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Introduction Le demi-tour est evalue en routine par le nombre de pas exterieurs et sa duree, ce qui ne rend pas compte de sa cinematique complexe. Nous proposons ici une methode quantitative d’etude et de representation du demi-tour (le rotagramme), mesure avec des capteurs inertiels (IMU). Methode Trente-sept patients droitiers hemiparetiques apres un AVC ont realise (43–73 ans, moyenne 59), apres 10 m de marche, un demi-tour dans la direction de leur choix puis dans la direction opposee en portant 1 IMU a la ceinture et 1 sur chaque pied. Le rotagramme represente, pour chaque appui, la rotation axiale parcourue par la ceinture. Il illustre plusieurs variables : debut et fin du demi-tour, pied qui initie le demi-tour, nombre de pas, duree, vitesse moyenne, vitesse maximale, taux de giration sur chaque pied et un indice de symetrie. Resultat Le rotagramme est realisable pour tous les demi-tours. Il offre une synthese visuelle quantifiee du demi-tour. Le demi-tour du cote hemiparetique est plus asymetrique que du cote sain (15 vs 35 %, p Discussion/Conclusion Le rotagramme permet une approche quantitative du demi-tour. Il ouvre la perspective d’un suivi longitudinal individuel precis de la mobilite du patient en complement de la quantification du controle postural statique et de la marche, que nous avions precedemment mis au point.

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).

La riabilitazione dopo un ictus cerebrale e efficace. Ha come obiettivo la stimolazione dei processi di plasticita cerebrale, la prevenzione delle complicanze secondarie e la restituzione della migliore autonomia possibile al paziente. Implica un lavoro di equipe specializzata, in condizioni ottimali in una struttura di medicina fisica e di riabilitazione. Fin dai primi giorni dopo l’ictus si tratta di prevenire la comparsa di complicanze, in particolare i dolori della spalla e le retrazioni muscolotendinee. La riabilitazione attiva inizia gradualmente a seconda dello stato del paziente e si basa su alcuni principi essenziali: la forte interazione sensibilita-motricita e cognizione-motricita, l’importanza di tener conto dell’individuo rispetto a se stesso e rispetto al suo ambiente, esercizi centrati sul compito da migliorare, la scelta di compiti che hanno un obiettivo significativo per il paziente, ripetizione dell’esercizio fino all’apprendimento, intensita crescente degli stimoli. Cosi, a seconda delle esigenze, la riabilitazione permette di migliorare la prensione, l’equilibrio, la deambulazione, la comunicazione o, ancora, i disturbi visuospaziali. I primi mesi dopo l’ictus sono essenziali, ma la riabilitazione puo essere necessaria anche oltre un anno dopo l’ictus e puo essere molto utile una sua ripresa tardiva.

Background and Purpose— There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction. The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. Methods— We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score ≤3) at 6 months’ follow-up (primary outcome) between the 2 treatment groups. Results— After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score ≤3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group ( P =0.18 and P =0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only ( P Conclusions— In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

Objective: This randomised, double blind, placebo controlled, two parallel group study was conducted to assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain in stroke patients with spastic hemiplegia. Methods: A single dose of botulinum toxin A (500 Speywood units) or placebo was injected into the subcapularis muscle. Pain was assessed using a 10 point verbal scale. Subscapularis spasticity was assessed by the change in passive shoulder lateral rotation and abduction. Upper limb spasticity was assessed using the Modified Ashworth Scale for shoulder medial rotators, and elbow, wrist and finger flexors. Assessments were carried out at baseline and at weeks 1, 2 and 4. Results: Twenty patients (10 patients per group), 11 with ischaemic stroke and 9 with haemorrhagic stroke, completed the study. Pain improvement with botulinum toxin A was observed from week 1; score difference from baseline at week 4 was 4 points versus 1 point with placebo (p = 0.025). Lateral rotation was also improved, with a statistically significant difference compared with placebo at week 2 (p = 0.05) and week 4 (p = 0.018). A general improvement in upper limb spasticity was observed; it was significant for finger flexors at week 4 (p = 0.025). Conclusions: Subscapularis injection of botulinum toxin A appears to be of value in the management of shoulder pain in spastic hemiplegic patients. The results confirm the role of spasticity in post-stroke shoulder pain.

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.

The gold standard to evaluate the severity of steoarthritis in the doctor’s office remains clinical scores (Bellamy 2002). The Western Ontario and McMaster Universities (WOMAC) oste- oarthritis index is the most largely used score in rheumatology for lower limb osteoarthritis. It is based on clinical observation and it assesses pain, stiffness, and physical function in patients with hip and knee osteoarthritis. It is valid, reliable, and sen- sitive to evaluate osteoarthritis and adapted to doctor’s office (Bellamy 2002). However, clinical scores are inherently subjective and they depend from the patient’s impression and from the clinician’s interpretation. Gait analysis in modern gait laboratories with force plates and photogrammetry is a good tool to have an objec- tive, quantified, and precise insight in osteoarthritis (Astephen et al. 2008). For practical reasons, skin-mounted inertial sensors are well suited for investigating gait kinematics (Auvinet et al. 2002). In accelerometer-based gait analysis, aging is also known to affect gait parameters (Oberg et al. 1993). To have a clinical measure of osteoarthritis, it is essential to find a technique that is independ- ent from aging. Footwear can also affect walking parameters (Chambon et al. 2014). Since it is too time consuming to ask the patient to take off his shoe for the measurement, it is essential to find a method independent from the shoe type. Walking ten meters go and ten meters back on a level sur- face at comfortable walking speed is a well-suited protocol for clinical situations. This study proposes to test a 3D pelvis accelerometer-based measurement method on a group of 47 patients suffering from lower limb osteoarthritis and 12 asymptomatic subjects. The aim was to see whether the ccelerometer-based method is correlated with the clinical severity of the lower limb osteoarthritis evalu- ated with the WOMAC index. In addition, this study valuates whether the accelerometer-based method is independent of aging on 75 asymptomatic subjects and whether the acceler- ometer-based method is independent from footwear on one asymptomatic subject.

National audience; Introduction L’étude des réactions posturales à une stimulation sensorielle permet de mieux comprendre les stratégies posturales comme nous l’avons proposé après AVC (Bonan et al., 2013). Nous rapportons ici l’analyse chez des PIDC. Matériel et méthode Étude prospective chez 15 contrôles (57 ± 13 ans, 6 M, 9 F) et 15 PIDC (63 ± 15 ans, 13 M, 2 F) avec une comparaison de la déviation moyenne principale du centre de pression (mm) durant la stimulation (35s) sur stabilométrie ; la proprioception stimulée par vibrations tendineuses des triceps suraux (TS) et tibiaux antérieurs (TA) et la vision stimulée par flux optocinétique dans 4 directions (haut, bas, droite, gauche). Résultats Les chutes ont été plus fréquentes chez les PIDC que chez les témoins (expliquant la perte de 31,1 % versus 2,2 % des enregistrements ; p < 000,1), essentiellement en condition visuelle (40 % versus 3,3 % sous optocinétique) notamment en rotation optocinétique vers le bas (16,6/9,5 mm, p = 0,019) et à droite (10/4,8 mm, p = 000,9). Ceci objective l’hypersensibilité aux informations visuelles des sujets PIDC. Cependant, les PIDC restaient sensibles aux stimulations proprioceptives et réagissaient sans différence aux témoins pour la stimulation des TS et de façon plus importante en antépulsion lors de la vibration des TA (13,48/7,89 mm, p = 0,017). Discussion–conclusion Les PIDC sont beaucoup plus sensibles aux informations visuelles, comme attendu, mais restent sensibles aux stimulations proprioceptives malgré les troubles sensitifs, ce qui encourage la rééducation visant à la récupération d’informations proprioceptives plutôt qu’à la compensation par les informations visuelles

Objective. The perception of visual verticality is often perturbed after stroke and might be an underlying component of imbalance. The aim of this study was to describe the evolution of visual vertical (VV) perturbation and to investigate the factors affecting it. Methods. Thirty patients with hemiplegia after a single hemispheric stroke (17 left lesioned [LL] and 13 right lesioned [RL]) were studied. Visual verticality was tested within 45 days of stroke, and then at 3 and 6 months. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. The differences between patients’ adjustments and vertical were calculated. The effects on VV evolution of the side, size, type, and location of the lesion were tested. Results. Sixty percent of the recent stroke patients had an initial inaccurate perception of verticality, and 39% of these patients recovered during the 1st 3 months after stroke. The evolution of VV tilt depended on the side of the lesion ( P = 0.01), with better recovery in LL patients. None of the other factors studied affected VV normalization. Conclusions. The poorer recovery of vertical perception after right-side stroke might be due to the predominant role of the right hemisphere in spatial cognition, and might be involved in the poorer recovery of balance after stroke in RL patients.

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.

Resume Objectifs. – Identifier et decrire les echelles d'incapacites fonctionnelles utiles pour l'evaluation des patients hemiplegiques vasculaires. Preciser les instruments de mesure les plus utilisables en pratique clinique et ceux les plus utilises dans les essais cliniques. Methode. – Revue de litterature sur la base de donnees Medline en ciblant les parametres fonctionnels suivants : deambulation et marche, equilibre, fonction du membre superieur et independance dans les activites de vie quotidienne. Les parametres metrologiques des differents instruments de mesure sont precises, ainsi que leur utilite en pratique clinique quotidienne. Resultats. – Trente-trois outils de mesure ont ete analyses et classes en cinq categories : equilibre (6 outils), deambulation et marche (4), capacites fonctionnelles du membre superieur (11), echelles globales de motricite (5) et independance dans les activites de vie quotidienne (7). Discussion et conclusion. – Il existe de tres nombreuses echelles fonctionnelles utiles pour l'evaluation des patients hemiplegiques vasculaires. Elles ont toutes un interet propre. Pour mesurer l'equilibre, la Postural Assessment Stroke Scale et la Berg Balance Scale sont les plus interessantes. La Functional Ambulation Classification et la Timed Up and Go Test sont les plus pertinentes pour mesurer les capacites de deambulation et de marche. L'Action Research Arm Test est la plus utilisee pour mesurer les capacites fonctionnelles du membre superieur. La mesure de l'independance fonctionnelle et l'index de Barthel sont les plus reconnus pour l'independance dans les activites de vie quotidienne.

Objective The positive effects on motor cortical excitability of stimulating proprioception with tendon vibration therapy have previously been reported in healthy individuals and in chronic stroke patient (Marconi et al., 2008 and 2011). The aim of this study is to evaluate the feasibility of a protocol of tendon vibration therapy in a neurorehabilitation service, with a view to proceeding to an efficacy study. Material/Patients and methods We performed a prospective, single-centre study, including 11 patients, 8 men, mean age 61,7 ± 10,6, with upper limb motor deficit secondary to a first stroke (5 ischaemic). Average time post-stroke was 116.8 days. Mean NIHSS at inclusion was 7,9 ± 5,7. Two 15-minute sessions per day for 5 days of vibration therapy associated to voluntary movement were applied to the elbow and wrist flexor and extensors of the hemiplegic arm. The vibration therapy was in addition to standard rehabilitation. The feasibility was assessed by the implementation of the protocol (logistic regression of sessions, who did it? Where? When?), adverses outcomes and tolerance. Assessment of motor function at baseline and at day 7 was performed with Fugl-Meyer (upper limb), ARAT, Box and Blocks Test and ARMEO was used to assess the volume of exploration of the arm. Functional recovery was measured by the difference between the two scores. Results Nine patients were eligible (1 transferred to another ward for a septicaemia; 1 incomplete assessment at day 7). 97.7% of planned vibration sessions were performed. There were no adverse outcomes. Treatment was well tolerated; 1 patient reported transient paraesthesias and 4 patients reported significant fatigue whilst undergoing therapy. Every patient improved motor control: mean delta (±SD): ARAT: +8.6 points ± 14.2; BBT: +3.5 points ± 10.8; Fugl Meyer: +3.3 points ± 4.2; volume of exploration ARMEO: +38% ± 75.1%. Discussion - Conclusion This preliminary, open-labelled, study demonstrates that this protocol is achievable in a neurorehabilitation clinic setting. Given the functional improvement seen, randomised controlled trials should be performed to further evaluate the effects on motor control.

Objective DASH, SPADI and Constant scales are commonly used for clinical evaluation of patients suffering from degenerative rotator cuff disease (DRCD) of the shoulder. However, their psychometric properties have not yet been compared. This comparison could help to choose the most suitable evaluation tool. The objective of this work is therefore to compare the psychometric properties of DASH, SPADI and Constant scales in patients with DRCD. Material/patients and methods Patients with DRCD were prospectively included. Each of the scales (0–100) were applied twice with a one-week interval before and after physiotherapy. The perceived improvement after treatment was assessed using a numerical scale (0–4). The test-retest reliability of DASH, SPADI and Constant scales was assessed before treatment using the interclass correlation coefficient (ICC, very good reliability > 0.9). The responsiveness was assessed using paired t-test (P 0.35, high > 0.5, P Results Fifty-three patients were included: age 59 ± 11 years, ratio F/M 37/16, duration of pain 27 ± 55 months, DASH 46 ± 16, SPADI 48 ± 18, Constant 53 ± 16. The test-retest reliabilities for DASH (0.97), SPADI (0.95) and Constant (0.92) scales were considered as very good. The scores for the 3 scales were improved after physiotherapy (P Discussion - conclusion The test-retest reliability of respectively DASH, SPADI and Constant scales was found to be very good in patients suffering from DRCD. The highest responsiveness is achieved with SPADI scale, the lower with Constant. These results support the high recommendation for use of SPADI scale to assess patients with DRCD.

Albert TA, Yelnik A, Bonan I, Lebreton F, Bussel B. Effectiveness of femoral nerve selective block in patients with spasticity: preliminary results. Arch Phys Med Rehabil 2002;83:692-96. Objectives: To determine if the vastus intermedius nerve can be blocked by using surface coordinates and to measure the effects of selective nerve block on quadriceps spasticity and immediate gait. Design: Case series. Setting: Physical medicine and rehabilitation department of a university hospital. Participants: Twelve patients with hemiplegia disabled by quadriceps overactivity. Intervention: Anesthesic block of the vastus intermedius by using surface coordinates, femoral nerve stimulation before and after block, and surface electrodes recording of the amplitude of the maximum direct motor response of each head of the quadriceps. Main Outcome Measures: Assessment of spasticity, voluntary knee extension velocity, speed of gait, and knee flexion when walking. Results: To be effective, the puncture point (.29 of thigh length and 2cm lateral) had to be slightly modified to 1cm laterally from a point situated at 0.2 of the thigh length. A selective block of the vastus intermedius could not be achieved, but a block of the vastus lateralis was always achieved, twice associated with a block of the vastus intermedius, resulting in decreased quadriceps spasticity, no changes in gait parameters, no decrease in voluntary knee extension velocity, and subjective improvement in gait for 3 patients. Conclusion: Selective block of the vastus lateralis with or without the vastus intermedius can be achieved by using surface coordinates without any dramatic effect on knee extension velocity, and it could be useful for phenol or alcohol block or surgical neurotomy. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Resume OBJECTIF : Apres accident vasculaire cerebral, le patient hemiplegique est souvent gene par une hyperactivite musculaire du membre inferieur. La toxine botulique est un traitement efficace de cette hyperactivite musculaire. Ce travail a ete conduit afin d’en evaluer la duree telle que ressentie par le patient. MATERIEL ET METHODE : L’etude a porte sur une cohorte de patients victimes dˈaccident vasculaire cerebral unique, genes par une hyperactivite musculaire distale du membre inferieur. L’injection intramusculaire de toxine botulique (Botox Allergan) etait realisee sous reperage par electrostimulation. L’efficacite etait mesuree par le patient, a un, trois et six mois, sur une echelle en trois points (aucune, reelle mais insuffisante, tres bonne) sur la base d’objectifs individualises, precisant pour chaque symptome le mode de declenchement et la gene que l’on souhaite attenuer. RESULTAT : Cinquante-sept seances ont ete pratiquees chez 36 patients. A un mois, 81 % des seances avaient un resultat positif, 39 % des resultats tres satisfaisants. A six mois, 57 % des seances maintenaient un resultat positif dont 25 % de resultats tres satisfaisants. Les meilleurs resultats portaient sur l’extension du gros orteil : 94 % d’efficacite a un mois, 47 % de resultats tres satisfaisants persistant a six mois. CONCLUSION : Lorsque le traitement par toxine botulique est apprecie par le patient apres definition d’objectifs personnalises, le resultat favorable obtenu peut persister largement au-dela de six mois. Les resultats doivent etre relativises par l’aspect partiellement subjectif de l’analyse proposee ici, mais celle-ci constitue le plus souvent en pratique la seule base possible des discussions therapeutiques.

Objective Neer, Hawkins, and Yocum tests are used in clinical practice to detect sub-acromial impingement as a pathogenic process of degenerative rotator cuff disorders. Reliability of Neer and Hawkins tests has been few investigated. Reliability of Yocum test has not been investigated. The goal of the study was therefore to investigate reliability of Neer, Hawkins and Yocum tests. We also considered in the study an original manoeuver as the first step of its development. Material/patients and methods Patients with shoulder pain due to degenerative rotator cuff disease were prospectively included. They were twice assessed at one-week interval by two independent observers. Results of Neer, Hawkins and Yocum tests were recorded as positive or not. Results of an original manoeuver (OM) including elevation in medial rotation followed by lateral one were also. Intra- and inter-observer reliability was assessed. Criteria of reliability were the percentage of agreement and the kappa coefficient of concordance with 95% confidence interval (CI). Kappa coefficient indicated moderate concordance if > 0.4, good > 0.61. It was considered suitable for clinical use if > 0.4. Results Thirty-four patients were included: age 60 ± 11, ratio F/M 26/8, pain duration 27 ± 67 months. For intra-observer reliability, agreement was 88%, 84% and 80% with Neer, Hawkins and Yocum tests. It was 80% with OM. Using kappa coefficient, intra-observer reliability was poor with Neer test (0.34 [–0.1;1]) and moderate with Hawkins (0.56 [0;.9]), Yocum (0.48 [0;0.8]) and OM (0.6 [0.2;0.9]). For inter-observer reliability, agreement was 88%, 79%, 73% with Neer, Hawkins and Yocum tests. It was 79% with OM. Using kappa coefficient, inter-observer reliability was poor with Yocum test (0.35 [0;0.7], moderate with Hawkins (0.54 [0.2;0.8]) and OM (0.58 [0.2;0.8]), and good with Neer (0.64 [0.2;0.9]). Discussion – conclusion Neer test was impaired by poor intra-observer reliability and Yocum test was impaired by poor inter-observer reliability. Hawkins test and OM had a balanced profile of moderate reliability suitable for clinical practice. There was a trend to higher values with OM than with Hawkins test. We underlined there an interesting profile of reliability of an original clinical manoeuver to detect sub-acromial impingement.

Objective Patient's endurance capacities are decreased after a central nervous system damage. Due to their motor impairment, the cardiorespiratory capacity assessment is compromised. The goal of this study was to assess the feasibility of an endurance-training program, without an exercise stress test but with cardiologic predefined parameters. Material/patients and methods An individualized endurance training program of 30 sessions divided into 3 sessions per week, was developed from predefined cardiovascular criteria: the heart rate (HR) throughout the exercise must be lower than that defined by Karvonen formula [Training HR = resting HR + 0.6 (220 – age – resting HR)] and the blood pressure (BP) must be lower or equal to 190 mmHg. Based on these criteria, exercise's duration and power were adjusted to obtain, in the first session, an exercise duration of 20 minutes with a perceived exertion ≤ 11/20, assessed with Borg scale. The duration and the power were gradually increased respecting a perceived exertion ≤ 12/20, to obtain, at the fifth session an exercise duration of 30 minutes. For next sessions, the duration of the effort was 30 minutes and the power was gradually increased and adjusted to keep a perceived exertion ≤ 14/20. Results Twenty-eight patients [age 51.3 ± 12.6, ratio M/F: 15/13, stroke: 19 (68%)] have fully underwent the first session of this program. Eleven have been assessed onto an arm motor driven, 11 onto a leg motor driven and 6 on a treadmill. Throughout the session, the perceived exertion was 12 ± 2, the training HR has been reached for only two patients and the blood pressure was lower than 180 mmHg for all patients. Discussion – conclusion This endurance training program can be proposed in patients after central nervous system damage to improve their endurance capacities.

The aim of this study was to assess the efficacy of dynamic humeral centering (DHC) according to Neer test results. The study was a stratified analysis of a previously reported randomized trial. The patients included had shoulder pain with impingement syndrome. Interventions were DHC or nonspecific mobilization for control. The primary outcome was the Constant score including subscores for pain, activity, mobility, and strength at 3 months. All patients improved at follow-up, with better results after DHC. There was no interaction between Neer test results, treatments, and time. However, a trend toward higher effect sizes was observed after DHC in patients with a positive Neer test in comparison with negative patients. Patients with a positive Neer test showed improvement after DHC for rotator cuff disease compared with nonspecific mobilization.

Neurological pathologies and conditions affecting the musculoskeletal system have significant effects on motor skills. Bone and joint disabilities are the most common but the most severe disabilities are linked to neurological conditions, particularly as they are often associated with cognitive deficits.

The development of European Union of Medical Specialists (UEMS) physical and rehabilitation medicine programmes of care (PRMPC) and physical and rehabilitation medicine care pathways (PRMCP) in France is a good example of the positive interaction between European and national organizations. PRMPC were defined at the European level to offer a robust template for the description and assessment of physical and rehabilitation medicine (PRM) clinical activity in various fields and contexts. An accreditation procedure was organized as a peer review. It has started to provide very informative documents. In France, discussions on this topic began in 2000. At the end of the same decade, the European approach fostered the interest of French PRM organizations in a period of negotiating with public authorities about two crucial issues: specifications required for reimbursement of functional instrumental assessments in PRM practice and funding of PRM care in postacute facilities. The French Society of PRM (SOFMER) decided to describe the PRM scope in a systematic way, emphasizing the best balance between patient needs, rehabilitation goals, relevant means and justified funding. Nine 'PRMCP' have been published since 2010 and others are in progress. PRMPC and PRMCP share the same concern about the best response offered by PRM to patients' needs. The first approach is the description of a local organization with respect to both scientific evidence and local conditions. The latter is an outline of PRM intervention related to a multidimensional pattern of patients' situations. Both enhance the role of PRM doctors, whose expertise is necessary for making a synthesis of medical diagnosis and functional assessment, for setting up a patient-centred care strategy and for supervising the rehabilitation team's intervention.

Background and Purpose— “Sinking skin flap” (SSF) syndrome is a rare complication after large craniectomy that may progress to “paradoxical” herniation as a consequence of atmospheric pressure exceeding intracranial pressure. The prevalence and characteristics of SSF syndrome after hemicraniectomy for malignant infarction of the middle cerebral artery are not well known. Methods— We analyzed a prospective cohort of 27 patients who underwent hemicraniectomy for malignant middle cerebral artery infarction. All had a clinical and brain imaging follow-up at 3 months and were followed until cranioplasty. Results— Three of 27 patients (11%) had, at 3 to 5 months posthemicraniectomy, SSF syndrome with severe orthostatic headache as the main symptom. In addition, 4 patients (15%) had radiological SSF syndrome but no clinical symptoms except partial seizures in one. Patients with SSF syndrome had a smaller surface of craniectomy (76.2 cm 2 versus 88.7 cm 2 , P =0.05) and a tendency toward larger infarct volume, an older age, and a longer delay to cranioplasty than those without this syndrome. Conclusions— SSF syndrome either clinically symptomatic or asymptomatic affects one fourth of patients 3 to 5 months after hemicraniectomy for malignant middle cerebral artery infarction. It should be diagnosed as early as possible to avoid progression to a paradoxical herniation.