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The repair of the finger flexor tendons can be complicated by the appearance of ruptures and peritendinous adhesions. Ruptures are often treated with tendon grafts. Peritendinous adhesions can require tenolysis. Following these two surgical procedures, there is a risk of new adhesions and rupture. Rehabilitation after this secondary surgery consists of a tailored, closely supervised protocol. Protocols used by the team at the Physical Medicine and Rehabilitation Department of the Regional Rehabilitation Institute and the team at the Plastic and Reconstructive Surgery Department of the Emile-Galle Surgical Center of Nancy (France) are described. A close collaboration between these teams of surgeons and physical therapists is essential. After tendon grafting, protected early motion helps to move the transplant immediately while still protecting it. After tenolysis, immediate (several times a day) and extended rehabilitation ensures that the mobility obtained intraoperatively is maintained. It is performed in a specialized rehabilitation center during the first three postoperative weeks. The goal is to prevent new adhesions from forming while taking into account tendon's fragility.

Introduction/Background The use of myoelectric prosthetics in upper limb amputees introduced compensations on the residual shoulder and trunk which could be the cause of musculoskeletal disorders. Task/work involving movements in abduction of shoulder (> 60°) more than two hours per day in cumulative have been identified to be responsible of musculoskeletal disorders. The aim of the study is to evaluate the shoulder compensations in upper limb amputees with the use of the new myoelectric multi-articulated prosthetic hands compared to tri-digital hands during different functional tasks. Material and method Five unilateral trans-radial upper limb amputees (4 male, 1 female; age 45.6 ± 13.8 years old) participated in this prospective crossover study. Evaluations were realized by each participant with their own tri-digital myoelectric prosthesis and 2 multigrip prosthesis: I Limb Ultra® (IL) without a wrist mobility and Michelangelo® (MA) with a wrist mobility, after specific rehabilitation and one month of home use. Mean of internal rotation, mean of abduction shoulder, percent time in abduction higher than 60° and its extrapolation in hours were calculated by an optoelectronic system (VICON) for the both sides (amputated - non-amputated) during the Box and Block Test (BBT) and 2 common daily life tasks (cut meat, make a knot). Results Whatever the tasks, there is any significant difference in internal rotation with the different prosthetic devices. Conclusion New types of grip of innovative prosthetic hands and wrist mobility seems to decrease shoulder abduction, considered as pathogenic compensations. However, the compensation strategy is different across patients, which involve a personalized analysis for his rehabilitation program and for the prosthetic device choice. Further studies are necessary to evaluate the impact of trunk compensations.

Introduction/Background The assessment and rehabilitation of aphasia through a neurolinguistic approach is well known, so as its functional impairments to communicate, and its psycho-social consequences. We make the hypothesis that severe aphasia might leads gradually to a decrease of communication among inpatients whose needs are supplied by the institution. We propose to evaluate a new tool, the Communication Independence Measurement (CIM) scale, built like the Functional Impairment Measurement (FIM) scale. Material and method The CIM scale was used among aphasic's inpatients in a neurorehabilitation center, at baseline (M0) and 3 months (M3), by 4 different professionals (2 speech therapists and 2 nurses or carers). Four subdomains were evaluated, from 1 to 7 (motivation to communicate, expression, understanding, interaction). Psychometric properties and correlation to the Boston Diagnostic Aphasia Examination (BDAE) severity grade were analysed. Results Fifty-five patients (mean age 48 ± 11.8 years old, sex ratio 0.83) were consequently included, at 0.91 ± 1.49 months from stroke. Seventeen of them were evaluated at M3. Inter-rater validity was good, with no statistically difference between the 4 examiners at M0 (Kruskal–Wallis test P = 0.77) and at M3 (Kruskal–Wallis test P = 0.96). CIM was highly correlated to BDAE at M0 [intraclass correction (ICC) = 0.60–0.69] and at M3 (ICC = 0.82–0.85). We founded that patients who obtained a score less than the cut-off value of 35 had a bad daily communication. Conclusion The CIM scale seems to be a reliable tool to measure communication in aphasics in rehabilitation center. It might help identifying and thus helping patients with a negative prognosis of communication early during post-stroke rehabilitation time.

Introduction/Background In the light of the development of polydigital hand prosthesis, we recently explored an intuitive control mode by surface EMG associated to phantom limb movements (PLM) in upper arm amputees (Jarrasse et al., 2017a, b). As little was known about PLM, we described types and characteristics of upper limb PLM and explored some factors potentially influencing these in a population of upper limb amputees (De Graaf et al., 2016; Touillet et al., submitted). We showed, among others, that one persistent characteristic of PLM is the associated fatigue, which potentially is a problem when using PLM for prosthesis control since fatigue diminish the mobilization capacity as well as the stability of the EMG signals and thus interferes with the prosthesis control. Material and method In the present study, we explored whether PLM training (not to confound with learning) can increase mobilization capacity and stabilize EMG signals. Five trans-humeral amputees volunteered for training of all their types of PLM at home on a daily basis during about 6 weeks. Kinematics (via the intact limb imitating the phantom movements) as well as EMG signals from the residual muscles were recorded just before and right after the training period. Results None of the participants experienced (phantom or residual limb) pain related to the training. Three participants increased the number of different PLM they could execute. All of them increased the amplitude and velocity, and thus diminished the cycle duration, as well as the number of cycles they could execute before the PLM blocked by fatigue. The amplitude of the EMG increased and became more specific to the type of PLM. Conclusion In conclusion, as is the case for intact limbs, training of PLM improves motor performance and stabilizes the EMG signals associated to PLM execution. This is encouraging for future PLM-based prosthesis control.

Numerous studies have recently been published on improving upper-limb motor function after stroke. There has been a particular interest in brain stimulation techniques, which could promote brain plasticity. In this review, transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS) are presented as techniques that could be relevant in Physical Medicine and Rehabilitation (PM&R) centers in the future. We are presenting a comprehensive literature review on the studies using tDCS or rTMS for upper-limb rehabilitation after a stroke. Both techniques have shown their ability to modify cortical excitability and to transitorily improve upper-limb function after one single stimulation session. The first placebo-controlled, blinded therapeutic trials, which included repeated daily sessions, seem quite promising, and deserve to be validated by further trials.

Patellofemoral pain is likely due to compressive force acting on the patella related in turn to knee extension moment. The latter variable was assumed to be (i) reduced during short-distance free walking in case of patellofemoral pain syndrome and (ii) increased after therapeutic pain reduction. Peak knee extension moment at beginning of stance phase was recorded by three-dimensional gait analysis in 22 controls and in 23 patients with patellofemoral pain syndrome before and after rehabilitation of knee extensors and flexors to reduce the pain. Pain would occur mainly in stressful activities such as stair negotiation or squatting and was quantified by the anterior knee pain scale. Peak knee extension moment was significantly reduced in all the patients before treatment (n = 23) compared to controls, although no one had pain during free walking. In the 17 patients who experienced significant postrehabilitation pain reduction in their stressful activities, the peak knee extension moment was significantly reduced before treatment compared to controls and significantly increased after treatment, reaching values similar to control values. The peak knee extension moment during free walking appears to be a good kinetic variable related to a compensatory mechanism limiting or avoiding anterior knee pain and may be of interest in assessing knee dynamics alteration in patients with PFPS.

Resume Objectif Evaluer la reproductibilite interjuges (comparaison des cotations faites par deux juges lors d’un meme test) et intrajuge (comparaison des cotations faites par un meme juge lors de la repetition du test) du « Bilan 400 points ». Le « Bilan 400 points » est une mesure de capacite fonctionnelle de la main evaluant quatre dimensions : la mobilite de la main, la force de prehension, la prise et le deplacement monomanuel d’objets et la fonction bimanuelle. Patients et methodes Trente patients ayant une lesion de la main. Comparaison des scores, mesures par trois ergotherapeutes : expert de l’outil (juge 1), novice pour l’outil (juge 2), stagiaire ergotherapeute apprenant (juge 3). Comparaison de deux mesures espacees d’une demi-heure pour chaque patient. La moyenne des ecarts et le coefficient de correlation intraclasse ont ete calcules. Resultats (i) L’ecart entre les trois juges etait non significatif a chacune des deux periodes sauf pour la fonction bimanuelle et dans une seule comparaison. Les coefficients de correlation intraclasses etaient tous superieurs a 0,95. (ii) L’ecart entre les mesures des deux periodes etait faible pour chaque juge et non significatif a l’exception de la fonction bimanuelle. La difference etait non significative pour le score de l’epreuve globale. Les coefficients de correlation intraclasses etaient tous superieurs a 0,82 et meme superieurs a 0,90 pour la mobilite de la main, la fonction bimanuelle et pour le resultat global. L’ecart entre les deux periodes pour l’epreuve globale etait faible (de 5 a 10 % pour sept patients, de 10 a 15 % pour deux patients). Les ecarts entre les deux periodes avaient la meme tendance pour les trois juges. Conclusion La reproductibilite de la cotation du « Bilan 400 points » dans ses dimensions interjuges et intrajuge est satisfaisante. L’epreuve de la « fonction bimanuelle » est l’epreuve dont la reproductibilite est la moins bonne.

Les techniques de stimulations cerebrales non invasives ont fait leur entree dans les laboratoires il y a un quart de siecle. La stimulation magnetique transcrânienne s’est rapidement imposee du fait de son excellente resolution temporelle et de la possibilite de produire des effets durables. Cette derniere a ete mise a profit avec succes dans de nombreux champs cliniques, dont la modulation des processus visuospatiaux et attentionnels. Plus recente, la stimulation transcrânienne directe par courant continu (tDCS) n’a pas encore beneficie de nombreuses etudes cliniques, mais elle pourrait etre appelee a jouer un role de premier plan en matiere de reeducation des troubles de la cognition spatiale.

Objective After upper limb amputation, the use of prosthesis usually causes compensation movements for trunk and stump. These compensations can lead to musculoskeletal pain or overuse syndromes. In the context of occupational pathologies, stress levels were defined as at risk for shoulder concerning abduction amplitude (60°) and duration of exposure (2/24 h or 8.5% of the time beyond 60°). The objective of this study is to evaluate the risk of shoulder complications in a population of below-elbow amputees when using different myoelectric prosthetic end-effectors. Material/patients and methods Eight below-elbow amputees fitted with tridigital myoelectric prosthetic hand potential users of non-morphometric end-effectors in professional or leisure time are evaluated. Shoulder abduction (mean abduction and percentage of time spent beyond 60° of abduction) is measured during a Box and Block Test in a sitting position with a VICON optoelectronic system. The measurements are performed for amputated limb in 2 or 3 conditions: non-morphometric end-effector with or without wrist flexion-extension ± with tridigital myoelectric prosthetic hand (for 3 amputees) and for healthy limb. Results There is no significant difference in dexterity between end-effectors but significant difference between all end-effectors and healthy limb. The mean shoulder abduction is greater than 60° and the median percentage of time beyond 60° abduction is greater than 8.5% only when using a non-morphometric end-effector without wrist flexion-extension. Moreover, there is a significant difference between the 2 limbs for the mean abduction only with the non-morphometric effector without wrist flexion-extension. There are no differences between the other end-effectors and healthy limb, nor between the end-effectors between them. Discussion, conclusion Prosthetic grip and mobility capacity of prosthetic wrist also influence shoulder kinematics. For some amputees, shoulder abduction is not at risk for musculoskeletal disorders but other compensation movements (internal shoulder rotation, trunk torso…) remain to be studied. The quantification of stresses on residual limb and trunk related to these compensations could allow to detect risk of musculoskeletal complications. A personalized analysis of compensations during common task could guide the choice of prosthetic end-effector and its adjustment and allow to quantify the influence of rehabilitation techniques on these compensations.

Objective Recovering a gait as close as possible to physiology is a real challenge after lower limb amputation. The objective of the multidisciplinary team, focused on amputee people, is to correct and ensure proper use of the prosthesis. However, to our knowledge, there are few studies which proposed personalized approach of motor learning. The aim of the study was to realize a visual gait analysis tool, considering gait cycle and the 3 motion planes, to be used by physiotherapists thanks to the knowledge of biomechanical analysis. This study was part of the project APSIC (ANR) which aimed at completing scientific knowledge about gait adjustment strategies to limiting daily living situations compared to level walking in transtibial (TT) and transfemoral (TF) amputees. Material/patients and methods Data collection was conducted in 2 centres (INI/CERAH-Creteil, IRR-Nancy). Twenty-one TF and 22 TT walked with their own prosthetic devices and shoes at their comfortable speed in a motion capture laboratory equipped with an optoelectronic system on five different surfaces (level ground, 2 slopes, cross-slope and stairs) instrumented with 3 AMTI® force platforms. The main outcomes measures were the asymmetry in loading between prosthetic and intact limbs, the nonspecific adaptations (spatiotemporal and kinematic parameters) and specific strategies as vaulting and pelvic hike. Results In situations of daily living, amputees increased asymmetry in loading, pelvic hike and vaulting especially TF amputees. By these biomechanical results, a visual gait analysis tool was proposed considering gait cycle events (toe off, heel strike, double support, stance and swing phase) and the 3 planes (sagittal, horizontal, frontal) for TF and TT amputees. At each moment of gait cycle, the rehab professional objectives and the amputee guidelines focused on exteroception, proprioception and kinesthesia were listed on a pocket brochure. Discussion, conclusion This study allowed to refine the gait rehabilitation by using the synchronisation of the three different sensitivities considering gait cycle events and the 3 motion planes by defining a couple “amputee-prosthesis”. The innovation was also the association of the rehab professional objectives and the amputee guidelines in the same pocket-sized tool. Its use will be very interesting for multidisciplinary team to decrease gait defaults in amputees.

Introduction Les enfants atteints de paralysie cerebrale (PC) presentent des difficultes de controle des segments axiaux qui pourraient expliquer certains deficits locomoteurs tels que le freinage excessif lors l’appui initial. Tandis que les interventions therapeutiques classiques se centrent majoritairement sur les membres inferieurs, cette etude visait a determiner si l’amelioration du controle du tronc des enfants PC, grâce a une reeducation axiale accentuee, pouvait entrainer des repercussions favorables sur le freinage initial lors de la marche. Materiel et methodes Treize enfants PC (8 ans ± 2,4), ont suivi en cross-over deux phases de reeducation de 3 mois, l’une de reeducation habituelle et l’autre ciblant davantage les segments axiaux (reeducation axiale accentuee, RAA). Avant et apres chaque phase de reeducation, ont ete realisees (1) une evaluation de la stabilisation des segments axiaux via un dispositif d’assise instable et via l’echelle Trunk Control Measurement Scale (TCMS) et (2) une analyse quantifiee de la marche. Les performances initiales des enfants PC etaient comparees a celles de 16 enfants controles (EC). Resultats Les enfants PC avaient davantage de difficultes pour stabiliser le tronc que les EC (score inferieur au TCMS et surface de deplacement du CoP superieure sur assise instable). Apres RAA, ces performances posturales etaient ameliorees et le freinage initial lors de la marche etait significativement moins important. La reeducation habituelle ne montrait pas d’effet significatif. Discussion/Conclusion Incorporer des activites challengeant les segments axiaux semble pertinent pour ameliorer le controle postural mais aussi la locomotion des enfants atteints de PC.

La reconnaissance du corps dans le miroir constitue une etape importante dans l'elaboration des representations du corps. Si l'existence de comportements anormaux dans les espaces speculaires est classiquement decrite chez patients les cerebroleses, les caracteristiques de ces conduites peuvent etre dissociees de celles rencontrees en cas de non-reconnaissance des objets ou lors d'un defaut de traitement des informations visuelles et constituer des syndromes distincts. L'utilisation therapeutique des informations speculaires a ete proposee initialement dans le traitement des douleurs fantomes de l'ampute. Le traitement par le feed-back visuel du miroir a ete utilise avec le meme succes dans un contexte de douleur chronique. Plusieurs etudes recentes, controlees suggerent que la therapie du miroir (TM) chez le patient hemiplegique ameliore la recuperation motrice, l'utilisation de l'espace et les fonctions de l'hemicorps paralyse. Les indications de la TM sont discutees a la lumiere de ces travaux et des mecanismes supposes sur le role des informations speculaires. Le recours a un miroir pourrait en effet, par l'image inversee renvoyee, forcer l'activation d'un membre deficitaire ou creer l'illusion de mouvement et, par consequent, l'evolution eventuellement constatee viendrait souligner le role de l'activite comme agent mediateur de la plasticite du systeme nerveux central.

Introduction/Background After amputation, hand and wrist phantom limb movements (PLM) are experienced as effortfull, slower and smaller than healthy limb movements. Our hypothesis is that this is caused by the altered somatosensory feedback coming from the residual limb muscle contractions that are associated to PLM. If this is true, one can expect to find differences between below- and above-elbow amputees since the latter ones still have many muscles left that were involved in hand and wrist movements, such that the sensory feedback is close to that before the amputation. To test this hypothesis, we compared PLM kinematics between above- and below-elbow amputees. Material and method Six above- and 8 below-elbow amputees performed phantom hand and wrist PLM. The kinematics of the PLM was indirectly obtained via the intact limb that synchronously mimicked the PLM at a comfortable velocity, using a Cyberglove for hand movements and an inertial measurement unit for wrist movements. For each patient and each type of PLM, we determined the number of executed cycles, the duration of the cycles and the velocity. Results Our results show that after above-elbow amputation the number of different types of PLM was higher, PLM repetitions were more numerous before blocking caused by fatigue, cycle duration was shorter and velocity was higher. Conclusion In conclusion, below-elbow amputees have more facilities for PLM execution (i.e., they perceive their PLM as faster and less tiring) than above-elbow amputees. This confirms our hypothesis that the more the somatosensory feedback is altered with respect to intact limb feedback, the slower and more effortfull are PLM.

Although post-stroke exercise training programmes improve aerobic capacity and functional capacities in the short-term, the impact on exercise performance at home has not been established. Objectives To assess compliance with prescribed physical activity by hemiplegic stroke patients. To compare the patients’ stated activity with their actual activity. Patients and methods This was a prospective pilot study of nine hemiplegic patients following an exercise training programme. Each patient's activity was measured using an activity monitor (the ActivPAL™) before, during and immediately after the programme and then 3 months after the end of the programme. The activity actually performed was compared with the levels recommended after a stroke (at least 30 minutes of non-stop activity three times a week). Three months after the end of the programme, the patient's stated and actual activities (in terms of frequency and duration) were compared. Results Activity patterns changed immediately after the end of the programme. Short-term compliance was good for four patients. However, 3 months later, only one patient was performing regular activity in accordance with the guidelines. Hence, medium-term compliance was poor. Most patients overestimated both the duration and frequency of their activity sessions. Conclusion Three months after the end of the supervised training programme, compliance with physical activity guidelines was low. The ActivPAL™ activity monitor is easy to use and performs satisfactorily. It can be used as a tool for activity assessment and education intervention. The use of an actimeter may increase the efficacy of health education interventions, which promote physical activity.

Objectives Retrospective analysis of the efficiency of a protocol for care of chronic vegetative states (CVS) and minimally conscious state (MCS) in Lorraine. Material and method Two indicators are used: protocol activity (number of patients hospitalized between 1988 and 2006, number of admissions per year, of requests per year, origin of requests, waiting time) and the epidemiological data (age, sex ratio, etiology, length of stay, geographic origin, number of deaths, number of hospital discharges). The number of CVS and MCS and patients having progressed towards arousal is specified as well as the technical procedures (orthopedic surgery, number of tracheotomies). Results Forty-seven patients (30 males and 17 females) were hospitalized in a 12-bed unit. The number of admissions per year was 2.4, and the annual number of requests varied between five and 15. Hospitalization times ranged from six to 18 months. The average length of hospitalization was 41 months. Eighty-eight percent of the cases were residents of Lorraine. The etiology was traumatic (53%), vascular (38% including 12% anoxia), miscellaneous (9%). Fifteen percent rate of return to arousal (average time period: 28.41 months, traumatic etiology) with hospital discharge in four cases. Conclusion The protocol is managed as part of a local scheme and enables an appropriate response to a specific clinical profile by providing up-to-date multidiscipline follow-up care and a rapid solution should intercurrent events occur (signs of arousal, orthopedic deterioration, change of environment). Typical limitations are geographical remoteness and difficulties with family support care.

Resume Objectif Le but de cette revue generale est de faire le bilan de connaissances actuelles sur l’evolution anatomique, histologique et physiologique des muscles chez les patients amputes tibiaux. Materiel et methode Revue de la litterature de PubMed et Reedoc, concernant les publications ayant trait au moignon des amputes tibiaux, son evolution, son volume, ses modifications histologiques et aussi les modifications de l’equilibre et de la marche apres une amputation. Resultats Les muscles des patients amputes presentent, du cote lese et du cote sain, une amyotrophie avec une reduction du diametre et du nombre de fibres et, en particulier, les fibres lentes (fibres de type I). Cette amyotrophie, heterogene dans son importance et dans sa repartition, atteint 25 % sur le quadriceps ou elle predomine sur le compartiment interne alors qu’elle est non significative sur les ischiojambiers. Elle trouve ses origines, d’une part, dans des modifications anatomiques secondaires au geste chirurgical. La perte de l’insertion distale d’un muscle ou sa reimplantation non anatomique favorise son amyotrophie. Et, d’autre part, dans des modifications du schema d’activation des muscles. Les ischiojambiers assurent la propulsion en l’absence du triceps sural et les muscles residuels du moignon presentent des contractions necessaires au maintien de l’emboiture. Le patient ampute presente un nouvel etat musculaire, retentissant sur la marche qui devient asymetrique et plus exigeante en energie, la sensibilite proprioceptive modifiee necessite une periode d’apprentissage pour retrouver un controle postural optimal.

Introduction Amputee people have gait defaults, as for example loading asymmetry, which increase with daily living situations. Replication of realistic daily living environment in a motion analysis laboratory (MAL) is difficult. Wearable pressure insoles, by providing normal ground reaction force (NGrF), can be used to quantify loading gait asymmetry in real life conditions. This asymmetry, considered as an indicator of the quality of the gait, is useful for physicians to monitor the rehabilitation progress or the prosthetic fitting suitability. The study aimed at quantifying the reliability of NGrF measurement and assessing the gait asymmetry of transfemoral amputee people with Pedoped ® insoles against force plates. Walking speed effect was also evaluated on gait asymmetry for transfemoral amputee people (TFP). Material and methods In a MAL, five active TFP walked at three self-selected speeds on level ground wearing Pedoped ® insoles. Reliability was assessed by comparing NGrF obtained from both systems with Bland-Altman plots, normalized RMSE (NRMSE) and correlation coefficient. Gait loading asymmetry was computed by Absolute Symmetry Index in loading at the three self-selected speeds with insoles. Results The mean NRMSE of NGrF was 7.2% (± 2.8%) and 9.8% (± 3.5%); and coefficient correlation was 0.91 and 0.95 for the prosthetic side and the intact side respectively. Loading asymmetry increased significantly with walking speed for each specific variable of NGrF. Discussion–conclusion After overcoming the calibration problem in amputee population, Pedoped ® insoles could be easily used for gait asymmetry follow-up during rehabilitation.

The aim of this study was to analyze the displacements of center of pressure (COP) using an in-shoe recording system (F-Scan) before and after motor nerve block and neurotomy of the tibial nerve in spastic equinovarus foot. Thirty-nine patients (age 45 ± 15 yr) underwent a motor nerve block; 16 (age 38 ± 15.2 yr) had tibial neurotomy, combined with tendinous surgery (n = 9). The displacement of the COP (anteroposterior [AP], lateral deviation [LD], posterior margin [PM]) was compared between paretic and nonparetic limbs before and after block and surgery. At baseline, the nonparetic limb had a higher AP (17.3 vs 12.3 cm, p < 0.001) and LD (4.0 vs 3.3 cm, p = 0.001) and a smaller PM (2.9 vs 4.7 cm, p = 0.001). For the paretic limb, a significant increase of AP was observed after block (13.5 vs 12.3 cm, p = 0.02) and after surgery (13.7 vs 12.3 cm, p = 0.03). A significant decrease of PM was observed after surgery (4.5 vs 3.3 cm, p < 0.001) with no more difference between two limbs (2.8 vs 3.3 cm; p = 0.44). This study shows that the F-Scan system can be used to quantify impairments and be useful to evaluate the effects of treatment for spastic foot. It suggests that changes in AP displacement following block may predict the effects of neurotomy.

Objective: To search for specular disorders of body representations in right hemisphere stroke. Background: Mirror self-misidentification, asomatognosia, and personal confabulation are similar to body illusions or changes in sensorial or sensorimotor perceptions generated by mirror in right brain damage patients with body image disorders. Method: Prospective study. Ten consecutive right-handed patients (1) performed body part naming and localization tasks and (2) were examined for asomatognosia at the acute phase of stroke, then at least 3 months after stroke, under 3 test conditions: without a mirror, with a conventional mirror, and with an inverted mirror. Video recordings of the tests were analyzed to assess performance. Results: Analysis of variance of the data confirmed that the interaction of mirror's conditions (specifically without a mirror vs. an inverted mirror) with subtest type was significant. The errors are symmetrically distributed. Asomatognosia was "reactivated" in 10 patients who experienced asomatognosia during the acute phase. No particular pattern characterized the clinical manifestations of asomatognosia. Conclusions: A causal conflict of sensorial input is proposed. The specific symptoms observed would suggest the existence of an incomplete specular Gerstmann syndrome and/or Anton Babinski syndrome. These results emphasize the role of specular input in the generation of body representations and self-awareness.

Resume Objectifs Exposer la place de l'exploration situationnelle de l'activite locomotrice et l'interet des methodes d'analyse ambulatoire. Decrire les capteurs, les variables mesurees, les systemes de monitorage a disposition. Materiel et methode Revue de la litterature et experience personnelle. Pour chaque methode et technique d'exploration ambulatoire, les principes, les objectifs et les limites sont decrits. Resultats Les monitorages d'activites d'origine accelerometriques tendent a s'imposer compte tenu de la richesse des informations contenues dans la variable « acceleration », de leur fiabilite et des applications aujourd'hui developpees. Leur pertinence clinique est accrue lorsque les resultats sont associes a un monitorage d'effort (frequence cardiaque). Les podometres et actimetres, d'utilisation plus simple, peuvent apporter des reponses quantifiees et resultantes de l'activite locomotrice. Leur choix et leur modalite d'utilisation doivent etre adaptes au probleme prealablement defini avec precision. Conclusion Les monitorages d'activite et de longue duree constituent un progres considerable en parfaite coherence avec la medecine physique et de readaptation : mesurant la performance ils sont les temoins de l'activite et de la participation. La connaissance simultanee des conditions environnementales de l'activite en ameliorerait l'interpretation.

Summary Introduction Evolution of comatose patients can be made either towards a persistent vegetative state (or unresponsive wakefulness syndrome–UWS), minimally conscious state or a recovery of self and environment awareness. Investigations remain insufficient to estimate the prognosis and optimize the orientation and long-term follow-up of these patients in physical and rehabilitation medicine (PRM). Multimodal magnetic resonance imaging (MRI) are being evaluated for the diagnosis and prognosis of altered consciousness states [1] , [2] . Diffusion tensor imaging (DTI) could predict the mid-term evolution within a 95%-specificity. Case report A 29-years-old woman gives birth by vaginal delivery (pre-eclampsia) with the onset of a HELLP syndrome. At 4 A.M., comatose state (GCS: 3/5). TDM showed a parenchymal pontine and midbrain hematoma. No sign of awakening. The brain MRI (M3) showed atrophy (pons, midbrain, and middle cerebellar peduncles). DTI sequence with tractography shows a complete interruption of the left corticospinal tract as well as a rarefaction of inferior cerebellar peduncle fibers. The patient occasionally opens her eyes, without eye-tracking or other awakening sign (M10). The question then arises of the orientation of this patient in a persistent vegetative states unit and the future taking care by PRM team. Discussion DTI MRI with measure of anisotropy fraction could be a promising tool in order to predict the prognosis of altered conscious states and optimize the orientation and long-term follow-up of these patients in PRM.

International audience; After limb amputation, patients often wake up with a vivid perception of the presence of the missing limb, called "phantom limb". Phantom limbs have mostly been studied with respect to pain sensation. But patients can experience many other phantom sensations, including voluntary movements. The goal of the present study was to quantify phantom movement kinematics and relate these to intact limb kinematics and to the time elapsed since amputation. Six upper arm and two forearm amputees with various delays since amputation (6months to 32years) performed phantom finger, hand and wrist movements at self-chosen comfortable velocities. The kinematics of the phantom movements was indirectly obtained via the intact limb that synchronously mimicked the phantom limb movements, using a Cyberglove® for measuring finger movements and an inertial measurement unit for wrist movements. Results show that the execution of phantom movements is perceived as "natural" but effortful. The types of phantom movements that can be performed are variable between the patients but they could all perform thumb flexion/extension and global hand opening/closure. Finger extension movements appeared to be 24% faster than finger flexion movements. Neither the number of types of phantom movements that can be executed nor the kinematic characteristics were related to the elapsed time since amputation, highlighting the persistence of post-amputation neural adaptation. We hypothesize that the perceived slowness of phantom movements is related to altered proprioceptive feedback that cannot be recalibrated by lack of visual feedback during phantom movement execution.

International audience; The main French language scales evaluating functioning after lower-limb amputation have not undergone exhaustive psychometric validation.OBJECTIVE:A transcultural validation of the Special Interest Group in Amputee Medicine (SIGAM) mobility grades questionnaire, with 21 closed questions, as an administered questionnaire.METHODS:The questionnaire translation, back-translation and original-author validation was followed by a pretest with 5 patients to check comprehension. The psychometric properties of the scale were validated with 49 patients at the definitive prosthesis stage by an investigator via telephone. Criterion validity was evaluated by comparison with the Houghton Scale score and construct validity by correlation between the questionnaire scores and convergent dimensions (performing everyday activities and performing transfers on a numerical rating scale [NRS], 2-min walk test) and divergent dimensions (managing medication and stump skin care on an NRS). Internal consistency was assessed by the Kuder-Richardson Formula 20 (KR-20) coefficient and test-retest reproducibility by the Cohen kappa coefficient.RESULTS:The resulting questionnaire was validated by the original author after the back-translation. It showed good psychometric properties when administered by an investigator as a self-reporting questionnaire, excellent criterion validity (r=0.89, P

Introduction. – Review of the literature about evaluation of amputees. Materials and methods. – A search of the Medline and Reedoc databases with the key words lower limb amputee, upper limb amputee, evaluation of lower limb amputee, evaluation of upper limb amputee, survey of lower limb amputee, survey of upper limb and the same words in French for reports on the evaluation of amputees. Results. – Evaluations of amputees differ according to the level of amputation (lower or upper limb) and age (adult or child). They concern standing balance, walking (lower limb) and the mono- or bimanual prehensile capacities with or without prostheses in daily living activities and leisure (upper limb) as well as quality of life, personal satisfaction, psychological impact and, in particular, coping strategies. Discussion. – For lower-limb amputees, tools to evaluate include scales of deambulation, of which few are valid in French, and global scales (on locomotor capacities, quality of life and satisfaction), which have been recently validated, but only one of them is valid in French. For upper-limb amputees, specific and valid tools are not available for adults; however, for children some functional capacity scales in daily activities have been validated and take into account psychomotor development. None of these tools are valid in French, and their use is scattered and limited to validation studies. Conclusion. – Only a few tools to evaluate amputees are valid in French for adults, and they concern lower-limb amputees only. Validating some of these tools in French is necessary.

Paysant J, Andre J-M, Martinet N, Beis J-M, Datie A-M, Henry S, Dap F. Transcranial magnetic stimulation for diagnosis of residual limb neuromas. Arch Phys Med Rehabil 2004;85:737–42. Objective To analyze the mechanism and examine the potential diagnostic contribution of transcranial magnetic stimulation (TMS) in diagnosing painful, clonic, and/or autonomic manifestations in amputees' residual limbs. Design Prospective study. Setting Regional rehabilitation institute at a medical school in France. Participants Thirty-four amputees (24 with myoclonus, stump pain, or trophic skin disorders; 10 controls with no stump symptoms). Interventions Not applicable. Main Outcomes Measures TMS performed before and after correcting prosthesis adaptation. Results TMS induced pain in 12 amputees, clonic manifestations in 4, and autonomic manifestations in 2. Twelve patients underwent magnetic resonance imaging that showed neuromas in all 12. After neuroma resection in 9 amputees, TMS no longer provoked abnormal manifestations. TMS did provoke abnormal manifestations after resection in 3 patients who had postoperative recurrent neuromas. The response to TMS was negative in subjects with a clinically silent neuroma (n=7). The response was also negative in all patients with other stump anomalies whose clinical manifestations fully regressed after conservative treatment. There was a highly significant correlation between the presence of a pathologic neuroma and TMS-induced abnormal manifestations ( P Conclusions TMS can provoke symptoms in patients who experience spontaneous or evoked symptoms related to a neuroma. Induced symptoms are proportional to spontaneous symptoms. Removing the neuroma can stop stump symptoms and reverse the TMS effect. The response to TMS was negative in the control subjects with clinically silent neuromas; conservative treatment was successful in these cases. TMS-induced abnormal manifestations underlying mechanisms are discussed (ephaptic transmission in neuromas).

Resume Introduction. – Les resultats fonctionnels des reimplantations apres amputation traumatique de main sont consideres comme bons en depit des frequents troubles de mobilite des doigts longs et des troubles de la sensibilite quasi constants. Objectifs. – Evaluer la recuperation et les compensations mises en œuvre a l’origine des performances de la prehension. Materiel et methodes. – Etude prospective de huit sujets masculins droitiers amputes distaux du membre superieur gauche reimplante depuis plus de deux ans. Groupe temoin de huit sujets apparies selon l’âge, le sexe, la lateralite. Evaluation des recuperations sensitive (monofilaments), motrice (TAM) et fonctionnelle (Box and Blocks test et 400 points) et de la reinsertion socioprofessionnelle. Evaluation cinematique par systeme opto-electronique et cube dynamometrique : sequences temporelles de la prehension lors d’une tâche de saisie–transport, deplacements du tronc et des membres (bras, avant-bras, main). Etudes des correlations entre les resultats fournis par les epreuves cliniques et fonctionnelles et les donnees cinematiques. Resultats. – La replantation se caracterise par une recuperation remarquable de la duree absolue et relative des differentes phases decrites lors de la prehension physiologique. Seule la phase de saisie est significativement allongee chez les reimplantes en rapport avec les difficultes motrices et sensitives residuelles comme en temoignent les correlations avec les tests cliniques. La dependance au controle visuel est accrue, probablement en raison des troubles sensitifs superficiels et profonds. Les compensations portent sur une deviation globale de l’ensemble du membre superieur reimplante, semblant a rapporter principalement a une deviation du tronc dans le plan lateral. Conclusion. – Le patient ampute et reimplante de main developpe une strategie de deplacement homogene du tronc et de la ceinture scapulaire de facon a compenser le raccourcissement et la reduction de la mobilite active de la main. Cette amplification d’une strategie observee chez le sujet sain aboutit a une compensation efficace, respectant les caracteristiques des phases de la prehension normale.

Objectif Le « Bilan 400 points » (B400) est utilise depuis 20 ans et evalue la fonction de la main dans quatre dimensions : mobilite, force, prise monomanuelle et deplacement d’objets, fonction bimanuelle. Nous presentons les resultats preliminaires d’une etude de validation de la nouvelle version standardisee du B400. Materiel methodes Etude multicentrique internationale, patients en reeducation avec atteinte orthopedique unilaterale de la main ou du poignet. Correlation (Pearson) de la nouvelle version du B400 avec le QuickDASH, le SF36 fonction physique (FP) et le Jebsen Hand Function Test (JHFT) pour la VCC (validite du construit convergente), avec le SF36 fonction mentale (FM) et la douleur pour la VCD (validite du construit divergente). Coefficients de correlation intraclasse (ICC) pour la reproductibilite intra- et interobservateur, et coherence interne par le Cronbach alpha. Calcul du changement de la taille de l’effet (ES), de la reponse standardisee moyenne (SRM), du changement minimum detectable (MDC) et du changement cliniquement important (MCID) pour la sensibilite au changement. Resultats Cent soixante-dix-huit patients inclus, EVA moyenne a 3,4, 10 (âge moyen 44 ans + femmes 31,9 %). Correlation moyenne avec le JHFT −0,543, satisfaisante avec le QuickDash −0,432 et le SF36FP 0,358. Pas de correlation avec le SF36FM −0,11 et la douleur moyenne −0,130. Reproductibilites intra-observateur excellente (0,97), interobservateur bonne (−0,86). Coherence interne du B400 et de ses 4 dimensions elevee (0,92). Sensibilite au changement : ES modere a 0,53, SRM bon a 1,06, MDC a 9,2 points, MCID a 3,3 points. Discussion La coherence interne excellente de la version 2 du B400 est comparable a celle de la version 1. La VCC est moyenne avec le JHFT mais il s’agit d’un test qui comprend beaucoup moins d’items + celle avec le QuickDash est comparable a celle entre le DASH et la version 1 du B400. Les reproductibilites intra- et interobservateur sont comparables a celles de la version 1. Concernant la sensibilite au changement, les valeurs d’ES, de SRM et de MDC sont comparables a celles de la version 1. Le MCID a des amplitudes importantes entre les differents centres qui temoignent de l’heterogeneite des groupes de patients. Conclusion La version 2 standardisee du B400 a de tres bonnes proprietes clinimetriques comparables a la version originale. Seule la sensibilite au changement necessite des etudes complementaires dans des populations plus homogenes.

Introduction Dans la litterature, plusieurs etudes se sont interessees a l’analyse cinematique des mouvements du bassin au cours de la marche des personnes amputees (Sjodahl et al., 2003). D’autres etudes ont montre le role essentiel des epaules au cours de la marche (Cappozzo et al., 1982). L’interaction entre le bassin et les epaules semble avoir une importance particuliere. L’objectif de ce travail est d’etudier la cinematique des deplacements des ceintures scapulaire et pelvienne dans le plan sagittal et horizontal au cours de la marche des personnes amputees trans-tibiales. Materiel et methodes Vingt sujets sains (47,35 ± 16,64 ans) et 19 personnes amputees (53 ± 12,08 ans) ont beneficie d’une analyse quantifiee de la marche avec un systeme optoelectronique VICON. Les mouvements des ceintures scapulaire et pelvienne ont ete analyses dans le plan sagittal et horizontal avec un logiciel VICON Workstation. Resultats Dans le plan sagittal, l’amplitude des mouvements des epaules est significativement plus elevee au cours de la marche des personnes amputees (sains : 53,1 ± 16,5° ; amputes : 65,6 ± 22,4°). L’amplitude des mouvements du bassin augmente de 21 % au cours de la marche des personnes amputees par rapport aux sujets sains (p Discussion–conclusion Les personnes amputees presentent des amplitudes de deplacement plus elevees des epaules et du bassin par rapport aux sujets sains (Goujon-Pillet et al., 2008). Le deplacement maximal des epaules dans un sens est suivi par un deplacement maximal du bassin dans le sens contraire. Ceci nous permet de comprendre le role compensatoire des epaules au cours de la marche. Les mouvements des epaules et du bassin devraient etre consideres au cours de la reeducation des personnes amputees.

Introduction L’indice d’ancrage (IA), proposee par Assaiante et Amblard (1993), permet d’identifier les differentes strategies de stabilisation segmentaire adoptee par l’enfant pendant la marche selon son developpement moteur. A notre connaissance, aucune etude n’a analyse les IA pendant la marche d’enfants atteints de paralysie cerebrale (PC) qui presentent pourtant des retards de developpement au niveau des synergies durant la posture debout statique (Woollacott et al., 1998). Materiel et methodes Les IA de la tete et du tronc ont ete calcules sur 9 cycles de marche a vitesse spontanee pour 59 enfants PC separes en 3 groupes : atteinte bilaterale symetrique (ABS) ( n = 25 ; 11,6 ± 3,2 ans), atteinte bilaterale asymetrique (ABA) ( n = 18 ; 11,5 ± 2,8 ans) ou atteinte unilaterale (AU) ( n = 16 ; 11,1 ± 2,9 ans). Resultats Le resultat le plus remarquable etait l’IA negatif de la tete dans le plan frontal pour les enfants du groupe ABS, differant significativement des indices positifs releves pour les deux autres groupes. La tete se comporte donc en bloc avec le thorax dans le plan frontal lors d’une ABS. En revanche, pour tous les groupes, le thorax n’etait pas ancre sur le bassin. Discussion–conclusion La strategie en bloc de la tete avec le thorax dans le plan frontal observee chez l’enfant PC seulement lors d’une ABS pose la question de son origine (retard developpemental, compensation) alors que l’enfant de developpement typique de plus de 7 ans, stabilise la tete par rapport a l’espace, dans les 3 plans de l’espace, meme lors d’une marche d’equilibre difficile. L’absence d’ancrage du thorax sur le bassin chez les enfants PC pourrait en partie etre imputee a la marche en Trendelenburg frequemment observee chez ces patients.

Foisneau-Lottin A, Martinet N, Henrot P, Paysant J, Blum A, Andre J-M. Bursitis, adventitious bursa, localized soft-tissue inflammation, and bone marrow edema in tibial stumps: the contribution of magnetic resonance imaging to the diagnosis and management of mechanical stress complications. Arch Phys Med Rehabil 2003;84:770-7 Objective: To assess the contribution of magnetic resonance imaging (MRI) in the diagnosis of tibial stump bursitis, in the establishment of differential diagnosis, and in the therapeutic management prosthetic-stump interface, mainly by adaptation of the prosthetic device. Design: Two-year, prospective, consecutive series. Setting: University-affiliated prosthetic and rehabilitation center and university department of radiology. Participants: A group of 17 persons with stump problems identified from a total of 139 consecutive below-knee amputees with prosthesis problems. Interventions: Not applicable. Main Outcome Measures: Clinical symptoms and MRI. Results: Clinical symptoms (variable stump volume, fluctuating mass at palpation with or without mechanical pain) were suggestive of bursitis in 10 patients. MRI confirmed bursitis in 9 and identified 1 in whom clinical signs suggested neuroma, giving an incidence of 10 of 139 amputees (7.2%). MRI identified 13 sites of bursitis (adventitious bursa, 11; synovial bursitis, 2) and 5 localized areas of soft tissue inflammation. MRI showed diffuse muscular edema at 1 site of clinically suspected bursitis, and bursitis at another site of suspected neuroma. Calcified bursitis was observed in 1 case. Bone abnormalities associated with bursitis (n=7) included osteophytes or fracture (n=4) or bone marrow edema (n=3). Two asymptomatic neuromas were also identified. MRI-guided modifications of the prosthetic interface led to favorable outcome in all cases. Conclusion: Bursitis, adventitious bursae, and areas of localized soft-tissue inflammation are different aspects of the same disorder resulting from a mechanical conflict between the stump and the prosthesis socket. Besides contributing to diagnosis, MRI provides a precise assessment necessary for correcting the prosthesis-stump interface in a way that reduces mechanical stress and subsequently cures bursitis.

Resume Introduction. – Le deconditionnement est une entite nosologique recente qui s’etablit sur un faisceau d’arguments (medicaux, socioprofessionnels, psychologiques,...). Ce travail a pour objectifs d’evaluer la faisabilite et l’efficacite d’un programme specifique de reentrainement a l’effort (SWEET) chez cinq patients douloureux chroniques et cinq patients non douloureux. Methode. – Au sein de ces deux populations, differents criteres ont ete analyses et compares au groupe temoins : les donnees physiologiques (VO2 max., puissance maximale toleree, FC max., temps de recuperation) au cours de deux epreuves — epreuve d’effort sur cyclo-ergometre, epreuve des 6 min — la douleur (EVA, echelle de Bourrhis) et la representation subjective du deconditionnement par un questionnaire qualitatif. Les criteres d’inclusion ont ete le volontariat, l’absence d’etiologie curable a la symptomatologie douloureuse et l’absence de medication cardiotrope. L’analyse statistique utilise le test t de Student. Cette etude a releve trois parametres essentiels (VO2 max., PMT et frequence cardiaque d’effort) confirmant le deconditionnement physique chez ces patients. Au terme du reentrainement specifique globalement bien supporte, les sujets sont satisfaits. Une amelioration significative de la VO2 max., de la PMT, du temps de recuperation et de l’adaptation cardiaque a l’effort est constatee. La douleur n’est pas apparue comme un facteur limitant du reconditionnement et a meme ete significativement amelioree apres le protocole. Conclusion. – Le reentrainement a l’effort par le protocole SWEET constitue donc un des moyens proposes pour reduire le deconditionnement de ces patients, qu’ils soient douloureux ou non. Les progres observes sont rapportes en partie a de meilleures capacites physiques mais aussi a une baisse de l’inhibition anxieuse. Cette prise en charge cadree a permis une prise de confiance globale du sujet en ses capacites.

Purpose : Limb amputation is followed by an important rehabilitation process, especially when a prosthesis is involved. The objective of this study is to assess the nature of factors related to health related quality of life (HRQL) of persons with limb amputation. Method : The Nottingham Health Profile (NHP) treated 1011 subjects with major amputation of one or several limbs. Correlations were sought in multivariate regression model analyses between the six categories of distress explored by the NHP and age, sex, cause and level of amputation and rehabilitation programme. Results : Response rate was 53.3%. HRQL measured by the NHP was mostly impaired in the categories of physical disability, pain and energy level. Controlling for sex and age, young age at the time of amputation, traumatic origin and upper limb amputation were independently associated with better HRQL. Conclusion : It is concluded that HRQL is largely related to factors which are inherent to the patient and the amputation.

We report a case of a 29-year-old woman suffering from chronic factitious disorder (FD) with torsion dystonia. For nearly five years, she traveled widely over the country, going from one hospital to another, taking serious medical risk in order to prolong her illness. After several admissions to Rehabilitation Units and multiple explorations, we find convincing evidence for factitious origin and the diagnosis of Munchausen syndrome was evoked. Such a clinical presentation is infrequent in Munchausen's syndrome. Indeed, most often the clinical picture is characterized by acute abdominal pain, fainting, hemoptysis, precordialgia, hematemesis or dermatological lesions. Physicians should be aware of this rare and potentially critical form of FD. Awareness in identifying these patients may lead to prevent unnecessary medical and/or surgical interventions.

We used bilateral electrogoniometric gait monitoring of the knees to demonstrate the existence of an angular asymmetry between the two legs in healthy subjects. We also searched for correlations between this asymmetry and handedness, footedness and ocular laterality and isokinetic strength of the flexor-extensor muscles of the two knees. Among the 40 subjects studied, 25 (62.5%) showed an asymmetric maximal knee flexion: the difference being superior or equal to 5 degrees between the knees. There was no correlation between this asymmetry and the lateralities studied. We termed this type of asymmetry 'angular preponderance' to differentiate it from the laterality defined by clinical tests. Isokinetic strength of the knee flexors and extensors was correlated with the gender and speed, but not with side or laterality. Appropriate interpretation of lower limb examination should take into consideration angular gait asymmetry in the healthy subject.

Introduction Lors de la marche spontanee, la retraction des ischio-jambiers est un facteur de flexion excessive du genou lors du contact initial (CI) chez l’enfant ayant une paralysie cerebrale (PC). En effet, la longueur des ischio-jambiers est maximale au CI quand la difference entre la flexion de hanche et la flexion de genou (DFH-FG) est maximale. Nous avons teste si la marche a grands pas peut augmenter la DFH-FG chez l’enfant PC et l’enfant sain. Materiel et methodes Chez 47 enfants PC (GMFCS I et II, diplegiques (n = 34) et hemiplegiques (n = 13), 12 ± 3 ans) et 10 enfants sains (9 ± 1 ans), l’angle poplite a vitesses lente et rapide etait mesure pour estimer la retraction et la spasticite des ischio-jambiers. Une analyse 3D de la marche spontanee et a grands pas etait realisee pour evaluer entre les 2 conditions la variation de longueur des pas et la variation de DFH-FG (ΔDFH-FG). Resultats Deux sous-groupes d’enfants PC etaient clairement observes, ceux avec ΔDFH-FG Discussion–conclusion Alors que les angles poplites etaient comparables entre les 2 sous-groupes d’enfants PC, la marche a grands pas a permis de distinguer les enfants PC capables d’allonger les ischio-jambiers. Cette condition de marche apparait utile pour orienter une decision therapeutique pour les ischio-jambiers.

Objective According to European guidelines, phosphodiesterase-5 inhibitors (PDE5I) are recommended as first-line treatment in erectile dysfunction after spinal cord injury (SCI), and intracavernous injections (ICI) as second choice. Vitaros ® (alprostadil) is a new treatment with intra-urethral administration; several studies have already proved its efficacy in general population. The aim of this monocentric retrospective study was to evaluate Vitaros ® ’s efficacy in SCI men. Side effects and benefits were also studied, and the whole results were compared with those obtained with PDE5I and ICI. Material/Patients and methods Eighteen to 60-years-old SCI patients were included if they suffered from erectile dysfunction secondary to the injury for which Vitaros ® had been prescribed. Self-evaluations were used to assess each treatment (Vitaros ® , PDE5I and ICI) and the baseline (without treatment); it included the Erection Hardness Score (EHS) and IIEF5 (abbreviated score from the International Index of Erectile Function), time duration, side effects, global satisfaction score and the preferred treatment for further use. The Wilcoxon test was used for statistical analysis. Results Forty patients were included, among whom 29 had completed all of the self-evaluations. The average age was 42.3 ± 10.4 years-old; 8 were tetraplegics and 21 were paraplegics. Vitaros ® implied an improvement of 3.9 points for the IIEF5 score from the baseline ( P = 0.0005). Seven of the 29 patients reported side effects with Vitaros ® , moderate and transitory. When Vitaros ® was compared to ICI, a significant difference to the benefit of ICI was found for the IIEF5 score (9.4 points, P = 0.0015), for the EHS score (2.21 points, P = 0.0010) and for time duration (90 min, P = 0.0020). When Vitaros ® was compared to PDE5I, a significant difference to the benefit of PDE5I was found for the IIEF5 score (3.03 points, P = 0.0288) and for the EHS score (1.04, P = 0.0040). Nine of the 29 patients had finally selected Vitaros ® for future use. Discussion/Conclusion As Vitaros ® may be an effective treatment of erectile dysfunction in SCI men, it seems to be less efficient than ICI and PDE5I; however, some patients choose it for future use.

Objective After knee surgery, sensitive disorders due to cutaneous nerve lesions are common and often described as benign. However, some patients may experience abnormally high levels of neuropathic pain. Therefore, we explored the link between the type and intensity of sensitive disorders and neuropathic pain intensity. Material/patients and methods In a prospective comparative study, we included every patient admitted for functional rehabilitation after knee surgery in our PRM center, irrespective of the time elapsed since surgery. They were screened for the intensity and the type of pain (nociceptive or neuropathic) using a numerical pain scale, a DN4 questionnaire and a McGill questionnaire (MGQ). The patients were evaluated by a quantitative sensitivity test. First, the main sensitive disorder was qualified and mapped. Second, hypoesthesia was quantified through the pressure and vibration perception thresholds (PPT, respectively VPT), and allodynia through a color code using the monofilaments of Semmes-Weinstein. Sixty patients were evaluated and classified in two groups: 41 in a neuropathic painful group and 19 in a non-painful group. Results Our first finding was that every painful patient had an underlying sensitive disorder. For them, we found mostly hypoesthesia (n = 31) and in some cases allodynia (n = 9) or hyperesthesia (n = 1). These disorders were not systematically found in the non-painful group: Three patients did not have any trouble and 16 had hypoesthesia. When comparing the painful with the non-painful group, but with the restriction of elapsed time since surgery (inferior to 6 months), we found a significant difference for PPT (P = 0.0053) with a higher level of hypoesthesia for the painful group. Discussion – conclusion Our results suggest that hypoesthesia intensity is linked to neuropathic pain after knee surgery. Systematic quantitative sensitivity testing of neuropathic painful patients after knee surgery could be proposed to track sensitive disorders. This assessment could lead to an appropriate sensitive rehabilitation that may possibly prevent an evolution to chronic pain.

International audience; Association d'une stimulation vibratoire cervicale gauche à un mouvement d'atteinte manuelle : vers une nouvelle prise en charge thérapeutique de la NSU Introduction Among "Bottom-Up" treatments of Unilateral Spatial Neglect (USN), left neck muscle vibration may reduce clinical symptoms in patients with right-sided brain damage. The major interest of this stimulation is that the patient is unaware of perceptual and behavioral changes induced 1 due to the the left shifting of whole egocentric coordinate system. Furthermore, several studies have shown superior effects of combination treatments when their own effects were convergent 2. However, their practical applications are often conflicting with the constraints of patient care. This study aimed to assess the effects of a protocol combining left neck muscle vibration to voluntary arm movements in the peri-personal space on the egocentric and allocentric perceptions of patients with left-sided spatial neglect (USNleft). Method 5 USNleft patients (54.5 ± 5.5 years) were asked to perform the Marguerite test and a straight-ahead test (20 ballistic pointing without vision) before combination protocol (Pre), immediately after (Post0), one hour later (Post1h). During 15 minutes left trapezius muscle vibration (100Hz-300µm), they were asked to point to one of 5 lit targets [0° (straight ahead), 10° and 20° on the right and on the left], from the base of the chin rest with their right index finger, as quickly as possible. Results The results [median (± IQR)] suggested a reduction of neglect symptoms for at least 1 hour after the combination protocol. The Marguerite test at Pre [18.2 (± 10.7)] showed an evolution by step of the laterality index 3 with a dramatic decreasing at Post0 [6.6 (± 9.0)] then a maintain underneath the pathological level despite a small reduction of this effect at Post1h [9.0 (± 11.7)] and Post24h [10.0 (± 2.63)] on. The SSA errors [11.2° (± 6.1)] indicated a left lasting deviation after the protocol: Post0 [5.0° (± 2.8)], Post1h [6.6° (± 5.4)]. The Post24h values of 2 patients are missing due to unavailability of the device. Discussion Combining left neck vibration to voluntary arm movements showed allocentric and egocentric improvements lasting for at least 1 hour, and our data in progress even suggest during 24 hours. Non-invasive and simple to use, these promising findings for the rehabilitation of spatial cognition disorders argue in favor of the ecological use of the vibratory tool during the rehabilitation sessions. Reference 1. Luauté J, Halligan P, Rode G, Rossetti Y, Boisson D. Visuo-spatial neglect: A systematic review of current interventions and their effectiveness. Neurosci Biobehav Rev. 2006;30(7):961-982. 2. Kerkhoff G. Modulation and rehabilitation of spatial neglect by sensory stimulation.

Objective Numerous studies have explored various kinematics, kinetics and spatiotemporal data in gait analysis of able-bodied subjects and amputees on slope and cross-slope. None have evaluated amputees’ shoulders-pelvis dissociation in these situations. It is important for health professionals to understand how these patients’ shoulder and pelvic girdles move and interact in theses situations to optimize their rehabilitation. The aim of this study is to compare shoulder girdle and pelvis forward progression and their dissociation in transtibial amputees as well as able-bodied subjects during slope and cross-slope conditions. Material/patients and methods Twenty transtibial amputees and 30 able-bodied subjects walked at self-selected paces uphill and downhill on a 12% slope incline and on a 10% cross-slope incline, in an eight-camera optoelectronic motion analysis system. Measurements included: distance between acromions; distance between anteriosuperior iliac spines according to the x-plane; and angle between the right acromion, left acromion, right anteriosuperior iliac spine and left anteriosuperior iliac spine according to the z-plane. These values were correlated with the gait cycle and compared between groups. Results Shoulder anterior displacements were significantly greater in the amputee population in every situation, except for downhill left shoulder maximal forward progression. In ascent, their timing of shoulder and pelvis forward progression was significantly altered when compared to able-bodied subjects. Amputees tended to delay their pelvis forward progression, which was quickly followed by their shoulder progression. Their shoulders-pelvis coordination was in-phase instead of being out-of-phase in this condition. During unstable situations, such as downhill and cross-slope, they tended to brake the movement by moving the shoulder after the pelvis, similar to able-bodied subjects. During downhill, amputees’ shoulder girdle and pelvis dissociation angles were significantly less than the control group. Discussion, conclusion Transtibial amputees, like able-bodied subjects, react differently depending on the surface they walk on. Due to the lack of adaptability of the prosthetic foot and the lesser muscular strength of the residual limb, transtibial amputees’ balance on difficult surfaces depends greatly on their shoulder girdle and its coordination with the pelvis. Therefore, sidewalks with slopes or cross-slopes may impede gait and increase risk of fall. As such, these conditions are important to address in rehabilitation.

Objective One of the complications after trauma or knee surgery is neuropathic pain associated with epicritic sensitive disorders, such as hypoesthesia, hyperesthesia or mechanical allodynia (MA). Different sensory rehabilitation techniques are proposed to relieve pain. After a first somatosensory and pain evaluation, we used vibro-tactile in situ or remote stimulation, respectively for hypoesthesia and allodynia, and desensitization for hyperesthesia or low MA. These techniques are essentially based on auto-exercises. The main objective is to evaluate the effect of this somatosensory rehabilitation protocol on neuropathic pain. Material/patients and methods In a retrospective study, we included patients admitted for neuropathic pain and sensitive disorders after surgery or knee injury treated by this somatosensory rehabilitation protocol between 2012 and 2016. For 47 patients, we evaluated, before and after rehabilitation pain and sensitive disorders. Pain was assessed with maximal numerical scale at rest (NSmax) and McGill questionnaire (MGQ). First, the sensitive disorder was qualified and mapped. Second, hypoesthesia was quantified through the pressure and vibration perception (respectively PPT, VPT), and allodynia through a rainbow color (RC) code using the monofilaments of Semmes-Weinstein. Thirty-three patients had hypoesthesia treated with tactile and or vibratory stimulation of the site. Twenty patients had MA: 14 of them treated with remote vibro-tactile rehabilitation, and 8 with desensitization in case of low MA, or both methods successively. Five patients had hyperesthesia, treated with desensitization. Results After rehabilitation, the MCQ decreased significantly of 29.9% (P Discussion – conclusion This protocol allows an improvement of sensitive disorders associated with pain decrease. Despite the duration of protocol (several successive methods, necessity of intermediate evaluations), adherence to this method, based on self-exercises, is good. Efficiency could be improved by identifying patients who are likely to cooperate with the method.

Objective Modification of the musculoskeletal system of lower limb amputees, as well as the inability of the prosthesis to compensate the loss of the elements necessary for “normal” walking, could disrupt postural control and thus specifically characterize the gait of amputees. Most studies focused on kinematics lower limbs parameters to assess transtibial amputees (TTA) gait. However, other studies have shown the essential role of shoulder movement in the human gait. The modification of this counter-rotation movement in the horizontal plane is characteristic of specific pathologies. The aim was to enhance the compensation strategies of TTA during walking on level ground, by assessing the kinematic of pelvic and scapular girdles’ movements in the sagittal and horizontal planes. Material/patients and methods Twenty able-bodies individuals (AB) and 19 TTA walked, with their own prosthetic devices and shoes, at their self-selected speed on level ground in a motion capture laboratory. Distance between the right and the left acromions and distance between the right and the left anteriosuperior iliac spines in the sagittal plane and the angle of counter-rotation between the pelvic and the scapular girdles in the horizontal plane were measured manually. These values were assessed considering gait cycle, and compared between groups. Results In the sagittal plane, the shoulder movements were significantly greater in TTA compared to AB (P = 0.03). Moreover, an anticipation of the maximum forward shoulder displacement in TTA was observed at 40% of gait cycle, contrary to AB, in whom it was observed at 53% of gait cycle. However, the amplitude of counter-rotation between shoulder and pelvis and the moment when counter-rotation occurred in gait cycle were not significantly different between groups in the horizontal plane. Two counter-rotations of scapular and pelvic girdles occurred at the beginning and in the middle of the gait cycle. Discussion, conclusion The kinematic analysis of the scapular and pelvic girdles movements during level walking showed a specific characterization of the gait of TTA related to their disability due to the loss of residual limb muscles. The displacement of scapular girdle in the sagittal plane is an important compensatory factor for transtibial amputees.

Objective The major function of the hand that the upper limb prosthesis tries to replicate is grasp. New myoelectric devices with multiarticulated hands are available and are reimbursed by French health care system. These devices propose several types of grip, which are getting closer to human hand movements. Few studies evaluated the impact of these devices on prehensile function. It is important for the rehabilitation team to know how upper limb amputees manage these devices in their daily lives to improve rehabilitation. The aim of this study was to evaluate the functional use of these new myoelectric prosthetic hand (NMPH) compared to tridigital myoelectric hand (TDMH). Material/patients and methods Eight unilateral transradial upper limb amputees (7 male, 1 female, age 39.5 ± 14 years old) wearing usually a myoelectric prosthesis participated in this prospective crossover study. Functional assessment was realized by each participant with their own tridigital myoelectric prosthesis and a multigrip prosthesis after specific rehabilitation and one month of home use. Self-report questionnaires included Quick DASH, Orthotics and Prosthetics Users Survey (OPUS) and the French version of the Quebec Users Evaluation Satisfaction with Assistive Technology (QUEST). Clinical tests included Box and Blocks Test (BBT) in sitting position, Southampton Hand Assessment Procedure (SHAP) and the third phase of Hand 400 points. These values were compared for each participant between both myoelectric prosthesis. Results There is no significant difference between both devices for manual dexterity (BBT), gripping capabilities (SHAP) and grasping capabilities, as assessed by the third phase of Hand 400 points which also visually evaluates shoulder and trunk compensations during the movement of the objects, and technology satisfaction (QUEST). Discussion, conclusion In this study, the use of these new multiarticulated prosthetic hands did not influence the gripping capabilities at 1 month of home use. In the literature, an increased manual dexterity was found at 3 months of home use (Luchetti et al., JRRD 2015). However, these new devices providing several types of grip, may be of interest in decreasing shoulder or trunk compensations during grasp in upper limb amputees. Further studies are mandatory to objectively evaluate these compensations using optoelectronic systems and could be used for assessment of rehabilitation programs.

Objective Symmetric peripheral gangrene (SPG) is a rare but severe complication of septic shock often leading to multiple amputations. Epidemiology of SPG and long-term outcome remain poorly known. Amputations are serious offense to body but can benefit from rehabilitation and prosthesis. Our objectives were to describe epidemiology of SPG and to assess health-related quality of life (HRQOL) once rehabilitation was achieved. Material/patients and methods A prospective and retrospective, multicentric study was performed. Adult patients hospitalised between 2005 and 2015 were included. They must have undergone at least two amputations (whatever the level) and have been discharged in a specialized rehabilitation Department. HRQOL was assessed with generic scale EQ-5D-3L by phone call. Epidemiologic data were extracted from medical letters. Results Nine centres on 13 participated, 32 patients were recruited and medical letters were available for 27 of them. SPG was observed in a majority of female (59%), aged around 53 yo. Mean intensive care unit (ICU) length of stay was 39 (±22) days. Infectious agents were in majority Gram positive or negative cocci (68%), but Escherichia Coli took an important part (17%). All patients were amputated of the two lower limbs and 84% were quadruple amputees. HRQOL estimated with EQ index was inferior to the French reference. However, patients rated themselves their health state as similar to the reference and superior to the reference before SPG. Intense pain due to phantom pain was the main factor of impaired EQ index. Painkillers use was statistically dependant of antidepressants use. All patient, except one, said they would be willing to be treated again for SPG. Discussion, conclusion SPG is mainly due to Gram positive or negative cocci but also Escherichia Coli and leads to severe amputations with impaired HRQOL. This is in line with the literature. However, patients report being in good health, but in excellent health before SPG. Such important decrease after sudden critical illness was observed in major trauma. A better analgesic strategy may improve HRQOL. Nevertheless, patients would be willing to be treated again. This should be taken into account before withdrawing life-sustaining therapies.

Objective After upper limb amputation, myoelectric prosthesis does not allow total functional recovery: grasping is executed with compensation motions. The objective of this study is to compare grasping's kinematics between prosthetic and healthy upper limb for myoelectric trans-radial prosthesis users. Material/Patients and methods This prospective study includes 10 trans-radial amputees (9 traumatic, 1 agenesis) using a myoelectric prosthesis. The kinematics of the trunk and upper limb were quantified during a mono-manual grasping task successively with each upper limb. The task was to grasp and lift one of three objects (mug, cylinder, cone) placed on a table at a close or far distance (60 and 80% of arm length). Motion was measured at 30 Hz with Polhemus Fastrak sensors placed on the ipsilateral acromion, the forearm and the hand (or prosthesis). A geometrical model was used to compute shoulder elevation and elbow flexion-extension angles as well as the elbow 3D position. The amounts of displacements and rotations were calculated during two phases: reach-to-grasp and lift. Both sides were compared. Results The initial velocity of reaching (peak velocity and duration of acceleration) was similar on both sides. On the amputated side, the duration of reach-to-grasp was significantly prolonged with a more curved and less smooth trajectory. The amount of elbow extension during reach-to-grasp was smaller on the amputated side for the far target but greater for the close target. The contribution of the trunk for reaching was greater on the amputated side, particularly for far targets. During lifting, the elbow had a tendency to flex on the amputated side, with a smaller shoulder elevation than on the control side. There were some differences between objects (i.e. the mug was grasped at lower height after a shorter hand displacement). Discussion/Conclusion After trans-radial amputation, grasping phases are disturbed for time of realization and trajectories, in particular because of shoulder and elbow compensations on the amputated side. Such kinematic bases could allow to evaluate the influence on grasping of medical technologies (active pronation and supination, wrist flexion-extension, poly-digital hands…) and effects of rehabilitation on compensation motions.

Objective Ankle osteoarthritis (AO) is a usual long-term complication of ankle trauma. Pain during walking is the main symptom limiting walking distance. Non-surgical treatment including drugs, corticosteroid intra-articular injection or orthosis, could be used to decrease pain. The gold standard treatment of end stage of AO is the definitive surgical ankle arthrodesis. The purpose of this study is to prove the effectiveness of the hind foot stabilisation orthosis called “arthrodesis simulation” (AS) on the walking-pain and walking distance in a population suffering from ankle and/or hind foot osteoarthritis. Material/patients and methods A single case experimental design (SCED) with a structure (A1-B1-A2-B2) used randomly repeated measurements of a 2 MWT to determine changes at each phase of the study. Pain at the end of the 2 MWT using a visual analogue scale and the walking distance were evaluated by a blind assessor. One patient from Regional Rehabilitation Institute in Nancy (IRR, France) suffering from AO and wearing an AS daily, walked at fast speed during the 2MWT without AS during the 2 baseline phases (A1, A2) and with AS during the 2 intervention phases (B1, B2). Visual analysis, mean, trend and nonoverlap of all pairs (NAP) were calculated for both values for each phase. Results The average pain was significantly different between each phase (A1-B1-A2-B2) (Wilcoxon test). The pain NAP was 100% which corresponds to all data points assessing pain were greater during walking without AS. The pain trend increased with the measurement time without AS whereas the pain trend was stable, close to 0, with AS. The average walking distance was significantly different between each phase (A1-B1-A2-B2) (t-test). The walking distance NAP was close to 100% corresponding to all data points assessing walking distance were greater with AS. The walking distance trend increased faster with AS compared to without AS. Discussion, conclusion This SCED demonstrated the effectiveness of the AS on walking-pain and walking distance in people suffering from AO. Wearing AS increased walking distance during 2MWT without pain. Further SCEDs are necessary to confirm AS efficiency. This device, which is an orthopaedic treatment, could be an interesting alternative to surgical ankle arthrodesis.