Dominique Boisson

Selective Posterior Rhizotomy in the Dorsal Root Entry Zone for Treatment of Hyperspasticity and Pain in the Hemiplegic Upper Limb

The authors report a series of 16 hemiplegic patients suffering from harmful spasticity in the upper limb and treated with selective posterior rhizotomy (SPR) in the dorsal root entry zone (DREZ). This severe spasticity was associated with irreducible abnormal postures in flexion in 11 cases and painful manifestations in 12. The method was introduced in 1972 on the basis of anatomical studies of the DREZ in humans, in which a topographical segregation of the root afferents, according to their anatomicofunctional destinations, has been shown. It consists of a DREZ microsurgical lesion 1 to 2 mm in depth and directed at a 45 degree angle, performed ventrolaterally in the posterolateral sulcus of the spinal cord and into the internal part of the Lissauers tract. The procedure is carried out in each rootlet of the posterior roots considered to be responsible for the harmful spasticity. SPR interrupts selectively the (lateral) nociceptive and (central) myotactic afferent fibers connecting the motor neurons, while sparing most of the (medial) lemniscal fibers and the inhibitory circuitry of Lissauers tract and the dorsal horn. The results were evaluated after a 1- to 12-year follow-up. There were no deaths and no general complications; in 1 case a loss of motility in the leg ipsilateral to the procedure occurred. The excess of spasticity was slightly diminished (2 cases), markedly reduced (9 cases), or totally abolished (5 cases), making possible an improvement in voluntary movements in 8 patients and at least a good passive mobilization in 7 further cases. In 1 case only, a marked tendency for spasticity to return was observed. Of the 12 patients with painful manifestations, 9 were completely relieved and 3 improved. These beneficial effects on both spasticity and pain led to a gain in functional status in 93% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Ankle dorsiflexion delay can predict falls in the elderly.

The aim of this study was to investigate the kinematic and kinetic characteristics of walking in healthy non-faller elderly in order to develop predictive parameters for falls. A 1-year prospective trial was completed on a walking circuit with two integrated force platforms and an optoelectronic system for three-dimensional movement analysis. Gait was investigated in 54 volunteers who were healthy people over 60 who had not fallen in the previous year. The subjects were contacted 2-monthly over a period of 1 year. The results showed that 16 of the 54 people tested had fallen. There was no significant age difference between the group of fallers and the group of non-fallers. Fallers walked more slowly and tended to use a double support for a longer period of time. Fallers were less powerful but mainly showed fewer power and moment variations. The range of motion at the ankle and the hip was reduced. We noticed a change in the walking pattern, showing a delay in the dorsiflexion of the ankle at the swing phase. In conclusion, subclinical gait parameters occur in older people. The advent of neuromotor pattern alterations when walking is related to the tendency to fall. Ankle dorsiflexion delays, in particular, appear to be predictive of falls.

Functional outcome after road-crash injury: Description of the ESPARR victims cohort and 6-month follow-up results

OBJECTIVE It is essential to know about the long-term consequences of road crashes involving corporal injury in order to adopt relevant public health measures. METHODS The ESPARR cohort comprises 1168 road-crash victims, aged 16 or over, managed in hospitals in the Rhône administrative départment (France). It is based on the Registry of Road Traffic Casualties, which has been collecting exhaustive data since 1995. Two groups are monitored: mild to moderate (M-AIS 1 or 2) and severe (M-AIS > or =3). Patients were interviewed at the point of primary care, between 1 October 2004 and 31 July 2006. 6 months later, their state of health and presence of pain were compared. Multivariate analysis (logistic regression) was performed to identify factors related to residual pain. RESULTS Adults of the cohort were compared to the road crash population as a whole recorded over the same period in the same area. At 6 months post-accident, only 31.9% of victims deemed their health status to have entirely returned to normal; 63.8% of mild to moderate and 89.2% of severe cases reported residual pain, but neither pain frequency nor intensity correlated with M-AIS. Residual pain was related to lower limb injuries (OR=1.6; 95% CI=1.1-2.4). After adjustment, pain was essentially related to age, seriousness of the lesions and a stay in a rehabilitation unit. CONCLUSION The ESPARR cohort provides a unique opportunity in France to describe the trajectory of a road crash victim, in terms both of care and rehabilitation and of resumption of work and personal activity.

Predictive factors of chronic post-traumatic stress disorder 6 months after a road traffic accident

BACKGROUND This study sets out to identify risk factors for post-traumatic stress disorder (PTSD) after a road traffic accident with a view to improving prevention. METHODS The study used a prospective cohort of road traffic accident casualties. All subjects over 15 years of age were recruited in the course of an interview conducted while they were receiving care in a hospital of the Rhône area administrative département. Six months after their accident, they answered a self-administered postal questionnaire that included the Post-traumatic Check-List Scale (PCLS) in order to evaluate PTSD. Multivariate logistic regression analysis was conducted to compare those subjects with a PCLS score of 44 or over with those with a lower score, in order to identify factors that might be associated with PTSD. RESULTS 592 subjects (out of 1168) returned the 6-month questionnaire and 541 completed the PCLS test. One hundred subjects had a PCLS score ≥ 44, suggesting PTSD, and 441 subjects did not. The factors associated with PTSD were initial injury severity, post-traumatic amnesia, the feeling of not being responsible for their accident and persistent pain 6 months after it. A lower odds-ratio was associated with users of two-wheel than four-wheel motor vehicles (OR=0.4; 0.2-0.9). CONCLUSION Besides predictive factors for PTSD (injury severity, post-traumatic amnesia and the feeling of not being responsible for their accident), our study suggested a reduced risk of PTSD among two-wheel motor vehicle users.

Return to work following road accidents: Factors associated with late work resumption

OBJECTIVE To analyse factors associated with late return to work in road accident victims. MATERIALS AND METHODS The ESPARR cohort comprises road accident victims monitored over time from initiation of hospital care. A total of 608 ESPARR cohort subjects were working at the time of their accident and answered questionnaires at 6 months and/or 1 year. For each level of overall severity of injury (Maximum - Abbreviated Injury Scale (M-AIS) 1, 2, 3 and 4-5), a time-off-work threshold was defined, beyond which the subject was deemed to be a late returner; 179 subjects were considered to be late in returning to work, while 402 showed a normal pattern of return. Logistic regression identified factors associated with late return. RESULTS Type of journey, overall injury severity and intention to press charges emerged as factors predictive of late return to work on the basis of the data collected at inclusion alone. After adjustment, pain (odds ratio (OR): 2.6; 95% confidence interval (95% CI) 1.0-6.7) and physical sequelae (OR: 3.8; 95% CI 1.7-8.3) at 6 months and the fact of pressing charges (OR: 2.6; 95% CI 1.2-5.5) remained significantly linked with late return to work. CONCLUSION Impaired health status at 6 months after the initial accident (in the form of persistent pain and physical sequelae) is a determining factor delaying return to work following a road traffic accident.

Diseases, consumption of medicines and responsibility for a road crash: A case-control study

UNLABELLED The role of medical conditions in crashes is a topic of public debate. Some studies suggest that there has been a reduction in road traffic crashes subsequent to the medical restrictions introduced on drivers with medical deficiencies. As in todays society the car is an important factor for independence and socialization, it seems important to consider whether diseases or consumption of drugs increase the risk of causing a road crash in comparison to well-known major crash risk factors. A case-control study was conducted (733 injured drivers). The cases were subjects who were partly or totally responsible for their crash. The 304 controls were the non-responsible drivers. Diseases and medicine consumption were analyzed using logistic regression models. Cases were characterized by a higher percentage of young men. They were more frequently affected by fatigue, as were subjects who had consumed alcohol. A higher risk in subjects suffering from hypertension is observed (adjusted odds ratio [adjOR]=3.82; 95%CI=[1.42-10.24]). An association between antidepressant consumption and responsibility appeared (adjOR=3.61; 95%CI=[1.30-10.03]). CONCLUSION Medical factors associated with responsibility were arterial hypertension and antidepressant consumption. Other medical conditions do not seem to play a preponderant role comparing to individual behaviours.

Constraint therapy versus intensive training: Implications for motor control and brain plasticity after stroke

Many studies have demonstrated that constraint induced movement therapy (CIMT) improves upper limb motor impairment following stroke. This rehabilitation method combines constraint of the less-affected upperlimb with intensive training of the paretic limb. The aim of the present study was to evaluate, in a single case study, the respective effects of each of these two therapeutic interventions. The patient selected was a 32-year-old right-handed woman. Three and a half years prior to inclusion, she suffered a left capsular infarct responsible for a right hemiparesis. Several assessments were carried out before and after constraint therapy and then after intensive training. Each assessment included measures of hand function as well as a three-dimensional (3D) analysis of prehension. Results showed a significant improvement of motor performance after the constraint period and an additional amelioration after the intensive training period. Kinematic analysis showed that the transport phase of movement (movement time and velocity peaks) was improved after the constraint period, whereas the grasping phase (maximum grip aperture) was modified after intensive training. These data could reflect a specific effect of treatment on each phase of the prehension task, or a more general proximal-to-distal gradient of recovery. Although firm conclusions are not warranted on the basis of this single case study, we confirm the utility of 3D motion analysis to evaluate objectively the effectiveness of a therapeutic intervention. We also discuss the implications of our findings for understanding processes of motor control reorganisation.

Cognitive and behavioural post-traumatic impairments: What is the specificity of a brain injury ? A study within the ESPARR cohort

OBJECTIVE The variety and extent of impairments occurring after traumatic brain injury vary according to the nature and severity of the lesions. In order to better understand their interactions and long-term outcome, we have studied and compared the cognitive and neurobehavioral profile one year post onset of patients with and without traumatic brain injury in a cohort of motor vehicle accident victims. METHOD The study population is composed of 207 seriously injured persons from the ESPARR cohort. This cohort, which has been followed up in time, consists in 1168 motor vehicle accident victims (aged 16 years or more) with injuries with all degrees of severity. Inclusion criteria were: living in Rhone county, victim of a traffic accident having involved at least one wheel-conducted vehicle and having occurred in Rhone county, alive at the time of arrival in hospital and having presented in one of the different ER facilities of the county. The cohorts representativeness regarding social and geographic criteria and the specificities of the accidents were ensured by the specific targeting of recruitment. Deficits and impairments were assessed one year after the accident using the Neurobehavioral Rating Scale - Revised and the Trail-Making Test. Within our seriously injured group, based on the Glasgow Score, the presence of neurological deficits, aggravation of neurological condition in the first 72hours and/or abnormal cerebral imaging, we identified three categories: (i) moderate/severe traumatic brain injury (n=48), (ii) mild traumatic brain injury (n=89), and (iii) severely injured but without traumatic brain injury (n=70). RESULTS The most frequently observed symptoms were anxiety, irritability, memory and attention impairments, depressive mood and emotional lability. While depressive mood and irritability were observed with similar frequency in all three groups, memory and attention impairments, anxiety and reduced initiative were more specific to traumatic brain injury whereas executive disorders were associated with moderate/severe traumatic brain injury. DISCUSSION-CONCLUSION The presence and the initial severity of a traumatic brain injury condition the nature and frequency of residual effects after one year. Some impairments such as irritability, which is generally associated with traumatic brain injury, do not appear to be specific to this population, nor does depressive mood. Substantial interactions between cognitive, affective and neurobehavioral disorders have been highlighted.

The female paraplegic: a statistical survey

From November 1969 to December 1979, 1234 patients with spinal cord lesions were treated at the Henry Gabrielle Hospital. Of these 386 were from medical causes and 848 from trauma. The computer study of these cases brings out statistical differences between the sexes as the overall incidence in females is 30 per cent and even lower if one considers traumatic cases only 22.4 per cent out of the 848 cases. Furthermore, the average female paraplegic is two years older and it was noted that more females are married. In females the causes of spinal cord injuries are more frequently car accidents and suicidal falls from high places, whereas in males the causes are related to direct blows, that is sport injuries, motorcycle accidents and industrial falls.Clinical symptoms are similar in the two groups with the exception that there is less heterotopic ossifications and fewer bladder stones in females. The duration of hospitalisation is shorter in females. A well equipped household is more important for the handicapped females than for males.

Evaluation of the Injury Impairment Scale, a tool to predict road crash sequelae, in a French cohort of road crash survivors

Objective: The objective of the present study was to validate sequelae prediction by the Maximal Injury Impairment Score (M-IIS) in comparison with the Functional Independence Measure (FIM) assessed at 1-year follow-up of severe road crash victims. Methods: The study population came from “the Etude et Suivi d’une Population d’Accidentés de la Route dans le Rhône” (ESPARR; Rhône Area Road Crash Victim Follow-up Study) cohort: 178 victims (with Maximal Abbreviated Injury Scale ≥ 3) of road crashes in the Rhône administrative department of France, aged ≥ 16 years and with medical examination including FIM scoring 1 year postaccident. Two thresholds were tested for both scores. Firstly, the relation between FIM and M-IIS was assessed on logistic regression models adjusted on age and presence of complications at 1 year postaccident. The predictive capacity of M-IIS was expressed as its negative and positive predictive values and was considered good when 80 percent or better. Results: Sixty-three of the 178 adult subjects (mean age = 37.7 years; range = 16.1–82.9 years) showed postaccident complications. One-year sequelae prediction on M-IIS was greater in head, spine, and limb lesions but limited to slight impairments (M-IIS = 1). There was a significant correlation between FIM and M-IIS, although age and medical complications were confounding factors on certain multivariate models. The predictive capacity of M-IIS was low for all types of sequelae. Conclusions: M-IIS, in this severely injured population, failed to predict sequelae at 1 year as measured by the FIM, despite a good correlation between the two. Complications are to be taken into account in assessing the M-IISs capacity to predict sequelae. Further evaluation will be needed on larger series or assessment of other indicators and measures of sequelae at 1 year to obtain a robust tool to predict road crash sequelae.