Charles Benaim

Validation of a Standardized Assessment of Postural Control in Stroke Patients: The Postural Assessment Scale for Stroke Patients (PASS)

BACKGROUND AND PURPOSE Few clinical tools available for assessment of postural abilities are specifically designed for stroke patients. Most have major floor or ceiling effects, and their metrological properties are not always completely known. METHODS The Postural Assessment Scale for Stroke patients (PASS), adapted from the BL Motor Assessment, was elaborated in concordance with 3 main ideas: (1) the ability to maintain a given posture and to ensure equilibrium in changing position both must be assessed; (2) the scale should be applicable for all patients, even those with very poor postural performance; and (3) it should contain items with increasing difficulty. This new scale has been validated in 70 patients tested on the 30th and 90th days after stroke onset. RESULTS Normative data obtained in 30 age-matched healthy subjects are presented. The PASS meets the following requirements: (1) good construct validity: high correlation with concomitant Functional Independence Measure (FIM) scores (r=0.73, P=10(-6)), with lower-limb motricity scores (r=0.78, P<10(-6)), and with an instrumental measure of postural stabilization (r=0.48, P<10(-2)); (2) excellent predictive validity: high correlation between PASS scores on the 30th day and FIM scores on the 90th day (r=0.75, P<10(-6)); (3) high internal consistency (Cronbach alpha-coefficient=0.95); and (4) high interrater and test-retest reliabilities (average kappa=0.88 and 0.72). CONCLUSIONS Our results confirm that the PASS is one of the most valid and reliable clinical assessments of postural control in stroke patients during the first 3 months after stroke.

Pressure ulcer risk factors in persons with spinal cord injury Part 2: the chronic stage

Introduction:Pressure ulcers (PUs) are a common complication following spinal cord injury (SCI). Prevalence for persons in the chronic SCI stage varies between 15 and 30%. The risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed for designing an SCI-specific assessment tool. The first results seem quite disappointing, probably because of the level of evidence of the risk factors used.Objective:To determine PU risk factors correlated to the chronic stage of SCI.Materials and methods:Systematic review of the literature.Results:There are several PU risk factors for chronic SCI stage: socio-demographics, neurological, medical or behavioral. The level of evidence varies: it is quite high for the socio-demographics and neurological factors and low for behavioral factors.Discussion and conclusion:Behavioral risk factors (relieving the pressure, careful skin monitoring, smoking) are probably the ones for which a preventive strategy can be established. It is important to develop specific assessment tools for these behavioral risk factors to determine their relevance and evaluate the effect of therapeutic educational programs on persons with SCI.

Validation of the Aphasic Depression Rating Scale

Background and Purpose— The Aphasic Depression Rating Scale (ADRS) was developed to detect and measure depression in aphasic patients during the subacute stage of stroke. Methods— Six experts selected an initial sampling of behavioral items from existing depression rating scales. Stroke patients (aphasic and nonaphasic) were assessed with these items by the rehabilitation staff, with the Hamilton Depression Rating Scale (HDRS) for nonaphasic patients only, by a psychiatrist, and by the rehabilitation staff with Visual Analog Scales (VAS). A second item selection was conducted after a regression algorithm was run including VAS as independent variables (criterion validity) and after their factorial structure was analyzed with a principal component analysis (factorial validity). The construct validity was evaluated with respect to the other depression assessments. A threshold for the diagnosis of depression was computed with respect to the psychiatrist’s diagnosis. Interrater and test-retest reliability were assessed in 2 additional groups of aphasic patients. Results— Eighty patients participated in the study (59 aphasic). Fifteen behavioral items from existing depression rating scales were selected, and 9 were retained after the validation process. ADRS correlated highly with VAS and HDRS (r =0.60 to 0.78, P =10−4 to 10−6). With respect to the psychiatrist’s diagnosis, the sensitivity and specificity of ADRS were 0.83 and 0.71, respectively, when the threshold was set at 9/32. Its factorial structure was comparable to HDRS structure. Interrater and test-retest reliability were high (average κ coefficient of the 9 items=0.69). Conclusions— ADRS is a valid, reliable, sensitive, and specific tool for the evaluation of depression in aphasic patients during the stroke subacute phase.

Three-dimensional study of pelvic asymmetry on anatomical specimens and its clinical perspectives

The aim of this study was to assess pelvic asymmetry (i.e. to determine whether the right iliac bone and the right part of the sacrum are mirror images of the left), both quantitatively and qualitatively, using three‐dimensional measurements. Pelvic symmetry was described osteologically using a common reference coordinate system for a large sample of pelvises. Landmarks were established on 12 anatomical specimens with an electromagnetic Fastrak system. Seventy‐one paired variables were tested with a paired t‐test and a non‐parametric test (Wilcoxon). A Pearson correlation matrix between the right and left values of the same variable was applied exclusively to values that were significantly asymmetric in order to calculate a dimensionless asymmetry index, ABGi, for each variable. Fifteen variables were significantly asymmetric and correlated with the right vs. left sides for the following anatomical regions: sacrum, iliac blades, iliac width, acetabulum and the superior lunate surface of the acetabulum. ABGi values above a threshold of ± 4.8% were considered significantly asymmetric in seven variables of the pelvic area. Total asymmetry involving the right and the left pelvis seems to follow a spiral path in the pelvis; in the upper part, the iliac blades rotate clockwise, and in the lower part, the pubic symphysis rotates anticlockwise. Thus, pelvic asymmetry may be evaluated in clinical examinations by measuring iliac crest orientation.

Use of the Faces Pain Scale by left and right hemispheric stroke patients.

Abstract No pain scale is available for stroke patients due to the presence of language or cognitive disorders. However, the Faces Pain Scale (FPS), which was initially developed for children, has been used with success in adults with cognitive impairments. The aim of this study is to test whether the FPS could be used in left or right hemispheric stroke patients (LHSP, RHSP). One hundred twenty‐seven stoke patients and 21 controls were recruited in 2 rehabilitation units. Construct validity of FPS was assessed by rating and ranking facial expressions. FPS was correlated to a Visual Analog Scale (VAS) and to a Verbal Rating Scale (VRS) for the assessment of shoulder pain. Reliability was determined by test–retest procedures. Performances of RHSP in the ranking and rating procedures were very poor compared to LHSP and to controls. However, in the assessment of patients’ shoulder pain, FPS scores were highly correlated with VAS and VRS in both stroke groups (r = 0.65–0.82, p < 10−3). FPS was more reliable in LHSP than in RHSP. It was preferred to VAS and VRS in LHSP, while in RHSP VAS was the preferred scale. The present study provides preliminary support for the validity and the reliability of FPS in LHSP. However, we do not recommend its sole use in stroke patients. Further studies are needed to determine whether FPS can be used in stroke patients for assessing changes in severity of pain over time.

Pressure ulcer risk factors in persons with SCI: Part I: Acute and rehabilitation stages.

Background:Pressure ulcers (PUs) are a common complication following a spinal-cord injury (SCI). Good prevention requires identifying the individuals at risk for developing PUs. Risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed to design an SCI-specific assessment tool. The first results seem quite disappointing, probably becuase of the level of evidence of the risk factors used.Objective:To determine PU risk factors correlated to the patients with SCI, medical care management during the acute as well as in the rehabilitation and chronic stages. This first part focuses on identifying the risk factors during the acute and rehabilitation stages.Materials and methods:Systematic review of the literature.Results:Six studies met our inclusion criteria. The risk factors during the acute stage of an SCI are essentially linked to care management and treatment modalities. There is insufficient evidence to make a recommendation on medical risk factors, except for low blood pressure on admission to the Emergency Room, with a moderate level of evidence. Regarding the rehabilitation stage, no study was deemed relevant.Discussion and conclusions:Additional observational studies are needed, for both the acute and rehabilitation stages, to improve this level of evidence. However, this systematic review unveiled the need for a carefully assessed t care management and the related practices, especially during the acute stage of an SCI.

Poststroke Disposition and Associated Factors in a Population-Based Study The Dijon Stroke Registry

Background and Purpose— The organization of poststroke care will be a major challenge in coming years. We aimed to assess hospital disposition after stroke and its associated factors in clinical practice. Methods— All cases of stroke from 2006 to 2010 were identified from the population-based Stroke Registry of Dijon, France. Demographic features, risk factors, and prestroke treatments were recorded. Admission stroke severity was assessed using the National Institutes of Health Stroke Scale score. At discharge, we collected dementia, disability using the modified Rankin Scale, length of stay, and hospital disposition (home, rehabilitation, convalescent home, and nursing home). Multivariate analyses were performed using logistic regression models to identify associated factors of postdischarge disposition. Results— Of the patients with 1069 stroke included, 913 survived acute care. Among them, 433 (47.4%) returned home, whereas 206 (22.6%) were discharged to rehabilitation, 134 (14.7%) were admitted to a convalescent home, and 140 (15.3%) to a nursing home. Old patients, those under anticoagulants before stroke, those with severe stroke on admission, severe disability at discharge, dementia, or prolonged length of stay were less likely to return home. Moreover, advanced age, severe initial stroke, severe disability at discharge, and dementia were associated with admission to convalescent and nursing homes rather than rehabilitation centers. Conclusion— This population-based study demonstrated that postdischarge destinations are associated with several factors. Our findings may be useful to establish health policy concerning the organization of poststroke care.

Late Contralateral Hyperhidrosis in Lateral Medullary Infarcts

BACKGROUND AND PURPOSE This study describes unilateral increases of sweating reactions observed in the months after contralateral medullary infarct; evaluation of sympathetic cutaneous response may help to explain sweating disorders. SUMMARY OF REPORT After the discovery of the clinical phenomenon in one case, patients admitted between 1990 and 1993 were systematically evaluated clinically and electrophysiologically. In a group of five patients presenting with lateral or dorsal medullary lesions, two exhibited an increase of contralateral sweating reactions that appeared 6 to 8 months after stroke, were elicited by effort and exposure to heat and stress, and were more severe over the forehead, face, and upper trunk. In one case, this was clinically associated with an absence of sweating on the side of the lesion. During the late phase after stroke, in three patients presenting with lateral medullary lesions, electrophysiological evaluation revealed significant asymmetry of the sympathetic skin response, which was higher on the side contralateral to the lesion than on the ipsilateral side. In one patient, no response could be elicited by stimulations applied on the side of the lesion. CONCLUSIONS Contralateral hyperhidrosis can be observed in the late phase after lateral medullary infarct and is likely due to lesion of the sympathetic pathway passing through the lateral medulla, which inhibits sudomotor neurons. Evaluation of sympathetic skin response may help to explain such clinical disorders.

Are Rotations in Perceived Visual Vertical and Body Axis After Stroke Caused by the Same Mechanism

Background and Purpose— The aim of this study was to investigate whether allocentric and egocentric coordinate systems are congruently biased after hemisphere stroke, which would suggest a single underlying mechanism. Methods— The perception of the long body axis (LBA), an egocentric reference, and that of the subjective visual vertical (SVV), an allocentric reference, was assessed in both the upright position and with 30° lateral body tilts in 15 patients with a hemisphere stroke and 12 control subjects. Results— In control subjects, estimates were accurate in upright but rotated in tilted positions (LBA 7°±6° overestimation and SVV 8.8°±7.8° toward the body). In patients, SVV (−4.4°±4.6°) and LBA (−4.8°±5.3°) were congruent in upright positions and when patients were ipsilesionally tilted (1.5°±7° and 1.9°±7°, respectively). In contrast, SVV and LBA were dissociated when the body was tilted to the contralesional side with overestimation of the LBA (−9.2°±4.6°) but no effect on SVV (−4.1°±6.4°). Conclusions— Because rotations in egocentric and allocentric reference systems found after stroke are differently modulated by lateral tilts, they are not due to a single underlying mechanism. However, they share common bases and can be simultaneously reduced by ipsilesional body tilt. Differences in the way somesthetic information is integrated may explain the differences in LBA and SVV.

Evaluation of the benefits of low back pain patients’ education workshops during spa therapy

OBJECTIVES To evaluate the medium-term impact of education workshops on low back pain (LBP) in the setting of a thermal spa on: fear-avoidance beliefs, disability, pain, and satisfaction. METHODS Randomized prospective alternate-month design-type study including 360 individuals having thermal spa therapy for LBP: 188 in the intervention group (three standardized education workshops lasting 1 h 30 each and usual thermal therapy for 3 weeks), 172 in the control group (usual thermal therapy and non-standardized verbal information). The principal analysis criterion was the difference in the fear-avoidance beliefs (physical FABQ) score between baseline and 6 months after the therapy; secondary criteria were: evolution of disability (Quebec Scale) and pain intensity (Visual Analogue Scale), and satisfaction with the information received. RESULTS There was a significant reduction in the physical FABQ score at 6 months (P<0.05), and this reduction was more marked in the intervention group (-5.8±0.7 vs. -2±0.72 points out of 24; P<0.0001). Disability and pain significantly decreased in both groups (P<0.05), with no difference between groups. These workshops also had a significant effect on satisfaction with the information received. CONCLUSION Standardized education workshops have a beneficial impact on LBP and contribute to an improvement in the medical services provided during spa therapy by reducing the effect of fear-avoidance beliefs as well as relieving pain. Extending the use of such workshops could contribute to enhance the positive impact of spa therapy in the management of chronic disabling diseases.