Actualités et perspectives dans la prise en charge de l’hémiplégie cérébrale infantile en médecine physique et de réadaptation

Hemiplegic (or spastic unilateral) cerebral palsy accounts for about 30% of all cases of cerebral palsy. With a population prevalence of 0.6 per 1000 living births, it is the most common form of cerebral palsy among children born at term and the second most common type among preterm infants. Precocity of care at observation of the first symptoms allows preventing orthopaedic disorders and furthermore the installation of pathological patterns. Before any therapeutic intervention, it is necessary to evaluate the lower and upper limb function by means of reliable, valid and reproducible tools. This helps define precise and mutual objectives for child and family as well as therapists, therefore allowing an objective evaluation of the results. This principle applies as much in fundamental techniques (physiotherapy, occupational therapy, psychomotricity, orthesis…) as in more recent developments such as botulinum toxin, exercise programs, constraint-induced therapy, motor mental imagery or virtual reality. These recent therapies present, at various degrees, scientific evidence of their efficiency in the improvement of limb function and are now an integral part of the usual care of children with hemiplegic cerebral palsy.     

Effets de l’exercice physique et de l’entraînement sur la neurochimie cérébrale. Conséquence comportementale

Physical exercises and training play on cerebral neurochemistry. Their action on mood is acute immediately after muscular exercises, or chronic for training. Physical training is significantly associated with a decrease in anxiety and its physiological indicators and can reduce the prevalence of depression on large populations. It was recently shown that it could improve cognitive functions and more particularly learning and memory. The neurochemical axes influenced by muscular exercising are the serotoninergical axis, the dopaminergical path and the GABA metabolism. The influence of muscular exercises on the biochemical path of neurogenesis has recently been underscored.     

Intérêt de la proprioception du tronc et de membre supérieur au moyen de « l’épreuve nez et doigt »

The capacities to keep upright or to move the trunk involve significant functional consequences for cerebral palsy patients. The quality of information related to the perception of the body position and how they are then treated contribute to the execution of the movement. Yet, they have not been much explored until now. The finger-and-nose test was created by M. Le Metayer as an assessment method. In this paper, we present the first results obtained with cerebral palsy patients using these testing methods.     

La force musculaire et son évaluation chez l’enfant infirme moteur cérébral

The muscular weakness is a determining factor in the cerebral palsy symptoms. Muscle strength should be evaluated as objectively as possible to improve the quality of diagnosis and treatment. To measure the muscle strength, we have at the present time a wide choice of tools. The most common and easy method is manual muscle testing, but its main inconvenience is its subjectivity. The manual muscle testing seems to be more appropriate for assigning grades 0 to 3 over 5. Hand held dynamometers give objective and quantifiable values. They are easy to use however the procedures, the positioning of the limb segment without or with the influence of the gravity, the stabilization or not of the joint, the experience of the clinician are responsible for a important errors of measurement which it is necessary to take into account in the follow-up of the programs of muscular training. The isokinetic testing machines are considered as golden standard, they offer a good stabilization of the patient, accurate end repeatable measurement and no examiner bias. Their clinical uses are limited due the lack of portability and the time required doing the measurements. All of these methods need an optimal level of the child participation and a good motor control. The spasticity and the contractures may interfere in the quality of the measurement. In the rehabilitation filed even if the strength improvement is important to reduce the disability, activity-based intervention are also necessary for reducing activity limitation in children with cerebral palsy.     

Une nouvelle prise en charge de la sphère oro-faciale des enfants paralysés cérébraux par un jeu interactif en 3D

Rehabilitation of facial praxia in children affected by cerebral palsy is an important goal, although its efficiency remains hard to evaluate. We have listed difficulties encountered by a child during a session of classical rehabilitation, and we propose a novel technique of rehabilitation based on the use of an interactive avatar. In addition to the game-like use of this interactive tool, motions captures that will be recorded during work sessions will also be usable to get metric measurements of the buccofacial movements of children with cerebral palsy. For each child, we will be able to define their own characteristics, which will probably reflect the great heterogeneity of clinical aspects and movements developed by these children. This study will require that each patient will be his own control to evaluate the efficiency of this new protocol.     

Apnée du sommeil et paralysie cérébrale à l’âge adulte. À propos de trois observations

Respiratory disorders are frequent in cerebral palsy with restrictive and also obstructive disorders. Obstructive sleep apnea has been described in childhood but there are few data about this problem in adults. Usually clinical symptoms are snoring, apneas, nycturia, sleepiness, awakenings, headache, cognitive disorders, and depressive syndrome. Obesity is a strong risk factor. Moreover, prevalence increases with age in adults. We report three cases of adults with cerebral palsy suffering from obstructive sleep apnea. Particularities of this syndrome are discussed in cerebral palsy. Diagnosis may be difficult because of the existing impairment, which can mask specific clinical signs. According to the risk of impairment worsening and of cardiovascular disease, obstructive sleep apnea must be evoked in case of any doubt. Individuals who are suspected of having obstructive sleep apnea should undergo polysomnography to confirm the presence and severity of sleep disordered breathing.     

Intérêts et limites des échelles d’évaluation de la douleur chez l’enfant en situation de handicap

Accessing to a management of pain is now considered as peoples’ fundamental right. The pain should be evaluated before being treated. Pain is always a subjective phenomenon. Assessing pain of those who express in a singular way is a great challenge. Children and adolescents with intellectual disabilities, with cerebral palsy or with autism are now recognized as sensitive to pain as well as anyone. If some of them are able to use self-report tools, we have to apply disability-adapted scales to others. Like any assessment tools, they have advantages and limitations. We need to know them in order to make appropriate use for the care of vulnerable people.     

Les contraintes en rééducation : réflexions d’une psychologue

Motor reeducation of children with cerebral palsy comprehends some constraints, both physical and psychological. Through the observation of a number of young patients, we wish to show how they feel about these constraints, what are the motives and the aims of their participation and how their psychological development can be affected. We shall then consider what the use of these constraints implies for the health care team. Finally, the notion of “therapeutic alliance” will be presented and distinguished from “compliance”.     

Dysfonctionnement de circuits neuronaux spinaux impliqués dans la motricité chez des patients présentant une paralysie cérébrale spastique

Cerebral palsy is defined as a non-progressive postural and movement impairment related to a perinatal lesion in an immature brain. The development of spasticity, i.e. the hyperexcitability of the stretch reflex certainly contribute to the appearance of contracture, structural deformations and functional impairments. Among presynaptic mechanisms regulating the stretch reflex, only homosynaptic depression of fibre Ia-motoneurone α, which is decreased in cerebral palsy patients, is correlated with the level of spasticity suggesting that it could play a role in spasticity. Central nervous system lesions present in cerebral palsy patients suggest two hypotheses explaining the decrease of homosynaptic depression: a phenomena similar to denervation hypersensitivity and changes in the motoneurones discharge induced by decending monoaminergic pathways. These two hypotheses may coexist but suggest two different new therapeutics options. These two pathophysiological mechanisms could be linked with the lesions of the central nervous system present in cerebral palsy patients and could coexist to varying degrees. However, these two physiopathological hypotheses suggest different therapeutic ways.     

Développement cérébral en psychiatrie de l’enfant et de l’adolescent. Approche par l’imagerie

Modifications in cerebral development have either been demonstrated or their presence is probable in a number of psychiatric disorders which arise during childhood or adolescence. Their detection depends on new methods of image analysis; examples are presented in this article. These methodological innovations permit the quantification of anatomical or functional imaging data, not only in patient groups, but also on an individual basis. This new technology could concern diagnostic aid, psychopathological information, therapeutic evaluation, and sometimes detecting a disorder. The implementation of this type of research depends on the organization of clinico-methodological networks for setting up the relevant databases.     

Rééducation de la position assise de l’enfant paralysé cérébral infantile. Les moyens préventifs orthopédiques non chirurgicaux. Présentation d’un cas clinique

There are several sitting positions, which need a specific control of adjustment against gravity and a postural organization available to be learnt. The acquisition of sitting position is a very important step of child's functional development: this step is a very crucial point for clinicians who take care of rehabilitation of children affected by cerebral palsy because these children have abnormalities of functions against gravity and bad propioceptive informations. There are several and different pathological factors that could disturb the sitting position and it is very important to know these factors to prevent the orthopaedic problems and offer the most suitable chair for each child. For the most part, the children affected by cerebral palsy, especially if they belong to 3 or 4%, spend in sitting position 80% of their living time. If the child spends a lot of his time in a particular position, we must pay attention to the postural abnormalities and their orthopaedic outcomes. For this reason, it is very important to understand the importance of preventive treatment and clinic assessment oriented to identify the abnormalities. The educational and therapeutic strategies should be organized in an integrated and multidisciplinary way.     

Le syndrome de vasoconstriction cérébrale réversible

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches, as well as vasoconstriction of cerebral arteries, which resolves spontaneously in one to three months. This condition has a moderate female preponderance. The mean age of onset is around 45 years. About 60% of the cases are secondary, mainly occurring during postpartum and/or after exposure to vasoactive substances. The main clinical presentation includes multiple recurrent thunderclap headaches over one to three weeks. The major complications of RCVS are localized cortical subarachnoid hemorrhages (cSAH) (20-25%) and parenchymal strokes (5-10%). Complications occur with different time courses: hemorrhages (cSAH and intracerebral hemorrhages), and posterior reversible encephalopathy syndrome are early events occurring during the first week, while ischemic events including TIAs and cerebral infarcts occur significantly later, during the second week. Diagnosis requires the demonstration of the “string and beads” aspect of cerebral arteries by a cerebral angiogram (MRA, CTA or conventional) and the demonstration of the complete or marked normalisation of arteries by a repeat angiogram performed within 12 weeks of onset. Treatment is based on nimodipine that seems to reduce thunderclap headaches within 48 h. However, nimodipine has not proven any efficacy against the hemorrhagic and ischemic complications of RCVS. Relapses are possible but rare and have not been reported yet in prospective series. It seems appropriate to advise the patients to avoid sympathomimetic and serotoninergic substances.     

Applications et apports de la vidéo augmentée en réhabilitation pédiatrique

Background

Augmented video enables digital video image treatment by augmenting it with computer generated information, measurements and/or virtual imagery. We tested this technology (1) as a measurement tool associated with a visual gait assessment scale for children with cerebral palsy to determine whether it improved it's interobserver reliability and (2) as an external feedback tool during physiotherapy sessions.

Methods and results

(1) Two observers watched a random selection of 20 gait videos of 12 children with cerebral palsy. The videos were scored using the Observational Gait Scale, one with standard video software, the other with augmented video software (Dartfish®). Interobserver agreement for the total score went from substantial to excellent with video augmentation (κ 0.785 → 0.809). The most important increases were noted for the items that required objective angle and/or duration measurements. (2) Qualitative study of augmented video use during two successive physiotherapy sessions in 13 children with motor impairments. The software's contribution had positive assessments especially in children aged 9 and above.

Conclusions

The use of augmented video software improves the reliability of filmed gait assessments, offering an accessible and versatile alternative to 3D kinematic analysis. The analysis tools and filmed sequence manipulation options provided by augmented video also have the potential for being clinically applied in motor therapy as a potent augmented feedback tool.     

Les résultats de l’accréditation ANAES en psychiatrie

In the year 1996, accreditation process started in France by the mean of a special law, which creates for any health structure an obligation to be assessed within 5 years and a specific organism to set up the assessment process and train a network of assessors which have to be professionals still in exercise (medical, nursing and administrative staff). Since the process has to be started from scratch it was decided to set up a unique accreditation manual, which has to be applied to any setting and speciality. In this context psychiatric resources fear to be penalised because of their specificities specially their extramural activities. This paper is using the first 120 accreditation processes completed by ANAES (the French accreditation organisation) in order to compare psychiatric and no psychiatric resource results to accreditation. The process was based on assessment on how the diverse quality criteria described in the manual were completed; they were 10 main chapters concerning patients rights and information, patients charts, care organisation, management, logistic, risk management and quality control. Each of the chapter has been divided into up to 10 criteria, which set up rules for quality and propose references which have to be first self assessed by the team; the assessors will then start from this self assessment to make their own and propose a note. The notes are compiled to decide if the reference has been fully completed, partially completed or not completed at all resulting in recommendations or reserve. At the end of the process all chapter results allow to pronounce the accreditation status of the structure: no reserve no recommendation, recommendation, reserve, major reserve. This last result means no accreditation and is attributed when a major risk has been assessed; in this case the structure will be given a short delay to modify the problem and is reassessed. This paper is based on analyses of 65 no psychiatric and 41 psychiatric hospitals private or public; the 14 hospitals, which include psychiatric units, were excluded since it was impossible to attribute results to a specific unit. In comparing the global accreditation results, the psychiatric one have better results: no one got a major reserve and 22% vs. 46.6% for the no psychiatric got reserve, on the other hand the psychiatric got more recommendation 58.5% vs. 35.4% but more no reserve no recommendation 19.5% vs. 13.8%. The comparison of the average number of either reserve or recommendation is also in the favour of the psychiatric ones. In order to look at the diverse domain we compare percentages of no psychiatric and psychiatric having at least a reserve or recommendation in one of the diverse domain covered by the manual: no psychiatric have better results in all domain especially patients charts, care organisation which were significantly worse in the no psychiatric. However, when the profiles are compared (relative percentage of either reserve or recommendation) psychiatric got lower results for patient’s rights and information and better results concerning patients charts and care organisation. Since this quantitative comparison was back up by a qualitative evaluation based on interview on diverse professionals, which participated to the accreditation process, some specific theme emerged which could be check by looking in detail to the corresponding criteria. The first theme is dealing with infectious risks: sanitarians risk controls and prevention mechanisms assessments were more frequently deficient in the psychiatric hospitals than in the control group, however they were not difference for setting up these controls and mechanisms. The second theme concerns patient’s rights and information: when results are looked at globally no difference appears however this theme appears higher if the psychiatric accreditation profiles; when looking at the specific reference concerning the intimacy and dignity patient’s respect psychiatric results seem lower: 9.4% of the psychiatric hospitals reserve or recommendation are concerned by this reference vs. 2.5% in the no psychiatric. Some limitation of these comparisons should be mentioned; size effects was controlled for and no difference was found but all results presented here concern the first accreditation procedures where the most concerned and performing structures were candidates. We assume that this obvious bias affects both type of structure at a similar degree, which may be wrong. To conclude the accreditation process could be applied to psychiatric as well as no psychiatric structures and it appears that psychiatric resources obtain globally better results than no psychiatric; however two conflicting areas appear for the psychiatric resources: risk control procedures and intimacy and freedom patients rights completion.     

Membre supérieur de l’enfant atteint de paralysie cérébrale. Utilisation de la toxine botulinique : évaluation,stratégies thérapeutiques

Since a few years the botulinum toxin is used at the level of the upper limb of the child affected by cerebral palsy. A precise evaluation of the driving possibilities of the child is indispensable to target at best the muscles to be injected. This treatment, in its functional objective is always associated with an intensive reeducation. A protocol of follow-up accompanies the management.     

Profil psychologique et comportemental de vulnérabilité à la dépendance à l’exercice et au risque de pratiques dopantes chez les sportifs amateurs : l’exemple des semi-marathoniens

Introduction

Most research on doping behaviors in sportsmen is relative to professionals. However, high-risk behaviors can also be observed in amateur sportsmen. Exercise dependence corresponds to an unsuitable practice of physical exercise which leads to complications characterized by a need to increase the amount of exercise significantly, the presence of tiredness or anxiety when discontinuing the exercise, the loss of control, the increase in the time spent in exercises, the restriction of other fields of activity and the maintenance of the exercise even with a recurring physical or mental problem (Veale, 1995). It appears that exercise dependent subjects have specific representations of physical activity (Davis et al. 1993, 1995). Our objective is to study the relationship between doping practices and behavioral dependence to physical exercise in amateur sportsmen. We hypothesize that high-risk doping amateur sportsmen have the following specific profile: A threshold of consumption of physical exercises, a particular representation of the sport, a restriction of the fields of activities apart from the sport.

Method

Mental representations and physical exercise habits of 317 semi-marathon runners were studied through semi-structured interviews. The sample consisted of 257 men and 60 women 20 to 60 years old. (i.e. 62 individuals from 20 to 30 years old, 116 from 30 to 40, 93 from 40 to 50, and 46 over 50 years old). All the participants were amateurs practicing foot racing in competition as principal sport. The participants were asked to answer to a self-questionnaire assessing: Their relation to physical activities, the number of hours of weekly physical exercises, the type of practice, the environment extra-sportsman, the representations of the sport, the importance given to the practice of the sport, the consumption of other products, the possibility of a consumption of doping products, their capacity to be abstinent to their physical activity. We determined an indicator of risk of doping, from different questions related to a possibility of consuming doping products. The indicator which appears most sensitive is the question: "Would you be ready to take doping products under medical control".

Results

The majority (75%) of the semi-marathonians practice their physical activity between 1 and 5 hours weekly whatever their age. The median observed is equal to 4. A discriminating analysis does not make it possible to show a good capacity of classification of the individuals saying it self ready to take doping products under medical control according to the only criterion of the number of hours of physical practice. 11.7% of the subjects reported that they would agree to take doping substances if they had the opportunity to do so under medical control. The mental representations and behavioral characteristics of this subgroup are the following: 1) A pervasive search of a surpassing of themselves through physical exercise; 2) An every day life predominantly focused on physical exercise; 3) The onset of negative feelings and irritability related to exercise discontinuation; 4) Paradoxically, a moderate amount of time spent exercising (59.5% reported exercising less than 5 hours weekly).

Discussion

In amateur sportsmen, the reported propensity to use doping substances is not correlated to the intensity of physical exercise measured by the amount of time weekly spent exercising. This propensity seems to occur in a specific sub-population of vulnerable subjects characterized by a behavioral dependence to physical exercise with a specific representation of their physical activity. These specific characteristics of high-risk individuals are independent from the age of the subjects. In a perspective of prevention, it is important to identify high-risk subjects to modify their manner of perceiving the sport, and to preserve other social investments.     

Évaluation du recrutement des muscles fessiers dans les exercices de rééducation chez le jeune paralysé cérébral

Gluteus muscles weakness, especially Gluteus Maximus and Gluteus Medius ones are frequently reported in Cerebral Palsy (CP) walking children. Thus, their reinforcement in rehabilitation is often justified. Many physiotherapy exercises solicit their recruitment, but their efficiency was not yet reported. Ten different exercises are assessed and compared using surface electromyography (EMGs). The activity of Gluteus Maximus and Gluteus Medius muscles was recorded in 18 CP and eight asymptomatic children while realizing those exercises. The levels of muscular activation were compared between each exercise, and the existence of patterns was sought in the group of CP children. CP children measures were also compared to those recorded for valid children. This study gives classification of the exercises with respect to their efficiency for the recruitment of Gluteus Medius and Gluteus Maximus. The activity of these muscles in the various phases of the exercises is stated. Finally selection criterions between the exercises are proposed according to rehabilitation objectives of the pelvic belt.     

Traitement pharmacologique de l’état de mal réfractaire

Status epilepticus (SE) refractory to benzodiazepines and other antiepileptic agents is managed with intravenous anesthetic compounds, such as thiopental, propofol or midazolam. These drugs display quite different pharmacodynamic and pharmacokinetic properties, but have not been prospectively compared to date. Their use is clearly advocated for the treatment of generalized convulsive SE, whereas partial-complex, or absence SE are generally managed less aggressively, in consideration of their better prognosis. The most important aspect seems to be related to the correct use of these anesthetics in the right context, rather than the choice of one specific compound. An electroencephalographic burst-suppression should be targeted for about 24 hour, before progressive weaning of the dosage under EEG monitoring. If this approach proves unsuccessful, the use of other drugs, including inhalational anesthetics, has been described.     

Neurofeedback dans le trouble déficit de l’attention avec hyperactivité : de l’efficacité à la spécificité de l’effet neurophysiologique

Clinical guidelines for attention deficit/hyperactivity disorder (ADHD) recommend a multimodal treatment encompassing pharmacological medication with methylphenidate, cognitive-behavioral therapy (CBT) and family treatments. Methylphenidate is the most effective treatment, though the relatively high rate of partial responders, and the possible parental reluctance against the pharmacological treatment. Thus, it is interesting to consider new non-pharmacological therapies based, such as CBT, on the learning capacity of children to self-regulate their behavior. Neurofeedback is interesting insofar as it would allow children to acquire self-control over certain brain activity patterns to improve the regulation of their behavior in daily-life situation. Early studies on neurofeedback in ADHD are nearly 30 years old. Two training protocols were created, based on EEG abnormalities in ADHD. First training allows the modulation of EEG frequency bands: increased activity in the beta band, or decreased activity in the theta rhythm. The second allows an increase in a slow cortical potential. In both protocols, feedback of the brain activity patterns is given to children in real time as a kind of computer game, and changes that are made in the desired direction are rewarded, i.e., positively reinforced. The evidence-based level of the neurofeedback is still unclear. But, unlike other mental disorders, many studies have investigated the effect of this treatment on symptoms of ADHD. Thus, we propose to analyze the data of literature and especially recent studies. A meta-analysis and randomized controlled studies seem to confirm the efficacy and the possible place of neurofeedback in the multimodal treatment strategies of ADHD. But, if this treatment supposes to allow self-regulation of children behavior by learning the control of EEG activity, the specific mechanisms of action on brain activity remains problematic. Thus, we propose to identify methodological and neurophysiological areas for future research on this therapy involving the subject and electrophysiology in psychiatry.