Assessment of quality of life in stroke patients with hemiplegia.

UNLABELLED: Stroke is a major public health issue. Even though most hemiplegic stroke patients may obtain a good functional outcome, many remain dissatisfied with their lives. Indeed, quality of life and subjective well-being should be taken into account in any assessment of stroke survival. OBJECTIVE: To assess long-term quality of life in stroke patients (compared with healthy controls) and the corresponding determinants and predictive factors. METHOD: The patient population consisted of 80 of the 217 first-stroke survivors treated between January and June 2005 in the Clinical Neurosciences Department at Bordeaux University Hospital. After a mean follow-up period of 2 years, 24 patients were interviewed in their homes and data from the 56 others were obtained in a telephone interview. Demographic information, clinical status on admission and functional status (as assessed by Barthel Index) and depression (on the ADRS) at the time of the study visit were recorded. Quality of life was assessed by using the Sickness Impact Profile (SIP-65) and Bränholm and Fugl-Meyer's Satisfaction with Life Scale (LiSat 11). The patients' data were compared with those from 149 healthy controls. RESULTS: Life satisfaction and quality of life were significantly impaired in stroke patients, compared with controls. All life domains were impaired. The worst scores were observed for independence and health-related items in the LiSat 11 and the physical and communication items in the SIP-65. Quality of life was strongly correlated with functional independence, the persistence of hemiplegia and depressive mood, which is in agreement with literature findings. Neither gender nor the initial Rankin score had a significant impact on these parameters. DISCUSSION-CONCLUSION: Quality of life at 2 years is significantly impaired in stroke survivors and seems more difficult to predict than functional independence. However, in addition to these objective results, our interviews suggest that receiving adequate social support might be as important to patients as recovering independence.

Stroke in under-75-year-olds: expectations, concerns and needs.

UNLABELLED: Most studies of functional outcomes in hemiplegic stroke patients use standard disability rating scales (such as the Barthel Index). However, planning the allocation of assistance and resources requires additional information about these patients' expectations and needs. AIMS OF THE STUDY: To assess functional independence in daily living and house holding, changes in home settings, type of technical aid and human helps, and expectations in hemiplegic patients 1 to 2 years after the stroke. METHODS: Sixty-one out of 94 patients admitted to the neurovascular unit of French university hospital for a first-ever documented stroke were consecutively enrolled. The study was restricted to patients under 75, since patients over 75 do not follow the same care network. Patients were examined at their homes or interviewed by phone 17 months (on average) after the stroke. Standard functional assessment tools (such as the Barthel Index and the instrumental activities of daily living [IADL] score) were recorded, along with descriptions of home settings and instrumental and human help. Lastly, patients and caregivers were asked to state their expectations and needs. RESULTS: Although only one person was living in a nursing home after the stroke, 23 (34%) of the other interviewees had needed to make home adjustments or move home. Seven patients (11%) were dependent in terms of the activities of daily living (a Barthel Index below 60) and 11 (18%) had difficulty in maintaining domestic activities and community living (an IADL score over 10). Although the remaining patients had made a good functional recovery, 23 were using technical aids and 28 needed family or caregiver assistance, including 23 patients with full functional independence scores. Twenty-five patients (42%) were suffering from depression as defined by the diagnosis and statistical manual of mental disorders (4th edition, text revision, DSM IV-R). The patients' prime concerns were related to recovery of independence, leisure activities and financial resources. Family members' expectations related to the complexity of administrative matters, lack of information and the delay in service delivery. DISCUSSION AND CONCLUSION: In under-75 hemiplegic stroke patients, high scores on standard disability rating scales do not always mean that no help is required.

Evolution of postural stability after subthalamic nucleus stimulation in Parkinson's disease: a combined clinical and posturometric study.

OBJECTIVES: The occurrence of postural and balance disorders is a frequent feature in advanced forms of Parkinson's disease (PD). However, the pathological substrate of these disturbances is poorly understood. METHODS: In the present work, we investigated the evolution of posturometric parameters [center of pressure (CoP) displacement and CoP area] and axial scores between the pre-operative period and 3 months post-operative in seven PD patients who underwent bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN). RESULTS: After surgery, the patients leaned backwards much more regardless of the STN stimulation, suggesting that surgery could have a deleterious effect on postural adaptation. During the post-operative period, the improvement in axial and postural scores was similar under levodopatherapy and DBS. On the other hand, DBS of the STN significantly reduced the CoP displacement and the CoP area, whereas levodopatherapy tended only to reduce the CoP displacement and to increase the CoP area significantly. CONCLUSIONS: These data suggest that DBS of the STN and levodopa do not act on the same neurological systems involved in posture regulation. DBS of the STN could improve posture via a direct effect on the pedunculopontine nucleus, which is known to be involved in posture regulation.

Anterior innervation of the proximal tibiofibular joint.

Mucoid cysts compressing the common peroneal nerve have been reported. Whether these cysts are schwannoma or are synovial in nature is the subject of controversy in the medical literature. To contribute to this debate, the present study was designed to detail the anterior innervation of the proximal tibiofibular joint. We dissected 10 knees of five fresh cadavers after staining the tibiofibular joint under fluoroscopic guidance. Through a lateral approach near the fibular head, the common peroneal nerve was isolated then dissected distally to determine whether it or its branches ramified over the proximal tibiofibular joint. In all 10 legs, only one collateral branch was observed on the common peroneal nerve proximal to its terminal division. This collateral sent a branch to the proximal tibiofibular joint before penetrating the tibialis anterior muscle. The articular branch coursed in a superior and posterior direction approximately 1 cm to attain the tibiofibular joint. In no specimen did the deep or superficial peroneal nerves send a twig to the tibiofibular joint. This study confirms and clarifies prior descriptions of the innervation of the anterior aspect of the proximal tibiofibular joint. It clarifies the mechanisms of compression of the common peroneal nerve by synovial cysts that originate from the proximal tibiofibular joint and provides anatomical landmarks that should facilitate complete resection of these cysts.

Does the motor branch of the long head of the triceps brachii arise from the radial nerve? An anatomic and electromyographic study.

Anatomy textbooks say that the motor branch of the long head of the triceps brachii (LHT) arises from the radial nerve. Some clinical observations of traumatic injuries of the axillary nerve with associated paralysis of the LHT have suggested that the motor branch of the LHT may arise from the axillary nerve. This anatomic study was performed, using both cadaver anatomical dissections and a surgical study, to determine the exact origin of the motor branch of the LHT. From the adult cadaver specimens (group I), 20 posterior cords were dissected from 10 subjects (eight embalmed, two fresh) using 3.5x magnification. The axillary nerve was followed from its onset to the posteromedial part of the surgical neck of the humerus and the radial nerve. We looked for the origin of the proximal branch of the LHT by a meticulous double anterior and posterior dissection. From the surgical group (group II), 15 posterior cords were dissected from 15 patients suffering from a C5-C6 injured paralysis, without paralysis of the LHT. During the surgical procedure, we looked for the origins of the motor branch of the LHT with a nerve stimulator. In group I, the motor branch of the LHT arose in 13 cases from the axillary nerve near its origin, in five cases from the terminal division of the posterior cord itself, and in two cases from the posterior cord 10 mm before its terminal division into the radial and axillary nerves. In no case did we find the motor branch of the LHT arising from the radial nerve. In eight cases, we found some accessory branches that arose near the principal branch. In group II, the motor branch of the LHT arose in 11 cases from the axillary nerve near its origin and in four cases from the terminal division of the posterior cord itself. The motor branch of the LHT never originated from the radial nerve. In four cases, we found some accessory branches that arose near the principal branch of the LHT. These results reveal that the motor branch of the LHT seems to originate most often from the axillary nerve. This contribution could be relevant for surgical treatment of traumatic nerve injuries.

[Interest of the criteria of Cochin to select patients with significant relief of low back pain after corticosteroid facet joint injections: a prospective study]. / Intérêt des critères de Cochin pour poser l'indication d'infiltrations articulaires postérieures chez le lombalgique chronique: étude comparative prospective.

UNLABELLED: The seven Criteria of Cochin (CC), clinical descriptive criteria of low back pain (LBP), have been shown to be able to select patients whose LBP would respond well to facet joint anesthesia. AIM: To determine if these seven criteria set are able to select patients with significant relief of LBP after corticosteroid facet joint injections (CFJI). METHODS: Ninety-one patients with chronic LBP were included in a positive group (PG) or a negative group (NG) according to the number of the positive CC. Patients placed in the PG had five or more of the positive CC and those in the NG had less than five of the positive CC. All of them received CFJI on day 0 (D0). The severity of LBP and leg pain, disability and CFJI effect were evaluated on a self-questionnaire on D0, D2, D8 and D30. RESULTS: Two hundred and seventeen CFJI were performed (mean 2.1 per patient). Compared to the initial values we observed a significant reduction of the LBP at D2, D8 and D30 in both the groups (P < 0.05), a significant augmentation of the leg pain at D30 in the GN (P < 0.05) and a significant improvement of the Quebec back pain disability scale (QBDS) at D8 and D30 in the PG (P <0.05). Compared to the NG values, the PG had a significant higher global estimation of the efficacy of the treatment (P < 0.05) and a significant lesser intensive LBP (P <0.05) on D2, D8 and D30, a significant lesser intensive leg pain (P < 0.05) on D30, and a tendency to a more important reduction of the QBDS on D8 and D30 (P > 0.05). CONCLUSION: CC seems to be an effective test to select patients whose LBP would respond well to CFJI.

[Botulinum toxin A and musculoskeletal pain]. / Toxine botulique A et douleurs musculosquelettiques.

INTRODUCTION: Relaxant muscle properties and pain relieve effectiveness in neurological spasmodic disorders of botulinum toxin A (BTXA) suggested its relevance to relieve musculoskeletal pain. The aim of this article was to collect literature data and to assess the different analgesia indications of BTXA proposed in the treatment of musculoskeletal pains. METHOD: The international literature was carried out with the Medline data bank using keywords toxin and pain. Only clinical trials have been analysed. RESULTS: Three hundred and seventeen articles were collected and 12 clinical trials were retained. They are focused on 4 chronic diseases, neck pain, tennis elbow, Piriformis syndrome and low back pain. Results of the 6 chronic neck pain studies are contradictory and emphasize the difficulty to display a satisfactory analgesia effect of BTXA in this indication. Results of the studies concerning other indications (tennis elbow, Piriformis syndrome and low back pain) seem to be more effective and clinically pertinent. DISCUSSION: Analgesia BTXA effect seems to be conditioned by the presence of an objective muscular spasm or stringy disease inducing musculoskeletal pain. CONCLUSION: The first data concerning use of BTXA to treat musculoskeletal pains are few and are worth specifying by other studies.

[Reiterated intravesical instillation of capsaicin in neurogenic detrusor hyperreflexia: a 5-years experience of 100 instillations]. / Capsaïcine intravésicale et hyperréflexie du détrusor. Expérience de 100 instillations sur une période de cinq ans.

INTRODUCTION: Capsaicin is a topic and specific C-fiber afferent neurotoxic. After spinal-cord injury, C-fiber afferent proliferate in the bladder mucosae and are involving in detrusor hyperreflexia AIM OF THE STUDY: To investigate middle-term efficacy and tolerance of intravesical instillation of capsaïcin in spinal-cord injured patients presenting severe urinary incontinence refractory to usual therapy due to detrusor hyperreflexia. METHODS: Thirty patients receveid a first intravesical instillation of 1mMol/L Capsaïcin solution in 30% alcohol. The efficacy (voiding diary, pads, quality of life, maximum cystometric capacity, maximum detrusor pressure, first and normal desire to void) and tolerance were evaluated before, 1 month and 3 months after each instillation, completed by anual cystoscopy. In patients who responded favorably to this instillation, repeated instillations were proposed when symptoms recurred. RESULTS: 25 patients (83.3%) were improved after the initial instillation (decrease of incontinence-frequency-urgency, best quality of life, rise on maximal cystometric capacity), since the 15(th) day and for 3.2 months. 76 reiterative instillations were performed in 22 patients (2 to 9 instillations per patient). 91.2% of them remained successfull, during an average period of 4.2 months. It does not appear loss of benefits after iterative instillations. Transient and moderate adverse effects followed 86% and 79% of the first and reiterated instillation (exacerbation of incontinence, supra-pubic pain). Two patients have presented a begnin and transient inflammatory cystitis after reiterated instillation. DISCUSSION-CONCLUSION: Intravesical instillation of capsaïcin are an effective treatment for incontinence and associated symptoms caused by neurogenic detrusor hyperactivity. Propositions to improve immediate tolerance are debated.

[Intravesical instillations of capsaicin in urology: from pharmacological principles to therapeutic applications]. / Instillations intravésicales de capsaïcine en urologie. Des principes pharmacologiques aux applications thérapeutiques.

Capsaicin is a specific neurotoxin for type C nonmyelinated vesical afferent fibres involved in the transmission of nociceptive stimuli and reorganization of voiding reflexes in disease. The presence of afferents sensitive to vanilloid substances in the human bladder suggests the potential value of intravesical instillations of capsaicin in patients with symptoms of bladder hypersensitivity or bladder hyperactivity. Ten clinical trials document the efficacy and safety of vesical instillation of capsaicin in 200 patients with neurological or non-neurological lower urinary tract symptoms. The objective of this review is to analyse these various publications in order to define the indications and practical conditions of intravesical instillation of capsaicin. The value of intravesical capsaicin in neurogenic bladder hyperactivity has been clearly demonstrated. In non-neurological indications, the diversity of instillation protocols and the heterogeneity of the evaluation parameters complicate analysis of the results. Repeated low-dose capsaicin appears to be useful in bladder hyperactivity, but the value of capsaicin is uncertain in idiopathic detrusor instability. Transient adverse effects are almost systematically observed after intravesical capsaicin. The short-term and medium-term local histological safety appears to be satisfactory, but needs to be documented in the long-term.

Intravesical instillation of capsaicin in urology: A review of the literature.

OBJECTIVES: Interest in the intravesical instillation of capsaicin is growing among urologists. Its efficacy on detrusor hyperreflexia, hypersensitive bladder disorders and bladder pain has been reported in several studies. However, the lack of common evaluation parameters and the absence of consensus concerning a protocol of instillation hamper the interpretation of results. The purpose of this review is to better delineate the indications and optimum protocol for intravesical use of capsaicin. METHODS: Eight open and two placebo-controlled human clinical trials were analyzed. All 200 patients involved had lower urinary tract disorders. RESULTS: Clinical or urodynamic symptoms improved in 84.3% of the patients who received intravesical capsaicin for neurogenic hyperreflexic bladder, a significantly greater efficacy than that of placebo. Capsaicin may also be beneficial in patients who have non-neurogenic disorders. Whether or not the patients has a neurologic deficit, side effects appear during and in the period immediately following instillation. CONCLUSIONS: Intravesical capsaicin appears to be indicated in neurogenic hyperreflexic bladder, but is less effective against detrusor instability, hypersensitive bladder disorders or pelvic pain. The best instillation protocol and long-term tolerance remain to be established.