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To conduct a systematic review to identify which tools are being used to assess body perception disturbances in Complex Regional Pain Syndrome (CRPS) and to provide an evidence-based recommendation in the selection of an assessment tool, based on measurement properties.Five electronic databases (EMBASE, Pubmed, PsycInfo, Science Direct and Web of Science) were searched for English or French written articles, with no time restrictions. All original articles using a body perception assessment tool with adult patients with CRPS were selected, regardless of their design (controlled trials, single case, qualitative study). Two investigators screened abstracts, selected full articles and extracted data independently.Thirty-eight full-text papers were obtained and three main methods to evaluate body perception disturbances were identified: The Bath Body Perception Disturbance Scale, the Neglect-like Symptoms questionnaire adapted from Galer and the patient's body perception description. No full psychometric assessments were found. The Limb Laterality Recognition Task was also used in conjunction with another method.Three main assessment methods for CRPS body perception disturbances are currently used. Full psychometric evaluation has not been completed for any of the assessment methods. As a consequence, we could not fully apply the COSMIN guideline. To date, there is no agreement concerning the use of a specific questionnaire or scale. The results indicate a need for further research such as psychometric properties of these questionnaires.This systematic review identified body perception disturbances assessment methods and their the psychometric properties in order to provide help and guidance to researchers and clinicians to investigate those clinical features.

Complex regional pain syndrome (CRPS) is a chronic pain condition with extensive symptoms. Motor imagery (MI) is a common therapy in chronic pain, however it is unknown whether patients with CRPS have a subjective MI deficit. In this single-center observational study, 120 patients were recruited, comprising 40 participants each with CRPS, chronic limb pain (CLP), and healthy individuals.. In this single-center observational study, 120 patients were recruited, comprising 40 participants each with CRPS, chronic limb pain (CLP), and healthy individuals. Participants completed the Motor Imagery Questionnaire - Revised Second (MIQ-RS) once on each side to assess their subjective kinesthetic (KMI) and visual (VMI) MI abilities. The study was performed in the University Hospital of Nîmes (France). The total MIQ-RS score and KMI and VMI subscores were compared between groups and between healthy and painful sides.. There was no difference between or within groups (p>0.05; 95% CI) for all scores. Bayesian analysis suggested that CLP patients had the same MI abilities as healthy individuals and between their healthy and painful sides for the KMI score (BF01>3). This approach allowed us to conclude that if a difference exists for CRPS patients, it is very small. Motor imagery training appears to be effective in rehabilitation programs for patients with CRPS, but not in improving a deficit in the ability to perform motor imagery. Future studies should aim to assess MI abilities by a subjective or objective method in a longitudinal study and observe changes in these abilities.

Clinical models of chronic low back pain (cLBP) highlight the role of excessive attention to pain and kinesiophobia on the origin of disability. At the motor control level, various mechanisms are involved in the impairments observed in patients with cLBP. We aimed to assess the role of maladaptative attentional behaviors by using a complex systems approach and a visual display as a distraction during walking. Sixteen patients with cLBP with no previous surgery or significant leg pain and 16 healthy matched controls were included. Patients walked on a treadmill at preferred walking speed with and without distraction. Stride time (ST) fractal complexity was assessed using detrended fluctuation analysis. A two-way analysis of variance with repeated measures on distraction was performed on fractal exponents. We found a significant group × distraction interaction effect on fractal complexity of ST series (F(1,30) = 9.972, P = 0.004). Post hoc analysis showed that, without distraction, patients with cLBP had significantly lower ST complexity than controls, but when distracted, they regained gait complexity, recovering the level of controls. Our results suggest that excessive attention to pain causes loss of complexity and adaptability in cLBP and explain alterations of motor control with pain. Fractal analysis seems to be a promising method to explore movement variability and individual adaptability in musculoskeletal disorders.

Inertial measurement units (IMUs) are a potentially useful tool for clinicians and researchers in assessing spine movement biomechanics and neuromuscular control patterns. This study assessed the between-day reliability of the HIKOB FOX IMU in measuring local dynamic stability (LDS) and variability of trunk movements in patients with chronic low back pain (LBP). The local divergence exponent (λmax) was used to quantify LDS and the mean standard deviation (MeanSD) between cycles was used to quantify variability during 30 repetitive cycles of flexion/extension, rotation, and complex movement tasks. For λmax the average coefficient of variation (CV) was ~10% in the flexion/extension and rotation tasks, and all CV values were max ranged from 0.28 to 0.81. Reliability of λmax was similar between the pelvis and thorax segments (CV: ~10%, ICC: 0.48–0.78) and worse for the lumbar spine (CV: ~15%, ICC: 0.28–0.59). The CV for MeanSD was typically in the range of 20–30%, with even greater CV in the non-primary axes during each task (30–52%). Similarly, ICC values were lowest about the anterior-posterior axis in the flexion/extension task (ICC: 0.15–0.29) and largest about the longitudinal axis in the rotation task (ICC: 0.76–0.88). The moderate between-day reliability of λmax in the sagittal and transverse planes offers improvement over manual and subjective tests with poor reliability that are currently used in clinics. The minimal detectable differences presented give a threshold for change in research and rehabilitation in patients with LBP.

International audience; Background: Individuals with chronic low back pain (cLBP) may benefit from multimodal functional restoration programs (FRPs).Objective: The aim of this study was to analyze characteristics of individuals with cLBP who were referred or not to an FRP. Because cLBP is a bio-psycho-social disorder, medical and social parameters were analysed.Methods: This was an observational cross-sectional study performed in 2017 in 6 tertiary centres in France. Consecutive individuals with cLBP visiting a rheumatologist or physical medicine and rehabilitation physician were included. Individuals referred or not to an FRP were compared by demographic characteristics, duration of sick leave over the past year, self-reported physical activity>1h/week, pain (numeric rating scale 0-10), anxiety/depression (Hospital Anxiety and Depression Scale), disability (Oswestry Disability Index) and kinesiophobia (Tampa Kinesiophobia Scale). Univariate and multivariate logistic regression analyses were performed, estimating odds ratios (ORs) and 95% confidence intervals (CIs).Results: We included 147 individuals with cLBP. The mean (SD) age was 49 (12) years and 88 (60%) were women; 58 (38%) were referred to an FRP. On multivariate analysis, referral to an FRP was associated with reduced pain level (OR: 0.95, 95% CI: 0.91-0.99, for each 1-point increase in pain score), self-reported lack of physical activity (OR: 0.84, 95% CI: 0.72-0.98) and longer sick leave (OR: 1.03, 95% CI: 1.01-1.05, for 30 more days of sick leave).Conclusion: In this multicentric observational study, referral to an FRP was linked to pain, self-reported physical activity and sick leave but not medical characteristics assessed. These findings confirm the bio-psycho-social approach of FRPs for cLBP.

BACKGROUND Technological developments have accelerated notably in the field of telecommunications in the last few decades. Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. OBJECTIVE This scoping review aimed to identify current areas of smartphone app use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development. METHODS We searched PubMed, PEDro and Embase for articles published up to May 2021 that investigated smartphone use for LBP healthcare and their purpose. RESULTS We included 42 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=5), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use. CONCLUSIONS This scoping review revealed a growing scientific literature regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage. Caution should be taken to monitor the impact of smartphone-related compulsive behavior.

If health can be defined as adaptability, then measures of adaptability are crucial. Convergent findings across clinical areas established the notion that fractal properties in bio-behavioural variability characterize the healthy condition of the organism, and its adaptive capacities in general. However, ambiguities remain as to the significance of fractal properties: the literature mainly discriminated between healthy vs. pathological states, thereby loosing perspective on the progression in between, and overlooking the distinction between adaptability and effective adaptations of the organism. Here, we design an experimental tapping paradigm involving gradual feedback deprivation in groups of healthy subjects and one deafferented man as a pathological-limit case. We show that distinct types of fractal properties in sensorimotor behaviour characterize, on the one hand impaired functional ability, and on the other hand internal adaptations for maintaining performance despite the imposed constraints. Findings may prove promising for early detection of internal adaptations preceding symptomatic functional decline.

Chronic low back pain (cLBP) affects a quarter of a population during its lifetime. The most severe cases include patients not responding to interventions such as 5-week-long in-hospital multi-disciplinary protocols. This document reports on a pilot study offering an alpha-phase synchronization (APS) brain rehabilitation intervention to a population of n = 16 multi-resistant cLBP patients. The intervention consists of 20 sessions of highly controlled electroencephalography (EEG) APS operant conditioning (neurofeedback) paradigm delivered in the form of visual feedback. Visual analogue scale for pain, Dallas, Hamilton, and HAD were measured before, after, at 6-month and 12-month follow-up. Full-scalp EEG data were analyzed to study significant changes in the brain’s electrical activity. The intervention showed a great and lasting response of most measured clinical scales. The clinical improvement was lasting beyond the 6-month follow-up endpoints. The EEG data confirm that patients did control (intra-session trends) and learned to better control (intersession trends) their APS neuromarker resulting in (nonsignificant) baseline changes in their resting state activity. Last and most significantly, the alpha-phase concentration (APC) neuromarker, specific to phase rather than amplitude, was found to correlate significantly with the reduction in clinical symptoms in a typical dose–response effect. This first experiment highlights the role of the APC neuromarker in relation to the nucleus accumbens activity and its role on nociception and the chronicity of pain. This study suggests APC rehabilitation could be used clinically for the most severe cases of cLBP. Its excellent safety profile and availability as a home-use intervention makes it a potentially disruptive tool in the context of nonsteroidal anti-inflammatory drugs and opioid abuses. These slides can be retrieved under Electronic Supplementary Material.

Background Flap surgery for deep pelvic pressure ulcers (PPUs) has been found effective, but the recurrence rate remains high and few risk factors have been identified. Objective We evaluated risk factors for PU recurrence after primary flap surgery in people with spinal cord injury (SCI). Patients and methods This observational retrospective study based on medical charts included all individuals with SCI who underwent primary flap surgery for a PPU in the Herault department in France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomic and care management factors were studied. The primary outcome was PPU recurrence (surgical site and/or other pelvic site). The secondary outcome was recurrence at the surgical site. Cox proportional hazards regression was used to determine associated factors, estimating hazard ratios (HRs) and 95% confidence intervals (CIs). Results We included 85 patients. Half had a PPU recurrence, and in one-third, the recurrence was at the surgical site. On multivariate analysis, global PPU recurrence was associated with colostomy (HR = 2.79) and living with a partner (HR = 2.29). Non-traumatic SCI and sacral wound were associated with PPU recurrence (HR = 3.39, HR = 0.48) and recurrence at the surgical site (HR = 3.3, HR = 0.3). Conclusion Risk factors of PPU recurrence are based on both biomedical and social models. After primary flap surgery, the risk of recurrence justifies regular follow-up and strict monitoring.

International audience; Since 1988, France has been committed to drafting laws regulating clinical research. These laws must both reflect general legal standards relating to personal data protection and patient information and comply with EU regulations, which are supra-national norms. The 2012 legislation known as "Jardé law" came into force in 2016 and distinguishes between 3 different types of research involving human subjects: category 1:interventional research implying an intervention on the patient which is not justified by their usual treatment. Category 2: interventional research, which does not focus on medicinal products and only entails minimal risks and constraints. Category 3: non-interventional research implying one or multiple acts or proceedings devoid of listed risks. These studies require preliminary favourable opinions from the French Ethical Research Committees (CPP), who are appointed by the State, and must ensure the protection of personal data. For the other types of studies (retrospective data, practice surveys), French legislation only requires that the protection of personal data is ensured. However, it is highly recommended to submit these studies to an Institutional Review Board (IRB) in order to confirm that human subjects are not involved and to obtain an ethical opinion in the event of a scientific journal submission. These laws are constantly evolving in order to comply with the various international recommendations and European regulations, which are binding in France.

International audience; Botulinum toxin-A (BoNT-A) blocks acetylcholine release at the neuromuscular junction (NMJ) and is widely used for neuromuscular disorders (involuntary spasms, dystonic disorders and spasticity). However, its therapeutic effects are usually measured by clinical scales of questionable validity. Single-fiber electromyography (SFEMG) is a sensitive, validated diagnostic technique for NMJ impairment such as myasthenia. The jitter parameter (µs) represents the variability of interpotential intervals of two muscle fibers from the same motor unit. This narrative review reports SFEMG use in BoNT-A treatment. Twenty-four articles were selected from 175 eligible articles searched in Medline/Pubmed and Cochrane Library from their creation until May 2020. The results showed that jitter is sensitive to early NMJ modifications following BoNT-A injection, with an increase in the early days’ post-injection and a peak between Day 15 and 30, when symptoms diminish or disappear. The reappearance of symptoms accompanies a tendency for a decrease in jitter, but always precedes its normalization, either delayed or nonexistent. Increased jitter is observed in distant muscles from the injection site. No dose effect relationship was demonstrated. SFEMG could help physicians in their therapeutic evaluation according to the pathology considered. More data are needed to consider jitter as a predictor of BoNT-A clinical efficacy.

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

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

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

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

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

Letter; International audience; Dear Editor. We read with interest the letter ‘‘Pelvic parameters and sagittal alignment in people with chronic low back pain and active discopathy (Modic 1 changes): a case–control study’’ by Blandin et al. [1] and would like to propose some comments.

Background Indications and techniques of rehabilitation differ widely across types of lumbar surgery, including timing (before or after surgery) and prescriptions (surgeons but also medical or paramedical professionals). Objectives This project aimed to build consensual recommendations for practice in this context. Methods The SOFMER methodology was used to establish recommendations for physical medicine and rehabilitation: a steering committee defined the types of lumbar surgery involved and developed the main questions to be addressed; a scientific committee performed a literature review for grading evidence and proposed the first version of recommendations, which were discussed during a dedicated session at the national Physical and Rehabilitation Medicine congress; then an e-Delphi method with cross-professional experts was used to finalise recommendations and reach a multidisciplinary consensus. Results The main questions developed were the value of rehabilitation before and after surgery, timing and type of rehabilitation, benefit of supervision and instrumental rehabilitation, value of patient education, and complementary interventions concerning rehabilitation for discectomy, fusion, and disc prosthesis (excluding decompression for spinal stenosis). The literature review identified 60 articles, but for several of the questions, no article in the literature addressed the issue. The multidisciplinary scientific committee analysed the literature and addressed the questions to propose the first version of a set of 23 recommendations. The congress session failed to answer all questions or to reach consensus for all items. After a three-step e-Delphi, 20 recommendations were retained, for which consensus among experts was reached. The recommendations are applicable only to patients without a neurological lesion. Conclusions These recommendations provide important and consensual knowledge to assist clinicians in decision-making for rehabilitation in lumbar surgery. Despite many of the recommendations relying exclusively on expert opinion rather than published evidence, this approach is an important advance to improve concordance among healthcare professionals.

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

Letter; International audience; Isokinetic testing is currently considered the gold standard for measuring dynamic muscle thigh strength (hamstring and quadriceps) [1], [2]. Isokinetic thigh muscle testing can provide valuable information to design effective preventive strategies for athletes.

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

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

Letter; International audience; Dear editor, Lumbar spinal stenosis (LSS) is the narrowing of the lumbar canal caused by degenerative processes [1]. LSS results in back and lower-limb pain when standing and walking, and symptoms regress in sitting position [1]. These symptoms are named neurogenic claudication and result from mechanical irritation and from exercise-induced ischemia of the cauda equina [2]. The inability to stand or walk alters functioning and health-related quality of life (HRQoL)

Unfortunately, the original version of this article has been published without the electronic supplementary material.

International audience; OBJECTIVE:This study compared the effects of high-force versus low-force lumbar traction in the treatment of acute lumbar sciatica secondary to disc herniation.METHODS:A randomized double blind trial was performed, and 17 subjects with acute lumbar sciatica secondary to disc herniation were assigned to high-force traction at 50% body weight (BW; LT50, n = 8) or low force traction at 10% BW (LT10, n = 9) for 10 sessions in 2 weeks. Radicular pain (visual analogue scale [VAS]), lumbo-pelvic-hip complex motion (finger-to-toe test), lumbar-spine mobility (Schöber-Macrae test), nerve root compression (straight-leg-raising test), disability (EIFEL score), drug consumption, and overall evaluation of each patient were measured at days 0, 7, 1, 4, and 28.RESULTS:Significant (P < .05) improvements were observed in the LT50 and LT10 groups, respectively, between day 0 and day 14 (end of treatment) for VAS (-44% and -36%), EIFEL score (-43% and -28%) and overall patient evaluation (+3.1 and +2.0 points). At that time, LT50 specifically improved in the finger-to-toe test (-42%), the straight-leg-raising test (+58), and drug consumption (-50%). No significant interaction effect (group-by-time) was revealed, and the effect of traction treatment was independent of the level of medication. During the 2-week follow-up at day 28, only the LT10 group improved (P < .05) in VAS (-52%) and EIFEL scores (-46%). During this period, no interaction effect (group-by-time) was identified, and the observed responses were independent of the level of medication.CONCLUSIONS:For this preliminary study, patients with acute lumbar sciatica secondary to disc herniation who received 2 weeks of lumbar traction reported reduced radicular pain and functional impairment and improved well-being regardless of the traction force group to which they were assigned. The effects of the traction treatment were independent of the initial level of medication and appeared to be maintained at the 2-week follow-up.

Many practitioners, pediatricians, and general practitioners prescribe physical therapy when tracking scoliosis. However, has physical therapy alone proved its efficacy in the care of the scoliosis to slow down progression? Our purpose is to report the results of a literature review on the effectiveness of rehabilitation in idiopathic scoliosis. No current study presents sufficient scientific proof to validate the efficacy of isolated exercise therapy in scoliosis. Learned societies recognize, however, the efficacy of combining conservative therapy (brace+physiotherapy) in idiopathic scoliosis. Should we then still prescribe rehabilitation without brace treatment? Although physical therapy alone does not seem effective in treating scoliosis, it can limit potential painful phenomena and be beneficial for respiratory function. The physical therapist can also teach the teenager the classic principles of hygiene of the back. It may therefore be appropriate to prescribe physical therapy, but the principles and objectives must be explained to the patient and family in light of current evidence-based medicine.

Background Functional Restoration Programs (FRP) are multi-disciplinary programs that have demonstrated effectiveness to promote functional status and return to work in patients with chronic low back pain (cLBP)1; 2; 3 and moderate or high disability. Objectives To explore the characteristics of cLBP patients oriented or not towards a FRP. Methods This was an observational cross-sectional, multi-centric study in France in 2017. Consecutive patients with cLBP (>6 weeks) with or without radiculalgia, aged 18–66 years and visiting the rheumatologist for cLBP were included. Patient and disease characteristics were collected. Patients oriented or not towards a FRP were compared in particular for demographic characteristics, duration of sick leave over the past 12 months, smoking, ongoing aerobic physical activity (patient-reported as 40%) and kinesiophobia (Tampa Kinesiophobia Scale≥40). Results In all, 166 patients were analysed: median age 48 years, median cLBP duration 5 years, and 100 (60%) were females. Overall, 62 (37%) were proposed for a FRP. Patients oriented towards a FRP, versus not, were more frequently male (50% vs 44%, p=0.04), younger (median 46 vs 52 years, p=0.02), and had lower pain levels (median 6 vs 7 of 0–10 numeric scale, p=0.006). They had longer sick leave (mean 18 vs 10 weeks/year, p=0.006), were more frequently smokers (33% vs 23%, p=0.02), had similar pain duration (60 month vs 72, p=0.32), functional disabilities (39% vs 49%, p=0.22), kinesiophobia (62% vs 55%, p=0.65), anxiety (52% vs 55%, p=0.60) and depression score (40% vs 35%, p=0.54), but less physical activity practice (38% vs 54%, p=0.04). Conclusions Patients oriented towards a FRP were younger and more often males, with higher smoking and longer sick leave. It appears that kinesiophobia, functional status and duration of low back pain didn’t influence the orientation toward a FRP. More comprehensive assessments of patients with cLBP are needed; multifactorial questionnaires such as StartBack or BP2 may be useful to orient patients towards FRPs. References [1] Poulain C, et al. Eur Spine J2010Jul;19(7):1153–61. [2] Veron O, et al. Ann Readapt Med Phys2008;51(8):642–9. [3] Roche-Leboucher, et al. Spine2011Dec 15;36(26):2235–42. Disclosure of Interest None declared

Background Functional restoration programs (FRP) are multi-disciplinary programs that have demonstrated their effectiveness in chronic low back pain (CLBP) but they appear to be little known by patients and/or physicians. Objectives To assess the knowledge and expectations of CLBP patients and physicians about FRP. Methods Multicenter cross-sectional study in 2017 in 6 tertiary-care hospitals in France. Consecutive patients with CLBP (more than 6 weeks) who were seen for their CLBP were included. Physicians (rheumatologists or general practitioners, GPs) who had referred at least 5 patients to the tertiary-care centres were sent a survey. Patients and physicians were asked about their knowledge and expectations of a FRP. Results were scored as ‘correct’ regarding health professionals involved in the FRP, if both doctors and (physiotherapists or physical activity coach) were ticked; and ‘correct’ for duration if 3 to 6 weeks. Expectations regarding the FRP were rated on a list of potential expectations on a scale of 0–10. Expectations were scored ‘ correct’ if return to work was scored ≥7/10, and ‘fully correct’ if physical activity and pain management, but not ‘healing’ were also expected. Responses were then compared between patients and physicians by Chi 2 test. Results Of 172 patients, median age 48 years (IQR 38–58), median CLBP duration 5 years (IQR 2–10), 60.0% women: 110 (64.0%) had no knowledge of FRP; 22 had already participated in an FRP. The remaining 40 patients were compared to physicians (figure 1). Of 80 physicians, 42.5% GPs and 53.7% rheumatologists, 57.5% women: 21 (26.2%) had no knowledge of FRP (p value Knowledge of FRP health professionals was ‘correct’ for 13/40 (32.5%) patients vs 41/59 (69.5%) physicians (p=0.0003); and knowledge of duration was ‘correct’ for 26/40 (65.0%) vs 46/59 (78.0%) physicians (p=0.15). Expectations were ‘correct’ for 21/40 (52.5%) patients vs 44/59 (74.6%) for physicians (p=0.02), and ‘fully correct’ for 9/40 (22.5%) patients vs 16/59 (27.1%) for physicians (p=0.6). Conclusions FRP was largely unknown to patients with CLBP. Even those who were aware of the FRP did not know what to expect. While physicians’ knowledge and perception of the FRP was better, there was still a lack of knowledge and therefore a likely underutilization or misuse of the FRP. Information campaigns are needed. Disclosure of Interest None declared

We aimed to determine whether a 5-day intensive inpatient spa and exercise therapy and educational program is more effective than usual care in improving the rate of returning to work at 1 year for patients with subacute and chronic low back pain (LBP) on sick leave for 4 to 24 weeks. We conducted a 12-month randomized controlled trial. LBP patients were assigned to 5-day spa (2 hr/day), exercise (30 min/day) and education (45 min/day) or to usual care. The primary outcome was the percentage of patients returning to work at 1 year after randomization. Secondary outcomes were pain, disability and health-related quality of life at 1 year and number of sick leave days from 6 to 12 months. The projected recruitment was not achieved. Only 88/700 (12.6%) patients planned were enrolled: 45 in the spa therapy group and 43 in the usual care group. At 1 year, returning to work was 56.3% versus 41.9% (OR 1.69 [95% CI 0.60–4.73], p = 0.32) respectively. There was no significant difference for any of the secondary outcomes. However, our study lacked power.

After a serious head trauma, the return home constitutes a key moment in the patient's reintegration. It is prepared by a multi-disciplinary team throughout the rehabilitation and re-adaptation process, taking into account the patient's prognosis for recovery.