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BACKGROUND AND PURPOSE: Intensive physical therapy (PT) facilitates motor recovery when provided during a subacute stage after stroke. The efficiency of very early intensive PT has been less investigated. We aimed to investigate whether intensive PT conducted within the first 2 weeks could aid recovery of motor control. METHODS: This multicentre randomized controlled trial compared soft PT (20-min/d apart from respiratory needs) and intensive PT (idem+45 minutes of intensive exercises/day) initiated within the first 72 hours after a first hemispheric stroke. The primary outcome was change in motor control between day (D) 90 and D0 assessed by the Fugl-Meyer score. Main secondary outcomes were number of days to walking 10 m unassisted, balance, autonomy, quality of life, and unexpected medical events. All analyses were by intent to treat. RESULTS: We could analyze data for 103 of the 104 included patients (51 control and 52 experimental group; 64 males; median age overall 67 [interquartile range 59-77], 67 right hemispheric lesions, 80 ischemic lesions, National Institutes of Health Stroke Scale score ≥8 for 82%). Fugl-Meyer score increased over time (P<0.0001), with no significant effect of treatment (P=0.29) or interaction between treatment and time (P=0.40). The median change in score between D90 and D0 was 27.5 (12-40) and 22.0 (12-56) for control and experimental groups (P=0.69). Similar results were found for the secondary criteria. CONCLUSIONS: Very early after stroke, intensive exercises may not be efficient in improving motor control. This conclusion may apply to mainly severe stroke. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01520636.
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Limitação da Mobilidade , Recuperação de Função Fisiológica , Reabilitação do Acidente Vascular Cerebral/métodos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Recuperação de Função Fisiológica/fisiologia , Reabilitação do Acidente Vascular Cerebral/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
Gait disorders are one of the leading patient complaints at the sub-acute stroke stage (SSS) and a main determinant of disability. Walking speed (WS) is a major vital and functional index, and the Ten-Meter Walk Test is considered the gold standard after stroke. Based on a systematic review of the literature, studies published between January 2000 and November 2021 were selected when WS was reported (ten-meter walk test for short distance and/or 6-min walking distance for long distance) within 6 months following a first ischemic and/or hemorrhagic stroke (SSS) in adults prior to receiving specific walking rehabilitation. Following PRISMA guidelines, a meta-analysis was conducted on two kinds of WS: the principal criterion focused on short-distance WS (ten-meter walking test) and the secondary criteria focused on long-distance WS (6-min test) and meta-regressions to study the association of WS with balance, cognitive disorders and autonomy. Nine studies comprising a total of 939 data on post-stroke patients were selected. The weighted average age was 61 years [95% IC [55-67] and males represented 62% ± 2.7 of patients [57-67]. Average short-distance WS was 0.36 ± 0.06 m.s-1 [95% CI (0.23-0.49)]. Average long-distance WS was 0.46 ± 0.1 m.s-1 [95% CI (0.26-0.66)]. The funnel plot revealed asymmetry of publication bias and high heterogeneity of the nine studies (I 2 index 98.7% and Q-test p < 0.0001). Meta-regressions of secondary endpoints could not be performed due to a lack of study data. At the SSS, WS would be lower than data in general population published in literature, but above all, lower than the WS required for safe daily autonomy and community ambulation after stroke. WS must be a priority objective of stroke rehabilitation to increase walking function but also for survival, autonomy, social participation and health-related quality of life.
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BACKGROUND: Extubation failure may have several causes, including swallowing dysfunction, aspiration, and excessive upper airway secretions. We hypothesized that a bedside global swallowing pattern assessment including 9 criteria (volume of pharyngeal secretions, 5 swallowing motor items, swallowing reflex, and 2 gag reflexes) performed prior to extubation could identify patients at risk of extubation failure. METHODS: In a multicenter prospective observational study, all consecutive patients intubated and mechanically ventilated for ≥6 d were included. Before a planned extubation, a physiotherapist evaluated the 9 criteria of the swallowing assessment. The final extubation decision was left to the physician's discretion, blinded to the swallowing assessment. Extubation failure was defined as the need for re-intubation related to aspiration or excessive upper airway secretions within the first 72 h after extubation. Results are expressed as median (interquartile range [IQR]). RESULTS: The study included 159 subjects (age 61 y [IQR 48-75]; male/female ratio 1.5; Simplified Acute Physiologic score II 54 [IQR 42-66]; duration of mechanical ventilation 11 d [IQR 8-17]). A total of 23 subjects (14.5%) required re-intubation, with 16 occurring within the first 72 h after extubation and 7 related to aspiration or excessive secretions. Swallowing assessment was significantly lower in subjects with re-intubation related to aspiration or excessive secretions within the first 72 h after extubation versus those not re-intubated for aspiration or excessive secretions (6 [IQR 5-7] vs 8 [IQR 7-8], P = .008, respectively). Among the 9 swallowing assessment criteria, normal right pharyngeal gag reflex was associated with a lower incidence of re-intubation related to aspiration or excessive secretions (odds ratio 0.12, 95% CI 0.03-0.59, P = .01), as well as normal left pharyngeal gag reflex (odds ratio 0.13, 95% CI 0.03-0.63, P = .01), with a negative predictive value of 0.98 for each reflex. CONCLUSIONS: In subjects with prolonged ventilation, the presence of one or both gag reflexes could predict a reduction in extubation failure related to aspiration or excessive upper airway secretions. (Clinical trials.gov registration NCT00780078.).
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Extubação , Deglutição , Faringe/fisiopatologia , Idoso , Secreções Corporais , Feminino , Engasgo , Humanos , Unidades de Terapia Intensiva , Laringe/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração , Respiração Artificial , Desmame do Respirador/métodosRESUMO
The increasing number of frail elderly people in our aging society is becoming problematic: about 11% of community-dwelling older persons are frail and another 42% are pre-frail. Consequently, a major challenge in the coming years will be to test people over the age of 60 years to detect pre-frailty at the earliest stage and to return them to robustness using the targeted interventions that are becoming increasingly available. This challenge requires individual longitudinal monitoring (ILM) or follow-up of community-dwelling older persons using quantitative approaches. This paper briefly describes an effort to tackle this challenge. Extending the detection of the pre-frail stages to other population groups is also suggested. Appropriate algorithms have been used to begin the tracing of faint physiological signals in order to detect transitions from robustness to pre-frailty states and from pre-frailty to frailty states. It is hoped that these studies will allow older adults to receive preventive treatment at the correct institutions and by the appropriate professionals as early as possible, which will prevent loss of autonomy. Altogether, ILM is conceived as an emerging property of databases ("digital twins") and not the reverse. Furthermore, ILM should facilitate a coordinated set of actions by the caregivers, which is a complex challenge in itself. This approach should be gradually extended to all ages, because frailty has no age, as is testified by overwork, burnout, and post-traumatic syndrome.
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OBJECTIVES: The usual complications after recent stroke such as disabling spasticity and shoulder pain seemed less frequent in recent years. This study examined the frequency of spasticity and shoulder pain in recent post-stroke patients over time in our physical and rehabilitation medicine department. METHODS: This was a retrospective study of post-stroke inpatients over the last 15 years. Spasticity and shoulder pain prevalence were analyzed, as were demographic, clinical and stroke characteristics. RESULTS: We reviewed medical records for 786 patients (506 men); mean age 58.1 years (SD 13.2); 530 (68%) with ischemic stroke and 256 (32.36%) hemorrhagic stroke. After a first increase from 2000 to 2006, the prevalence of disabling spasticity decreased from 2006 to 2015 (31%-10%; P<0.001). Shoulder pain at admission and during hospitalization also decreased (13% of patients in 2000 to 8% in 2015, P<0.001). Disabling spasticity was associated with shoulder pain (26% of patients with disabling spasticity presented shoulder pain at admission vs 7% with hyperreflexia of the deep tendon reflexes, P<0.05). Characteristics of stroke, time of admission after stroke and length of stay did not change over the years. We observed an increase in number of walking patients at admission and number with a functional paretic arm at admission and discharge (P<0.05), which may explain the increase in functional independence measure scores at admission and discharge (both P<0.05). Prevalence of cognitive disorders increased over the same period (24% in 2000 vs 63% in 2015, P<0.05). CONCLUSIONS: Disabling spasticity and shoulder pain frequency in recent post-stroke patients decreased over the last 15 years, and functional abilities both at admission and discharge improved. Confirmation of these results in a multicentric study may be important evidence of an improvement in stroke healthcare both in stroke and physical and rehabilitation medicine units in the last 10 years in France and could affect future estimations of the need for rehabilitation care after stroke.
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Pacientes Internados/estatística & dados numéricos , Espasticidade Muscular/epidemiologia , Dor de Ombro/epidemiologia , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Acidente Vascular Cerebral/complicações , Idoso , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/etiologia , Prevalência , Estudos Retrospectivos , Dor de Ombro/etiologiaRESUMO
INTRODUCTION: Motor nerve blocks with anesthetic drug for local anesthesia are commonly used in physical and rehabilitation medicine (PRM), especially in the field of spasticity. Guidelines in this context are currently lacking. METHOD: Eighteen experts selected on the basis of their recognized experience by the scientific committees of the French PRM (SOFMER) and Anesthesia and Intensive care (SFAR) societies were invited to work and propose guidelines for the use of loco-regional anesthetic drug for motor nerve blocks in PRM setting. Eight issues were addressed: which neural blocks for which indications; drugs and contraindications; medical survey and attitude in case of adverse event; injection and guidance material; patient preparation and pain relief; efficacy assessment; patient information; education of PRM physiatrists. The Medline, Cochrane and Embase databases for the period 1999 to 2018 were consulted and 355 papers analyzed. The drafts were commented then approved by the whole group using electronic vote, before final approval by scientific committee of each society. RESULTS: No scientific evidence emerged from the literature. Thus, these guidelines are mainly based on the opinion of the expert panel. Guidelines for each issue are reported with the main points of arguments. The main question deals with the recommendation about doses for each drug: for lidocaine - up to 2mg/kg - "check contraindications, emergency truck available, no need of previous anesthetic consultation nor presence of anesthetic physician"; for ropivacaine - up to 1.5mg/kg, with a maximum of 100mg - the same but after intravenous line. Beyond these doses, SFAR guidelines have to be applied with the need of anesthetic physician. CONCLUSION: These are the first organizational guidelines devoted to increase the security of motor nerve block use in PRM settings.
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Espasticidade Muscular/tratamento farmacológico , Bloqueio Nervoso/métodos , Medicina Física e Reabilitação/métodos , Anestesiologia/educação , Anestésicos Locais/efeitos adversos , Anestésicos Locais/farmacocinética , Anestésicos Locais/uso terapêutico , Contraindicações de Medicamentos , Contraindicações de Procedimentos , França , Humanos , Neurônios Motores , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/normas , Dor Processual/etiologia , Dor Processual/prevenção & controle , Medicina Física e Reabilitação/educação , Ultrassonografia de IntervençãoAssuntos
Baclofeno/efeitos adversos , Hipotonia Muscular/induzido quimicamente , Relaxantes Musculares Centrais/efeitos adversos , Paralisia/induzido quimicamente , Baclofeno/administração & dosagem , Baclofeno/uso terapêutico , Encéfalo/patologia , Overdose de Drogas , Humanos , Injeções Espinhais , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Relaxantes Musculares Centrais/administração & dosagem , Relaxantes Musculares Centrais/uso terapêutico , Espasticidade Muscular/complicações , Espasticidade Muscular/tratamento farmacológico , Coluna Vertebral/patologiaRESUMO
BACKGROUND: Unsuccessful extubation may be due to swallowing dysfunction that causes airway obstruction and impairs patients' ability to cough and expectorate. OBJECTIVE: To determine whether swallowing assessment before extubation is helpful in predicting unsuccessful extubation due to airway secretions. METHODS: This prospective study included all patients intubated orotracheally for more than 6 days. Before extubation, 3 tests designed to assess (1) cervical, oral, labial, and lingual motility; (2) gag reflex; and (3) swallowing were used at the bedside. Causes of reintubation were identified, and their relationship to patients' swallowing function before extubation was evaluated. RESULTS: Sixty-two patients were enrolled. Data on 55 patients reintubated for swallowing dysfunction were analyzed. Nine patients were reintubated because of obstruction related to upper airway secretions. Evaluation before extubation enabled prediction of 7 of those 9 unsuccessful extubations. Among the 23 patients with central nervous system disease, 3 of 4 unsuccessful extubations were predicted. According to a multivariate logistic regression model, motility and swallowing were independent predictors of unsuccessful extubation (area under receiver-operating-characteristic curve, 80%). The gag reflex was the only significant predictor of the ability to cough (area under curve, 73%) and excessive pulmonary secretion (area under curve, 67%). Swallowing was an independent predictor of the need for suctioning (area under curve, 78%). CONCLUSIONS: Using simple bedside tests to evaluate swallowing before extubation is helpful when deciding whether to extubate patients who have been intubated for more than 6 days. Involvement of nurses in these decisions would improve patients' management.
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Transtornos de Deglutição/complicações , Intubação Intratraqueal/enfermagem , Adulto , Idoso , Feminino , Nível de Saúde , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Exame Físico , Estudos ProspectivosRESUMO
OBJECTIVE: To investigate the weight of visual and proprioceptive inputs, measured indirectly in standing position control, in patients with chronic acquired demyelinating polyneuropathy (CADP). DESIGN: Prospective case study. SUBJECTS: Twenty-five patients with CADP and 25 healthy controls. METHODS: Posture was recorded on a double force platform. Stimulations were optokinetic (60°/s) for visual input and vibration (50 Hz) for proprioceptive input. Visual stimulation involved 4 tests (upward, downward, rightward and leftward) and proprioceptive stimulation 2 tests (triceps surae and tibialis anterior). A composite score, previously published and slightly modified, was used for the recorded postural signals from the different stimulations. RESULTS: Despite their sensitivity deficits, patients with CADP were more sensitive to proprioceptive stimuli than were healthy controls (mean composite score 13.9 ((standard deviation; SD) 4.8) vs 18.4 (SD 4.8), p = 0.002). As expected, they were also more sensitive to visual stimuli (mean composite score 10.5 (SD 8.7) vs 22.9 (SD 7.5), p <0.0001). CONCLUSION: These results encourage balance rehabilitation of patients with CADP, aimed at promoting the use of proprioceptive information, thereby reducing too-early development of visual compensation while proprioception is still available.
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Estimulação Luminosa/métodos , Polineuropatias/complicações , Equilíbrio Postural/fisiologia , Postura/fisiologia , Estudos de Casos e Controles , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Propriocepção/fisiologia , Estudos ProspectivosRESUMO
The fact that almost one third of population >65 years-old has at least one fall per year, makes the risk-of-fall assessment through easy-to-use measurements an important issue in current clinical practice. A common way to evaluate posture is through the recording of the center-of-pressure (CoP) displacement (statokinesigram) with force platforms. Most of the previous studies, assuming homogeneous statokinesigrams in quiet standing, used global parameters in order to characterize the statokinesigrams. However the latter analysis provides little information about local characteristics of statokinesigrams. In this study, we propose a multidimensional scoring approach which locally characterizes statokinesigrams on small time-periods, or blocks, while highlighting those which are more indicative to the general individual's class (faller/non-faller). Moreover, this information can be used to provide a global score in order to evaluate the postural control and classify fallers/non-fallers. We evaluate our approach using the statokinesigram of 126 community-dwelling elderly (78.5 ± 7.7 years). Participants were recorded with eyes open and eyes closed (25 seconds each acquisition) and information about previous falls was collected. The performance of our findings are assessed using the receiver operating characteristics (ROC) analysis and the area under the curve (AUC). The results show that global scores provided by splitting statokinesigrams in smaller blocks and analyzing them locally, classify fallers/non-fallers more effectively (AUC = 0.77 ± 0.09 instead of AUC = 0.63 ± 0.12 for global analysis when splitting is not used). These promising results indicate that such methodology might provide supplementary information about the risk of fall of an individual and be of major usefulness in assessment of balance-related diseases such as Parkinson's disease.
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Acidentes por Quedas , Exame Físico/métodos , Equilíbrio Postural , Idoso , Área Sob a Curva , Fenômenos Biomecânicos , Feminino , Humanos , Aprendizado de Máquina , Masculino , Exame Físico/instrumentação , Curva ROC , Processamento de Sinais Assistido por Computador , Percepção VisualRESUMO
OBJECTIVE: This randomised, double blind, placebo controlled, two parallel group study was conducted to assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain in stroke patients with spastic hemiplegia. METHODS: A single dose of botulinum toxin A (500 Speywood units) or placebo was injected into the subcapularis muscle. Pain was assessed using a 10 point verbal scale. Subscapularis spasticity was assessed by the change in passive shoulder lateral rotation and abduction. Upper limb spasticity was assessed using the Modified Ashworth Scale for shoulder medial rotators, and elbow, wrist and finger flexors. Assessments were carried out at baseline and at weeks 1, 2 and 4. RESULTS: Twenty patients (10 patients per group), 11 with ischaemic stroke and 9 with haemorrhagic stroke, completed the study. Pain improvement with botulinum toxin A was observed from week 1; score difference from baseline at week 4 was 4 points versus 1 point with placebo (p = 0.025). Lateral rotation was also improved, with a statistically significant difference compared with placebo at week 2 (p = 0.05) and week 4 (p = 0.018). A general improvement in upper limb spasticity was observed; it was significant for finger flexors at week 4 (p = 0.025). CONCLUSIONS: Subscapularis injection of botulinum toxin A appears to be of value in the management of shoulder pain in spastic hemiplegic patients. The results confirm the role of spasticity in post-stroke shoulder pain.
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Toxinas Botulínicas Tipo A/uso terapêutico , Hemiplegia/complicações , Fármacos Neuromusculares/uso terapêutico , Dor/tratamento farmacológico , Articulação do Ombro/efeitos dos fármacos , Método Duplo-Cego , Feminino , Humanos , Injeções Intramusculares , Masculino , Músculo Esquelético/efeitos dos fármacos , Dor/etiologia , Articulação do Ombro/patologia , Resultado do TratamentoRESUMO
OBJECTIVE: We analyzed spontaneous 180° turning strategies in poststroke hemiparetic patients by using inertial measurement units (IMUs) and the association of turning strategies with risk of falls. METHODS: We included right paretic (RP) and left paretic (LP) post-stroke patients, and healthy controls (HCs) from a physical and rehabilitation department in France between July 2015 and October 2015. All subjects were right-handed and right-footed for mobilization tasks. Participants were instructed to turn 180° in a self-selected direction after a 10-m walk while wearing three IMUs on their trunk and both feet. We defined three turning patterns based on the number of external steps (pattern I = 1; II = 2-4 steps; and III ≥ 5) and four turning strategies based on the side chosen to turn (healthy or paretic) and the stance limb used during the first step of the turn (healthy or paretic). Falls in the 6 months after measurement were investigated. RESULTS: We included 17 RP [mean (SD) age 57.5 (9.5) years (range 43-73)], 20 LP patients [mean age 60.7 (8.8) years (range 43-63)], and 15 HCs [mean age 56.7 (16.1) years (range 36-83)]. The LP and RP groups behaved similarly in turning patterns, but 90% of LP patients turned spontaneously to the paretic side versus 59% of RP patients. This difference increased with turning strategies: 85% of LP versus 29% of RP patients used strategy 4 (paretic turn side with paretic limb). Patients using strategy 4 had the highest rate of falls. CONCLUSION: We propose to consider spontaneous turning strategies as new indicators to evaluate the risk of fall after stroke. IMU could be routinely used to identify this risk and guide balance rehabilitation programs.
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BACKGROUND: Shortly after stroke, patients exhibit excessive sensitivity to visual, proprioceptive and vestibular perturbations regarding balance control. OBJECTIVE: To evaluate the stability of this perceptual behaviour after stroke and test the relationships between sensory sensitivity and balance. METHODS: Thirty subjects following a hemispheric stroke (mean age 54.7 (standard deviation (SD) 10.6 years), 21 men, right hemisphere lesion = 13) and 30 control subjects (mean age 52.0 (SD 12.0), 14 men). Sensitivity to sensory perturbations was evaluated using the displacement of the centre of pressure during tendon vibration (proprioception score), optokinetic (visual score) and galvanic perturbations (vestibular score) while standing on a force-platform a mean of 2 months after stroke, and 1 month later. Balance and independence were evaluated using the Berg Balance Scale (BBS), Timed Up and Go test (TUG) and Barthel Index (BI). RESULTS: Global sensitivity to perturbations decreased (p = 0.001). Patients remained more sensitive to visual perturbation than did controls (p = 0.033). The Vestibular Score was correlated with BBS (Rs = -0.576, p = 0.006), TUG (Rs = 0.408, p = 0.045), BI (Rs = -0.481, p = 0.016); the Visual Score was correlated with BBS (Rs = -0.500, p = 0.019), TUG (Rs = 0.401, p = 0.049). CONCLUSION: The initial months following stroke appear to be a period of individual perceptual motor adaptation. Sensory re-weighting is likely to be a major component of that process.
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Propriocepção/fisiologia , Acidente Vascular Cerebral/fisiopatologia , Vestíbulo do Labirinto/fisiopatologia , Percepção Visual/fisiologia , Estudos de Casos e Controles , Feminino , Hemiplegia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND PURPOSE: Perception of the subjective visual vertical (SVV) is affected by cerebral hemispheric lesions. Knowledge of this disturbance is of interest for the study of its possible relation to balance disturbances. There is still uncertainty about the possible effects of a visual field defect and of the side and site of the lesion. This study was conducted to assess SVV with the head upright or tilted and to explore its relation to a visual field defect, visuospatial neglect, and the site of lesion. METHODS: Forty patients with hemiplegia after a recent hemispheric stroke (20 with left and 20 with right stroke) were studied. The site of the lesion was determined on CT scan, with special attention focused on the vestibular cortex. A neurological examination with determination of the visual field and visual neglect was conducted before SVV was tested. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. Measures were repeated with binocular and monocular vision and with the head upright or tilted to the right or left. RESULTS: SVV was abnormally deviated in 23 of 40 patients (57%). The deviation was significantly greater among patients with a right or left hemispheric lesion than among healthy controls (-2.2 degrees and 1.5 degrees versus 0.2 degrees ); the same applied to the range of uncertainty (7.6 degrees and 4.7 degrees versus 1.9 degrees ). SVV deviation was not significantly related to the location of the lesion but was closely related to visuospatial neglect. The "E" effect observed in controls with the head tilted, ie, an SVV shift in the direction opposite to the head tilt, was not observed in hemiplegic patients with the head tilted toward the nonparetic side. CONCLUSIONS: Recent hemispheric stroke affects SVV perception, which is closely correlated to visuospatial neglect. It is suggested that the E effect might be mediated by the stretching of the somatosensory structure of the neck.
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Percepção Espacial , Acidente Vascular Cerebral/fisiopatologia , Encéfalo/diagnóstico por imagem , Encéfalo/fisiopatologia , Feminino , Lateralidade Funcional , Hemiplegia/etiologia , Hemiplegia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos da Percepção/diagnóstico , Transtornos da Percepção/fisiopatologia , Estimulação Luminosa/métodos , Valores de Referência , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Visão Binocular , Visão Monocular , Campos VisuaisRESUMO
The development of European Union of Medical Specialists (UEMS) physical and rehabilitation medicine programmes of care (PRMPC) and physical and rehabilitation medicine care pathways (PRMCP) in France is a good example of the positive interaction between European and national organizations. PRMPC were defined at the European level to offer a robust template for the description and assessment of physical and rehabilitation medicine (PRM) clinical activity in various fields and contexts. An accreditation procedure was organized as a peer review. It has started to provide very informative documents. In France, discussions on this topic began in 2000. At the end of the same decade, the European approach fostered the interest of French PRM organizations in a period of negotiating with public authorities about two crucial issues: specifications required for reimbursement of functional instrumental assessments in PRM practice and funding of PRM care in postacute facilities. The French Society of PRM (SOFMER) decided to describe the PRM scope in a systematic way, emphasizing the best balance between patient needs, rehabilitation goals, relevant means and justified funding. Nine 'PRMCP' have been published since 2010 and others are in progress. PRMPC and PRMCP share the same concern about the best response offered by PRM to patients' needs. The first approach is the description of a local organization with respect to both scientific evidence and local conditions. The latter is an outline of PRM intervention related to a multidimensional pattern of patients' situations. Both enhance the role of PRM doctors, whose expertise is necessary for making a synthesis of medical diagnosis and functional assessment, for setting up a patient-centred care strategy and for supervising the rehabilitation team's intervention.
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Medicina Física e Reabilitação/organização & administração , Acreditação , Procedimentos Clínicos , Europa (Continente) , França , Humanos , Assistência Centrada no PacienteRESUMO
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.
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Espasticidade Muscular , Paresia , Adulto , Toxinas Botulínicas Tipo A/administração & dosagem , Lesões Encefálicas/complicações , Lesões Encefálicas/reabilitação , Humanos , Espasticidade Muscular/diagnóstico , Espasticidade Muscular/fisiopatologia , Espasticidade Muscular/terapia , Bloqueadores Neuromusculares/administração & dosagem , Paresia/diagnóstico , Paresia/fisiopatologia , Paresia/terapia , Modalidades de Fisioterapia , Amplitude de Movimento Articular/fisiologia , Acidente Vascular Cerebral/complicações , Reabilitação do Acidente Vascular CerebralRESUMO
OBJECTIVE: To compare 2 rehabilitation strategies to improve balance after stroke: (1) a multisensorial approach based on higher intensity of balance tasks and exercise during visual deprivation and (2) a conventional neurodevelopmentaltheory-based treatment (NDT) that used a general approach for sensorimotor rehabilitation. METHODS: This prospective, multicenter, randomized, parallel-group study measured outcomes with blinded assessors. Sixty-eight patients able to walk without human assistance were entered from 3 to 15 months (mean, 7 months) after a first hemispheric stroke. They received 20 sessions in 4 weeks of NDT or multisensorial rehabilitation. On day 0, day 30, and day 90, assessment included the Berg Balance Scale (BBS), posturography, gait (velocity, double stance phase, climbing 10 steps, amount of walking per day), the Functional Independence Measure, and the Nottingham Health Profile. RESULTS: All subjects improved significantly in balance and walking parameters. Regarding the main dependent variable (BBS on day 30), no difference between groups was found. Analysis of secondary outcomes suggested small differences in favor of the experimental group, but the differences are not likely to be clinically relevant. CONCLUSION: No evidence was found for the superiority of a multisensorial rehabilitation program in ambulatory patients with impairments beyond the time of inpatient therapy. Additional studies are recommended.
Assuntos
Exercício Físico , Retroalimentação Sensorial , Equilíbrio Postural/fisiologia , Transtornos de Sensação/reabilitação , Reabilitação do Acidente Vascular Cerebral , Caminhada/fisiologia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desempenho Psicomotor , Recuperação de Função Fisiológica , Transtornos de Sensação/etiologia , Transtornos de Sensação/fisiopatologia , Método Simples-Cego , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVE: To determine whether misperception of the subjective visual vertical (SVV) underlies balance difficulties in hemiplegic patients. DESIGN: Descriptive study, using a convenience sample. SETTING: Department of physical medicine of a university hospital. PARTICIPANTS: Thirty inpatients with hemiplegia after a hemispheric stroke during the 3 previous months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The SVV was tested while subjects sat in a dark room and were asked to adjust a luminous line to the vertical position. Mean SVV deviation and uncertainty, defined as the standard deviation, were calculated for 8 trials. Balance was assessed by the Postural Assessment Scale for Stroke (PASS) and while patients sat on a laterally rocking platform placed on a Satel force platform. The mean body position and the instability score (Lx), calculated as the length of the course of the center of pressure, were recorded. Functional outcome was also evaluated by the FIM instrument. RESULTS: An abnormal SVV was recorded for 20 of 30 patients. Balance (ie, PASS, Lx) and FIM correlated significantly with SVV tilt (P<.001, P=.01, and P<.001, respectively) and with uncertainty (PASS, P=.006; FIM, P=.003). CONCLUSIONS: Verticality misperception was related to poor balance and might be an important element in the assessment of contributing factors to balance disorders after stroke. It should probably be taken into account when establishing balance rehabilitation programs for patients with hemiplegia.
Assuntos
Hemiplegia/fisiopatologia , Hemiplegia/psicologia , Equilíbrio Postural/fisiologia , Percepção Espacial/fisiologia , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Adulto , Idoso , Isquemia Encefálica/complicações , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/psicologia , Estudos de Casos e Controles , Feminino , Hemiplegia/etiologia , Humanos , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/fisiopatologia , Hemorragias Intracranianas/psicologia , Masculino , Pessoa de Meia-Idade , Atividade Motora/fisiologia , Acidente Vascular Cerebral/complicaçõesRESUMO
OBJECTIVES: To describe the clinical characteristics of persistent extension of the great toe related to overactivity of the extensor hallucis longus (EHL) after a stroke and to explore the efficacy of treatment with botulinum toxin type A. DESIGN: Case series. SETTING: A physical medicine and rehabilitation department in France. PARTICIPANTS: Eleven patients with hemiplegia disabled by overactivity of the EHL were classified according to the different ways in which that overactivity was triggered. Disability was related to pain in 5 patients, to shoe difficulties in 10 patients, and to varus foot in 6 patients. INTERVENTION: Injection of botulinum toxin type A into the EHL. MAIN OUTCOME MEASURES: Efficacy was assessed on day 15 by triggering of pain, shoe difficulties, and varus deformity and by patients' subjective assessment on day 15, at 3 months, and at 6 months. RESULTS: On day 15, EHL overactivity disappeared after 16 of the 18 injections in 10 patients; subjective assessment was very good for pain and shoe difficulties and remained good or very good at 3 months for 8 patients who received 12 injections. CONCLUSION: Botulinum toxin type A is effective in treating disability related to poststroke overactivity of the EHL.