P. Dehail

Physical and rehabilitation medicine (PRM) care pathways: “Stroke patients”

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. Care pathways in PRM is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Stroke patients are divided into four categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.

Acquired deforming hypertonia and contractures in elderly subjects: definition and prevalence in geriatric institutions (ADH survey).

OBJECTIVEnBy proposing a new terminology (acquired deforming hypertonia or ADH) and a new definition for contractures, the main objective of this study was to establish their prevalence among institutionalized elderly patients. Secondary objectives were to analyze the negative impact of ADH and collect the opinions of clinicians on the possible treatments available.nnnMETHODOLOGYnA multicenter cross-sectional study was conducted among residents of 39 geriatric institutions (29 EHPAD and 10 USLD). All subjects presenting at least one ADH were surveyed over a one-week period.nnnRESULTSnAmong 3145 observed patients (mean age 88.9±9.7 years) 22% (n=692) presented at least one ADH. In average, each patient presented 4.4±3.2 ADHs. Negative consequences on self-care, nursing and difficulties in getting dressed were most frequently observed. Only 25.4% of clinicians considered the ADH to be potentially reversible. Physical therapy was the therapeutic option most frequently chosen over medication and surgery.nnnCONCLUSIONnThis study confirms the important prevalence of ADH among elderly institutionalized patients. Consequences on the level of dependence were significant. It seems relevant to elaborate hierarchical therapeutic strategies in order to counter these disorders and the fatalism that ensues.

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

UNLABELLEDnPsychotherapy 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.nnnOBJECTIVEnTo report a preliminary report of a neuro-systemic psychotherapy for patients with TBI.nnnPATIENTS AND METHODSnAll 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.nnnRESULTSnForty-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.nnnDISCUSSION/CONCLUSIONnFrom 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.