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.

[Non-medicinal treatments of spasticity in multiple sclerosis]. / Traitements non médicamenteux de la spasticité dans la sclérose en plaques.

Non-medicinal treatments of spasticity may be proposed in patients with multiple sclerosis as either an adjunct to pharmacological treatments or the first line of treatment. Assessment of non-medicinal treatments, whether manual, surgical or with instrumentation, shows it to be beneficial for limb spasticity. Studies also reveal that, contrary to expectations, physical exercise does not increase spasticity. This means that physical exercise may be prioritized and that sports practice should not be forbidden, provided that the patient has an adequate neurological status and takes sufficient breaks to avoid fatigue.

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.

[Strength, postural and gait changes following rehabilitation in multiple sclerosis: a preliminary study]. / Evaluation préliminaire des effets de la rééducation sur les paramètres de force, d'équilibre et de marche dans la sclérose en plaques.

OBJECTIVE: To evaluate the impact of rehabilitation on balance, gait and strength in inpatients with multiple sclerosis (MS). METHODS: Twenty-one in patients with MS benefited from a program of rehabilitation with evaluation before and after rehabilitation. Balance was assessed by stabilometry, walking speed with use of a locometer device and maximal peak torque of knee extensor and flexor with use of an isokinetic dynamometer at 60 degrees /s speed. The functional independence measure (FIM) was also applied before and after rehabilitation. RESULTS: After rehabilitation, patients showed significant improvement in balance with opened and closed eyes, velocity gait, strength of the lower quadriceps and the higher hamstrings and FIM values. Absolute values of gait speed and strength parameters were related as were improvement in velocity speed and the higher hamstrings. CONCLUSION: The results are encouraging and confirm the interest and tolerance of a program of rehabilitation among patients with MS.

Intrathecal baclofen for treatment of spasticity of multiple sclerosis patients.

We conducted a retrospective study of the case files of 64 multiple sclerosis (MS) patients presenting severe spasticity, who had received intrathecal (IT) baclofen test injections between 1992 and 2004 in a rehabilitation unit. In almost all cases of our series, IT baclofen was proposed to patients who were no longer able to walk. IT baclofen is a safe and effective treatment to reduce spasticity in MS patients. Despite an advanced stage of the disease at the time of pump placement, the complication rate was low and the efficacy of this treatment was maintained over time.

[Surgical treatment of orthopedic deformities due to spasticity in the lower limb]. / Les traitements orthopédiques des conséquences dela spasticité membre inférieur.

Orthopedic deformities in the lower limb concern all joints (hip, knee, ankle, foot) with a wide range of clinical forms. Spasticity, contracture, stiffness, laxity, neurological deficit are assessed to establish the surgical procedure. Surgical techniques are adapted to the goals that are detailed with the patient and his family: standing, transferring, walking, hygiene, devices (shoes, orthosis, canes, wheelchair). Surgical procedures can associate: lengthening of contractured muscles (tenotomy with or without sutures, fractional lengthening at the musculo-tendinous junction or desinsertion), strengthening of antagonists (passive or active tendon transfer) and correction of joint deformity (arthrolysis, arthrodesis, arthroplasty). In adults, the most common deformities are the equinus or equinovarus foot, toe curling, hip adductum, knee flessum. Talus or knee recurvatum are less frequently observed. The association of various deformities raises questions concerning the hierarchy of surgical procedure, from an anatomical point of view (do we start with proximal or distal joint first?) as from chronological concerns (shall we do one or more procedures?). Pluridisciplinary assessment using neurological anesthetic blocs and dynamic EMG or gait analysis is necessary to detail the aims of surgery and choose the surgical procedures.

[Double dissociation between unilateral neglect and anosognosia]. / Double dissociation entre négligence unilatérale gauche et anosognosie.

We report two patients presenting with a subacute right hemisphere stroke. These cases demonstrate a double dissociation between unilateral neglect and anosognosia for hemiplegia. The first patient suffered from a severe left hemiplegia associated with severe and persisting unilateral neglect. He appeared fully aware of his motor impairment. The second patient had a severe left hemiplegia, without any major sign of unilateral neglect on clinical tests nor on behavioural assessment. Nevertheless, he presented a severe and sustained anosognosia for hemiplegia. These case reports support the assumption that anosognosia and unilateral neglect, although they are frequently associated, may rely on independent mechanisms.

[Spasticity and multiple sclerosis]. / Spasticité et SEP.

Spasticity is a common symptom in MS patients. It is easy to recognize and evaluate spasticity at rest. The efficacy of numerous treatments has been well documented. Nevertheless, it is difficult, particularly in MS patients, to assess the functional disability due to spasticity and the functional benefit due to treatment. This is why it is appears more appropriate to use therapeutic tests with transitory effects such as anesthetic blocks in case of focal spasticity or intrathetical baclofen in case of diffuse spasticity. It is also possible to use reversible treatments such as botulinum toxin injections before proposing section of a peripheral nerve.

[Conduction aphasia and phonemic disorder]. / Aphasie de conduction par trouble phonémique.

Conduction aphasia is usually described as a repetition impairment. Semiology or pathophysiology cannot be explained with this definition. We report a single case particularly demonstrative. The patient showed spontaneous speech, denomination, repetition and reading impairments. Main errors were phonemic paraphasia. No arthric disorder nor comprehension impairment was observed. Damage of supramarginalis gyrus and Wernicke's area was found. A cognitive analysis suggested that the phonological buffer and the working memory were impaired. Implication for rehabilitation, which included segmentation and semantisation associated to phonological training, is discussed. The course of the conduction aphasia was good and the patient was able to work again.