B. Parratte

Descriptive anatomy of the femoral portion of the iliopsoas muscle. Anatomical basis of anterior snapping of the hip

Abstract: Anterior hip snapping is a rare clinical observation. The physiopathological hypothesis currently held is a sudden slip of the iliopsoas tendon over the iliopectineal eminence. For symptomatic cases, a surgical technique is proposed. The aim of this work is to describe the anatomy of the femoral portion of the iliopsoas, which is the target of surgery. We have studied, through dissection of embalmed cadavers, the different components of the musculotendinous complex forming the femoral portion of the muscle and the gliding apparatus associated with it. The psoas major tendon exhibited a characteristic rotation. The iliacus tendon, more lateral, received the most medial iliacus muscular fibers, then fused with the main tendon. The most lateral fibers, starting in particular from the ventral portion of the iliac crest, ended up without any tendon on the anterior surface of the lesser trochanter and in the infratrochanteric region. The most inferior muscular fibers of the iliacus, starting from the arcuate line, joined the principal tendon of the psoas major passing around it by its ventromedial surface. An ilio-infratrochanteric muscular bundle was observed, in a deeper position, under the iliopsoas tendon; it arose from the interspinous incisure and on the anterior inferior iliac spine, ran along the anterolateral edge of the iliacus and inserted without any tendon onto the anterior surface of the lesser trochanter of the femur and in the infratrochanteric area. The iliopectineal bursa was studied on horizontal cross sections of a frozen pelvis and on 5 of the non-frozen preparations after dividing the iliopsoas tendon. The iliopectineal bursa had the shape of a 5 to 6-cm high and 3-cm wide cavity; in its upper part, it was divided into 2 compartments a medial compartment for the main tendon and a lateral compartment for the accessory tendon.

Development and validation of the short form of a urinary quality of life questionnaire: SF-Qualiveen.

PURPOSE The 30-item Qualiveen is a specific health related quality of life questionnaire for urinary disorders in patients with neurological conditions, such as multiple sclerosis and spinal cord injury. Previous studies have demonstrated the reliability, validity and responsiveness of Qualiveen. However, to address the needs of large clinical trials and long-term monitoring, in which efficiency may compete with precision of measurement, we developed the 8-item self-administered SF-Qualiveen. MATERIALS AND METHODS A total of 180 English speaking and French speaking outpatients with multiple sclerosis at multiple sclerosis clinics and departments of rehabilitation in Canada and France completed the entire Qualiveen, the Multiple Sclerosis Quality of Life-54 questionnaire or its French version (SEP-59) as well as urinary function assessments at study enrollment and 2 to 10 weeks later. At visit 2 patients also made global ratings of change in urinary health related quality of life. SF-Qualiveen development and testing used this data set. RESULTS Correlations of SF-Qualiveen with its original form were high (r = 0.70 to 0.92). SF-Qualiveen proved reliable (ICC 0.83 to 0.93). Its responsiveness was similar to that of the long form (SRM 0.75 to 1.62). Correlations with other measures were consistent with our a priori predictions (weighted kappa 0.55 for cross-sectional correlations and 0.66 for correlations of change), supporting the cross-sectional and longitudinal construct validity of SF-Qualiveen. CONCLUSIONS SF-Qualiveen has excellent measurement properties, similar to those of the long form. The new instrument is likely to perform well in the clinical and research context.

Effects of a wheelchair ergometer training programme on spinal cord-injured persons

Study design: Before and after investigation of the effects of a wheelchair ergometer Training programme.Objective: To investigate the effects of an original interval-training programme on work capacity and cardiorespiratory variables with spinal cord-injured persons (SCIPs) on a wheelchair-specific ergometer.Setting: BESANCON, FRANCE.Methods: Seven SCIPs (male) performed 45 min of wheelchair ergometry three times per week, for 6 weeks. Training effects on maximal dynamic performance and endurance capacity were studied by comparison of performance and cardiorespiratory responses observed during both a maximal progressive test (10 W/2 min) and the same training session performed before and after training.Results: Training induced significant improvements in maximal tolerated power (+19.6%), in peak oxygen consumption (V O2+16%), and in oxygen pulse (O2p,+18.7%).At ventilatory threshold, significant improvements were also observed in power output (+63%), V O2VT(+ 34.1), ventilation V EVT(+ 37.1%), and V 2pVT(+ 19.9% ). Heart rate and ventilation were significantly lower (−11 and −14.6%, respectively) after training at the same work rate, while V O2 was unchanged. Between the first and the last training session, the total physical work was improved by 24.7%, whereas heart rate was unchanged.Conclusion: An interval-training programme individualised to each paraplegic subject using a wheelchair ergometer can significantly improve the fitness level and endurance capacity.

HOW TO CLINICALLY ASSESS AND TREAT MUSCLE OVERACTIVITY IN SPASTIC PARESIS

OBJECTIVE This educational paper aims to describe, in adult patients, the different aspects of muscle overactivity after a central nervous system lesion, including spasticity, spastic dystonia and spastic co-contraction, the assessment of their symptoms and consequences, and therapeutic options. DISCUSSION AND CONCLUSION Clinical evaluation involves the assessment of passive range of motion, angle of catch or clonus, active range of motion, rapid alternating movements and functional consequences. A number of scales have been developed to assess patients with spastic paresis, involving both patient and caregivers. Not all persons with spasticity require treatment, which is considered only when muscle overactivity is disabling or problematic. A list of personal objectives may be proposed for each patient, which will drive assessment and treatment. Prior to treatment the patient must be informed of the intended benefits and possible adverse events. Clinical evaluation may be supported by the use of transient neuromuscular blocks and/or instrumental analysis. Physical therapies usually represent the mainstay of treatment. Self-rehabilitation with stretching and active exercises, intramuscular injections of botulinum toxin, alcohol or phenol injections, oral or intrathecal drugs, and surgery comprise the treatment options available to the clinician. Follow-up must be scheduled in order to assess the benefits of treatment and possible adverse events.

Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments

The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.

Drug treatments for spasticity

Drug treatments for spasticity A.P. Yelnik , O. Simon , D. Bensmail , E. Chaleat-Valayer , P. Decq , P. Dehail , V. Quentin , P. Marque , B. Parratte , F. Pellas , M. Rousseaux , J.-M. Trocello , M. Uzzan , N. Dumarcet l a Department of Physical and Rehabilitation Medicine, GH Lariboisiere-F.-Widal, AP–HP, universite Paris-7, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France b Department of PRM, hopital R.-Poincare, CHU Versailles-St-Quentin-Garches, AP–HP 104, boulevard R.-Poincare, 92380 Garches, France c CMPR-Les Massues, 92, rue du Dr-Edmond-Locard, 69000 Lyon, France d Department of Neurosurgery, CHU H.-Mondor, AP–HP, 51, avenue du Marechal-de-Lattre-de-Tassigny, 94000 Creteil, France e Department of PRM, hopital Xavier-Arnozan, avenue du Haut-Leveque, 33000 Bordeaux, France f Department of PRM, hopital Saint-Maurice, 14, rue du Val-d’Osne, 94410 Saint-Maurice, France g Department of PRM, CHU Rangueil, 31000 Toulouse, France h Department of PRM, CHU Besancon 2, place St-Jacques, 25000 Besancon, France i Department of PRM, CHU Caremeau, place du Pr-Robert-Debre, 30000 Nimes, France j Department of PRM, hopital Swynghedauw, 59037 Lille, France k Department of Neurology, hopital Saint-Antoine, AP–HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France l Agence francaise de securite sanitaire des produits de sante (Afssaps), 143, boulevard Anatole-France, 93200 Saint Denis, France

Extra- and intramuscular nerve supply of the muscles of the anterior antebrachial compartment: applications for selective neurotomy and for botulinum toxin injection

Hypertonia of the upper limb due to spasticity causes pronation of the forearm and flexion of wrist and fingers. Nowadays this spasticity is often treated with injections of botulinum toxin and sometimes with selective fascicular neurotomy. To correctly perform this microsurgical technique, it is necessary to get precise knowledge of the extramuscular nerve branching in order to be better able to select the motor branches which supply the muscles involved in spasticity. The same knowledge is required for botulinum toxin injections which must be made as near as possible to the zones where intramuscular nerve endings are the densest, which is also where neuromuscular junctions are the most numerous. Thus, it is necessary to better know these zones, but their knowledge remains today imprecise. The muscles of the anterior compartment of 30 forearms were dissected, first macroscopically, then microscopically, to study the extra- and intramuscular nerve supply and the distribution of terminal nerve ramifications. The results were then linked to surface topographical landmarks to indicate the precise location of motor branches for each muscle with the aim of proposing appropriate surgical approaches for selective neurotomies. Then for each muscle, the zones with the highest density of nerve endings were divided into segments, thus determining the optimal zones for botulinim toxin injections.

The human pineal gland: Relationships with surrounding structures and blood supply

Abstract After a short overview of the history of our knowledge of the pineal gland, Its anatomy and its function, this work is primarily devoted to the relationships of the pineal gland to the nerve structures which delineate the pineal region. The complex surrounding blood vessels located in the quadrigeminal cistern are described with a special focus on the numerous venous trunks. Finally, the pineal blood supply is studied in three steps:, (1) The arterial supply obtained through several groups of pineal arteries stemming mainly from the medial posterior choroidal arteries; (2) The venous drainage by the lateral pineal veins flowing; in most cases, into the cerebral vein of Galen; (3) The intrapineal vascular architecture with specific features concerning the central part of the gland highly vascularized by large sinusoid capillaries and its peripheral part poorly vascularized by small and fine blood vessels. [Neurol Res 2000; 22: 747-790]

A SPECIFIC ARM-INTERVAL EXERCISE PROGRAM COULD IMPROVE THE HEALTH STATUS AND WALKING ABILITY OF ELDERLY PATIENTS AFTER TOTAL HIP ARTHROPLASTY: A PILOT STUDY

OBJECTIVE To investigate the influence of an arm-interval exercise program for the upper limbs on health status and walking ability in elderly patients after total hip arthroplasty. DESIGN A randomized controlled investigation. After surgery, a control group started a general rehabilitation program, and a training group combined it with an arm-interval exercise program. SUBJECTS Fourteen patients (age 75.1 +/- 4.8 years) were randomly assigned to the control group (n = 7) and the training group (n = 7). METHODS A Western Ontario and MacMaster University (WOMAC) Osteoarthritis Index was completed and an incremental exercise test on an arm crank ergometer was also performed 1 month before (T(-1)) and 2 months after surgery (T2). Moreover, a 6-minute walk test was performed at T2. RESULTS Both groups significantly improved all dimensions of WOMAC, except in WOMAC physical function subscale in the control group. The training group covered a significantly longer distance in the walking test than the control group and also presented significantly higher VO2 peak value at T2. Correlation analyses indicate that VO2 peak value and the distance covered in the 6-minute walking test were significantly associated with functional status. After calculating the ratio distance covered/score at WOMAC physical function, we observed a significantly higher ratio value in the training group than in the control group. CONCLUSION Preliminary results indicate that the improvement in physical fitness and functional status of the training group seems to be associated with better health status.

Manual needle placement: accuracy of botulinum toxin A injections.

Introduction: Electrophysiological or ultrasound guidance can facilitate botulinum toxin A (BoNt‐A) injection accuracy, but clinical landmarks and palpation are often used for superficial muscles. We evaluated the accuracy of manual needle placement in the gastrocnemius muscles (GC) guided only by anatomical landmarks and palpation. Methods: Bilateral limbs from 30 cadavers were used to evaluate ink injection into the GC. One anatomist and one orthopedic surgeon verified the accuracy of manual needle placement postinjection by calf muscle dissection. Injection was considered a failure if the ink was not located in the head of the target GC. Results: One hundred twenty‐one practitioners were evaluated. Fifty‐two injections were successful (43%), and 69 failed (57%). This result was unrelated to injector experience (P = 0.097). Conclusions: Our findings show a poor success rate, regardless of injector experience. Therefore, muscle palpation and anatomical landmarks are insufficient to ensure the accuracy of BoNt‐A injections, even for large, superficial muscles. Muscle Nerve 46: 531–534, 2012