Clinical assessment of upper limb hypertonia in central neurological diseases.

The clinical assessment of a hypertonic upper limb in central neurological diseases should be analytical, systematic (shoulder, elbow, extrinsic and intrinsic hand) and focused on the patient or caregiver's wishes and on the expected objectives (esthetic, hygienic, functional). Nerve blocks can help to separate mixed contractures, show the existence of antagonist muscles or find a starter muscle in dystonia patterns. The etiology (especially the evolving nature of the disease), general health condition (especially in older adults), associated deficits (cerebellar, sensory and cognitive; hemineglect) are considered together to arrive at a contract with patients and/or caregivers.

Environmental performance of commercial beef production systems utilizing conventional productivity-enhancing technologies.

The objective of this study was to evaluate the effects of using conventional productivity-enhancing technologies (PETs) with or without other natural PETs on the growth performance, carcass traits, and environmental impacts of feedlot cattle. A total of 768 cross-bred yearling steers (499 ±â€…28.6 kg; n = 384) and heifers (390 ±â€…34.9 kg; n = 384) were offered a barley grain-based basal diet and divided into implanted or non-implanted groups. Steers were then allocated to diets that contained either: (i) no additive (control); natural feed additives including (ii) fibrolytic enzymes (Enz), (iii) essential oil (Oleo), (iv) direct-fed microbial (DFM), (v) DFM + Enz + Oleo combination; conventional feed additives including (vi) Conv (monensin, tylosin, and beta-adrenergic agonists [ßAA]); or Conv with natural feed additives including (vii) Conv + DFM + Enz; (viii) Conv + DFM + Enz + Oleo. Heifers received one of the first three dietary treatments or the following: (iv) probiotic (Citr); (v) Oleo + Citr; (vi) Melengesterol acetate (MGA) + Oleo + ßAA; (vii) Conv (monensin, tylosin, ßAA, and MGA); or (viii) Conv + Oleo (ConvOleo). Data were used to estimate greenhouse gas (GHG) and ammonia (NH3) emissions, as well as land and water use. Implant and Conv-treated cattle exhibited improvements in growth and carcass traits as compared to the other treatments (P < 0.05). Improvements in the performance of Conv-cattle illustrated that replacing conventional feed additives with natural feed additives would increase both the land and water required to satisfy the feed demand of steers and heifers by 7.9% and 10.5%, respectively. Further, GHG emission intensity for steers and heifers increased by 5.8% and 6.7%, and NH3 emission intensity by 4.3% and 6.7%, respectively. Eliminating the use of implants in cattle increased both land and water use by 14.6% and 19.5%, GHG emission intensity by 10.5% and 15.8%, and NH3 emission intensity by 3.4% and 11.0% for heifers and steers, respectively. These results demonstrate that the use of conventional PETs increases animal performance while reducing the environmental impacts of beef production. Restricting use would increase the environmental footprint of beef produced for both domestic and international markets.

Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques.

Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.

Resection of neurogenic heterotopic ossification (NHO) of the hip.

Neurogenic heterotopic ossification of the hip is secondary to neurologic lesions such as cranial trauma, stroke, medullary injury or cerebral anoxia. We shall not deal here with the other etiologies of heterotopic ossification. There are numerous locations within the hip, depending on etiology and relations with adjacent neurovascular structures are sometimes close. Preoperative work-up should include contrast-enhanced CT; scintigraphy is non-contributive. Indications for surgery are decided in a multidisciplinary team meeting, with a contract laying out expected functional gain. It is this contract that determines the extent of resection, without seeking complete resection, which would incur an increased risk of complications. The surgical approach and resection strategy depend on lesion location and any resulting neurovascular compression. The most common complications are infection and postoperative hematoma. No adjuvant treatments have demonstrated efficacy against recurrence.

Postoperative infections after excision of neurogenic heterotopic ossifications at the hip: Risk factors and causative organisms.

BACKGROUND: Neurogenic heterotopic ossification (NHO) is usually treated by surgical excision. Postoperative infection (POI) is a possible complication, whose epidemiology, causative organisms, and risk factors are poorly known. We therefore conducted a case-control study to (1) identify the risk factors for POI after surgical excision of NHO at the hip, (2) determine the frequency of POI, (3) and identify the causative organisms. HYPOTHESIS: Risk factors for POI after NHO excision at the hip can be identified. MATERIAL AND METHODS: In this retrospective case-control study, the BANKHO database for patients with NHO at our centre was used to identify risk factors by comparing patients with and without POI after NHO excision at the hip. To this end, odds ratios (ORs) with their 95% confidence intervals (95%CIs) were computed for each main criterion. Postoperative follow-up was at least 6 months. RESULTS: Between 1993 and 2013, 411 hip NHO excisions were performed. Among them, 42 (10%) were followed by POI. The American Society of Anesthesiologists (ASA) score was I in 2/42 (5%) patients with vs. 74/369 (20%) patients without POI, II in 30/42 (71%) patients with vs. 258/369 (70%) patients without POI, and III in 10/42 (24%) patients with vs. 37/369 (10%) patients without POI (P<0.01). Mean age was 31±11 years (range, 17-79years) in the group with POI and 39±14 years (range, 15-77years) in the group without POI (P<0.01). The NHO was related to spinal cord injury in 26/42 (62%) patients with POI compared to 92/369 (25%) patients without POI (P<0.01). ORs indicated a significant risk increase in patients with an ASA score of III (2.84; 95%CI, 1.28-6.31), age younger than 30 years (1.85; 95%CI, 1.03-3.32), and spinal cord injury as the cause of NHO (4.89; 95%CI, 2.67-8.98). The predominant organisms were staphylococci (skin flora) in the patients with spinal cord injury and bacteria commonly found in intensive care units in the other patients. DISCUSSION: A higher ASA score, younger age, and spinal cord injury as the cause of NHO at the hip are risk factors for POI. The proportion of patients with POI after hip NHO excision was 10%, in accordance with previous reports. POI was more common among patients with spinal cord injury (22% vs. 5% in the other patients). Neither changes in prophylactic antibiotic therapy regimens nor the institution of a detailed skin preparation protocol affected the frequency of POI. Skin pH alterations may deserve to be investigated with the goal of diminishing the risk of POI, most notably in spinal cord injury patients. LEVEL OF EVIDENCE: III, case-control study.

Successive motor nerve blocks to identify the muscles causing a spasticity pattern: example of the arm flexion pattern.

Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Européenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6 ± 23.7 to 52.6 ± 24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6 ± 24.2 to 48.7 ± 23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7 ± 23.7to 34.2 ± 20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted.

Botulinum toxin A for treating spasticity in adults: costly for French hospitals?

INTRODUCTION: Intramuscular injection of botulinum toxin (BoNTA) is one of the primary treatments for focal spasticity. This treatment is considered costly and the level of reimbursement by health insurance has been decreasing in many countries for several years. The aim of this study was to determine the real cost of treating spasticity with BoNTA and to compare this with the level of reimbursement by the national health insurance in France in 2008 and with a new fee, specific to the injection of BoNTA in ambulatory services. METHOD: A single-center, retrospective study using the 2008 database from a French secondary-care day-hospital unit (treating spasticity in adults with sequelae of stroke, multiple sclerosis or traumatic brain injuries). The level of reimbursement by the French ministry of health for BoNTA treatment for adults with spasticity constituted the "calculated cost" and corresponded to the hospital's "budget". The "real cost" (incurred by the hospital) included the sum of staffing and material costs as well as the number of toxin vials used. The calculated costs for 2009 and 2013 were based on the levels of reimbursement during those years. The difference between real and calculated cost for 2009 and 2013 was estimated considering that the real cost of 2008 was stable. RESULTS: In 2008, 364 patients received BoNTA, resulting in 870 day-hospital admissions. The calculated cost was 459,056€/year and the real cost was 567,438€/year (equivalent to 4.27€/day/patient). The total budget deficit (hospital income minus hospital costs) was 108,383€. The deficit was estimated at 222,892€ in 2009 and 241,188€ in 2013. CONCLUSION: The daily cost of BoNTA treatment for spasticity is reasonable; however, because of the level of reimbursement by the national health insurance in France, the treatment is costly for French hospitals.

Beliefs relating to recurrence of heterotopic ossification following excision in patients with spinal cord injury: a review.

STUDY DESIGN: Review of the literature. OBJECTIVES: It is widely believed that the timing of surgery and the size of the initial Neurological Heterotopic Ossification (NHO) affect the recurrence risk of NHO after SCI. A large number of studies were published in the 80s and the 90s, mostly of poor quality despite the fact that they were carried out by experienced surgical teams. The aim of this study was to suggest recommendations relating to the timing of excision of heterotopic ossification after SCI following the analysis of a recent review of the literature. SETTING: France. METHODS: A systematic literature search was performed in the PubMed Embase from January 2002 until June 2014 using the MESH headings 'spinal cord injury', 'paraplegia', 'heterotopic ossification' and 'surgery'. Results were compared with results from epidemiological studies based on the BANKHO database (patients who underwent surgery for troublesome HO after central neurological system (CNS) lesions in our center (357 patients, 539 surgeries)). RESULTS: Few studies were found in the literature, results were sometimes contradictory and practices heterogeneous. Results from the BANKHO database showed that troublesome recurrence of NHO was not associated with 'early' surgery (before 6 months), and no association was found between recurrence and the size of the NHO around the joint (Brooker status). CONCLUSION: We suggest that surgical excision of the NHO should be carried out when it begins to be troublesome, as soon as comorbid factors are under control and the HO is sufficiently constituted for excision.

Effects of a knee-ankle-foot orthosis on gait biomechanical characteristics of paretic and non-paretic limbs in hemiplegic patients with genu recurvatum.

BACKGROUND: A knee-ankle-foot orthosis may be prescribed for the prevention of genu recurvatum during the stance phase of gait. It allows also to limit abnormal plantarflexion during swing phase. The aim is to improve gait in hemiplegic patients and to prevent articular degeneration of the knee. However, the effects of knee-ankle-foot orthosis on both the paretic and non-paretic limbs during gait have not been evaluated. The aim of this study was to quantify biomechanical adaptations induced by wearing a knee-ankle-foot orthosis, on the paretic and non-paretic limbs of hemiplegic patients during gait. METHODS: Eleven hemiplegic patients with genu recurvatum performed two gait analyses (without and with the knee-ankle-foot orthosis). Spatio-temporal, kinematic and kinetic gait parameters of both lower limbs were quantified using an instrumented gait analysis system during the stance and swing phases of the gait cycle. FINDINGS: The knee-ankle-foot orthosis improved spatio-temporal gait parameters. During stance phase on the paretic side, knee hyperextension was reduced and ankle plantarflexion and hip flexion were increased. During swing phase, ankle dorsiflexion increased in the paretic limb and knee extension increased in the non-paretic limb. The paretic limb knee flexion moment also decreased. INTERPRETATION: Wearing a knee-ankle-foot orthosis improved gait parameters in hemiplegic patients with genu recurvatum. It increased gait velocity, by improving cadence, stride length and non-paretic step length. These spatiotemporal adaptations seem mainly due to the decrease in knee hyperextension during stance phase and to the increase in paretic limb ankle dorsiflexion during both phases of the gait cycle.

[Surgical management of spasticity of the intrinsic muscles of the long fingers in adults after cerebral palsy, 68 operated hands]. / Prise en charge chirurgicale de la spasticité des muscles intrinsèques des doigts longs dans la main spastique de l'adulte cérébrolésé, à propos de 68 mains opérées.

Between November 2001 and January 2008, 56 patients (68 hands) out of 110 patients operated for spastic hand deformities, presented with spasticity of the intrinsic muscles of the long fingers (interosseii and the abductor pollicis brevis). All patients were adults (mean age 42.1 years). The surgical indication was discussed during multidisciplinary consultations with selective nerve blocks enabling us to distinguish between extrinsic and intrinsic pathologies on the one hand and muscular spasticity and tendon retractions on the other hand. The aim of the treatment was defined in a "contract" signed with the patient and/or his family. It was hygienic, aesthetic and analgesic in 15 cases, hygienic and analgesic in 32 cases and functional in 21 cases. Four hands were treated by neurectomy of the ulnar nerve's motor ramus, 54 by tenotomies of the interosseous muscles, 18 by tenotomy of the abductor digiti minimi, six by metacarpal disinsertion of the interosseous muscles. On a total of 67 hands operated associating surgery of the extrinsic and intrinsic flexors, 63 had good primary results as defined in the contract. We noted four relapses, two of which required revision. The authors emphasize the frequency of mixed spastic hands in adults after cerebral palsy. However modest the functional results may be, correction of hygienic and pain problems of non-functional hands as well as aesthetic improvements make surgery of the mixed spastic hand a successful intervention, which should be shared.

[Imaging features of neurologic and orthopedic complications from severe trauma]. / Imagerie des complications neuro-orthopédiques des traumatismes graves.

Cranial and spinal trauma are a frequent cause of disability in the general population. Post-traumatic paraplegia or quadriplegia or hemiplegia from vascular injury (CVA) can lead to early complications (respiratory, cardiovascular, urinary, cutaneous, infectious...) that may have an impact on the immediate prognosis. Neurologic and orthopedic complications occur later and further impair the quality of life of patients. Orthopedic complications include: neurogenic paraosteoarthropathy (NPOA) or neurogenic osteoma or myositis ossificans (NMO). The nomenclature currently in use is NMO; Osseous complications: osteoporosis and secondary insufficiency fractures; Joint complications: degenerative arthropathy and stiffness; Overuse mechanical complications; Muscular complications; Infectious complications: arthritis and myositis complicating skin ulcers and bed sores. The purpose of this paper is to describe these neuro-orthopedic complications and review their imaging features.

Orthotic devices and gait in polio patients.

Polio survivors are aging and facing multiple pathologies. With age, walking becomes more difficult, partly due to locomotor deficits but also as a result of weight gain, osteoarticular degeneration, pain, cardiorespiratory problems or even post polio syndrome (PPS). These additional complications increase the risk of falls in this population where the risk of fractures is already quite high. The key joint is the knee. The muscles stabilizing this joint are often weak and patients develop compensatory gait strategies, which could be harmful to the locomotor system at medium or long term. Classically, knee recurvatum is used to lock the knee during weight bearing; however, if it exceeds 10 degrees , the knee becomes unstable and walking is unsafe. Thus, regular medical monitoring is necessary. Orthoses play an important role in the therapeutic care of polio survivors. The aim is usually to secure the knee, preventing excessive recurvatum while respecting the patient's own gait. Orthoses must be light and pressure-free if they are to be tolerated and therefore effective. Other joints present fewer problems and orthoses are rarely indicated just for them. The main issue lies in the prior evaluation of treatments' impact. Some deformities may be helpful for the patients' gait and, therefore, corrections may worsen their gait, especially if a realignment of segments is attempted. It is therefore essential to carefully pre-assess any change brought to the orthoses as well as proper indications for corrective surgery. In addition, it is essential for the patient to be monitored by a specialized team.

Impact of late surgical intervention on heterotopic ossification of the hip after traumatic neurological injury.

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.

Comparison of the repercussions of cLBP in four French-speaking countries.

INTRODUCTION: Sociocultural factors may influence the impact of chronic low back pain (cLBP) on patients. The goal of this study was to compare pain and disability levels, and psychobehavioural parameters in four French-speaking countries in patients with cLBP. METHODS: Two hundred and seventy-eight patients were included: 83 in France, 36 in Morocco, 75 in the Ivory Coast and 84 in Tunisia. Demographic data were collected; pain was assessed using a visual analogue scale (VAS), disability with the Quebec scale, psychobehavioural factors by the hospital anxiety depression scale (HAD), the fear and avoidance beliefs questionnaire (FABQ) and the coping strategy questionnaire (CSQ). A Student t-test was used to compare means. Anova (covariance) was used to test for a "Country Effect", i.e. the incidence of country on outcomes. OUTCOMES: There was no difference in disability levels between countries. A "country effect" was found (p<0.001) for pain (F=2.707), anxiety (F=3.467), depression (F=5.137), fear and avoidance beliefs regarding professional activity (F=1.974) and physical activity (F=5.076), strategy of distraction, dramatization, efforts to ignore pain, prayer, seeking social support and reinterpretation (p<0.01). Pain level was higher in Morocco (p<0.05); anxiety, depression, fear and avoidance beliefs about physical activities were higher in Tunisia (p<0.05) and fear and avoidance beliefs about professional activities were higher in the Ivory Coast (p<0.01). Among the coping strategies used, distraction, dramatization, prayer and search for social support were used more in the Ivory Coast; reinterpretation in Tunisia; seeking social support was less common in France. CONCLUSION: In this population of patients with cLBP, despite similar disability levels across the four French-speaking countries, there were considerable variations in pain level and psychobehavioural repercussions.

Undesirable distant effects following botulinum toxin type a injection.

OBJECTIVES: To study the incidence of clinical signs linked to botulinum toxin type A (BoNTA) spread from the injection site. METHODS: Single-center, retrospective, cohort study. All patients who received BoNTA injections for spasticity treatment were assessed 1 month postinjection. Adverse effects indicative of BoNTA treatment were systematically sought. Any patient with adverse effects possibly due to BoNTA spread underwent further clinical examination and single-fiber electromyography. One patient underwent neuromuscular biopsy. RESULTS: Between January and September 2005, 266 BoNTA injection sessions (187 patients) were performed (233 BOTOX, 33 Dysport). Five patients presented with clinical signs of toxin spread. Four of these underwent single-fiber electromyography, which showed increased jitter. Neuromuscular biopsy detected signs of recent denervation without signs of reinnervation. CONCLUSIONS: Diffusion diagnosis of BoNTA from the injection site depends on clinical, temporal, and electromyographic factors. Clinical expression of spread varies widely, with mechanisms remaining largely unknown, and further prospective, randomized clinical trials are required.

Change of impairment, disability and patient satisfaction after total knee arthroplasty in secondary care practice.

OBJECTIVES: To assess the evolution of impairment and disability after total knee arthroplasty (TKA) for osteoarthritis and to seek an association with patient satisfaction with surgery. METHOD: Consecutives patients (n=45, 18 women) with osteoarthritis undergoing primary TKA in two secondary care inpatient clinics were prospectively assessed before one month and six months after surgery. Disability was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-900) and the Lequesne Index (range 1-24). Patients' perceived handicap was assessed on a visual analog scale (VAS, range 1-100). At one month and six months postoperatively, kinetic strength of quadriceps and hamstrings was obtained by isokinetics measures and patient satisfaction on a VAS (range 1-100). RESULTS: Mean age was 71.7+/-7.0 years; mean duration of symptoms was 38.3+/-33.4 months. Patient satisfaction was 83.9+/-17.7 and 83.1+/-22.4 at one month and six months after TKA, respectively. At one month, significant improvements were observed over baseline for pain (-30.73+/-32.2; p<0.01), physical function (Lequesne Index -2.28+/-3.6, p<0.01; and WOMAC score, -82.60+/-148.5, p<0.01), and patient perceived handicap (-21.84+/-29.6, p<0.01). A significant decrease in global knee range of motion was also observed. At six months, significant improvement was observed for pain (-47.96+/-26.8; p<0.01), physical function (Lequesne Index, -5.08+/-3.66, p<0.01; and WOMAC score, -157.04+/-153.2, p<0.01) and patient perceived handicap (-39.60+/-24.1; p<0.01). All isokinetics measures for quadriceps and hamstring were significantly improved between one month and six months after surgery. At one month and six months, the correlation between patient satisfaction and change in impairment, disability and patient perceived handicap was weak. DISCUSSION AND CONCLUSION: Impairment, disability and patient perceived handicap improved significantly after TKA for osteoarthritis. However, these improvements were poorly correlated with patient overall satisfaction with surgery.

The benefits of ambulatory physiotherapy after total hip replacement. Clinical practice recommendations.

AIM: To develop clinical practice guidelines for prescribing ambulatory physiotherapy for patients able to leave the surgery department directly for home just after total knee replacement (THR). METHOD: We used the SOFMER (French Society of Physical and Rehabilitation Medicine) methodology, which associates a systematic revue of the literature, collection of information regarding current clinical practice and external review by a multidisciplinary expert panel. Main outcomes considered in the recommendations were impairment, disability, medico-economic implications and postoperative complications. RESULTS: The literature review results showed some advantage for programs of ambulatory physiotherapy for patients able to return home just after total hip replacement. The main outcomes ameliorated are muscle strength and function. However, studies were methodologically limited. When the patient can return home directly from the surgery department, we recommend ambulatory physiotherapy as suggested by French clinical practice. The program and number and objectives of the ambulatory rehabilitation must be defined in future trials with good methodology. No difference in cost was found if home therapy is used.

The benefits of ambulatory physiotherapy after total knee replacement. Clinical practice recommendations.

AIMS: To develop clinical practice guidelines for ambulatory physiotherapy for patients able to leave the surgery department directly for home just after total knee replacement (TKR). METHOD: We used the SOFMER (French Society of Physical and Rehabilitation Medicine) methodology, which associates a systematic revue of the literature, collection of information regarding current clinical practice and external review by a multidisciplinary expert panel. Main outcomes considered in the recommendations were impairment, disability, medico-economic implications and postoperative complications. RESULTS: The literature review did not allow for recommending systematic prescription of ambulatory physiotherapy for patients able to leave the surgery department directly for home just after TKR. However, this prescription could improve muscle strength and function but not mobility. When patients can return home directly after surgery, we recommend ambulatory physiotherapy as suggested by French clinical practice to increase function. CONCLUSION: Good methodological trials must be developed to define the criteria for prescribing ambulatory physiotherapy for patients able to return home just after total knee replacement (TKR) and to evaluate the content of the optimal program.

[Psychobehavioural assessment for chronic low back pain]. / Evaluation psychocomportementale dans la lombalgie chronique.

INTRODUCTION: Psychobehavioural assessment may be a complementary approach to assess response to treatment for pain and disability in patients with low back pain. OBJECTIVES: To assess the correlation between psychobehavioural factors and pain and disability in patients with chronic low back pain in France. METHODS: We asked 83 patients with chronic low back pain to complete questionnaires during a primary care consultation by a general practitioner. Pain was measured by a visual analog scale (VAS), disability by the Quebec Back Pain Disability Scale and psychobehavioural factors by the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Coping Strategy Questionnaire (CSQ). RESULTS: Pain was poorly correlated with anxiety (R = 0.36) and scores on the FABQ 1 (R = 0.46) and FABQ 2 (R = 0.30) and not correlated with depression (R = 0.22), duration of pain evolution (R = 0,10) and body mass index (R = 0.12). The duration of stopping work was poorly correlated with disability (R = 0.35) and FABQ 1 score (R = 0.43) and not correlated with pain (R = 0.11), anxiety (R = 0.11), depression (R = 0.26) and FABQ 2 score (R = 0.23). Disability was poorly correlated with scores on the FABQ 1 (R = 0.45) and FABQ 2 (R = 0.3), anxiety (R = 0.39) and depression (R = 0.47) and not correlated with pain (R = 0.25). Dramatization is the only way to cope with pain and was correlated with pain (R = 0.34), scores on the FABQ 1 (R = 0.47) and FABQ 2 (R = 0.43), disability (R = 0.38), anxiety (R = 0.44) and depression (R = 0.46). The use of prayer was poorly correlated with FABQ 1 score (R = 0.37) and anxiety (R = 0.30). Distraction was poorly correlated with scores on the FABQ 1 (R = 0.40) and FABQ 2 (R = 0.30). No strategy was correlated with duration of pain and stopping work. DISCUSSION-CONCLUSION: All the correlation assessments with psychobehaviour factors are weak. So evaluating each of these parameters will be interesting. Duration of pain was not correlated with increasing pain or change in behavioural strategy. Psychobehavioural factors are more invalidating than pain. More study is needed to assess psychobehavioural therapies in patients with low back pain.

[Radiculopathy following intrathecal baclofen pump implantation]. / Radiculalgie après implantation de pompe à baclofène.

INTRODUCTION: Intrathecally delivered baclofen has been used as a treatment for severe spasticity since 1984. After a successful intrathecal baclofen trial, a programmable drug delivery system was implanted. Few early complications such as infection or hematoma are observed after this surgery. OBJECTIVE: To describe an unusual and unknown complication of intrathecal baclofen therapy. METHOD: We report 2 cases of complications of intrathecal baclofen therapy, radiculalgy, that appeared early after pump implantation. The clinical symptoms and computed tomography (CT) results are described. RESULTS: The first patient described pain, which evoked left S1 radiculopathic features. The second had left L5 radiculopathic involvement. The mean pain level was estimated on a 10-point visual analog scale as 7.5 (range 4-9). Lumbar CT scan showed a conflict between the symptomatic root and the catheter and eliminated other causes of the symptoms. Treatment with analgesic drugs was successful in 1 patient. The other presented with proximal disconnection of the catheter, which led to surgical replacement of the catheter. The pain disappeared after this surgery. CONCLUSION: Intrathecal baclofen therapy with a subcutaneously implanted progammable pump can be complicated by radiculalgy secondary to a conflict between the catheter and symptomatic root. The diagnosis is made by CT lumbar scan. If medical treatment is not sufficient, surgery could be proposed to replace the catheter.