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.

An Automated Recording Method in Clinical Consultation to Rate the Limp in Lower Limb Osteoarthritis.

For diagnosis and follow up, it is important to be able to quantify limp in an objective, and precise way adapted to daily clinical consultation. The purpose of this exploratory study was to determine if an inertial sensor-based method could provide simple features that correlate with the severity of lower limb osteoarthritis evaluated by the WOMAC index without the use of step detection in the signal processing. Forty-eight patients with lower limb osteoarthritis formed two severity groups separated by the median of the WOMAC index (G1, G2). Twelve asymptomatic age-matched control subjects formed the control group (G0). Subjects were asked to walk straight 10 meters forward and 10 meters back at self-selected walking speeds with inertial measurement units (IMU) (3-D accelerometers, 3-D gyroscopes and 3-D magnetometers) attached on the head, the lower back (L3-L4) and both feet. Sixty parameters corresponding to the mean and the root mean square (RMS) of the recorded signals on the various sensors (head, lower back and feet), in the various axes, in the various frames were computed. Parameters were defined as discriminating when they showed statistical differences between the three groups. In total, four parameters were found discriminating: mean and RMS of the norm of the acceleration in the horizontal plane for contralateral and ipsilateral foot in the doctor's office frame. No discriminating parameter was found on the head or the lower back. No discriminating parameter was found in the sensor linked frames. This study showed that two IMUs placed on both feet and a step detection free signal processing method could be an objective and quantitative complement to the clinical examination of the physician in everyday practice. Our method provides new automatically computed parameters that could be used for the comprehension of lower limb osteoarthritis. It may not only be used in medical consultation to score patients but also to monitor the evolution of their clinical syndrome during and after rehabilitation. Finally, it paves the way for the quantification of gait in other fields such as neurology and for monitoring the gait at a patient's home.

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.

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.

Walking with eyes closed is easier than walking with eyes open without visual cues: The Romberg task versus the goggle task.

BACKGROUND: The Romberg test, with the subject standing and with eyes closed, gives diagnostic arguments for a proprioceptive disorder. Closing the eyes is also used in balance rehabilitation as a main way to stimulate neural plasticity with proprioceptive, vestibular and even cerebellar disorders. Nevertheless, standing and walking with eyes closed or with eyes open in the dark are certainly 2 different tasks. We aimed to compare walking with eyes open, closed and wearing black or white goggles in healthy subjects. METHODS: A total of 50 healthy participants were randomly divided into 2 protocols and asked to walk on a 5-m pressure-sensitive mat, under 3 conditions: (1) eyes open (EO), eyes closed (EC) and eyes open with black goggles (BG) and (2) EO, EO with BG and with white goggles (WG). Gait was described by velocity (m·s(-1)), double support (% gait cycle), gait variability index (GVI/100) and exit from the mat (%). Analysis involved repeated measures Anova, Holm-Sidak's multiple comparisons test for parametric parameters (GVI) and Dunn's multiple comparisons test for non-parametric parameters. RESULTS: As compared with walking with EC, walking with BG produced lower median velocity, by 6% (EO 1.26; BG 1.01 vs EC 1.07 m·s(-1), P=0.0328), and lower mean GVI, by 8% (EO 91.8; BG 66.8 vs EC 72.24, P=0.009). Parameters did not differ between walking under the BG and WG conditions. CONCLUSION: The goggle task increases the difficulty in walking with visual deprivation compared to the Romberg task, so the goggle task can be proposed to gradually increase the difficulty in walking with visual deprivation (from eyes closed to eyes open in black goggles).

Lack of repercussions of sleep apnea syndrome on recovery and attention disorders at the subacute stage after stroke: a study of 45 patients.

INTRODUCTION: Sleep apnea syndrome (SAS) frequently occurs after a stroke. Its association with a poor prognosis is open to discussion. OBJECTIVE: To study, in a physical and rehabilitation medicine (PRM) unit, the possible repercussions of SAS on neurological and functional recovery as well as attentional abilities following a stroke. PATIENTS AND METHODS: Forty-five patients, all of whom had recently had a stroke without previously documented SAS, were screened using the ApneaLink(®) system. An apnea-hypopnea index (AHI) score ≥10 was considered as indicative of SAS. The NIHSS, Fugl-Meyer (FM) and Functional Independence Measure (FIM) Scales were applied on admission and at two months as means of assessing neurological and functional recovery, which was expressed by the difference between the first and the second scores (delta FM, delta NIHSS, delta FIM). The Battery Attention William Lennox (BAWL) Test was given once in order to evaluate attention disorders. SAS severity was categorized according to the AHI. We compared the groups formed (mild, moderate and severe) using the same method. RESULTS: Twenty-eight patients (62.2%) presented AHI ≥ 10. Stroke characteristics were comparable in the SAS+ and the SAS- groups, with average post-stroke time lapse of 26 days, initial average FIM score of 71.2 points ± 26.3 and initial average NIHSS score of 8.9 ± 4.9. The demographic characteristics of the two groups were likewise comparable with the exception of age, as the SAS+ group was pronouncedly older (65.4 vs. 53.5 years). As for delta FIM, which evaluated functional recovery, it averaged 31.8 ± 20.6. Cases of SAS were found to be mild (37.1%), moderate (28.6%) or severe (34.3%). No significant difference was observed on admission or at 2 months as regards the clinical scales or the BAWL test between the two groups or according to severity, except for the NIHSS score at 2 months in the severe sub-group. DISCUSSION AND CONCLUSION: This study did not demonstrate the supposed repercussions of SAS on the recovery or attentional abilities of post-stroke patients. The tests were maybe given too early; they should take place at a lengthier time interval after the stroke, and also to be more complete.

Rehabilitation of a hemiplegic patient with cardiac assistive device.

INTRODUCTION: Possible admission to a PRM unit of a hemiplegic patient equipped with a left ventricular assistance device (LVAD) may constitute a cause for concern. We are reporting our observation on the subject. OBSERVATION: A 30-year-old hemiplegic patient presented with left hemiparesis secondary to a right middle cerebral artery (MCA) ischemic stroke having occurred during cardiopulmonary arrest. Persistence of major left ventricle dysfunction necessitated installation on 8 November 2011 of a mono-ventricular HEART-MATE II assistive device. Possible later recourse to cardiac transplantation would depend on clinical development. When admitted to a PRM unit on 18 January 2012, the patient presented with left hemiparesis and cognitive disorders. Virtually all members of the attendant medical and paramedical team were given instruction on the functioning of electrical power assistance systems. In spite of the complexity of the logistics, and notwithstanding the difficulty of managing potentially worrisome medical problems, multidisciplinary rehabilitation efforts were successful. The patient's improved condition led to the decision to undertake heart transplantation, which was carried out on 27 October 2012. DISCUSSION AND CONCLUSION: This observation illustrates the undeniable role of PRM in decision-making and, more generally, in the opportunities that may arise in sensitive and challenging situations.

Poliomyelitis sequels in France and the clinical and social needs of survivors: a retrospective study of 200 patients.

INTRODUCTION: Polio survivors in France are estimated at 50,000. This study aimed at describing their needs from their clinical and vocational conditions. METHOD: A retrospective study of our physical and rehabilitation medicine (PRM) consultation activity. RESULTS: One hundred and fifteen women/85 men, with a mean age of 51years±14.3 (17 to 82). Paralysis involved only one lower limb in 108 patients, the two lower limbs in 56 patients and only one upper limb in 4. At the time of the first consultation 137 patients had experienced functional worsening. The complaints were pain (105 subjects), fatigue (59) and new paresis (58). Only 25% had retired. Post-polio syndrome criteria were present in 46 subjects (23%). Patients who had contracted poliomyelitis in France (56%) differed from the other subjects with regard to age (58.4 versus 41.5), professional status and frequency of PPS (30.9% versus 12.6%). CONCLUSION: These polio survivors were not particularly aged and they had often experienced functional worsening. The evolution of their disease shall represent a public health issue over the decades to come.

Sensory reweighting in controls and stroke patients.

OBJECTIVE: To test sensitivity to proprioceptive, vestibular and visual stimulations of stroke patients with regard to balance. METHOD: The postural control of 20 hemiparetic patients after a single hemispheric stroke that had occurred at least 6 months before the study along with 20 controls was probed with vibration, optokinetic, and vestibular galvanic stimulations. Balance was assessed using a force platform (PF) with two miniature inertial sensors placed on the head (C1) and the trunk (C2) under each sensory condition and measured by three composite scores as the mean displacement of the body (PF, C1, C2) during the stimulation. A subject with a composite score greater than the 75th percentile of the composite scores found in the control subjects was arbitrarily considered to be sensitive to that stimulation. RESULTS: Both control and stroke patients showed large inter-individual variations in response to the three types of sensory stimulation. Among the hemiparetic patients, nearly 65% were sensitive to the optokinetic stimulation, 60% to the galvanic stimulation and 65% to the vibration stimulation. In contrast to the control group, all the hemiparetic subjects were sensitive to at least one type of stimulation. CONCLUSION: Stroke patients are highly dependent on visual, proprioceptive and vestibular information in order to control their standing posture and individually differ in their relative sensitivity to each type of sensory stimulation. SIGNIFICANCE: Contrarily to what one might suppose, the increased visual dependence manifested by stroke patients does not necessarily entail any neglect of proprioceptive and vestibular information.

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

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

Care pathways in physical and rehabilitation medicine (PRM): the patient after proximal humeral fracture and shoulder hemi-arthroplasty.

This document is part of the "Care Pathways in Physical and Rehabilitation Medicine" series developed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Physical and Rehabilitation Medicine Federation (Fedmer). For a given patient profile, each concise document describes the patient's needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with acute proximal humeral fracture requiring shoulder hemi-arthroplasty are classified into four care sequences and two clinical categories, both of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO's International Classification of Functioning, Disability and Health) that may influence patient needs.

Care pathways in physical and rehabilitation medicine (PRM): the patient after shoulder stabilization surgery.

This document is part of the "Care pathways in physical and rehabilitation medicine" series developed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Physical and Rehabilitation Medicine Federation (FEDMER). For a given patient profile, each concise document describes the patient's needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with shoulder instability requiring surgical stabilization are classified into five care sequences and two clinical categories, each of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO's International Classification of Functioning, Disability and Health) that may influence patient needs.

Therapeutic patient education for stroke survivors: Non-pharmacological management. A literature review.

OBJECTIVES: Focus on the different therapeutic patient education (TPE) programs for stroke survivors found in the literature. Verify their content and efficacy. METHOD: A literature review was conducted by searching for entries from 1966 to 2011 in the Medline and Cochrane Library databases. The references for the accepted articles were taken into consideration and the articles corresponding to the criteria inclusion but not present within the initial search were selected. The keywords used were "self care", "self management", "patient education" and "stroke". Given the multiplicity of symptoms that may be addressed in TPE programs, and following expert advice, the symptoms were grouped after expanding the bibliographic search using the following, additional keywords: "dysphagia"; "swallowing disorder"; "urinary incontinence"; "caregiver"; "fall prevention"; "falling"; "injury"; "shoulder pain"; "physical activity"; "exercise"; "aphasia" and "cognitive impairment". RESULTS: We found 30 article abstracts. In the end, we only accepted seven articles on general TPE programs that were well structured and detailed enough. The TPE programs found in the literature were often of questionable methodological quality. The multiplicity of symptoms led to very general TPE programs that covered all possible stroke after-effects. The purpose of these programs was to reduce stress and anxiety, to improve quality of life and to alleviate psychosocial after-effects. A change in caregiver and patient behavior was observed at times. We expanded the bibliographic search to include scientific arguments that could help implement TPE programs for more specific targets. CONCLUSION: TPE programs for stroke survivors could be improved by standardizing and assessing programs that focus on a specific problem caused by the various possible after-effects of strokes. In order to promote education for stroke survivors, specific training for health care professionals and appropriate funding are necessary.

Physical and rehabilitation medicine (PRM) care pathways: "spinal cord injury".

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. The patients after spinal cord injury are divided into five categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.