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Immobilization secondary to spinal cord injury is associated with a marked and rapid atrophy of trabecular bone (disuse osteoporosis). This is due to an early increase of osteoclastic bone resorption associated with a pronounced decreased osteoblastic bone formation. Bisphosphonates are antiosteoclastic compounds and they have been effective in preventing disuse osteoporosis. However, some of them also depress osteoblastic activity and may impair the mineralization process. Tiludronate was shown effective in reducing bone resorption in several metabolic bone diseases without inducing mineralization defects. Twenty paraplegic patients (6 females and 14 males) were randomly assigned to three groups: 6 patients entered the placebo group; 7 patients received tiludronate 200 mg/day; and 7 received 400 mg/day. Histomorphometric analysis was performed on transiliac bone biopsies before and after 3 months treatment. An insignificant decrease of bone volume was observed in the placebo group and the 200 mg group. In patients receiving 400 mg/day, a slight increase was noted. Osteoid parameters changed nonsignificantly in three groups although the 400 mg group exhibited a slight tendency to decrease osteoid volume and thickness. Eroded surfaces increased in all groups. The number of osteoclasts (identified histochemically by TRAP staining) increased in the placebo group but decreased in groups receiving tiludronate. Tiludronate appears effective in reducing bone resorption without impairing bone formation in a manner that preserved bone mass and bone cell coupling.

To study the global quality of life (QOL) of spouses of chronic stroke patients, and to determine its most pertinent factors, we assessed nine stroke patients and their spouses, using the Barthel index, the Functional Independence Measure (FIM), the Montgomery and Asberg Depression Rating Scale (MADRS), the Reintegration to Normal Living Index (RNLI), and a 10-cm visual analogue scale (VAS) to evaluate spouses' QOL. Correlation analysis was performed with the Spearman rank correlation analysis. Mean age of spouses was 53.6 +/- 11.3 years (male:female ratio, 8:1). The mean interval from stroke was 17.6 +/- 10.6 months. The spouses' median QOL score was 4.9, with a significant correlation between spouses' QOL scores and patients Barthel index scores, FIM global scores, and FIM locomotion scores. Spouses complained of the physical burden, but psychological, social, economic and marital consequences of the stroke were also reported. This study confirms the constant impact of stroke on the QOL of the spouses, and demonstrates the role of patients' physical disability. However, the VAS allows only a global approach. A self-administered composite index, exploring the consequences of the stroke on the spouses' daily life, would be a useful complement.

Based on a review of the literature, this article analyses the application of measurement of the agonist/antagonist ratio of muscular strength in functional rehabilitation. According to many authors this ratio constitutes an element of functional specificity of a joint, but it is subject to numerous factors of variation: the joint considered, dominance, sex, age, physical activity and velocity of movement. Despite these various factors, the ratio may constitute a clinical element in the functional analysis of the joint, providing either an index of the risk of developing certain traumatic sports lesions, or a guide control in the modalities of rehabilitation.

Resume Avec les criteres de la classification internationale des deficiences, incapacites, handicaps recommandes par l'Organisation Mondiale de la Sante, la deficience correspond au mauvais fonctionnement du bas appareil urinaire, l'incapacite a la perte involontaire d'urines, le handicap au desavantage vecu par la personne du fait de l'incontinence. Ce triple aspect explique les resultats disparates des etudes epidemiologiques de l'incontinence urinaire. La prevalence selon l'âge varie de 5,1 a 11,2% entre 5 et 14 ans, de 1,4% chez l'homme a 57% chez la femme entre 15 et 64 ans, avec une elevation sensible vers 45–50 ans. Apres 65 ans elle varie de 7 a 18% a domicile, 30 a plus de 80% pour les personnes âgees vivant en institution, avec une prevalence croissante selon le degre de dependance physique ou psychique. La typologie de l'incontinence urinaire revele une prevalence croissante de l'incontinence urinaire par urgence mictionnelle avec l'âge, dont l'impact psychosocial est plus important que les autres types. En matiere de prevention, il convient de considerer les formes mineures d'incontinence par tranche d'âge, sexe et selon la typologie. Les etudes economiques doivent s'appuyer sur des chiffres de prevalence obtenus en population generale et chez les retraites vivant a domicile par exemple, 22,4% des femmes, 17,3% des hommes. L'incontinence urinaire represente en effet un marche commercial important.

This study examined the correlations between isokinetic muscle strength of knee and elbow flexors and extensors with vertebral and femoral bone mineral density in a population of 106 women between the ages of 44 and 87 years. The absolute value of muscle strength correlated significantly with bone mineral density; muscle strength of the upper limb appeared to be more closely correlated with bone mass, while muscle strength in the lower limb was more specific for femoral mineral bone density. The most important finding that these results demonstrated was a concomitant decline in muscle strength of the upper limb and bone mineral density between the 5th and 6th decades. In contrast, they also showed a decline in muscle strength of the lower limbs after the 6th decade, occurring before the decline in bone mineral density observed between the 7th and 8th decades. From these results it would appear that other studies are required to examine the relationship between the essentially hormonal role in postmenopausal decline in muscle strength and the decline in physical activity during the senile period. These elements are important because they must be taken into account in physical exercise programmes designed to prevent osteoporosis.

This paper describes the medical activity performed during the 1990 World Games for the Disabled, in Saint-Etienne, France. These Games were attended by 1200 athletes, 229 consultations were performed, and 175 treatments were administered by the medical team. This activity represents a rather high frequency of medical problems, linked either to the disabling disease or to sports injuries. There is a need for specific equipment, for better training of disabled athletes and for improved preparation.

to study the changes in the strength of the elbow flexors and extensors in paraplegic subjects, and the agonist/antagonist mass and strength ratio in paraplegic wheelchair users.10 paraplegic wheelchair basketball players were compared with 10 healthy basketball players. The 20 subjects underwent a clinical and dynamometric isokinetic assessment, and a CT scan measurement of the muscle cross-sectional surface area of the flexor and extensor muscles of the elbows.there was an increase in muscle strength in paraplegic subjects. There was no significant difference in the agonist/antagonist ratio between the dominant and non dominant upper limb in paraplegics whereas such a difference was found in healthy subjects. The muscle mass was increased in the paraplegics, but a correlation between muscle mass and strength was only found in the healthy subjects.

This study analyses the proprioceptive effect of wearing a unilateral and then bilateral ankle orthosis on 34 healthy volunteer subjects by posturography. An elastic orthosis with a ligamentous support band was used, and evaluation was performed by a posturographic statokinesimetric platform. Three tests, one without an orthosis, one with one orthosis, and one with two orthoses, were recorded for each volunteer. The results and statistical analyses demonstrated a significant difference in the antero-posterior measurement between the test without ankle orthosis and the tests with one and with two orthoses. This study provides information about the prophylactic effect of wearing a flexible support; it appears that there are important inter-individual variations in postural equilibrium, and the wearing of prophylactic ankle orthoses should be reserved for subjects after a posturographic examination.

Heterotopic ossification and rhabdomyolysis are well described entities but, as far as we know, their association has never been described in the literature. We recently treated a patient who presented with this association. After a suicide attempt, this patient developed rhabdomyolysis of the left upper and lower limbs with peripheral neurological impairment. Two months later radiographs showed ectopic ossification around the left hip. Rhabdomyolysis is underdiagnosed, and is due to local disturbance of the calcium-phosphorus metabolism resulting in soft tissue calcifications. Underlying rhabdomyolysis may be a possible aetiology of heterotopic ossification. Recognition of this may help us to understand the pathophysiology and to improve the management of heterotopic ossification.

Hormonal dosages and testicular biopsy are discussed in paraplegic patients of several neurological levels. There are no absolute biological criteria but histology showed slowing of spermatogenesis.

A twenty-minute film shows how tetraplegic patients can compensate their disability thanks to very simple means. The independence of tetraplegic patients is considered with non-sophisticated equipment that are to be used every day in every department of occupational therapy.

Up to date, we have carried out 100 external sphincterotomies, of which 65 only concerned traumatic spinal cord injuries.

A study of 1000 neurologic bladders has shown us that a well-balanced working of the bladder must be keenly searched for, and that sphincterotomy must be early indicated, and even performed several times if necessary. So 100 sphincterotomies performed on male patients, out of 730 cases, have shown us that their one-and-only risk, incontinence, depended chiefly on the condition of the detrusor, therefore on the short or long evolution of the sclerosis ofthe externa l sphincter, which is only one out of all the possible impediments. The Effects of the Detrusor in the Neuro-Urinary Troubles THIS chiefly concerns lesions at low level with atonic bladders but with a normal abdominal musculature. The pressure of the bladder for voiding is very high indeed (for example, 100 mm. of mercury), but the patient still suffe rs from retention.

A ten years survey of 848 patients having sustained traumatic spinal cord injury between 1969 and 1979 was conducted in the Rhône-Alpes Region, France. All patients had been referred to the spinal cord injury unit, Hôpital Henry Gabrielle. 48 deaths were recorded: 36 patients admitted early to the Unit, and 12 patients injured before 1969 but followed-up in the Unit. The deceased patients were older and more frequently male and tetraplegic than the rest of the group. In 75 per cent of the deceased patients, the survival time was less than 1/5 of the theoretical life expectancy. In 59 per cent, it was less than 1/10. Twenty tetraplegics died of respiratory complications. Three patients committed suicide, the rest died of urinary complications. The results appear to determine a secondary period with high mortality rate, after the initial high mortality of these patients. About one year post-injury, the life expectancy in our series appears to tend towards the values observed in the French population.

About 85 cases of spinal cord male injured patients; the authors bring their experience of the painful sensitivity of the testis by squeezing the gland. This sign has a semiological value about the topography and the level of complete and incomplete cord syndromes. It is of no value for the testicular fertility. The rehabilitation of neurological bladders must take this sign into account so as to appreciate the type of micturition.

21 paraplegic patients with recent traumatic spinal cord injury were orally administered 400 (n = 7) or 1,600 (n = 7) mg/d of disodium dichloromethylene diphosphonate (Cl2MDP) and compared with a placebo group (n = 7) to test the preventive effects of the drug on acute bone loss and osteoclastic resorption. Cl2MDP therapy was initiated at a mean of 17.6 d after the onset of paraplegia. The study lasted at least 6 mo, consisting of a 3.5-mo treatment period, and a variable follow-up period. The effects of Cl2MDP were assessed by blood and urine biochemistry, bone histomorphometry on transilial samples, photon absorptiometry of the tibia and fibula, and radiomorphometry of the femur. The elevation in serum and urinary calcium and in urine hydroxyproline observed in the placebo group did not appear under treatment. With both doses of Cl2MDP there was no further decrease in the bone mineral content. In the treated groups, a smaller percentage increase in osteoclastic population was also noted when compared with the placebo group, but this difference was not significant. There was no mineralization defect induced by Cl2MDP, as shown by tetracycline double labeling. It thus appears that at doses ranging between 400 and 1,600 mg, given as early as possible, Cl2MDP can prevent or reduce the development of the acute bone loss of paraplegic patients, without adverse side effects, though it does not prevent the development of heterotopic ossification.

Out of 180 cervical cord syndromes (traumatic, neoplastic and vascular) studied we examined the prognosis of rehabilitation in 31 central cord syndromes dating back from 6 months at the least or 6 years at the most.

The computer study of 783 paraplegics treated at H. Garbrielle hospital has been presented in 1977 at Stoke Mandeville. This study allows a useful comparison between suicidal by defenestration mean and accidental falls and confirms the clinical impression of a most favourable evolution for the suicide.

Five pregnant growing rats were orbited for 5 days aboard the Soviet COSMOS 1514 biologic satellite. The bone effects of weightlessness were studied and compared to those of five pregnant rats kept in vivarium and five pregnant conditioned rats. Bone histomorphometric studies were performed to investigate the early effects of weightlessness in loaded (tibia-femur) and unloaded (thoracic and lumbar vertebrae) bones. A short exposure to weightlessness does not induce any change in bone mass and inner structure in either type of bone. In unloaded bones, the number of osteoclasts per square millimeter of the trabecular surface significantly increased when measured after histochemical demonstration of tartrate-resistant acid phosphatase. It is likely that a stimulation of bone resorption activity occurs in the trabeculae of unloaded bones during the early phase of a spaceflight. In tibia, osteoid seam thickness and total osteoclastic resorption surfaces at the endosteal level were not modified.

Acute osteoporosis is known to occur after immobilization in spinal cord injured patients and is related to an early increase in osteoclastic bone resorption. Whether osteoporosis develops in healthy immobilized human patients is still a matter of controversy. Furthermore, acute osteoporosis was thought to be a good model to study the effects of weightlessness on the human skeleton and to adapt preventive procedures. A bed rest experiment was developed in the USSR on 15 healthy human volunteers to determine the precise effects on bone structure and cell activities. A preventive protocol, including an anti-osteoclastic drug (1-hydroxyethylidene-1,1 bisphosphonic acid; K salt) was investigated. Two transiliac bone biopsies were performed on the 15 individuals before and at the end of the 120-day bed rest period. Undecalcified bone biopsies were studied with automatic and semi-automatic image analyzers specially devoted to bone histomorphometry. Trabecular bone volume, osteoid amount, and eroded surfaces were measured. Osteoclast number was measured after histochemical identification of tartrate-resistant acid phosphatase. After the bed rest period, an insignificant bone loss was observed in healthy humans while osteoclast number was highly increased. In bisphosphonate-treated subjects, osteoclast number was markedly reduced and so was osteoid amount. Bisphosphonates were shown to present a highly cytotoxic activity on osteoclasts, a finding that has never been demonstrated in normal subjects.

Three hundred and fifty-one cases of traumatic spinal cord injuries concerning only inhabitants of the Rhone-Alpes region have been collected at Henry Gabrielle Hospital. Incidence and prevalence are discussed, as well as male/female ratio, causes of accidents, and their relationship to sex, race, age, vertebral level, associated injuries and profession.

The effect of immobilization on human bone was studied through a longitudinal, as well as cross-sectional, quantitative and dynamic histological analysis of 34 decalcified and undecalcified iliac crest biopsies. They were obtained at various times after the onset of immobilization in 28 patients of which 22 were suffering from post-traumatic spinal cord lesions. Trabecular bone volume, osteoid volume, trabecular osteoclastic resorption surfaces, size of the periosteocytic lacunae, thickness of iliac cortices and volume of the cell population of the marrow were measured. The histodynamic study was made by double tetracycline labeling in 19 patients. The histological data were compared with biological data from another group of 68 immobilized patients including 22 of the patients undergoing biopsy. Calcemia, phosphoremia, alkaline phosphatase, calciura, phosphaturia and hydroxyprolinuria were measured. The decrease of the trabecular bone volume averaged 33% over 25 weeks and then stabilized. Immobilization also caused an early increase in the trabecular osteoclastic resorption surfaces and later in the size of periosteocytic lacunae, an early depression of osteoblastic bone formation and a thinning of the cortices. Calciuria was high, as was hydroxyprolinuria which correlates with resorption surfaces. The histological and biochemical changes suggest an histodynamic hypothesis according to which the global lifespan of the BMU (Basic Multicellular Unit from Frost) would be increased. These changes reflect atransient, leading to a newsteady state: rarefied bone with a low rate of subsequent turn-over. They emphasize the importance of mechanical factors in the development of bone cells.

Biopsies of the iliac crest bone of 65 paraplegic patients were studied after various periods of immobilisation. The histomorphometric study included measurement of the trabecular bone volume (TBV), the relative osteiod volume, the surfaces of osteoclastic resorption, the number of osteoclasts per mm2, the size of the periosteocytic lacunae, and the adipose marrow tissue volume. The decrease of the TBV reached 33 per cent of the control values, over a period of six months, and remained at this level. Tetracycline double-labelling showed a decrease in the calcification rate. An increase in osteoclastic resorption was observed, and a decrease in the osteoid volume. After six months, a new steady state was obtained, with osteoclastic resorption and osteoid volume at normal values. There was a 75 per cent increase in adipose tissue of the marrow between zero and six months. Calciuria and hydroxyprolinuria were elevated during the first six months, with peaks respectively at one week and ten weeks. Thus, our study shows that there is an acute and early osteoporosis in spinal cord injury patients, due to increased osteoclastic resorption, and decreased bone formation. This creates a temporary negative bone balance, leading to bone loss. These changes are triggered by the vascular modifications and maintained by the loss of mechanical stress, especially muscular periosteal traction and axial loading. There is no suggestion of spontaneous recovery in the latest results. It appears likely that drug treatment can be beneficial, such as Calcitonin and diphosphonates, but these are still under investigation. The best ‘treatment’ is prevention, which should be instituted as early as possible.

Embryonic chick long bone develops in a series of temporally controlled, cellular events and involves the integration of at least three distinctly different sets of cells: collar osteoblasts, core osteoblasts, and resorptive or osteoclastic cells. The morphology of the long bones is established by the developing cartilage rudiment or model. All of these events seem to be influenced by positional cues. The cultivation of all of these cells and their presumptive progenitor cells potentially allows a detailed analysis of their individual and collective phenotypic traits. Future studies can include how long bones form, how bone-forming and bone-resorbing cells interact, and how osteogenic cells influence each other throughout each stage of their respective developmental lineages.