Search

The aim of our study is to describe the assessment of the upper limb in tetraplegic patients to follow his (her) neurological progression and to define the medical or surgical treatment program. We selected upper limb assessment tools and scales for tetraplegic patients described in the medical literature through a PubMed search over the last four decades. For each method, we present the implementation rules and its metrological properties, including its validity in French. We selected five clinical scales for functional evaluation of grasping, as well as four scales for evaluating the overall function of these patients. Finally, we identified three complementary precision assessment tools. The AIS (ASIA Impairment Scale) classification describes the level and the severity of the spinal cord lesion. The Giens classification is more practical for describing the upper limb in middle and low tetraplegia. Impairments can be assessed with most common generic scales and nonspecific measurement devices: range of motion, strength, sensory loss, spasticity, joint pain. Measurement of pinch and grip strength is widely used and easy to perform. The Capabilities of Upper Extremity (CUE) and the Jebsen Taylor Test are the best validated and usable scales. At a general functional level, the Spinal Cord Independence Measure (SCIM) is the most relevant scale in these patients. Motor nerve blocks, electromyography, movement analysis and echography are promising additional methods. Assessment of the upper limb of tetraplegic patients relies both on generic and specific assessment tools and scales.

Resume Les patients en fauteuil representent 2 % de la population generale. Dans cette population, l’epaule assure la fonction locomotrice et presente, avec l’âge, des pathologies degeneratives, notamment de la coiffe des rotateurs (CDR). L’association epaule locomotrice et rupture de la CDR pose plusieurs questions : par quels mecanismes la propulsion du fauteuil et les transferts surchargent-ils l’epaule, et quelles en sont les specificites lesionnelles ? Elles surviennent chez des patients plus jeunes que dans le reste de la population, apres une duree d’utilisation du fauteuil assez constante, d’une quinzaine d’annees. A cote de l’atteinte classique du supra-spinatus, une extension anterieure de la CDR est la plus frequente. La presentation clinique en cas de rupture est-elle particuliere dans cette population ? L’epaule ne pouvant pas etre fonctionnellement protegee, la douleur est constante et les ruptures de coiffe asymptomatiques sont rares. Toute douleur apres 12 ans de fauteuil devra faire l’objet d’une exploration morphologique. En quoi differe la strategie therapeutique de l’epaule locomotrice ? Plus que par la classique recherche de compensations, en cas d’epaule locomotrice, la CDR devra etre preservee de toute agression locale par des gestes systematiques de recalibrage de l’espace sous-acromial et une reparation de toutes les lesions pour eviter leur extension. Faut-il craindre des resultats fonctionnels inferieurs dans cette population ? A condition de respecter une protection prolongee de la suture par une reprise des transferts uniquement apres 4 mois, et la mise en place quotidienne de mesures de protection de l’epaule, les resultats analytiques et les taux de cicatrisation sont comparables a ceux de la population generale. Par contre, les complications generales et cutanees sont plus frequentes et necessitent preventivement une prise en charge postoperatoire en centre specialise.

Background. Early Mobilization in Intensive Care Units (ICUs) enhances patients’ evolution, but its benefits and practical implementation have rarely been studied in neurological ICUs. To report on tolerance, feasibility and benefits of walking with a specific body-weight support (BWS) device for patients admitted to a neurological intensive care unit. Methods. Observational single-center one-year study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria. Results. Patients’ conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, 33 performed BWS walking. Regarding non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Regarding the 45 eligible patients who did not receive BWS training, main reasons were workload and week-ends (31%), medical barriers (29%), early ICU discharge (22%). For the 33-patient study sample, 78 BWS sessions were performed. Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), battery failure (1). All adverse events ended upon session interruption. Patients walked on median 17 meters. During 51% of sessions, patients showed a spontaneous smile. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended. Conclusions. Verticalization and walking using a suspension device patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated. Trial registration. ClinicalTrials database (ID: NCT04300491)

Decubitus pressure ulcers (PU) are a major complication of immobilised patients. Staphylococcus aureus is one of the most frequently detected microorganisms in PU samples; however, its persistence and role in the evolution of these wounds is unknown. In this study, we analysed S. aureus strains isolated from PU biopsies at inclusion and day 28. Eleven S. aureus (21.1%) were detected in 52 patients at inclusion. Only six PUs (11.5%) continued to harbour this bacterium at day 28. Using a whole genome sequencing approach (Miseq®, Illumina), we confirmed that these six S. aureus samples isolated at D28 were the same strain as that isolated at inclusion, with less than 83 bp difference. Phenotypical studies evaluating the growth profiles (Infinite M Mano, Tecan®) and biofilm formation (Biofilm Ring Test®) did not detect any significant difference in the fitness of the pairs of S. aureus. However, using the Caenorhabditis elegans killing assay, a clear decrease of virulence was observed between strains isolated at D28 compared with those isolated at inclusion, regardless of the clinical evolution of the PU. Moreover, all strains at inclusion were less virulent than a control S. aureus strain, i.e., NSA739. An analysis of polymicrobial communities of PU (by metabarcoding approach), in which S. aureus persisted, demonstrated no impact of Staphylococcus genus on PU evolution. Our study suggested that S. aureus presented a colonising profile on PU with no influence on wound evolution.

Bacterial species and their role in delaying the healing of pressure ulcers (PU) in spinal cord injury (SCI) patients have not been well described. This pilot study aimed to characterise the evolution of the cutaneous microbiota of PU in SCI cohort. Twenty-four patients with SCI from a French neurological rehabilitation centre were prospectively included. PU tissue biopsies were performed at baseline (D0) and 28 days (D28) and analysed using 16S rRNA gene-based sequencing analysis of the V3–V4 region. At D0, if the overall relative abundance of genus highlighted a large proportion of Staphylococcus, Anaerococcus and Finegoldia had a significantly higher relative abundance in wounds that stagnated or worsened in comparison with those improved at D28 (3.74% vs 0.05%; p = 0.015 and 11.02% versus 0.16%; p = 0.023, respectively). At D28, Proteus and Morganella genera were only present in stagnated or worsened wounds with respectively 0.02% (p = 0.003) and 0.01% (p = 0.02). Moreover, Proteus, Morganella, Anaerococcus and Peptoniphilus were associated within the same cluster, co-isolated from biopsies that had a poor evolution. This pathogroup could be a marker of wound degradation and Proteus could represent a promising target in PU management.

Pressure ulcers are a risk for bedridden patients and various supports exist to prevent them. The Pressure Relief Index (PRI) evaluates pressure relief of dynamic mattresses over time. This study compared the PRI of the SUMMIT mattress (AKS-France) and the NIMBUS 3 (HNE Medical).In this non-blinded, randomized, crossover, non-inferiority study, patients aged ≥60 with a BMI of 16-35 kg/m2, predominantly confined to bed, able to walk with aid and with pelvic symmetry were recruited from a hospital rehabilitation department from March-April 2012. Exclusion criteria included past or present pressure ulcers, inability to remain supine and deep vein thrombosis. Peak pressures of the sacrum were recorded at 0.1 Hz during a single complete 10-min inflating cycle on both mattresses, with the order determined via electronic randomization allocation.Thirty-one subjects were included and randomized; with 14 finally analyzed in the SUMMIT-NIBMUS 3 order group and 16 in the NIMBUS 3-SUMMIT group. The difference in PRI30 mmHg between the two mattresses was 13.2% [0.3-26.1] (p 0.05), allowing a non-inferiority - superiority switch. The SUMMIT mattress demonstrated a significantly higher percentage of time30 mmHg (p = 0.0454). No significant difference in mean minimal pressure was seen (p = 0.3231) and mean maximal pressure was in favor of SUMMIT mattress (p = 0.0096). BMI did not affect pressure profile. There were no adverse events.Evaluated by the PRI, the SUMMIT mattress had a better interface pressure profile than the NIMBUS 3 in older patients. The PRI is a promising tool for clinical decision-making and research, warranting validation.

Decubitus pressure ulcers (PU) are a major complication of immobilised patients. Staphylococcus aureus is one of the most frequently detected microorganisms in PU samples; however, its persistence and role in the evolution of these wounds is unknown. In this study, we analysed S. aureus strains isolated from PU biopsies at inclusion and day 28. Eleven S. aureus (21.1%) were detected in 52 patients at inclusion. Only six PUs (11.5%) continued to harbour this bacterium at day 28. Using a whole genome sequencing approach (Miseq®, Illumina), we confirmed that these six S. aureus samples isolated at D28 were the same strain as that isolated at inclusion, with less than 83 bp difference. Phenotypical studies evaluating the growth profiles (Infinite M Mano, Tecan®) and biofilm formation (Biofilm Ring Test®) did not detect any significant difference in the fitness of the pairs of S. aureus. However, using the Caenorhabditis elegans killing assay, a clear decrease of virulence was observed between strains isolated at D28 compared with those isolated at inclusion, regardless of the clinical evolution of the PU. Moreover, all strains at inclusion were less virulent than a control S. aureus strain, i.e., NSA739. An analysis of polymicrobial communities of PU (by metabarcoding approach), in which S. aureus persisted, demonstrated no impact of Staphylococcus genus on PU evolution. Our study suggested that S. aureus presented a colonising profile on PU with no influence on wound evolution.

BACKGROUND Clinical evaluation of a pressure ulcer is based on quantitative and qualitative evaluation. In clinical practice, acetate tracing is the standard technique used to measure wound surface area; however, it is difficult to use in daily practice (because of material availability, data storage issues, and time needed to calculate the surface area). Planimetry techniques developed with mobile health (mHealth) apps can be used to overcome these difficulties. OBJECTIVE The goal of this study was to evaluate the metrological properties of a free-access mHealth app, called imitoMeasure, to assess pressure ulcers. METHODS This was a noninterventional, validation study. We included patients with spinal cord injury presenting with a pressure ulcer, regardless of its stage or location. We performed wound measurements with a ruler, and we performed acetate tracing using a transparent dressing with a wound measurement grid. Wound evaluation via the mHealth app was conducted twice by the main investigator and also by a coinvestigator to determine validity, intrarater reproducibility, and interrater reproducibility. Bland-Altman plots and intraclass correlation coefficients were used to compute the minimal detectable change percentage. RESULTS Overall, 61 different pressure ulcers were included. The validity, intrarater reproducibility, and interrater reproducibility of the mHealth app vs acetate tracing (considered the method of reference) were good, with intraclass correlation coefficients of 0.97 (95% CI 0.93-0.99), 0.99 (95% CI 0.98-0.99), and 0.98 (95% CI 0.96-0.99), respectively, and minimal detectable change percentages between 17% and 35%. CONCLUSIONS The imitoMeasure app had good validity and reproducibility. It could be an alternative to standard wound assessment methods. Further studies on larger and more diverse wounds are needed. CLINICALTRIAL ClinicalTrials.gov NCT04402398; http://clinicaltrials.gov/ct2/show/NCT04402398

Background Clinical evaluation of a pressure ulcer is based on quantitative and qualitative evaluation. In clinical practice, acetate tracing is the standard technique used to measure wound surface area; however, it is difficult to use in daily practice (because of material availability, data storage issues, and time needed to calculate the surface area). Planimetry techniques developed with mobile health (mHealth) apps can be used to overcome these difficulties. Objective The goal of this study was to evaluate the metrological properties of a free-access mHealth app, called imitoMeasure, to assess pressure ulcers. Methods This was a noninterventional, validation study. We included patients with spinal cord injury presenting with a pressure ulcer, regardless of its stage or location. We performed wound measurements with a ruler, and we performed acetate tracing using a transparent dressing with a wound measurement grid. Wound evaluation via the mHealth app was conducted twice by the main investigator and also by a coinvestigator to determine validity, intrarater reproducibility, and interrater reproducibility. Bland-Altman plots and intraclass correlation coefficients were used to compute the minimal detectable change percentage. Results Overall, 61 different pressure ulcers were included. The validity, intrarater reproducibility, and interrater reproducibility of the mHealth app vs acetate tracing (considered the method of reference) were good, with intraclass correlation coefficients of 0.97 (95% CI 0.93-0.99), 0.99 (95% CI 0.98-0.99), and 0.98 (95% CI 0.96-0.99), respectively, and minimal detectable change percentages between 17% and 35%. Conclusions The imitoMeasure app had good validity and reproducibility. It could be an alternative to standard wound assessment methods. Further studies on larger and more diverse wounds are needed. Trial Registration ClinicalTrials.gov NCT04402398; http://clinicaltrials.gov/ct2/show/NCT04402398

Introduction: Repeated transfers and wheelchair propulsion in patients with a neurological deficit of the lower limbs overloads the upper limbs mechanically, particularly the shoulders, which become weight-bearing. Under these conditions, arthroplasty implants are subjected to large stresses, even though this indication is controversial in such a context. We hypothesized that joint replacement in weight-bearing shoulders will relieve pain and improve range of motion, with a positive impact on function and autonomy, without increasing the complication rate relative to the able-bodied population. Materials and Methods: This retrospective study involved 13 implants in 11 patients (4 total shoulder arthroplasty, 4 hemi-arthroplasty and 3 reverse shoulder arthroplasty) who had a mean follow-up of 33.7 ± 27 months (12-85 months). The clinical assessment included active and passive range of motion, pain, Constant score, and the Wheelchair User’s Shoulder Pain Index (WUSPI). Radiographs were evaluated to look for signs of loosening and scapular notching. The patients’ autonomy was evaluated through the number of transfers, means of locomotion (manual or electric wheelchair) and the functional independence measure (FIM). Two subgroups were defined based on the initial pathology: neurological shoulder or functional shoulder. Results: The 11 patients had a mean age of 64 ± 19 years (23-85 years) and were all long-term wheelchair users (electrical or mechanical). The pain level on VAS decreased from 8 ± 3 preoperatively to 4 ± 2 postoperatively (p = 0.003). The mean Constant score increased 90% from 22 ± 11 preoperatively to 42 ± 23 postoperatively (p = 0.008). The WUSPI score decreased by 73% from 80 ± 30 to 21 ± 15 (p = 0.001). The range of motion improved in the subgroup of patients with functional shoulders but not in the subgroup of patients with neurological shoulders. The means of locomotion was altered in five patients (63%) by the acquisition of an electric wheelchair, but with no significant change in the number of daily transfers. There were no radiographic signs of implant loosening at the final assessment. Two implants had to be revised: one anatomical prosthesis was converted to a reverse configuration because of a secondary rotator cuff rupture; one case of early infection required a two-stage implant change. Discussion: Joint replacement in weight-bearing shoulders is an effective medium-term solution for cuff tear arthropathy and glenohumeral OA, mainly for addressing pain, with slight improvements in range of motion, depending on the initial pathology. This intervention requires lifestyle adaptations such as changes in daily transfer practices and means of locomotion. Level of evidence: IV, retrospective study.

Background Few rehabilitation methods have proven their efficacy in increasing sensori-motor recovery and/or function of the upper limb (UL) after stroke. Video games (VGs) are promising tools in this indication. Objective To compare UL rehabilitation by using VGs and conventional rehabilitation (CR) in patients with sub-acute stroke. Design Single-blind, multicentric trial, with central randomization and stratification by center. Setting Physical and rehabilitation medicine departments of 2 university hospitals. Participants Adults within 3 months after a first vascular cerebral accident, with UL Fugl Meyer Score (UL-FMS) Intervention A 45-min additional session of conventional occupational therapy (OT) or a VG-based OT session as add-on therapy to usual rehabilitation programs, 5 days/week for 6 weeks. Main Outcome Measures Primary outcome: UL-FMS. Secondary outcome: Box and Block Test (BBT), Wolf Motor Function test (WMFT), Motor Activity Log (MAL), Barthel Index and quality of life (SF-36). Results We included 51 patients (20 women) at a mean (SD) of 27.2 (19.4) days post-stroke (mean age 58 years [range 24–83]), 26 in the CR group and 25 in the VG group (23 in each group at 6-month follow-up). The mean duration of the additional rehabilitation session was similar in both groups: 29.3 (4.3) vs 28.0 (4.4) min in CR and VG groups. Shoulder pain occurred in 4 patients in the VG group versus 7 in the CR group. At day 45, gain in UL-FMS did not significantly differ between the groups (CR mean 17.8 [14.6] vs VG 24.1 [14.8]; P = 0.10), whereas gain in BBT was doubled in the VG group (CR 7.4 [12.2] vs VG 15.7 [16.3]; P = 0.02). At 6-month follow-up, the study was inconclusive about between-group differences in UL-FMS, BBT and other criteria. Post-hoc analysis showed that gains in UL-FMS or BBT were significantly higher in the VG than CR group for patients included within 30 days post-stroke. Conclusion In general, we cannot conclude that video gaming and conventional OT led to different long-term sensorimotor recovery of the UL after sub-acute stroke. However, when applied within the first month after stroke, video gaming was more efficient than conventional rehabilitation on both sensorimotor recovery and gross grasping function. Trial registration ClinicalTrials.gov ( NCT01554449 ).

Background Flap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors. Methods This observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Herault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure. Results 85 patients were included. Median healing time was 48 days (R: 20–406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02). Conclusion After primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.

Two percent of the general population are wheelchair-dependent. The shoulder takes on the weight-bearing locomotor function, and tends with age to develop degenerative pathologies, notably in the rotator cuff. The association between weight-bearing shoulder and rotator cuff tear raises several questions: what are the mechanisms by which wheelchair propulsion and transfer overload the shoulder, and what specificities do the lesions display? They occur in younger patients than in the rest of the population, after about 15 years' fairly constant wheelchair use. As well as the classical supraspinatus damage, an anterior cuff extension is the most frequent case. Is there a particular clinical presentation of cuff tear in this population? As the shoulder cannot be functionally protected, pain is constant and asymptomatic cuff tear is rare. Any pain after 12 years' wheelchair use requires morphologic exploration. How does treatment strategy differ for the weight-bearing shoulder? More than the classic quest for compensation, in the weight-bearing shoulder, the rotator cuff should be protected against any local aggression by systematic surgical recalibration of the subacromial space, and all lesions should be repaired, to avoid extension. Are functional results to be expected to be poorer in this population? On condition that the suture is protected by postponing any transfer beyond 4 months and that the shoulder is protected on a daily basis, analytic results and healing rates are comparable to those in the general population. However, general complications and skin complications are more frequent and require postoperative care in a specialized center.

Objectives Explore the perceptions and beliefs related to pressure ulcers (PU), their prevention and treatment strategies, in order to discuss potential learning objectives for PU-related therapeutic education in persons with spinal cord injury (SCI). Design Qualitative study, using grounded theory for the analysis of data collected via a questionnaire. Setting Nine SCI referral centers, inpatient care. Participants 131 persons with SCI were included. 76% were male, and 65% presented with paraplegia. The median age was 48 years (33.5; 58) and median time since injury was 11 years (3; 24.5). 70% had experience with PU. Interventions None. Main outcome measures Data collection via an open-ended questionnaire on the representation of PU, its prevention and life experience of having a PU. Results Six categories were identified: (1) identifying what might become problematic, (2) daily preventive actions, (3) detecting the early signs, (4) managing the early signs, (5) need for care, (6) experience with PU and being bedridden. Pressure ulcers have dramatic consequences on psychosocial health. Prevention and treatment require self-management skills, such as self-risk assessment abilities, self-detection skills and problem-solving strategies, to optimise daily PU prevention in persons with SCI. Conclusion PU prevention tackled by persons with SCI bears some specificities that the physician must take into account in the construction of a self-management program in this high-risk population.

International audience; Background: Spinal cord injury (SCI) induces an acute alteration in bone metabolism. Although the aetiology of the bone disturbances is not precisely known, immobilisation reduces mechanical loading and the morphology of osteocytes, which are the primary mechanosensors. Periostin and sclerostin are secreted mostly by osteocytes and are involved in bone's mechanical response.Objective: The present study was conducted to determine whether individuals with SCI present alterations in serum periostin and sclerostin and to assess their relationships with bone mineral density, bone turnover markers, fracture status, time since injury, densitometric osteoporosis and paraplegic vs. tetraplegic status.Subjects and methods: One hundred and thirty-one individuals with SCI (96 males and 35 females; 42.8 ± 13.7 yr old) with a mean 14.2 ± 12.1 years since the time of injury were evaluated and compared with 40 able-bodied controls in a cross-sectional study. Periostin and sclerostin were assayed by ELISA from Biomedica® (Vienna, Austria), and bone turnover markers and areal bone mineral density (aBMD) were concomitantly analysed.Results: Compared with controls, individuals with SCI presented higher periostin (p

BackgroundFunctional Electrical Stimulation (FES) is used for decades in rehabilitation centers. For patients with a spinal cord injury (SCI), FES can prevent muscular atrophy, reduce spasticity and/or restore limb movements. To this last aim, FES external devices can be used, but elicit imprecise movements. FES implanted devices used neuromuscular stimulation and required implantation of one electrode for each site (muscle) to stimulate, an heavy surgical procedure and 10 times more electrical charges than nerve stimulation. Moreover, complications related to the numerous implanted components could appear over time. The purpose of this work is to evaluate whether a multi-contact nerve cuff electrode can selectively activate forearm and hand muscles and restore functional movements in patient with a complete tetraplegia.MethodsA 12-contacts cuff electrode was designed to selectively activate, without damage it, multi fascicular peripheral nerve (1). Six subjects rwith at least one extensor or one flexor muscle stimulable by surface electrical stimulation, have been enrolled into the study. During the surgical procedure, radial or median nerve was stimulated through up to 35 different configurations of stimulation at an intensity up to 2.1 mA (25 Hz, pulse width 250 µs, inter-pulse 100 µs). Surface electrodes were positioned upon the forearm to record compound muscle action potentials elicited by nerve electrical stimulation. Recruitments curves and videos were recorded.ResultsThe multicontact cuff electrode allowed us to selectively activate group of muscles to produce multiple, independent and functional hand and forearm movements in persons with tetraplegia. A surface electrical stimulation did not allow all those movements.

Background There is little evidence regarding the best way to treat adhesive capsulitis. Physical therapy can reduce pain and improve function and range of motion. However, we lack clear indications on the regimen, techniques or intensity of physical therapy to achieve better results. Intensive physical therapy seems to be confined to the later stages of adhesive capsulitis (chronic stage) given that rehabilitation-induced pain could worsen the outcomes. Here we describe a protocol for a study comparing the efficacy of a standardized program of intensive mobilization under analgesic gas to a similar program under placebo gas and questioning the impact of pain. Method/Design A randomized, double-blind, multicenter study — the MEOPA Trial — was designed to include adults with strictly defined clinical adhesive capsulitis for a 14-day intensive physical rehabilitation program under an equimolar mixture of oxygen and nitrous oxide or sham gas administration. Efficacy will be assessed by the Constant-Murley score. Data for secondary criteria including pain, disability, quality of life and perceived efficacy by the patient or physiotherapist will be collected over 6 months. Discussion This randomized controlled trial has been designed to test the effectiveness of intensive physical therapy under a simple and safe analgesic method. This study will also address the effect of pain during rehabilitation in adhesive capsulitis. Furthermore, results from the 6-month multidimensional follow-up of painful mobilization for this condition could be extrapolated to other musculoskeletal conditions. Trial registration ClinicalTrials.gov No. NCT01087229 .

The benefit of an intradiscal injection of corticosteroids for low back pain with active discopathy is not totally resolved.The objective of this study was to estimate the clinical efficacy of an intradiscal injection of glucocorticoids versus lidocaine in patients with low back pain and active discopathy (Modic 1 changes).A prospective, single-blind, randomized controlled study was conducted in 2 tertiary care centers with spine units. We enrolled 50 patients (mean age 50 years; 46% women) with lumbar active discopathy on MRI and failure of medical treatment for more than 6 weeks. Participants were randomly assigned to receive an intradiscal injection of glucocorticoids [50mg prednisolone acetate (GC group), n=24] or lidocaine [40mg (L group), n=26] by senior radiologists. Outcome measures were low back pain in the previous 8 days (10-point visual analog scale), Dallas Pain Questionnaire, Oswestry Disability Index, analgesic treatment and work status at 1, 3 and 6 months as well as pain at 1, 2 and 3 weeks. The primary outcome was change in pain between baseline and 1 month.Data for 39 patients (78%; 17 in the GC group, 22 in the L group) were analyzed for the primary outcome. Pain intensity was significantly reduced at 1 month in the GC versus L group [mean (SD) -2.7 (2.3) and +0.1 (2.0), P0.001] but not at 3 and 6 months. At 1 and 3 months, the groups significantly differed in daily activities of the Dallas Pain Questionnaire in favour of the GC group. The groups did not differ in consumption of analgesics or professional condition at any time. No serious intervention-related adverse events occurred. Study limitations included patients lost to the study because of injection-related technical issues in the L5/S1 disc and short time of follow-up.As compared with intradiscal injection of lidocaine, intradiscal injection of prednisolone acetate for low back pain with active discopathy may reduce pain intensity at 1 month but not at 3 and 6 months.

Lucas Fonseca was among the 15th finalists selected for the 2018 EMBS Student Paper Competition; International audience; Spinal cord injury (SCI), stroke and other nervous system conditions can result in partial or total paralysis of individual's limbs. Numerous technologies have been proposed to assist neurorehabilitation or movement restoration, e.g. robotics or neuroprosthesis. However, individuals with tetraplegia often find difficult to pilot these devices. We developed a system based on a single inertial measurement unit located on the upper limb that is able to classify performed movements using principal component analysis. We analyzed three calibration algorithms: unsupervised learning, supervised learning and adaptive learning. Eight participants with tetraplegia (C4-C7) piloted three different postures in a robotic hand. We achieved 89% accuracy using the supervised learning algorithm. Through offline simulation, we found accuracies of 76% on the unsupervised learning, and 88% on the adaptive one.

International audience; This article introduces a new human-machine interface for individuals with tetraplegia. We investigated the feasibility of piloting an assistive device by processing supra-lesional muscle responses online. The ability to voluntarily contract a set of selected muscles was assessed in five spinal cord-injured subjects through electromyographic (EMG) analysis. Two subjects were also asked to use the EMG interface to control palmar and lateral grasping of a robot hand. The use of different muscles and control modalities was also assessed. These preliminary results open the way to new interface solutions for high-level spinal cord-injured patients.

Nous rapportons les resultats de la comparaison d’un programme de chirurgie fonctionnelle du membre superieur chez des patients tetraplegiques comprenant une reanimation de l’extension du coude et la construction d’une key grip en « un seul temps » operatoire ou en « deux temps » operatoires. Une serie de 36 patients tetraplegiques avec 45 membres superieurs operes a ete analysee retrospectivement avec un recul moyen de 55 mois (12–96 mois). Nous avons evalue la force analytique de l’extension du coude a l’aide du score MRC ainsi que la force de la key grip (Kg F). L’autonomie des patients a ete evalue a l’aides de scores fonctionnels — Lamb (100), QIF (100) et score de temps de presence de tierce personne (PTP) (de 1 a 4). Les complications ont egalement ete notees. Seize membres superieurs ont ete inclus dans le groupe « un temps » et 29 membres superieurs dans le groupe « deux temps ». Les groupes etaient comparables en preoperatoire. La force d’extension du coude etait de 3,5–5 dans le groupe « un temps » contre 3,6–5 dans le groupe « deux temps », p = 0,74. La force de pinch etait de 1,8 Kg F dans le groupe « un temps » contre 1,3 Kg F dans le groupe « deux temps », p = 0,22. Concernant les scores fonctionnels, il n’existait pas de difference statistiquement significative entre les deux groupes pour le test Lamb (64,9 contre 58,6 p = 0,24), le QIF (54,3 contre 49,7, p = 0,42), le score de temps de PTP (2,8 contre 2,7, p = 0,6). Nous rapportons un taux similaire de complications entre les deux groupes, 37,5 % sans difference significative entre les deux groupes. Les resultats cliniques et fonctionnels postoperatoires des deux programmes ne presentaient pas de difference statistiquement significative. Nous ne rapportons pas de difference statistiquement significative en termes de complications dans les deux groupes analyses. Le programme de chirurgie fonctionnelle du membre superieur pour tetraplegique en « un temps » operatoire apparait etre une option fiable a proposer aux patients tetraplegiques. En effet, le nombre de temps operatoires est un frein pour certains patients qui « abandonnent » le programme en cours. L’option chirurgicale tout en un temps permettant de diminuer la duree d’hospitalisation et les taux d’abandon des patients en cours de programme.

International audience; This article introduces a new approach of selective neural electrical stimulation of the upper limb nerves. Median and radial nerves of individuals with tetraplegia are stimulated via a multipolar cuff electrode to elicit movements of wrist and hand in acute conditions during a surgical intervention. Various configurations corresponding to various combinations of a 12-poles cuff electrode contacts are tested. Video recording and electromyographic (EMG) signals recorded via sterile surface electrodes are used to evaluate the selectivity of each stimulation configuration in terms of activated muscles. In this abstract we introduce the protocol and preliminary results will be presented during the conference.

International audience; As a neuroprosthetic technique, functional electrical stimulation (FES) can restore lost motor performance of impaired patients. Through delivering electrical pulses to target muscles, the joint movement can be eventually elicited. This work presents a real-time FES system which is able to deal with two neuroprosthetic missions: one is estimating FES-induced joint torque with evoked electromyograph (eEMG), and the other is artificially controlling muscle activation with such eEMG feedback. The clinical experiment results on spinal cord injured (SCI) patients and healthy subjects show promising performance of the proposed FES system.

Objective Sleep apnea is a frequent issue for the general population, with a prevalence between 2 and 4%. It is 2 to 5 times more frequent for the spinal cord-injured population. The night ventilation by positive pressure is the reference treatment but the compliance is still an issue. Its determinants are well studied in the general population, but we have limited data for the spinal cord-injured patients. The goal of this study is to elaborate a comprehensive model of compliance with ventilatory assistance using positive pressure for spinal cord-injured patients affected by sleep apnea. Material/Patients and methods Qualitative, prospective, monocentric study based on semi-directed interview, which are based on Bandura social cognitive theory. Each interview is recorded and transcribed. Data are analysed by the working group according to the grounded theory: codification, categorisation and liking. Results We included 15 patients which allows to generate 90 codes. This code's categorisation is in process and highlights the fact that spinal cord-injured patients face the same compliance determinants than the general population (factors related to material, provider, medical team, patient belief) but also factors specific to the handicap situation of the spinal cord-injured patient in term of constraints, autonomy and priority of care. Discussion/Conclusion The model of compliance generated by this study will lead the practitioner in setting up the ventilatory assistance and its integration in the day-to-day functioning for a spinal cord-injured person.

Fattal C, Fabbro M, Gelis A, Bauchet L. Metastatic paraplegia and vital prognosis: perspectives and limitations for rehabilitation care. Part 1. Objective To evaluate the vital prognosis of patients with metastatic epidural spinal cord compression (MESCC) to determine the relevance and duration of physical medicine and rehabilitation (PM&R) admission. Data Sources Publications from 1980 to January 2010 selected from 3 databases. Study Selection Publications reporting data correlated with survival and prognosis factors, highlighting publications with level A scientific evidence (prospective randomized controlled studies with significant casuistry and relevant judgment criteria). The work focused on patients with MESCC below T1. Data Extraction Standardized reading grid. Data Synthesis Thirty-eight studies met the inclusion criteria. Most were retrospective. For survival rate at 1 year, they reported data ranging from 12% to 58%. The 12-month and median survival rates were the data reported most often in the articles. The median survival rate ranged from 2.4 to 30 months, and 12-month survival rates ranged from 12% to 58%. Of publications that chose this parameter, 95% reported 12-month survival rates less than 55.2% (95th percentile) regardless of patients' functional status and associated risk factors (eg, location of primary cancer, metastases spreading, pretreatment ambulatory status). Conclusions Despite major progress in cancer care, patients with MESCC still have a limited vital prognosis. The relevance and duration of PM&R care must be evaluated against the patient's functional need for rehabilitation while making time for family. The hypothesis of a 1-month stay extended only once appears reasonable for patients to adapt to their new functional status without taking precious time away from their loved ones.

Introduction/Background Bacterial species and their role in delaying the healing of pressure ulcers (PU) in spinal cord injury (SCI) patients have not been well described. The aim of this study was to characterize temporal evolution of superficial and deep microbiota of PU in SCI population. Material and method Patients treated for PU between 05/2015 and 12/2016 at the Propara Neurological Rehabilitation Center in Montpellier (France) were included. After wound debridement, samples for bacterial cultures were obtained by swabs (superficial) and tissue biopsies (deep) at the day of inclusion (D0) and 28 after (D28). Results Forty-nine patients were included (median age: 56 years; 79.6% men). At deep level, coagulase-negative staphylococci (33.8% at D0; 20% at D28), S. aureus (17% at D0; 21% at D28), Enterococcus sp. (12,3% at D0; 16% at D28) and Corynebacterium sp. (13.8% at D0; 16% at D28) were the most frequent bacterial species isolated. After 28 days, percentage of Enterobacteriaceae had significantly increased (0% at D0; 10.5% at D28; P Conclusion This study highlights for the first-time the evolution of the ecology of PU during one month. The low proportion of Gram-negative bacilli suggests that these bacteria are often colonizing bacteria that could be eliminated by an efficient surgical or mechanical debridement. Moreover, this work demonstrates the uselessness of superficial swabs that do not reflect the bacterial ecology present in depth of the wound.

Functional electrical stimulation (FES) is a neuroprosthetic technique to help restore motor function of spinal cord-injured (SCI) patients. Through delivery of electrical pulses to muscles of motor-impaired subjects, FES is able to artificially induce their muscle contractions. Evoked electromyography (eEMG) is used to record such FES-induced electrical muscle activity and presents a form of [Formula: see text]-wave. In order to monitor electrical muscle activity under stimulation and ensure safe stimulation configurations, closed-loop FES control with eEMG feedback is needed to be developed for SCI patients who lose their voluntary muscle contraction ability. This work proposes a closed-loop FES system for real-time control of muscle activation on the triceps surae and tibialis muscle groups through online modulating pulse width (PW) of electrical stimulus. Subject-specific time-variant muscle responses under FES are explicitly reflected by muscle excitation model, which is described by Hammerstein system with its input and output being, respectively, PW and eEMG. Model predictive control is adopted to compute the PW based on muscle excitation model which can online update its parameters. Four muscle activation patterns are provided as desired control references to validate the proposed closed-loop FES control paradigm. Real-time experimental results on three able-bodied subjects and five SCI patients in clinical environment show promising performances of tracking the aforementioned reference muscle activation patterns based on the proposed closed-loop FES control scheme.

Camptocormia is an abnormal posture with marked flexion of thoracolumbar spine that abates in the recumbent position. Camptocormia has been described in various neurological (Parkinsonism), muscular (myopathy), psychogenic or orthopedic disorders. There are several hypotheses that can explain this impaired posture but they are usually related to the concomitant pathologies. We report the first case of a patient with confirmed myotonic dystrophy addressed to our medical center for impaired posture who underwent extensive medical exams and explorations because of a myotonic hand. Axial weakness and muscle atrophy, validated by CT-scan imaging, are discussed independent of the concomitant pathology (Parkinson, myopathy).

Gelis A, Fattal C, Dupeyron A, Perez-Martin A, Colin D, Pelissier J. Reproducibility of transcutaneous oxygen pressure measurements in persons with spinal cord injury. Objectives To assess the reproducibility and the effects of the subjects' characteristics on the reproducibility of transcutaneous oxygen pressure (TcPO 2 ) measurements in the sacral area in persons with spinal cord injury during loading in the supine position. Design Test-retest study. Setting Physical medicine and rehabilitation center. Participants Thirty spinal cord–injured American Spinal Injury Association grade A subjects. Main Outcome Measures Two TcPO 2 monitoring sessions in the sacral area during loading in the supine position were performed at 24-hour intervals, including the measurement of absolute resting sacral and chest TcPO 2 values and the calculation of regional perfusion index (RPI) and delta from rest oxygen pressure, taking into account systemic TcPO 2 changes. Results The intraclass coefficient of the sacral TcPO 2 absolute resting value, RPI, and delta from rest oxygen pressure was .787 and .798, .704 and .635, .760 and .465, respectively, at 20 and 40 minutes. The only characteristic with an influence on RPI reproducibility was the subject's smoking status, whereas age, weight, time since injury, lesion level, and presence of pressure ulcer showed no influence. Conclusions TcPO 2 measurement is a reproducible method for assessing cutaneous microcirculation during loading over 20-minute monitoring sessions, with RPI exhibiting better reproducibility than delta from rest oxygen pressure at 40 minutes.

Resume Objectifs Elaborer des recommandations concernant la prescription d’ortheses plantaires dans la gonarthrose et la coxarthrose. Methode La methodologie utilisee, proposee par la Societe francaise de medecine physique et de readaptation (Sofmer), associe une revue systematique de la litterature, un recueil quantitatif et qualitatif des pratiques professionnelles et une validation par un panel d’experts pluridisciplinaires. Les criteres d’analyses retenus concernent la douleur, l’incapacite fonctionnelle, la consommation d’antalgiques et d’anti-inflammatoires non steroidiens (AINS) et la progression radiologique de l’arthrose. Les recommandations sont classees, suivant le niveau de preuve scientifique fourni par la litterature, en grade A, B ou C, selon la grille de l’Agence nationale d’accreditation et d’evaluation en sante (Anaes). Resultats Au cours de la gonarthrose femorotibiale interne, la prescription d’ortheses pronatrices pourrait – en l’absence de contre-indication – avoir un interet dans la prise en charge symptomatique de la gonarthrose en reduisant la consommation d’AINS (grade B). Les effets sur l’evolution structurale de l’arthrose ou le retentissement fonctionnel ne sont a ce jour pas demontres (grade B). En dehors de ce cadre precis, il ne parait pas indique d’avoir recours a des ortheses plantaires dans la prise en charge de la gonarthrose ou de la coxarthrose (grade C). Conclusion Il est necessaire d’entreprendre des etudes randomisees controlees complementaires afin de preciser l’indication des ortheses plantaires (severite de la gonarthrose, genu varum), voire l’efficacite d’autre type d’orthese comme les ortheses amortissantes. Les effets secondaires a long terme, notamment sur le compartiment femoro-tibial externe, pourraient etre evalues. Une evaluation medicoeconomique dede la prescription des ortheses plantaires est egalement souhaitable.

Pressure ulcers (PUs) are a common complication following a spinal-cord injury (SCI). Good prevention requires identifying the individuals at risk for developing PUs. Risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed to design an SCI-specific assessment tool. The first results seem quite disappointing, probably becuase of the level of evidence of the risk factors used. To determine PU risk factors correlated to the patients with SCI, medical care management during the acute as well as in the rehabilitation and chronic stages. This first part focuses on identifying the risk factors during the acute and rehabilitation stages. Systematic review of the literature. Six studies met our inclusion criteria. The risk factors during the acute stage of an SCI are essentially linked to care management and treatment modalities. There is insufficient evidence to make a recommendation on medical risk factors, except for low blood pressure on admission to the Emergency Room, with a moderate level of evidence. Regarding the rehabilitation stage, no study was deemed relevant. Additional observational studies are needed, for both the acute and rehabilitation stages, to improve this level of evidence. However, this systematic review unveiled the need for a carefully assessed t care management and the related practices, especially during the acute stage of an SCI.

Resume Objectif. – Determiner le niveau de preuve d'efficacite biomecanique et clinique des ortheses plantaires (OP) dans la gonarthrose. Materiel et methode. – Revue systematique de la litterature a partir des bases de donnees Medline, Pascal et Embase en utilisant les mots cles knee, insole, plantar orthosis pour l'analyse biomecanique ; knee osteoarthritis, insole et plantar orthosis pour l'analyse clinique. Double lecture des essais cliniques et classification a l'aide de l'echelle de Jadad. Resultats. – On retrouve deux theories biomecaniques : la theorie du moment d'adduction, qui explique l'effet biomecanique des ortheses plantaires avec coin pronateur posterieur, et celle des chaines articulaires pour les ortheses plantaires avec barre pronatrice. L'efficacite clinique des ortheses est plus antalgique que structurale ou fonctionnelle, par le biais notamment d'une consommation d'anti-inflammatoires non steroidiens moins importante confirmee jusqu'a deux ans de traitement. Le niveau de preuve est faible compte tenu des carences methodologiques et du faible nombre d'essai retrouve. La tolerance rapportee est le plus souvent bonne. Discussion. – Les ortheses plantaires a action valgisante sont proposees dans les gonarthroses predominant sur le compartiment femorotibial interne. L'effet clinique serait faible mais pourrait reduire les evenements indesirables digestifs et renaux lies a l'utilisation prolongee des AINS. Le niveau de preuve actuel n'est pas un obstacle a leur utilisation en pratique courante lorsqu'on le compare au niveau de preuve d'autres therapeutiques utilisees dans la gonarthrose. Conclusion. – Les OP sont une therapeutique non medicamenteuse d'appoint de la gonarthrose predominant sur le compartiment femorotibial interne.

Background This article is a prospective review of patients with spinal cord injury who underwent multidisciplinary consultation from January 2005 to September 2013 for pain in one or both shoulders. Methods We performed clinical, functional, and lesion evaluations of 38 patients with paraplegia and quadriplegia presenting with rotator cuff pathologies. Results Surgery was indicated and performed on 38 shoulders in 28 patients. The lesion assessment during surgery showed injuries that were more severe than one would have thought based on imaging data. The mean pain intensity rating in the operative and nonoperative groups was 0 and 1.6, respectively, at rest and 2 and 4.9, respectively, during paroxysmal peaks. On average, for patients who had surgery, the Functional Independence Measure score decreased by 2.3. The mean satisfaction index in operated patients was 8.5 of 10. Conclusions When the surgical indication was based on a multidisciplinary decision, no negative results were reported that could have challenged the validity of this decision. Pain relief was the primary benefit reported after surgery. The functional status was modified because of the technical aids needed to prevent shoulder overuse. There are several arguments in favor of rotator cuff surgery for wheelchair-bound patients with spinal cord injury. Because of their functional impairments, wheelchair-bound patients will continue to overburden their shoulders after rotator cuff surgery. A multidisciplinary approach emerges as the solution to inform and educate patients to limit the risk of recurrence.

Opinion/Feedback Surgical indication is recommended for specific locations (pelvic stage 3 and 4 pressure ulcers) and if medical treatment is impossible: – global patient assessment is recommended before surgical indication with benefits and risks analysis; – analysis is conducted on several stages; – risk factors analysis and control level; – efficiency analysis about medical and preventive coverage; – pressure ulcer origin analysis; – compliance patient assessment (care contract); – systematic pre operative procedure is recommended: – multi-disciplinary et pluriprofessionnal consultation; – psychological assessment and follow up; – radiological assessment (systematical, no systematical IRM except if osteitis, no TDM, no scintigraphy); – biological assessment (inflammatory nutritional, micro biological); – no pre-operative antibiotherapy; – specify definition of surgical type – realize pre-operative micro biological taking is recommended:(according to bone aspect): – enforce systematic post operative procedures is recommended: – plan patient installation: every patient must have a preventive mattress and book curative mattress for multiple scrap; – plan total immediate post operative dumped according to patient compliance in PRM ward (during at least 3 weeks, often 4); – organize seated station progressive recharging in PRM ward (during at least 3 weeks); – extend patient supervision and allow seated station; – plan further supervision.

International audience; STUDY DESIGN: Cross-cultural adaptation and reliability study. OBJECTIVE: To translate, evaluate the reliability and cross-culturally adapt the Skin Management Needs Assessment Checklist (SMnac), a questionnaire evaluating the knowledge on pressure ulcer (PU) prevention measures in persons with spinal cord injury (SCI). SUBJECTS: 138 persons with SCI, mean age 45.9 years, mean time since injury 94 months. MATERIAL AND METHOD: The study was carried out in two stages. First, the questionnaire went through a forward-backward translation process and was cross-culturally adapted, according to a validated methodology for self-reported measures. Then, the test-retest reliability was evaluated on a population of persons with SCI. RESULTS: The standardized back-translation and cross-cultural adaptation led to the revised Smack grid, with the addition of seven items representing an update of PU prevention measures. The reliability was excellent (intraclass correlation coefficient: 0.899). CONCLUSION: The revised SMnac is an adaptation of the SMnac, including therapeutic education frameworks and the latest PU prevention practices. It appears to be a reliable tool for assessing the knowledge and benefits of PU prevention in persons with SCI. Further studies are needed to explore its validity and responsiveness to change.

OBJECTIVE Although 40 assessment tools are described in the literature, very few of them have been correctly validated. The Standardized Index of Shoulder Function (FI2S) encompasses pain, mobility, strength and function. The aim of this work is to describe the FI2S and to study its construct validity, reliability and responsiveness to change. PATIENTS Fifty-nine patients with non-surgical (rotator cuff lesions, frozen shoulders, osteoarthritis) or post-surgical (acromioplasty, repairs of rotator cuff tears, arthroplasty) shoulder disorders were included. METHODS The FI2S was compared with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), with the Constant-Murley Score (CMS), and with a visual analogue scale for pain. RESULTS Inter-test reliability and inter-rater reliability are excellent, with intra-class correlation coefficient of 0.93 (0.88-0.96) and 0.94 (0.90-0.96), respectively. Under a convergent hypothesis, the Spearman's correlation coefficients with the CMS and DASH score are 0.91 (p < 0.0001) and -0.64 (p < 0.0001), respectively. Correlations between the FI2S and the CMS are excellent for mobility and strength, but moderate for pain and functional capacities. Under a divergent hypothesis, no correlation is observed between the FI2S total score and age. Responsiveness to change is excellent. CONCLUSION The FI2S appears to be a proper assessment tool for pain, mobility, strength and function in shoulder disorders, easy to administer and of good metric value.

Objective To develop clinical practice guidelines for the use of foot orthotics (FO) in the treatment of knee and hip osteoarthritis. Method The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating a systematic review of the literature, input from every day clinical practice and external review by a multidisciplinary expert committee, was used. The selected analysis criteria were pain, disability, medications used and X-ray evolution of osteoarthritis. The recommendations are classified according to the level of proof in Grade A, B or C according to the French National Agency for Health Accreditation and Evaluation (NAHAE). Results In medial knee osteoarthritis, foot pronation orthotics – when there are no contraindications – can be proposed for their symptomatic impact, especially in the decrease of NSAIDs consumption (Grade B). To this day, there is no evidence of a structural or functional impact on osteoarthritis (Grade B). Outside of this specific clinical framework, there is no validated indication for prescribing foot orthotics in the treatment of knee or hip OA (Grade C). Conclusion It is necessary to have further randomized controlled trials to better define the indication of Foot orthotics (severity of knee OA, genu varum), test the efficacy of other orthoses such as cushioning FO. The long-term side effects, mainly on the external femorotibial compartment could also be assessed. A medical and economical assessment of FO prescriptions is also quite necessary.