Introduction

The functional explorations represent a set of medico-technical tests allowing to confirm, to direct or to refine a diagnosis, a therapeutic follow-up or a treatment.

Balance and posture

The functional competence center of the posture and the balance of the Rehazenter is dedicated to the evaluation and the treatment of people presenting disorders of the function of the equilibration or asking for an improvement of the performance in these domains. The indications of such a care are:

  • the disorders of the equilibration in the large sense,
  • the functional consequences of the central and peripheral neurological lesions,
  • the pathologies of the vestibular system and dizzinesses,
  • the cinetose or travel sickness,
  • the neurovisual disorders,
  • etc.

The traumato-orthopaedical or sports pathologies (hip and knee prostheses, traumas and amputations of the lower limb) are taken care of , as well as the disorders of the static and dynamic posture.

The service is at the disposal of the doctors and other healthcare professionals of the Rehazenter or the external healthcare professionals.
This competence center is composed of a therapist team of various disciplines (doctorsin physical medicine and rehabilitation, physiotherapist, occupational therapist, psychologist, psychomotor therapist, orthoptist and sport instructors) which operate in a multi -and interdisciplinary way.
The spectre of functioning of this pole spreads out between:

  • The complete course of treatment of the patient within the group, beginning with a consultation by the practitioner of physical medicine and specific rehabilitation in the domain of balance disorders and dizzinesses, then is usually followed by an instrumental balance assessment and the care which is adapted by the various members of the team according to a pluri and interdisciplinary mode.
  • Exact Balance sheets of posturography/stabilometry made by the members of this group at the request of an external therapeutic team during a pathway of care of a patient.

The complete pathway of care is piloted by the medical practitioner in physical medicine and rehabilitation. The treatment of the multi and interdisciplinary team takes place individually or in a group, it includes various approaches according to the pathology and especially according to the result of the clinical and functional balance assessments made before.

At the end of six weeks, the team meets to make a synthesis on the evolution of the patient and decides on the continuation (adaptation of the treatment, end of treatment).

On the operational plan, the pole usually works in their specific rooms which bring into play the different sensory inputs and postural responses. The means of instrumental exploration and rehabilitation made available are:

  • Posturography / computerized dynamic stabilometry (Equitest ©, Multitest ©, Satel ©), Posturo-Pro software.
  • Videonystagmography, the Rotational Chair.
  • The subjective measurement of vertical and horizontal, of dynamic visual acuity.
  • Software for Rehabilitation in increased visual reality controlled by a multitest platform.
  • Optokinetic stimulation, 2D video projection system.
  • Assessments of functional balance as well as the use of classical physiotherapeutical equipment.
  • Specific work in orthoptics (visual stabilization, combined ocular motricity disorders, prisms).
  • In psychology (stress management, autohypnosis).
  • In occupational therapy, assess the risk of falling and the fear of falling, as well as the impact of balance disorders in the various activities of daily life. Find preventive strategies that are appropriate for everyone, both on a personal level and at the level of the indoor and outdoor environment (home visits, technical assistance, workplace visits, etc.). The goal is to preserve the autonomy and independence of each person in his daily life.
  • Support in groups in adapted gymnastics activities by static and dynamic balance exercices, in situations of course or adapted collective games.
  • Psychomotricity: Psychomotor assessments on different items, including body diagram, dynamic and static coordination / dissociation, space, time, etc. It follows a possible management, individually or in a group, responding to different goals defined during the assessment, using various means: relaxation (body awareness, management of emotions, etc.), motor paths (balance, coordination, etc.), expression of the body (mime, theater, dance, etc.), etc.

Quantified Exploration of the movement and of the posture

Walking is an essential activity of the human being. It allows everyone to move in an autonomous way and in independence. However, walking is a complex requiring activity, which needs before reaching maturity, a learning of several years. Once mature, walking becomes an “automatical” activity that no longer requires special attention and breaks down into a series of movements that are repeated according to a specific cycle.

The automation of this activity facilitated its study, mainly by measuring and establishing biomechanical standards in all three spatial dimensions of the normal walking space. The establishment of standards is essential for the study of a movement because it allows a comparison for the study of a pathological movement.
The quantified analysis of walking thus makes it possible to carry out a three-dimensional study of a pathological walk and to compare it with previously established norms.
In a quantified analysis of walking, the kinematic, kinetic and electromyographic variables are studied. In addition, we can complete this quantified analysis of walking by measuring energy consumption during walking.

The kinematic variables describe the movement and in particular the displacement, the speed and the linear and angular acceleration of the different segments of the body. The movements of the different segments are studied using opto-electronic equipment, consisting of six infrared cameras. These cameras will make it possible to locate and follow the 3-dimensional displacement of reflective markers attached to specific anatomical places of the body. By connecting these points together, we have a reconstruction in “sticks”, representing the movements of the different segments of the body. From the displacements thus calculated, one can quantify the linear and angular displacements of each segment with respect to each other and determine by successive integrations the different speeds and accelerations.

The kinetic variables make it possible to determine the forces that generate the movement. To do this, we use force platforms that will allow, using previously measured kinematic data, to calculate the moments (defined by the product of the force by the distance between the force vector and the articular center) at the level of each articulation and the powers (defined by the product of the joint moment and the angular velocity) which are developed there.
The kinematic and kinetic data are expressed in form of curves, which are, as previously explained, compared with standards.

The electromyographic data are collected most often using surface electrodes attached to the skin, which gives us information on the moments of muscle activity analyzed during the walking cycle. By comparing the pattern of activity collected with standards, we can identify the muscles with deleterious activity during walking. In addition, electrodes implanted in the muscles can be used to collect either the electrical activity of muscles located deeply (posterior tibialis, ilio-psoas) or the activity of different chiefs of the same muscle (the quadriceps, by example) to identify the leading muscle with abnormal activity.

All of this data allows us to quantify biomechanical data related to walking and to identify in a relatively precise manner the abnormalities as well as the muscle or muscles whose inappropriate activity causes a dysfunction.

In this way, we can define whether the abnormalities are related to either muscle weakness or spastic hypertonia, or to co-contractions of agonist-antagonist muscles resulting in joint stiffness.

These results will enable us, in some cases, to propose a medical (botulinum toxin) or surgical (intrathecal Baclofen pump implantation, muscle lengthening, bone remodeling osteotomy, etc.) treatment.

In addition to the diagnostical potential of this examination, quantified walking analysis is also a powerful assessment review. In fact, we use this test a lot to evaluate the impact that the inactivation of one or more muscles, obtained with the help of a neurological motor block or to a lesser extent a toxin injection of Boltulinium,, would have on the walking. Once the proof is made that the walking is improved by such a gesture, we can advise with more certainty the realization of surgical gestures, having definitive but irreversible results.
Progress of a quantified analysis of walking:


Duration: 2 to 3 hours depending on the acquisition difficulties encountered during the exam.

1. Clinical examination of the lower limbs and walking, in which the amplitudes of the different joints, the strength and spasticity of the different muscles are evaluated.
2. The walking is filmed.

3.Equipment of the patient : Reflective markers are placed on precise anatomical sites and electromyographyical electrodes are attached to the muscles whose activity is to be studied during walking.
4. Acquisition of biomechanical data during the walk: several acquisitions (about ten) are necessary in order to be able to calculate averages.
5. Reconstructing the model by the physician in order to obtain and interpret the kinematic, kinetic and electromyography curves.
Energy expenditure   allows us to measure the energy consumed during walking. The measurement of this metabolic cost is carried out according to the conventional method of indirect calorimetry, in an open circuit, and using a spirometer. The indirect calorimetric method consists in evaluating energy expenditure from the measurement of oxygen consumption and the production of carbon dioxide. This method is based on the fact that during physical exercise, all energy-producing reactions result from the oxidation of carbon and hydrogen atoms and their transformation into carbon dioxide and water. In exercise physiology, spirometry is generally performed in open circuit, the subject inhaling the ambient air whose composition is constant (20.93% oxygen, 0.03% carbon dioxide, 79.04% nitrogen and inert gas). ). The expiratory ventilation flow measurement and the O2 and CO2 concentration of expired gases can be used to determine O2 consumption and CO2 production.

In our laboratory we use a spirometer equipped paramagnetic O2 analyzer (QUARK, Cosmed, Italy, Polar), which can not be moved and, imposing to perform the analysis on either a cyclo-ergometer or treadmill.

Electrophysiological explorations

Neuromuscular exploration is used to study the central and peripheral nervous system, the muscles and the neuromuscular junction (contact between the neuron and the muscle). Exams do not require special preparation and last about half an hour, sometimes an hour for a complete exploration.

The evaluation is based on different techniques:

Electromyography is performed using electrodes that are placed on the surface of the body, sometimes consisting of thin needles positioned in the muscle that is to be studied. This examination can detect muscle activity spontaneously, at rest or at the time of muscle activity. The result that is obtained is called “electromyogram“.

The stimulation-detection tests make it possible to measure the conduction velocity of the sensory or motor nerve fibers, to detect and locate, within the central or peripheral nervous system, the suspected lesion.

Sensitive or motor evoked potentials are stimulative -detection techniques that provide an overview of the level or levels of dysfunction of the central and / or peripheral nervous system.

The indications of neurophysiological explorations: these examinations are indicated in front of a suspicion of neuromuscular affection, mainly in the presence of a paralysis but also of a disturbance of the sensitivity. The examinations guide the diagnosis in the various fields of neurology, orthopedics, neurosurgery, rheumatology, reanimation, urology, and physical medicine and rehabilitation.

The primary goal of these explorations is to optimize our proposals for treatment and functional revalidation through accurate diagnosis and decoding of neuromuscular disorders.

Neuro-urodynamic explorations

As early as 1992, the National Center for Functional Reeducation and Rehabilitation of Luxembourg wanted to develop the treatment of vesico-sphincter dysfunctions mainly of neurological origin.

This treatment included a time of evaluation with urodynamic and electrophysiological examinations and a therapeutic time oriented mainly towards intermittent self-probing education. The Sexo-Neuro-Urological Assessment and Monitoring Service (SESSNU) was set up.

Quickly, our interests and patients’ demands spread to the sexual sphere, with the development of erectile and ejaculatory disorders. Our action was again double, both evaluative and therapeutic: electrophysiological explorations, education in intracavernous injections, semen collection by vibro-massage.

In 2007, following the move to our new premises, we developed, in collaboration with the team of the radiology department of the hospital of Kirchberg , the realisations of dynamic radiological assessments, the Retrograde Uretro-Cystographies and Micro-cliches (UCRM).

Finally, since the beginning of 2010, we have equipment that enables diagnostic cystoscopic examinations to be carried out in our institution, in collaboration with the Urology Department of the Hospital Center of Luxemburg.

The contribution of these different approaches and techniques allows us at this stage to have a platform for evaluating the entire pelvi-perineal sphere and its three functions, urinary, anorectal and sexual, and to offer coherent and integrated care for the global disability.

As part of these developments, the SESSNU is giving way to a new unit called pelvic-perineal assessment unit (UdEPP).

 

Medical-technical services:

Urodynamic assessment: this examination allows to study the vesico-sphincter function in the context of incontinence or dysuria phenomena. It measures the intra-vesical and sphincteric pressures generated during a filling with water, performed via a probe placed intra-vesical. The concomitant recording of the electrical activity of the striated urethral sphincter makes it possible to evaluate the degree of coordination between the bladder and the sphincter. This examination is always coupled with a mictional calendar, which allows the daily follow-up in ecological conditions, of the urinary behavior.

Anorectal manometry: this examination allows to evaluate ano-rectal functioning. It measures the pressures within the anal canal, in its upper part (smooth internal sphincter) and lower (striated external sphincter) in three conditions: rest, response to the filling of an intra-rectal balloon, and demands of restraint efforts .
This exploration is part of the focus towards constipation and anal incontinence

Perineal electrophysiological assessment: the involvement of the sacral nerve pathways is accompanied by impaired bladder, sexual and rectal functions. These electrophysiological explorations (EMG – Conduction velocities – Potential Evoked Somesthesic Internal Shame Nerve (PESNHI)) make it possible to objectify the existence of a lesion of the neurological pathways intended for the pelvi-perineal organs. Potential evoked vegetative supplement the balance assessment.

Furthermore, the immediate proximity of the radiology room makes it possible to couple urodynamic assessments to dynamic X-ray assessments (Uretro-Retrograde and Micular Cystography – UCRM).

Diagnostic cystoscopic examinations: assessment of the impact of neuro-urological dysfunctions on the vesico-urethral status.