Serious Game with Electromyography Feedback and Physical Therapy in Young Children with Unilateral Spastic Cerebral Palsy and Equinus Gait: A Prospective Open-Label Study.

The clinical effects of a serious game with electromyography feedback (EMGs_SG) and physical therapy (PT) was investigated prospectively in children with unilateral spastic cerebral palsy (USCP). An additional aim was to better understand the influence of muscle shortening on function. Thirty children with USCP (age 7.6 ± 2.1 years) received four weeks of EMGs_SG sessions 2×/week including repetitive, active alternating training of dorsi- and plantar flexors in a seated position. In addition, each child received usual PT treatment ≤ 2×/week, involving plantar flexor stretching and command strengthening on dorsi- and plantar flexors. Five-Step Assessment parameters, including preferred gait velocity (normalized by height); plantar flexor extensibility (XV1); angle of catch (XV3); maximal active ankle dorsiflexion (XA); and derived coefficients of shortening, spasticity, and weakness for both soleus and gastrosoleus complex (GSC) were compared pre and post treatment (t-tests). Correlations were explored between the various coefficients and gait velocities at baseline. After four weeks of EMGs_SG + PT, there was an increase in normalized gait velocity from 0.72 ± 0.13 to 0.77 ± 0.13 m/s (p = 0.025, d = 0.43), a decrease in coefficients of shortening (soleus, 0.10 ± 0.07 pre vs. 0.07 ± 0.08 post, p = 0.004, d = 0.57; GSC 0.16 ± 0.08 vs. 0.13 ± 0.08, p = 0.003, d = 0.58), spasticity (soleus 0.14 ± 0.06 vs. 0.12 ± 0.07, p = 0.02, d = 0.46), and weakness (soleus 0.14 ± 0.07 vs. 0.11 ± 0.07, p = 0.005, d = 0.55). At baseline, normalized gait velocity correlated with the coefficient of GSC shortening (R = -0.43, p = 0.02). Four weeks of EMGs_SG and PT were associated with improved gait velocity and decreased plantar flexor shortening. A randomized controlled trial comparing EMGs_SG and conventional PT is needed.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi.

OBJECTIVE: To establish international recommendations for the management of spastic equinovarus foot deformity. DESIGN: Delphi method. SETTING: International study. PARTICIPANTS: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). INTERVENTIONS: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. MAIN OUTCOME MEASURES: A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. CONCLUSION: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

A 6-Month Home-Based Functional Electrical Stimulation Program for Foot Drop in a Post-Stroke Patient: Considerations on a Time Course Analysis of Walking Performance.

Foot drop is a common disability in post-stroke patients and represents a challenge for the clinician. To date, ankle foot orthosis (AFO) combined with conventional rehabilitation is the gold standard of rehabilitation management. AFO has a palliative mechanical action without actively restoring the associated neural function. Functional electrical stimulation (FES), consisting of stimulation of the peroneal nerve pathway, represents an alternative approach. By providing an FES device (Bioness L-300, BIONESS, Valencia, CA, USA) for 6 months to a post-stroke 22-year-old woman with a foot drop, our goal was to quantify its potential benefit on walking capacity. The gait parameters and the temporal evolution of the speed were collected with a specific connected sole device (Feet Me®) during the 10-m walking, the time up and go, and the 6-minute walking tests with AFO, FES, or without any device (NO). As a result, the walking speed changes on 10-m were clinically significant with an increase from the baseline to 6 months in AFO (+0.14 m.s-1), FES (+0.36 m.s-1) and NO (+0.32 m.s-1) conditions. In addition, the speed decreased at about 4-min in the 6-minute walking test in NO and AFO conditions, while the speed increased in the FES conditions at baseline and after 1, 3, and 6 months. In addition to the walking performance improvement, monitoring the gait speed in an endurance test after an ecological rehabilitation training program helps to examine the walking performance in post-stroke patients and to propose a specific rehabilitation program.

Parafacial neurons in the human brainstem express specific markers for neurons of the retrotrapezoid nucleus.

The retrotrapezoid nucleus (RTN) is a hub for respiratory chemoregulation in the mammal brainstem that integrates chemosensory information from peripheral sites and central relays. Chemosensitive neurons of the RTN express specific genetic and molecular determinants, which have been used to identify RTN precise location within the brainstem of rodents and nonhuman primates. Based on a comparative approach, we hypothesized that among mammals, neurons exhibiting the same specific molecular and genetic signature would have the same function. The co-expression of preprogalanin (PPGAL) and SLC17A6 (VGluT2) mRNAs with duplex in situ hybridization has been studied in formalin fixed paraffin-embedded postmortem human brainstems. Two specimens were processed and analyzed in line with RTN descriptions in adult rats and macaques. Double-labeled PPGAL+/SLC17A6+ neurons were only identified in the parafacial region of the brainstem. These neurons were found surrounding the nucleus of the facial nerve, located ventrally to the nucleus VII on caudal sections, and slightly more dorsally on rostral sections. The expression of neuromedin B (NMB) mRNA as a single marker of chemosensitive RTN neurons has not been confirmed in humans. The location of the RTN in human adults is provided. This should help to develop investigation tools combining anatomic high-resolution imaging and respiratory functional investigations to explore the pathogenic role of the RTN in congenital or acquired neurodegenerative diseases.

Anal incontinence and vesico-sphincter events in systemic sclerosis: An epidemiologic bicentric cohort study.

OBJECTIVE: To estimate the frequency and severity of anal incontinence and vesico-sphincter events, associated factors, and impact on the quality of life of patients with systemic sclerosis. METHODS: Questionnaires assessing anal incontinence (Miller score), vesico-sphincter events (Urogenital Distress Inventory) and quality of life [Short Form Health Survey 36v2 (SF-36), and Hospital Anxiety and Depression Scale] were mailed to 139 patients with systemic sclerosis at the university hospitals of Besançon and Poitiers, France. Clinical data were collected from the medical records to identify risk factors. RESULTS: Among the 121 (87%) responders, severe vesico-sphincter events or severe anal incontinence occurred in 3.4% and 12.4% of cases, respectively. Frequent urination (66.3%) and anal incontinence to gas (50.4%) were the most frequent symptoms. Anal incontinence was associated positively with vesico-sphincter events, unrelated to obstetrical factors. No correlations were seen with age, sex, or systemic sclerosis characteristics. In multivariate analysis, moderate or severe vesico-sphincter events was associated with higher anxiety and depression scores and lower SF-36 scores; the same results were observed for anal incontinence, but did not reach significance. CONCLUSION: Vesico-sphincter events and anal incontinence are common in systemic sclerosis, and sometimes severe, with a potential negative impact in quality of life. These results will be confirmed by a case-control study with dynamic and manometric assessment, and could legitimate a systematic screening to ensure early therapy and multidisciplinary individual management.

An alternative treatment for contractures of the elderly institutionalized persons: Microinvasive percutaneous needle tenotomy of the finger flexors.

BACKGROUND: Almost 10% of older adults in nursing homes have a fixed flexion deformity of the fingers (claw hand). Such contractures have important functional consequences, often leading to hygiene difficulties. Medical treatment (such as botulinum toxin injections, physiotherapy or positioning) is not always effective and surgery is often not possible in such fragile patients. Microinvasive tenotomy with a large needle could be a useful alternative because it can be carried out in an ambulatory setting under local anaesthesia. METHODS: A single center, retrospective study involving the 2012-2014 database from the day-hospital unit of a neuro-orthopaedic department in France. All patients who underwent percutaneous needle tenotomy of the finger or thumb flexors were included. Outcomes included Goal Attainment Scaling (GAS) and the distance in centimeters between the palm and the pulp of the most flexed digit (PPD). RESULTS: Eighteen patients underwent tenotomy (13 women; mean age: 76±14 years); all patients lived in a nursing home. The limb to be treated was nonfunctional in all patients. The principal goal was determined by consensus with the patients and their health-care teams and was most often to facilitate hand hygiene. Eight patients had at least one secondary goal. In total, 10 patients underwent microinvasive tenotomy for 4 fingers, 5 patients 1 to 4 fingers and 3 patients only the thumb. At 3 months after treatment, goals were achieved for 11 patients, 5 patients progressed toward the goal without attaining it, and for 2 patients, scores were worse. The T-scores of the GAS and the PPD were significantly increased at 3 months (P=0.0326 and P=0.0002, respectively). No serious adverse events occurred. CONCLUSION: Large-needle tenotomy seems safe and effective for treating claw hand in fragile older patients.

Effectiveness and Complications of Percutaneous Needle Tenotomy with a Large Needle for Muscle Contractures: A Cadaver Study.

BACKGROUND: Twenty-two percent of institutionalised elderly persons have muscle contractures. Contractures have important functional consequences, rendering hygiene and positioning in bed or in a chair difficult. Medical treatment (such as botulinum toxin injections, physiotherapy or positioning) is not very effective and surgery may be required. Surgery is carried out in the operating theatre, under local or general anaesthesia but is often not possible in fragile patients. Mini-invasive tenotomy could be a useful alternative as it can be carried out in ambulatory care, under local anaesthesia. OBJECTIVE: To evaluate the effectiveness of percutaneous needle tenotomy and the risks of damage to adjacent structures in cadavers. METHOD: Thirty two doctors who had never practiced the technique (physical medicine and rehabilitation specialists, geriatricians and orthopaedic surgeons) carried out 401 tenotomies on the upper and lower limbs of 8 fresh cadavers. A 16G needle was used percutaneous following location of the tendons. After each tenotomy, a neuro-orthopaedic surgeon and an anatomist dissected the area in order to evaluate the success of the tenotomy and any adjacent lesions which had occurred. RESULTS: Of the 401 tenotomies, 72% were complete, 24.9% partial and 2.7% failed. Eight adjacent lesions occurred (2%): 4 (1%) in tendons or muscles, 3 (0.7%) in nerves and 1 (0.2%) in a vessel. CONCLUSION: This percutaneous needle technique effectively ruptured the desired tendons, with few injuries to adjacent structures. Although this study was carried out on cadavers, the results suggest it is safe to carry out on patients.

Stroke impact scale version 2: validation of the French version.

BACKGROUND: Almost 1 person in 1,000 experiences a stroke annually in France. Health-related quality-of-life (HRQoL) measurement with specific questionnaires is useful to study the consequences of stroke on patients' daily lives. OBJECTIVE: The purpose of this study was to validate the French version of the Stroke Impact Scale (SIS) questionnaire, as no disease-specific questionnaire was validated in French heretofore. METHODS: Two hundred eighty-eight patients with stroke were classified into 2 groups (158 acute, 130 chronic). Rate of item completion, test-retest reliability, sensitivity to change, and construct validity, convergent validity, and discriminant validity of the questionnaire were assessed. Acute group patients were recruited during the first month poststroke and followed for 3 months. Chronic group patients (stroke dating from 1 year) were recruited from outpatient consultations. The first 100 patients in the chronic group were called back 15 days after inclusion for test-retest measurements. The Barthel Index, Hospital Anxiety and Depression Scale (HADS), and Duke Health Profile questionnaires were administered. RESULTS: The French version of the SIS was well accepted by all participants. It had good reproducibility. Cronbach alpha was 89% for all scales. A ceiling effect was noted in the majority of scales. Physical domains were significantly correlated to other measures of physical capacity (Barthel Index and Duke Health Profile; Spearman coefficients were between .5 and .73), and the emotional and social domains were significantly correlated to almost all domains of the Duke Health Profile. Psychometric properties were similar to those of the US version. Responsiveness was good for physical and emotional domains. LIMITATIONS: Validation was conducted only on people who were able to answer the questionnaire. CONCLUSIONS: The French SIS version presents good psychometric properties, except for ceiling effect. This is the first stroke-specific questionnaire evaluating perceived health after stroke to be validated in France and could be useful for further investigations of HRQoL after stroke.

Manual needle placement: accuracy of botulinum toxin A injections.

INTRODUCTION: Electrophysiological or ultrasound guidance can facilitate botulinum toxin A (BoNt-A) injection accuracy, but clinical landmarks and palpation are often used for superficial muscles. We evaluated the accuracy of manual needle placement in the gastrocnemius muscles (GC) guided only by anatomical landmarks and palpation. METHODS: Bilateral limbs from 30 cadavers were used to evaluate ink injection into the GC. One anatomist and one orthopedic surgeon verified the accuracy of manual needle placement postinjection by calf muscle dissection. Injection was considered a failure if the ink was not located in the head of the target GC. RESULTS: One hundred twenty-one practitioners were evaluated. Fifty-two injections were successful (43%), and 69 failed (57%). This result was unrelated to injector experience (P = 0.097). CONCLUSIONS: Our findings show a poor success rate, regardless of injector experience. Therefore, muscle palpation and anatomical landmarks are insufficient to ensure the accuracy of BoNt-A injections, even for large, superficial muscles.

Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments.

The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.

Motor branch of extensor carpi radialis longus: anatomic localization.

OBJECTIVE: To identify extensor carpi radialis longus (ECRL) motor nerve coordinates in relation to anatomic surface landmarks. DESIGN: Descriptive study. SETTING: Anatomy institute of a school of medicine in Paris, France. CADAVERS: Fresh adult cadaver upper limbs (N=20). INTERVENTION: Anatomic dissection of upper limbs. MAIN OUTCOME MEASURES: Three measurements (mm) were taken of the position of the ECRL motor branch: the distance between the lateral epicondyle and the emergence of the ECRL branch along the forearm axis, the branch depth, and the ratio between the distance corresponding to the nerve depth and the intercondylar distance. RESULTS: The radial nerves of 4 men and 6 women (age range 59-80 y) were identified between the brachioradialis and the ECRL and traced proximally to the lateral epicondyle. The injection point was between the lateral epicondyle posteriorly and the wrist extensor group anteriorly. Direction was perpendicular to the axis of the forearm. Mean depth was 35.6 mm (minimal value: 24.0; maximal value: 58.0; SD=9 mm). Ratio between nerve depth and intercondylar distance was .46 (.37; .53±.05). CONCLUSIONS: The ECRL motor nerve branch is easy to reach using specified landmarks. Selective motor nerve block of the ECRL branch should be considered in the clinical assessment to test the capacity of the extensor carpi radialis brevis to extend the wrist alone and to assess the command and overactivity of antagonists before surgery.

Construction and pilot assessment of the Upper Limb Assessment in Daily Living Scale.

OBJECTIVE: The upper limb function of hemiplegic patients is currently evaluated using scales that assess physical capacity or daily activities under test conditions. The present scale, the Upper Limb Assessment in Daily Living (ULADL) Scale, was developed to explore the subjective and objective functional capacities of such patients in a proximal to distal sequence. METHODS: A group of experts constructed a scale addressing 17 upper limb functions (five active passive and 12 active) which could be explored by a questionnaire (Q) and a test (T). Reproducibility, internal consistency, concurrent validity (Rivermead Motor Assessment (RMA)) and learning effect were estimated in a multicentre study. RESULTS: 49 stroke patients were each rated three times within 7 days by a total of 21 physicians, yielding a total of 142 ratings. The ULADL took 16±8 min to complete compared with 9±5 min for the RMA. Cronbach's alpha coefficient was 0.95 for Q and 0.97 for the practical tests (T). The global Q and T scores, and in particular the global Q score, were slightly higher at the second rating. The intra-rater intraclass correlation coefficient (ICC) was 0.65 (95% CI (0.44 to 0.79)) for Q and 0.97 (0.95 to 0.98) for T, and the inter-rater ICC was 0.95 for both Q and T. The Bland and Altman method showed good intra- and inter-rater reliability with no systematic trend. Correlation coefficients for ULADL versus RMA were >0.80 for both Q and T. CONCLUSIONS: The ULADL Scale has good psychometric properties and can explore patients with different degrees of upper limb impairment.

A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE.

BACKGROUND: Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth. AIM: To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France. METHODS: This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale). RESULTS: BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management. CONCLUSIONS: We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.

How to clinically assess and treat muscle overactivity in spastic paresis.

OBJECTIVE: This educational paper aims to describe, in adult patients, the different aspects of muscle overactivity after a central nervous system lesion, including spasticity, spastic dystonia and spastic co-contraction, the assessment of their symptoms and consequences, and therapeutic options. DISCUSSION AND CONCLUSION: Clinical evaluation involves the assessment of passive range of motion, angle of catch or clonus, active range of motion, rapid alternating movements and functional consequences. A number of scales have been developed to assess patients with spastic paresis, involving both patient and caregivers. Not all persons with spasticity require treatment, which is considered only when muscle overactivity is disabling or problematic. A list of personal objectives may be proposed for each patient, which will drive assessment and treatment. Prior to treatment the patient must be informed of the intended benefits and possible adverse events. Clinical evaluation may be supported by the use of transient neuromuscular blocks and/or instrumental analysis. Physical therapies usually represent the mainstay of treatment. Self-rehabilitation with stretching and active exercises, intramuscular injections of botulinum toxin, alcohol or phenol injections, oral or intrathecal drugs, and surgery comprise the treatment options available to the clinician. Follow-up must be scheduled in order to assess the benefits of treatment and possible adverse events.

Evaluating the porcine dermis graft InteXen in three-compartment transvaginal pelvic organ prolapse repair.

INTRODUCTION AND HYPOTHESIS: The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension. METHODS: Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification >or= stage II and subjective recurrence as a symptomatic bulge. RESULTS: Each group consisted of 63 patients. Surgery time was longer using InteXen (72 +/- 24.5 vs 55 +/- 23.5 min, p = 0.0002). Length of hospital stay (4.6 +/- 1.6 vs 4.9 +/- 2.1 days, p = 0.34) as well as duration of follow-up (37.1 vs 35.7 months, p = 0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p = 0.12) and subjective recurrence rates (13% vs 5%, p = 0.12) between the two groups were not statistically different. CONCLUSIONS: InteXen was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.

Can shoulder muscle coordination during the support scale at ring height be replicated during training exercises in gymnastics?

The support scale at ring height, the swallow, is a difficult strength element, usually performed in gymnastics. Coaches try to simulate the swallow position during training to strengthen muscles, specifically in the position used for competition. However, the real effect of this position's simulation on muscle force and coordination and consequently on the muscle activity has not been determined. The purpose of the study was to compare muscle activity and coordination during a swallow performed on the rings, using a counterweight and during 2 training exercises using dumbbells or barbells, respectively. Six top-level gymnasts participated in the study. Electromyograms from the biceps brachii, triceps brachii, deltoideus (clavicular part), pectoralis major, serratus anterior, infraspinatus, trapezius (middle part), and latissimus dorsi in the right shoulder were collected during the 4 exercises and analyzed using root mean square (RMS) and mean power frequency (MPF). The RMS were normalized to the maximal voluntary contraction, and a co-activation index was also determined between biceps and triceps brachii. Our results show specific shoulder muscle coordination for each exercise. As compared with the swallow on the rings, the pectoralis major participates less in shoulder flexion during the counterweight exercise, whereas the deltoideus is more activated during the dumbbells exercise (p < 0.05). The barbell exercise reduces the participation of the serratus anterior in stabilizing the scapula (p < 0.05). Training exercises must therefore be chosen with knowledge of the specific muscle coordination induced by each. The counterweight exercise preserves the pectoralis major. The barbell exercise reduces participation of the serratus anterior. The dumbbells exercise may be useful to prepare the rotator cuff muscles carefully for use.

[Prescribe clean intermittent self-catheterization]. / Prescrire des autosondages intermittents propres.

Clean intermittent self-catheterization is the recommended mode of voiding in patients with urinary retention. CISC is a non-sterile catheterization, done by the patient himself to insure complete emptying of the bladder several times per day. Its prescription rests on well-established recommendations with a sufficient frequency of self-catheterization (minimum 4), collected volumes less than 400 mL and a diuresis higher than 1.5 L. Clean intermittent self-catheterization allows a reduction in complications of infection, protects the upper urinary tract and provides urinary continence for the patient. Asymptomatic bacteriuria is very frequent in patients treated with intermittent catheterization and does not justify antibiotic therapy. Only symptomatic urinary tract infections have to be treated by a short course of antibiotics. Patient education and personalized medical follow-up must ensure adapted management dependant on this voiding mode and its risk factors. A guideline is provided to prescribe clean intermittent self-catheterization with its indications, its advantages and complications, its medical surveillance and treatment of urinary tract infection. This procedure should be well-known to general practitioners who are responsible for the follow up of these patients.

Development and validation of the short form of a urinary quality of life questionnaire: SF-Qualiveen.

PURPOSE: The 30-item Qualiveen is a specific health related quality of life questionnaire for urinary disorders in patients with neurological conditions, such as multiple sclerosis and spinal cord injury. Previous studies have demonstrated the reliability, validity and responsiveness of Qualiveen. However, to address the needs of large clinical trials and long-term monitoring, in which efficiency may compete with precision of measurement, we developed the 8-item self-administered SF-Qualiveen. MATERIALS AND METHODS: A total of 180 English speaking and French speaking outpatients with multiple sclerosis at multiple sclerosis clinics and departments of rehabilitation in Canada and France completed the entire Qualiveen, the Multiple Sclerosis Quality of Life-54 questionnaire or its French version (SEP-59) as well as urinary function assessments at study enrollment and 2 to 10 weeks later. At visit 2 patients also made global ratings of change in urinary health related quality of life. SF-Qualiveen development and testing used this data set. RESULTS: Correlations of SF-Qualiveen with its original form were high (r = 0.70 to 0.92). SF-Qualiveen proved reliable (ICC 0.83 to 0.93). Its responsiveness was similar to that of the long form (SRM 0.75 to 1.62). Correlations with other measures were consistent with our a priori predictions (weighted kappa 0.55 for cross-sectional correlations and 0.66 for correlations of change), supporting the cross-sectional and longitudinal construct validity of SF-Qualiveen. CONCLUSIONS: SF-Qualiveen has excellent measurement properties, similar to those of the long form. The new instrument is likely to perform well in the clinical and research context.

The uterosacral complex: ligament or neurovascular pathway? Anatomical and histological study of fetuses and adults.

The aim of this study was to define the anatomical relationships of the uterosacral ligament complex (USLC) and to analyze histologically its content. Three fetal and four adult cadavers were used. Anatomical dissections were carried out. Eight fresh biopsies (four fetal and four adult) of the USLC were analyzed histologically and immunohistochemically. Specimens were stained with hematoxylin eosin safran coloration, with anti-nervous cell antibodies (PS 100) and with anti-smooth muscle antibodies (to visualize vessel walls). By removing the visceral pelvic fascia, nervous fibers were found within the USLC forming the hypogastric plexus. Histologically, the USLC contained connective tissue, nervous fibers, sympathetic nodes, vessels, and fatty tissue. No structured ligamentous organization was identified. The uterosacral "ligament" is a "complex" integrating connective tissue as well as nervous and vascular elements. Radical excisions and USLC suspension during pelvic floor reconstructive surgery should be performed with caution in order to preserve pelvic innervation.