Physiotherapy for people with stroke has been found to be beneficial but details of the most effective interventions are unclear. Further development of the evidence base for stroke physiotherapy is limited by a lack of clinical practice models, sensitive clinically based outcome measures and effective stratification techniques to characterise homogenous groups of subjects. These issues are addressed here with regard to balance and posture. These aspects were chosen because they form a cornerstone of stroke physiotherapy as they are thought essential for the rehabilitation of functional activities. A systematic review of assessment methods in the literature revealed a lack of measurement tools which met the utility criteria: reliability, validity, sensitivity to short-term change, suitability for a wide range of abilities, ease of use and suitability for different settings. This prompted the development of a new measurement tool. Firstly, a model of the clinical assessment process was developed using an adapted focus group method with neurological physiotherapists. This informed the content of a new measurement tool which combined an ordinal scale with functional performance tests- the Brunel Balance Assessment. The tool was evaluated in a series of studies involving 92 stroke patients. It was hierarchical (coefficient of reproducibility= 0.99, coefficient of scalability = 0.69), reliable (100% agreement) and valid as a measure of balance disability (r=0.58-0.97). The psychometric properties of the individual functional performance tests were also tested and found to be reliable (ICCs =0.88-1) and valid (r=0.32-0.63). Measurement error ranged 0-40% and the minimum change needed to detect true clinical change was calculated for each test. Balance disability, measured with the Brunel Balance Assessment, is heterogeneous with sitting, standing and stepping balance forming distinct levels of ability (p<0.027). Consequently, the BBA could be used to stratify people with stroke according to balance ability. Weakness, sensation and age were significant independent contributors to balance disability (r2=82.7%). Balance ability was a strong contributor to independence in ADL (p<0.0001). The findings of this thesis address the issues that have limited research into stroke physiotherapy with regard to balance disability. In relation to clinical practice, a robust measurement and stratification tool has been developed.

Objective: Vestibular Evoked Myogenic Potentials (VEMP) were investigated to differentiate between parkinsonian syndromes. We correlated balance and VEMP parameters to investigate the VEMP brainstem circuits as possible origin for postural instability. Methods: We assessed clinical status, ocular and cervical VEMP (oVEMP, cVEMP) and a balance assessment (posturography, Activities-specific Balance Confidence Scale, Berg Balance Scale, modified Barthel Index) in 76 subjects: 30 with Parkinson’s disease (PD), 16 with atypical parkinsonism (AP) and 30 healthy controls. VEMP were elicited by using a mini-shaker on the forehead. Results: Patients with PD had a prolonged oVEMP n10 in comparison to controls and prolonged p15 compared to controls and AP. Patients with AP showed reduced oVEMP amplitudes compared to PD and controls. CVEMP did not differ between groups. Postural impairment was higher in AP compared to controls and PD, particularly in the rating scales. No correlations between VEMP and posturography were found. A classifier using support vector machine was able to automatically classify controls and patient subgroups with moderate to good accuracy based on oVEMP latencies and balance questionnaires. Conclusions: Both oVEMP and posturography, but not cVEMP, may be differentially affected in PD and AP. We did not find evidence that impairment of the cVEMP or oVEMP pathways is directly related to postural impairment. Significance: OVEMP and balance assessment could be implemented in the differential diagnostic work-up of parkinsonian syndromes.:1. Einleitung 2. Publikationsmanuskript 3. Zusammenfassung 4. Literaturverzeichnis 5. Anlagen 6. Darstellung des eigenen Beitrages 7. Selbstständigkeitserklärung 8. Lebenslauf 9. Danksagung

The graduation thesis deals with the issue of balance disorders due to a cerebellar damage. It deals in detail with the treatment of patients suffering from degenerative cerebellar ataxia and with the use of biofeedback technologies as means of postural stability treatment. The aim of practical part of this work was to investigate the effectiveness of therapy using biofeedback for patients suffering from progressive ataxia due to cerebellar neurodegeneration. The research sample consisted of 8 patients. The patients underwent a total of 18 therapy sessions within a twelve-day rehabilitative program. The therapy contained a training of stability in various positions with the elimination of visual control. A device provided an additive information about head sways for the patients via a tongue electrotactile stimulation. The effects were assessed by means of posturography, functional clinical tests (BESTest, Dynamic Gait Index) and questionnaires (Activities-specific Balance Confidence Scale, Dizziness Handicap Inventory). Three assessments were performed: immediately before, immediately after, and 30 days after the rehabilitative program. A statistical analysis of the data showed significant improvement in all observed parameters. In addition, there was no loss of the benefits in the interval of 30...

Abstract available through Journal of Geriatric Physical Therapy.

Dans un contexte réglementaire incitant fortement les industriels à la réduction de la pollution à la source, l’application de stratégies telles que des bonnes pratiques environnementales et un meilleur contrôle des procédés constituent une réponse aux enjeux environnementaux. Le traitement de surface par voie aqueuse est une activité grande consommatrice d’eau et de produits chimiques et donc génératrice de rejets aqueux pollués. L’objectif de ce travail est de proposer à ce secteur d’activité une méthodologie simple de limitation des flux de pollution ainsi que de la consommation en eau. Cette méthodologie se base notamment sur le postulat que l’entraînement est le principal vecteur de pollution au sein d’une chaîne de traitement de surface.Des études expérimentales ont permis, d’une part de créer une méthode rapide de calcul de l’entraînement et, d’autre part, de montrer et de quantifier l’influence de la forme et de la rugosité des pièces traitées, du temps d’égouttage, de la tension superficielle des solutions de traitement ou encore du type et de la durée du rinçage des pièces sur l’entraînement.L’ensemble de ces éléments, intégrés à la méthodologie de minimisation de la pollution, permet d’une part de réaliser un diagnostic de la chaîne mais aussi d’estimer l’impact d’une modification de cette chaîne sur la consommation spécifique en eau, le bilan de pollution ainsi que sur la qualité des rinçages. Cette méthodologie aide ainsi à limiter les consommations d’eau et de réactifs non seulement sur la chaîne mais également en station de détoxication, diminuant ainsi les impacts environnementaux et les coûts de fonctionnement. / Currently, via the prevention principle, environmental regulations incite industries to implement strategies to reduce the pollution at the source (ICPE, IPPC, IED). Industries are sometimes lost in front of various proposed technical solutions. The application of cleaner production strategies such as good operational procedures and good practices of management allow to answer these constraints.The metal finishing activity uses a lot of water and chemicals and thus generates polluted effluents. The objective of this work is to propose a simple methodology of limitation of the pollution flows and of the water specific consumption of metal finishing workshops.Then, experimental studies have allowed, on one hand, to create an easy method of the drag-out calculation and, on the other hand, to show and to quantify the influence of different parameters on the drag-out, from a qualitative and quantitative point of view. They are, for example, the shape and the roughness of the treated pieces, the draining time, the superficial tension of the treatment solutions but also the stirring type and duration of rinsing.All these elements, integrated into the methodology of pollution minimization, allow to realize a diagnosis of the process line. Moreover, it permits to estimate the impact of a modification of this installation on the specific consumption of water, on the pollution balance assessment and on the rinsing quality. So, this methodology can help to optimize and to limit consumptions of water and chemicals not only on the process line but also in wastewater treatment plant, so decreasing the environmental impacts and the running costs.

[pt] O equilíbrio corporal é uma importante habilidade física e um aspecto fundamental para a saúde dos idosos, sendo as quedas a principal causa de lesões não intencionais que levam a perda de autonomia e ao óbito neste grupo. Com o envelhecimento da população mundial e sendo os déficits de equilíbrio uma das maiores causas de atendimentos fisioterapêuticos, o uso de instrumentos portáveis de baixo custo e confiáveis para avaliação do equilíbrio são de extrema relevância. Diversos estudos avaliaram a validade concorrente e/ou confiabilidade do Microsoft Kinect (Kinect) e do Nintendo Wii Balance Board (WBB) durante testes de equilíbrio. Estes estudos foram favoráveis ao uso destes equipamentos nestas avaliações em posições semi-estáticas. Este estudo examinou a confiabilidade teste-reteste com o uso concorrente do Kinect e do WBB durante um teste de equilíbrio em três posições semi-estáticas, analisando variáveis do centro de pressão (CoP) e do centro de gravidade (CoG) em manequins e em 70 indivíduos saudáveis. Cada participante executou dois testes na mesma sessão. Os equipamentos demonstraram sensibilidade para identificar diferentes padrões de oscilação corporal. As variáveis mais confiáveis foram a velocidade média e o percurso total em todas as direções e tarefas. A confiabilidade foi considerada de fraca a boa nos testes com pessoas e nos testes com manequins, excelente. Porém, os resultados com as variáveis das pessoas baseadas em dados consolidados das três tarefas alcançaram confiabilidade excelente. Propriedades do CoP demonstraram ser mais confiáveis do que as do CoG, sugerindo que o WBB seja superior ao Kinect nesta tarefa. O presente trabalho corrobora estudos anteriores, podendo, estes dispositivos, prover informações quantitativas confiáveis, aprimorando avaliações qualitativas do equilíbrio. / [en] Body balance is an important physical skill and it is fundamental for elderly´s health, considering that falls are a major cause of unintentional injuries leading to the loss of autonomy and death in this group. Growth of aging in world population and being balance impairment one of the major causes of physiotherapeutic attendance, simple, affordable, portable, and reliable devices for evaluating body balance are of great relevance. Several studies have been examining concurrent validity and reliability of Microsoft Kinect (Kinect) and Nintendo Wii Balance Board (WBB) during balance tests. The majority of these studies suggested that those devices could be used as reliable and valid tools for assessing balance in semi-static positions. Based on that, this study investigated test-retest reliability using Kinect and WBB, concurrently, in three standing positions, and analyzed variables related to center of pressure (CoP) and center of gravity (CoG), in static manikins and in 70 healthy subjects. Each participant performed the set of tests twice in the same day. Our solution demonstrated sensibility to identify different body sway patterns. Tests showed that the most reliable variables were average speed and total path length in all directions and tasks. Despite tests with static manikin signalized excellent reliability, tests with individuals were considered poor to good. However, variables of consolidated data based on different tasks achieved excellent scores. CoP properties outperformed those related to CoG, suggesting that WBB was superior when compared to Kinect in providing more reliable body sway information. This study reinforced that these devices may provide reliable quantitative information that enhances qualitative body balance assessments.

Cette étude, accompagnée d’un volume d’annexes, est une réflexion sur la manière d’aborder le sujet aphasique, dans les contextes médical et de réadaptation auxquels il est confronté, dès le diagnostic de son atteinte : l’aphasie, ou perte du langage acquis, touche généralement l’adulte. Puisant aux sources de la philosophie, la réflexion initiale évoque la problématique d’une éthique couvrant le parcours médical et paramédical complexe de ce type de patient, pointant aussi certains obstacles spécifiques à l’éthique médicale, psychologique ou de l’éducation. Ensuite, une définition succincte de la neuropsychologie du langage est suivie d’une présentation de l’aphasie, propos adossé à l’étude d’un cas d’aphasie mixte, comportant une anamnèse familiale (médecine narrative) et une anamnèse médicale, puis un bilan neuropsychologique, narratif également, centré sur le langage : il s’agit de montrer que, de façon plus ou moins diffuse, le sujet aphasique, dans un état de maladie chronique (séquelles durables le plus souvent) souffre d’une situation de handicap qui le conduit à un état de grande vulnérabilité. Il est fort difficile de lui proposer un suivi homogène sur l’ensemble de la chaîne du soin, et jusqu’à la fin de cette longue période de réadaptation du langage (au moins trois ans) quand sa langue maternelle est devenue langue étrangère. La didactique des langues, six fois millénaire, dont l’histoire est brièvement exposée, est le matériau pédagogique de la réadaptation proposée : préceptorat conçu et adapté au sujet, montrant l’intérêt du champ des sciences humaines et sociales, dans un parcours de soin. La prise en charge tient compte de l’état psychologique du patient, à l’identité profondément meurtrie, du bilan neuropsychologique et du bilan de langage effectués. Enfin, cette étude tend à montrer la réalité pluridisciplinaire de l’éthique médicale, dans le champ de l’aphasiologie. Elle évoque une synergie où la position du psychologue, du neuropsychologue ou de l’orthophoniste, du linguiste, didacticien des langues peuvent se rejoindre. / This study, with an annexe, is a reflection on the approach of aphasic subject, in his medical and rehabilitation contexts, from the very start of the diagnosis of his language disturb: the aphasia, or the loss of the acquired language, is generally a syndrome of adult subject. Based on the fundamentals of philosophy, the initial reflection evokes the difficulty of a homogeneous and satisfactory ethics, during the complex medical and paramedical course of this kind of patient, pointing some specific obstacles in the medical, psychological ethics or in the ethics of education. Then, a brief definition of the neuropsychology of language is followed by a presentation of the aphasia, a comment leaned on a mixed aphasia case study, containing a familial and a medical anamneses (Narrative medicine) and a neuropsychological balance assessment (narrative also), focused on the language, witch tends to show that, in a more or less diffuse way, the aphasic subject suffers from a lack of homogeneity on the set or part of the care chain, till the end of the long period of his language rehabilitation (at least three years), when his mother tongue became foreign language. The didactics of the languages, six-thousand-years-old, and its short history is briefly explained; it is the teaching aids proposed for the rehabilitation: the tutorage is especially conceived and adapted to the subject, showing the interest of the field of humanities and social sciences, in a course of care. The care takes into account the psychological state of the patient, his profoundly bruised identity, the neuropsychological balance assessment and the balance assessment of language. Finally, this study suggests the reality of the multidisciplinary field of medical ethics in the field of aphasiology. It expresses a synergy where the position of psychologist, neuropsychologist or speech pathologist, linguist, educationalist language can join.