J.M. Viton

Eccentric reinforcement of the ankle evertor muscles after lateral ankle sprain

To compare two methods of ankle evertor muscle reinforcement after ankle sprain: concentric vs eccentric reinforcement. Eighteen subjects practising sport with first episode of ankle sprain. The first randomized group underwent conventional physical therapy including concentric reinforcement of the evertor ankle muscles [concentric group (CG)]. The second randomized group underwent eccentric reinforcement [eccentric group (EG)]. At the end of the physical therapy, the strength of the evertor muscles was tested using an isokinetic dynamometer. The measurements were peak torques in the concentric and eccentric modes; ankle strength deficits, expressed as percentages of the healthy ankle values recorded in the concentric and eccentric modes; ratios between concentric/eccentric values. After the concentric reinforcement, in the CG group, there is both significant concentric strength deficit and an eccentric strength deficit on the injured side in comparison with the healthy side. After the eccentric reinforcement in the EG group, the muscle strength was significantly greater during concentric movements. Eccentric rehabilitation therefore restored the strength of the injured evertor muscles. These results show the value of this method, especially as the weakness of these muscles after sprains is one of the main risk factors contributing to instability and the recurrence of sprains.

Asymétries chronométriques, cinétiques et cinématiques de l'initiation de la marche chez un sujet hémiplégique

OBJECTIVE To investigate the temporal, kinetic and kinematic asymmetry of gait initiation in one subject with hemiplegia with an equinus varus foot. MATERIAL AND METHODS A kinetic analysis with two AMTI force plates and a kinematic analysis with an ELITE optoelectronic system of gait initiation were performed in one subject with hemiplegia. RESULTS The duration of the gait initiation phases was asymmetrical. The monopodal phase was shorter when the affected lower limb was supporting than when the healthy one was supporting. The propulsion resulted from the force exerted on the healthy lower limb. The distribution of body weight on the lower limbs was asymmetrical. Body weight support was more important on the healthy side than on the affected side. Maximal extension of the ankle on the hemiplegic side occurred during the swing phase. Ground clearance was increased by elevating the knee higher on the affected side than on the healthy side during the swing phase. Initial contact with the floor was performed with the foot flat on the affected side. CONCLUSION This preliminary study has shown that gait initiation in one subject with hemiplegia was asymmetrical in kinetics and kinematics. The results concerning kinematics have not been reported previously for gait initiation in subjects with hemiplegia. The study of gait initiation should allow for better understanding postural and movement control strategies developed by patients with hemiplegia.

Peroneus quartus and functional ankle instability

INTRODUCTION Physical and rehabilitation medicine physicians commonly see patients with chronic functional ankle instability. The main anatomical structures involved in ankle stability are the peroneus (fibularis) brevis and peroneus longus muscles. Several anatomical muscle-tendon variations have been described in the literature as being sometimes responsible for this instability, the peroneus quartus muscle being the most frequent. The objective of this clinical study is to discuss the implication of the bilateral peroneus quartus muscle in functional ankle instability. CLINICAL CASE This 26-year-old patient was seen in PM&R consultation for recurrent episodes of lateral ankle sprains. The clinical examination found a moderate hyperlaxity on the right side in bilateral ankle varus. We also noted a bilateral weakness of the peroneus muscles. Additional imaging examinations showed a supernumerary bilateral peroneus quartus. The electroneuromyogram of the peroneus muscles was normal. DISCUSSION In the literature the incidence of a supernumerary peroneus quartus muscle varies from 0 to 21.7%. Most times this muscle is asymptomatic and is only fortuitously discovered. However some cases of chronic ankle pain or instability have been reported in the literature. It seems relevant to discuss, around the clinical case of this patient, the impact of this muscle on ankle instability especially when faced with lingering weakness of the peroneus brevis and longus muscles in spite of eccentric strength training and in the absence of any neurological impairment. One of the hypotheses, previously described in the literature, would be the overcrowding effect resulting in a true conflict by reducing the available space for the peroneal muscles in the peroneal sheath.

Plastic changes in spinal synaptic transmission following botulinum toxin A in patients with post-stroke spasticity.

OBJECTIVE The therapeutic effects of intramuscular injections of botulinum toxin-type A on spasticity can largely be explained by its blocking action at the neuromuscular junction. Botulinum toxin-type A is also thought to have a central action on the functional organization of the central nervous system. This study assessed the action of botulinum toxin-type A on spinal motor networks by investigating post-activation depression of the soleus H-reflex in post-stroke patients. Post-activation depression, a presynaptic mechanism controlling the synaptic efficacy of Ia-motoneuron transmission, is involved in the pathophysiology of spasticity. PATIENTS Eight patients with chronic hemiplegia post-stroke presenting with lower limb spasticity and requiring botulinum toxin-type A injection in the ankle extensor muscle. METHODS Post-activation depression of soleus H-reflex assessed as frequency-related depression of H-reflex was investigated before and 3, 6 and 12 weeks after botulinum toxin-type A injections in the triceps surae. Post-activation depression was quantified as the ratio between H-reflex amplitude at 0.5 and 0.1 Hz. RESULTS Post-activation depression of soleus H-reflex, which is reduced on the paretic leg, was affected 3 weeks after botulinum toxin-type A injection. Depending on the residual motor capacity of the post-stroke patients, post-activation depression was either restored in patients with preserved voluntary motor control or further reduced in patients with no residual voluntary control. CONCLUSION Botulinum toxin treatment induces synaptic plasticity at the Ia-motoneuron synapse in post-stroke paretic patients, which suggests that the effectiveness of botulinum toxin-type A in post-stroke rehabilitation might be partly due to its central effects.

ORTHOTIC FITTING IMPROVES GAIT IN A PATIENT WITH GENERALIZED SECONDARY DYSTONIA

OBJECTIVE To determine whether an orthotic fitting improved gait in an adult patient presenting with generalized secondary dystonia. PATIENT The patient had stance and gait disturbances associated with pain, ankle instability and fatigability. Clinical examination showed the presence of dystonia in the foot and ankle, along with equinovarus foot, mainly on the left side. The patient was fitted with a patellar tendon-bearing orthosis on the left side, orthopaedic shoes and plantar orthoses. METHODS The outcome of the treatment after 12 months was assessed on the basis of a physical examination and an instrumental gait assessment, using the GAITRite(R) system to analyse spatiotemporal parameters and force-plates to measure body weight distribution. RESULTS The fitting resulted in a significant improvement in gait, reduced pain and ankle instability, decreased cadence, increased step length and single foot support time, and reduced asymmetry of the temporo-spatial patterns and body weight distribution. CONCLUSION Patellar tendon-bearing orthoses and orthopaedic shoes could provide a good therapeutic approach for improving gait in patients with generalized secondary dystonia.

Should European PRM residents be taught in English? The experience of the European School Marseille

OBJECTIVE To assess the level of comprehension of the courses taught in English at the annual European school on Physical and Rehabilitation Medicine (PRM) (European School Marseille). MATERIALS AND METHODS The English level of 37 students, mainly from European countries, was tested using three written questionnaires: an initial test of English grammar, a questionnaire about comprehension at the end of a basic PRM class taught in English by a French specialist and a final multiple-choice test (MCT) on the contents of the course. RESULTS We found a difference between the level of English given by the residents and the level shown by the initial test. The overall level of English comprehension of the group was good, an average of 8.2/10 (S.D.: 2.1) on a Visual Analogue Scale. The mean MCT score on the contents of the course was good, an average of 6.1/10 (S.D.: 2.2). For residents with lower levels of English, the level of comprehension for courses taught in English by the French specialist was greater than the level of comprehension for courses taught by native English speakers (p=0.033). CONCLUSION The level of comprehension of most European PRM residents for courses taught in English by French PRM specialists and by English-speaking specialists is good. The level of comprehension is, of course, influenced by the English level of European residents. It thus appears worthwhile to organize programmes taught in English for European PRM residents. Nonetheless, it is important to assess the language skills of the residents and to use specific tools to help the small number of trainees whose English level is to low.

Return to surfing using an adapted prosthesis: A case report:

Background: Surfing with transfemoral knee prosthesis requires flexion of the hip, knee, and ankle and balance between flexibility and stiffness of the prosthetic limb. We report on Mr D, a transfemoral amputee, who wanted to surf again. Case Description and Methods: Technical specifications were based on Mr D’s complaint. The prosthesis is salt water resistant and combines a shock absorber associated with elastic tendons to permit the knee to bend easily and to facilitate eccentric braking. Surfing was observed using videos of movements and subjective analysis of compensations. Findings and Outcomes: Mr D uses this prosthesis for surfing with good results and got back to his former level using compensations. During the takeoff, he cannot shorten his left leg. He makes a circumduction movement to put his leg in front of the board. Conclusion: This prosthesis is adapted for surfing and allows precise adjustments to surfing conditions. Clinical relevance Appropriate prosthesis design can enable return to surfing for a transfemoral amputee.

Long-term functional improvement in hemiplegic patients after stroke: A series of case

from C5 to C8 and absent in the lower limbs. Two months later, a motor control on the left hand was observed. Discussion.– For this patient, the relevance of the MEP in sub-acute stage of brainstem infarct was initially discussed because of the presence of a beginning of motor control but they were finally performed with two objectives: try to better predict functional recovery and mainly to contribute to the announcement of the disability. Further reading Bembenek JP., et al. The prognostic value of MEP in motor recovery and functional outcome after stroke-a systematic review. Funct Neurol 2012; 27: 79–84.

Census study of the students with disabilities and of the compensations implemented by the Handicap Mission within the Aix-Marseille University

P503-e Census study of the students with disabilities and of the compensations implemented by the Handicap Mission within the Aix-Marseille University M. Prats a,∗, B. Delorge b, M. Kerzoncuf a, L. Bensoussan a, J.M. Viton a, A. Delarque a a CHU La Timone, Service de Médecine Physique Réadaptation, Marseille, France b Responsable de la Vie étudiante et handicap de l’université d’Aix Marseille, Marseille, France ∗Corresponding author.

Central effects of botulinum toxin: Neurophysiological study in post-stroke patients with lower limb spasticity

Conclusions.– This suggests that BoNT-A induces spinal plasticity leading to the recovery of reciprocal inhibition, which is likely to be due to the withdrawal of inhibitory control from Renshaw cells directly blocked by BoNT-A. This could help in limiting ankle muscle cocontractions in the transition phase from stance to swing, to assist dorsiflexion. Further readings Aymard C, Giboin LS, Lackmy-Vallée A, Marchand-Pauvert V. Spinal plasticity in stroke patients after botulinum neurotoxin A injection in ankle plantar flexors. Physiol Rep 2013. Marchand-Pauvert V, Aymard C, Gibouin LS., Dominici F, Rossi A. Mazzocchio R. Depression of spinal recurrent inhibition after botulinum toxin A, J Physiol 2013.