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International audience; Objective: To establish international recommendations for the management of spastic equinovarus foot deformity. Design: Delphi method. Setting: International study. Participants: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). Interventions: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. Main Outcome Measures: A consensus was established when at least 80% of experts agreed on a statement Results: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. Conclusion: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

BACKGROUND: Dynamic humeral centering (DHC) is a physiotherapy modality that aims to prevent sub-acromial impingement of rotator cuff tendons. We recently developed a new clinical manoeuver – the Viggo-Cochin test – to enhance the ability of the Neer test to detect sub-acromial impingement. Here we hypothesised whether the DHC effect may differ between individuals with positive and negative Viggo-Cochin test results. OBJECTIVE: To assess the association between DHC and Viggo-Cochin test results. METHODS: Individuals with shoulder pain due to sub-acromial impingement underwent the Neer and Viggo-Cochin tests at baseline. They were assessed before and after DHC by the Shoulder Pain and Disability Index (SPADI). A positive response to DHC was defined as a 20% reduction in the SPADI. RESULTS: We included 50 individuals (53 shoulders). The response to DHC did not differ by Neer test result at baseline: OR 0.73 [95% CI 0.22–2.38] (p= 0.601). By contrast, the response to DHC was 5-fold higher with a positive than negative Viggo-Cochin test result: OR 5.11 [95% CI 1.47–17.78] (p= 0.010). CONCLUSIONS: We found a higher clinical response to DHC with a positive than negative Viggo-Cochin test result at baseline in individuals with shoulder pain due to rotator cuff disease.

Background and Purpose: Additional therapy may improve poststroke outcomes. Self-rehabilitation is a useful means to increase rehabilitation time. Mechanized systems are usual means to extend time for motor training. The primary aim was to compare the effects of self-rehabilitation using a mechanized device with control self-exercises on upper extremity impairment in patients with stroke. Methods: Phase III, parallel, concealed allocation, randomized controlled, multicenter trial, with 12-month follow-up. Patients aged 18 to 80 years, 3 weeks to 3 months poststroke with a Fugl-Meyer Assessment score of 10 to 40 points, were randomized to the Exo or control groups. All undertook two 30-minute self-rehabilitation sessions/day, 5 days/wk for 4 weeks in addition to usual rehabilitation. The Exo group performed games-based exercises using a gravity-supported mechanical exoskeleton (Armeo Spring). The control group performed stretching plus basic active exercises. Primary outcome was change in upper extremity Fugl-Meyer Assessment score at 4 weeks. Results: Two hundred fifteen participants were randomly allocated to the Exo group (107) or the control group (108). Mean age (SD), 58.3 (13.6) years; mean time poststroke, 54.8 (22.1) days; and mean baseline Fugl-Meyer Assessment score, 26.1 (9.5). There was no between-group difference in mean change in Fugl-Meyer Assessment score following the intervention: 13.3 (9.0) in the Exo group and 11.8 (8.8) in the control group ( P =0.22). There were no significant between-group differences in changes for any of the other outcomes at any time point (except for perception of the self-rehabilitation). There was no between-group difference in cost utility at 12 months. Conclusions: In patients with moderate-to-severe impairment in the subacute phase of stroke, the purchase and use of complex devices to provide additional upper limb training may not be necessary: simply educating patients to regularly move and stretch their limbs appears sufficient. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01383512.

Objective:To compare psychometric properties of Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Shoulder Pain and Disability Index (SPADI) and Constant–Murley scale, in patients with degenerative rotator cuff disease (DRCD).Design:Longitudinal cohort.Setting:One French university hospital.Methods:The scales were applied twice at one-week interval before physiotherapy and once after physiotherapy two months later. The perceived improvement after treatment was self-assessed on a numerical scale (0–4). The test–retest reliability of the DASH, SPADI and Constant–Murley scales was assessed before treatment by the intraclass correlation coefficient (ICC). The responsiveness was assessed by the paired t-test ( P Results:Fifty-three patients were included. Twenty-six only were available for reliability. The test–retest reliability was very good for the DASH (ICC = 0.97), SPADI (0.95) and Constant–Murley (0.92). The scale score was improved after treatment for each scale ( P Conclusion:The test–retest reliability of the DASH, SPADI and Constant–Murley scales is very good for patients with DRCD. The highest responsiveness was achieved with the SPADI.

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.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.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%; P0.001). Shoulder pain at admission and during hospitalization also decreased (13% of patients in 2000 to 8% in 2015, P0.001). 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, P0.05). 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 (P0.05), which may explain the increase in functional independence measure scores at admission and discharge (both P0.05). Prevalence of cognitive disorders increased over the same period (24% in 2000 vs 63% in 2015, P0.05).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.

BACKGROUND The diagnosis of adhesive capsulitis is currently based on restricted range of motion (ROM) but its diagnostic value has only been rarely investigated. AIM The aim of this study is to assess the diagnostic value of active global and passive gleno-humeral ROM to diagnose shoulder adhesive capsulitis. DESIGN Cross-sectional descriptive study. SETTING One French center for Rehabilitation Medicine. POPULATION Patients referred for treatment of shoulder adhesive capsulitis in our center were included. Inclusion criteria were: shoulder pain; limitation of active global ROM (abduction or flexion

International audience

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.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.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.These are the first organizational guidelines devoted to increase the security of motor nerve block use in PRM settings.

International audience; Background: Botuloscope is a cohort study supported by a French public grant and aiming to evaluate a 1year treatment of the post-stroke spastic upper limb with botulinum toxin type A (BoNT-A) in terms of individual satisfaction with respect to personalized goals and quality of life. Methods: This was an open-label prospective, multicentric study (11 French centres) that followed 330 adults [mean (SD) age 53.7 (13.7) years] over 1 year; participants had ranked 5 therapeutic goals at inclusion [mean (SD) 5.1 (7.3) years post-stroke], had severe hemiparesis [median motricity index (MI) 40 (Q1-Q3 24 to 60)], and were assessed at inclusion (M0) and at month 3 (M3) and M12. Outcome criteria were: spasticity, range of motion, pain [visual analog scale (VAS)], motor function [Modified Ashworth Scale (MAS)] and activities (MI; Frenchay Arm Test), and overall satisfaction with the achievement of each goal (VAS) and quality of life (Reintegration to Normal Life Index). Criteria at M0 and M12 were compared. Adverse effects were also collected, as were medication changes. Results: The primary goal was comfort and activities for 63% of participants and motor function for 36%. Participants underwent a mean of 2.4 injection sessions, 19% causing adverse effects. The greatest spasticity attenuation occurred with wrist flexors (median decrease in MAS À2 [Q1-Q3; À2 to À1], P < 10 À3). Fewer individuals took oral anti-spastic drugs (56% at M12 vs 50% at M0; P < 10 À2). Range of motion increased by 168, on average (13 to 19; P < 10 À3) for wrist extension. Pain prevalence decreases at rest (29% at M0 vs. 19% at M12; P < 10 À4) and during mobilization (64% vs. 43%; P < 10 À4), and fewer participants took analgesics (25% vs. 17%; P < 10 À3). Satisfaction was high for the goals ''hand hygiene'' and ''pain release'' and moderate for ''improvement in upper limb function''. However, function was more improved for participants who selected this goal as the first priority than others (P < 10 À2). Overall, 22% had the goal ''improving gait and balance'', which was reasonably achieved at M12. Quality of life improved markedly [median 8 (4 to 11) vs. 6 (3 to 10); P < 10 À4 ]. Prevalence of complete dissatisfaction with the first objective was 10% to 15%. Conclusion: This is the first long-term follow-up of BoNT-A treatment for upper limb spasticity involving a large cohort independent of industry. Quality of life was improved by treating upper limb spasticity with BoNT-A, even at 5 years post-stroke. Personalizing objectives of the treatment amplified its efficacy. BoNT-A was a powerful analgesic when pain was spasticity-related. Treating the spastic upper limb also improved balance and gait abilities.

International audience; Objective: To investigate the postural effect of 2 types of sensory stimulation in patients with a left hemispheric lesion (LHL) or right hemispheric lesion (RHL) compared with controls. Methods: 35 patients (18 LHL, 17 RHL) and 27 controls (Mean age 54.1 years), with a mean delay post-stroke of 3.0 months were enrolled. Subjects stood on a force platform and were stimulated on the left and right side by optokinetic (Okn) and galvanic vestibular (Gv) stimulation. Lateral displacement following stimulation towards the right and left directions was calculated as the mean position of the centre of pressure (CP) during the stimulation period minus the mean position at rest. Results Postural asymmetry was reduced in LHL and RHL patients. CP displacement was higher in cases of left-sided stimulation in the RHL group compared with control subjects and LHL patients (respectively 2.8 and 2.4 times higher, group effect, p

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper addresses the structure, organization and activities of PRM bodies in Europe. There are four main bodies, the Section of Physical and Rehabilitation Medicine of the European Union of Medical Specialists (UEMS) very close to the European Union and is committed to define the professional competencies of PRM, the quality management and accreditation and with the Board the educational matters. The European College of PRM is served by the UEMS PRM Board and its main activities are analyzed below in the description of the Board of the UEMS PRM Section. The European Society of Physical and Rehabilitation Medicine (ESPRM) mainly dedicated to promoting research in rehabilitation and create a network of knowledge of PRM across the Europe. The European Academy of Rehabilitation Medicine mainly dedicated to defining the ethical issues in rehabilitation and finding strategies for better educational approaches in rehabilitation. There are 2 further bodies (the regional Fora) aimed to create bridges across the Mediterranean area (Mediterranean Forum of PRM) and across the northern Europe including the eastern countries such as Russia, Belarus and Ukraine (Baltic and North Sea Forum of PRM). To support the knowledge, we have in Europe 7 main journals dedicated to Rehabilitation with a growing impact factor. Last but not least the PRM bodies have an important role across the world with a connection with the International Society of PRM and WHO. The UEMS Section approved motion of international collaboration. In conclusion, PRM activity in Europe is not limited to the official border but in the network included eastern countries and Mediterranean area. The European extended network is strongly connected with the international PRM bodies, first of all the International Society of PRM.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with a global overview of the role of PRM in healthcare systems in Europe. Several documents and reports by WHO and the UN call for the worldwide strengthening of rehabilitation as a key health strategy of the 21st century. Therefore, further implementation of PRM in healthcare systems is crucial. Many aspects need to be considered when implementing PRM in a health system. Since PRM should be provided along the whole continuum of care, a specific phase model has been developed. Those phases depend on patients’ functional needs as well as on temporal aspects of a health condition: it can be congenital or acquired, and the disorder can have an acute onset or a progressive or degenerative course. The following phases are described in the paper: habilitation, prehabilitation, PRM in acute settings, in post-acute and in long-term settings. Regular triage and reassessment to assign the patient to the appropriate level and setting of rehabilitation care is mandatory. Therefore, rehabilitation services should be stratified and organized in networks, in order to allow for the best possible care adapted to the individual’s needs and goals, over the continuum of care. Providing correct PRM services requires good planning of service delivery, capacity building and resource allocation. The needed resources are human (with complex multi-professional teams), technical (diagnostic and therapeutic equipment, equipment for performing complementary diagnostic means, rehabilitation technology and assistive devices), and financial. Decisions on the allocation of the usually limited resources require a reasoned process and clear and fair criteria. Principles of clinical governance must be respected, and appropriate competencies are required. Disease prevention (primary, secondary and tertiary), health maintenance and support in chronic conditions as well as global health promotion are gaining growing importance in PRM. They include encouraging physical activity and promoting healthy behavior aiming at the maintenance of maximum function and avoiding complications in disabling or progressive conditions. This is discussed in the paper together with some ethical reflections on the choices PRM physicians continuously have to make during service delivery.

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

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with the education of PRM physicians in Europe. To acquire the wide field of competence needed, specialists in Physical and Rehabilitation Medicine have to undergo a well organised and appropriately structured training of adequate duration. In fact they are required to develop not only medical knowledge, but also competence in patient care, specific procedural skills, and attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. This paper provides updated detailed information about the education and training of specialists, delivers recommendations concerning the standards required at a European level, in agreement with the UEMS rules of creating a Common Training Framework, that consists of a common set of knowledge, skills and competencies for postgraduate training. The role of the European PRM Board is highlighted as a body aimed at ensuring the highest standards of medical training and health care across Europe and the harmonization of PRM physicians’ qualifications. To this scope, the theoretical knowledge necessary for the practice of PRM specialty and the core competencies (training outcomes) to be achieved at the end of training have been established and the postgraduate PRM core curriculum has been added. Undergraduate training of medical students is also focused, being considered a mandatory element for the growth of both PRM specialty and the medical community as a whole, mainly in front of the future challenges of the ageing population and the increase of disability in our continent. Finally, the problems of continuing professional development and medical education are faced in a PRM European perspective, and the role of the European Accreditation Council of Continuous Medical Education (EACCME) of UEMS is outlined.

International audience

BACKGROUND: The Romberg test, with the subject standing and with eyes closed, gives diagnostic arguments for a proprioceptive disorder. Closing the eyes is also used in balance rehabilitation as a main way to stimulate neural plasticity with proprioceptive, vestibular and even cerebellar disorders. Nevertheless, standing and walking with eyes closed or with eyes open in the dark are certainly 2 different tasks. We aimed to compare walking with eyes open, closed and wearing black or white goggles in healthy subjects. METHODS: A total of 50 healthy participants were randomly divided into 2 protocols and asked to walk on a 5-m pressure-sensitive mat, under 3 conditions: (1) eyes open (EO), eyes closed (EC) and eyes open with black goggles (BG) and (2) EO, EO with BG and with white goggles (WG). Gait was described by velocity (m·s(-1)), double support (% gait cycle), gait variability index (GVI/100) and exit from the mat (%). Analysis involved repeated measures Anova, Holm-Sidak's multiple comparisons test for parametric parameters (GVI) and Dunn's multiple comparisons test for non-parametric parameters. RESULTS: As compared with walking with EC, walking with BG produced lower median velocity, by 6% (EO 1.26; BG 1.01 vs EC 1.07m·s(-1), P=0.0328), and lower mean GVI, by 8% (EO 91.8; BG 66.8 vs EC 72.24, P=0.009). Parameters did not differ between walking under the BG and WG conditions. CONCLUSION: The goggle task increases the difficulty in walking with visual deprivation compared to the Romberg task, so the goggle task can be proposed to gradually increase the difficulty in walking with visual deprivation (from eyes closed to eyes open in black goggles). Language: en

International audience

Background The Neer, Hawkins, and Yocum clinical tests detect sub-acromial impingement as a pathogenic process of degenerative rotator cuff disease. Their reproducibility has been little investigated. Objectives We tested the reproducibility of the Neer, Hawkins, and Yocum clinical tests for detecting this sub-acromial impingement and also an original clinical manoeuver, the countertest with elevation with lateral rotation (CELR), which is a test of sub-acromial impingement. Methods Patients with shoulder pain due to degenerative rotator cuff disease were prospectively included. They were assessed with the Neer, Hawkins and Yocum tests as well as the CELR twice at a 1 week interval. Intra- and inter-observer reproducibility was assessed by percentage agreement and the kappa coefficient of concordance with 95% confidence intervals (CIs). Concordance was poor with kappa ≤ 0.4, moderate > 0.4, and good > 0.61. It was considered suitable for clinical use with kappa > 0.4. Results We included 34 patients (mean [SD] age 60 [11] years; 26 females). For intra-observer reproducibility, agreement was 80% to 88%. By the kappa coefficient, intra-observer reproducibility was poor for the Neer test and moderate for the Hawkins test (0.56 [95% CI 0;0.9]) and Yocum test (0.48 [0;0.8]) and CELR (0.6 [0.2;0.9]). For inter-observer reproducibility, agreement was 73% to 88%. By the kappa coefficient, inter-observer reproducibility was poor for the Yocum test, moderate for the Hawkins test (0.54 [0.2;0.8]) and CELR (0.58 [0.2;0.8]), and good for the Neer test (0.64 [0.2;0.9]). Conclusion The Hawkins test and CELR had a balanced profile of reproducibility suitable for clinical practice. We underline the potential interest of CELR, an original manoeuver.

Objectives Spasticity causes significant long-term disability-burden, requiring comprehensive management. This review evaluates evidence from published systematic reviews of clinical trials for effectiveness of non-pharmacological interventions for improved spasticity outcomes. Methods Data sources: a literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, CINAHL, PubMed, and the Cochrane Library) databases for published systematic reviews up to 15th June 2017. Data extraction and synthesis: two reviewers applied inclusion criteria to select potential systematic reviews, independently extracted data for methodological quality using Assessment of Multiple Systematic Reviews (AMSTAR). Quality of evidence was critically appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Results Overall 18 systematic reviews were evaluated for evidence for a range of non-pharmacological interventions currently used in managing spasticity in various neurological conditions. There is “moderate” evidence for electro-neuromuscular stimulation and acupuncture as an adjunct therapy to conventional routine care (pharmacological and rehabilitation) in persons following stroke. “Low” quality evidence for rehabilitation programs targeting spasticity (such as induced movement therapy, stretching, dynamic elbow-splinting, occupational therapy) in stroke and other neurological conditions; extracorporeal shock-wave therapy in brain injury; transcranial direct current stimulation in stroke; transcranial magnetic stimulation and transcutaneous electrical nerve stimulation for other neurological conditions; physical activity programs and repetitive magnetic stimulation in persons with MS, vibration therapy for SCI and stretching for other neurological condition. For other interventions, evidence was inconclusive. Conclusions Despite the available range of non-pharmacological interventions for spasticity, there is lack of high-quality evidence for many modalities. Further research is needed to judge the effect with appropriate study designs, timing and intensity of modalities, and associate costs of these interventions.

Introduction Sleep apnea syndrome (SAS) frequently occurs after a stroke. Its association with a poor prognosis is open to discussion. Objective To study, in a physical and rehabilitation medicine (PRM) unit, the possible repercussions of SAS on neurological and functional recovery as well as attentional abilities following a stroke. Patients and methods Forty-five patients, all of whom had recently had a stroke without previously documented SAS, were screened using the ApneaLink® system. An apnea-hypopnea index (AHI) score ≥10 was considered as indicative of SAS. The NIHSS, Fugl-Meyer (FM) and Functional Independence Measure (FIM) Scales were applied on admission and at two months as means of assessing neurological and functional recovery, which was expressed by the difference between the first and the second scores (delta FM, delta NIHSS, delta FIM). The Battery Attention William Lennox (BAWL) Test was given once in order to evaluate attention disorders. SAS severity was categorized according to the AHI. We compared the groups formed (mild, moderate and severe) using the same method. Results Twenty-eight patients (62.2%) presented AHI ≥ 10. Stroke characteristics were comparable in the SAS+ and the SAS– groups, with average post-stroke time lapse of 26 days, initial average FIM score of 71.2 points ± 26.3 and initial average NIHSS score of 8.9 ± 4.9. The demographic characteristics of the two groups were likewise comparable with the exception of age, as the SAS+ group was pronouncedly older (65.4 vs. 53.5 years). As for delta FIM, which evaluated functional recovery, it averaged 31.8 ± 20.6. Cases of SAS were found to be mild (37.1%), moderate (28.6%) or severe (34.3%). No significant difference was observed on admission or at 2 months as regards the clinical scales or the BAWL test between the two groups or according to severity, except for the NIHSS score at 2 months in the severe sub-group. Discussion and conclusion This study did not demonstrate the supposed repercussions of SAS on the recovery or attentional abilities of post-stroke patients. The tests were maybe given too early; they should take place at a lengthier time interval after the stroke, and also to be more complete.

International audience; OBJECTIVES: Focus on the different therapeutic patient education (TPE) programs for stroke survivors found in the literature. Verify their content and efficacy. METHOD: A literature review was conducted by searching for entries from 1966 to 2011 in the Medline and Cochrane Library databases. The references for the accepted articles were taken into consideration and the articles corresponding to the criteria inclusion but not present within the initial search were selected. The keywords used were "self care", "self management", "patient education" and "stroke". Given the multiplicity of symptoms that may be addressed in TPE programs, and following expert advice, the symptoms were grouped after expanding the bibliographic search using the following, additional keywords: "dysphagia"; "swallowing disorder"; "urinary incontinence"; "caregiver"; "fall prevention"; "falling"; "injury"; "shoulder pain"; "physical activity"; "exercise"; "aphasia" and "cognitive impairment". RESULTS: We found 30 article abstracts. In the end, we only accepted seven articles on general TPE programs that were well structured and detailed enough. The TPE programs found in the literature were often of questionable methodological quality. The multiplicity of symptoms led to very general TPE programs that covered all possible stroke after-effects. The purpose of these programs was to reduce stress and anxiety, to improve quality of life and to alleviate psychosocial after-effects. A change in caregiver and patient behavior was observed at times. We expanded the bibliographic search to include scientific arguments that could help implement TPE programs for more specific targets. CONCLUSION: TPE programs for stroke survivors could be improved by standardizing and assessing programs that focus on a specific problem caused by the various possible after-effects of strokes. In order to promote education for stroke survivors, specific training for health care professionals and appropriate funding are necessary.

This document is part of the “Care Pathways in Physical and Rehabilitation Medicine” series developed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Physical and Rehabilitation Medicine Federation (Fedmer). For a given patient profile, each concise document describes the patient's needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with acute proximal humeral fracture requiring shoulder hemi-arthroplasty are classified into four care sequences and two clinical categories, both of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO's International Classification of Functioning, Disability and Health) that may influence patient needs.

This document is part of the “Care pathways in physical and rehabilitation medicine” series developed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Physical and Rehabilitation Medicine Federation (FEDMER). For a given patient profile, each concise document describes the patient's needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with shoulder instability requiring surgical stabilization are classified into five care sequences and two clinical categories, each of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO's International Classification of Functioning, Disability and Health) that may influence patient needs.

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. “Care pathways in PRM” is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. The patients after spinal cord injury are divided into five categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. “Care pathways in PRM” is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after rotator cuff tear surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients’ needs, in accordance with the International Classification of Functioning (ICF) (WHO).

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. “Care pathways in PRM” is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after knee ligament surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients’ needs, in accordance with the International Classification of Functioning (WHO).

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Stroke patients are divided into four categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.

The Field of Competence (FOC) of specialists in Physical and Rehabilitation Medicine (PRM) in Europe follows uniform basic principles described in the White Book of PRM in Europe. An agreed basis of the field of competence is the European Board curriculum for the PRM-specialist certification. However, due to national traditions, different health systems and other factors, PRM practice varies between regions and countries in Europe. Even within a country the professional practice of the individual doctor may vary because of the specific setting he or she is working in. For that reason this paper aims at a comprehensive description of the FOC in PRM. PRM specialists deal with/intervene in a wide range of diseases and functional deficits. Their interventions include, prevention of diseases and their complications, diagnosis of diseases, functional assessment, information and education of patients, families and professionals, treatments (physical modalities, drugs and other interventions). PRM interventions are often organized within PRM programmes of care. PRM interventions benefit from the involvement of PRM specialists in research. PRM specialists have knowledge of the rehabilitation process, team working, medical and physical treatments, rehabilitation technology, prevention and management of complications and methodology of research in the field. PRM specialists are involved in reducing functional consequences of many health conditions and manage functioning and disability in the respective patients. Diagnostic skills include all dimensions of body functions and structures, activities and participation issues relevant for the rehabilitation process. Additionally relevant contextual factors are assessed. PRM interventions range from medication, physical treatments, psychosocial interventions and rehabilitation technology. As PRM is based on the principles of evidence-based medicine PRM specialist are involved in research too. Quality management programs for PRM interventions are established at national and European levels. PRM specialists are practising in various settings along a continuum of care, including acute settings, post acute and long term rehabilitation programs. The latter include community based activities and intermittent in- or out-patient programs. Within all PRM practice, Continuous Medical Education (CME) and Continuous Professional Development (CPD) are part of the comprehensive educational system.

Introduction : Physical medicine and rehabilitation (PMR) cares are limited in practice in France. The complexity of treat- ments and their potential effects on disability, life expectancy, constitute some chronic factors of the cancer diseases. This chro- nic evolution is more and more indication of PMR interventions to limit deficiency or disability. Objectives : To present the PMR modalities at different situa- tions of the cancer diseases evolutions. Methodology : This paper reports the orientation in our out- patient unit, the modalities for cares in PMR, the role of PMR doc- tors and the different technologi- cal or competent needs for cancer patients with deficiency or disability. Discussion : A new and impor- tant reflexion with information, studies and acquired experiences are necessary. Organization of cares, institutions and coopera- tionmustbedevelopedinthisspe- cific domain of the rehabilitation for cancer patients with disability.

Introduction/Background Ambulatory care is the most frequent type of rehabilitation for chronic diseases. French guidelines recommend after a stroke assessment and rehabilitation by a multidisciplinary team for all the patients with a persistent deficiency. According to the needs of each patient, different ways to provide home rehabilitation can be used in France. For simple needs targeting specific deficiency, rehabilitation can be provided by a professional alone in ambulatory care. Only Physiotherapy (PT) and speech therapy (ST) are refunded by the national health insurance. For complex needs a PRM multidisciplinary team, can be ordered either in day hospital (the patient living home and receiving rehabilitation during repeated stays) which is the main organization, or mobile rehabilitation team, the team coming each day at home like an early supported discharge team (not very developed in France). Material and method We report here the global activity base on the analysis of the national registry on the 80,000 annual new strokes (excluding transient attacks and deceased) Results After the acute care, 37% of stroke patients received a multidisciplinary rehabilitation during a mean of 3 months (33% in an inpatient center and 4% in an outpatient center). For the patient discharge at home 30% (directly discharge from an acute center) to 50% (discharge from a rehabilitation center) receive PT and 9 to 15% ST. At the chronic phase 35% of the patients receive PT at home. Ambulatory occupational therapy and ST are less developed and less available. Conclusion Effort is needed to improve multidisciplinary rehabilitation at home in France. Home hospital could be interesting to develop for dependent and fragile patients, mobile rehabilitation team for the rehabilitation of the instrumental activities of daily livings, and day hospital for rehabilitation requiring technical platform of a rehabilitation center.

Introduction/Background The development of multidisciplinary work around patients receiving cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) with thoracic epidural analgesia led us to articulate our reciprocal skills in a care program. Since 2012, a preoperative consultation of physiotherapy has been set up for these patients. Between 2009 and 2013, 124 patient's files have been analysed, comparing “Patient controlled epidural analgesia (PCEA) with physiotherapy” (67 patients) and “PCEA without physiotherapy” (57 patients). The reduction of the patient's apprehension of physiotherapy and mobilization contributed to the reduction of the length of stay in intensive care unit (on average 5 days instead of 7) and an early out of bed mobilization (one day gained). Material and method After 4 years of operation, we conducted a retrospective study of patient's files in order to evaluate the efficiency of this first step programme about the role of physiotherapy in this patient's care pathway. We estimated the length of stay and the way to go back home. Results Three hundred and sixty-six files had been analysed. Patient’ pathway had been systematically organized including this physiotherapy consultation during the month before surgery. The content of the consultation has been adapted including 3 parts leading to a real therapeutic educational program; –information on the physiotherapy that will begin the day after the surgery: respiratory mechanics, interest of early mobilization to warn the postoperative complications; –education of the patient with teaching of techniques of respiratory physiotherapy; –a notebook containing advice for improving the physical condition is given to the patient by adjusting the dosage and the intensity according to his basic state. Conclusion Physiotherapy included in preoperative management is part of improving the quality of care provided to patients, allowing them a better participation in the postoperative care. This preoperative consultation had been adapted to better support the patient and his family.

Introduction/Background Treatments of Dupuytren's disease are currently not aetiological but symptomatic. They aim at reducing the flexion contracture of fingers and improving hand function, without excluding the possibility of recurrence. Percutaneous needle aponeurotomy (PNA) can be used as an iterative treatment for repeated recurrences. However, it has only been assessed as a unique therapeutic sequence and its long-term functional results have not been described. The aim of the study was to assess functional results of iterative PNA for Dupuytren's disease at 5-year follow-up. Material and method Patients with digital flexion contracture due to Dupuytren's disease were prospectively included and treated using PNA. Iterative treatment was performed as necessary during the follow-up. Assessment criteria were Tubiana score at 1 month, URAM functional score at 1-month and 5 years, satisfaction and need of second line open surgery at 5 years. Primary outcome was URAM functional score at 5 years in patients who did not undergo second line open surgery at follow-up. Results Thirty patients were included: age 72 ± 10, ratio Female/Male 0.2, diabetes 3, Tubiana score 7 ± 3, URAM score 13 ± 10. Three sessions of PNA were performed per patient in mean at 5-year follow-up. Two adverse events were observed: skin fissure recovering in one week (1 case), digital paresthesia recovering in 2 years (1 case). PNA reduced flexion contracture (Tubiana 2 ± 3, range 0–13, n = 30, P Conclusion Iterative PNA is safe, reduces flexion contracture and improves hand function in patients with Dupuyren's disease. Functional improvement persists at 5 years in 90% of cases. Only 10% require second line open surgery.

Physical therapy (PT) has to be provided early after stroke with early mobilization. But it seems that during the first days after stroke, intensive training cannot be recommended. The AMOBES study had been designed to assess the effect of early intensive PT provided within the first two weeks, during the 3 first months. The results were not in favour of intensive training (Yelnik et al., Stroke 2017). We report here the results in patients who could have being followed for one year. Patients have been recruited in this multicentre randomized controlled trial to compare “soft” (20 min/day apart from respiratory needs) versus “intensive” PT (idem + 45 minutes of intensive exercises/day), initiated within the 72 first hours after a first hemispheric stroke. Blind assessment has been made. The primary criterion was the motor control assessed by the Fugl Meyer score at D90. At one year the following secondary criteria were assessed: Fugl Meyer, postural balance (PASS), autonomy (Rankin and FIM), unexpected medical events, length of hospital stay, quality of life (SIS). The study has been registered on clinical trial.gov NCT01520636 . Sixty-one survivors of the 103 included patients could be examined, 40 males, 45 right hemispheric lesions, 47 ischemic lesions, age 63.1 ± 12.1. Number of patients with moderate stroke (NIHSS The result of the initial study seems to be confirmed, but deserves to be qualified according to the initial stroke severity: mild severe stroke might beneficiate from early intensive physical therapy.

Objective Deconditioning syndrome in chronic low back pain is admitted. It is comprised of low lombo-pelvic mobility, low muscular strength of the trunk, anxiety, depression and altered lifting capacity. However, profile of physical fitness, on the basis of energy expenditure, is controversial. The goal of the study was therefore to assess physical fitness in chronic low back pain patients, using markers of energy expenditure. Material/Patients and methods This was a monocentric, retrospective case-control study, with prospective recording. Patients with chronic low back pain and healthy age- and sex-matched controls underwent bicycle exercise test, up to muscle exhaustion. Recorded energy variables were: duration of exercise in seconds, maximal power (P max) in watts, percentage of age-predicted maximum heart rate (HR max) and metabolic equivalents (MET). Pain intensity using the 0-100-VAS, pain duration and functional limitation using the Quebec scale were also assessed in chronic low back pain patients. Relationship between energy variables and clinical parameters was investigated using the Spearman correlation coefficient. Results of both groups were compared using the Student t-test. Results One hundred and ninety-two chronic low back pain patients (age 44 ± 8, ratio M/F 106/86, pain intensity 47 ± 19, pain duration 51 ± 57 months, Quebec 39 ± 16) and 325 healthy controls (44 ± 8, ratio M/F 199/126) were included. Duration of exercise (−0.23), P max (−0.21), and MET (−0.29) were related with the Quebec score in chronic low back pain patients (P Discussion/Conclusion Physical fitness was not altered in the entire chronic low back pain population. However, physical fitness appeared to be decreased in chronic low back pain patients with highest functional limitation.

Introduction/Background Lumbar spinal stenosis is a major contributor to disability in adults with achondroplasia. It arises from congenital dysplasia and acquired degenerative changes. The aim of the study was to characterize degenerative changes of the intervertebral disk in adult achondroplasia patients with lumbar spinal stenosis and to identify factors associated with the process. Material and method The study was a case series of adult achondroplasia patients. Clinical parameters were recorded. Radiographs were used to analyze spino-pelvic parameters. MRI of the lumbar spine was used to measure antero-posterior diameter of the canal and disk degeneration using the Pfirrmann grading system. Comparisons were done using the Kruskal–Wallis test and correlations using the Spearman coefficient. Results Eighteen patients were included: age 37 ± 17, female 12, size 127 ± 7 cm, weight 57 ± 13 kg. All had symptoms due to lumbar spinal stenosis. Antero-posterior diameters of the spinal canal differed according to level (P Conclusion Spinal stenosis and disk degeneration mainly involve the upper part of the lumbar spine in adult achondroplasia patients. Thoraco-lumbar kyphosis and lumbar lordosis are related with these processes. The findings may be of importance in rehabilitation and in early prevention of spinal stenosis in the course of achondroplasia.

Introduction/Background Rehabilitation robotics has been proposed as an efficient strategy to improve upper extremity (UE) motor function after stroke especially at the subacute phase. Many trials with several robots have been performed but very few large multicenter RCTs at the subacute phase. Material and method A multicenter parallel group, two arm, single blind, phase III, superiority, randomized, controlled trial has been conducted in France in 22 rehabilitation centers equipped with an Armeo Spring robot. Two hundred and twenty subjects must be included. The main inclusion criteria were an UE Fugl Meyer (UEFM) score between 10 and 40 and an occurrence of the stroke between 3 and 12 weeks before inclusion. The main outcome measure was the UE FM 30 days. Each patient performed usual treatment (2 hours a day of motor rehabilitation) with 20 additional rehabilitation sessions (1 h each, 5 days a week, 4 weeks). Patients were randomized either to rehabilitation robotic sessions with the Armeo Spring device or to self-rehabilitation (stretching and self paced movements) in equal timed sessions. Secondary outcome measures were, pain, hypertonia, functional improvement (FIM and Action research arm test ARAT) and quality of life (EQ5D and stroke impact scale). Evaluation were performed at day 30, 3, 6 and 12 months after inclusion. Results Two hundred and eighteen subjects have been included and an attrition rate of 10% at 6 months and 20% at 12 months was observed. The gain in the main outcome criteria was not significantly different at day 30 nor any other secondary criteria except ARAT. Conclusion An additional time 1 h a day during 4 weeks of rehabilitation robotics to usual intensive rehabilitation seems not significantly influence the motor deficiency prognosis of the upper limb after stroke. It might influence functional outcome but this has to be explored in another design randomized control study.

Objectives To observe whether medical complications, the evolution of neurological disorders and dependence and/or the discharge destinations are different for patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery compared to patients treated medically for severe or malignant cerebral infarction in the same cerebral territory, during their hospitalization in a physical medicine and rehabilitation department. Patients and methods This retrospective study compared patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery and patients treated medically for severe or malignant cerebral infarction in the same cerebral territory. Patients were paired according to age, lesion side and hospitalization period. Results Twelve patients treated by craniectomy (age 43 ± 10.44) were paired with 12 patients treated medically (age 49 ± 7.66). The two groups were comparable in terms of general undesirable medical events. The medical events related to craniectomy are described. The evolution of patient deficiencies, the length of the hospital stay (194 ± 118.93 days vs 152 ± 94.64 days), the Functional Independence Measure at discharge (87 ± 21.28 vs 95 ± 22.19) and the number of direct home discharges (7 vs 9) did not significantly differ between groups. Discussion and conclusion No more medical problems were observed in the patients treated by craniectomy than in the patients treated medically, except for the medical events specifically related to craniectomy, which extended the hospital stay but had no major repercussions.

Post-polio syndrome (PPS) refers to a clinical disorder affecting polio survivors with sequelae years after the initial polio attack. These patients report new musculoskeletal symptoms, loss of muscular strength or endurance. PPS patients are tired, in pain and experience new and unusual muscular deficits, on healthy muscles as well as deficient muscles initially affected by the Poliovirus. Once a clinical diagnosis is established, the therapeutic options can be discussed. Some pathophysiological mechanisms have been validated by research studies on PPS (inflammatory process in cerebrospinal fluid [CSF] and cytokines of the immune system). Several studies have been conducted to validate medications (pyridostigmine, immunoglobulin, coenzyme Q10) or physical exercises protocols. This article focuses on the relevance and efficacy that can be expected from these therapeutics. Very few studies reported some improvements. Medications combined to individual and supervised exercise training programs are promising therapeutic strategies for PPS patients care management.

Objectives After several decades of stability, polio survivors often experience new signs and symptoms of their condition, characterized by global and muscular fatigue, decreased muscular strength and pain. The hypothesis of a potential underlying psychological component has been suggested. Method This article aims to report how polio survivors cope with their condition based on an analysis of the literature and the authors’ experience. Results The literature does not report a higher prevalence of psychological disorders (mood disorders, depression) in polio survivors than in the general population. Conversely, the psychological impact of the patients’ decreasing abilities, regardless of the cause, is regularly reported. Most patients report a restricted involvement in their daily life activities. Discussion and conclusion It is essential to be aware of the patients’ experience in coping with polio as children as well as the medical treatments they went through in order to better understand their various types of complaints and sometimes their reluctance to go back to a medical environment. With such widespread information on post-polio syndrome (PPS) and all the uncertainties surrounding it, patients fear a late onset deterioration of their condition. In order to provide the best therapeutic advice, it is essential to have a good knowledge of the symptoms but also take the time and listen to patients in order to differentiate the underlying physical and psychological components in symptoms of pain and fatigue.

Objective We estimate that there are about 50,000 persons who survived poliomyelitis in their childhood in France (mean age estimated between 50 and 65 years). After a few decades of stability, 30 to 65% of individuals who had been infected and recovered from polio begin to experience new signs and symptoms. Method Review of the literature on Pubmed with the following keywords “Poliomyelitis” and “Post-Polio Syndrome (PPS)”. Results These new signs and symptoms are characterized by muscular atrophy (decreased muscle mass), muscle weakness and fatigue, muscle and/or joint pain. All these symptoms lead to significant changes in mobility with falls and inability to carry on with daily life activities. There are several intricate causes. The normal aging process and weight gain are regularly blamed. Respiratory disorders and sleep disorders must be looked for: respiratory insufficiency, sleep-related breathing disorders such as sleep apnea, restless legs syndrome. Orthopedics complications are quite common: soft-tissue pathologies of the upper limbs, degenerative pathologies of the large joints or spinal cord, fall-related fractures. Finally, the onset of an authentic PPS is possible. Conclusion The therapeutic care of this late functional deterioration requires regular monitoring check-ups in order to implement preventive measures and appropriate treatment. This therapeutic care must be multidisciplinary as physical rehabilitation; orthotics and technical aids are all essential.

Resume Les decrets de 2008 reglementant l’activite en soins de suite et de readaptation (SSR) ont pour objectifs de clarifier ce domaine de soins et de donner les memes regles aux secteurs publics et prives, notamment dans la perspective de l’application de la tarification a l’activite. Le champ du SSR sera ainsi compose d’un socle commun a toutes les structures et de secteurs d’activites specialisees, pour lesquelles chaque structure qui le souhaite peut demander une autorisation d’activite sur la base de moyens humains et techniques minimum. La necessaire coordination par un medecin de la medecine physique et de readaptation (MPR) est prevue dans tous les secteurs de reeducation et de readaptation, obligatoire notamment a la pratique d’une activite specialisee en « affections de l’appareil locomoteur » ou en « affections de l’appareil locomoteur et du systeme nerveux ». L’admission sur la base d’un projet therapeutique evalue est exigee et le role d’expertise de ces structures est reconnu par la possibilite d’admission directe a partir du domicile. Les textes ne detaillent pas les indications precises d’admission et ne fixent que les grandes lignes des moyens. Ils seront accompagnes d’une circulaire d’application qui guide les agences regionales d’hospitalisation pour la mise en place de cette reglementation et de fiches techniques qui decrivent le champ d’activite des domaines specialises. Les notions de niveau de proximite, de recours et de reference devront etre apportees regionalement par les schema regionaux d’organisation sanitaire (SROS).

Introduction Muscle vibration leads to agonist muscle contraction and antagonist muscle relaxation, this is the Tonic Vibration Reflex (TVR) [1] . Central nervous system interprets tendon vibration as a lengthening of this one inducing a virtual movement sensation [2] . The objective of this study is to observe this effect after stroke. Method Thirty-eight subjects have been evaluated: 19 stroke patients (10 men, 60.7 ± 9.8 years old) and 19 healthy subjects (5 men, 56 ± 11 years old). Vibrators (VibraSens VB200, TechnoConcept) were placed on the biceps brachii and wrist flexors tendons. Each subject received a vibration (80 Hz, 40 s) for each upper limb. An accelerometer was placed on the forearm in order to quantify the TVR with the elbow flexion angle. Movement perception of the subject was highlighted through a perception score created for the study. Subjects were seated on a chair, blindfolded, dangling arm. Results Flexion angle of the elbow (TVR) was identical on the left (32.2 ± 22.9°) and right (35.2 ± 32.2°) healthy subjects upper limb. For stroke patients it was identical on the healthy upper limb (33.1 ± 21.2°) compared to the upper limb of healthy subjects but greatly decreased on the deficient upper limb (9.6 ± 13.7°) of stroke patients compared to their healthy upper limb (P = 0.0003). Perception score was less important on the hemiplegic side than the healthy side (P Conclusion TVR and usual movement illusion under tendon vibration are affected on the hemiplegic side after stroke. Any relationship or not on the observed deficiencies require confirmation with a larger sample.

Introduction A few studies have found short-term effects of tendon vibration therapy on upper limb function in chronic hemiplegia [1] , [2] . We report the effect of tendon vibrations of the elbow and wrist flexor muscles on recovery of the upper limb in a recent hemiplegic patient. Observation A 69-year-old woman was admitted to our department for right hemiplegia and aphasia after a left middle cerebral artery (MCA) stroke and a left cerebellar infarct secondary to cardiac arrhythmia. Initial NIHSS 22/44. Motor function on upper limb was limited to slight abduction and elevation of the shoulder, slight flexion of the wrist and elbow. The initial Functional Independence Measure score was 38/126. Intensive classical reeducation was started with little progress of upper limb recovery despite upper limb suspension, bimanual work and mirror therapy for 1 month. Two months after the stroke, the vibration program began. Evaluation using Fugl-Meyer assessment (FMA) for the upper limb, the Action Research Arm Test (ARAT) and the modified Tardieu Scale was performed at days 0, 7, 21, 28 and 35. The tolerance and feasibility were studied. Vibrations (80 Hz) were applied on right distal biceps brachii, flexor carpi radialis and ulnaris muscle tendons during 16 min, twice a day, 5 days a week for 2 weeks on days 7 to 21. No side effects or pain were reported. The FMA score increased 6 points the first week, 9 points during the vibration period, 9 new points the third week, and then stabilized. The ARAT score increased from 0 to 11 during the vibration period and reach 24 at D35. Discussion Tendon vibration seemed to give a new impetus to motor recovery in this patient and leads to the elaboration of a controlled trial to assess its real effectiveness in subacute stroke.

International audience; 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.

International audience; This issue of NCCN combines review articles and original contributions by speakers who participated in the 2014 and 2015 SOFPEL congresses. As always, these SOFPEL congresses bring together different professionals interested in balance and gait disorders, ranging from physiology to treatment and rehabilitation, including physicians (mainly neurologists and rehabilitation medicine specialists), physiologists, physical therapists and podiatrists. During the 2014 congress held in Rennes, the main topics addressed by the invited speakers were: balance in cerebral palsy (Olivier Remy-Néris); vision and hearing in gait (Benoit Bardy), freezing in Parkinsonism (Arnaud Delval); and biomechanics of standing (Armel Cretual). In the 2015 congress to be held in Paris, cortical aspects of balance control (Alfredo Bronstein), the role of the mesencephalon (Carine Karachi), walking exoskeletons (Jacques Kerdraon) and use of Tai chi for balance control (Luce Condamine) will be the topics of the main conferences, along with current scientific communications.

Introduction This study was conducted to assess visual dependence of postural control early after stroke. Design Case control study. Setting A Physical Medicine and Rehabilitation Department. Method Twenty-five patients impaired by severe hemiplegia due to a recent first stroke, were examined. Fourteen had a right and 11 a left hemispheric lesion. There were aged 52 ± 13 years, time since stroke was 30 ± 12 days. Patients’ data were compared to data for 25 healthy subjects. Sitting posture was assessed on a dynamic balance, using two parameters: frontal plane displacement of the centre of pressure under optokinetic stimulation (OKS), and the total length of centre of pressure displacement for the stability reaction. On the basis of 90th percentile control data, patients’ behaviour was classified as totally visuo independent (VI), totally visuo dependent (VD) or mixed. Results Body tilt under OKS was greater in patients than controls. No control subject was totally VD, 19 subjects were totally VI. Four patients were totally VD and only six were VI. The only clinical parameter linked to the effect of OKS was the sensitivity impairment. Overall patients with visuospatial neglect were the most perturbed, but two were totally visuo independent. Discussion and conclusion Assessment of postural variations in sitting under OKS is proposed for estimating visual dependence early after stroke. Individual reactions are more important than mean group reactions. Visual dependence is not solely due to neurological impairment, implying that previous physiological behaviour may be involved. Knowledge of these characteristics may affect rehabilitation programmes.

Objectives To examine the phenomenon of fatigue after stroke and to review the knowledge about frequency, consequences, associated factors, physiopathology and treatment. Materials and method Medline was systematically searched with the following keywords: stroke, fatigue, sleep disorders, exercise, and rehabilitation. All relevant articles found in the references were screened as well. Results and discussion Fatigue is a common complaint after stroke and occurs in 39–72% of stroke survivors. Some studies show a severe functional impact of this symptom as well as a high mortality rate. Available evidence concerning associated factors is limited, but fatigue is clearly multifactorial. Some studies show that limited exercise capacity, increased gait energy cost, sleep-disordered breathing and sleep disorders can be related to physical fatigue. Other studies show a link between fatigue and depression. The existence of primary fatigue is still controversial. Treatment must follow a diagnostic approach. Treadmill training, among other treatments, improves fitness reserve and lowering of the energy cost of hemiparetic gait, which could be useful in relieving fatigue.

Resume Introduction. – Il existe une dependance visuelle excessive chez les patients hemiplegiques a distance de leur AVC dont le mecanisme n'est pas certain. Le but de cette etude est d'evaluer l'importance et les caracteristiques de cette dependance visuelle precocement apres AVC. Methode. – Trente patients AVC hemispherique unique (14 G, 16 D), de moins de trois mois. L'âge, le delai, le cote, le siege et la taille de la lesion, l'autonomie (MIF), la motricite, la negligence et la sensibilite ont ete etudies. Chaque sujet a realise le rod and frame test ou il devait ajuster a la verticale une baguette d'abord isolee sans reference visuelle, puis au sein d'un cadre perturbateur incline de 18° a droite ou a gauche. Huit essais ont ete realises. La perturbation engendree par le cadre incline des patients a ete comparee a celle de 23 temoins comparables en âge et sexe et correlee aux caracteristiques du patient. Resultats. – Cinquante-six pour cent des patients etait visuodependants (17/30) contre 26 % (6/23) des temoins. La dependance visuelle n'etait pas liee a la lesion, la MIF, la motricite, le PASS, l'âge, la sensibilite ni la negligence. Discussion. – Il y a deux fois plus de dependants visuels apres AVC que dans la population temoin. Le mecanisme de cette dependance visuelle precoce est discute. Il parait necessaire de prendre en compte cette dependance visuelle excessive dans le programme de reeducation des patients AVC.

Bonan IV, Guettard E, Leman MC, Colle FM, Yelnik AP. Subjective visual vertical perception relates to balance in acute stroke. 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 P =.01, and P 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.