Laurent Bensoussan

Kinematic and kinetic asymmetries in hemiplegic patients' gait initiation patterns.

OBJECTIVEnTo assess the kinetic and kinematic characteristics of hemiplegic stroke patients gait initiation patterns during the various gait initiation phases.nnnDESIGN AND SUBJECTSnGait initiation was studied in 3 hemiplegic subjects with a spastic equinus varus foot and 3 control subjects.nnnMETHODSnTemporal and kinetic analysis of gait initiation was performed with 2 AMTI force plates, and kinematic analysis of gait initiation with an ELITE optoelectronic system. A one-way ANOVA was performed directly on the phase durations, forces, centre of pressure displacements, stride length, and ankle motion range.nnnRESULTSnDuration of the monopodal phase was shorter in hemiplegic patients when the affected leg rather than the sound one was used as the supporting leg. Propulsion forces were exerted by the hemiplegic patients sound leg during the postural phase. Hemiplegic patients body weight was supported more by the sound leg than by the affected leg. Knee was lifted higher on the affected side during the swing phase to compensate for the equinus. Initial contact was performed with a flat foot on the affected side.nnnCONCLUSIONnQuantitative data obtained on the gait initiation phase suggest that hemiplegic patients develop asymmetrical adaptive posturo-motor strategies to compensate for their impairments.

Evaluation of patients with gait abnormalities in physical and rehabilitation medicine settings.

The first step in the assessment of patients with gait abnormalities in physical and rehabilitation medicine settings is a clinical examination based on the International Classification of Functioning, Disabilities and Health. Body structure, activities and participation, and environmental factors (physical and human factors) must all be assessed. Qualitative and quantified assessments of gait are part of the activity and participation evaluation. Scales are also used to assess gait activities. Gait assessment tools can be used in laboratory environments for kinematic, kinetic, electromyographic and energy consumption analysis and other tools, such as videotape and walkways, can be used in clinical practice, while ambulatory assessment tools can be used to analyse patients usual everyday activities. The aims of instrumental gait assessment are: to understand the underlying mechanisms and the aetiology of the disorders, to obtain quantified gait parameters, to define suitable therapeutic methods, and to follow the course of the disease.

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.

DOES FASCICULAR NEUROTOMY HAVE LONG-LASTING EFFECTS?

OBJECTIVEnTo determine whether fascicular neurotomy has long-lasting effects on spasticity.nnnDESIGNnWe present 4 clinical cases and a critical analysis of the literature.nnnPATIENTSnThis is a retrospective study on 4 patients referred to our department for spastic equinovarus foot deformity. For all 4, neurotomy was successful not long after surgery, but spasticity reappeared after a few months.nnnMETHODSnWe compared our results with those in the PubMed database.nnnRESULTSnMost publications acknowledge the immediate effectiveness of this surgery, but do not study the long-term effects of neurotomy. No publication proved long-lasting effects of neurotomy for spastic equinovarus foot deformity. The only long-term follow-up with a sufficient population is the one of Berard et al. who reported 61% recurrence.nnnCONCLUSIONnThere is no study showing that tibial nerve neurotomy has long-lasting effects. The 4 cases reported are an illustration that recurrence of spasticity may occur after neurotomy. These findings have to be taken into account for treatment decision-making and for provision of information to patients.

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

OBJECTIVEnThe 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.nnnPATIENTSnEight patients with chronic hemiplegia post-stroke presenting with lower limb spasticity and requiring botulinum toxin-type A injection in the ankle extensor muscle.nnnMETHODSnPost-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.nnnRESULTSnPost-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.nnnCONCLUSIONnBotulinum 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

OBJECTIVEnTo determine whether an orthotic fitting improved gait in an adult patient presenting with generalized secondary dystonia.nnnPATIENTnThe 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.nnnMETHODSnThe 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.nnnRESULTSnThe 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.nnnCONCLUSIONnPatellar tendon-bearing orthoses and orthopaedic shoes could provide a good therapeutic approach for improving gait in patients with generalized secondary dystonia.

Knee-ankle-foot orthoses for treating posterior knee pain resulting from genu recurvatum: Efficiency, patients' tolerance and satisfaction

OBJECTIVEnTo assess the efficiency of knee-ankle-foot orthoses for treating painful genu recurvatum, and to determine users tolerance and satisfaction.nnnPATIENTSnPatients included in the study had a genu recurvatum during the stance phase, confirmed by a medical doctor on physical examination. A total of 27 patients with 31 knee-ankle-foot orthoses were included.nnnMETHODSnThe main outcome was scored on a verbal numerical rating scale (VNRS) before and at least 3 months after a knee-ankle-foot orthosis was fitted, and scored on a verbal numerical pain rating scale (VRS). Secondary outcomes were rated with the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST).nnnRESULTSnAfter fitting the knee-ankle-foot orthosis, the median VNRS pain score decreased from 85/100 to 25/100 (pu2009≤u20090.001) and the description of pain on the VRS decreased from extreme to mild (pu2009≤u20090.001). The QUEST total score was 4.0.nnnCONCLUSIONnTreating a painful genu recurvatum with a knee-ankle-foot orthosis reduced the pain efficiently whatever the patients diagnosis, and high scores were obtained for patients satisfaction.

Orthopaedic shoes along with physical therapy was effective in Charcot-Marie-Tooth patient over 10 years.

Background: The aim was to investigate the effectiveness of custom-made orthopaedic shoes (derby shoes) along with physiotherapy (twice a week) on a person with Charcot-Marie-Tooth over a period of 10u2009years. Case description and methods: A 66-year-old woman with Charcot-Marie-Tooth disease, who did not have other health conditions, complained of pain and frequent falls. Physical examination, including ankle, knee and hip muscle strength; sensory evaluation of foot and joint range of motion; self-reported assessment of pain, frequency of falls and sprains; and gait analyses, including spatial and temporal parameters and motion analyses, were performed in 2001, 2007 and 2011. Findings and outcomes: During the 10 years of follow-up, the physical examination parameters had stabilized since 2001; falls, sprains and walking distance had improved as compared to 2000; pain had alleviated since 2001 and gait parameters had improved up to 2007 and stabilized between 2007 and 2011. Conclusion: Bracing with orthopaedic shoes along with physical therapy was effective in treating pain, improving the gait and enhancing the walking distance (>500u2009m) without assistive device in a person with Charcot-Marie-Tooth disease. Clinical relevance Orthopaedic shoes along with physical therapy can be a good option for treating Charcot-Marie-Tooth associated pain, foot drop, falls and sprains, improving the gait abnormalities and also increasing the walking distance.

A census of students with disabilities and the support provided at the University of Aix-Marseille.

Access to the college cycle for students with disabilities and their employability have become a priority for universities. The Handicap Mission manages it within the Aix-Marseille University (AMU). Few studies have focused on the students with disabilities’ insertion/integration within the universities and on the compensations. The objective of this study is to analyze within the AMU the students with disabilities census and characteristics, and the Handicap Mission’s operating. The census was conducted using a self-administered questionnaire (Handi need card: university curriculum, deficiencies, technical and social help, adjustments appealed for at the university). It was performed by the staff at the AMU’s Mission Handicap Department/Office. If supporting measures seem to be necessary, the interdisciplinary team (comprised of representatives of the University teaching, Administrative and Technical staff, Mission Handicap staff, Preventive Medicine staff, and partners from associations involved in assisting people with disabilities) then defines and sets up suitable means of assistance. The Handicap Mission improves students with disabilities insertion, defines necessary adjustments, and promotes research on disability. A total of 551 students with disabilities were identified, 304 in law and human sciences. In all, 141 deficiencies encountered related to language disorders, among which 105 were not defined by the students (‘Other’ in the questionnaire). In all, 519 SWD benefited from extra time when sitting exams and 40 were helped to take notes by others students. Compensations and Handicap Mission improve the monitoring and the link between high school and university for the students with disabilities, promote their exam success, and support them in their working life.

Obturator externus musculotendinous injury in a professional basketball player

Introduction Acute muscle injuries in the lateral rotator group have been rarely described in the medical literature. The purpose of this study is to describe the diagnosis and treatment of an uncommon injury: obturator externus musculotendinous injury. Case presentation A 30-year-old male patient, professional basketball player, presented with right groin pain during a game, resulting from a controlled slide movement. Pain increased 1xa0hour after the game in the right groin and radiated to the buttock area. Examination finds no abnormalities during the specific testing of the adductor, hamstring or iliopsoas muscles, but the patient presents with diffuse pain during active hip mobilisation. Muscle testing in resisted external rotation reveals slight but existing specific pain. Slight pain and tenderness to palpation was also noted on the ischial tuberosity. Ultrasound examination and MRI revealed grade III distal obturator externus musculotendinous injury, combined with quadratus femoris muscle oedema. Our patient followed a functional treatment, combining rehabilitation (eccentric and proprioceptive exercises of pelvic and hip stabilising muscles), and reathletisation, which allowed him to return to professional competition 10 days after trauma. Discussion In the medical literature, no international publication has ever reported this type of injury, due to its typical minor functional impact. This injury is caused by an eccentric contraction of the obturator externus. It seems to be under-diagnosed. Discomfort can be minor in daily life, due to muscular compensations, but it can be detrimental for elite athletes. Patients seem to recover rapidly, without an actual relation to the severe imaging findings. In addition, those muscles are not routinely assessed during ultrasound scan, and MRI is not often performed due to relative minor functional limitations. As a consequence, we insist on the need to perform a comprehensive clinical examination which will guide the ultrasound scan to the lateral rotator group of muscles. The ultrasound will confirm the need for hip MRI. Our clinical case shows that targeted rehabilitation will ensure a rapid return to competition without sequelae, and provide excellent functional performance, with a return to pre-injury level of sport.