Etienne Allart

Anatomical and psychometric relationships of behavioral neglect in daily living

Spatial neglect has been related to both cortical (predominantly at the temporal-parietal junction) and subcortical (predominantly of the superior longitudinal fasciculus) lesions. The objectives of this observational study were to specify the anatomical relationships of behavioral neglect in activities of daily living (N-ADLs), and the anatomical and psychometric relationships of N-ADLs on one hand and components of neglect (peripersonal neglect and personal neglect) and anosognosia on the other. Forty five patients were analyzed for behavioral difficulties in daily living (on the Catherine Bergego scale) and the main components of neglect (using conventional clinical assessments) during the first months post right hemisphere stroke. Voxel-based lesion-symptom mapping was used to identify brain areas within which lesions explained the severity of bias in each assessment (non-parametric permutation test; p<0.01, one tailed). N-ADLs was associated with lesions centered on the posterior part of the superior temporal gyrus and extending to the temporo-parietal junction, temporo-occipital junction and subcortical white matter (including the superior longitudinal fasciculus). Peripersonal neglect resulted from extended cortical lesions centered on the superior temporal gyrus and the inferior parietal gyrus, with subcortical extension. Personal neglect resulted predominantly from lesions centered on the somatosensory cortex and at a lesser degree on the superior temporal sulcus. Anosognosia resulted from lesions of the posterior inferior temporal gyrus and superior temporal gyrus. In anatomic terms, N-ADLs was strongly related to peripersonal neglect, and those relationships were also shown by the psychometric analysis. In conclusions, superior temporal gyrus and superior longitudinal fasciculus lesions have a pivotal role in N-ADLs. N-ADLs is principally related (anatomically and psychometrically) to peripersonal neglect, and at a lesser degree to anosognosia and personal neglect.

Onabotulinumtoxin-A injection for disabling lower limb flexion in hemiplegic patients.

BACKGROUND Hemiplegic patients with supraspinal spasticity can present with a flexor pattern at the hip and knee that hampers both passive and active functions. OBJECTIVE To investigate the efficacy of OnabotulinumtoxinA injections on this flexor scheme. METHODS This open-label observational study included eleven patients who had suffered a unilateral stroke or traumatic brain injury. All had impairment in the activities of daily living caused by severe hip and knee flexion. OnabotulinumtoxinA injections of 300-400U (total dose) were administered to the iliopsoas (iliacus) and knee flexors and, when necessary, to other muscles of the hip and knee. Evaluations were performed pre-treatment (weeks -4 to -8, and day 1) and post-treatment (week 10 and week 21): spasticity, range of motion, limb positioning, passive functions and pain. RESULTS A modest improvement in hip and knee extension was observed, as evidenced by the Modified Ashworth Score and range of passive extension movements. Limb positioning was also improved. Clear benefits were found on passive functioning, including toileting, dressing and bed facilities, as well as pain levels. Active functions remained unchanged. More definite improvement was found in patients with severe difficulties. CONCLUSIONS OnabotulinumtoxinA injection can contribute to reducing the consequences of disabling lower limb flexion.

Construction and pilot assessment of the Lower Limb Function Assessment Scale.

BACKGROUND Stroke often leads to upright standing and walking impairments. Clinical assessments do not sufficiently address ecological aspects and the patients subjective evaluation of function. OBJECTIVE To perform a pilot assessment of the psychometric properties of the Lower Limb-Function Assessment Scale (LL-FAS). METHODS The LL-FAS includes 30 items assessing the patients perception (in a questionnaire) and the examiners perception (in a practical test) of upright standing and walking impairments and their impact on activities of daily living. We analyzed the LL-FASs reliability, construct validity, internal consistency, predictive validity and feasibility. RESULTS Thirty-five stroke patients were included. The scales mean ± SD completion time was 25 ± 6 min. Intra-observer reliability was good to excellent (intraclass correlation coefficients (ICC >0.82). Interobserver reliability was moderate (0.67 < ICC < 0.9). The questionnaire and test items showed excellent construct validity for neuromotor disabilities (p < 0.05), postural ability (Postural Assessment Scale for Stroke; p < 10-5), severity of gait disorders (Gait Assessment and Intervention Tool; p < 10-3), walking ability (New Functional Ambulation Categories, 10 m walk test, Rivermead Mobility Index; p < 10-3) and functional level (Barthel Index; p < 10-3). Internal consistency (Cronbach-α >0.9) and predictive validity were excellent. CONCLUSIONS The LL-FAS showed fair psychometric properties in this pilot study and may be of value for evaluating post-stroke lower limb impairment.

The interaction between cognition and motor control: A theoretical framework for dual-task interference effects on posture, gait initiation, gait and turning

Studies of dual-tasks (i.e. situations during which an individual performs two tasks simultaneously) and the subsequent inter-task interference have shown that locomotion and posture involves motor and cognitive components. Dual-tasks therefore constitute a promising avenue for improving the diagnosis, prevention and management of falls or cognitive impairment in populations at risk. However, tackling these major public health concerns with dual-task interventions requires a better understanding of the mechanisms underlying dual-task interference. In this context, we review (i) the main dual-task theories proposed to date and (ii) the factors that can influence dual-task interference effects in healthy young individuals and might therefore explain the current lack of consensus on the mechanisms of dual-tasks. We also consider cognitive-motor dual-tasks in which the motor task is a less frequently studied transition movement (such as gait initiation or turning), rather than only the often-studied gait and posture tasks. In general, the review focuses on the behavioral effects of dual-tasking.

Parietomotor connectivity in the contralesional hemisphere after stroke: A paired-pulse TMS study

OBJECTIVES To assess the contralesional connectivity between the posterior parietal cortex (PPC) and the motor cortex (M1) in stroke patients, and to probe putative relationships with spatial neglect and motor impairment. METHODS In 12 right-side stroke patients and 12 age-matched healthy controls, we used paired-pulse transcranial magnetic stimulation to assess the contralesional connectivity between three left-side PPC sites (the anterior intraparietal sulcus (aIPS), the posterior intraparietal sulcus and the superior parieto-occipital cortex (SPOC)) and M1. The interstimulus interval (ISI) was set to 4 or 6ms. RESULTS Although there were no differences between the stroke patient group and the controls, a subgroup analysis showed that stimulation over the SPOC with an ISI of 6ms facilitated motor-evoked potential responses in patients with neglect (and especially those with severe peripersonal neglect), relative to non-neglect patients. With an ISI of 4ms, the aIPS exerted an inhibitory influence on M1 in all subjects. The severity of motor impairment was not associated with PPC-M1 connectivity. CONCLUSIONS aIPS-M1 connectivity seems to be unaffected in stroke patients, whereas connectivity from the most posterior parts of the parietal cortex depends on the patients neglect status. SIGNIFICANCE These results provide insight into post-stroke changes in contralesional PPC-M1 connectivity.

Pilot assessment of a comfort scale in stroke patients.

INTRODUCTION Comfort/discomfort (C/D) is an important factor of quality of life (QoL). Brain damage is a major source of discomfort. We developed a questionnaire for assessing C/D in daily living situations and for identifying the main causes of any discomfort and presented its pilot assessment in a population of stroke patients. METHODS The scale is a questionnaire of the patient or caregiver that addresses (i) comfort/discomfort in 15 situations of daily living (including getting dressed, washing, lying in bed and sitting in a chair) and (ii) the roles of physical difficulties, psychological problems and a poorly adapted environment. We analysed its metrological qualities in a group of 62 stroke patients. RESULTS For the patients, the most uncomfortable activities were eating, dressing the lower body, urine and faeces elimination and walking, and the most significant factors of discomfort were motor impairments, fatigue, limb stiffness, joint pain, depression and anxiety. The reliability was fair for the overall score and for each C/D item and moderate for the impact of impairments on comfort/discomfort. We also found fair internal consistency and convergent validity against measures of functional status, QoL and burden of care. Sensitivity to change over a 6-week period was modest. CONCLUSIONS The scale can help to define difficulties in daily living situations and identify opportunities for intervention in stroke patients.

Caractéristiques de la fatigabilité à la marche dans la sclérose en plaques

Méthode.– Revue systématique de la littérature par recherche dans les bases de données PubMed et Cochrane Library de 1966 à 2010 avec les mots clés « multiple sclerosis », « self-care », « self-management ». Les essais cliniques et les études en langue anglaise, française, ainsi que les revues de la littérature et les recommandations pour la pratique sont analysés. Résultats.– Les programmes publiés concernent la santé générale (7 études), la gestion de la fatigue (12 études) ou de la douleur (7 études). Le nombre d’études est beaucoup plus restreint pour la prévention des chutes (1 étude), la gestion de la douleur (7 études), les troubles cognitifs, de l’humeur et du comportement (3 études) et les troubles génito-sexuels (1 étude). Conclusion.– L’ETP fait partie de la prise en charge de la SEP, notamment via la pratique d’une activité physique et la gestion de la fatigue. Il est également indispensable de valider le contenu des documents d’information et de développer des outils d’aide au bilan éducatif des patients SEP.

Validation d’une échelle d’évaluation analytique et fonctionnelle de l’équilibre et de la marche chez le patient hémiplégique vasculaire

presentant une aphasie totale (score ASRS de Goodglass et Kaplan a 0) n’a pu passer l’entretien. Celui-ci a ete difficile chez 3 patients (deux ASRS 1, un ASRS 2), possible avec reformulations chez 16, et facile chez les 12 autres. Il existe des differences significatives avec les scores des temoins dans 5 des 6 categories CIF notamment pour les itemsRP entretien du linge, deplacements exterieurs, courses et achats, budget, relations avec des inconnus, loisirs de groupe, vie associative et demarches administratives. Parmi les facteurs d’environnement, le soutien social est juge satisfaisant dans 79,5%des situations. Les attitudes des autres sont jugees 3 a 4 fois plus souvent facilitatricesqu’obstacles. Le facteurSystemeset politiques est facilitateur pour Soins personnels, Vie domestique, Vie communautaire, mais plutot obstacle pour Relations et Loisirs. Discussion.– La GMAP est applicable a la plupart des personnes aphasiques, mais des versions multi-sources seront utiles chez ces patients. Le modele CIF parait pertinent pour comprendre leurs difficultes de participation. Reference [1] Belio C, Prouteau A, Koleck M, Saada Y, Merceron K, Destaillats JM, et al. Participation in patients with psychic and/or cognitive impairments. Annals PRM 2013 [in print]..

Fate of abstracts presented at the 2008 congresses of the French and the European societies of PRM (SOFMER vs ESPRM)

handicap implique une visite sur les lieux de vie. Matériel et méthode.– Un questionnaire a été diffusé par mail à l’ensemble des professeurs de rééducation dans les CHU métropolitains, portant sur l’existence, les personnels, l’organisation et le financement d’équipes de rééducation intervenant extra muros au domicile des patients. Résultats.– Trente-trois services contactés ; 27 réponses ; dix équipes interviennent en dehors de l’hôpital, dont neuf au domicile des patients. Les missions, les moyens humains, l’organisation de ces équipes sont très hétérogènes, allant de la visite de l’ergothérapeute à une hospitalisation à domicile. Conclusion.– Les équipes évaluant les situations de handicap hors CHU sont peu nombreuses avec des modalités de fonctionnement très différentes. Une harmonisation paraît nécessaire.

Quelle stratégie pour les dystonies du long extenseur de l’hallux et celle du long extenseur des orteils ?

Mots clés : Fibularis longus ; Fibularis brevis ; Spasticité ; Clonus ; Chirurgie fonctionnelle ; Neurotomie ; Hyponeurotisation ; Toxine botulique La spasticité de la loge latérale de la jambe n’est guère connue : aucune référence dans PubMed avec les mots-clés suivants : Fibularis, Hypertonia, Spasticity, Botulinum toxin, Superficial peroneal nerve, Neurotomy, Hyponeurotization. Elle se traduit par un clonus du court et/ou du long fibulaire. Le premier se manifeste dans le plan transversal, les patients ne s’en plaignent habituellement pas ; le second se produit dans le plan sagittal, pouvant faire croire à tort que persiste un clonus du triceps sural, malgré une hyponeurotisation préalable. L’hypertonie des muscles fibulaires joue un rôle dans le valgus des pieds neurologiques. Lorsqu’elle est gênante, cette spasticité est accessible à des injections répétées de toxine botulique ou à une neurotomie des rameaux du nerf fibulaire superficiel. Les bases anatomiques de cette neurotomie ont été étudiées par la dissection de cinq jambes de cadavres formolés. Les rameaux les plus proximaux destinés au long fibulaire naissaient déjà du nerf fibulaire commun. La technique opératoire est décrite : abord postéro-latéral, désinsertion du faisceau postérieur du long fibulaire ou son ouverture, pour suivre le nerf fibulaire superficiel jusqu’au court fibulaire. Un neurostimulateur peropératoire est indispensable, pour identifier les rameaux pour le long fibulaire naissant du nerf fibulaire commun. Les premiers résultats cliniques sont décrits à propos de quatre cas (2H, 2F, recul maximum 28 mois, minimum six mois : disparition des clonus préopératoires pour trois patients, mais réapparition chez le dernier des clonus, par un mécanisme de sprouting confirmé par l’apparition de potentiels d’action géants a l’électromyogramme, chez un patient qui avait récidivé également un clonus du triceps sural après neurotomie des rameaux du nerf tibial. Le caractère partiel de la neurotomie a permis de conserver un contrôle volontaire sur les muscles fibulaires, préservant la stabilité de la cheville. Notre tendance actuelle est à la recherche systématique de la spasticité des fibulaires et à l’inclusion de son traitement dans le schéma thérapeutique. Nous n’hésitons pas à inclure la neurotomie des rameaux destinés au long fibulaire dans le programme chirurgical, à l’occasion d’un geste réalisé sur l’extrémité distale du membre, notamment le traitement du varus, de l’équin, et des orteils.