P. Gallien

Clinical Experience With Functional Electrical Stimulation-Assisted Gait With Parastep in Spinal Cord-Injured Patients

STUDY DESIGN Clinical evaluation of the Parastep method, a six-channel transcutaneous functional electrical stimulation device, in spinal cord-injured patients. OBJECTIVES To investigate the motor performances of this new technique regarding energy expenditure and to evaluate its advantages and limitations, especially in social activities involving ambulation. METHODS This study was conducted in 15 thoracic spine-injured patients. The lesion was complete except in two patients. The gait ability and the functional use were judged clinically. Energy cost was evaluated from heart rate, peak oxygen uptake, and lactatemia. RESULTS Thirteen patients completed the training (mean: 20 sessions) and achieved independent ambulation with a walker. The mean walking distance, without rest, was 52.8 +/- 69 m, and the mean speed was 0.15 +/- 0.14 m/sec. One patient with incomplete lesion, who had been nonambulatory for 8 months after the injury, became able to walk without functional electrical stimulation after five sessions. The follow-up was 40 +/- 11 months. Five patients pursued using functional electrical stimulation-assisted gait as a means of physical exercise but not for ambulation in social activities. The patients experienced marked psychological benefits, with positive changes in their way of life. In three subjects, a comparison of physiologic responses to exercise between a progressive arm ergometer test and a walking test with the Parastep (Sigmedics, Inc., Northfield, IL) at a speed of 0.1 m/sec was performed, showing that the heart rate, the peak oxygen uptake, and lactatemia during gait were close to those obtained at the end of the maximal test on the ergometer. CONCLUSIONS In spite of its ease of operation and good cosmetic acceptance, the Parastep approach has very limited applications for mobility in daily life, because of its modest performance associated with high metabolic cost and cardiovascular strain. However, it can be proposed as a resource to keep physical and psychological fitness in patients with spinal cord injury.

Treatment of detrusor sphincter dyssynergia by transperineal injection of botulinum toxin

Detrusor-sphincter dyssynergia is an involuntary contraction of the external urethral sphincter during the detrusor contraction. It causes voiding dysfunction and can lead to urologic complications such as hydroureteronephrosis and renal failure. Patients with spinal cord injuries are particularly vulnerable. Botulinum toxin has been used via cystoscopy to decrease the activity of the external urethral sphincter. This report describes the treatment of 5 tetraplegic patients by single transperineal injections of botulinum toxin for detrusor-sphincter dyssynergia, proved by a urodynamic study with electromyography. A total of 15 injections was given, resulting in improved bladder function in all patients. Urodynamic assessment after treatment showed an increase of the functional detrusor capacity and a decrease of the maximal detrusor pressure during voiding. These results confirm the consideration of botulinum toxin as a treatment for detrusor sphincter dyssynergia. A single transperineal injection is a valuable, less invasive treatment using a cystoscopic technique.

Influence of urinary management on urologic complications in a cohort of spinal cord injury patients

OBJECTIVE To study urologic complications in patients with spinal cord injury (SCI) in relation to their bladder management. DESIGN AND SETTING A cohort study of patients with SCI in a rehabilitation center. PARTICIPANTS One hundred eighty-two patients were studied; demographic data, disease characteristics, and urologic history were obtained for each. INTERVENTION Patients responding to a questionnaire were given a clinical exam. Their medical records were reviewed, with particular attention given to the following urologic complications: lithiasis, urinary infections, orchiepididymitis, urethral trauma, vesicorenal reflux, and renal failure. RESULTS Results are reported for 123 patients. Time since SCI was 8 years. Intermittent catheterization was the main method of bladder management. Only 32 patients had changed their method of vesical voiding. Urinary complications had developed in 75% of patients. The most common complication was urinary infection. Vesicoureteral reflux occurred in 26% of patients using percussion. Trauma related to catheterization was the main problem with intermittent catheterization, responsible for a high rate of orchiepididymitis. CONCLUSION Intermittent catheterization is the most-used method of bladder management, but with a nonnegligible rate of urethral trauma in men. Percussion and Credé maneuver appear to be acceptable techniques of bladder management if the patient is closely monitored.

Caudal spinal cord ischemia after lumbar vertebral manipulation

Neurological complications after lumbar spine manipulation are uncommon. The cause is usually a herniated disk or displaced bony structure. We report a case of paraplegia that developed a few hours after manipulation of the lumbar spine. Magnetic resonance imaging was consistent with ischemia of the caudal spinal cord. No disk fragment or bony structure impinging on the spinal cord was seen. Spinal cord ischemia may deserve to be added to the list of possible adverse events after lumbar spine manipulation.

Role for botulinum toxin in back pain treatment in adults with cerebral palsy: report of a case

OBJECTIVE To report a case illustrating the usefulness of botulinum toxin A in the treatment of spinal dystonia responsible for low back pain and postural disorders. METHODS Critical appraisal of a case report. CASE REPORT A young woman with cerebral palsy had lumbar paraspinal muscle dystonia responsible for pain and hyperlordosis unresponsive to oral medications for muscle spasm. Botulinum toxin A (Botox(R), 200 U) was injected into the paraspinal muscles at six sites, to good effect. DISCUSSION The few reported cases consistently show a favorable effect of local botulinum toxin A injections in patients with painful paraspinal muscle dystonia related to neurological disease or chronic low back pain. CONCLUSION Botulinum toxin A may be a useful treatment for incapacitating painful dystonia of the paraspinal muscles. This treatment improves posture in the sitting position and facilitates the fitting of orthotic devices. Furthermore, botulinum toxin A treatment may help to determine whether an intrathecal baclofen test is in order.

Effects of pregnancy and child birth on urinary symptoms and urodynamics in women with multiple sclerosis

ObjectiveOur objective was to study the impact of pregnancy and delivery on vesicourethral disorders in patients with multiple sclerosis (MS).Design and settingWe performed a retrospective chart review of records of women diagnosed with MS who were referred to the clinic.ParticipantsA total of 102 women with MS (mean age of 44.7±11.4 years at the time of the study and mean age of 30.0±9.6 years at the onset of MS) participated in the study. The mean duration of disease was 15±10 years. The mean Expanded Disability Status Scale score was 5.4±1.8.Main outcome measuresFor each patient, demographic data, disease characteristics, urological and obstetrical history and urodynamic data were collected. Urinary disorders were classified as irritative (urinary urgency and frequency) or as obstructive (hesitancy of micturition, reduced or interrupted urinary stream and sensation of incomplete bladder emptying). Urodynamic study consisted of cystometry with continuous recording of urethral sphincter electromyography in 77 (76%) cases. Intravesical and intraurethral pressures were recorded. Bladder dysfunctions were classified into neurogenic detrusor overactivity or detrusor underactivity.ResultsPregnancies and deliveries did not influence symptoms. Moreover, the only statistical difference from a urodynamic point of view was a decrease in maximal urethral closure pressure.ConclusionNo interaction between pregnancy, delivery and urinary symptoms was found in this study. The effects of pregnancy and delivery seemed to be the same in women with MS and in healthy women, with a tendency towards a decrease in urethral pressure in women with MS.

Maintien à domicile et qualité de vie à distance d'un accident vasculaire cérébral

Introduction. – Stroke is the most disabling chronic disease among adults. The assessment of quality of life is of great importance to improve the management of patients with stroke sequelae returning to the community. Method. – A total of 93 patients and their referring clinicians were contacted. Quality of life of patients three years after stroke was assessed by use of the Short-Form Health Survey (SF-36). Results. – Thirteen patients died during this period. Fifty participated in the study. The average age was 66.8 years. The patients who died were older and had an initial greater impairment after stroke than survivors. In most of the cases, a life plan, built during the inpatient rehabilitation period, could be achieved. Just six patients had to change their way of life during the three years after stroke. A total of 44% of the patients needed human assistance for basic daily living activities. Patients with stroke had lower scores on the SF-36 than their healthy peers. All subscale scores differed for patients with stroke, as compared with health peers. Initial disability, the occurrence of falls, age and urinary incontinence at the time of the study indicated poor prognosis. Discussion. – Our results are close to those previously published: a great number of people who survive stroke live with sequelae that requires assistance in the home and have decreased quality of life. These results stress the importance of follow-up by a rehabilitation team to prevent altered quality of life, with a special care to urinary incontinence and falls, especially in old people with abundant sequelae of stroke.

Atypical low back pain: stiff-person syndrome

Stiff-person syndrome was diagnosed in a patient with chronic low back pain. The diagnosis of this rare neurological condition rests mainly on the clinical findings of axial and proximal limb rigidity, increased lumbar lordosis often accompanied with pain, and normal neurological findings apart from brisk deep tendon reflexes. Electromyography of the lumbar paraspinal muscles shows motor unit firing at rest with normal appearance of the motor unit potentials. Titers of antibody to glutamic acid decarboxylase are elevated. Diazepam is the treatment of reference. Physical therapy can substantially improve quality of life.

Intérêt de la toxine botulinique dans le traitement des dyssynergies vésicosphinctériennes

Resume La dyssynergie vesicosphincterienne frequemment retrouvee chez les blesses medullaires. Ce tableau peut aboutir a des complications renales. Dykstra et al ont montre l’interet de la toxine botulinique A injectee par voie endoscopic dans le traitement des dyssynergies vesicosphincteriennes. Le but de ce travail est d’etudier l’effet de la toxine botulinique injectee par voie perineale sous controle electromyographique. Quatre patients tetraplegiques ont beneficie de cette therapie. Un examen urodynamique a ete constatee, avec une diminution des phenomenes d’hyperreflectivite autonome. Aucune modification urodynamique significative n’a ete relevee. A 3 mois, les resultats cliniques etaient toujours satisfaisants chez trois patients. La toxine botulinique A injectee par voie perineale est une possibilite therapeutique a connaitre dans le traitement des dyssynergies vesicosphincteriennes.

Une lombalgie atypique : le syndrome de l’homme raide

Resume Nous rapportons une observation de stiff man syndrome, decouvert a l’occasion d’une lombalgie chronique. Le stiff man syndrome est une pathologie neurologique rare de diagnostic principalement clinique avec une hypertonie axiale et des racines des membres, une hyperlordose souvent douloureuse, et un examen neurologique normal en dehors d’une augmentation des reflexes osteotendineux. Le diagnostic est confirme par l’examen electromyographique des muscles para-spinaux lombaires avec persistance d’une activite au repos de potentiel d’unite motrice d’allure normale, et une augmentation des anticorps anti acide glutamique decarboxylase (GAD). A cote du traitement de reference le diazepam, une prise en charge reeducative peut ameliorer considerablement la qualite de vie de ces patients.