[Evaluation of adherence and satisfaction with intermittent catheterization in children: Feasibility and first steps of validation of InCaSaQ and ICAS in the pediatric population]. / Évaluation de l'adhérence et de la satisfaction aux sondages intermittents chez l'enfant : étude de faisabilité et premières étapes de validation d'InCaSaQ et ICAS dans la population pédiatrique.

INTRODUCTION: In pediatric neurourology, clean intermittent catheterization (CIC) setting, and then self catheterization learning are important steps for children with neurogenic bladder. There is no adherence and satisfaction evaluation scale for children who are using self or hetero CIC. The aim of this article is to study the feasibility of using InCaSaQ (Intermittent Catheterization Satisfaction Questionnaire) and ICAS (Intermittent Catheterization Adherence Scale) in children, and to validate the first steps. PATIENTS AND METHODS: Scale validation monocentric study. Inclusion criterias were patients with neurogenic bladder, under the age of 18, using CIC (auto or hetero). The questionnaires ICAS and InCaSaQ were sent twice between 2017 March and April, and then filled by the child or his parents depending on who was doing the CIC. The internal concistency (Cronbach's alpha) measured the construct validity. The reproductibility was measured by the intraclass correlation cœfficient (ICC) and the Wilcoxon and McNemar tests. Filling facility was evaluated for each score (evaluation with a 0 to 10 scale from the person who filled the questionnaire). RESULTS: Twenty two patients were included, and 50 questionnaires filled (25 ICAS and 25 InCaSaQ), twice each. Internal consistency was good for InCaSaQ (Cronbach's alpha>0,7) and so was ICAS and InCaSaQ reproductibility (ICC>0,7 for most of the questions). Patients under hetero-CIC had a worse adherence than parents of children under hetero-CIC (ICAS 3,25 versus 0,7 for children under hetero-CIC). The lowest InCaSaQ item was the way of throwing away their catheter. CONCLUSIONS: ICAS and InCaSaQ are interesting tools which can be used for children under auto and hetero-CIC. Studies with more patients will be necessary for finalizing the validation of these scales in the pediatric population. LEVEL OF PROOF: 4.

[Outcomes of transcutaneous posterior tibial nerve stimulation for overactive bladder in diabetic patients]. / Résultats de la neurostimulation tibiale postérieure transcutanée pour hyperactivité vésicale chez les patients diabétiques.

OBJECTIVE: Treatment with transcutaneous posterior tibial neurostimulation (NTPT) has been shown to be effective in the treatment of overactive bladder (OAB), but its outcomes in diabetic patients have never been assessed. The aim of this study was to compare the efficacy of NTPT in diabetic OAB patients and in OAB patients without diabetes. METHODS: A single-center prospective study included all patients treated with NTPT for lower urinary tract storage symptoms between 2012 and 2016. The primary endpoint was symptoms improvement≥50% assessed using a Visual Analog Scale (VAS) two months after starting NTPT. Treatment consisted in a daily 20-minute NTPT single-session. The secondary endpoints were lower urinary tract symptoms reported by bladder diary, the Urinary Symptom Profile, the impact on mood and on daily activities. RESULTS: Seventy-one patients were included, 10 of whom were diabetic. The efficacy rate (EVA>50%) was not significantly different in the diabetic group (70% vs. 44.1%, P=0.17), like the mean EVA efficacy was similar in both groups (4/10 vs. 4/10, P=0.98). OAB USP sub-score diminished significantly in both groups at 2 months (-3 points in the diabetic group; -1.9 points in the non-diabetic group; P=0.03 and P<0.0001, respectively). There was no significant difference between the groups, except for the rate of patients who stopped treatment at 6 months, higher in diabetic patients (100% vs. 63.5%, P=0.04). CONCLUSION: The functional outcomes of NTPT appear to be similar in the treatment of OAB in diabetic patients and in non-diabetic patients. LEVEL OF EVIDENCE: 4.

Routine enema before urodynamics has no impact on the quality of abdominal pressure curves: Results of a prospective controlled study.

AIMS: The presence of stools in the rectum might affect the quality of the abdominal pressure curve during filling cystometry, but, to date, no study has evaluated the impact of bowel preparation before urodynamics. We evaluated the influence of a sodium phosphate enema before urodynamics on the quality of the abdominal pressure curve. METHODS: A prospective, controlled, single-blind study was conducted in a single center from May to June 2013. The patients were divided into 2 consecutive groups: patients seen in outpatient clinics during the first 6 weeks (group A) who underwent urodynamics without bowel preparation and patients seen in outpatient clinics during the second 6 weeks (group B) who had a prescription of sodium phosphate enema before urodynamics. The primary endpoint was the quality of the abdominal pressure curve evaluated independently by three physicians who were blinded to the study group. The following data were also collected: age, gender, the presence of a neurological disorder, complicated nature of urodynamics and bother related to preparation for it, assessed using a Likert scale (0 to 10), and the equipment used. A per protocol analysis and an intent-to-treat analysis were conducted. RESULTS: One hundred and thirty-nine patients were included: 54 in group A and 85 in group B. One-third of patients had neurological conditions. 14 patients in group B did not perform their scheduled enema. Thus, 68 patients performed an enema before urodynamics and 71 did not. There was no difference between groups A and B regarding the complicated nature of urodynamics (Likert scale: 3.12 vs. 3.18; P=0.91) or bother related to preparation for it (Likert scale: 3.46 vs. 2.97; P=0.43). In the per protocol analysis, the abdominal pressure curve was considered perfectly interpretable (PI) in 69% of patients who did not receive an enema before urodynamics and in 65% of patients who did (P=0.61). The between-group difference was not statistically significant in intent-to-treat analysis (P=0.99). In patients who did not receive an enema before urodynamics, the only factors statistically associated with better quality of abdominal pressure curves were age <60years (P=0.001) and the urodynamic equipment used (Dantec®>Laborie®; P=0.01). CONCLUSION: In this prospective study, routine enema before urodynamics did not improve the quality of the abdominal pressure curve and did not increase the complicated nature of urodynamics or the bother of preparation for it. LEVEL OF EVIDENCE: 3.

[Preliminary study: Lower urinary tract dysfunction and anorectal disorders in children with cerebral palsy]. / Étude préliminaire des troubles vésico-sphinctériens et anorectaux chez les enfants paralysés cérébraux.

GOAL: Describe lower urinary tract dysfunction and anorectal disorders to children with cerebral palsy (CP), indicating their impact on quality of life. MATERIALS: This was a prospective single-center study. A data collection was: type of PC, Gross Motor Function-Classification System (GMF-CS), mainstream education or not, Functional Independence Measure in children (MIF-kid), standardized vesicosphincteric symptoms and quality of life questionnaires (specific issue of impact sphincter dysfunction and generic scale Kidscreen-52). RESULTS: Between January and March 2013, 19 children aged 5-17 years were included, including 16 into mainstream schooling. Of the 19, 16 had bladder and sphincter disorders: 14 urinary incontinence, 3 nycturies, 6 dysuria, 12 urgenturies, no urinary infection. Of the 14 urinary incontinence, 13 were in school. Of the 16 children enrolled, 5 were daytime fecal incontinence and 2 nocturnal fecal incontinence. Functional scores (GMF-CS and MIF-kid) children urinary incontinence were lower than those of children urinary continents (P=0.04 and 0.0007). Ten children had an impact of these disorders on quality of life. All were enrolled, eight (80%) in the mainstream. CONCLUSION: The bladder and sphincter disorders were common in children with CP. They led to an impact on quality of life in more than half of the children studied, mostly educated in mainstream schools.

Management of unfavorable outcome after mild traumatic brain injury: Review of physical and cognitive rehabilitation and of psychological care in post-concussive syndrome.

INTRODUCTION: Mild Traumatic Brain Injury (mTBI) is a public health issue with approximately 42 million people worldwide affected yearly. Most patients have a favorable short-term recovery but 10-20% are likely to develop post-concussive syndrome (association of physical, cognitive, and psychological difficulties after injury). Post-concussive syndrome can be associated with Post-Traumatic Stress Disorder (PTSD). There is to date no recommendation on the interventions that could be done to reduce post-concussive syndrome. The present review aims at summarizing the effect of therapeutic education, physical and cognitive rehabilitation and of psychological care in mTBI patients with post-concussive syndrome. METHODS: In the current international literature, we investigated the effects of therapeutic education, physical and cognitive rehabilitation and of psychological care in this population using the Medline database and we discussed the results of these studies. RESULTS: The application of a therapeutic education intervention within 3 months after mTBI has been found appropriate and effective to prevent post-concussion syndrome in several studies but the timeline of this intervention differs among the existing studies. Concerning physical disabilities, several pharmacological, rehabilitative and non-pharmacological techniques have shown some efficacy in reducing headache and vertigo; rTMS seems also promising in this context. The management of fatigue is also crucial and requires a multidisciplinary approach. We did not find any intervention in mTBI patients with post-concussive syndrome suffering from dysosmia and/or dysgueusia. No pharmacological treatment is currently recommended to reduce the cognitive symptoms of post-concussive syndrome after mTBI. Rehabilitation and brain-stimulation techniques have already proven their efficacy to reduce the cognitive impairment in this population. Even if the use of Virtual Reality software seems well tolerated in this population, its efficacy and additional value needs to be demonstrated in larger studies. Concerning the psychological care after mTBI, Cognitive and Behavioral Therapy interventions are the most frequently reported in this population, followed by psychoeducational interventions. PTSD management seems crucial in overall recovery of patients with post-concussive syndrome. CONCLUSION: Many studies have sought to demonstrate the effectiveness of various rehabilitation techniques, including different cognitive rehabilitation programs, technology-assisted rehabilitation, different types of brain stimulation and some pharmacological treatments. However, most of these studies are of a low level of scientific evidence and it would be necessary to carry out well-conducted prospective randomized trials in order to offer an appropriate and effective multidisciplinary management for patients with post-concussive syndrome after mTBI.

Adjunct therapies to improve outcomes after botulinum toxin injection in children: A systematic review.

BACKGROUND: Botulinum toxin (BTX) injection alone is not sufficient to treat spasticity in children, notably those with cerebral palsy; thus, there is an emerging trend for adjunct therapies to offer greater outcomes than BTX alone. OBJECTIVE: The aim of this systematic review was to evaluate the general effectiveness of adjunct therapies regardless of their nature in children with spasticity. METHODS: Medline, Cochrane and Embase databases were searched from January 1980 to March 15, 2018 for reports of parallel-group trials (randomized controlled trials [RCTs] and non-RCTs) assessing adjunct therapies after BTX injection for treating spasticity in children. Two independent reviewers extracted data and assessed the risk of bias by using the PEDro scale for RCTs and Downs and Black scale (D&B) for non-RCTs. RESULTS: Overall, 20 articles involving 662 participants met the inclusion criteria. The average quality was good for the 16 RCTs (mean PEDro score 7.4 [SD 1.6]) and poor to moderate for the 4 non-RCTs (D&B score 9 to 17). Adjunct therapies consisted of casting/posture, electrical stimulation, resistance training and rehabilitation programmes. Casting associated with BTX injection improved the range of passive and active motion and reduced spasticity better than did BTX alone (9 studies), with a follow-up of 1 year. Resistance training enhanced the quality and performance of muscles without increasing spasticity. Only 3 rehabilitation programmes were studied, with encouraging results for activities. CONCLUSION: Lower-limb posture with casting in children has a high level of evidence, but the long-term efficacy of short-leg casting needs to be evaluated. A comparison between the different modalities of casting is missing, and studies specifically devoted to testing the different kinds of casting are needed. Moreover, the delay to casting after BTX injection is not clear. Data on electrical stimulation are not conclusive. Despite the small number of studies, resistance training could be an interesting adjunct therapy notably to avoid loss of strength after BTX injection. Rehabilitation programmes after BTX injection still need to be evaluated.

Clinical tools for assessing balance disorders.

Three main issues have to be addressed by the examination of a patient complaining from balance disorders: physiopathology and aetiology, severity and consequences, and evolution. A precise clinical analysis must be then conducted, including close anamnesis and clinical examination, with scale measurements depending on the objectives. Daily consequences can be assessed by the Dizziness Handicap Inventory, which considers a large field of daily activities. The International Classification of Functioning evaluates activities and participation, influence of environmental factors, and quality of life. Then, patient's examination aims at objectifying and measuring the balance disorder. Quantified measurement is possible even in a simple doctor's office. Clinical scales for balance assessment should be used for a standardized assessment and to allow comparison of different subjects. Although the Tinetti test is the most-widely used in older people, it is quite approximate. The Berg Balance Scale has also been first validated in older people, it is rather easy to use, but uncertainty between two close scores is frequent. The Timed Up-and-Go Test is the simplest one and probably the most reliable. The Unipodal Stance Testing is also a simple test and a good predictor of fall. The Functional Ambulation Classification focuses attention on the physical support needed by the patient during walking. The Postural Assessment Scale for Stroke Patients (PASS) is easy to use after a recent stroke. Instrumental analysis by means of static and dynamic platforms, often coupled together with accelerometers or video, can be used to complete the clinical examination. Its main interest is to contribute to give insight into physiologic and pathologic mechanisms underlying the postural trouble.

Influence of subjective visual vertical misperception on balance recovery after stroke.

BACKGROUND: Subjective visual vertical (SVV) perception can be perturbed after stroke, but its effect on balance recovery is not yet known. AIM: To evaluate the influence of SVV perturbations on balance recovery after stroke. METHODS: 28 patients (14 with a right hemisphere lesion (RHL) and 14 with a left hemisphere lesion (LHL)) were included, 5 were lost to follow-up. SVV perception was initially tested within 3 months after stroke, then at 6 months, using a luminous line, which the patients adjusted to the vertical position in a dark room. Mean deviation (V) and uncertainty (U), defined as the standard deviation of the SVV, were calculated for eight trials. Balance was initially assessed by the Postural Assessment Scale for Stroke (PASS), and at 6 months by the PASS (PASS6), a force platform (lateral and sagittal stability limits (LSL6 and SSL6)), the Rivermead Mobility Index (RMI6) and gait velocity (v6). Functional outcome was also assessed by the Functional Independence Measure at 6 months (FIM6). RESULTS: The scores for balance and for FIM6 were related to the initial V value: PASS6 (p = 0.01, tau = -0.38); RMI6 (p = 0.002, tau = -0.48), LSL6 (p = 0.06, tau = -0.29), SSL6 (p = 0.004, tau = -0.43), v6 (p = 0.01, tau = -0.36) and FIM6 (p = 0.001, tau = -0.49), as well as to the initial U value: PASS6 (p = 0.03, tau = -0.32), RMI6 (p = 0.02, tau = -0.35), SSL6 (p = 0.005, tau = -0.43) and FIM6 (p = 0.01, tau = -0.38). CONCLUSIONS: Initial misperception of verticality was related to a poor score for balance after stroke. This relationship seems to be independent of motricity and neglect. Rehabilitation programmes should take into account verticality misperceptions, which could be an important factors influencing balance recovery after stroke.

Difference between individuals with left and right hemiparesis in the effect of gluteus medius vibration on body weight shifting.

OBJECTIVE: To test the effect of gluteus medius (GM) vibration on the reduction of asymmetric body weight distribution in individuals with hemiparesis (HP) at two stages of postural recovery. METHODS: The effects of GM vibration according to the shift of the body weight (%Shift) onto the paretic leg during GM vibration were registered while standing on a force-platform in 40 HP (19 left and 21 right; mean age 54.7±10.6years, mean time after stroke 2.0±1.3months), as soon as they could stand without assistance and 4 to 6 weeks later, and in 40 control subjects (mean age 54.7±10.5years). RESULTS: Without vibration, baseline body weight (BW) distribution was characterized by underloading of the paretic limb (mean BW on the paretic limb 37.2%±13.1%). At the early stage of balance recovery, % shift toward the paretic limb induced by GM vibration differed significantly between left and right HP (P=0.049) and between left HP and controls (C) (P=0.022) and was related to BW asymmetry (r=0.437, P=0.004). Later, GM vibration reduced asymmetric BW distribution in most HP and no difference was found between left and right HP and between left and C. CONCLUSION: At an advanced stage of postural recovery, GM vibration could help encourage HP to put weight on the affected limb. Interestingly, a behavioral difference was initially observed between right and left HP that could probably be explained by a different strategy due to the baseline severity of the BW asymmetry.

Efficiency of physical therapy on postural imbalance after stroke: study protocol for a systematic review and meta-analysis.

INTRODUCTION: Stroke frequently results in balance disorders, leading to lower levels of activity and a diminution in autonomy. Current physical therapies (PT) aiming to reduce postural imbalance have shown a large variety of effects with low levels of evidence. The objectives are to determine the efficiency of PT in recovering from postural imbalance in patients after a stroke and to assess which PT is more effective. METHODS AND ANALYSIS: We will search several databases from inception to October 2015. Only randomised controlled trials assessing PT to recover from poststroke postural imbalance in adults will be considered.Outcome measures will be the Berg Balance Scale (BBS), the Postural Assessment Scale for Stroke (PASS), the 'weight-bearing asymmetry' (WBA), the 'centre of pressure' (COP) and the 'limit of stability' (LOS). WBA, COP and LOS are measured by a (sitting or standing) static evaluation on force plate or another device.Two independent reviewers will screen titles, abstracts and full-text articles, evaluate the risk of bias and will perform data extraction. In addition to the outcomes, measures of independence will be analysed. This study will aim at determining the effects of PT on the function (WBA, COP, LOS), the activity (BBS, PASS) and the independence of patients. Subgroup analyses will be planned according to the location of brain lesion (hemispheric, brainstem or cerebellum), the time since stroke (early, late, chronic), the PT (type, main aim (direct effect or generalisation), overall duration), the type of approaches (top-down or bottom-up) and the methodological quality of studies. ETHICS AND DISSEMINATION: No ethical statement will be required. The results will be published in a peer-reviewed journal. This meta-analysis aims at managing the rehabilitation after postural imbalance by PT after a stroke. TRIAL REGISTRATION NUMBER: Prospero CRD42016037966;Pre-results.

Evolution of subjective visual vertical perturbation after stroke.

OBJECTIVE: The perception of visual verticality is often perturbed after stroke and might be an underlying component of imbalance. The aim of this study was to describe the evolution of visual vertical (VV) perturbation and to investigate the factors affecting it. METHODS: Thirty patients with hemiplegia after a single hemispheric stroke (17 left lesioned [LL] and 13 right lesioned [RL]) were studied. Visual verticality was tested within 45 days of stroke, and then at 3 and 6 months. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. The differences between patients' adjustments and vertical were calculated. The effects on VV evolution of the side, size, type, and location of the lesion were tested. RESULTS: Sixty percent of the recent stroke patients had an initial inaccurate perception of verticality, and 39% of these patients recovered during the 1st 3 months after stroke. The evolution of VV tilt depended on the side of the lesion (P = 0.01), with better recovery in LL patients. None of the other factors studied affected VV normalization. CONCLUSIONS: The poorer recovery of vertical perception after right-side stroke might be due to the predominant role of the right hemisphere in spatial cognition, and might be involved in the poorer recovery of balance after stroke in RL patients.

Postural visual dependence after recent stroke: assessment by optokinetic stimulation.

INTRODUCTION: This study was conducted to assess visual dependence of postural control early after stroke. DESIGN: Case control study. SETTING: A Physical Medicine and Rehabilitation Department. METHOD: Twenty-five patients impaired by severe hemiplegia due to a recent first stroke, were examined. Fourteen had a right and 11 a left hemispheric lesion. There were aged 52+/-13 years, time since stroke was 30+/-12 days. Patients' data were compared to data for 25 healthy subjects. Sitting posture was assessed on a dynamic balance, using two parameters: frontal plane displacement of the centre of pressure under optokinetic stimulation (OKS), and the total length of centre of pressure displacement for the stability reaction. On the basis of 90th percentile control data, patients' behaviour was classified as totally visuo independent (VI), totally visuo dependent (VD) or mixed. RESULTS: Body tilt under OKS was greater in patients than controls. No control subject was totally VD, 19 subjects were totally VI. Four patients were totally VD and only six were VI. The only clinical parameter linked to the effect of OKS was the sensitivity impairment. Overall patients with visuospatial neglect were the most perturbed, but two were totally visuo independent. DISCUSSION AND CONCLUSION: Assessment of postural variations in sitting under OKS is proposed for estimating visual dependence early after stroke. Individual reactions are more important than mean group reactions. Visual dependence is not solely due to neurological impairment, implying that previous physiological behaviour may be involved. Knowledge of these characteristics may affect rehabilitation programmes.

Fatigue after stroke.

OBJECTIVES: To examine the phenomenon of fatigue after stroke and to review the knowledge about frequency, consequences, associated factors, physiopathology and treatment. MATERIALS AND METHOD: Medline was systematically searched with the following keywords: stroke, fatigue, sleep disorders, exercise, and rehabilitation. All relevant articles found in the references were screened as well. RESULTS AND DISCUSSION: Fatigue is a common complaint after stroke and occurs in 39-72% of stroke survivors. Some studies show a severe functional impact of this symptom as well as a high mortality rate. Available evidence concerning associated factors is limited, but fatigue is clearly multifactorial. Some studies show that limited exercise capacity, increased gait energy cost, sleep-disordered breathing and sleep disorders can be related to physical fatigue. Other studies show a link between fatigue and depression. The existence of primary fatigue is still controversial. Treatment must follow a diagnostic approach. Treadmill training, among other treatments, improves fitness reserve and lowering of the energy cost of hemiparetic gait, which could be useful in relieving fatigue.

[Visual dependence after recent stroke]. / Dépendance visuelle après accident vasculaire cérébral récent.

INTRODUCTION: After chronic stroke, inability to use pertinent somatosensory or vestibular information have been described. The aim of the study was to determine whether visual dependence occurred early after stroke before rehabilitation. METHOD: Thirty patients with recent hemiplegia (16 right and 14 left hemispheric stroke) performed the rod and frame test (RFT). Patients were asked to adjust the rod to the vertical position under 3 conditions: basically, with a frame tilted 18 degrees to the right and then with the frame tilted to the left. Bias in each condition (mean, SD) was recorded and compared to adjustments of the rod by 23 controls. Motor control, sensibility, functional level (functional independence measure), age, neglect, and then balance by the postural assessment scale for stroke were assessed. RESULTS: Fifty-six per cent (17/30) of patients but only 26% of controls were influenced by the tilt of the frame on the 2 sides (visual dependence). No correlation was found between visual dependence and the characteristics of the patients. DISCUSSION: Many patients with recent hemiplegia seem to rely on visual input. The mechanisms of such visual dependence are discussed. Rehabilitation programs should take into account the possible impairment of sensory organisation and should include exercises to be performed under visual disturbances.

The effect of optokinetic and galvanic vestibular stimulations in reducing post-stroke postural asymmetry.

OBJECTIVE: To investigate the postural effect of 2 types of sensory stimulation in patients with a left hemispheric lesion (LHL) or right hemispheric lesion (RHL) compared with controls. METHODS: 35 patients (18 LHL, 17 RHL) and 27 controls (mean age 54.1 years), with a mean delay post-stroke of 3.0 months were enrolled. Subjects stood on a force platform and were stimulated on the left and right side by optokinetic (Okn) and galvanic vestibular (Gv) stimulation. Lateral displacement following stimulation toward the right and left directions was calculated as the mean position of the centre of pressure (CP) during the stimulation period minus the mean position at rest. RESULTS: Postural asymmetry was reduced in LHL and RHL patients. CP displacement was higher in cases of left-sided stimulation in the RHL group compared with control subjects and LHL patients (respectively 2.8 and 2.4 times higher, group effect, p<0.001, group × direction of stimulation interaction, p=0.007). The magnitude of displacement under Okn significantly correlated with Gv in all cases (ρ=0.635, p<0.001). CONCLUSIONS: Both GV and Okn stimulations can modulate hemiparetic's CP and their postural effects are correlated. SIGNIFICANCE: Results support a high level cortical postural effect of sensory stimulation on supramodal spatial network.

[Evaluation of the disabilities of hemiplegic patients]. / Evaluation des incapacités fonctionnelles chez le patient hémiplégique: mise au point.

OBJECTIVES: To identify and describe the most useful functional disability scales for assessing post-stroke hemiplegic patients and those used largely in clinical trials. METHODS: A literature review of Medline about the functional parameters for balance, gait and mobility, upper extremity functional abilities, and activities of daily living. The metrologic properties of the scales were specified as were their clinical use. RESULTS: Thirty-three scales were evaluated and classified into five categories: balance (6 scales), gait and mobility (4), upper limb function (11), global motricity scales (5) and independence in activities of daily living (7). DISCUSSION AND CONCLUSION: Many functional scales are useful for assessing post-stroke hemiplegic patients. To assess balance, the Postural Assessment Stroke Scale and Berg Balance Scale are the most interesting. The Functional Ambulation Classification and the Timed Up and Go Test are the most relevant to assess gait and mobility. The Action Research Arm Test is largely used to assess upper limb functional abilities. The Functional Independence Measure and the Barthel Index are largely used to assess independence in activities of daily living.

Motor strategies of postural control after hemispheric stroke.

After stroke, the causes of balance disorders include motor disorders, sensory loss, perceptual deficits and altered spatial cognition. This review focuses on motor strategies for postural control after stroke. Weight-bearing asymmetry, smaller surface of stability, increased sway, body tilting and sometimes pushing syndrome are observed. Weakness and sensory impairments account only for some of these disturbances; altered postural reactions and anticipated postural adjustments as well as abnormal synergistic muscular activation play an important part. These disorders are often linked to cognitive impairments (visuospatial analysis, perception of verticality, use of sensory information, attention, etc.), which explain the preeminent disorders of postural control seen with right rather than left-hemisphere lesions. Most of the motor changes are due to an impaired central nervous system but some could be considered adaptive behaviors. These changes have consequences for rehabilitation and need further studies for building customized programs based on the motor comportment of a given patient.

Effect of sensorial stimulations on postural disturbances related to spatial cognition disorders after stroke.

Balance disorders related to disturbances in perception of spatial reference systems are common especially after right hemispheric stroke. Mental misrepresentation of bodily orientation in space is then often superimposed upon other factors affecting imbalance such as motor and sensory impairments. Traditional rehabilitation for balance recovery has not been specifically designed to improve balance disorders related to spatial cognition. The traditional approach, consisting of stimulating the conscious perception of body orientation in space, is demanding and laborious. The approach based on sensorial stimulation is completely different. The relevance of this method lies in the fact that, firstly it is specifically active in the cognitive component of balance disorders; and secondly, it can passively be applied with minimal patient participation, which is of particular importance for this patient group characterized by disorders of attention and concentration. These techniques, such as proprioceptive, visual or vestibular stimulation, have been found to correct spatial neglect but also postural bias. Clinical and data from functional neuro-imaging suggest a direct central action on cortical structures involved in the elaboration of spatial representation. These are promising techniques for the rehabilitation of postural disturbances related to spatial cognition disorders but are as yet at the stage of preliminary results.