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Urgent transfers of severely impaired patients with chronic neurological disability (PwND) from a neurological physical and rehabilitation medicine (nPRM) to an intensive care unit (ICU) or an emergency room (ER) served as the basis for this study. We hypothesized that human and structural factors interfered with but were not directly related to the acute context.We decided to use a qualitative methodology, based on in-depth interviews with 16 ICU/ER physicians. We used mixed bottom-up and top-down methods. We interpreted our data using a thematic approach based on the key principles of grounded theory, which were modified with consideration of the literature.Three main domains emerged. TheThe existence of healthcare pathways for many years has created an organizational culture between departments of nPRM and ICUs. But urgent transfers also imply organizational ethics, as a balance should be struck between utility and equity. IMPLICATIONS FOR REHABILITATIONStructural and human factors interfere in urgent transfers, involving the settings within health pathways, the key elements of negotiation to get confidence and a perceived utility of transfer, and certain categories of people, especially those with cognitive impairment.Transfers that imply negotiation between practitioners from physical and rehabilitation medicine and intensive care unit departments, lead to a need of organizational ethics, as a balance should be struck between the principles of utility and equity.The development of facilitating tools such as a commitment charter is of paramount importance as it can support ethical decision-making.

Resume Objectif Evaluer a court et moyen terme le succes de la sphincterotomie endoscopique (SE) dans la dyssynergie vesico-sphincterienne chez l’homme neurologique. Methode Etude retrospective, monocentrique, conduite chez 51 patients ayant eu une premiere SE entre janvier 2003 et juin 2018 avec au moins deux ans de suivi. Le critere de jugement principal etait le succes defini par le maintien du mode mictionnel reflexe au terme du suivi. Les criteres de jugement secondaires etaient les complications postoperatoires, le taux de reinterventions, le retentissement fonctionnel, le suivi urodynamique et le retentissement sur le haut appareil urinaire. Resultats L’âge median etait de 50,6 ans et le suivi median de 4,6 ans. Le taux de succes etait de 80 % (n = 41). Dix patients ont change de mode mictionnel dont 5 lies a une diminution de la contractilite detrusorienne. Le taux de reintervention etait de 39 %. Au terme du suivi, il est observe une amelioration significative des hyperreflexies autonomes (HRA) (26 vs 7 patients, p Conclusion La SE permet de maintenir un mode mictionnel reflexe chez 80 % des patients. Elle ameliore significativement les episodes d’HRA et d’IUF avec cependant un taux de reintervention de 39 %. Un suivi neuro-urologique regulier a long terme est necessaire afin de ne pas meconnaitre la recidive d’un obstacle sous vesical ou une diminution de la contractilite detrusorienne pouvant justifier d’une reintervention ou d’un changement de mode mictionnel. Niveau de preuve III.

International audience; Aim: To compare transanal irrigation with conservative bowel management for the treatment of bowel dysfunction in Spina bifida (SB) patients.Methods: Patients with SB and bowel dysfunction were randomly assigned to receive either transanal irrigation or conservative bowel management. The effectiveness of the treatment was defined as a decrease of 4 points in the neurogenic bowel dysfunction (NBD) score at week 10. Data on incontinence (Cleveland scores; Jorge-Wexner [JW]) and constipation (Knowles-Eccersley-Scott Symptom Constipation Score [KESS]) were recorded at 10 and 24 weeks after inclusion. Data were analysed on an intention-to-treat basis.Results: A total of 34 patients were randomised: 16 patients to conservative bowel management and 18 patients to transanal irrigation. A total of 19/31 (61%) patients improved at week 10, 13 (76%) in the transanal irrigation group versus six (43%) in the conservative group (p = 0.056). In the irrigation group, the decrease in NBD score was -6.9 (-9.9 to -4.02) versus -1.9 (-6.5 to -2.8) in the conservative group (p = 0.049 in univariate and p = 0.004 in multivariate analysis). The NBD, Cleveland (JW and KESS) and Rosenberg scores were significantly lower in the transanal irrigation group than in the conservative bowel management group at week 10.Conclusions: This prospective, randomised, controlled, multicentre study in adult patients with SB suggests that transanal irrigation may be more effective than conservative bowel management.

Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.

Objectives: To describe the employment situation of individuals with spinal cord injury (SCI) in 22 countries participating in the International Spinal Cord Injury community survey, to compare observed and predicted employment rates, to estimate gaps in employment rates among people with SCI compared with the general population, and to study differences in employment between men and women.Design: Cross-sectional survey.Setting: Community.Participants: People of employable age (N=9875; 18-64 y) with traumatic or non-traumatic SCI (including cauda equina syndrome) who were at least 18 years of age at the time of the survey, living in the community, and able to respond to one of the available language versions of the questionnaire.Interventions: Not applicableMain Outcome Measures: The observed employment rate was defined as performing paid work for at least 1 hour a week, and predicted employment rate was adjusted for sample composition from mixed logistic regression analysis.Results: A total of 9875 participants were included (165-1174 per country). Considerable differences in sample composition were found. The observed worldwide employment rate was 38%. A wide variation was found across countries, ranging from 10.3% to 61.4%. Some countries showed substantially higher or lower employment rates than predicted based on the composition of their sample. Gaps between the observed employment rates among participants with SCI and the general population ranged from 14.8% to 54.8%. On average, employment rates were slightly higher among men compared with women, but with large variation across countries. Employment gaps, however, were smaller among women for most countries.Conclusions: This first worldwide survey among people with SCI shows an average employment rate of 38%. Differences between observed and predicted employment rates across countries point at country-specific factors that warrant further investigation. Gaps with employment rates in the general population were considerable and call for actions for more inclusive labor market policies in most of the countries investigated.

Spinal cord injury (SCI) is a major cause of severe disability. This study aims to assess the effectiveness of a quality improvement program on neurological recovery after SCI. Before-after study during two phases was done in one intensive care unit in a university hospital. The quality improvement project comprised protective mechanical ventilation, early tracheostomy in anatomical injury above the sixth cervical vertebra, early enteral nutrition, early mobilization, and active perineal care in adult SCI patients. The primary endpoint was the difference between the American Spinal Injury Association (ASIA) motor score between discharge and intensive care unit (ICU) admission (Delta ASIA). Fifty-seven and 60 patients were included in the control and in the intervention period respectively. The ASIA motor score upon ICU admission was 16 (7-37) before and 11 (2-30) after the implementation (

Background The pronator teres and pronator quadratus muscles are frequently injected with neuromuscular blocking agents to improve supination in children with spastic cerebral palsy and limited active elbow supination. However, determining by simple clinical examination whether these muscles are overactive during active movement is difficult. Objective This study aimed to develop a semi-automatic method to detect pronator muscle overactivity by using surface electromyography (EMG) during active supination movements in children with cerebral palsy. Methods In total, 25 children with unilateral spastic cerebral palsy (10 males; mean [SD] age 10.6 [3.0] years) and 12 typically developing children (7 males; mean age 11.0 [3.0] years) performed pronation–supination movements at 0.50 Hz. Kinematic parameters and surface EMG signals were recorded for both pronator muscles. Three experts visually assessed muscle overactivity in the EMG signals of the children with cerebral palsy, in comparison with the reference group. The reliability and discrimination ability of the visual assessments were analysed. Overactivity detection thresholds for the semi-automatic method were adjusted by using the visual assessment by the EMG experts. The positive and negative predictive values of the semi-automatic detection method were calculated. Results Intra-rater reliability of visual assessment by EMG experts was excellent and inter-rater reliability was moderate. For the 25 children with unilateral spastic cerebral palsy, EMG experts could discriminate different profiles of pronator overactivity during active supination: no pronator overactivity, one overactive pronator, or overactivity of both pronators. The positive and negative predictive values were 96% and 91%, respectively, for this semi-automatic detection method. Conclusions Detection of pronator overactivity by using surface EMG provides an important complement to the clinical examination. This method can be used clinically, with the condition that clinicians be aware of surface EMG limitations. We believe use of this method can increase the accuracy of treatment for muscle overactivity, resulting in improved motor function and no worsening of paresis.

Objective To evaluate the clinical efficacy, urodynamic effect and safety of Botulinum Toxin A (BTXA) injections after failure of augmentation enterocystoplasty (AE) performed for neurogenic detrusor overactivity. Patients and Methods We performed a multicenter retrospective study that included patients who had AE and at least one injection of BTXA after AE in 15 GENULF (French Speaking Neuro-Urology Study Group) centers. Clinical and urodynamic data were collected from medical files according to a standardized questionnaire and colligated in an anonymous database. Results Thirty-three patients with an injection of BTXA after AC in 9 out of 15 centers were included. Mean age at the time of AE was 24 ± 15 years. Overall efficacy (defined by clinical efficacy associated with a request by the patient for reinjection) was observed in 58% of the patients. Mean maximum cystomanometric capacity increased by 28% (333 ± 145 vs 426 ± 131 mL; P = .007) and maximum detrusor pressure (Pdet max) decreased by 43% (44 ± 37 vs 25 ± 18 cm H2O; P = .02) after BTXA. Only one side effect was recorded out of the 152 procedures (transient generalized muscle weakness without respiratory distress). Conclusion In patients with failure after AE performed for neurogenic detrusor overactivity, injection of BTXA in the enlarged bladder was effective in over half of the cases with low morbidity. If this therapeutic approach were confirmed, it could be proposed as an alternative to AE surgical revision.

Scientific evidence indicates the presence of secondary conditions (such as pressure injuries) after spinal cord injury (SCI). Treatment methods focusing on the management of paraplegia and tetraplegia include systematic preventive follow-up. These advances have significantly improved the functional and vital prognosis of people with SCI, but some people may not have access to these specialized organizations or may not adhere closely to this medicalized vision. We used a narrative approach to explore the perceptions of people with SCI to better understand their adherence to follow-up.We aimed to determine the "common denominators" that lead to adherence or non-adherence to long-term follow-up after SCI.People with SCI who had completed their first rehabilitation period for1 year were included with regard to 2 variables: 1) an actual medical follow-up or not and 2) a history of pressure injury or not. A review of the literature was used as preparation for semi-directive interviews, which were prospectively analysed by using qualitative analysis software. Thematic saturation was reached at 28 interviews, and 32 interviews were ultimately completed.Three main areas concerning participants' perceptions emerged: people's readiness, appropriation and modulation of the systematic follow-up. We developed a broad conceptual framework representing follow-up and the promotion of the long-term health of people with SCI from their perspectives.The medical environment should ensure that people with SCI are ready to actively consider the implementation of prevention strategies and should take into account their ability to establish their own truth, to integrate various life stages after SCI and to negotiate systematic follow-up. The implementation of data about functioning should be conducted using the concept of the Learning Health System.

Background The impact of social support on the long-term condition after a spinal cord injury (SCI) varies across studies mainly involving self-report questionnaires. Objective We aimed to establish the common factors associated with social support leading individuals with an SCI to the effective prevention of secondary complications, including via adherence to medical follow-up. Methods Inclusion criteria were a history of acquired SCI of any etiology, wheelchair use, and age ≥ 18 years at the time of the study. Participants should have completed their initial rehabilitation program in France ≥ 1 year earlier and were also enrolled according to 2 related study variables: routine medical follow-up (patients were or were not followed up) and the medically supervised reporting of a pressure ulcer after the initial rehabilitation session (0 or ≥ 1 pressure ulcers). We performed a preparatory quantitative and qualitative literature review to identify factors affecting long-term follow-up after SCI, then adopted a narrative design with semi-structured interviews, transcribed and analyzed progressively by using qualitative analysis software. Results We included 32 participants. We categorized our results based on the knowledge, attitudes, beliefs and practices of participants with respect to pressure ulcer prevention and long-term medical follow-up. Our narrative approach allowed us to identify 3 main domains relevant to social support: reciprocity, self-management and timing related to social support. Conclusions Our study showed social support as a dynamic process, a reciprocal phenomenon evolving in variations over time. These findings should be central to short- and long-term therapeutic education programs for patients and for people providing social support. Effective changes should also be implemented through the concept of the Learning Health System.

Summary Introduction Intermittent self-catheterisation has revolutionised the management of neurogenic bladder-sphincter dysfunctions. The Liquick Base catheter is characterised by a streamlined Ergothan tip. The purpose of this study is to assess the tolerance and perception of patients using this catheter. Materials and methods A French prospective multicentre observational study was conducted on patients with neurogenic bladder-sphincter dysfunctions. Upon inclusion in the study, the doctor completed a questionnaire on the patient's pathology. After 3 and 6 months, the doctor checked for neurogenic developments or observations and looked for any complications relating to intermittent self-catheterisation. The patient completed a questionnaire to assess his or her perception of using the catheter. Results Out of 42 patients included in the study, two were excluded. Out of the 40 assessed patients (30 males, 10 females) with an average age of 50.1 ± 14.9 years, there were no reported cases of false passage. Bleeding occurred at least once in 10 patients (25%) in the first three months and in three out of 20 patients (15%) between 3 and 6 months. Two (5%) patients sought medical attention in the first three months for complications related to the catheter and 4 patients sought medical attention (10%) between 3 and 6 months. After 3 months 90% of patients were still using the catheter and after 6 months 90% of patients were still using the catheter. Conclusion The Liquick Base catheter is well tolerated. Patient perception is positive for all parameters being examined, leading to the continued use of the catheter in 90% of cases. Level of evidence 2.

The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR).We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies).Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section.Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Retrospective cohort study. To assess the effectiveness and complications of treatment for neurogenic stress urinary incontinence (nSUI) by Adjustable Continence Therapy (ACT™ and ProACT™). France. A retrospective multicentre study of consecutive patients with neurological pathologies treated for nSUI with ACT balloons. From January 2001 to January 2013, 102 patients were implanted. Mean (SD) age at implantation was 48.4 (16.5) years. Patients were followed-up for a mean 2.7 (2.3) years. After implantation, 5.9% of patients were totally continent, 51.2% had an improvement in symptoms of at least 50% (including 14.6% with improvements of at least 90%), and 48.8% had improvements of

Resume Introduction La prevalence des tumeurs de vessie (TV) chez les patients neurologiques semble similaire a celle de la population generale, mais les formes histologiques sont differentes avec une predominance de formes agressives, notamment epidermoides et infiltrantes. L’objectif de notre etude etait de rapporter les etiologies, la prise en charge et l’evolution des TV dans cette population. Materiel et methode Les dossiers des patients neurologiques ayant presente une TV entre 2004 et 2017 ont ete revus retrospectivement. Les donnees suivantes ont ete relevees : âge, sexe, duree d’evolution de la maladie, mode de decouverte, type histologique, traitement et evolution. Resultats Les dossiers de 27 patients ont ete retenus. Les vessies neurologiques concernaient 11 blesses medullaires, 7 maladies de Parkinson, 5 scleroses en plaques, 3 traumatises crâniens, 3 accidents vasculaires cerebraux, 2 paralysies cerebrales et 1 spina bifida. Les types histologiques etaient repartis ainsi : 22 carcinomes urotheliaux, 4 carcinomes epidermoides, un mucineux, un sarcomatoide et un neuroendocrine avec 19 tumeurs de haut grade et 15 tumeurs infiltrantes au diagnostic. Sept patients (26 %) ont presente une TV avant 15 ans d’evolution de la pathologie neurologique. Le recul median etait de 14 mois (1–210 mois) avec 8 deces dont 5 lies au cancer. Le tabac, le mode mictionnel ou les antecedents lithiasiques et infectieux ne semblaient pas lies a la survenue de cancer epidermoide. Conclusion Le stade avance au diagnostic et le caractere agressif des TV dans cette population justifient un suivi neuro-urologique rapproche, y compris avant 15 ans d’evolution de la pathologie neurologique. Niveau de preuve 4.

Objectives To specify outcomes and identify prognostic factors of neurologic and functional recovery in patients with an acute traumatic spinal cord injury (SCI) associated with cervical spinal canal stenosis (SCS), without spinal instability. Methods A retrospective study was conducted using data from a Regional Department for SCI rehabilitation in France. A description of the population characteristics, clinical data and neurological and functional outcomes of all patients treated for acute SCI due to cervical trauma associated with SCS was performed. A statistical analysis provided insights into the prognostic factors associated with the outcomes. Results Sixty-three patients (mean age 60.1 years) were hospitalized for traumatic SCI with SCS and without instability between January 2000 and December 2012. Falls were the most frequent cause of trauma (77.8%). At admission, most patients had an American Spinal Injury Association Impairment Scale (AIS) grade of C (43.3%) or D (41.7%) and the most frequent neurological levels of injury were C4 (35.7%) and C5 (28.6%). Clinical syndromes were frequently identified (78.6%), with the most frequent being the Brown-Sequard plus syndrome (BSPS) (30.9%), followed by central cord syndrome (CCS, 23.8%). Almost 80% of survivors returned to the community, 60% were able to walk and 75% recovered complete voluntary control of bladder function. Identified prognostic factors of favourable functional outcomes were higher AIS at admission, age under 60 years and presence of BSPS or CCS. Conclusion Traumatic SCI, associated with SCS results mostly in incomplete injuries, can cause various syndromes and is associated with favourable functional outcomes.

Objectifs Les patients avec vessie neurologique sont plus a risque de developper des calculs renaux. Les etudes sur la Mini-Nephrolithotomie percutanee (Mini-NLPC) chez ces patients sont limitees. L’objectif de notre etude etait de comparer l’efficacite et la morbidite de la Mini-NLPC a la NLPC et a l’Ureterorenoscopie souple (URSS) pour le traitement des calculs renaux de plus de 15 mm chez les patients avec vessie neurologique. Methodes Nous avons mene une etude retrospective, monocentrique entre 2005 et 2020 dans notre centre de neuro-urologie tertiaire. Les patients inclus etaient tous porteurs d’une vessie neurologique et ont ete traites pour calculs renaux de taille superieure a 15 mm, ou 10 mm s’ils etaient situes dans le calice inferieur, par l’une des trois techniques chirurgicales etudiees. Le succes etait defini par l’absence de fragment residuel (sans fragment residuel = SFR) sur le scanner de controle a 3 mois, et les complications etaient rapportees selon la classification de Clavien-Dindo. Resultats 98 patients ont ete inclus sur la periode d’etude. Les techniques operatoires se repartissaient comme suit : 76 NLPC, 46 URSS et 25 Mini-NLPC. Le taux de succes de la Mini-NLPC (SFR 37,5 %) etait comparable a la NLPC (SFR 38,2 %) et a l’URSS (SFR 37 %) (p > 0,05) pour des tailles moyennes de calculs respectivement de 30,32 mm, 52,55 mm et 25,57 mm, c’est a dire des tailles de calculs significativement plus elevees pour la NLPC(p Tableau 1 ). Conclusion Chez les patients avec vessie neurologique, la Mini-NLPC semble avoir une efficacite comparable a la NLPC avec moins de complications et des durees d’hospitalisation plus courtes, pour des tailles de calculs plus petites. La mini-NLPC apparait comme une alternative seduisante a la NLPC pour le traitement des calculs renaux entre 15 et 30 mm chez les patients porteurs d’une vessie neurologique.

To compare the neurological evolution, functional improvement, and outcomes after acute hospitalization for elderly patients with newly non-traumatic (NTSCI) and traumatic (TSCI) spinal cord injury. Retrospective single-center study conducted with a cohort of patients older than 70 years old with NTSCI and TSCI, admitted between January 2004 and December 2014.in a Rehabilitation center in Nantes France. One hundred and ten patients were included (43 TSCI and 67 NTSCI). Most of the NTSCI had incomplete paraplegia (p0.001) whereas TSCI had incomplete tetraplegia (p=0.002). Falls were the main cause of traumatic injury. NTSCI and paraplegia had a favourable neurological improvement (p=0.14 and 0.02) whereas TSCI and tetraplegia remained stable (p=0.13 and p=0.007). Therefore functional status remained stable for almost half the patients. Sixty percent of the patient get an assistance or were independent in Katz ADL Index assessment, mostly were NTSCI and paraplegic (p=0.17 and 0.40). About 44% of the patients had normal micturition at discharge, they all had incomplete lesion. Fifteen patients used intermittent catheterization, most of them were TSCI (p=0.02). Private residence was the first place of residence after discharge (47%), 17% goes in nursing home residence. NTSCI were more likely to go home at discharge (p=0.07), to have less comorbidities (p=0.08), length of stay shorter (p=0.053) and a mean age at death higher (p=0.01). Twenty-six percent of the patient deceased, mostly by respiratory problem. The etiology of the lesion and level of neurological impairment influence the neurological evolution, functional improvement and the outcomes of elderly patient with newly SCI. Rehabilitation of elderly SCI must be adapted to enhance neurological and functional recovery.

Background Stiff knee gait is a troublesome gait disturbance related to spastic paresis, frequently associated with overactivity of the rectus femoris muscle in the swing phase of gait. Objective The aim of this study was to assess the short-term effects of rectus femoris neurotomy for the treatment of spastic stiff-knee gait in patients with hemiparesis. Patients and methods An Intervention study (before-after trial) with an observational design was carried out in a university hospital. Seven ambulatory patients with hemiparesis of spinal or cerebral origin and spastic stiff-knee gait, which had previously been improved by botulinum toxin injections, were proposed a selective neurotomy of the rectus femoris muscle. A functional evaluation (Functional Ambulation Classification and maximal walking distance), clinical evaluation (spasticity – Ashworth scale and Duncan-Ely test, muscle strength – Medical Research Council scale), and quantitative gait analysis (spatiotemporal parameters, stiff knee gait-related kinematic and kinetic parameters, and dynamic electromyography of rectus femoris) were performed as outcome measures, before and 3 months after rectus femoris neurotomy. Results Compared with preoperative values, there was a significant increase in maximal walking distance, gait speed, and stride length at 3 months. All kinematic parameters improved, and the average early swing phase knee extension moment decreased. The duration of the rectus femoris burst decreased post-op. Conclusion This study is the first to show that rectus femoris neurotomy helps to normalise muscle activity during gait, and results in improvements in kinetic, kinematic, and functional parameters in patients with spastic stiff knee gait.

International audience; Background: The aim of this study was two-fold: (1) to quantify the variability of upper limb electromyographic patterns during elbow movements in typically developing children and children with unilateral spastic cerebral palsy, and to compare different amplitude normalization methods; (2) to develop a method using this variability to detect (a) deviations in the patterns of a child with unilateral spastic cerebral palsy from the average patterns of typically developing children, and (b) changes after treatment to reduce muscle activation.Methods: Twelve typically developing children ([6.7-15.9yo]; mean 11.0 SD 3.0yo) and six children with unilateral spastic cerebral palsy ([7.9-17.4yo]; mean 12.4 SD 4.0yo) attended two sessions during which they performed elbow extension-flexion and pronation-supination movements. Surface electromyography of the biceps, triceps, brachioradialis, pronator teres, pronator quadratus, and brachialis muscles was recorded. The Likelihood method was used to estimate the inter-trial, inter-session, and inter-subject variability of the electromyography patterns for each time point in the movement cycle. Deviations in muscle patterns from the patterns of typically developing children and changes following treatment were evaluated in a case study of a child with cerebral palsy.Findings: Normalization of electromyographic amplitude by the mean peak yielded the lowest variability. The variability data were then used in the case study. This method detected higher levels of activation in specific muscles compared with typically developing children, and a reduction in muscle activation after botulinum toxin A injections.Interpretation: Upper limb surface electromyography pattern analysis can be used for clinical applications in children with cerebral palsy.

IntroductionHome-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke.Methods and analysis220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored.Ethics and disseminationPatients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients.Trial registration numberNCT02944929.

AIMS To assess the outcomes of switching to a different brand of botulinum toxin A (BTA, from Botox® to Dysport®) in case of failure of intradetrusor injections (IDI) of Botox® in the treatment of neurogenic detrusor overactivity (NDO). METHODS The charts of all patients who underwent a switch to IDI of Dysport® after failure of an IDI of Botox® at six departments of neurourology were retrospectively reviewed. The main outcomes of interest were the bladder diary data and four urodynamic parameters: maximum cystometric capacity (MCC), maximum detrusor pressure (PDET max), and volume at first uninhibited detrusor contraction (UDC). RESULTS Fifty-seven patients were included. After the first injection of Dysport®, no adverse events were reported. A significant decrease in number of urinary incontinence episodes per day was observed in 52.63% of patients (P

The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18–24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications., Feasibility, safety and usefulness of phrenic neurotisation by the inferior laryngeal nerve in tetraplegic patients http://ow.ly/6S5s30fD2lf

Retrospective study reporting characteristics and management of septic arthritis of the hip due to pressure sores in spinal cord-injured patients.To describe clinical and biological data of septic arthritis of the hip and its treating management.The database of the regional SCI referral center, Nantes, France.We retrospectively collected data from 33 cases of septic arthritis of the hip in the medical files of 26 patients.We analyzed 33 cases of septic arthritis of the hip treated in one French referent center for spinal cord-injured patients from January 1988 to December 2009. Most patients had a thoracic complete paraplegia and nearly two-third (17 out of 26) had no systematic follow-up. In 25 out of 33 cases, the septic arthritis of the hip was due to a trochanteric pressure sore. The causal pressure sore was most frequently associated with a persistent drainage. The standard radiological examination led to the diagnosis in 30 cases and, in 7 questionable cases, magnetic resonance imaging was more contributory. Surgery always consisted of a wide carcinological-like excision and of a subtrochanteric proximal femoral resection including both greater and lesser trochanters. A musculocutaneous flap was realized for all cases and the choice of the muscle depended on the localization of the causal pressure sore but also of the remaining choices, as most of the patients had already undergone a prior surgery. An antibiotic treatment was adapted to multiple samples during surgery.We do advocate for a one-stage procedure including a subtrochanteric proximal femoral resection and a musculocutaneous flap.

Introduction/Background Behavioral disorders (BD) after Traumatic Brain Injury (TBI) are common and have a major impact on the patient, his family and caregivers, leading to longer length of stay in hospitalization, and difficulties of social rehabilitation. The usual psychoactive drugs are not efficient, leading to side effects harmful for neurological recovery. French guidelines about management of these BD have been elaborated by the French Society of Physical and Rehabilitation Medicine and the French High Authority for Health in July 2013. We focused on pharmacological interventions of disruptive behavior by excess (aggressiveness, agitation, irritability). Propranolol is recommended in first-line treatment, mood regulating antiepileptics in second. The purpose of this work was to evaluate the impact of the guidelines on the practitioner's prescriptions for BD in intensive care, neurosurgery and physical and rehabilitation medicine (PRM) units. We compared the period 2011–2012 versus 2014–2015. Material and method This was a retrospective, descriptive, multicentric study. All adult patients with TBI hospitalized at primary stage in PRM, in the PRM center of Nantes and Angers University Hospitals were included. Results Among 208 patients analyzed, 84 (40,4%) had BD by excess. Propranolol was more prescribed after the guidelines: 34% vs 13.5% (P = 0.03). It was prescribed at the average dose of 45 mg, guidelines recommend 40 to 80 mg. Over 21 prescriptions of Propranolol, 10 were stopped, 3 for cardiovascular side effects. Patients with BD had more psychoactive drugs prescribed (2.7 vs. 0.93, P Conclusion There is a need to inform all the doctors who take care of these patients about the guidelines. Propranolol is more prescribed but at the limit of the efficient dose, and psychoactive drugs are still long-term prescribed.

Introduction/Background Equinovarus foot is the most frequent complication in patients suffering from spastic paresis. Surgical treatment of equinovarus spastic foot includes different kinds of surgery, such as: selective tibial neurotomy, lengthening of the gastrocnemii, soleus, or Achilles tendon, tendon transfer, or rear- and midfoot arthrodesis. So far, there is a lack of precise guidelines about the surgery to consider, for these patients according to their clinical situation. Aim To describe the outcome and complications of equinovarus foot surgery. Material and method We performed an analytic, retrospective, single centre study. We included all patients with spastic paresis acquired after 18 years who were operated for an equinovarus foot, on a 12-year period. Four time points were studied: the preoperative situation, postoperative at 3 and 12 months, and the last assessment during follow-up. Considering three main clinical situations (dynamic equinus, fixed equinus and fixed rear and midfoot deformities), we described the surgical procedures and their outcomes. Results From 200 patients who underwent surgery, 126 feet were included. Forty-eight percent of patients presented with a dynamic equinus foot and had a neurotomy; in such cases 10% of surgery failed, whereas only 6% failed in fixed equinus. The rate of subjective success (assessed by the patients) was 86%. Thirty percent of patients experienced a revision surgery, and 15% presented with complications. Fifteen percent of patients had claw toes after surgery in each group. Five patients had bone surgery because of a fixed varus. The occurrence of postoperative neuropathic pain, was associated with neurotomy of the plantar nerve (P Conclusion Equinus/equinovarus foot is a complex situation in patients with spastic paresis. Several clinical pictures can be identified. An important variety of surgical procedures is performed in these patients. The predictive factors of failure and complications of such surgeries can be suggested from this study.

Study design: Review article. Objectives: To provide a consensus expert review of the treatment modality for transanal irrigation (TAI). Methods: A consensus group of specialists from a range of nations and disciplines who have experience in prescribing and monitoring patients using TAI worked together assimilating both the emerging literature and rapidly accruing clinical expertise. Consensus was reached by a round table discussion process, with individual members leading the article write-up in the sections where they had particular expertise. Results: Detailed trouble-shooting tips and an algorithm of care to assist professionals with patient selection, management and follow-up was developed. Conclusion: This expert review provides a practical adjunct to training for the emerging therapeutic area of TAI. Careful patient selection, directly supervised training and sustained follow-up are key to optimise outcomes with the technique. Adopting a tailored, stepped approach to care is important in the heterogeneous patient groups to whom TAI may be applied. Sponsorship: The review was financially supported by Coloplast A/S. Spinal Cord (2013) 51, 732–738; doi:10.1038/sc.2013.86; published online 20 August 2013

Objective To address the roles and mechanisms of co-activation in two flexor/extensor pairs during elbow extension in children with cerebral palsy (CP). Methods 13 Typically Developing (TD) and 13 children with unilateral spastic CP performed elbow extension/flexion at different speeds. Elbow angle and velocity were recorded using a 3D motion analysis system. The acceleration and deceleration phases of extension were analyzed. Co-activation of the brachioradialis/triceps and biceps/triceps pairs was computed for each phase from surface electromyographic signals. Statistical analysis involved linear mixed effects models and Spearman rank correlations. Results During the acceleration phase, there was strong co-activation in both muscle pairs in the children with CP, which increased with speed. Co-activation was weak in the TD children and it was not speed-dependent. During the deceleration phase, co-activation was strong and increased with speed in both groups; co-activation of brachioradialis/triceps was stronger in children with CP, and was negatively correlated with extension range and positively correlated with flexor spasticity. Conclusions Abnormal patterns of co-activation in children with CP were found throughout the entire movement. Co-activation was specific to the movement phase and to each flexor muscle. Significance Co-activation in children with CP is both physiological and pathological.

AIM In certain cases, a patient's anxiety, fear, or misconceptions can represent significant obstacles to the learning of Clean Intermittent Self Catheterization (CISC), and little is known about these psychological barriers. The aim of the present study is thus to construct and validate an “Intermittent Catheterization Acceptance Test (I-CAT)” to evaluate the psychological acceptance of CISC. METHODS A study was carried out in nine neuro-rehabilitation and urology departments in French university hospitals. Fifty-five items were identified, following a comprehensive review of the literature and cognitive debriefing interviews with patients. Following an initial expert panel meeting (EPM) with a French-speaking neuro-urology study group (GENULF), this list was refined and reduced to a draft I-CAT comprising 34 items. The face validity of the draft I-CAT was determined, and the results were then analyzed in a second EPM, leading to the elaboration of a second version of the I-CAT (23 items, 5 dimensions). Psychometric validation of this second version was established from a longitudinal, non-randomized study involving 201 neurological and non-neurological patients. Linguistic validation was carried out in English. RESULTS Following the construct validity analyses, several items were deleted due to item overlap, ceiling effects, or poor content validity and 14 items were retained. Confirmatory factor analysis shows that this version has 2 dimensions. Cronbach's alpha was 0.93. The ICC demonstrated good test-retest reliability and satisfactory responsiveness. CONCLUSION The upstream identification and solving of potential psychological barriers prior to the learning of CISC could improve patients’ acceptance of this procedure.

Objectives To evaluate and compare the morbidity and mortality of cystectomy–ileal conduit urinary diversion in patients with neurogenic lower urinary tract dysfunction according to the surgical approach, and to evaluate predictive factors of early and late morbidity. Methods This was a single-center retrospective study based on 65 patients operated between May 2005 and December 2011. The surgical approach consisted of: laparotomy (n = 11), laparoscopy (n = 14) and robotic (n = 40). Evaluation of early ( 30 days) morbidity and mortality was carried out according to the Clavien–Dindo classification. Results The operating time was longer (P = 0.007) and the mean time to return of bowel function was shorter (P = 0.012) in the robotic group. The early complication rate for the overall population was 41.5%: minor complications in 32.3% of cases and major complications in 9.2% of cases. A tendency towards a lower minor complication rate was observed in favor of robotic surgery (P = 0.08), with a reduction of the postoperative hemorrhagic complication rate (P = 0.03). The late complication rate for the overall population was 43.1%: minor complications in 20% and major complications in 23.1%. A lower surgical revision rate under general anesthesia was observed in favor of robotic surgery (P = 0.03). No predictive factor of early and late morbidity was identified. Conclusion Robotic cystectomy–ileal conduit urinary diversion in patients with neurogenic lower urinary tract dysfunction is feasible and safe. Its morbidity in experienced hands seems to be limited and comparable with laparoscopy or open surgery.

Objective Patients with C5/C6 tetraplegia have a paralyzed triceps. Elbow extension can be restored by transferring a preserved muscle's tendon onto the triceps’. The transferred muscle need several months of rehabilitation to adapt to its new function. Techniques like motor imagery or electromyo-feedback are being developed to improve the outcome of the surgery. However, this outcome is measured by clinical assessments, without information on muscle function. The objective is to propose a quantitative analysis of upper limb muscle activation and co-activation (CA) as supplementary outcome measurement. Material/Patients and methods Two patients with C5 and C6 tetraplegia underwent a biceps-triceps and posterior deltoid (post. deltoid.)-triceps tendon transfer (subjects A and B respectively). Subjects A and B pre-op and 5 months post-op, and a control subject C, performed active elbow extension/flexion (EF) with various degrees of shoulder abduction. Upper limb kinematics was computed, and muscle activations of the biceps, brachialis (brachia.), brachio., triceps and post. deltoid were measured by surface EMG. CA (%) was calculated as the common activation of two antagonist muscles during extension or flexion, divided by their activation during the EF cycle. Results Subjects A and B post-op became able to extend their elbow with a shoulder abducted up to 120°. At 90° of shoulder abduction, proportion of activation during extension over activation during the EF cycle was 78% for the triceps of subject C, 80% for the biceps of subject A post-op and 96% for the post. deltoid of subject B post-op. Flexor/extensor CAs during extension were Discussion/Conclusion Biceps of subject A and posterior deltoid of subject B adapted well to their new function. During rehabilitation of subject A, electromyo-feedback was used to dissociate the brachio. and the biceps, but the brachialis was not monitored. This could explain the higher brachia./biceps CA of subject A post-op during extension. Monitoring muscle activation is necessary for better management of rehabilitation after surgical restoration of elbow extension in patients with tetraplegia.

We performed a retrospective extended-spectrum β-lactamase (ESBL) molecular characterization of Proteus mirabilis isolates recovered from urine of spinal cord injury patients. A incorrectly detected TEM-24-producing clone and a new weakly expressed TEM-derived ESBL were discovered. In such patients, ESBL detection in daily practice should be improved by systematic use of a synergy test in strains of P. mirabilis resistant to penicillins.