questionnaire asked about the use of telephones, computers, wheelchairs and environmental controls at home. RESULTS: When a piece of equipment was acquired, it was very often used. Patient satisfaction with equipment was 79.3%. Home phones and mobile phones were often used with options such as hands-free devices (78 and 59% respectively). A total of 64.4% of subjects acquired a manual wheelchair and 61% a power wheelchair. The most commonly acquired options on the power wheelchairs were the powered recline (73,7%) and tilt (71,1%) systems. All options were used but all were more desired than acquired. A total of 27.1% of subjects desired a pushrim-activated power-assist wheelchair, but only 15.3% had acquired one; 695% of subjects had a computer. Communication was the first use for the computer (82.5%); 49.2% of subjects had acquired an environmental control system, but 20% desired one. The first reason for lack of acquisition was financial difficulties but also accessibility and information problems. The factor that influenced the acquisition and need for equipment was the degree of spinal cord injury. No other factor reduced patient satisfaction with equipment. CONCLUSION: Patients were satisfied with the equipment they acquired. But their needs, especially wheelchair options and environmental control systems, were not satisfied.

[Pharmacological treatment of neurogenic detrusor hyperactivity: intrathecal drugs]. / Traitement pharmacologique de l'hyperactivité détrusorienne neurologique: drogues intrathécales.

Intrathecal clonidine has been tested in spinal cord injury patients not supporting or resistant to anticholinergic drugs. Although the acute effect of clonidine on urodynamic parameters was satisfactory, cardiovascular adverse effects limited the long-term efficacy of this treatment. Intrathecal baclofen has a limited effect on overactive bladder in patients with spinal spasticity, but can modify the quality of erections and induce an incapacity to trigger ejaculation by vibratory penile stimulation.

Kinematic analysis of handbike propulsion in various gear ratios: implications for joint pain.

BACKGROUND: Though considered more efficient and less constraining than the hand-rim wheelchair, the handbike has rarely been studied especially as regards its kinematic parameters. The hypothesis of this investigation is that the range of upper extremity motions are risk factors for joint pain during handbiking as is the case during hand-rim wheelchair propulsion. This paper aims to study handbike propulsion in maximal sprint conditions in order to determine potential risk factors for joint pain. METHODS: Eight able-bodied participants with no experience in handbike propulsion performed three sprints of 8 s each using three gear ratios in a handbike mounted on a home-trainer. The mean velocity per arm cycle, the cycle frequency, the angular parameters for the upper extremities were calculated, as well as the corresponding angular accelerations, with the help of a 3D movement analysis. FINDINGS: An increase in gear ratio (22/21, 32/21, and 44/21) significantly increases the maximal velocity, the flexion/extension of the trunk, as well as the adduction/abduction of the elbow, while it reduces the frequency of movements and the flexion/extension angular accelerations of the shoulder and the elbow. Regardless of what gear ratio is used, maximal angular amplitudes of the upper extremities are comparable to the values obtained with a hand-rim wheelchair. Interpretation. The high amplitudes and fast angular joint accelerations of the upper extremity found in this study are near or superior to the ergonomic recommendations generally advised. These considerations could be taken into account to prevent overuse injuries.

Intrathecal clonidine for controlling spastic hypertonia.

Intrathecal clonidine is a powerful antispastic drug. Its mechanism of action is more selective than baclofen. The acute effects are reviewed. An assessment of side effects of clonidine during chronic infusion is needed.

[Guillain-Barré syndrome. Recent clinical and therapeutic aspects]. / Syndrome de Guillain-Barré. Aspects cliniques et thérapeutiques récents.

Guillain-Barré syndrome is an acute primary polyradiculoneuritis. A prototype of demyelinating disease, its essential characteristic is that it spontaneously evolves towards recovery from paralysis. Yet the vital and functional prognosis may be compromised in severe cases. Death and motor sequelae are particularly to be feared when the maximum deficit is severe and the maximum paralysis phase is prolonged. Cardiovascular vegetative disorders are also more frequent in these extended types. Symptomatic treatment rests on close supervision of the patients during the paralysis extension phase. Transferring the patient to an intensive care unit is mandatory as soon as disorders of deglutition and/or a significant decrease of vital capacity appear. Plasma exchange is the only treatment proven to be effective. It must be carried out early on in patients whose deficit is severe enough to interfere with walking and for whom this treatment is not contra-indicated. Fresh frozen plasma must not be used as replacement solution: it creates more incidents and complications than diluted albumin and has no additional beneficial effect on the course of the neurological disease.

[Spastic gait analysis. Contribution of the motion lab]. / Analyse de la marche spastique. Contribution du laboratoire d'analyse du mouvement.

Etienne-Jules Marey introduced gait motion analysis at the end of the XIXth century. It was rapidly adopted by clinicians and Charcot used it at the beginning of the XXth century in La Salpêtrière. Motion analysis was widely used after the first optoelectronic system was built by Furné in 1968. The optoelectronic system calculates the orientation of each body segment in the space after the determination of the space co-ordinates of cutaneous markers placed over them. It is particularly useful for spastic gait. Many disturbances of kinematics and kinetics have been described during spastic gait. They are the consequences of spasticity and other motor and sensory deficits of central nervous system lesions. Motion analysis must be coupled with electromyographic recording of spastic muscles activity which, with kinetic analysis, enables distinguishing the mechanisms underlying gait disturbances. Motion analysis provides clinicians with an indispensable tool for understanding spasticity and evaluating therapeutic efficacy.

[Intrathecal therapy for bladder hyperreflexia]. / Traitement de la vessie hyperactive par les drogues intrathécales.

Intrathecal clonidine was tested for the control of bladder hyperreflexia resistant to pararsympathicolytic drugs in spinal cord injured patients. Urodynamic parameters were significantly improved after acute bolus of intrathecal low doses of clonidine. Unfortunately, the chronic intrathecal infusion of clonidine induced cardiovascular side-effects. Intrathecal baclofen did not modified significantly neurogenic bladder dysfunction from spinal lesion. But intrathecal baclofen modified penile erection quality and impaired the ejaculation reflex induced by penile vibratory stimulation in the same population.

Quantitative study of knee joint surface configurations using a morpho-functional approach.

Several models exist in the literature to describe knee kinematics. In this paper we propose a morpho-functional approach based on the determination of a simulated kinematics of flexion/extension from a unique CT scan acquisition. We will compare this kinematics to the real one obtained from experiments on one cadaver. In parallel, we have developed quantitative tools for the assessment of the motion. As the computation of these tools depends on the bone morphology, they can describe the state of the joint, which is not classical in the literature. Both tools follow the evolution of the distances between two bones during motion. They are called the Figure of Articular Coherence and the Index of Articular Coherence. In order to verify the relevance of these tools, we have tested them to compare different surgeries of Anterior Cruciate Ligament (ACL) reconstruction.

A survey of medical and paramedical involvement in children with cerebral palsy in Britanny: preliminary results.

AIM: To describe the amount of medical and paramedical involvement in a sample of Breton children with cerebral palsy as a function of the Gross Motor Function Classification System (GMFCS). MATERIALS AND METHODS: This is a transversal descriptive study. All children with cerebral palsy in Brittany were eligible. Parents who accepted to participate were asked to fill in a questionnaire regarding medical and paramedical involvement with their child. RESULTS: One hundred and thirty-three parents participated. 40.6% of the children were level I on the GMFCS, 20.3% II, 12.03% III, 13.53% IV and 13.53% were level V. Thirty-nine percent of the children took at least one medication (of which 43% were antiepileptic drugs). 33.1% of the children had received at least one injection of botulinum toxin within the year. Forty-four percent used a mobility aid. Eighty-five percent of the children had at least one orthotic device, most often a night ankle-foot orthosis. The median number of rehabilitation sessions per week was 3.85 [0.5-11.5]. The frequency and type of sessions were mostly related to the GMFCS level. CONCLUSION: This study reports high levels of medical and paramedical involvement. Studies must attempt to define optimal practice.

ANSO study: evaluation in an indoor environment of a mobile assistance robotic grasping arm.

OBJECTIVE: To evaluate the reliability and functional acceptability of the ''Synthetic Autonomous Majordomo'' (SAM) robotic aid system (a mobile Neobotix base equipped with a semi-automatic vision interface and a Manus robotic arm). MATERIALS AND METHODS: An open, multicentre, controlled study. We included 29 tetraplegic patients (23 patients with spinal cord injuries, 3 with locked-in syndrome and 4 with other disorders; mean SD age: 37.83 13.3) and 34 control participants (mean SD age: 32.44 11.2). The reliability of the user interface was evaluated in three multi-step scenarios: selection of the room in which the object to be retrieved was located (in the presence or absence of visual control by the user), selection of the object to be retrieved, the grasping of the object itself and the robot's return to the user with the object. A questionnaire was used to assess the robot's user acceptability. RESULTS: The SAM system was stable and reliable: both patients and control participants experienced few failures when completing the various stages of the scenarios. The graphic interface was effective for selecting and grasping the object ­ even in the absence of visual control. Users and carers were generally satisfied with SAM, although only a quarter of patients said that they would consider using the robot in their activities of daily living.

Unstable gait due to spasticity of the rectus femoris: gait analysis and motor nerve block.

We present the case of a 54 year-old man presenting with a right Brown-Séquard plus syndrome (BSPS) after a traumatic cervical spinal cord injury. After being operated on with selective tibial neurotomy and triceps surae lengthening because of a right spastic equinus foot, he developed a gait disorder at high speed. The patient complained about an instability of the right knee. Observational gait analysis exhibited an oscillating, flexion/extension motion of the right knee during stance, which was confirmed by gait analysis. Dynamic electromyographic recordings exhibited a clonus of the right rectus femoris (RF) during stance. The spastic activity of the RF and the abnormal knee motion totally reversed after a motor nerve block of the RF, as well as after botulinum toxin type A injection into the RF. We emphasize that complex, spastic gait disorders can benefit from a comprehensive assessment including gait analysis and nerve blocks.

Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs.

Robust local estimation in anisotropic diffusion process.

In this work we propose to use an anisotropic diffusion process using robust statistics. We show that smoothing, while preserving edges, helps the segmentation of upper limb bones (shoulder) in MRI data bases. The anisotropic diffusion equation is mainly controlled using an automatic edge stopping function based on Tukey's biweight function, which depends on the values of gradients pixels. These values are divided into two classes: high gradients for pixels belonging to edges or noisy pixels, low ones otherwise. This process also depends on a threshold gradient parameter which splits both former classes. So a robust local estimation method is proposed to better eliminate the noise in the image while preserving edges. Firstly, the efficiency of the model in the noise reduction is quantified using an entropy criterion on synthetic data with different noise levels to evaluate the smoothing of the regions. Secondly, we use the Pratt's Figure of Merit (FOM) method to evaluate edges preservation. Eventually, a qualitative edge evaluation is given on a MRI volume of the shoulder joint.