J.-M. Mazaux

Critical Illness Polyneuropathy

Critical illness polyneuropathy (CIP) is a reported cause of varying degrees of neuromuscular weakness in patients with multiple organ failure. Little is known concerning predictive factors of neurological recovery. The critical care conditions, neurological explorations and 2-year clinical follow-up of 19 patients who suffered from severe forms (quadriplegia or quadriparesis) of CIP were analyzed. Characteristics of patients who recovered clinically were compared with those of patients who did not. Two patients died within 2 months, 11 recovered completely, 4 remained quadriplegic and 2 remained quadriparetic. All patients suffered from sepsis, multiple organ dysfunction syndrome and a catabolic state before the onset of CIP. Outcome appears difficult to predict with clinical or electrophysiological data. Three parameters were significantly correlated with poor recovery: longer length of stay in the critical care unit, longer duration of sepsis and greater body weight loss. A relationship seems to exist between the severity of CIP and that of sepsis and its associated hypercatabolism. The favorable outcome usually attributed to CIP must be reconsidered. The authors recommend aggressive measures against sepsis to limit CIP and its sequelae.

The effects of capsaicin on the neurogenic hyperreflexic detrusor. A double blind placebo controlled study in patients with spinal cord disease. Preliminary results.

Purpose: Several recent open studies have provided encouraging results as to the efficacy of intravesical installations of capsaicin for neurogenic hyperreflectivity. The present trial was performed to verify these results under controlled conditions. Intravesical installation of capsaicin represents a new therapeutic hope for the treatment of the neurogenic hyperrelfexic bladder. Method: This randomized, double-blind study compared the results of the intravesical installation of 30 mg capsaicin in 100 ml of 30% alcohol (experimental group) with those of installing 100 ml 30% alcohol alone (control group). On day 0 and day 30, urodynamic and biopsic examinations were performed in all subjects of each group. Patients: All the subjects included in the study had a functionally disabling form of neurogenic hyperreflexic bladder resistant to the usual therapies. Cystoscopy and retrograde cystography were performed to exclude any patient who presented with a tumor-like lesion or had vesicoureteral reflux. Results: Twelve paraplegic of tetraplegic subjects, seven women and five men whose average age was 46, were included. Eight had multiple sclerosis, and four had sustained a traumatic spinal cord injury. The patients were randomly separated into two groups of six. Initially, there was no clinical or urodynamic differences in these groups. Installation immediately triggered side effects and during the first 7 days (suprapubic burning sensation, sensory urgency, hot flushes, autonomic hyperreflexia, hematuria) in five of the six subjects in both groups. Bladder biopsy revealed no significant deterioration. On day 30, there was improvement in all of the experimental-group of patients with significant regression of leakage (P=0.002) and of sensory urgency (P=0.01). Only one control subject had amelioration. Urodynamic examination showed a rise in bladder capacity from 172.5 to 312.3 ml in the experimental group, significantly greater (P=0.03) than the rise from 129 to 175.3 ml observed in the control group. Conclusion: This trial fully confirms the efficacy of intravesical installations of capsaicin, an efficacy obtained at the cost of nonnegligible side effects. An intermediate-term follow-up of this treatment will be necessary before considering more widespread use of this agent.

Initial factors predicting functional performance in patients with traumatic tetraplegia

The authors present a prospective analysis of the functional outcome in 99 patients with traumatic tetraplegia consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 29% death rate. Eighteen months after injury, 33% of the patients were dependent (not able to perform activities of daily living without the presence of a helping individual), 38% were independent. Two predictors of independence (age and initial Yale Scale Score) were found by a statistical analysis of the course of the disorder.

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.

Toxine botulique A et douleurs musculosquelettiques.

Resume Les proprietes myorelaxantes de la toxine botulique A (TBA), corroborees par les resultats encourageants des premiers travaux temoignant de l’action antalgique des injections topiques de TBA chez des patients souffrant de dystonie ou de spasticite focale, ont suggere la pertinence du recours aux injections de TBA dans l’arsenal therapeutique des douleurs musculosquelettiques. L’objectif de cet article est de faire une mise au point sur les differentes indications antalgiques des injections de TBA proposees dans le domaine des maladies musculosquelettiques. Methode. – Nous avons procede a une analyse de la litterature internationale en interrogeant la banque de donnees Medline avec pour mots cles toxine et douleur. Seuls les essais cliniques ont ete retenus. Resultats. – Trois cent dix-sept articles ont ainsi ete selectionnes, comprenant 12 essais cliniques sur le traitement des douleurs musculosquelettiques. Ils sont consacres a 4 indications therapeutiques de pathologies chroniques, cervicalgie, syndrome du piriforme, epicondylite et lombalgie. Les resultats des 6 etudes portant sur les cervicalgies chroniques sont contradictoires et soulignent la difficulte de mettre en evidence une action antalgique satisfaisante de la TBA dans cette pathologie. Les resultats des essais cliniques concernant les autres indications (epicondylite, syndrome du Piriforme et lombalgie) semblent positifs et cliniquement pertinents. Discussion. – L’effet antalgique de la TBA semble conditionne par la participation d’un surmenage tendineux ou d’un dysfonctionnement musculaire a l’origine de la douleur chronique. Conclusion. – Les premieres donnees concernant l’utilisation de la TBA dans les douleurs musculosquelettiques sont encore pauvres et contradictoires et meritent d’etre precisees.

Inter-observer reproducibility of back surface topography parameters allowing assessment of scoliotic thoracic gibbosity and comparison with two standard postures.

The objective of this work was to analyze the inter-observer reproducibility of an upright posture designed to bring out the thoracic humps by folding the upper limbs. The effect of this posture on back surface parameters was also compared with two standard radiological postures. A back surface topography was performed on 46 patients (40 girls and 6 boys) with a minimum of 15° Cobb angle on coronal spinal radiographs. Inter-observer reliability was evaluated using the typical error measurement (TEM) and Intraclass Correlation Coefficient (ICC). Variations between postures were assessed using a Students t test. The inter-observer reproducibility is good enough for the three postures. The proposed posture leads to significant changes in the sagittal plane as well as in the identification of thoracic humps. This study shows the reproducibility of the proposed posture in order to explore the thoracic humps and highlights its relevance to explore scoliosis with back surface topography systems.

Participation restrictions in patients with psychiatric and/or cognitive disabilities: preliminary results for an ICF-derived assessment tool.

UNLABELLED Participation in community life is a major challenge for most people with psychiatric and/or cognitive disabilities. Current assessments of participation lack a theoretical basis. However, the new International Classification of Functioning, Disability and Health (ICF) provides a relevant framework. AIMS The present study used an ICF-derived assessment tool to activity limitations and participation restrictions in two groups of participants with disabilities linked to schizophrenia or traumatic brain injury respectively. METHODS Twenty-six items (related to six ICF sections) were selected by reviewing the literature and gathering the clinicians opinions and representatives of patient associations. These items, yielded an ordinal rating of activity limitations, participation restrictions and contextual factors (social support, attitudes and, systems & politics). Special attention was paid to contextual and environmental factors. The final checklist (called the Grid for Measurements of Activity and Participation, G-MAP) was administered to 16 participants with traumatic brain injury (the TBI group) and 15 participants with schizophrenic disorders (the SD group). Psychometric assessments of cognition and, neurobehavioural, psychological and psychosocial functioning were also performed. RESULTS The internal consistencies for activity limitations (Cronbachs alpha coefficient=0.89) and participation restriction (Cronbachs alpha coefficient=0.89) were satisfactory. We did not observe any significant differences between the two groups in terms of the psychometric test results. The G-MAP scores demonstrated that the two groups were confronted with the same limitations in self care, domestic life, leisure and community life (i.e., the intergroup differences were not statistically significant in Mann-Whitney tests). However, interpersonal relationships and economic and social productivity appeared to be more severely limited in the SD group than in the TBI group. Similarly, participation restrictions in domestic life, interpersonal relationships and economic and social productivity were more severe in the SD group than in the TBI group. CONCLUSION G-MAP is a useful, feasible, relevant tool for performing a detailed, individualized assessment of participation restrictions in people with psychiatric and/or cognitive disabilities.

Psychotherapeutic follow up of out patients with traumatic brain injury: Preliminary results of an individual neurosystemic approach

UNLABELLED Psychotherapy for affective/behaviour disorders after traumatic brain injury (TBI) remains complex and controversial. The neuro-systemic approach aims at broadening the scope in order to look at behaviour impairments in context of both patients cognitive impairments and family dysfunctioning. OBJECTIVE To report a preliminary report of a neuro-systemic psychotherapy for patients with TBI. PATIENTS AND METHODS All patients with affective/behaviour disorders referred to the same physician experienced in the neuro-systemic approach were consecutively included from 2003 to 2007. We performed a retrospective analysis of an at least 1-year psychotherapy regarding the evolution of the following symptoms: depressive mood, anxiety, bipolar impairment, psychosis, hostility, apathy, loss of control, and addictive behaviours as defined by the DSM IV. Results were considered very good when all impairments resolved, good when at least one symptom resolved, medium when at least one symptom improved, and bad when no improvement occurred, or the patient stopped the therapy by himself. RESULTS Forty-seven patients, 35 men and 12 women, with a mean age of 33.4 years, were included. Most suffered a severe TBI (mean Glasgow coma score: 6.4) 11 years on average before the inclusion. At the date of the study, 11 patients (23%) had a poor outcome, 23 (48%) suffered Moderate disability and 13 (27%) had a Good recovery on the GOS scale. All therapy sessions were performed by the same physician, with 10 sessions on average during 13.5 months. Results were classified very good in six cases (13%), good in 18 others (38%), medium in 10 patients (21%) and bad in 13 cases (27%). We observed a significant improvement of affective disorders, namely anxiety (P<0.001) depressive mood (P<0.001) and hostility (P<0.01). However, bipolar symptomatology, apathy, loss of control and addictive disorders did not improve. DISCUSSION/CONCLUSION From our best knowledge, this is the first clinical report of neuro-systemic psychotherapy for affective/behaviour disturbances in TBI patients. This kind of therapy was shown to be feasible, with a high rate of compliance (72%). Psycho-affective disorders and hostility were shown to be more sensitive to therapy than other behaviour impairments. These preliminary findings have to be confirmed by prospective trials on broader samples of patients.

Communication dans la vie quotidienne des personnes aphasiques après accident vasculaire cérébral

CO08-007–FR Communication dans la vie quotidienne des personnes aphasiques apres accident vasculaire cerebral T. Lagadec , D. Zongo , J. Asselineau , E. Douce , J. Trias , M.F. Delair , M. Michot , B. Darrigrand , J.-M. Mazaux g,∗ a EA 4136, universite Bordeaux-Segalen, hopital IA–Robert-Picque, Bordeaux, France b ISPED, universite Bordeaux-Segalen, Bordeaux, France c Hopital Nouvielle, Mont-de-Marsan, France d Hopital Robert-Boulin, Libourne, France e Centre hospitalier universitaire de Bordeaux, Bordeaux, France f EA 4136, universite Bordeaux-Segalen, hopital Robert-Boulin, Libourne, Bordeaux et Libourne, France g EA 4136, universite Bordeaux-Segalen, CHU de Bordeaux, Bordeaux, France Auteur correspondant.