P. Decavel

Piriformis muscle syndrome: Diagnostic criteria and treatment of a monocentric series of 250 patients

OBJECTIVESnPiriformis Muscle Syndrome (PMS) is caused by sciatic nerve compression in the infrapiriformis canal. However, the pathology is poorly understood and difficult to diagnose. This study aimed to devise a clinical assessment score for PMS diagnosis and to develop a treatment strategy.nnnMATERIAL AND METHODSnTwo hundred and fifty patients versus 30 control patients with disco-radicular conflict, plus 30 healthy control subjects were enrolled. A range of tests was used to produce a diagnostic score for PMS and an optimum treatment strategy was proposed.nnnRESULTSnA 12-point clinical scoring system was devised and a diagnosis of PMS was considered probable when greater or equal to 8. Sensitivity and specificity of the score were 96.4% and 100%, respectively, while the positive predictive value was 100% and negative predictive value was 86.9%. Combined medication and rehabilitation treatments had a cure rate of 51.2%. Hundred and twenty-two patients (48.8%) were unresponsive to treatment and received OnabotulinumtoxinA. Visual Analogue Scale (VAS) results were Very good/Good in 77%, Average in 7.4% and Poor in 15.6%. Fifteen of 19 patients unresponsive to treatment underwent surgery with Very good/Good results in 12 cases.nnnCONCLUSIONSnThe proposed evaluation score may facilitate PMS diagnosis and treatment standardisation. Rehabilitation has a major role associated in half of the cases with botulinum toxin injections.

Sensitivity to change of two depression rating scales for stroke patients

Objective: To assess the sensitivity to change of two depression scales for stroke patients: the Aphasic Depression Rating Scale (ADRS), which is a 9-item external assessment, and the Visual Analog Mood Scale (VAMS), which is a visual self-assessment scale. Patients: Forty-nine stroke patients admitted to two rehabilitation units. Methods: Symptoms of depression were assessed twice at a one-month interval (D0—D30) using the ADRS, the VAMS, and by a trained psychologist (PSY). Sensitivity to change was assessed by effect size and standardized response mean. A one-way ANOVA on ranks was performed to determine if the scales distinguished between deteriorated, stable and improved patient status. Spearman’s correlation coefficient (r) was used to assess the relationship between changes in PSY and changes in the ADRS and the VAMS between D0 and D30. Results: Mean depression scores at D0 and D30 were 2.6 ± 1.8 and 2.4 ± 1.7 (ADRS/10), 3.1 ± 2.9 and 3.0 ± 3.2 (VAMS/10), 2.9 ± 2.3 and 2.4 ± 2.4 (PSY/10). Percentages of deteriorated, stable and improved patient status were 22%, 45% and 33% (ADRS); 41%, 22% and 37% (VAMS); and 20%, 41% and 39% (PSY). Changes in PSY correlated with the ADRS (r = 0.72, P<10 —6) and the VAMS (r = 0.41, P<10— 2). The ADRS was better than the VAMS in terms of effect size, standardized response mean and ability to discriminate between deteriorated, stable and improved patient status. This result was partly due to the difficulty encountered by nine (19%) patients in understanding directions to complete the VAMS. Conclusions: The ADRS is more sensitive than the VAMS for detecting changes in post-stroke depression. The VAMS is less appropriate in very cognitively impaired stroke patients.

Enquête de la pratique de l’autosondage intermittent propre auprès des médecins généralistes

INTRODUCTIONnClean intermittent self-catheterization is the recommended mode of bladder voiding in patients with urinary retention. Hence, this procedure should be well known and understood by the general practitioners (GP) who are responsible for monitoring such patients.nnnOBJECTIVEnTo assess GP state of knowledge regarding clean intermittent self-catheterization and to make recommendations for dealing with problems that occur during patient follow-up.nnnMETHODnA questionnaire focusing on the practice of clean intermittent catheterization was sent to 910 family GP in the Franche-Comté region of eastern France.nnnRESULTSnTwo hundred and fourty-six replies were analyzed. Sixty-four percent of GP believed that the appropriate number of bladder catheterizations per day was between two and four. Ninety percent of the GP prescribed perineal cleaning before catheterization and 29% prescribed the use of sterile gloves. Eighty-seven percent of general practitioners considered urinary tract infection to be the main complication of intermittent catheterization. Thirty percent always requested a urine culture in patients performing self-catheterization and 29% prescribed antibiotic therapy in cases of bladder colonization.nnnDISCUSSIONnGeneral practitioners need to receive additional information on the role of clean intermittent catheterization in the prevention of urinary tract infection. In accordance with the French Urology Association guidelines, we produced a practical summary guide on preventing asymptomatic bacteriuria and urinary tract infections and/or preparing for urological investigations.

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study

Introduction Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke. Methods and analysis 220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10u2009min of stretching, 10u2009min of strengthening and 10u2009min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored. Ethics and dissemination Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients. Trial registration number NCT02944929.

Effectiveness of functional electrical stimulation of gait. Evaluating of modifications to the center of pressure for a hemiparetic patient

Introduction/Background Drop foot is the principal ambulatory anomaly impacting hemiplegic patients. The effectiveness of Functional Electric Stimulation (FES) on gait parameters in hemiplegics has been demonstrated over the medium and long term. Clinical evaluation of this setup and its’ effectiveness is not always easy; changes in gait parameters being difficult to measure solely by observation. Ideally, the application of FES should be done along with a 3-D analysis of the patients gait, which can be a time-consuming procedure. The goal of this study is to evaluate dynamic changes in the center of pressure (COP), measured using an instrumented walkway, when applying FES. Material and method A mono-paretic patient, stable after frontal tumor surgery, was treated with FES of the fibularis communis nerve. The evaluation of gait, at a comfortable walking pace, was realized using an analysis of both spatio-temporal parameters and COP, obtained using the GAITRite walkway. The evaluation was conducted, immediately before and after application of FES. Results Spatio-temporal gait parameters (walking speed, stride length, cadence) were not modified by FES. Our analysis confirms an immediate ‘posteriorization’ of the COP upon initial application of FES. Net postero-anterior displacement of the COP was increased by FES. Conclusion This study confirms the findings in the referenced literature, where during same-day evaluation, FES is shown to not modify spatio-temporal parameters. These modifications only being manifest during prolonged use. We observed changes in the net displacement of the COP on initial application of FES. This corroborates a recent study, which suggests that FES could have an immediate effect on weight transfer and thus increase gait stability. The evaluation of the displacement in the COP could represent a readily observable parameter in gauging the effectiveness of FES when applied to patients with drop-foot. This parameter could be easily and objectively measured with available tools such as an instrumented walkway.

Value of real-time sharewave elastography in Achilles tendinopathy: Ultrasound technology of the future?

Purpose To determine if the viscoelastic properties of Achilles tendon assessed by real-time sharewave elastography (SWE) are modified in tendinopathy and provide informations for subsequent applications of this technique. Method and materials Twenty-six abnormal tendons (16 unilateral and 5 bilateral tendinopathy) from 21 patients with Achilles tendinopathy and 176 normal tendons (from 16 patients and 80 healthy volunteers) were prospectively included and compared. Mean sharewave velocity (Vmean) was measured on axial and sagittal SWE images at two degrees of passive ankle flexion (position 1: complete plantar flexion? and position 2: 0 degree flexion). Tendon maximum anteroposterior and lateral diameters, cross sectional area and the presence of tears were also noted. Results In position 1, the abnormal tendons Vmean was significantly lower than for contralateral normal tendons on sagittal (Δxa0=xa01.23xa0m/s, Pxa0=xa00.004) and axial elastograms (Δxa0=xa00.68xa0m/s, Pxa0=xa00.03)? and significantly lower than for normal tendons only on axial images (Δxa0=xa00.49xa0m/s, Pxa0=xa00.01). In position 2 and on axial elastograms, the abnormal tendons Vmean was 1.14xa0m/s lower than for contralateral normal tendons however without reaching statistical significance (Pxa0=xa00.07). In position 2, the abnormal tendons Vmean was significantly lower than for normal tendons on sagittal (Δxa0=xa01.26xa0m/s, Pxa0 Conclusion Abnormal Achilles tendons have lower Vmean and are therefore softer than normal tendons. There is no SWE signal into tendon tears. Tendon softening, assessed by realtime SWE, is a new helpful tool in the evaluation of Achilles tendinopathy. SWE may also provide quantitative parameters to assess the severity of tendinopathy to monitor the effect of therapeutics.

Évaluation IRM des modifications morphologiques du muscle piriforme après injection de toxine botulinique

avec une profondeur de 4,8 cm pour la face superficielle du muscle et une epaisseur moyenne de 1,9 cm (sur la plus grande epaisseur mesuree). Le reperage scanographique permet de valider le positionnement de l’aiguille dans la partie proximale proche de la base du triangle defini precedemment, de meme que les coupes anatomiques realisees sur cadavre. Conclusion.– Les injections de toxine botulinique pour les sites difficiles ou profonds beneficient des progres de l’imagerie et en particulier de l’echographie qui couplee a l’electromyographie donne une analyse interessante et securisante du muscle injecte. Cette association, meme si elle necessite une formation prealable, reste facile a mettre en place, non irradiante et merite certainement d’etre diffusee.

Clinical, ultrasonographic and CT markers for botulinum toxin injections into the piriformis muscle

Results.– Amnesic effect on pain may occur during mobilization. Flexion: 958 active. Pain: 0/10 at rest and walking. Improving the quality of walking with a smooth and not increase walking speed without technical assistance. Resumption of his previous 26 months work after the diagnosis of CRPS-I. Scintigraphy: net regression process CRPS-I detected in his right knee in 2010. Regularization of all households hyperactive. Discussion and conclusion.– This would be for the benefit of nitrous oxide in the mobilization of a stiff joint including CRPS-I through a permitting algofunctional improvement and joints that enabled our patient to return to his previous work. References [1] Collado V, Nicolas E, Faullks D, Hennequin M. A revue of the safety of 50 % nitrous oxyde/oxygen on conscious sedation. Expert Opin Drug Saf 2007;6(5):559–71. [2] http://www.cnrd.fr/IMG/pdf/RCP_KALI.pdf.

Troubles vésicosphinctériens comme principale séquelle d'une maladie de décompression : à propos d'un cas

INTRODUCTIONnBladder dysfunction is common in the acute phase of decompression sickness and often precedes motor disorders. Few studies have reported the persistence of urinary problems, and no prior reports describe a neurogenic bladder in the primary presentation of decompression sickness.nnnCASE REPORTnWe report the case of a 21-year-old female scuba diver with no medical history. After two successive deep dives, dysbaric myelitis developed. The risk factors were foramen ovale and history of diving. The patient initially showed tetraparesia, which was quickly followed by paraparesia with urinary retention. Treatment consisted of recompression with high concentrations of inspired oxygen, aspirin administration and continuous drainage by an indwelling catheter. No lesion was found on 2 sessions of magnetic resonance imaging (MRI) (cerebral and spinal), and somatosensory-evoked potentials were normal. Motor-evoked potential onset latencies were delayed. Neuro-urodynamic investigations revealed detrusor sphincter dysynergia and detrusor overactivity. On quick, complete motor recovery, the patient returned to work and continued with sports (except scuba diving). A year later, she still had urinary and faecal urgencies which were not completely resolved with medication and altered her quality of life.nnnCONCLUSIONnHalf of the cases of neurological decompression involve dysbaric myelitis. Venous ischemia is the most likely cause. Foramen ovale is an important risk factor, but the pathophysiology is obscure. Bladder problems, common in the acute phase of decompression sickness, may be the primary presentation, and may be prolonged.