Prism adaptation effects in complex regional pain syndrome: A therapo-physiological single case experimental design exploratory report.

Complex Regional Pain Syndrome (CRPS) is an invalidating chronic condition that can occur after an acute peripheral lesion. Prism adaptation therapy is regarded as a promising tool to improve chronic pain in this syndrome but the mechanisms which lead to pain amelioration remain unknown. In this exploratory report we performed a retrospective analysis of longitudinal data collected from a single, atypical patient, who showed hyper-attention toward her affected (left) hand. Repeated assessments of pain and spatial neglect made during the course of the prism adaptation treatment revealed differential contributions of the two hands to adaptation-induced pain reduction. Treatment response appeared to be associated with a relative modification of the spatial behaviour of the two hands. This case study provides a new example of pain relief following prismatic deviation away from the pathological side.

[Skin shrinkage study for skin oncologic surgery. Clinical study of 79 cases]. / Étude de la rétraction cutanée en chirurgie carcinologique cutanée. Étude clinique de 79 cas.

BACKGROUND: Skin tumors surgery is common and well established. There is discrepancy between recommendations on macroscopic margins to apply and therapeutic decisions taken on histological margins. The purpose of this study is to examine skin shrinkage upon exeresis, then in formalin, to understand the anatomo-clinical discrepancy, which is often found. MATERIAL AND METHODS: It was a prospective study, lasting a month, including patients receiving skin surgery. For each tumor, the surgeon carried out 4 margins measurements before and after exeresis ; margins measured again in histology. The evaluation criterion was the difference between preoperative, postoperative and histological margins measurement. These data was weighting according to factors linked to the patient and the tumor. RESULTS: Seventy-nine tumors for 61 patients had been studied. The study showed a significant shrinkage between preoperative measurements and postoperative, from 0.4 to 0.6mm. It is correlated with no one tested factors. Significant shrinkage between 0.4 and 0.5mm was also established between preoperative and histological measurements. However, there is a significant augmentation between postoperative and histological measurements. CONCLUSION: This last result could be linked to the inflammatory peri-wound skin that surgeon consider as tumoral process so exclude of his margin, while histology could show a healthy area. In front of these results, an expert committee leading a more important study could include histological margins recommendations to the actual clinical recommendations.

Long-term sensorimotor and therapeutical effects of a mild regime of prism adaptation in spatial neglect. A double-blind RCT essay.

Spatial neglect (SN) is commonly associated with poor functional outcome. Adaptation to a rightward optical deviation of vision has been shown to benefit to SN rehabilitation. The neurophysiological foundations and the optimal modalities of prism adaptation (PA) therapy however remain to be validated. This study is aimed at exploring the long-term sensory-motor, cognitive and functional effects produced by weekly PA sessions over a period of four weeks. A double-blind, monocentric randomized and controlled trial (RCT) was carried out. Twenty patients with left SN secondary to stroke were included, 10 in the "prism" group and 10 in the "control" group. The sensory-motor effects of PA were evaluated by measurement of manual and visual straight-ahead, and also by precision of pointing without visual feedback before and after each PA session. The functional independence measure (FIM) was evaluated before and at 1, 3 and 6 months after PA, while SN severity was assessed using the Behavioural Inattention Test (BIT) before and 6 months after PA. Before the intervention, only manual straight-ahead pointing constituted a reproducible sensory-motor measurement. During prism exposure, a questionnaire showed that not a single patient were aware of the direct effects of optical deviation on pointing movement performance. The sensory-motor after-effects produced by the PA produced a more rapid reduction of the rightward manual straight-ahead, which was secondarily followed by visual straight-ahead. These sensory-motor effects helped to clarify the action mechanisms of PA on SN. At the conclusion of the 6-month follow-up, the two groups showed similar improvement, indicating that a weekly PA session over 4 weeks was not sufficient to produce long-term functional benefit. This improvement was correlated with the evolution of visual straight-ahead, which can be proposed as a marker for patients outcome.

Does the rectus femoris nerve block improve knee recurvatum in adult stroke patients? A kinematic and electromyographic study.

Knee recurvatum (KR) during gait is common in hemiplegic patients. Quadriceps spasticity has been postulated as a cause of KR in this population. The aim of this study was to assess the role of rectus femoris spasticity in KR by using selective motor nerve blocks of the rectus femoris nerve in hemiparetic stroke patients. The data from six adult, post-stroke hemiplegic patients who underwent a rectus femoris nerve block for a stiff-knee gait were retrospectively analyzed. An extensive clinical and functional evaluation was performed and gait was assessed by motion analysis (kinematic, kinetic and electromyographic parameters) before and during the block realized using 2% lidocaine injected under a neurostimulation and ultrasonographic targeting procedure. The main outcome measures were the peak knee extension in stance and peak knee extensor moment obtained during gait analysis. No serious adverse effect of the nerve block was observed. The block allowed a reduction of rectus femoris overactivity in all patients. Peak knee extension and extensor moment in stance did not improve in any patient, but peak knee flexion during the swing phase was significantly higher after block (mean: 31.2° post, 26.4 pre, p < 0.05). Our results provide arguments against the hypothesis that the spasticity of the rectus femoris contributes to KR.

Kinematic characteristics of tenodesis grasp in C6 quadriplegia.

STUDY DESIGN: Descriptive control case study. OBJECTIVES: To analyze the kinematics of tenodesis grasp in participants with C6 quadriplegia and healthy control participants in a pointing task and two daily life tasks involving a whole hand grip (apple) or a lateral grip (floppy disk). SETTING: France. METHODS: Four complete participants with C6 quadriplegia were age matched with four healthy control participants. All participants were right-handed. The measured kinematic parameters were the movement time (MT), the peak velocity (PV), the time of PV (TPV) and the wrist angle in the sagittal plane at movement onset, at the TPV and at the movement end point. RESULTS: The participants with C6 quadriplegia had significantly longer MTs in both prehension tasks. No significant differences in TPV were found between the two groups. Unlike control participants, for both prehension tasks the wrist of participants with C6 quadriplegia was in a neutral position at movement onset, in flexion at the TPV, and in extension at the movement end point. CONCLUSION: Two main kinematic parameters characterize tenodesis grasp movements in C6 quadriplegics: wrist flexion during reaching and wrist extension during the grasping phase, and increased MT reflecting the time required to adjust the wrist's position to achieve the tenodesis grasp. These characteristics were observed for two different grips (whole hand and lateral grip). These results suggest sequential planning of reaching and tenodesis grasp, and should be taken into account for prehension rehabilitation in patients with quadriplegia.

Could motor imagery be effective in upper limb rehabilitation of individuals with spinal cord injury? A case study.

STUDY DESIGN: A case study. OBJECTIVE: The aim was to investigate whether motor imagery (MI) could be successfully incorporated into conventional therapy among individuals with spinal cord injury (SCI) to improve upper limb (UL) function. SETTING: The Physical Medicine and Rehabilitation Unit at the Henry Gabrielle Hospital in Lyon, France. METHODS: The participant was an individual with a complete C6 SCI. MI content was focused on functional UL movements, to improve hand transport to reach out and grasp with tenodesis. The participant was tested before and after 15 MI training sessions (45 min each, three times a week during 5 consecutive weeks). MI ability and program compliance were used as indicators of feasibility. The Minnesota and Box and Blocks tests, as well as movement time and hand trajectory during targeted movements were the dependent variables, evaluating motor performance before and after MI training. RESULTS: The participant's ability to generate MI was checked and compliance with the rehabilitation program was confirmed. The time needed to complete the Minnesota test decreased by 1 min 25 s. The Box and Blocks score was improved by three units after MI program. Decreased movement time and enhanced hand trajectory smoothness were still observed 3 months later, despite a slight decrease in performance. CONCLUSIONS: This study supports the feasibility for introducing MI in conventional therapy. Further studies should confirm the potential role of MI in motor recovery with a larger sample.

Facial macrosomatognosia and pain in a case of Wallenberg's syndrome: selective effects of vestibular and transcutaneous stimulations.

Macro- and micro-somatognosia refer to rare disorders of the cerebral representation of the body whereby patients perceive body parts as disproportionately large or small. Here we report the experimental study of a patient who, following a left lateral medullary stroke (Wallenberg's syndrome, including vestibular deficits) complained of a persistent somatosensory illusory sensation of swelling, confined to the left side of his face (i.e., left macrosomatognosia). This hemifacial somatosensory distortion was associated with a left facial anesthesia, and a neuropathic pain affecting the three branches of the left trigeminal nerve. In this study, we first document quantitatively the patient's somatosensory illusion by using a somatosensory-to-visual matching task in which the patient modified the picture of his own face to fit his left-sided somatosensory misperception. The patient's performance revealed that macrosomatognosia was confined to the second branch of the left trigeminal nerve. Perception of the size of visual objects was comparatively preserved. Second, we investigated the effects of two peripheral stimulations, which may affect the spatial component of somatosensory deficits (caloric vestibular stimulation, CVS; transcutaneous electrical nervous stimulation, TENS) and pain (TENS). Left CVS abolished the facial somatosensory illusion, for about 30min, but had no effect on the left facial pain. Conversely, left TENS substantially reduced the neuropathic pain during stimulation, but had no effect on macrosomatognosia, indicating a double dissociation between the two disorders. These results reveal that facial macrosomatognosia may be regarded as a high-order deficit of somatosensory perception of the shape and volume of the face, which fits the definition of 'hyperschematia' (i.e., when the body takes up too much room) originally proposed by Bonnier (1905). Our data also indicate that CVS may favor the restoration of the conscious representation of the shape and size of the face. Overall, these findings lend support to the view that afferent inputs from the vestibular system can affect in a specific fashion the activity of cerebral structures involved in the building up and updating of the topological description of body parts.

Representation and disconnection in imaginal neglect.

Patients with neglect failure to detect, orient, or respond to stimuli from a spatially confined region, usually on their left side. Often, the presence of perceptual input increases left omissions, while sensory deprivation decreases them, possibly by removing attention-catching right-sided stimuli (Bartolomeo, 2007). However, such an influence of visual deprivation on representational neglect was not observed in patients while they were imagining a map of France (Rode et al., 2007). Therefore, these patients with imaginal neglect either failed to generate the left side of mental images (Bisiach & Luzzatti, 1978), or suffered from a co-occurrence of deficits in automatic (bottom-up) and voluntary (top-down) orienting of attention. However, in Rode et al.'s experiment visual input was not directly relevant to the task; moreover, distraction from visual input might primarily manifest itself when representation guides somatomotor actions, beyond those involved in the generation and mental exploration of an internal map (Thomas, 1999). To explore these possibilities, we asked a patient with right hemisphere damage, R.D., to explore visual and imagined versions of a map of France in three conditions: (1) 'imagine the map in your mind' (imaginal); (2) 'describe a real map' (visual); and (3) 'list the names of French towns' (propositional). For the imaginal and visual conditions, verbal and manual pointing responses were collected; the task was also given before and after mental rotation of the map by 180 degrees . R.D. mentioned more towns on the right side of the map in the imaginal and visual conditions, but showed no representational deficit in the propositional condition. The rightward inner exploration bias in the imaginal and visual conditions was similar in magnitude and was not influenced by mental rotation or response type (verbal responses or manual pointing to locations on a map), thus suggesting that the representational deficit was robust and independent of perceptual input in R.D. Structural and diffusion MRI demonstrated damage to several white matter tracts in the right hemisphere and to the splenium of corpus callosum. A second right-brain damaged patient (P.P.), who showed signs of visual but not imaginal neglect, had damage to the same intra-hemispheric tracts, but the callosal connections were spared. Imaginal neglect in R.D. may result from fronto-parietal dysfunction impairing orientation towards left-sided items and posterior callosal disconnection preventing the symmetrical processing of spatial information from long-term memory.

Optokinetic stimulation induces illusory movement of both out-of-the-body and on-the-body hand-held visual objects.

The coding of body part location may depend upon both visual and proprioceptive information, and allows targets to be localized with respect to the body. The present study investigates the interaction between visual and proprioceptive localization systems under conditions of multisensory conflict induced by optokinetic stimulation (OKS). Healthy subjects were asked to estimate the apparent motion speed of a visual target (LED) that could be located either in the extrapersonal space (visual encoding only, V), or at the same distance, but stuck on the subject's right index finger-tip (visual and proprioceptive encoding, V-P). Additionally, the multisensory condition was performed with the index finger kept in position both passively (V-P passive) and actively (V-P active). Results showed that the visual stimulus was always perceived to move, irrespective of its out- or on-the-body location. Moreover, this apparent motion speed varied consistently with the speed of the moving OKS background in all conditions. Surprisingly, no differences were found between V-P active and V-P passive conditions in the speed of apparent motion. The persistence of the visual illusion during the active posture maintenance reveals a novel condition in which vision totally dominates over proprioceptive information, suggesting that the hand-held visual stimulus was perceived as a purely visual, external object despite its contact with the hand.

Optic ataxia is not only 'optic': impaired spatial integration of proprioceptive information.

Optic ataxia is considered to be a specific visuo-manual guidance deficit, which combines pointing errors due to the use of the contralesional hand ("hand effect") and to the presentation of the visual target in the contralesional field ("field effect"). The nature of the hand effect has not been identified. The field effect is acknowledged as an impaired spatial integration of visual target location. However, spatial integration of proprioceptive information from the arm has never been experimentally tested in these patients. Here, we specifically investigated the capacity of two patients with unilateral optic ataxia in tasks requiring different levels of proprioceptive integration from primary information processing to proprioceptivo-motor integration. In a first experiment -proprioceptive pointing with the ipsilesional hand toward the index finger of the contralesional hand- revealed a large mislocalisation of the ataxic hand accounting for the hand effect. In a second experiment -proprioceptive pointing with the ataxic arm toward the finger of the ipsilesional hand- revealed reaching errors for non-visual targets, i.e. optic ataxia is not specific to 'optic' targets. Altogether, the present results call for a redefinition of this neurological condition in the framework of parietal functions.

Looking while imagining: the influence of visual input on representational neglect.

BACKGROUND: Subjects with hemispatial neglect often exhibit representational neglect: a failure to report details from the left side of mentally visualized images. This failure could reflect impaired ability to generate the left side of the mental image, or it could reflect failure to explore the left side of a normally generated mental image. When subjects with hemispatial neglect look at pictures or drawings, their attention tends to be drawn to objects on the right side, thereby aggravating their failure to explore the left side. If representational neglect represents a failure to explore the left side of a normally generated mental visual image, then it should be improved by blindfolding, which removes the attention-catching right-sided stimuli. However, if representational neglect represents a failure to generate the left side of the mental visual image, then blindfolding should have little impact on reporting of details of the image. METHODS: To determine which of these explanations is correct, we asked eight normal participants and eight brain-damaged patients with left representational neglect to imagine the map of France and to name as many towns as possible in 2 minutes. In different sessions, participants performed the task with eyes open or while blindfolded. RESULTS: Normal participants mentioned more towns while blindfolded than with vision, thus suggesting a distracting effect of visual details on mental imagery. Patients with neglect, however, showed no appreciable effect of blindfolding on reporting of details from either side of mental images. CONCLUSION: Representational neglect may represent a failure to generate the left side of mental images.

[Free fibular flaps in children: morbidity of the donor site and pitfalls to avoid]. / Lambeau libre de fibula chez l'enfant: morbidité du site donneur et piège à éviter.

INTRODUCTION: We report a case of donor site morbidity late after harvesting a free fibular flap for reconstruction of the mandibular symphsis. CASE REPORT: An 8-year-old boy presented a valgus deformity of the ankle 4 years harvesting of a vascularized fibular graft for mandibular reconstruction. The deformation was repaired with a tibial bone slit and pin fixation. The biomechanical result was very satisfactory, allowing normal gait. DISCUSSION: We recall the rules for fibular flap harvesting needed to prevent deformation of the donor site in children aged less than 9 years.

[Growth defects of fibular flaps in children]. / Troubles de croissance des lambeaux fibulaires prélevés chez l'enfant.

BACKGROUND: Mandibular reconstruction with fibula free flap is a challenge in pediatric patients because of the size of the bone and absence of growth without epiphyseal transplantation. CASE REPORT: We report 2 cases of free fibula flap in children for mandibular reconstruction. The 2 patients presented with growth insufficiency of the bone graft after few years of evolution. DISCUSSION: Growth insufficiency was treated with different surgical procedures which were discussed We review the consequences on growth after fibula free flap and the specific indications to achieve epiphyseal fibular growth in children.

Visually guided reaching: bilateral posterior parietal lesions cause a switch from fast visuomotor to slow cognitive control.

The visually guided reaching of two patients with bilateral optic ataxia was explored in two experiments. In Experiment 1 simple delayed pointing was compared with immediate pointing. In the immediate pointing task both variable and constant errors increased with target eccentricity. In contrast to the performance of control subjects and contrary to their own beliefs, the patients both showed improved accuracy in the delay condition. This improvement was manifest as a reduction in both pointing variability and in the constant angular error towards the point of fixation. Both angular errors and their improvement with the delay were proportional to target eccentricity. Experiment 2 used a task in which the target was pre-viewed 5s prior to its re-exposure for pointing ('delayed real pointing'). On some trials a conflict was introduced between the present and previous visual information by changing the target's location during the delay. In contrast to control subjects, who ignored the pre-viewed location and aimed directly at the current target, both patients with optic ataxia initiated their movements towards the previously viewed target location. Evidently they relied on off-line information in preference to on-line visual information. In addition, the patients often failed to detect the changes in target location. One of the patients sometimes even guessed incorrectly that the target had changed its location, and her movement trajectory was then more affected by her false belief than by the target's actual location. These findings confirm that posterior parietal lesions severely disrupt direct visuomotor transformations, and suggest that the residual performance is mediated indirectly by expectations or beliefs about target position.

[Brain abscess and diffuse cervico-facial cellulitis: complication after mandibular third molar extraction]. / Abcès intracérébral et cellulite cervico-faciale diffuse: complications d'une extraction de dent de sagesse: à propos d'un cas.

The authors report a case of cervico-facial cellulitis with brain abscess after mandibular third molar removal. This is the observation of a 26 years old boy surgically treated for a cervico-facial cellulitis ten days after a third molar's removal. He was given anti-inflammatory drugs after removal for analgesia. After a phase of clinical improving, the patient developed pulmonary and brain abscess with neurological signs. He needed neurosurgery in emergency. After eight weeks of antibiotic treatment, the patient was cured with aftereffects (jaw constriction and sensory disorders of the right thigh). Cerebro-meningeal complications of diffuse cervico-facial cellulitis are exceptional but are responsible for heavy aftereffects. This observation confirms that using anti-inflammatory drugs for analgesia is associated with a higher rate of complications after dental removal.

Pointing errors in immediate and delayed conditions in unilateral optic ataxia.

The present paper provides an analysis of the pointing errors of a patient with unilateral optic ataxia (O.K.) following right hemispheric damage, revealing the type of errors related tothe use of the contralesional hand and/or to the reaching of targets located in the contralesional visual field. In addition, comparison between immediate and delayed pantomime pointing allow testing of whether pointing deficits of this patient are specific to real-time visuo-motor control and, subsequently, whether delay could improve his pointing performance. The results show different patterns in the four hand-field combinations. The following conclusion can be drawn from the results of the delayed condition. In the case of patient O. K., the delay reduced the pointing variability for both hands in the left visual field but not in the right visual field. However, the pointing biases did not improve accordingly. As in healthy subjects, target locations tended to be coded in memory with a bias directed toward the fixation point. These results are discussed and contrasted with respect to those previously obtained in the literature in patients with bilateral optic ataxia.

[Giant lymphedema of the upper extremity. A case report]. / Lymphoedème géant du membre supérieur droit. A propos d'un cas.

The giant lymphoedema of upper limb still a difficult therapeutic problem. The authors report a case treated as a Charle's operation derived. They underline the operation's value. As they are experienced with the third-degree burned patients, they insist on the respect of the pre-muscular aponevrosis during the excision and how as possible it's better to take the split-thickness skin graft on the excised skin. Excision and graft are made during the same operation. They come back to the initial medical treatment and to the different surgical treatments.

Immunity to antigens associated with a cell line derived from nasopharyngeal cancer (NPC) in non-Chinese NPC patients.

Delayed hypersensibility to antigens derived from four lymphoid cell lines was measured in 27 non-Chinese patients with nasopharyngeal cancer (NPC) and 63 non-NPC cancer patients. Of the NPC patients, 17/27 (63%) had a positive skin test response to antigens derived from HKLY-28, a lymphoid cell line which was developed from an NPC biopsy. Only 10/51 (20%) and 1/13 (8%) patients with solid tumors and hematopoietic malignancies, respectively, had positive skin test responses to HKLY-28. Positive skin tests were found less frequently when extracts from cell lines derived from normal individuals or lymphoma patients were utilized, although NPC patients were more reactive to two of the non-NPC derived cell lines than the controls. The NPC patients in this study also had significantly elevated antibody titers to the Epstein-Barr virus (EBV), capsid antigen (VCA) and early antigen (EA). Titers were highest in the patients with more anaplastic nasopharyngeal carcinomas. The skin test and serologic data are consistent with studies in Chinese patients, indicating that NPC in non-Chinese and Chinese patients is biologically similar.