[Physical medicine and rehabilitation and oncology: ethical reflexion]. / Médecine physique et de réadaptation et cancérologie: réflexion éthique à partir de cas cliniques.

INTRODUCTION: Physical medicine and rehabilitation (PMR) can involve the care of cancer patients requiring rehabilitation for associated deficiencies. In this case, rehabilitation methods may differ due to the evolutive nature of the disease. OBJECTIVE: To reflect on this aspect of PMR based on real cases. METHOD: Cases study of patients hospitalised in the PMR unit for neurological rehabilitation and diagnosed with cancer. RESULTS: Twenty-four recorded cases (1998-2006); four cases are described because of difficult problems; in only seven cases the coexisting cancer had no impact on the rehabilitation process. DISCUSSION AND CONCLUSION: Supportive care for patients with a bad vital prognosis differs from standard rehabilitation and raises therapeutic and relational issues not commonly faced in PMR. Responses when confronted with a terminal disease are not the same as when confronted with a handicap. The role of the rehabilitation team is brought into question when functionality is of secondary importance. The response to physical pain is different in rehabilitation and often implies a behavioural approach, which requires the commitment of the patient to therapeutic programmes. We do not find this approach in oncology and the treatment of pain uses first some drugs. Supportive care of these patients requires a close working relationship with the oncology unit. Thus, a different approach must be taken to rehabilitation. It should always take into account the evolutive nature of cancer, which can undermine the patient's functions or setback the patient's recovery. It also requires the support of a care team, which is fully prepared for these setbacks.

Diagnosis and treatment of osteoporosis in spinal cord injury patients: A literature review.

OBJECTIVE: To present an up-to-date literature review of osteoporosis in spinal cord injury (SCI) patients, in view of the seriousness of this complication (with a high risk of fractures) and the complexity of its diagnosis, evaluation and treatment. METHODS: A Medline search with the following keywords: immobilization osteoporosis, spinal cord injury, bone loss, dual energy X-ray absorptiometry (DEXA), bisphosphonate. RESULTS: Our analysis of the literature noted a bone metabolism imbalance in SCI patients, with accelerated early bone resorption (particularly during the first 6 months post-injury). Although dual energy X-ray absorptiometry constitutes the "gold standard" diagnostic method, the decrease in bone mineral density only becomes significant 12 months after the injury. Bisphosphonate therapy has proven efficacy. Despite the frequent use of various physical therapies, these methods have not been found to be effective. CONCLUSION: Although our literature review did not identify any guidelines on the strategy for diagnosing and treating osteoporosis in SCI patients, several findings provide guidance on procedures for early diagnosis and preventive treatment.

[Osteoporosis in spinal cord injury. Screening and treatment. Results of a survey of physical medicine and rehabilitation physician practices in France. Proposals for action to be taken towards the screening and the treatment]. / Ostéoporose du blessé médullaire. Dépistage et traitement. Résultats d'une enquête sur les pratiques des médecins de MPR en France. Propositions de conduite à tenir vis-à-vis du dépistage et du traitement.

OBJECTIVE: The management of osteoporosis in spinal cord injury that is a recurring issue in daily practice, but unfortunately, no standard protocol is provided by the literature review, either for screening or for a strategy of prevention and even for therapy. We assessed the practices of the physicians in physical medicine and rehabilitation from all over France, with the ultimate aim to propose a consensus for preventive and curative cares of that osteoporosis. METHODS: A questionnaire was sent to practitioners engaged with spinal cord injury (SCI) patients residing in the center and patients in medical monitoring. The questionnaire consisted mainly of closed questions. RESULTS: Twenty-six questionnaires are analyzed. The screening for osteoporosis is made routinely by only 19.2% of the practitioners and after a fracture in only 80.2% of the cases. The diagnosis of osteoporosis is based on bone densitometry (DEXA) (96%). Standing still remains a means of prevention for 88% of physicians in the acute phase and for 77% in the chronic phase. Ninety-two percent of practitioners treat at the stage of established osteoporosis. CONCLUSION: There is generally no standardized management of osteoporosis in practice for SCI patients. The searching for osteoporosis is usually performed after a fracture. All the literature data and results of the questionnaire led us to propose a protocol consisting in a systematic monitoring of the bone mineral density for the screening of osteoporosis, but also a procedure for early diagnosis and for preventive treatment of osteoporosis in the acute phase.

Sensitivity to change of the Quebec Back Pain Disability Scale and the Dallas Pain Questionnaire.

OBJECTIVE: To study and compare the sensitivities to change of the French versions of the Quebec Back Pain Disability Scale (QBPDS) and the Dallas Pain Questionnaire (DPQ). METHOD: A retrospective study of the medical records of 30 chronic low back pain (LBP) outpatients undergoing a 4-week functional training program in a physical medicine and rehabilitation unit. Physical data (a visual analogue pain scale, the Schöber index, Sorensen and Shirado tests and the finger-to-floor distance) and functional status (QBPDS and DPQ scores) were measured at D0 and D25. Sensitivity to change was assessed in terms of the standardized response mean (SRM) and the effect size (ES). RESULTS: With the exception of the DPQ's "social interest" domain, all QBPDS and DPQ scores improved significantly over the course of the rehabilitation programme. Sensitivity to change was high for the QBPDS (SRM=0.80; ES=0.62) but only moderate for the DPQ (SRM=0.59; ES=0.61). DISCUSSION-CONCLUSION: Our results show that the QBPDS was more sensitive to clinical change than the DPQ in a sample of chronic LBP sufferers. It would be interesting to assess this sensitivity in a population of acute LBP patients and to evaluate the long-term effects of a functional rehabilitation program on the DPQ's "social interest" domain.

Are there indications (other than scoliosis) for rigid orthopaedic brace treatment in chronic, mechanical low back pain?

OBJECTIVES: Mechanical low back pain (LBP) is a major public health problem. Today's standard care strategy involves a combination of drug-based and non-drug therapies. The use of conservative orthopaedic brace treatment is subject to debate. The lack of data and consensus in the literature on the value of this treatment in chronic LBP prompted to us to seek to estimate the modalities and indications for brace use in France. MATERIALS AND METHOD: We performed a questionnaire-based survey of physician members of the French Society of Physical Medicine and Rehabilitation (SOFMER). RESULTS: We received 55 completed questionnaires. Although the indications for this treatment were very heterogeneous (in both clinical and paraclinical terms), the prescribing behaviour was rather uniform. The brace is worn during the day for less than 3 months (with a progressive reduction in use over 1 to 2 months), together with physiotherapy before and after immobilization. The patient keeps the brace at the end of the treatment period. Orthopaedic treatment appears to be prescribed in many chronic LBP situations. Analysis of spinal posture and magnetic resonance imaging results (and Modic changes in particular) influence the therapeutic decisions. CONCLUSION: Clinical and paraclinical indications of this treatment must be precisely defined and evaluated in prospective, multicenter studies with homogeneous cohorts.