The management of stroke patients. Conference of experts with a public hearing. Mulhouse (France), 22 October 2008

AbstractThe objective is to define as early as possible appropriate criteria for managing patients who have had a cerebrovascular accident (CVA), or stroke, beginning in the Neurovascular and Acute Care Services, in order to facilitate the patient's return home (or the equivalent of home) or continuing care in the most appropriate health care facility.Three clinical assessment tools are used in the initial care phase because they are robust and reproducible:– the National Institutes of Health Stroke Scale (NIHSS) score appears to be the best clinical assessment tool. It is the reference scale used during the acute phase of a stroke because it predicts the patient's chances of recovery and the medium-term functional recovery;– the Glasgow Coma Scale (GCS) is an initial assessment tool useful in predicting the medium-term evolution in terms of level of consciousness, essentially in cases of cerebral hemorrhage or severe cerebral infarction;– the Barthel Index (BI), scored from 0 – 100, is used during the first seven days after a stroke, and the index's progression over the following two weeks is a factor in predicting the functional recovery of stroke patients.The values of these tools must take the markers of clinical stability into account during the initial phase. These markers also have a predictive value:– the curve of the relationship between blood pressure (BP) and the prognosis of stroke patients would have a U-shape, with extreme BP values having a negative influence;– hyperthermia and hypoxia are also early predictive factors of poor functional and vital prognoses;– the presence and continuation of urinary incontinence and/or swallowing disorders are important predictive factors for a poor functional prognosis and a higher mortality rate in the medium term.Complementary examinations make it possible to approximate the anatomical, metabolic and physiological status of the injured cerebral parenchyma early on, when the processes of reparation and plasticity restoration have already begun. The reparation process is a complex multifactor phenomenon that can, at any moment, be called into question; it cannot be predicted with certainty by complementary examinations only, at least at the current level of knowledge.Two parameters seem decisive in using imaging to predict stroke recovery: MRI exploration of the cerebral parenchyma and the exploration of vascular permeability via perfusion imaging. Currently, the place of functional and molecular imaging appears to be limited. Among the possible neurophysiological explorations, only motor evoked potentials (MEP) represent a simple, non-invasive, low-cost procedure that can have additional prognostic value. Hyperglycemia also has a negative impact on the functional and vital prognoses. The usefulness of biomarkers has not yet been validated.Other clinical factors influence the prognosis. Though age is an aggravating factor in the vital prognosis of stroke patients, it cannot be considered an independent factor in the functional prognosis due to the multiple co-morbidities associated with age. Diabetes, ischemic cardiopathies and atrial fibrillation are co morbidities that worsen the functional and vital prognoses of stroke patients.Cognitive disorders without dementia also have a negative influence on the functional prognosis, particularly hemi spatial neglect and phasic disorders accompanied by comprehension problems. Post-stroke dementia plays a very detrimental role. However, even though they can delay the acquisition of increased autonomy, cognitive disorders are not an obstacle for rehabilitation, and depression apparently has no influence on the rehabilitation results.Family is an essential factor. Family support is a necessary condition for the patient's discharge from the hospital and affects the length of the hospital stay. Wide-ranging effective organized family support improves the patient's functional status. The factors that make it possible for the patient to return home are the existence of home support, a moderate level of impairment and being of the masculine gender. Social rank and socioeconomic status also play a role: when rank and status are low, they are not only stroke risk factors but also increase the risks of poststroke mortality and of institutionalization.For the health care system to perform well, stroke management plans must respect two requirements:– individual requirement: the best possible match between the patient's needs and possibilities and the follow-up services, without missing any patient opportunity for an optimal return to normalcy;– organizational requirement: early intervention and the optimal transfer time in order to insure system flexibility and make it possible for the greatest number of patients to benefit from care in a specialized facility, particularly during the acute phase of the stroke.Patients will preferably be directed towards:– an intermediary or Intensive Care facility and then a rehabilitation facility specialized in brain injuries. Patients with severe impairment (NIHSS over 16), when they are conscious and off artificial ventilation, with or without a tracheotomy; malignant stroke patients, postdecompressive hemicraniectomy; and stroke patients with basilar trunk occlusion, after thrombolysis recanalization;– a follow-up and rehabilitation care facility specialized in neurological disorders. Patients with medium-level hemiplegia (NIHSS between 5 and 15 and/or Barthel Index≥20) who begin to improve in the first 7 days and younger patients with more serious hemiplegia if there is no rehabilitation facility specialized in brain injuries nearby;– a non-specialized follow-up and rehabilitation care facility or one that is specialized in the disorders of polypathologic elderly patients who are dependent or at risk of being dependent. Patients with serious hemiplegia without any signs of recovery in the first 7 days, who have multiple indicators of a poor prognosis (Barthel Index<20, persistent incontinence, multiple complex deficiencies) and/or who do not need a coordinated multidisciplinary rehabilitation program or will not, in the immediate future, be able to take part in at least 3hours of exercise per day;– a facility for dependent elderly people. Elderly patients, especially those over 80 years of age, who are socially isolated and/or have had a severe stroke resulting in motor and cognitive deficits, swallowing disorders and incontinence;Except for the case of minor strokes that spontaneously evolve towards recovery, the decision for an early return home for patients with deficits is based on three criteria: need (i.e., a persistent incapacity that is nonetheless compatible with life at home and rehabilitation), feasibility (i.e., patient residence in the same geographic zone as the hospital) and safety (i.e., stability of the medical situation). This kind of return is more frequent in northern Europe than in France, and it is significantly correlated with a better medium-term recovery, in terms of preventing death and increasing autonomy and satisfaction. The positive impact of an early discharge is more significant in moderately dependent patients (initial Barthel Index>45).Two factors are essential for the success of such early returns home:– a home visit carried out before the patient's discharge;– a multidisciplinary team (physiotherapists, occupational therapist, speech therapist, doctor, nurse and social worker) who, at the end of the patient's hospital stay, takes responsibility for appropriate patient care immediately following the patient's discharge, for a period of approximately three months and a minimum frequency of four sessions per week.The Early Supported Discharge (ESD) model developed in Anglosaxon countries, which facilitates and conditions this kind of discharge plan, does not correspond exactly to the French health system's Hospitalisation à domicile (HAD), but the correspondence between the two is worth exploring. In the absence of a multidisciplinary intervention, the early long-term intervention (at least 5 months) of an occupational therapist in the patient's home can reduce the patient's level of impairment after an early return home (less than 1 month after the stroke).Maintaining the patient in his/her home starts by identifying the needs of both the patient and the caregivers, updating these needs as the situation evolves. The multidisciplinary team plays an important role in maintaining, even increasing, the patient's autonomy, and improving the patient's quality of life and that of his/her caregivers, while ensuring an optimal level of safety in the home. This is accomplished by educating both the patient and caregivers and by home interventions. The failure to maintain the patient at home can be caused by the worsening of the patient's condition (e.g., intercurrent disorders, loss of autonomy) or unpredictable factors (e.g., death of the patient's spouse), but also by the exhaustion of the patient's caregivers.When patient autonomy backslides or the patient loses interest, the intervention of a multidisciplinary team in the home of the stroke patient can help to reduce the deterioration rate of the activities of daily living (ADLs) and increase the patient's capacity to do personal activities. This intervention consists of repeat visits in the three months that follow the patient's discharge from the hospital. The health care providers and the caregivers need information about transfer techniques, adapting and using technical aids, fall prevention and the development of safety strategies for the home, improving communication difficulties, and adapting to the patient's visual disturbances and emotional changes. In the absence of a structured multidisciplinary team, occupational therapy can have a positive effect on personal and instrumental ADLs and social participation. Physiotherapy in the home alone doesn’t seem to have a significant effect on the patient's functional capacities

TER: A Robot for Remote Ultrasonic Examination: Experimental Evaluations

This chapter: o Motivates the clinical use of robotic tele-echography o Introduces the TER system o Describes technical and clinical evaluations performed with TE

Pantropical variability in tree crown allometry

Aim: Tree crowns determine light interception, carbon and water exchange. Thus, understanding the factors causing tree crown allometry to vary at the tree and stand level matters greatly for the development of future vegetation modelling and for the calibration of remote sensing products. Nevertheless, we know little about large‐scale variation and determinants in tropical tree crown allometry. In this study, we explored the continental variation in scaling exponents of site‐specific crown allometry and assessed their relationships with environmental and stand‐level variables in the tropics. / Location: Global tropics. / Time period: Early 21st century. / Major taxa studied: Woody plants. / Methods: Using a dataset of 87,737 trees distributed among 245 forest and savanna sites across the tropics, we fitted site‐specific allometric relationships between crown dimensions (crown depth, diameter and volume) and stem diameter using power‐law models. Stand‐level and environmental drivers of crown allometric relationships were assessed at pantropical and continental scales. / Results: The scaling exponents of allometric relationships between stem diameter and crown dimensions were higher in savannas than in forests. We identified that continental crown models were better than pantropical crown models and that continental differences in crown allometric relationships were driven by both stand‐level (wood density) and environmental (precipitation, cation exchange capacity and soil texture) variables for both tropical biomes. For a given diameter, forest trees from Asia and savanna trees from Australia had smaller crown dimensions than trees in Africa and America, with crown volumes for some Asian forest trees being smaller than those of trees in African forests. / Main conclusions: Our results provide new insight into geographical variability, with large continental differences in tropical tree crown allometry that were driven by stand‐level and environmental variables. They have implications for the assessment of ecosystem function and for the monitoring of woody biomass by remote sensing techniques in the global tropics

Pantropical variability in tree crown allometry

Aim Tree crowns determine light interception, carbon and water exchange. Thus, understanding the factors causing tree crown allometry to vary at the tree and stand level matters greatly for the development of future vegetation modelling and for the calibration of remote sensing products. Nevertheless, we know little about large‐scale variation and determinants in tropical tree crown allometry. In this study, we explored the continental variation in scaling exponents of site‐specific crown allometry and assessed their relationships with environmental and stand‐level variables in the tropics. Location Global tropics. Time period Early 21st century. Major taxa studied Woody plants. Methods Using a dataset of 87,737 trees distributed among 245 forest and savanna sites across the tropics, we fitted site‐specific allometric relationships between crown dimensions (crown depth, diameter and volume) and stem diameter using power‐law models. Stand‐level and environmental drivers of crown allometric relationships were assessed at pantropical and continental scales. Results The scaling exponents of allometric relationships between stem diameter and crown dimensions were higher in savannas than in forests. We identified that continental crown models were better than pantropical crown models and that continental differences in crown allometric relationships were driven by both stand‐level (wood density) and environmental (precipitation, cation exchange capacity and soil texture) variables for both tropical biomes. For a given diameter, forest trees from Asia and savanna trees from Australia had smaller crown dimensions than trees in Africa and America, with crown volumes for some Asian forest trees being smaller than those of trees in African forests. Main conclusions Our results provide new insight into geographical variability, with large continental differences in tropical tree crown allometry that were driven by stand‐level and environmental variables. They have implications for the assessment of ecosystem function and for the monitoring of woody biomass by remote sensing techniques in the global tropics

Régionalisation et déconcentration administrative : rôle du Préfet de Région

The region and the local authority : role of the « Préfet de région » Representing at first the authority of the State, the authority of the Préfet de Region has increased as far as of the coordination, control, proposals and decisions are concerned. The decisions at the county level are made by the Mission régionale, the Conférence administrative régionale and the CODER. The attempt to reduce the importance of Central Government is still limited.D'abord relais de l'autorité de l'Etat, le pouvoir régional exercé par le Préfet de région s'est peu à peu affirmé dans les domaines de l'animation, la coordination, le contrôle, la proposition et la décision. La Mission régionale, la Conférence administrative régionale, la CODER permettent d'établir les orientation souhaitables. Les efforts de déconcentration des pouvoirs publics restent timides...Pelissier Jacques. Régionalisation et déconcentration administrative : rôle du Préfet de Région. In: Économie rurale. N°84, 1970. La région, image ou réalité ? pp. 31-36

Etude d'une famille présentant sur cinq générations une association CMT et luxation congénitale de la hanche

MONTPELLIER-BU Médecine (341722104) / SudocMONTPELLIER-BU Médecine UPM (341722108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Dynamique posturale de l'hémiplégique (évaluation et rééducation)

Chez la personne atteinte d'hémiplégie, la restauration des capacités posturales est considérée comme un des objectifs majeurs du processus de réhabilitation. Aujourd'hui, les grandes caractéristiques de la posture érigée chez le patient hémiplégique sont bien connues. Cependant, un certain nombre d'interrogations, relatives à la nature des mécanismes déficitaires et au type de rééducation à développer, subsiste. Au cours de ce travail doctoral, nous avons utilisé les concepts et les outils de l'approche dynamique des systèmes sensori-moteurs pour étudier les déficits posturaux de cette population. Dans ce cadre, ces déficits sont assimilés aux anomalies spatio-temporelles observables dans les coordinations hanche/cheville. Dans un premier temps, nous avons cherché à quantifier la nature des modifications de la dynamique posturale consécutives à une lésion cérébrale. Nous avons étudié, d'une part, la dynamique spontanée lors d'une tâche de poursuite de cible, et d'autre part, la dynamique intentionnelle en présence d'une information comportementale spécifiant la coordination à produire. A travers ces deux expérimentations, une disparition de l'attracteur en phase et une diminution de la stabilité de l'attracteur en anti-phase ont pu être mises en évidence. Dans un second temps, sur la base de ces résultats, nous avons proposé un (ré)apprentissage des deux modes de coordination préférentiels à l'aide d'un dispositif de biofeedback. L'objectif était de déterminer si la restauration d'une dynamique posturale dite "normale" était possible en dépit de la pathologie. Les résultats montrent un (ré)apprentissage du patron en phase suite au protocole; (ré)apprentissage qui s'accompagne d'une amélioration du niveau d'indépendance fonctionnelle des patients. Dans leur ensemble, ces résultats contribuent à une plus grande compréhension des déficits posturaux du patient hémiplégique et proposent des pistes de réflexion intéressantes pour la mise en place de futurs protocoles de rééducation.The improvement of postural capacities is regarded as one of the major goals of rehabilitation of hemiplegic patients. Today, the main characteristics of the upright posture are well-known. However, many questions concerning the nature of affected mechanics and possible physical therapies remain open. In this work, we studied postural deficits in a hemiplegic population following the concepts and tools of the dynamical approach of sensori-motor systems. Deficits were considered as spatio-temporal anomalies of the organization of the postural system and analyzed through ankle/hip coordination patterns. First, we investigated modifications of postural dynamics following stroke in two different experiments. We observed both spontaneous dynamics during a tracking task and intentional dynamics using behavioral information specifing the to be produced coordination pattern. Results of both studies showed disappearance of the in-phase pattern and less stable performance in the anti-phase pattern. Second, based on gained knowledge, we proposed a (re)learning task of the two preferred postural patterns using a biofeedback design. The aim was to assess the success of this protocol for the recovery of "normal" dynamics and to explore the effect of this (re)learning on postural and functional abilities. Results suggested that the recovery of the in-phase pattern is possible and seemed to improve independence of patients. Summarized, this work proposes a new way to investigate postural deficits in post-stroke population and provided a base for the development of new therapies.MONTPELLIER-BU STAPS (341722109) / SudocSudocFranceF

Les adaptations du rachis lombaire en situation aiguës et chroniques

Le rachis lombaire est à la fois capable de répondre à des exigences de stabilité pour protéger les structures neurologiques ou ostéo-ligamentaires et de mouvement pour assumer les gestes de la vie quotidienne, professionnelle et sportive. La lombalgie, pathologie multifactorielle, s'accompagne de perturbations musculaires, réflexes ou comportementales. La complexité de ces adaptations explique pourquoi il est encore difficile de savoir comment un sujet devient lombalgique ou pourquoi il le reste. Ce travail de recherche s'est focalisé sur l'étude de certaines adaptations du rachis lombaire en situation aiguës ou chroniques. Les objectifs étaient d'analyser l'influence (i) des tissus de soutien sur le comportement musculaire lombaire (ii) du gainage abdominal sur l'efficience des membres inférieurs, (iii) de la fatigue des érecteurs spinaux sur la réponse réflexe chez le sujet sain et (iv) d'un programme de rééducation chez le lombalgique. Les résultats obtenus soulignent le rôle central de l'effecteur neuromusculaire lombaire. Le maintien de certaines postures entraîne des adaptations mécaniques (pression intramusculaire) et métaboliques (oxygénation musculaire) limitant l'efficience des érecteurs spinaux. Le renforcement abdominal, probablement par son action stabilisatrice lombaire, modifie la raideur du système tronc -membres inférieurs et peut-être l'aptitude au saut vertical. Une fatigue lombaire induite provoque une adaptation réflexe chez le sujet sain (gain d'amplitude et peut-être de latence) pour compenser la perte de force. Enfin, un programme de restauration fonctionnelle permettrait, chez le lombalgique chronique, de modifier les capacités d'anticipation en limitant les activations musculaires exagérées et la réponse réflexe à une perturbation, évoquant l'émergence de nouvelles stratégies d'adaptation. Ce travail suggère la possibilité de nouvelles approches dans un cadre sportif ou médical.The lumbar spine is able to meet both stability requirements for protecting neurological and osteoligamentous spine structures and movement requirements for performing professional, sports, and daily life activities. Low back pain, a multi-factorial disease, is associated with abnormal muscle function, neuromuscular alterations, and adverse behavioural reactions. The complexity and the variability of all these changes explain why the exact cause of back pain remains unknown. This thesis focused on the study of the lumbar spine adaptations in various acute or chronic situations. The goal was to explore (i) the influence of posture and passive contributions on paraspinal muscle pressure and oxygenation adaptations, (ii) the consequences of abdominal reinforcement on trunk and leg stiffness, (iii) the effects of induced paraspinal fatigue or (iv) rehabilitation programs on reflex modulation in healthy subjects and chronic low back pain patients, respectively. The results emphasize the central role of the neuromuscular lumbar effector. Maintaining certain postures causes mechanical and oxygenation paraspinal muscular changes that may explain passive limitations on paraspinal muscle efficiency; the modifications induced by abdominal training in healthy subjects suggest a possible role of the spine on trunk and leg stiffness changes; a paraspinal muscle fatigue paradigm illustrates the reflex modulation which compensates a loss of force; finally, a functional restoration program designed for chronic low back pain disorders targets neuromuscular behaviour changes via modulation of the trunk reflex response, thus advocating a possible way to increase the range of control strategies. This work opens the door for new therapeutic strategies.MONTPELLIER-BU Médecine UPM (341722108) / SudocSudocFranceF