Annales de readaptation et de medecine physique : revue scientifique de la Societe francaise de reeducation fonctionnelle de readaptation et de medecine physique最新文献

In France, inpatient care is provided in three different sectors: “medicine, surgery and obstetrics”, “follow-up care and rehabilitation” (soins de suite et de réadaptation = SSR) and “long-term care”. Physical medicine and rehabilitation is involved mainly in SSR. As of April 2008, there are new regulations aiming to improve prior texts, to implement rules that will be identical for public and private sectors and to prepare for the new payment-by-the-act funding system (in place of the prior global funding). Now, all SSR structures have a common general basis in terms of purpose and means and specific rules for various specialties. For example, coordination of a multidisciplinary team in specialized facilities dealing with musculoskeletal and nervous system disorders must be conducted by a physical medicine and rehabilitation (PMR) specialist. Patient admission criteria still need to be defined, as does the assessment of therapeutic objectives. The expertise of SSR facilities is recognized by the possibility of direct admission from home for ambulatory patients. Nevertheless, many specifics are missing in these new decrees. These specifications will be elaborated on a regional basis, in future endeavours within regional healthcare organizations.

Introduction

The cognitive model of music processing has a modular architecture with two main pathways (a melody pathway and a time pathway) for processing the musical “message” and thus enabling music recognition. It also features a music-specific module for tonal encoding of pitch which stands apart from all other known cognitive systems (including language processing). To the best of our knowledge, rehabilitation therapy for amusia has not yet been reported.

Objective

We developed a therapeutic method (inspired by work on word deafness) in order to determine whether specific rehabilitation based on melody discrimination could prompt the regression of amusia.

Method

We report the case of a patient having developed receptive, acquired amusia four years previously. His tone deafness disorder was assessed using the Montreal Battery of Evaluation of Amusia (MBEA), which revealed impairment of the melody pathway but no deficiency in the time pathway. A computer-assisted rehabilitation method was implemented; it used melody discrimination tasks and an errorless learning paradigm with progressively fading visual cues.

Results

After therapy, we noted an improvement in the overall MBEA score and its component subscores which could not be explained by spontaneous recovery (in view of the number of years since the neurological accident). The improvement was maintained at seven months post-therapy. Although post-therapy improvement in daily life was not systematically assessed, the patient started listening to his favourite music again.

Conclusion

Specific amusia therapy has shown efficacy.

Aim

To describe the health and professional status of multiple sclerosis patients of working age and to compare a group of patients in work (group T1) with a group of unemployed patients (group T2).

Materials and methods

A case-controlled study was performed. In the course of a specific consultation with a neurologist, demographic, medical and professional data were gathering using a questionnaire. Descriptive and comparative statistical analyses were then performed.

Results

A total of 76 patients were included in the study: 54 were in work (group T1) and 22 were unemployed (group T2). Hence, the employment rate was 71%, with an average time since disease onset of nine years at the time of the study. Low educational level (p = 0.02), disease progression (p = 0.0001), the presence of motor symptoms (p = 0.01), cerebellar symptoms (p = 0.02) or cognitive symptoms (p = 0.03), a worse EDSS (p = 0.0001) and a job requiring force (p = 0.05) or manual dexterity (p = 0.05) were found to be negative factors. Employment in the public sector (p = 0.003) or large companies (p = 0.03) were found to be protective factors. Access to the workplace was better for currently employed patients (p = 0.03).

Conclusion

This study shows that differences exist within the MS patient population according to the professional situation. It underlines the importance of clinical and demographics variables as determinants of differences in employment status. Not surprisingly, unemployed patients are more likely to have been classified as handicapped workers. Factors linked to work-induced constraints did not emerge from the survey because the questionnaire items were not appropriate for addressing this latter issue.

Introduction

The most serious accidents after cervical spine manipulation are vertebrobasilar ischemia. Their incidence is underestimated. Their risk of apparition is lower if the contraindications are respected and if they are realised according to suitable practice.

Case report

Mrs B, 39 years old, was an active smoker and had migraine for 10 years ago. One day, she presented an unusual headache associated with neck pain that was treated by a cervical spine manipulation. Seven hours after, she developed an alternate syndrome with a right sensory motor defect, a cerebellar syndrome, a pyramidal syndrome and a left defect of cranial nerves. The arteriography showed a thrombosis of the basilar trunk and a dissection of the left vertebral artery. A thrombolysis “in situ” was realized six hours and a half after the onset of the neurological defects. After eight months of rehabilitation, there were still a paralysis of the right upper limb, of the cranial nerves and a cerebellar syndrome but the patient was able to walk with two crutches and can eat by herself.

Discussion

Several risk factors were present in this case and there was also a major contraindication to manipulations: unusual acute occipital headache. Given the long period between the onset of neurological symptoms and the confirmation of the diagnosis, intravenous thrombolysis could not be done. Unfortunately, after eight months, important neurological sequelas persisted. In order to avoid this type of accident after cervical manipulations, it is necessary to realize a strict medical examination and to implement the recommendations from the French society of manual and orthopaedic osteopathic medicine (Société française de médecine manuelle orthopédique et ostéopathique [SOFMMOO]).

This paper presents a phenomenological study illustrative how paraplegia may have a serious debilitating impact on the sufferer's subjective experience. Exploratory interviews were conducted with seventeen patients and the transcripts subjected to qualitative analysis. The interpretative phenomenological analysis points to the powerful ways in which paraplegia has negative impact on patients’ experience and well-being. Some of the participants describe two major approaches of their situation: dimensional (the links between disability and society, others and self) and temporal (the “disability work”). The results section gives a detailed account of these processes at work. The results are then considered in relation to relevant constructs in the literature, including grief work, illness work and identity, adaptation and acceptance.

Objectives

Determination of the utility of C-reactive protein (CRP) levels when measured 21 days after hip and knee arthroplasties for early diagnosis of infectious complications.

Method

This study was performed in two parts: establishment of a reference curve by measurement of CRP levels once a week in a cohort of 94 patients (50 total hip arthroplasties and 44 total or unicondylar knee arthroplasties); study of the diagnostic value of two different CRP cut-offs (25 mg/l, the mean CRP level and two standard deviations; 18 mg/l, mean and one standard deviation) at D21 postoperative in a population of 48 patients, of whom 12 presented septic complications (four surgical site infections [SSIs] and eight intercurrent infections).

Results

We observed very high interindividual variations in CRP values two weeks after arthroplasty. These variations decreased strongly in the third week postoperative. In the seven patients with a CRP level above 25 mg/l at D21, there were no false-positives. In the 41 patients with a CRP level below 25 mg/l at D21, there were five false-negatives and no false-positives. With the CRP threshold set at 18 mg/l, we observed four false-positives and four false-negatives.

Discussion–conclusion

A CRP level threshold of 25 mg/l is not sufficiently reliable for early detection of postoperative infections (whether at the surgical site or elsewhere), as judged by a sensitivity of 58.3% and a negative predictive value of 87.8%. However, the 25 mg/l threshold displays first-rate specificity and positive predictive values (both 100%). A CRP threshold at 18 mg/l is no better because even though it yields slightly a higher sensitivity value (66.7%), it strongly decreases specificity (88.9%). CRP is an important tool for postoperative monitoring but often appears to be difficult to use. The diagnosis of septic complications is based on clinical and paraclinical arguments. Local discharge, fever over 38 °C and local/persistent pain and stiffness are more informative indicators of postoperative infection.

Objective

To analyze the shoulder joint complex in high level swimmers. We formulated the assumption that high level swimming weakens this complex, resulting in laxity of the anterior–inferior capsuloligamentous structures with atraumatic anterior instability, impingement with rotator cuff tendonitis and muscle imbalance of the rotator cuff muscles.

Method

Two 20-subject groups took part in this study (a group of high level swimmers and a group of sedentary people). The swimmers were all national-level front crawl specialists. The evaluations included clinical examination and isokinetic testing of the shoulder.

Results

Isokinetic testing (at 60 °/s) revealed that the swimmers have an external rotation/internal rotation ratio that is unbalanced (right shoulder: 0.52) and significantly lower than that seen in sedentary subjects (right shoulder: 0.75). Even though swimming is a symmetrical sport, our data confirm that intensive front crawl swimming involves asymmetry, with a stronger shoulder (right shoulder: 61.2 ± 10.2 N m; left shoulder: 52.8 ± 9.8 N m). The results of the clinical examination showed that 55% of the swimmers presented scapular protraction and that 35% were positive for mechanical impingement. These clinical elements were not observed in the control group. Laxity of the anterior–inferior capsuloligamentous structures was also noted in 67% of the swimmers.

Conclusion

high level swimming ineluctably weakens the shoulder joint complex.

Aims

To evaluate the value of our driving simulator in deciding whether or not to allow patients with physical and/or cognitive deficits to resuming driving and to analyze whether or not the medical expert's final decision is based more on the results of the driving simulator than those of the neuropsychological examination.

Methods

One hundred and twenty-three patients were evaluated with the driving simulator. Thirty-five of those with cognitive deficits also underwent a neuropsychological examination prior to the medical expert's decision on driving aptitude. In cases of uncertainty or disagreement, a driving assessment in real conditions was performed by a driving instructor.

Results

In cases of physical handicap, the medical expert's decision concurred with that of the occupational therapist. For brain-injured patients, there was a significant correlation between the neuropsychologist's opinion and that of the occupational therapist (κ = 0.33; P = 0.01). However, the sensibility and specificity were only 55 and 80%, respectively. The correlation between an occupational therapy decision based on the driving simulator and that of the medical expert was very significant (κ = 0.81; P < 0.0001) and the sensibility and specificity were 84 and 100%, respectively. In contrast, these values were lower (63 and 71%, respectively) for the correlation between the neuropsychologist's opinion and that of the medical expert.

Conclusion

Our driving simulator enables the danger-free evaluation of driving aptitude. The results mirror an in situ assessment and are more sensitive than neuropsychological examination. In fact, the neuropsychologist's opinion often is more negative or uncertain with respect to the patient's real driving aptitude. When taking a decision on a patient's driving aptitude, the medical expert is more inclined to trust the results of the driving simulator.